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NIHR Signal Exercise training improves physical capacity after lung cancer surgery

Published on 3 September 2019

doi: 10.3310/signal-000813

People who receive exercise training following surgery for lung cancer can walk about 57 metres further in six minutes than controls who did not exercise. After surgery like this to remove all or part of a lung, people typically manage about 500 metres in six minutes on the test, and anything above 20 metres is considered a worthwhile improvement. Exercise also increases leg strength and quality of life.  

A decline in physical fitness is a common and debilitating effect of lung resection. Exercise training is already recommended in the rehabilitation of many chronic conditions including obstructive lung disease.

This Cochrane update reviewed eight trials exploring the effect of combined aerobic and resistance exercise after lung cancer surgery. Despite being of small size (450 participants in total), the trials demonstrated consistent and meaningful improvements in exercise capacity.

There is a need to improve understanding of the best programme format, and how exercise can be tailored alongside other rehabilitation measures to give the best outlook for health and wellbeing after lung cancer surgery.

Share your views on the research.

Why was this study needed?

Lung cancer is the third most common cancer in the UK, with around 47,200 new diagnoses every year. About eight per cent of people are suitable for curative surgery to remove the tumour and surrounding lung tissues.

Around 40% of people receiving curative resection will survive for at least five years. Yet physical debilitation, with fatigue and breathlessness, is common and perceived by many to be the most undesirable effect of surgery.

Exercise training is established in the management of many chronic respiratory conditions, as well as benefitting the recovery of certain cancers like breast and prostate, but less is known about its benefits or harms after lung cancer surgery.

This Cochrane review aimed to combine the results of new and old trials that evaluated exercise training following surgery in non-small cell lung cancer.

What did this study do?

This updated review added five randomised controlled trials to the three included in a previous review completed in 2013. The eight trials included 450 patients (40% women) who had undergone lung resection for non-small cell lung cancer (with or without chemotherapy) and been allocated to control or exercise training, starting within 12 months of surgery.

Studies varied in the extent of lung resection and used either keyhole or open surgical approaches. Six studies assessed combined aerobic and resistance exercise, and two involved inspiratory muscle training. Session frequency ranged from two to five days per week, with exercise at variable intensity. Intervention duration varied from 4 to 20 weeks. Control groups received standard outpatient care, with two studies including breathing exercises or exercise instruction.

Participants and researchers were aware of study allocation, which introduces some uncertainty in outcome reporting. Two studies came from the UK. All were published from 2011 onwards.

What did it find?

  • People who received exercise training could walk an average of 57 metres further (95% confidence interval [CI] +34m to +80m) in six minutes compared with controls. This exceeded the clinically important difference of 22 to 42 metres. The evidence was high certainty, based on five studies (182 people) with similar direction of effect.
  • Peak oxygen consumption during exercise was also higher than controls (mean difference in V02max, 2.97 ml/kg/min, 95% CI 1.93 to 4.02). This was moderate certainty evidence from four trials (135 people).
  • There was moderate certainty evidence that exercise improved the strength of the quadriceps muscle (standard mean difference [SMD] 0.75, 95% CI 0.4 to 1.2; four studies, 133 people).
  • Four trials reported on adverse effects, with one trial reporting a single case of hip fracture in the exercise group.

What does current guidance say on this issue?

The NICE lung cancer guideline (2019) gives recommendations on assessing people with non-small cell lung cancer for surgery with curative intent but no advice on exercise training. People are considered suitable for surgery if they have good existing exercise tolerance and normal lung function.

NICE recommends walking tests and cardiopulmonary exercise testing to measure oxygen uptake in people considered at risk of shortness of breath after surgery. Good prior function is considered to be at least 400m walked in six minutes and oxygen uptake above 15ml/kg/minute.

What are the implications?

This review shows consistent effects across several studies, and new trials confirm that combined aerobic and resistance training can give an important improvement in exercise capacity after lung resection for non-small cell lung cancer.

The authors suggest that following lung resection, referral for exercise programmes should be considered, as is the case for various other chronic lung and cardiovascular conditions. They warn that because of the small risk of increased falls, participants are offered balance training and supervision when needed.

Citation and Funding

Cavalheri V, Burtin C, Formico VR et al. Exercise training undertaken by people within 12 months of lung resection for non‐small cell lung cancer. Cochrane Database Syst Rev. 2019;(6):CD009955.

This review was supported by Curtin University, Perth, Australia, and by Cancer Council Western Australia.

Bibliography

Cancer Research UK. Lung cancer statistics. London: Cancer Research UK; (undated).

NICE. Lung cancer: diagnosis and management. NG122. London: National Institute for Health and Care Excellence; 2019.

NICE. Physical activity: exercise referral schemes. PH54. London: National Institute for Health and Care Excellence; 2014.

Why was this study needed?

Lung cancer is the third most common cancer in the UK, with around 47,200 new diagnoses every year. About eight per cent of people are suitable for curative surgery to remove the tumour and surrounding lung tissues.

Around 40% of people receiving curative resection will survive for at least five years. Yet physical debilitation, with fatigue and breathlessness, is common and perceived by many to be the most undesirable effect of surgery.

Exercise training is established in the management of many chronic respiratory conditions, as well as benefitting the recovery of certain cancers like breast and prostate, but less is known about its benefits or harms after lung cancer surgery.

This Cochrane review aimed to combine the results of new and old trials that evaluated exercise training following surgery in non-small cell lung cancer.

What did this study do?

This updated review added five randomised controlled trials to the three included in a previous review completed in 2013. The eight trials included 450 patients (40% women) who had undergone lung resection for non-small cell lung cancer (with or without chemotherapy) and been allocated to control or exercise training, starting within 12 months of surgery.

Studies varied in the extent of lung resection and used either keyhole or open surgical approaches. Six studies assessed combined aerobic and resistance exercise, and two involved inspiratory muscle training. Session frequency ranged from two to five days per week, with exercise at variable intensity. Intervention duration varied from 4 to 20 weeks. Control groups received standard outpatient care, with two studies including breathing exercises or exercise instruction.

Participants and researchers were aware of study allocation, which introduces some uncertainty in outcome reporting. Two studies came from the UK. All were published from 2011 onwards.

What did it find?

  • People who received exercise training could walk an average of 57 metres further (95% confidence interval [CI] +34m to +80m) in six minutes compared with controls. This exceeded the clinically important difference of 22 to 42 metres. The evidence was high certainty, based on five studies (182 people) with similar direction of effect.
  • Peak oxygen consumption during exercise was also higher than controls (mean difference in V02max, 2.97 ml/kg/min, 95% CI 1.93 to 4.02). This was moderate certainty evidence from four trials (135 people).
  • There was moderate certainty evidence that exercise improved the strength of the quadriceps muscle (standard mean difference [SMD] 0.75, 95% CI 0.4 to 1.2; four studies, 133 people).
  • Four trials reported on adverse effects, with one trial reporting a single case of hip fracture in the exercise group.

What does current guidance say on this issue?

The NICE lung cancer guideline (2019) gives recommendations on assessing people with non-small cell lung cancer for surgery with curative intent but no advice on exercise training. People are considered suitable for surgery if they have good existing exercise tolerance and normal lung function.

NICE recommends walking tests and cardiopulmonary exercise testing to measure oxygen uptake in people considered at risk of shortness of breath after surgery. Good prior function is considered to be at least 400m walked in six minutes and oxygen uptake above 15ml/kg/minute.

What are the implications?

This review shows consistent effects across several studies, and new trials confirm that combined aerobic and resistance training can give an important improvement in exercise capacity after lung resection for non-small cell lung cancer.

The authors suggest that following lung resection, referral for exercise programmes should be considered, as is the case for various other chronic lung and cardiovascular conditions. They warn that because of the small risk of increased falls, participants are offered balance training and supervision when needed.

Citation and Funding

Cavalheri V, Burtin C, Formico VR et al. Exercise training undertaken by people within 12 months of lung resection for non‐small cell lung cancer. Cochrane Database Syst Rev. 2019;(6):CD009955.

This review was supported by Curtin University, Perth, Australia, and by Cancer Council Western Australia.

Bibliography

Cancer Research UK. Lung cancer statistics. London: Cancer Research UK; (undated).

NICE. Lung cancer: diagnosis and management. NG122. London: National Institute for Health and Care Excellence; 2019.

NICE. Physical activity: exercise referral schemes. PH54. London: National Institute for Health and Care Excellence; 2014.

Exercise training undertaken by people within 12 months of lung resection for non-small cell lung cancer

Published on 18 June 2019

Cavalheri, V.,Burtin, C.,Formico, V. R.,Nonoyama, M. L.,Jenkins, S.,Spruit, M. A.,Hill, K.

Cochrane Database Syst Rev Volume 6 , 2019

BACKGROUND: Decreased exercise capacity and health-related quality of life (HRQoL) are common in people following lung resection for non-small cell lung cancer (NSCLC). Exercise training has been demonstrated to confer gains in exercise capacity and HRQoL for people with a range of chronic conditions, including chronic obstructive pulmonary disease and heart failure, as well as in people with prostate and breast cancer. A programme of exercise training may also confer gains in these outcomes for people following lung resection for NSCLC. This systematic review updates our 2013 systematic review. OBJECTIVES: The primary aim of this review was to determine the effects of exercise training on exercise capacity and adverse events in people following lung resection (with or without chemotherapy) for NSCLC. The secondary aims were to determine the effects of exercise training on other outcomes such as HRQoL, force-generating capacity of peripheral muscles, pressure-generating capacity of the respiratory muscles, dyspnoea and fatigue, feelings of anxiety and depression, lung function, and mortality. SEARCH METHODS: We searched for additional randomised controlled trials (RCTs) in the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library 2019, Issue 2 of 12), MEDLINE (via PubMed) (2013 to February 2019), Embase (via Ovid) (2013 to February 2019), SciELO (The Scientific Electronic Library Online) (2013 to February 2019), and PEDro (Physiotherapy Evidence Database) (2013 to February 2019). SELECTION CRITERIA: We included RCTs in which participants with NSCLC who underwent lung resection were allocated to receive either exercise training, which included aerobic exercise, resistance exercise, or a combination of both, or no exercise training. DATA COLLECTION AND ANALYSIS: Two review authors screened the studies and identified those eligible for inclusion. We used either postintervention values (with their respective standard deviation (SD)) or mean changes (with their respective SD) in the meta-analyses that reported results as mean difference (MD). In meta-analyses that reported results as standardised mean difference (SMD), we placed studies that reported postintervention values and those that reported mean changes in separate subgroups. We assessed the certainty of evidence for each outcome by downgrading or upgrading the evidence according to GRADE criteria. MAIN RESULTS: Along with the three RCTs included in the original version of this review (2013), we identified an additional five RCTs in this update, resulting in a total of eight RCTs involving 450 participants (180 (40%) females). The risk of selection bias in the included studies was low and the risk of performance bias high. Six studies explored the effects of combined aerobic and resistance training; one explored the effects of combined aerobic and inspiratory muscle training; and one explored the effects of combined aerobic, resistance, inspiratory muscle training and balance training. On completion of the intervention period, compared to the control group, exercise capacity expressed as the peak rate of oxygen uptake (VO2peak) and six-minute walk distance (6MWD) was greater in the intervention group (VO2peak: MD 2.97 mL/kg/min, 95% confidence interval (CI) 1.93 to 4.02 mL/kg/min, 4 studies, 135 participants, moderate-certainty evidence; 6MWD: MD 57 m, 95% CI 34 to 80 m, 5 studies, 182 participants, high-certainty evidence). One adverse event (hip fracture) related to the intervention was reported in one of the included studies. The intervention group also achieved greater improvements in the physical component of general HRQoL (MD 5.0 points, 95% CI 2.3 to 7.7 points, 4 studies, 208 participants, low-certainty evidence); improved force-generating capacity of the quadriceps muscle (SMD 0.75, 95% CI 0.4 to 1.1, 4 studies, 133 participants, moderate-certainty evidence); and less dyspnoea (SMD -0.43, 95% CI -0.81 to -0.05, 3 studies, 110 participants, very low-certainty evidence). We observed uncertain effects on the mental component of general HRQoL, disease-specific HRQoL, handgrip force, fatigue, and lung function. There were insufficient data to comment on the effect of exercise training on maximal inspiratory and expiratory pressures and feelings of anxiety and depression. Mortality was not reported in the included studies. AUTHORS' CONCLUSIONS: Exercise training increased exercise capacity and quadriceps muscle force of people following lung resection for NSCLC. Our findings also suggest improvements on the physical component score of general HRQoL and decreased dyspnoea. This systematic review emphasises the importance of exercise training as part of the postoperative management of people with NSCLC.