Reducing complications after lung cancer surgery could generate positive changes across healthcare, from better outcomes and quality of life to cost savings.
Even a small decrease in incidence of postoperative complications could have meaningful results as they affect approximately 10% to 30% of those who undergo pulmonary resection and up to 50% of those treated with lobectomy, with risk especially high among people who are elderly.1
In populations with other illnesses, it has been shown that preconditioning can help prevent postoperative complications, shorten the length of hospitalization, improve recovery, and enhance health-related quality of life. In lung cancer, similar evidence has been accumulating over the past couple of years, said Anne-Marie Baird, PhD, president of Lung Cancer Europe and Immediate Past Chair of the IASLC Communications Committee.
“Research has shown that prehabilitation programs and rehabilitation postsurgery have had a positive impact on outcomes,” she said, “and not just in terms of getting out of the hospital earlier, but also by increasing the quality of life because of the positive improvements it can make in terms of breathlessness, pain, and fatigue.”
Yet, according to a team of researchers who presented findings during the IASLC’s 2021 World Conference on Lung Cancer, it can be difficult to implement prehabilitation programs in people with lung cancer, who tend to be older, averse to exercise, and living with multiple comorbidities. As a result, studies in this population have demonstrated low recruitment and compliance rates.
To help overcome those obstacles, Yogita S. Patel, of McMaster University in Canada, and colleagues designed Move For Surgery (MFS), a home-based, 3- to 4-week preoperative conditioning intervention that encourages aerobic and deep breathing exercises facilitated by wearable technology. In a prospective, randomized trial (Abstract OA04.01), the team compared MFS with the usual preoperative standard of care in patients scheduled to undergo resection for early-stage NSCLC.
Study Design and Findings
Between October 2018 and November 2020, the team assigned 51 participants to the MFS program and 51 to receive the control treatment.
Participants had stage I to IIIa NSCLC and were a median 67 years old, with 91% having a history of smoking and nearly 94% living with comorbidities. Participants had to own a smart device to participate.
Each participant in the MFS group was given a Fitbit and a booklet describing aerobic and deep breathing exercises and tips on healthy eating, sleep hygiene, and smoking cessation. Their daily step counts, sleep cycles, and calories burned were synced and tracked remotely.
The program lasted 3 to 4 weeks because that was the length of time participants were expected to wait for surgery following diagnosis, Ms. Patel said. Personalized step count goals were established by increasing baseline count by 10% each week until the day of surgery. Participants were motivated to reach their goals through daily automatic Fitbit reminders.
In both groups, participants completed the EQ-5D-5L health-related quality-of-life questionnaire at baseline, on the day of surgery, and at 3 and 12 weeks after surgery.
Participants spent a mean 22 days in the trial, with the program completed by 45 of those in the MFS group and 50 of those in the control group. In the experimental group, participants wore a Fitbit 94.35% of the time and achieved their daily step goals on 57.46% of the days they participated, Ms. Patel reported.
The experimental intervention met its primary endpoint by significantly shortening the length of hospitalization post-surgery when compared with usual preoperative care, she said. The mean length of stay was 2.67 days for those in the MFS group versus 4.44 days for those in the control arm (p = 0.002).
Furthermore, on postoperative Day 1, participants in the MFS group reported a mean discomfort level of 2.40 out of 5, significantly less than the 2.88 reported by those in the control group (p = 0.01).
Based on data from the EQ-5D-5L, the researchers found that health-related quality of life increased in the MFS group from a mean 69.38 out of 100 before the program to 79.60 out of 100 afterwards (p ˂ 0.001).
Between the groups, Ms. Patel said, the researchers found no significant differences in the rate of intraoperative complications, the duration of chest tube use, adverse events during hospitalization, or adverse events at 3 and 12 weeks.
“Length of stay is a good surrogate measure for postoperative complications and speed of recovery,” she concluded. “This suggests that preconditioning with MFS improves health-related quality of life and may help to prepare people for thoracic surgery.”
Considering Next Steps
Discussant Carolyn Peddle-McIntyre, PhD, of Edith Cowan University in Australia, said there is “a strong rationale for prehabilitation in lung cancer due to evidence that lower preoperative exercise capacity is strongly associated with worse long- and short-term clinical outcomes.”
However, she said, accessibility can be a problem. She cited a 2020 paper in which lung surgeons reported reduced postoperative complications and length of hospital stay when people with lung cancer participated in prehabilitation programs, but just 17% of the doctors said that such programs were readily available.
Dr. Peddle-McIntyre praised MFS for having high eligibility and low drop-out rates and good “generalizability,” but noted that the study demonstrated poorly balanced arms when it came to the type of surgery participants had and their history of myocardial infarction. Dr. Baird added that there were more women than men in the study, potentially problematic as the two groups may experience symptoms and side effects differently.
Despite the study’s modest compliance rate, Dr. Baird said the results were significant, illustrating that small tweaks to physical activity levels can meaningfully affect outcomes.
A final concern about the MFS model, Dr. Peddle-McIntyre said, is that it revolves around walking and breathing, while other prehabilitation programs are multimodal. However, that difference could “develop our understanding about the feasibility and efficacy of different delivery methods,” she said.
Dr. Baird saw the program’s simplicity as an advantage, suggesting that models that start with uncomplicated, home-based strategies but have the capacity to expand are likely to best support implementation, compliance, and results. Programs should be designed for personalization based on age, comorbidity profile, and time until surgery, she said, adding that good communication is crucial so that people, who are often anxious about their breathing capacity, will understand that participating does not have to be physically taxing and can substantially benefit their health and quality of life.
For future studies, Ms. Patel envisions adding cardiovascular and resistance training components to the MFS program. Ideally, she said prehabilitation would last longer, allowing people more time to prepare for surgery.
Reference:
- 1. Motono N, Ishikawa M, Iwai S, Iijima Y, Usuda K, Uramoto H. Individualization of risk factors for postoperative complication after lung cancer surgery: a retrospective study. BMC Surg. 2021;21:311.
