2. WHO
Lung Cancers (along with
trachea and bronchus
cancers)
caused 2.9% deaths
worldwide (2.2% in 2000:
it’s increasing)
High mortality (the deadliest
cancer, the leading cause of
cancer death worldwide)
3. Lung cancer rates are high, are falling in males but rising in females
4. It is frequently diagnosed at a late stage but … if localized there is Hope for survival, in particular those eligible for
tumour resection
5.
6. pré-operative Education: Standart Care
• Pharmacological optimization (COPD)
• SmoKing cessation
Warner et all. Role of preoperative cessation of smoking and other factors in
postoperative pulmonary complications,… Mayo Clinic Proc 64:609
Turan et al. Smoking and perioperative outcomes. Anesthesiology 2011
Mason et al. Impact of smoking cessation before resection of lung cancer: a Society
of Thoracic Surgeons General Thoracic Surgery Database study. Ann Thor Surg 2009;
Barrera et al. Smoking and timing of cessation: impact on pulmonary complications
after thoracotomy. Chest 2005;
• Training in lung expansion
• Training of secretion clearance technics including deep breathing, incentive
spirometry and assisted coughing
7. Patients with lung cancer in general have:
Reduced peak aerobic capacity,
Reduced functional capacity, physical inactivity
Deconditioning, muscle weakness, fatigue,
caquexia
Poor quality of life
Increased levels of anxiety and depression
Concurrent COPD
Dispnea
Studies indicate that physical training can improve
these issues.
ATS, ERS Statment
2013
8.
9. Mean preoperative FEV(1) and VO(2) max of patients who developed pulmonary
complications were significantly lower
Eur J Cardiothorac Surg. 2009
10. 2.1.3.2 Exercise testing To assist the prediction of surgical outcome, a range of cardiopulmonary exercise tests has
been used. These include assessments of exercise capacity such as walk tests and stair climbing and formal
measurements of cardiopulmonary function such as measurement of peak oxygen consumption (VO2max).
Good performance on the 6 min walk test and stair climbing have been associated with improving surgical outcomes
and have been reported to be similar predictors of mortality to formal exercise testing in patients with chronic
obstructive pulmonary disease (COPD) and pulmonary hypertension.
Consider cardiopulmonary exercise testing to measure peak oxygen consumption as functional assessment in patients
with moderate to high risk of postoperative dyspnoea using >15 ml/kg/min as a cut-off for good function. [D]
11. Pre-Op Exercise Training Safe for Patients With Lung Cancer
n= 20 pre-surgical
4 to 6 weeks of training:
5 cycle ergometry sessions per week
intensities ranging from 60% to 100% of peak oxygen consumption (VO2 peak).
Adherence: 72%.
Those who completed 80% or more of the sessions achieved:
• a significant increase in VO2 peak and
• 6 minute walk distance increased by 49 meters.
Jones LW, … Effects of presurgical exercise training on cardiorespiratory fitness among
patients undergoing thoracic surgery for malignant lung lesions. Cancer 2007;
;
12. • VO2 max< or =15 ml/kg/min
• 4 weeks
• N=12
• mean increase in maximal oxygen consumption: 2.8 ml/kg/min (p<0.01).
• no postoperative mortality
Bobbio….Preoperative pulmonary rehabilitation in patients undergoing lung
resection for non-small cell lung cancer. Eur J Cardiothorac Surg. 2008
Pre-Op Exercise Training Safe for Patients With Lung Cancer
13. 1. 4 weeks of guideline-based PR vs.usual care:
that study proved to be very difficult to recruit as patients and providers were reluctant to delay
surgery.
2. 10 preoperative PR sessions using a protocol with nonstandard components (exercise prescription
based on self efficacy, inspiratory muscle training, and the practice of slow breathing) (n=10) vs.
usual care (N=9).
The PR arm had shorter length of hospital stay by 3 days (p=0.058), fewer prolonged chest tubes (11%
vs. 63%, p=0.03) and fewer days needing a chest tube (8.8 vs.4.3 days p=0.04) compared to the
controlled arm.
14. • Lower extremity (LE) endurance training :
• 20 minutes
• on a treadmill or Nu-Step .
• Upper extremity (UE) endurance:
• arm-R-size exercises or the use of an arm ergometer or the Nu-Step.
• Strengthening exercises:
• Thera-band alternating UE/LE every other day.
• 2 sets of 10–12 repetitions starting with the lowest Thera-band resistance.
• If the patient perception was “too easy” or “requires no effort”, resistance was increased.
• Patients were asked to perform exercises at an intensity that they felt high self efficacy -“very confident”-
they could sustain and that was at least light by Borg scale envisioning that in patients with greater self
efficacy the likelihood of performing under stress (post-surgery) would increase.
• Inspiratory muscle training (IMT) :
• Threshold Inspiratory Muscle Trainer IMT or the P-Flex valve (Philips Healthcare Andover, MA).
• level of perceived exertion of “Somewhat hard”
• as long as they were able with a goal of 15–20 minutes of daily use.
• Participants were coached to establish a slow, rhythmical pattern of breathing keeping inspiration and
expiration times equal while using the IMT.
• When participants were able to complete 10 minutes of IMT time in a session or noted perceived
exertion less than “somewhat hard”, the next IMT setting was increased to achieve the desired effort.
• Incentive Spirometry training
• The Practice of slow breathing (prolonging expiratory time and thereby decreasing respiratory rate to less
that 10 breaths per minute) Patients were instructed to “just watching their breath with pursed lips to
prolong the expiratory phase” for at least 10 minutes in each PR session.
15. 4 weeks of pulmonary rehabilitation (PR) versus chest physical therapy (CPT)
(N=24).
• Patients were randomly assigned to receive PR (strength with free weights and endurance trainingtreadmill, IMT) versus
CPT (breathing exercises for lung expansion).
Both groups received educational classes.
• 12 patients PR arm and 12 CPT arm.
• 3 patients in the CPT arm were not submitted to lung resection because of inoperable cancer.
• most functional parameters in the PR group improved from baseline to 1 month: forced vital capacity (FVC) (1.47L vs
1.71L [1.65-2.80L], P=.02); percentage of predicted FVC (FVC%; 62.5% vs 76% , P<.05); 6-minute walk test
(425.5±85.3m vs 475±86.5m; P<.05); maximal inspiratory pressure (90±45.9cmH(2)O vs 117.5±36.5cmH(2)O, P<.05); and
maximal expiratory pressure (79.7±17.1cmH(2)O vs 92.9±21.4cmH(2)O, P<.05).
• the PR group had a lower incidence of postoperative respiratory morbidity (P=.01), a shorter length of postoperative
stay (12.2±3.6d vs 7.8±4.8d; P=.04), and required a chest tube for fewer days (7.4±2.6d vs 4.5±2.9d, respectively; P=.03)
compared with the CPT arm.
16.
17.
18. small study demonstrated that a 4-week inpatient pulmonary rehabilitation
program improved exercise tolerance and enabled 8 patients who had
previously not met criteria for lung resection for lung cancer to undergo
surgery
Cesario A, Ferri L, Galetta D, et al. Pre-operative pulmonary rehabilitation and
surgery for lung cancer. Lung Cancer. Jul 2007;
19. Standart Postoperative Care
• Positioning (correction of antalgic postures)
• Lung expansion maneuvers: Diafragmatic ventilation, incentive spirometry .
Conflicting results about incentive spirometry may be due to disparities in
patient populations, as incentive spirometry and other lung expansion
maneuvers appear to be effective in higher risk patients.
• Secretion clearance technics
• Analgesy (TENS, massage,…)
• Energy conservation
• Early mobilization and ambulation
Kaneda H, et al Early postoperative mobilization
with walking at 4 hours after lobectomy in lung cancer patients. General Thor
Cardiovasc Surg 2007
20. Patient education
Lung expansion, deep breathing and coughing, and incentive
spirometry are best taught to the patient before surgery
and are useful for postoperative reduction of atelectasis.
Perioperative Pulmonary Management
Mark A Yoder, MD, Assistant Professor, Pulmonary and Critical Care
Medicine, Rush University Medical Center, Chicago. Sat Sharma, MD,
FRCPC, Professor and Head, Division of Pulmonary Medicine, Department
of Internal Medicine, University of Manitoba; Site Director, Respiratory
Medicine, St. Boniface General Hospital
21. Bobbio ….Changes in pulmonary function test and cardio-
pulmonary exercise capacity in COPD patients after lobar
pulmonary resection. Eur J Cardiothorac Surg. 2006;
N= 9 lobectomy +2 bilobectomy
Dispnea, physical activity levels, stair climbing capacity and quality of life worse imediately after surgery
and stay worse at 6 months
Holland … How to adapt the pulmonar rehabilitation programme to patients with crhronic respiratory
disease other than COPD . Eur Resp Review. 2013
Lung resection reduces physical fitness
further impiring the patient’s ability to
function in daily life.
Despite the possibility of a cure,
surgical resection is associated with
significant functional limitations and
decreased quality of life post-surgery
22.
23.
24. Riesenberg H, …. In-patient rehabilitation of lung cancer patients—a prospective study. Support
Care Cancer 2010;
Granger CL,…. Exercise intervention to improve exercise capacity and health related quality of
life for patients with non–small cell lung cancer: a systematic review. Lung Cancer 2011;
Spruit MA, …. Exercise capacity before and after an 8-week multidisciplinary inpatient
rehabilitation program in lung cancer patients: a pilot study. Lung Cancer 2006;
Cesario A, ... Post-operative respiratory rehabilitation after lung resection for non–small cell lung
cancer. Lung Cancer 2007
Jones LW, …. Safety and feasibility of aerobic training on cardiopulmonary function and quality of life
in postsurgical nonsmall cell lung cancer patients: a pilot study. Cancer 2008;
Arbane G,… Evaluation of an early exercise intervention after thoracotomy for non–small cell lung
cancer (NSCLC), effects on quality of life, muscle strength and exercise tolerance: randomised
controlled trial. Lung Cancer 2011;
Jones LW,…. The lung cancer exercise training study: a randomized trial of aerobic training, resistance
training, or both in postsurgical lung cancer patients: rationale and design. BMC Cancer 2010;
25.
26.
27.
28. High-intensity training following lung cancer surgery: a randomised controlled trial
•E Edvardsen et al
•Thorax 2015;
single-blind randomised controlled trial of high-intensity endurance and strength training (60 min, three
times a week, 20 weeks), starting 5–7 weeks after surgery. The control group received standard
postoperative care. The primary outcome was the change in peak oxygen uptake measured directly
during walking until exhaustion. Other outcomes included changes in pulmonary function, muscular
strength by one-repetition maximum (1RM), total muscle mass measured by dual energy X-ray
absorptiometry, daily physical functioning and quality of life (QoL).
61 randomised patients
showed that the exercise group had a greater increase in peak oxygen uptake (3.4 mL/kg/min
between-group difference, p=0.002), carbon monoxide transfer factor (Tlco) (5.2% predicted, p=0.007),
1RM leg press (29.5 kg, p<0.001), chair stand (2.1 times p<0.001), stair run (4.3 steps, p=0.002) and
total muscle mass (1.36 kg, p=0.012) compared with the controls. The mean±SD QoL (SF-36) physical
component summary score was 51.8±5.5 and 43.3±11.3 (p=0.006), and the mental component
summary score was 55.5±5.3 and 46.6±14.0 (p=0.015) in the exercise and control groups, respectively.
29.
30. Exercise intervention compared with usual care both pre and post-surgery is associated with:
- Improved cardiopulmonary exercise capacity
- -increased muscle strength
- -reduce fatigue
- - reduce post-operative complications
- -reduced hospital length of stay
- More high quality randomized controlled trials are required
31.
32. Maddocke, … Randomized controlled pilot study of neuromuscular electric
stimulation of the quadricips in patients with NCC lunf cancer. J Pain Symptom
Manage 2009
33. • There is strong interest in the role of exercise in cancer survivors, but most
research has looked at its relation to quality of life and physical function.
But whether or not it has any affect on disease recurrence or survival is an area
of huge interest for cancer survivors,
Kerry S. Courneya, PhD, American Association for Cancer Research (AACR) 2008
Annual Meeting.
34. Smoking and lung cancer: the role of inflammation
Sonia Buist. Proc Am Thorac Soc 2008. vol5:796-799
Exercise: immune modulation and anti-
inflammatory action
Mathur N, exercise as a mean to control low-
grade systemic inflammation mediators.
Inflamm 2008
Friedenreich, physical activity and cancer
prevention: etiologic evidence and biological
mechanisms . J Nutr 2002;
35. Exercise for at least 30 minutes a day at moderate to high intensity halved the risk
of dying prematurely from cancer, mainly gastrointestinal and lung cancer.
N=2560 men,
Sudhir ….British J Sports Medicine 2009
Prevention
Increased physical activity has been associated with decreased lung cancer risk in
former and current smokers.
In contrast, physical activity was unrelated to lung carcinoma among never smokers
N= 501,148 men and women
Leitzmann… Prospective Study of Physical Activity and Lung Cancer by Histologic
Type in Current, Former, and Never Smokers. Am J Epidemiology 2009
36. functional capacity is a strong independent predictor of survival in
advanced NSCLC
adds to the prediction of survival beyond traditional risk factors,
may improve risk stratification and prognostication in NSCLC.
Jones LW, Hornsby WE, Goetzinger A, Forbes LM, Sherrard EL, Quist M, et al:
Prognostic significance of functional capacity and exercise behavior in
patients with metastatic non-small cell lung cancer. Lung Cancer 2012,
37. ATS /ERS Statment 2013
Exercise as a continuum of care in lung cancer
38. • Stage IIIb and IV NSCLC
• 8 weeks Pulmonary Rehabilitation
• Reduction of symptoms and maintenance of walking endurance and
muscle strength
Temel JS, …. A structured exercise program for patients with advanced
non–small cell lung cancer. J Thorac Oncol 2009;
39. a pilot study
advanced (inoperable) lung cancer patients (NSCLC IIIb-IV SCLC ED) in chemotherapy
increase exercise capacity (fitness, strength), functional capacity (6MWD) and emotional
well-being (FACT-L) in a physical intervention (supervised and home exercises) two times
weekly for 6 weeks. Patients reported no change in HRQOL.
This study showed that this intervention was feasible and safe for inoperable lung cancer
patients receiving chemotherapy. Home training in addition to the supervised training
was not feasible due to lack of compliance.
Quist M, Roerth M, Langer S, Jones LW, Laursen JH, Pappot H, et al: Safety
and feasibility of a combined exercise intervention for inoperable lung
cancer patients undergoing chemotherapy: a pilot study. Lung Cancer
2011
Adamsen L, Stage M, Laursen J, Rorth M, Quist M: Exercise and relaxation
intervention for patients with advanced lung cancer: a qualitative
feasibility study. Scand J Med Sci Sports 2012
40. Benzo …Pulmonary rehabilitation in lung cancer: a scientific opportunity. J
Cardiopulm Rehabil Prev 2007
Dimeo F, …. Effects of an endurance and resistance exercise program on
persistent cancer related fatigue after treatment. Ann Oncol 2008
Hofman, … Virtual reality bringing a new reality to posthoracotomy lung
cancer patients via a home-based exercise intervention targeting fatigue while
undergoing adjuvant treatment (quimio/radio) . Cancer Nurs 2013
(adherence 88% to the use of Wii fit plus with improvement of fatigue
scores )
42. will test the effects of the
exercise intervention in
216 patients
with advanced lung cancer
(non-small cell lung cancer
(NSCLC) stage IIIb - IV and
small cell lung cancer
(SCLC)
extensive disease (ED)).
Primary outcome is
maximal oxygen uptake
(VO2peak). Secondary
outcomes are muscle
strength (1RM), functional
capacity (6MWD), lung
capacity (Fev1) and
patient reported outcome
(including anxiety,
depression (HADS) and
quality of life (HRQOL)).
Target population: median survival after diagnosis 10–13 months
43. Wang, … Regular Tai Chi exercise decreases the percentage of type 2 cytocine
production cells in postsurgical non-small cell lung cancer survivors. Cancer
nurs 2013
Holland … How to adapt the pulmonar rehabilitation programme to
patients with crhronic respiratory disease other than COPD . Eur Resp Review.
2013
44. Contraindications for exercise:
• Bone metastasis (fracture risk)
• Severe Anemia ( 10g/dl), leucopenia (< 3.000 ), thrombocitopenia
(50.000). Caquexia
• Disorientation
• imunodepression
• hipertermy , acute infection
• Diharrea, desidratation.
• Monitorization if cardiotoxic quimiotherapy
45. Relaxation,
Breathing control,
Thoracic flexibility and expansion
Posture
Exercise
Group Interaction
QiGong
(since 2009 in our hospital )
Acceptability by
patients:
Less pain
Less dyspnea,
More energy, less
fatigue
46. Reich, … Stress, depression, the immune system and cancer. Lancet Oncology 2004;
Scott,…Cancer survival rises with group therapy. The Los Angeles Times 1989
Courneya KS,...The group psychotherapy and home-based physical exercise (group-hope) trial
in cancer survivors: physical fitness and quality of life outcomes. Psychooncology. 2003
47. • Pulmonary rehabilitation provided to individuals with chronic
respiratory diseases other than COPD (i.e., interstitial lung disease,
bronchiectasis, cystic fibrosis, asthma, pulmonary hypertension, lung
cancer, lung volume reduction surgery, and lung transplantation) has
demonstrated improvements in symptoms, exercise tolerance, and
quality of life.
48. • Deconditioning, muscle weakness, fatigue, cachexia, and anxiety and
concurrent COPD frequently result in disability among individuals
with lung cancer.
• Dyspnea and depressed mood also contribute to impaired quality of
life.
• Physical inactivity may be an underlying cause.
• Therefore,these processes can be improved by pulmonary
rehabilitation
