Pre-treatment optimization with pulmonary rehabilitation in lung cancer: Making the inoperable patients operable

Abstract

Background Anatomical lung resection offers the best prospect of long-term survival in patients with non-small cell lung cancer (NSCLC). However, some patients with significant dyspnoea, impaired performance status (PS), borderline or poor pulmonary function are considered inoperable and instead referred for radiotherapy, chemotherapy or palliative care. The aims of the study were to determine whether pre-operative pulmonary physiotherapy (Prehab), by improving clinical parameters, (i) makes patients suitable for surgery who were considered inoperable on subjective criteria of dyspnoea >3 and PS >2, and objective criteria of diffusing capacity for carbon monoxide (DLCO) <50%; and (ii) thereby allows them to safely receive curative surgery with reduced morbidity and mortality. Methods From January 2017 to December 2018 a total of 306 patients were prospectively and sequentially assessed for Prehab and 216 patients with lung cancer studied. Their mean age (95% CI) was 71.7 ± 1.1 years, 50.5% ( n = 109) were men and they received Prehab over 39.0 ± 7.0 days averaging 3.1 ± 0.6 sessions. Their dyspnoea scores, PS, level of activity, six minute walk test (6MWT) and frailty index prior to and following Prehab were determined. Following surgery the post-operative length of hospital stay (LOHS), complications and mortality at 30 days, 90 days and 1 year determined. Similar outcomes were determined for (i) high-risk patients with dyspnoea scores >3 and PS >2, and compared with low-risk patients having dyspnoea scores <2 and PS <2 (subjective criteria); and (ii) high-risk patients with DLCO <50% and compared with low-risk patients with DLCO >80% (objective criteria). Findings In the total cohort following Prehab, there was significant improvement in the dyspnoea scores <2 / ≥2 (40%/60% prior to Prehab vs. 65%/35% following Prehab, p = 0.00002), PS <2 / ≥2 (45%/55% prior to vs. 62%/38% following Prehab, p = 0.003), frailty index ≤3 / >3 (49%/51% vs 70%/30%, p = 0.0006), and 6MWT (306.6 ± 6.8 m vs 354.8 ± 52.7 m, p = 0.04). Post-operative major complication rates were 8.7%; median LOHS was 7 (IQR 6) days; hospital mortality at 30 days 1.3%, 90 days 4.7% and 1 year 16%. Using subjective criteria of dyspnoea scores >3 and PS >2, 100% of high-risk patients were considered inoperable. Following optimization with Prehab 84.2% of the high-risk patients were ready to proceed with radical treatment and 52.6% with surgery, and subsequently 42.8% of patients underwent surgery. Likewise, 78.8% of patients with DLCO <50% were considered inoperable. Following Prehab 86.5% of high-risk patients were ready to proceed with radical treatment and 59.1% with surgery, and 54.6% of high-risk patients underwent surgery. In each category there were no significant differences in complications, LOHS or mortality rates between the high-risk a...

Evaluation of the Structure and Health Impacts of Exercise-Based Cardiac and Pulmonary Rehabilitation and Prehabilitation for Individuals With Cancer: A Systematic Review and Meta-Analysis

“…When comparing program type, the improvement in six-minute walk distance was only significant for rehab ( n = 7, WMD = 57 m, 95% CI = 29 to 85, p < 0.001, I 2 = 96%) ( 20 , 22 , 27 , 35 , 40 , 43 , 44 ) and not for prehab ( n = 3, WMD = 25 m, 95% CI = −16 to 67, p = 0.236, I 2 = 11%) ( 20 , 28 ) but was not statistically different between types ( p = 0.211). For treatment timing, the improvement was significant only among programs with participants exclusively post-treatment ( n = 7, WMD = 50 m, 95% CI = 18 to 81, p = 0.002, I 2 = 97%) ( 22 , 24 , 29 , 30 , 42 , 45 ) and was only a trend among programs that allowed patients on active treatment with surgery, chemotherapy, or radiation ( n = 3, WMD = 41 m, 95% CI = −8 to 90, p = 0.100, I 2 = 76%) ( 22 , 24 , 37 ) but did not differ between subgroups ( p = 0.765). Retrospective studies had larger improvements in six-minute walk distance ( n = 5, WMD = 70 m, 95% CI = 39 to 101, p < 0.001, I 2 = 97%) ( 24 , 29 , 37 , 42 , 46 ) than prospective ( n = 5, WMD = 25 m, 95% CI = −5 to 56, p = 0.107, I 2 = 66%) ( p = 0.042 between groups).…”

“…Eight studies with n = 680 participants among 10 different programs evaluated change in six-minute walk test distance ( 22 , 24 , 29 , 30 , 37 , 42 , 45 , 46 ). Including all programs, pre/rehabilitation improved six-minute walk distance by 47 meters (95% CI = 23 to 71, SMD = 0.78, p < 0.001, I 2 = 96%; Figure 2 ).…”

“…The only programs that reported surgical outcomes were five prehabilitation programs implemented prior to surgical resection for lung cancer ( 21 , 23 , 30 , 41 , 50 ). Four of these studies compared post-operative outcomes, including complications (e.g., pneumonia, infections), and length of hospital stay between patients who participated in prehabilitation to patients that did not participate ( 21 , 23 , 30 , 50 ) but could not be combined by meta-analysis due to variability in outcome reporting formats. All four studies reported a significant reduction or trend to significance for incidence of various post-operative complications and post-operative hospital stay length among participants in the prehabilitation program ( 21 , 23 , 30 , 50 ).…”

Optimal resection rate for lung cancer in the UK: how high should we go?

“…In a study from Finland, an increase in resection rate over time, mainly due to inclusion of higher risk patients, resulted in fewer complications and shorter hospital stays while increasing recurrence-free 5-year survival from 64.0% to 76.8%. 14 Goldsmith et al 15 demonstrated that introduction of a prehabilitation programme to a surgical unit was associated with improvement in dyspnoea scores, PS, level of activity and frailty, particularly in high-risk patients. Prehabilitation facilitated resection in previously inoperable patients without increases in complications, length of hospital stay or mortality.…”

“…Prehabilitation facilitated resection in previously inoperable patients without increases in complications, length of hospital stay or mortality. 15 …”