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Catherine L Granger
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ES 03 - Current Topics for Nurses & Allied Health (ID 512)
- Event: WCLC 2017
- Type: Educational Session
- Track: Nursing/Palliative Care/Ethics
- Presentations: 1
- Moderators:Anne Fraser, S. Kim
- Coordinates: 10/16/2017, 15:45 - 17:30, Room 313 + 314
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ES 03.02 - Pulmonary Rehabilitation (ID 7593)
16:05 - 16:25 | Presenting Author(s): Catherine L Granger
- Abstract
- Presentation
Abstract:
This presentation will outline the rationale, role and evidence supporting pulmonary rehabilitation for people with lung cancer. Lung cancer is associated with high disease burden and physical hardship. Individuals with lung cancer experience complex symptoms, which can include dyspnoea, fatigue and pain. These frequently lead to a cycle of inactivity and functional decline. Individuals with lung cancer are less physically active than similar aged healthy peers at time of diagnosis, with less than 40% meeting the physical activity guidelines [1]. Following diagnosis, physical activity levels are lowest whilst patients undergo treatment and do not recover back to pre-treatment levels within six months [1]. Progressive functional decline occurs over this time, with reduction in exercise capacity and muscle strength [1]. In lung cancer, reduced exercise performance is associated with poorer functional independence, worse cancer treatment tolerability and higher all-cause mortality [2]. People with lung cancer, who are less physically active, have worse symptoms, and poorer exercise capacity and health-related quality of life (HRQoL) compared to those who are more active [1]. There is a strong need for pulmonary rehabilitation for this patient group [3]. There are well-established guidelines regarding exercise for people with cancer [4]. The guidelines state that people with cancer should engage in 30 minutes of moderate intensity physical activity on five or more days of the week and muscle strengthening exercises at least twice a week. This is supported by research which demonstrates that exercise is associated with improved exercise capacity, physical function, muscle strength, HRQoL, symptoms and depression in many cancer types [4]. The evidence for pulmonary rehabilitation specifically in non-small cell lung cancer (NSCLC) is growing rapidly [3, 5, 6]. Studies consistently demonstrate that pulmonary rehabilitation and exercise training is safe in lung cancer [3]. Pulmonary rehabilitation can be applied at any stage along the disease spectrum. The majority of evidence currently exists in the pre- and post-operative settings, however there is now growing evidence for pulmonary rehabilitation in advanced stage disease [3]. Prehabilitation is exercise training delivered before treatment. This is a relatively new concept in lung cancer. A recent Cochrane review [5] of exercise training for patients before surgery for NSCLC, included five randomised controlled trials (RCTs), and found pre-operative exercise training compared to usual care (no exercise) was associated with a 67% reduced risk of patients developing a postoperative pulmonary complication, fewer days that patients needed an intercostal catheter (mean difference MD -3.33 days, 95%CI -5.35 to -1.30); shorter post-operative hospital stay (MD -4.24 days, 95%CI -5.43 to -3.06) and improvement in exercise capacity (6-minute walk test MD 18.23m, 95%CI 8.50 to 27.96 m). Recently Licker and colleagues found that preoperative high-intensity interval training and resistance training improved exercise performance, as compared with an exercise and lifestyle advice group who experienced deterioration in exercise capacity while waiting for surgery [7]. The Cochrane review concluded the overall quality of evidence is low and more high-quality trials are needed [5]. Pulmonary rehabilitation following treatment with curative intent is associated with improvements in exercise capacity, muscle function and fatigue [3]. The Cochrane review of exercise training after lung resection included three RCTs, and found significant improvements in exercise capacity in favour of the intervention compared to usual care (no exercise) (6-minute walk test MD 50m, 95% CI 15 to 85) [6]. More recently, Edvardsen and colleagues found a 20-week high intensity endurance and resistance training program compared to usual care, commencing 5-7 weeks post-operatively, was associated with improved exercise capacity, quadriceps muscle strength and mass, and physical function [8]. There is less evidence published to date on pulmonary rehabilitation in advanced disease, however the early evidence suggests that exercise may be effective at increasing exercise capacity, function and HRQoL, and reducing symptoms [3] There are a number of current RCTs in progress at the moment specifically investigating exercise in inoperable or advanced lung cancer. The specific exercise training prescription in lung cancer has varied in the studies completed to date. It is likely that a combination of aerobic and resistance training is required for maximum effect to target both skeletal muscle function and cardiorespiratory fitness; both of which contribute to poor exercise performance in lung cancer [9]. Similarly, the duration of programs (weeks to months) and delivery (inpatient, outpatient, home based) has varied. Further research is required to confirm the optimal timing, prescription and delivery of pulmonary rehabilitation for people with lung cancer. In most countries, pulmonary rehabilitation is not currently part of routine clinical practice for people with lung cancer. As the evidence base grows our next challenge is to translate findings into clinical practice [10]. 1. Granger, C., et al., Low physical activity levels and functional decline in individuals with lung cancer. Lung Cancer, 2014. 83(2):292-299. 2. Jones, L.W., et al., Prognostic significance of functional capacity and exercise behavior in patients with metastatic non-small cell lung cancer. Lung Cancer, 2012. 76(2):248-252. 3. Granger, C., Physiotherapy management of lung cancer. Journal of Physiotherapy, 2016. 62(2):60-67. 4. Schmitz, K., et al., ACSM roundtable on exercise guidelines for cancer survivors. Medicine Science Sports Exercise, 2010. 42(7):1409-1426. 5. Cavalheri, V. and C. Granger, Preoperative exercise training for patients with non-small cell lung cancer. Cochrane Database of Systematic Reviews, 2017(6). 6. Cavalheri, V., et al., Exercise training undertaken by people within 12 months of lung resection for non-small cell lung cancer. Cochrane Database of Systematic Reviews, 2015(7). 7. Licker, M., et al., Short-Term Preoperative High-Intensity Interval Training in Patients Awaiting Lung Cancer Surgery: A Randomized Controlled Trial. J Thorac Oncol, 2017. 12(2):323-333. 8. Edvardsen, E., et al., High-intensity training following lung cancer surgery: a randomised controlled trial. Thorax, 2015. 70(3):244-250. 9. Burtin, C., et al., Lower-limb muscle function is a determinant of exercise tolerance after lung resection surgery in patients with lung cancer. Respirology, 2017. 22(6):1185-1189. 10. Granger, C.L., et al., Barriers to Translation of Physical Activity into the Lung Cancer Model of Care. A Qualitative Study of Clinicians' Perspectives. Ann Am Thorac Soc, 2016. 13(12):2215-2222.
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