Background
Methods
1. Define the review questions.
2. Determine the inclusion criteria.
Inclusion criteria | Exclusion criteria | |
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Population | Adults aged ≥ 18 years old with a diagnosis of lung cancer | Studies addressing other tumour sites |
Intervention | Unimodal or multimodal* prehabilitation interventions prior to lung cancer treatment | Not applicable |
Comparator | Usual care or another type of intervention | Not applicable |
Outcome | The intended and unintended outcomes for lung cancer patients participating in a prehabilitation programme The effectiveness of prehabilitation programmes | Not applicable |
Study design | Quantitative studies Qualitative studies Mixed method studies If relevant systematic reviews identified, primary papers will be included Study protocols for ongoing or upcoming prehabilitation studies specific to lung cancer Published from 2016 up to and including 03 February 2023 | Commentaries Opinion articles Book reviews Conference abstracts Social media posts Blogs Podcasts |
Language | Written in the English language | Articles published in a language other than English due to limited translation resources |
3. Search strategy.
4. Evidence screening and selection.
5&6. Data extraction and analysis.
Results
Title and year | Country of origin | Aims and purpose | Study population / sample size | Study design/type | Key findings related to the scoping review objectives | Strengths/limitations | ||
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Prehabilitation sessions can be provided more frequently in a shortened regimen with similar or better efficacy in people with non-small cell lung cancer: A randomised trial 2022 [34] | France | To evaluate the relative effect of condensing 15 prehabilitation sessions into a 3-week regimen compared with a 5-week regimen | N = 36 (18 in the intervention arm and 18 in the control arm) patients with Non-Small Cell Lung Cancer (NSCLC) and moderate - high risk of postoperative complications | Randomised controlled trial | Condensing prehabilitation sessions led to similar or better improvement in cardiorespiratory fitness and did not decrease adherence or increase adverse events | Strengths: Concealed allocation, blinded assessment of the primary outcome and intention-to-treat analysis Limitations: External validity is limited with regards to inpatient or homebased programmes | ||
Multimodal prehabilitation for lung cancer surgery: A randomised controlled trial 2021 [35] | Canada | To investigate the effect of a personalised and structured multimodal intervention on postoperative functional recovery | N = 95 (52 in the prehab arm and 43 in the rehab arm) lung cancer patients scheduled for NSCLC surgical resection | Randomised controlled trial | No difference in functional capacity during the perioperative period between the 2 groups Eight weeks after surgery, both groups returned to baseline functional capacity | Limitations: A four-week prehabilitation intervention may not be highly translatable to patients with short durations between diagnosis and surgery. Patients who did not speak English or French were excluded | ||
Feasibility of a novel mixed-nutrient supplement in a multimodal prehabilitation intervention for lung cancer patients awaiting surgery: A randomised controlled pilot trial 2021 [36] | Canada | To investigate the feasibility of delivering a novel four-week multimodal prehabilitation intervention and its effects on preoperative functional capacity and Health-Related Quality Of Life (HRQOL) compared to standard hospital care | N = 34 (24 in the intervention arm and 10 in the control arm) patients with stage I, II or IIa lung cancer awaiting elective thoracotomy | Randomised controlled trial | A multimodal prehabilitation intervention for lung cancer patients awaiting surgery is feasible as demonstrated by 84.1% adherence to the prescribed intensity of the supervised exercise program, 88.2% adherence to the self-reported home-based exercise program and 93.2% adherence to the nutritional supplement No statistical differences in the six minute walk test or HRQOL between groups | Strengths: One of the first studies to include a specifically tailored preoperative nutritional intervention beyond dietary advice and/or whey protein supplementation in lung cancer patients undergoing surgery. Flexibility of the exercise intervention Limitations: Nature of the study design (an open-label trial) could have led to a possible placebo effect in the prehabilitation group and self-supplementation in the control group. Due to the behavioural nature of the intervention, control patients may have sought out similar exercises on their own, as evidenced by the significant increase in self-reported moderate -vigorous intensity physical activity. High proportion of missing data at the preoperative visit, due to the COVID-19 pandemic. No data on adherence to the anxiety-reducing component of the intervention | ||
Preoperative exercise to improve fitness in patients undergoing complex surgery for cancer of the lung or oesophagus (PREHIIT): Protocol for a randomised controlled Trial 2020 [37] | Ireland | To examine the influence of exercise prehabilitation on physiological outcomes and postoperative recovery and through evaluation of health economics, the impact of the programme on hospital costs | N = 78 (39 in the intervention arm and 39 in the control arm) patients scheduled for either an oesophagectomy or major lung resection | Randomised controlled trial (Protocol) | Planned outcomes: Primary outcomes: Cardiorespiratory fitness. Secondary outcomes: Post-operative morbidity, pulmonary and physical performance and quality of life | Strengths: A randomised controlled trial. An examination of the economic implications of the exercise prehabilitation programme will be done as part of the outcomes Limitations: Absence of nutritional screening despite nutritional adequacy being examined. Inclusion of both lung and oesophageal cancer patients | ||
Effects of an exercise intervention for patients with advanced inoperable lung cancer undergoing chemotherapy: A randomised clinical trial 2020 [38] | Denmark | To evaluate the effect of a physical exercise program comprising 12 weeks of supervised, structured aerobic, strength, and relaxation training twice weekly for patients with advanced inoperable lung cancer | N = 218 (110 in the intervention arm and 108 in the control arm) patients with stage IIIb-IV NSCLC | Randomised controlled trial | No significant difference between the intervention and control group in VO2 peak. Statistically significant difference in strength; leg press (p = 0.01), leg extension (p = < 0.01), chest press (p = < 0.01) and lateral pull down (p = 0.04) and in social well-being (p = 0.04), anxiety (p = 0.02) and depression (p = 0.01) between the intervention and control group | Limitations: 36.6% drop out rate. Adherence to the intervention was only 44%. Patients unable to attend the hospital for the exercise program were excluded | ||
Cost-effectiveness of a technology supported multimodal prehabilitation program in moderate-to-high risk patients undergoing lung cancer resection: Randomised controlled trial protocol 2020 [39] | Spain | To evaluate the cost-effectiveness of a multimodal prehabilitation program supported by information and communication technologies | N = 158 (79 in the intervention arm and 79 in the control arm) | Randomised controlled trial (Protocol) | Planned outcomes: (i) Patient and professional experience, (ii) Population health-based outcomes (e.g. hospital length of stay, number and severity of postoperative complications, peak oxygen uptake and levels of systemic inflammation) and (iii) Healthcare costs | Strengths: One of the first studies to look at cost-effectiveness and factors which could modulate service adoption Limitations: Patients without access to a smartphone will be excluded | ||
Preoperative respiratory muscle endurance training improves ventilatory capacity and prevents pulmonary postoperative complications after lung surgery 2020 [40] | France | To evaluate preoperative Respiratory Muscle Endurance Training (RMET) on respiratory muscle capacity and postoperative complications | N = 26 patients (14 in the intervention arm and 12 in the control arm) undergoing lung resection for NSCLC | Randomised controlled trial | Statistically significant improvement in respiratory muscle endurance (p = 0.001) and reduction in pulmonary postoperative complications (p = 0.037) in the intervention group compared to the control group | Strengths: One of the first studies to demonstrate the benefits of prehabilitation via RMET Limitations: Small sample size. Possible selection bias – highly motivated group of participants | ||
Impact of one-week preoperative physical training on clinical outcomes of surgical lung cancer patients with limited lung function: A randomised trial 2019 [41] | China | To investigate the influence of preoperative physical training combining aerobic and breathing exercises on surgical lung cancer patients with impaired lung function | N = 68 (34 in the intervention arm and 34 in the control arm) NSCLC patients | Randomised controlled trial | Preoperative physical training (aerobic and breathing exercises) can improve exercise capacity, as evidenced by a statistically significant increase in distance covered by the 6 min walk test (6MWD) (p = 0.004), reduction in post-operative pulmonary complications (p = 0.022), shorter length of stay (p = < 0.001) and lower in-hospital costs (p = 0.016). No statistically significant differences in lung function or quality of life, except for the emotional function of the EORTC QLQ-C30 (p = 0.001) between groups | Strengths: Inclusion of a cost-effectiveness analysis of the intervention Limitations: Generalisability of findings is limited as it’s a small single centre study with the inclusion of non NSCLC patients | ||
Pre-operative high intensity interval training is effective and safe in deconditioned patients with lung cancer: A randomised clinical trial 2019 [42] | Switzerland | To examine the effect of prehabilitation in patients diagnosed with lung cancer | N = 151 (74 in the intervention arm and 77 in the control arm) patients with NSCLC stage IIIa or less | Randomised controlled trial | Short-term high intensity interval training is feasible in deconditioned patients as evidenced by 87% adherence. It increases cardio-respiratory fitness and walking capacity as evidenced by a statistically significant increase in high-intensity interval training power (p = < 0.001), heart rate (p = < 0.01), aerobic capacity (p = 0.004) and 6MWD (p = < 0.001) in the intervention group compared to usual care | Strengths: Demonstrated benefit of exercise prehabilitation in a short time period (8 training sessions over 3 weeks). High adherence. Limitations: Absence of nutrition and psychological components of prehabilitation | ||
Two week multimodal prehabilitation program improves perioperative functional capability in patients undergoing thoracoscopic lobectomy for lung cancer: A randomised controlled trial 2019 [43] | China | To investigate the effects of a two week, homebased, multimodal prehabilitation program on perioperative functional capacity and other outcomes | N = 73 (37 in the intervention arm and 36 in the control arm) patients with stage I-III NSCLC undergoing Video Assisted Thoracoscopic Surgery (VATS) lobectomy | Randomised controlled trial | Statistically significant improvement in the 6 min walk test (6MWT) (p = < .001) and forced vital capacity (p = .0.21) in the intervention group compared to the control group (p = < .001) No difference in lung function, disability, psychological assessment, length of stay, postoperative complications and mortality | Strengths: Tri modal prehabilitation programme (nutrition, exercise and psychology) Limitations: Patients only included if they were having a VATS lobectomy, all other lung cancer surgeries were excluded. No information on lifestyle changes | ||
Precision-Exercise-Prescription (PEP) in patients with lung cancer undergoing surgery: Rationale and design of the PEP study trial 2018 [44] | United States of America | To test the clinical effectiveness and feasibility of a personalised exercise intervention in patients with lung cancer undergoing surgery | N = 200 (100 in the intervention arm and 100 in the control arm) patients with primary lung cancer stage I, II or IIIa or secondary lung cancer undergoing surgery | Randomised controlled trial (protocol) | Planned outcomes: Primary outcome: Level of physical function assessed by the 6MWT at 2 months post-surgery. Secondary outcomes: Quality Of Life (QOL), fatigue, self-efficacy, length of stay, complications, readmission, pulmonary function and treatment-related costs up to 6 months post-surgery | Strengths: One of the first RCT’s to examine a personalised exercise programme for patients with primary and secondary lung cancer across the continuum of care from pre surgery to post surgery. Limitations: Patients unable to follow directions and complete questionnaires and exercise diaries in English would be excluded | ||
A comparison of the effects of medical Qigong and standard exercise therapy on symptoms and quality of life in patients with advanced cancer 2017 [45] | Canada | To compare the impact of medical Qigong and standard exercise therapy on anxiety and depression levels and QOL and to establish whether medical Qigong or standard exercise training is superior for improving functional capacity and reducing symptoms | N = 24 patients with stage three or four NSCLC or gastrointestinal cancer | Randomised controlled trial | No significant differences in anxiety, depression or QOL between Qigong and standard exercise therapy. However, standard exercise therapy was superior to Qigong as demonstrated by statistically significant improvements in perceived strength (p = 0.05) and walking distance (p = 0.02) | Strengths: One of the first studies to compare Qigong with another exercise intervention Limitations: Study was underpowered. Only 19 patients completed both assessments | ||
Impact of physical activity on fatigue and quality of life in people with advanced lung cancer: A randomised controlled trial 2017 [46] | Australia | To assess whether a 2-month physical activity intervention improves fatigue and QOL | N = 112 (56 in the intervention arm and 55 in the control arm) patients with stage III/IV NSCLC or Small Cell Lung Cancer (SCLC) | Randomised controlled trial | No significant differences in fatigue, QOL, symptoms, physical or functional status or survival between the groups | Strengths: Physical activity intervention adherence was good (69%), demonstrating that advanced lung cancer are able to participate in structured physical activity programmes Limitations: Selection bias – motivated group | ||
Preoperative exercise training prevents functional decline after lung resection surgery: A randomised, single-blind controlled trial 2017 [47] | Spain | To investigate the effects of a preoperative exercise programme in patients with lung cancer undergoing VATS | N = 22 (10 in the intervention arm and 12 in the control arm) patients with suspected or confirmed diagnosis of NSCLC | Randomised controlled trial | Statistically significant improvement in exercise tolerance (p = 0.0001), the physical summary component of the Short Form (SF) 36 survey (p = 0.008) and muscle strength (p = < 0.01) in the intervention arm compared to the control group. There were no significant differences between groups after surgery. However, 3 months post-surgery, there were statistically significant differences in mean change of exercise capacity (p = 0.005), physical summary component (p = 0.001) of the SF-36 and upper (p = 0.045) and lower body strength (p = 0.002) | Strengths: Demonstrated that a preoperative exercise based programme can improve exercise capacity, muscle strength and the physical component of health related quality of life in patients with lung cancer Limitations: Small study with a high dropout rate – of the 20 patients randomised to the prehabilitation group, only 50% completed the study | ||
Short-term preoperative exercise therapy does not improve long-term outcome after lung cancer surgery: A randomised controlled study 2017 [48] | Switzerland | To evaluate the impact of adding rehabilitation with High Intensity Interval Training (HIIT) before lung cancer surgery to enhance cardio-respiratory fitness and improve long-term postoperative outcome | N = 151 (74 in the intervention arm and 77 in the control arm) patients with suspected or confirmed stage IIIa or less NSCLC | Randomised controlled trial | A HIIT program before lung cancer resection did not improve clinical and functional outcomes at 1 year after surgery as evidenced by no statistical significant difference in survival, pulmonary function or cardiorespiratory difference between the 2 groups | Strengths: One of the first studies to examine the impact of prehabilitation on long-term outcomes after resection Limitations: A third of patients did not complete the pulmonary function and cardiopulmonary exercise tests for unknown reasons | ||
Short-term preoperative high-intensity interval training in patients awaiting lung cancer surgery: A randomised controlled trial 2017 [49] | Switzerland | To evaluate and compare short-term preoperative HIIT to usual care by assessing cardio-respiratory fitness parameters and the incidence of postoperative complications | N = 151 (74 in the intervention arm and 77 in the control arm) patients undergoing NSCLC resection | Randomised controlled trial | Preoperative HIIT resulted in statistically significant improvements in peak oxygen consumption (p = 0.003) and 6MWD (p < 0.001) There were no statistically significant differences in complication rates between groups | Strengths: Demonstrated the safety and effectiveness of a short-term exercise training program in improving aerobic performance Limitations: Study was underpowered. 25% did not experience any benefit in aerobic fitness despite attending the prescribed training sessions | ||
Is preoperative protein-rich nutrition effective on postoperative outcome in non-small cell lung cancer surgery? A prospective randomised study 2016 [50] | Turkey | To investigate the benefit of preoperative nutritional support for NSCLC patients who underwent anatomic resection | N = 58 (31 in the intervention arm and 27 in the control arm) patients with NSCLC | Randomised controlled trial | Preoperative nutrition provided a statistically significant reduction in complications (p = 0.049) and chest tube removal time (p = 0.019) in patients who were in the intervention arm compared to the control group There was also a statistically significant reduction of 25% in postoperative albumin levels in patients in the control arm compared to only a 14% reduction in those in the intervention arm (p < 0.001) | Strengths: One of the first studies examining the effect of nutritional prehabilitation in patients with NSCLC Limitations: Disproportionate number of males versus females; 54 versus 4 respectively. Excluded malnourished patients and patients with a low Body Mass Index (BMI). Changes in albumin could be multifactorial | ||
Effect of prehabilitation on ventilatory efficiency in non–small cell lung cancer patients: A cohort study 2019 [51] | France | To assess the effect of prehabilitation on the minute ventilation / carbon dioxide production slope (VE/VC02) and its relationship with VO2peak | N = 50 patients with NSCLC | Cohort study | No statistically significant change in VE/VCO2 slope (p = 0.09), length of hospital stay (p = 0.55) and post-operative complications (p = 0.50) from baseline to post prehabilitation. However, there was a statistically significant increase in VO2peak (p = 0.01) and cardiorespiratory parameters (p = 0.01) from baseline to post prehabilitation | Strengths: One of the first studies to evaluate the effect of prehabilitation before lung resection for NSCLC on VE/VCO2 slope Limitations: Retrospective study design. Exercise intensity was not accounted for | ||
Impact of prehabilitation on morbidity and mortality after pulmonary lobectomy by minimally invasive surgery: A cohort study 2018 [52] | France | To determine whether participation in a prehabilitation program would improve outcomes after surgery and lower morbidity according to the Clavien-Dindo classification | N = 38 (19 in the intervention arm and 19 in the control arm) patients with NSLC stage IIIA or less who had pulmonary lobectomy by minimally invasive surgery | Cohort study | Statistically significant difference in favour of the prehabilitation group with a Clavien-Dindo grade of ≤ 2 (p = 0.02) and fewer postoperative complications (p = 0.03) No significant difference between the two groups in length of stay and severity of complications | Strengths: One of the first studies to focus on prehabilitation and the severity of post-operative complications using the Clavien-Dindo classification Limitations: Small sample size. Post-operative complications were only recorded up to 30 days post-surgery. Patients unable to attend the hospital for the exercise program were excluded | ||
Application and practice of trimodal prehabilitation model in preoperative management of patients with lung cancer undergoing video-assisted thoracoscopic surgery 2023 [53] | China | To analyse the application of trimodal prehabilitation model in preoperative management of patients with lung cancer undergoing VATS | N = 148 (74 in the intervention arm and 74 in the control arm) stage I-II NSCLC patients due to undergo VATS | Prospective study | Statistically significant improvement in the 6MWT and activity levels (p values not provided) and a reduction in the Hospital Anxiety Depression Scale (HADS) and post-operative complications (p values not provided) between groups post intervention | Strengths: Tri modal prehabilitation programme (nutrition, exercise and psychology) Limitations: Results to be interpreted with caution owing to the absence of P values | ||
Pre-treatment optimisation with pulmonary rehabilitation in lung cancer: Making the inoperable patients operable 2021 [54] | United Kingdom | To determine whether pre-operative prehabilitation, by improving clinical parameters, (i) makes patients suitable for surgery who were considered inoperable and (ii) thereby allows them to safely receive curative surgery with reduced morbidity and mortality | N = 216 lung cancer patients | Prospective study | Clinically and statistically significant improvement in dyspnoea scores (p = 0.00002) performance status (p = 0.003) level of activity (p = < 0.00001) and frailty (p = 0.00058) from baseline to post prehabilitation intervention 42.8% underwent surgery following prehabilitation | Strengths: Prehabilitation intervention is as short as 2 weeks, which is more translatable to patients with short durations between diagnosis and surgery. Prospective study so all data is collected in real time Limitations: Lack of a control group. No information on nutrition | ||
Neoadjuvant prehabilitation therapy for locally advanced non–small-cell lung cancer: Optimizing outcomes throughout the trajectory of care 2022 [55] | Canada | To assess whether neoadjuvant prehabilitation helps to optimise outcomes | N = 141 (20 in the intervention arm and 121 in the control arm) lung cancer patients who underwent neoadjuvant treatment followed by surgery | Retrospective study | Statistically significant improvement in the 6WMT (p = .1), self-reported functional status (p = .03) and HADS (p = .005) in the intervention group compared to the control group | Strengths: Tri modal prehabilitation programme (nutrition, exercise and psychology). Use of validated tools for assessment of nutrition, exercise and psychological wellbeing Limitations: Significant difference in the number of patients between both arms | ||
Malnourished lung cancer patients have poor baseline functional capacity but show greatest improvements with multimodal prehabilitation 2021 [56] | Canada | To characterise the presence of malnutrition, examine the association between malnutrition and baseline functional capacity and the extent to which patients benefit from preoperative multimodal prehabilitation | N = 162 (number in the prehabilitation group vs control not specified) lung cancer patients undergoing lung cancer resection | Retrospective study | High nutrition risk patients had significantly lower baseline functional capacity compared with those who were low risk (p = 0.022), but experienced significant improvements in preoperative functional capacity upon receiving multimodal prehabilitation (p = 0.01) | Strengths: One of the first prehabilitation studies to look at the association between patients categorised as being high nutritional risk and functional capacity Limitations: High proportion of missing data (30%). Change in nutritional status was not measured, as the assessment tool was not repeated at follow up visits. Study was not powered | ||
Feasibility and outcomes of a real-world regional lung cancer prehabilitation programme in the UK 2022 [57] | United Kingdom | To evaluate the feasibility, uptake and outcomes of the Prehab 4 Cancer service delivery model during the 11 months before COVID-19 restrictions | N = 377 lung cancer patients with a treatment recommendation of surgical resection | Feasibility study | The programme was feasible at scale with high uptake and had a positive impact on preoperative physiological and subjective functional assessments, providing a framework for wider implementation | Strengths: Multi- disciplinary team approach. Triage based on the principles of NHS England’s personalised care model Limitations: Risk of selection bias owing to no control group. Incomplete end of prehabilitation assessment data. Only 120 patients completed the programme; 1 in 5 opted not to participate in the programme and the reasons for this are poorly understood | ||
Feasibility of setting up a pre-operative optimisation ‘prehab’ service for lung cancer surgery in the UK 2020 [58] | United Kingdom | To assess the feasibility of setting up a prehabilitation service for lung cancer surgery | N = 50 lung cancer patients due to undergo surgery | Feasibility study | A lung cancer prehabilitation programme is feasible and safe as demonstrated by a statistically significant improvement in forced expiratory volume (p = 0.0045), 6MWT (p = < 0.0001), sit to stand (p = 0.0011) and QOL (p = 0.0213) scores from baseline to post prehabilitation intervention and no adverse events | Strengths: Use of the Orsmond and Cohn framework for feasibility studies to assess feasibility | ||
A feasibility study of an unsupervised, pre-operative exercise program for adults with lung cancer 2020 [59] | United States of America | To explore the feasibility, acceptability and perceived utility of the provision of a wearable fitness device and an exercise prescription from a surgeon | N = 30 patients with stage I, II or III lung cancer scheduled for surgery | Feasibility study | A wearable fitness device and exercise prescription is feasible and acceptable as evidenced by 79% completing the pre-operative study activities. 71% successfully synchronised their device during the pre-operative period. Data was transmitted from the device to the study team for an average of 70% of pre-operative days | Strengths: High engagement with the device and study assessments Limitations: Some patients voiced confusion as to how to use the device, which could limit future trials with older populations. Questions surrounding the generalisability of findings as patients who were willing to enrol on the programme may be more active than an average lung cancer patient. Patients who did not speak English were excluded | ||
Pre-radiotherapy daily exercise training in non-small cell lung cancer: A feasibility study 2019 [60] | Denmark | To examine the feasibility of an individual, supervised, structured moderate-to-high intensity cycle ergometer exercise training immediately before radiotherapy | N = 15 patients with locally advance NSCLC | Feasibility study | Feasible and safe as demonstrated by 90% attendance to exercise, 88% adherence to full exercise participation and no adverse events | Strengths: First study to test whether daily individualised structured exercise is feasible and safe in patients with advance NSCLC. Ease of access for patient participation Limitations: Small sample size. Selection bias – motivated group | ||
Patients’ and healthcare professionals’ views on a pre-and post-operative rehabilitation programme (SOLACE) for lung cancer: A qualitative study 2021 [61] | United Kingdom | To explore patients and healthcare professionals views and experiences of a pre-and post-operative rehabilitation intervention | N = 25 (17 patients who had early-stage lung cancer and had surgery + 8 healthcare professionals who work with lung cancer patients in pre and post-surgical care) | Qualitative study | The SOLACE service was positively perceived by patients and healthcare professionals. Patients valued the provision of tailored support/advice and peer support and reported benefits to their health and well-being Barriers to patient uptake of the classes included time constraints, motivation and access for patients who lived at a distance Virtual support may address equality of access to service for those who live at a distance from the hospital | Strengths: Provided an understanding of the value of a pre and post rehabilitation programme. The semi-structured interviews shed light on what was acceptable as well as the barriers to participation Limitations: Views of patients who did not participate in the exercise classes were not represented in the interviews. Individuals who did participate in the exercise programme were more likely to be highly motivated to participate. Not an ethnically diverse group, therefore generalisability of the findings is limited. Equality of access to the service for those who live a distance away from the hospital | ||
Attitudes and perceptions to prehabilitation in lung cancer 2020 [62] | Australia | To determine the acceptability and perceived benefit of prehabilitation in lung cancer among thoracic surgeons | N = 28 thoracic surgeons | Online cross-sectional survey | 91% were willing to delay surgery to optimise patients via prehabilitation The main barriers to prehabilitation were patient comorbidities and access to allied health professionals 92% believe that further research into prehabilitation in lung cancer is warranted | Strengths: One of the first studies to look at the attitudes and perceptions of prehabilitation amongst thoracic surgeons Limitations: Response rate was only 14% | ||
Potential effectiveness of a surgeon-delivered exercise prescription and an activity tracker on pre-operative exercise adherence and aerobic capacity of lung cancer patients 2021 [63] | United States of America | To determine the level of Moderate-Vigorous Physical Activity (MVPA) and change in aerobic capacity after participation in a home-based pre-operative exercise intervention | N = 18 patients with stage I-III lung cancer due to undergo surgery | Proof of concept study | Mean MVPA per day: 20.4 min during the pre-operative period. On average, patients met the goal of 30 min of MVPA on 16.4% of the days during the pre-operative period No statistical significant difference found in the 6MWT between baseline and post MVPA (p = 0.14). 47% demonstrated a clinically significant improvement of 14 m or more, highlighting that a surgeon-delivered exercise prescription plus an activity tracker may promote clinically significant improvement in aerobic capacity and MVPA engagement | Strengths: One of the first studies to look at the level of adherence when exercise is enthusiastically prescribed by a surgeon and objectively measured Limitations: Patients who did not have access to the internet were excluded. An objective measure of pre-intervention MVPA to compare MVPA levels during the intervention was not obtained. The Garmin Vivoactive heart rate device used had not been validated for MVPA assessment among the general population or among pre-operative cancer patient populations | ||
Prehabilitation in thoracic cancer surgery: From research to standard of care 2021 [64] | Canada | To determine whether personalised, stepped prehabilitation care is a feasible, safe, and effective implementation strategy | N = 81 (45 in the intervention arm and 36 in the control arm) lung cancer patients due to undergo lung cancer surgery | Quality Improvement Project | A personalised, stepped prehabilitation program targeting high-risk patients undergoing elective lung cancer surgery is feasible, safe, and effective as evidenced by a statistically significant improvement in 6MWD (p = 0.001), oxygen uptake (p = 0.004) and hospital length of stay (p = 0.101) after prehabilitation. There were no significant differences in the number of complications and there were no adverse events | Strengths: Tri-modal (nutrition, exercise and psychological wellbeing) prehabilitation approach Limitations: Selection bias - only patients who lived in the metropolitan area and had an expected waiting time of about four-to-five weeks before surgery were referred. Limited external validity as no predefined and universal outcome variables used or consistent time points. The intervention and control groups were not balanced |
Study | What | Who provided | How | Where | When and how much | Tailoring | How well (actual/planned) | ||||||||||||
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Components | Description | ||||||||||||||||||
Prehabilitation sessions can be provided more frequently in a shortened regimen with similar or better efficacy in people with non-small cell lung cancer: A randomised trial (Randomised controlled trial) [34] | • Exercise • Wellbeing Not based on a model or theory, but on the findings of a previous study which found that patients who completed ≥ 15 sessions showed more improvement in cardiorespiratory measures after the prehabilitation program than those who performed fewer sessions | Exercise: Consists of aerobic endurance training on a cycle ergometer, peripheral muscle strengthening and inspiratory muscle strengthening Wellbeing: Smoking cessation support and education on mucus clearance techniques, deep-breathing, directed and protected coughing, and postoperative mobilisation | Physiotherapist | Exercise: One to one and group sessions Wellbeing: Support and education was delivered during the first individual session and reminders and advice were provided during the following group sessions | Information not provided | Intervention arm: 5 × 90-min sessions per week for 3 weeks Control arm: 3 × 90-min sessions per week for 5 weeks | Load / intensity / resistance increased according to individual tolerance | Mean estimates of VO2peak and VE/VCO2 slope favoured the dense prehabilitation regimen and the confidence intervals indicated that the effects are as good as or better than the control regimen. However, this was not associated with a reduction in postoperative complications in this study | |||||||||||
Multimodal prehabilitation for lung cancer surgery: A randomised controlled trial (Randomised controlled trial) [35] | • Exercise • Nutrition • Wellbeing Not based on a model or theory, but research that although exercise training has been shown to significantly improve physical function, lung cancer patients are at nutritional risk due to a reduced food intake and often experience psychological stress which could lead to a delayed recovery and mortality | Exercise: Moderate-vigorous intensity aerobic training and resistance training Nutrition: Patients screened using validated tools, advised to aim for 1.5 g/kg/d of protein and prescribed whey protein supplements if required Wellbeing: Relaxation exercises based on imagery, visualisation and deep breathing to help reduce anxiety | Exercise: Certified kinesiologist Nutrition: Registered dietitian Wellbeing: Psychology trained personnel | Exercise: Personalised exercise prescription Nutrition: All patients screened using the Patient Generated Subjective Global Assessment (PG-SGA) and the Nutritional Risk Screening tool. Daily protein calculated at 1.5 g/kg ideal body weight Wellbeing: A compact disc with relaxation exercises provided | Home-based unsupervised programme | Immediately after baseline assessment (approximately 4 weeks prior to surgery) and up to 8 weeks after surgery Exercise: 30 min of moderate-vigorous intensity aerobic training 3 days a week + resistance training (8–12 repetitions) and stretching exercises 3 days a week Nutrition: 1.5 g/kg ideal body weight of protein per day + protein supplements within 1 hour of exercise Wellbeing: 2–3 times a week | Exercise: Tailored to a patient’s preferred type of exercise and fitness level Nutrition: Advice given based on a 3 day food diary completed at the time of enrolment Wellbeing: Information not provided | No difference in the trajectory of functional capacity post-surgery No difference in median hospital length of stay, but 42% versus 16% were discharged post-operatively by day two. No discussion on the influence of nutritional optimisation and anxiety reducing strategies | |||||||||||
Feasibility of a novel mixed-nutrient supplement in a multimodal prehabilitation intervention for lung cancer patients awaiting surgery: A randomised controlled pilot trial (Randomised controlled trial) [36] | • Exercise • Nutrition • Wellbeing Not based on a model or theory, but the hypothesis that during the preoperative period the novel multimodal prehabilitation intervention would be feasible and improve preoperative functional capacity compared to standard hospital care | Exercise: Consisted of supervised and unsupervised moderate aerobic exercise and resistance exercise Nutrition: Individualised dietary assessment to meet protein intake of > 1.2 g/kg/d and energy of 25–30 kcal/kg/d + a whey protein isolate supplement with leucine + a daily fish oil supplement with vitamin D Wellbeing: Relaxation exercises based on imagery, visualisation and deep breathing | Exercise: Kinesiologist Nutrition: Dietitian Wellbeing: Psychology trained personnel | Exercise: Personalised exercise prescription Nutrition: One to one dietary assessment based on intake, anthropometry, nutrition-impact symptoms, biochemistry and a nutrition-focused physical exam Wellbeing: One to one sessions and patients were given a compact disc with relaxation exercises to be performed at home. Adherence was assessed based on responses in a patient information booklet | Hospital based combined with unsupervised sessions at home | 4 weeks prior to surgery: Supervised exercise: 1 h / week of aerobic exercise + resistance exercises: 1–2 sets of 8–15 repetitions for 30 min Unsupervised exercise: 30 min of moderate aerobic exercise + resistance exercises every second day Nutrition: Whey protein supplementation twice a day Wellbeing: 2–3 times a week | The exercise program was individualised based upon initial assessments. Dietary advice was individualised | High adherence rates to suggest feasibility for the exercise and nutritional component, but no data on the psychological component Recruitment rate was 58.6% No improvement observed in preoperative functional capacity | |||||||||||
Preoperative exercise to improve fitness in patients undergoing complex surgery for cancer of the lung or oesophagus (PREHIIT): Protocol for a randomised controlled trial (Randomised controlled trial protocol) [37] | • Exercise • Nutrition Not based on a model or theory, but based on preliminary evidence that 12–15 sessions of HIIT significantly improves cardio-pulmonary fitness in low-fit older adults undergoing lobectomy and hepatic resection, however further evaluation in larger cohorts and in those with highest postoperative risk is required | Exercise: Supervised HIIT programme Nutrition: Tailored dietetic assessment to ensure nutritional adequacy is maintained throughout the intervention | Exercise: Physiotherapist Nutrition: Dietitian | Exercise: One to one supervised sessions on a cycle ergometer at a time convenient to the patient Nutrition: Ensuring an adequate dietary energy (25-30 kcals/kg/day) and protein intake (1.25–1.5 g/kg/day) | Hospital based | Exercise: At least 2 weeks up to 5 days a week with each session lasting 40 min Nutrition: Information not provided | Exercise and dietary intervention will be tailored to the individual | The following will be measured at diagnosis, baseline and post intervention prior to surgery: cardio-pulmonary fitness (CPET), pulmonary and physical performance (maximal inspiratory pressure, peripheral muscle strength, short physical performance battery, International Physical Activity Questionnaire) and QOL (EORTC). The following will be measured at post-operative recovery: post-operative morbidity index, post-operative morbidity (Clavien-Dindo classification), complex complications index, mortality, length of stay, self-reported functional recovery at 30 days and QOL (EORTC, EQ5DL). A sub cohort of patients will take part in a semi-structured interview to feedback on how the study has impacted their preparation for surgery. Economic evaluation will also be undertaken. Discharge destination, use of community health services and EQ5D5L scores will be collected to assess if the intervention has longer term effects beyond discharge | |||||||||||
Effects of an exercise intervention for patients with advanced inoperable lung cancer undergoing chemotherapy: A randomised clinical trial (Randomised controlled trial) [38] | • Exercise No model or theory base reported | Physical training and relaxation comprising of strength training, aerobic training and stretching | A clinical nurse specialist or physiotherapist screened all patients prior to participation. A research physiotherapist delivered the exercise training | Supervised group training consisting of stationary cycling and strength training | Information not provided | 2 × a week for 1.5 h over 12 weeks | The exercise sessions were tailored to the patient’s fitness level | Attrition rate was 37% due to death (n = 12), refusal to participate (n = 22), disease progression (n = 20), and absence from test (n = 27). All patients were undergoing concurrent systemic treatment and 67% received radiotherapy. No significant difference seen in the primary outcome; peak V02 | |||||||||||
Cost-effectiveness of a technology supported multimodal prehabilitation program in moderate-to-high risk patients undergoing lung cancer resection: Randomised controlled trial protocol (Randomised controlled trial) [39] | • Exercise • Nutrition • Wellbeing Not based on a model or theory, but the hypothesis that surgical lung cancer patients are likely to benefit from prehabilitation as they usually have a significant reduction in functional capacity from multifactorial origin | Intervention arm: Exercise: High-intensity endurance exercise, strength training and a personalised pedometer based program. Nutrition: Individualised dietary counselling to meet 1.5–2 g/kg/d of protein + a whey protein powder or casein supplement Wellbeing: Smoking cessation and cognitive behavioural therapy Control arm: patients will receive advice on physical activity, smoking cessation and alcohol intake. If deemed at risk of malnutrition, patients will receive nutritional intervention | Exercise: Physiotherapist Nutrition: Dietitian Wellbeing: Clinical health psychologist | Exercise: One to one on a cycle ergometer and use of a physical activity tracker linked to a mobile app Nutrition: Personalised dietary counselling with educational material and follow-up surveys in the mobile app Wellbeing: Group sessions and audio guides for coping strategies and exercises in the mobile app | Community based and via a mobile app | Prior to surgery. Duration not specified Exercise: 3 × week Nutrition: Information not provided Wellbeing: 1 × week | Exercise: Endurance training will be tailored to the individual according to symptoms (using the modified Borg scale) and the strength training will be adapted to an individual’s tolerance Nutrition: Individualised dietary assessment Wellbeing: Information not provided | Study outcomes to follow a quadruple aim approach. (1) Patient experience (Person Centred Coordinated Experience Questionnaire, Nijmegen Continuity Questionnaire and focus groups and structured interviews to identify facilitators and barriers to prehabilitation) (2) Population health-related outcomes (Length of stay, postoperative complications, readmissions, physical activity, wellbeing and nutrition markers) (3) Healthcare costs (4) Healthcare professionals’ perspective (Advancing Care coordination and Telehealth deployment at Scale questionnaire, focus groups and structured interviews) | |||||||||||
Preoperative respiratory muscle endurance training improves ventilatory capacity and prevents pulmonary postoperative complications after lung surgery (Randomised controlled trial) [40] | • Exercise Not based on a model or theory, but based previous RCTs which have showed significant improvements in respiratory muscle endurance and exercise capacity in patients with Chronic Obstructive Pulmonary Disease (COPD) patients following RMET | RMET, consisting of isocapnic hyperpnoea and usual pre-operative chest therapy | A physical therapist | Using a Spirotiger® device. The RMET was supervised once a week by the same physical therapist | Hospital and home based | Pre-operatively. Patients receive 12 sessions of RMET over three weeks and are asked to complete a 30-min training session daily. RMET is performed on 2 consecutive days and rested for 1 day | RMET was tailored to each patient via use of the Spirotiger® device | 86% adherence to the training programme. Minute ventilation and endurance time increased significantly after RMET. The number of post-operative complications was significantly lower in those who received RMET | |||||||||||
Impact of one-week preoperative physical training on clinical outcomes of surgical lung cancer patients with limited lung function: A randomised trial (Randomised controlled trial) [41] | • Exercise No model or theory base reported | Consisted of physical training including breathing exercises and aerobic exercise | Nurse specialists and physical therapists | Breathing exercises: Using a volumetric incentive spirometer Aerobic exercise: Using a Nu-Step instrument | Information not provided | The intervention was provided over 1 week. Breathing exercises: 3 × day and aerobic exercise: 30 min a day | Information not provided | Significant difference in the distance covered in the 6MWT in the intervention arm compared to the control group, indicating that short-term high-intensity training regimen could improve cardiopulmonary endurance. No significant difference in lung function or quality of life (except for emotional function) between the two groups, suggesting that intense training before surgery is only effective on mental health | |||||||||||
Pre-operative high intensity interval training is effective and safe in deconditioned patients with lung cancer: A randomised clinical trial (Randomised clinical trial) [42] | • Exercise Not based on a model or theory, but research that HIIT has shown to be feasible and safe in deconditioned patients with chronic heart disease and this could be replicated in patients awaiting primary lung resection surgery for NSCLC | HIIT exercise program | Respiratory physiotherapists | Supervised group sessions using a cycle ergometer | Information not provided | 3 weeks prior to surgery; 30 min 1–3 times a week | If patients were unable to complete sessions at 100% power, the power was lowered according to the patients capacity to obtain a dyspnoea and leg fatigue of at least 5 on the Borg scale. Power was increased again if dyspnoea or the sense of effort decreased below 5. Work rate was adjusted each session as Borg ratings and heart rate evolved | Median duration between clinical decision and surgery was 25 days, which allowed a median of 8 high-intensity interval training sessions to be performed over 3 weeks. Adherence was 87%. Although 30% had COPD the training was well tolerated, indicating the possibility of its regular application in pulmonary rehabilitation programmes | |||||||||||
Two week multimodal prehabilitation program improves perioperative functional capability in patients undergoing thoracoscopic lobectomy for lung cancer: A randomised controlled trial (Randomised controlled trial) [43] | • Exercise • Nutrition • Wellbeing No model or theory base reported | Exercise: Moderate intensity aerobic training, resistance exercises and respiratory training Nutrition: Nutritional counselling with whey protein supplementation Wellbeing: Mental relaxation including imagery and visualisation with relaxing music | Exercise: A doctor of physical therapy undertook all baseline assessments Nutrition: Information not provided Wellbeing: Information not provided | Exercise: Intensity based on the rate of perceived exertion (Borg scale) and target heart rate and set to achieve moderate training. Patients given an elastic resistance band to match their fitness level Nutrition: 3 day total food recall questionnaire Patients advised to change unhealthy eating habits, avoid high-calorie and high fat diets, eat more vegetables and fruits and high-quality proteins. Whey protein powder given to patients to take within one hour after exercise to achieve an intake of 1.5 g/kg/d of protein Wellbeing: A music player with relaxing music was provided | Home based | Immediately after baseline visit (2 weeks before surgery) Exercise: Aerobic exercise; 30 min 3 × week + resistance exercises 2 × week Wellbeing: Daily prior to sleeping | Exercise: Tailored to patients fitness level Nutrition: Advice given based on a 3-day total food recall questionnaire Wellbeing: Information not provided | Improvement in 6MWD, but no differences in lung function, disability, psychological assessment, length of stay, short-term recovery quality, postoperative complications, and mortality | |||||||||||
Precision-Exercise-Prescription in patients with lung cancer undergoing surgery: Rationale and design of the PEP study trial (Randomised controlled trial protocol) [44] | • Exercise • Wellbeing The wellbeing component is based on motivational interviewing and the social cognitive theory | Intervention arm: Exercise: Consists of 5 stages: (1) Basic transfer mobility exercise (low-moderate intensity), (2) callisthenic mobility exercise (moderate-high intensity), (3) aerobic and resistance exercise (low-moderate intensity), (4) aerobic and resistance exercise (moderate intensity), (5) aerobic and resistance exercise (high intensity) Wellbeing: Motivational and problem solving telephone calls Control arm: Patients will be encouraged to increase walking both in the pre surgery and post-surgery period as part of usual clinical care, but there will be no formalised exercise programme | A physical therapist | Exercise: Instructional exercise sheets will be given to patients demonstrating exercise modes and intensity. Patients will be given access to light weights and resistance bands, an exercise diary and an activity tracker Wellbeing: Motivational interviewing techniques, identification of barriers to exercising and problem-solving solutions, goal setting and self-monitoring | Either at home, the wellness centre or a recreational centre | Pre-surgery up to 6 months post-surgery. Exercise: Stages 1 and 2: Low intensity = 30 s-1 min 2 × day. Moderate intensity = 1–13 min 2 × day. High intensity = 1.5–2 min 4 × day Stages 3, 4 and 5: Low intensity = 10 min of aerobic exercise + 5 min of resistance exercise. Moderate intensity = 20 min of aerobic exercise + 10 min of resistance exercise. High intensity = 30 min of aerobic exercise + 15 min of resistance exercise Wellbeing: Weekly | Exercise: Based on an individual’s Activity Measure for Post Acute Care (AM-PAC) outpatient basic mobility score. It can be adjusted depending on a patients level of fatigue, muscle weakness, pain and/or shortness of breath Wellbeing: Based on motivation and self-efficacy to engage in exercise | The following will be measured at baseline, on discharge, 2 months post-surgery and at 6 months post-surgery: AM-PAC mobility score, physical function (6MWD), strength, endurance and balance (short physical performance battery), patient-reported outcomes (functional assessment of cancer therapy-lung and chronic illness therapy-fatigue, Pittsburgh sleep quality index, physical activity, nutrition and wellbeing markers, subjective social status ladders, symptoms, living condition), exercise diary, length of stay, complications, healthcare costs and smoking assessment (saliva) | |||||||||||
A comparison of the effects of medical Qigong and standard exercise therapy on symptoms and quality of life in patients with advanced cancer (Randomised cross over study) [45] | • Exercise No model or theory base reported | Medical Qigong consisted of “Walking Qigong”. A walking exercise programme involving coordinated arm movements while in a state of deep relaxation or meditation. Patients were advised to refrain from independent resistance or cardiovascular training during this period Standard exercise therapy: Consisted of cardiovascular and resistance training exercises. No details provided re: type of exercises. Patients were also advised to walk daily and to refrain from practising Qigong | A physiotherapist. Patients were also evaluated by a second physiotherapist (not involved in training and blinded to group assignment) at three time points: baseline 0–2 weeks before starting the training periods, up to 2 weeks after completing the first arm of the study and up to 2 weeks after completing the second arm | Medical Qigong and standard exercise therapy were delivered over a 6-week period. Patients stopped for a minimum of 2 weeks and then attended for a further 6 weeks to receive the other type of intervention Medical Qigong was delivered as group sessions whereas standard exercise therapy was delivered either individually or as a group Patients kept logbooks of physical activities performed at home during both 6-week training periods | At the local hospital and at home | Over a 6 week period. Medical Qigong: 12 × 45 min face to face sessions + 1 h a day at home Standard exercise therapy: Tailored to the individual + one hour of walking daily | Tailored to a patient’s individual training intensity | 51 patients consented. 36 (71%) completed baseline assessment, 24 (47%) completed the first assessment after the first exercise intervention, but only 19 (37%) completed both exercise interventions and all assessments In all cases, the beneficial effects of the exercise interventions were markedly reduced during the second interval. The order in which the interventions were performed had a significant impact on the improvement in certain symptoms | |||||||||||
Impact of physical activity on fatigue and quality of life in people with advanced lung cancer: A randomised controlled trial (Randomised controlled trial) [46] | • Exercise • Wellbeing Based on the theory of planned behaviour | Intervention arm: A physical activity and behavioural support programme incorporating aerobic physical activity, advice about resistance exercises and behavioural support sessions. Control arm: Patients received cancer-specific education materials regarding nutrition and exercise | A physical activity consultant | Exercise: One to one supervised sessions + unsupervised home physical activity sessions The behaviour support sessions use behaviour lifestyle change principles. Patients were also given a physical activity and behaviour change guidebook to use throughout the intervention | Information not provided | For 2 months Exercise: Weekly; 30–45 min Wellbeing: Weekly; 15–30 min behaviour support sessions | Exercise: Tailored to the patient’s baseline fitness, performance status and physical activity preferences Wellbeing: Information not provided | Both groups reported more baseline physical activity than anticipated and symptoms and physical function did not deteriorate greatly over time No significant differences between the two groups in terms of fatigue or QOL. Intervention adherence was good, with 69% completing all physical activity and 75% all behavioural change sessions. Attrition occurred in both groups, mainly due to disease progression | |||||||||||
Preoperative exercise training prevents functional decline after lung resection surgery: A randomised, single-blind controlled trial (Randomised controlled trial) [47] | • Exercise No model or theory base reported | Preoperative exercise training consisted of a combination of moderate endurance and resistance training. Patients were also asked to perform breathing exercises | Physiotherapist | Endurance training: On a cycle ergometer At the beginning and end of the training, dyspnoea and leg fatigue were logged using the modified version of the Borg Scale Resistance training: Using elastic bands and body weight exercises Breathing exercises: Using a volume-oriented incentive spirometer | Hospital based | 3–5 times a week depending on the surgical date | Endurance training load was determined after a symptom-limited incremental cycle test Resistance training load was determined using a 25-maximum repetition test | Out of the 40 patients who were randomised, only 22 (55%) completed at least one postoperative evaluation and were analysed. In the prehabilitation group, mean time from baseline assessment to surgery was 54.5 days with a median of 16 sessions. Patients in the prehabilitation group were able to maintain and/or increase their baseline values in all the parameters examined, whereas in the control group there was a progressive decline throughout follow-up, especially in exercise capacity | |||||||||||
Short-term preoperative exercise therapy does not improve long-term outcome after lung cancer surgery: A randomised controlled study (Randomised controlled trial) [48] | • Exercise No model or theory base reported | HITT training program. Patients in both the intervention arm and the control group were given advice regarding active mobilisation and risk factor management (e.g., healthy nutrition and smoking and alcohol cessation) | Physiotherapist | Using a cycle ergometer | Hospital based | Pre-operatively 3 × week | The work rate was adjusted on each session according to an individual’s maximal heart rate | Short-term preoperative rehabilitation with HIIT did not improve pulmonary function and aerobic capacity measured at 1 year after lung cancer resection | |||||||||||
Short-term Preoperative High-Intensity Interval Training in patients awaiting lung cancer surgery: A randomised controlled trial (Randomised controlled trial) [49] | • Exercise No model or theory base reported | HITT training program. Patients in both the intervention arm and the control group were given advice regarding active mobilisation and risk factor management (e.g., healthy nutrition and smoking and alcohol cessation) | Physiotherapist | Using a cycle ergometer | Hospital based in an outpatient clinic | Pre-operatively 3 × week | The work rate was adjusted on each session according to an individual’s maximal heart rate | A HIIT programme helps prepare patients before lung cancer resection by enhancing their physical fitness. However, the HIIT programme did not improve postoperative clinical outcomes | |||||||||||
Is preoperative protein-rich nutrition effective on postoperative outcome in non-small cell lung cancer surgery? A prospective randomised study (A prospective randomised study) [50] | • Nutrition No model or theory base reported | Patients were given an immune modulating formulae (enriched with arginine, omega-3 fatty acids and nucleotides) for 10 days | Information not provided | Information not provided | Information not provided | Information not provided | Information not provided | Statistically significant difference in complication rates, mean tube drainage times and in drop in albumin levels in the intervention arm compared to the control group | |||||||||||
Effect of prehabilitation on ventilatory efficiency in non–small cell lung cancer patients: A cohort study (Cohort study) [51] | • Exercise Not based on a model or theory, but based on research that pulmonary prehabilitation improves postoperative risk factors and ventilatory inefficiency > 35 is a high risk factor for postoperative complications | Endurance training, peripheral and inspiratory muscle strengthening | Information not provided | Endurance training: Via a cycle ergometer or a treadmill. Peripheral muscle strengthening: Information not provided. Inspiratory muscle strengthening: Using a threshold valve Patients were also taught bronchial drainage techniques and directed coughing | In an ambulatory setting | Prior to surgery. Endurance training and peripheral muscle strengthening: 90 min 3–5 × week. Inspiratory muscle strengthening: 15 min daily | Load / intensity / resistance increased according to individual tolerance | Prehabilitation did not change ventilatory efficiency. 15 or more sessions of prehabilitation seems to be a rational threshold to improve other CPET outcomes, while remaining applicable in clinical practice | |||||||||||
Impact of prehabilitation on morbidity and mortality after pulmonary lobectomy by minimally invasive surgery: A cohort study (Cohort study) [52] | • Exercise No model or theory base reported | Endurance exercise, muscular strengthening and inspiratory muscle strengthening | Two physiotherapists | Endurance exercise and muscle strengthening was performed on a cycle ergometer Inspiratory muscle strengthening was performed using a resistive valve | Hospital based | Pre-operatively: 90 min 3–5 × week | Endurance exercise was tailored to an individual’s ventilator threshold | Although significant differences were observed in the prehabilitation group in terms of a reduction in post-operative complications and Clavien-Dindo classification, no significant differences were seen in length of stay and severity of complications between groups | |||||||||||
Application and practice of trimodal prehabilitation model in preoperative management of patients with lung cancer undergoing video-assisted thoracoscopic surgery (Prospective study) [53] | • Exercise • Nutrition • Wellbeing No model or theory base reported | Exercise: Aerobic exercise and stair-climbing training. Deep breathing training and abdominal breathing exercise. Nutrition: Whey protein supplement drink 1 h after exercise Wellbeing: Relaxation training | Nursing staff Dietitian | Exercise: Information not provided Nutrition: Using the Nutrition Risk Screening tool. Wellbeing: Using a professional scale to evaluate psychological state and via relaxation training | Information not provided | Exercise: Aerobic exercise: 30 min 2 × day. Stair climbing: 2 × day Deep breathing training and abdominal breathing exercise: 10–15 min 3 × day. When the perceived fatigue was heavy, the exercise intensity was reduced Nutrition: Information not provided Wellbeing: 20 min daily The intervention ended after the first week of the operation | Nutritional input was tailored to the individual based on the Nutrition Risk Screening tool No information provided for exercise and wellbeing | The application of a trimodal prehabilitation model for the preoperative management of patients with lung cancer undergoing video-assisted thoracoscopic surgery is conducive to improving the functional state and psychological state, preventing complications and improving nursing satisfaction | |||||||||||
Pre-treatment optimisation with pulmonary rehabilitation in lung cancer: Making the inoperable patients operable (Prospective observational study) [54] | • Exercise Not based on a model or theory, but on the hypothesis that older patients may have frailty and smoking related cardiopulmonary disease with reduced pulmonary function, which could impair post-operative ventilatory function predisposing them to dyspnoea, cardiopulmonary complications and death. Patients with significant dyspnoea, poor performance status or poor pulmonary function are considered in-operable | Comprised of four main elements (1) Respiratory muscle training and breathing exercises (2) Cardiovascular exercises (3) Education—Health education and smoking cessation advice (4) Pharmacology agents—Where necessary bronchodilator therapy was provided | Trained cardiothoracic physiotherapists | Information not provided | At the prehabilitation centre or outreach unit and home based | Over 2–4 weeks. 70 min face to face sessions with cardiovascular exercises 2 × week + home based respiratory muscle training and breathing exercises 3 × day | Individual training zones were calculated for the cardio-vascular exercises. Exercise intensity was based on the rate of perceived exertion (Borg scale) and target heart rate | Following optimisation with prehabilitation, 84.2% of the high-risk patients were ready to proceed with radical treatment. 42.8% of patients underwent surgery No significant differences in post-operative complications, length of hospital stay or mortality between the low and high risk groups | |||||||||||
Neoadjuvant prehabilitation therapy for locally advanced non–small-cell lung cancer: Optimising outcomes throughout the trajectory of care (Retrospective study) [55] | • Exercise • Nutrition • Wellbeing No model or theory base reported | Exercise: Moderate-vigorous intensity aerobic training and resistance training Nutrition: Patients screened using validated tools, advised to aim for 1.5 g/kg/d of protein and prescribed whey protein supplements if required Wellbeing: Relaxation exercises based on imagery, visualisation and deep breathing to help reduce anxiety | Exercise: Certified kinesiologist Nutrition: Dietitian Wellbeing: Psychology trained personnel | Exercise: According to a patient’s preferred type of aerobic training Nutrition: All patients screened using the PG-SGA and the Nutritional Risk Screening tool. Daily protein calculated at 1.5 g/kg ideal body weight Wellbeing: A compact disc with relaxation exercises provided | Home-based unsupervised programme | Immediately after baseline assessment (approximately four weeks prior to surgery) and up to eight weeks after surgery. Exercise: 30 min 3 × week + resistance training 3 × week Nutrition: 1.5 g/kg ideal body weight of protein per day + protein supplements within 1 h of exercise Wellbeing: 2–3 × week | Exercise: Tailored to a patient’s preferred type of exercise and fitness level Nutrition: Advice given based on a 3 day food diary completed at the time of enrolment Wellbeing: Information not provided | The prehabilitation programme was individualised and home-based, which allowed patients to complete the programme at home at any convenient time, simplifying the already demanding schedule of a patient undergoing neoadjuvant therapy. Only 1 patient dropped out after initiation of the prehabilitation programme, demonstrating good feasibility | |||||||||||
Malnourished lung cancer patients have poor baseline functional capacity but show greatest improvements with multimodal prehabilitation (Retrospective study) [56] | • Exercise • Nutrition • Wellbeing No model or theory base reported | Exercise: The home-based training included moderate intensity aerobic training, resistance exercises and flexibility exercises Nutrition: Individualised plan to meet each patients nutritional needs + whey protein supplementation to achieve a total protein intake of 1.2–1.5 g/kg/d Wellbeing: Patients given techniques aimed at reducing anxiety, such as relaxation exercises based on imagery, visualisation and deep-breathing exercises | Exercise: Kinesiologist Nutrition: Dietitian Wellbeing: Psychology trained personnel | Exercise: Patients provided with an information booklet with instructions and figures on all elements of the program and exercise progressions. The booklet also included a journal to record all activities related to the program. Nutrition: A comprehensive dietary assessment based on a 3-day food diary, anthropometry, nutrition impact symptoms, biochemistry and a nutrition focused physical exam. Instructions included eating well-balanced meals with a focus on protein intake. Wellbeing: One to one sessions and a compact disc with relaxation exercises for home | Hospital based combined with unsupervised exercise sessions at home | 4 weeks prior to surgery. Exercise: 30 min 5 × week Nutrition: Information not provided Wellbeing: 2–3 × week | Exercise: Individualised based upon initial assessments Nutrition: Individualised dietary advice Wellbeing: Tailored according to a patients needs | Patients classified with moderate or high nutrition risk (according to the PG-SGA) exhibited significantly lower physical performance at baseline, including functional capacity, timed get up and go, grip strength and self-reported physical activity levels compared with low-nutrition-risk patients. High nutrition risk patients have the most to gain (functionally) from multimodal prehabilitation compared with low nutrition risk patients | |||||||||||
Feasibility and outcomes of a real-world regional lung cancer prehabilitation programme in the UK (Feasibility study) [57] | • Exercise • Nutrition • Wellbeing Based on the principles of NHS England’s Personalised Care model | Exercise: All patients triaged into ‘universal’ or ‘targeted’ pathways. For the universal pathway, patients could exercise independently with weekly monitoring with an exercise specialist. Exercise prescriptions included high-intensity interval training and resistance training Nutrition and wellbeing: Assessed at baseline and at intervals throughout the programme. A three-tier risk assessment (low, medium and high) was used to identify those in need of nutritional or wellbeing support and each category received simple interventions or onward referral when required | Exercise specialists (level four cancer rehabilitation qualified exercise practitioners) were responsible for screening patients and delivering all components of the intervention | Patients initially contacted by telephone to organise a face-to-face appointment at a first assessment clinic. Baseline assessments took place face-to-face and an individualised programme was prescribed | Patients could complete their individualised programme at any one of the 87 local leisure centres | Exercise prescriptions for the targeted pathway included 3 supervised group gym sessions x No information is provided on the length of the prehabilitation period. Baseline functional and QOL assessments were repeated immediately before the date of surgery After treatment, a 12 week postoperative rehabilitation programme was provided | Individualised prehabilitation programme prescription for all tri modal components | Of the 377 patients referred, overall participation on an intention to treat basis was 47.7%. Median interval from assessment to surgery was 36 days. There were no adverse events. Statistically significant improvements in the Incremental Shuttle Walk Test (ISWT), 6MWT, 60 min sit to stand test (STS), Hand Grip Dynamometry (HGD), World Health Organisation Disability Assessment Scheduled (WHODAS), Self-Efficacy for Exercise (SEE), International Physical Activity Questionnaire (IPAQ), and the European Quality of Life Five Dimensions (EQ-5D) scores | |||||||||||
Feasibility of setting up a pre-operative optimisation ‘prehab’ service for lung cancer surgery in the UK (Feasibility study) [58] | • Exercise Not based on a model or theory, but based on the hypothesis that respiratory function could be improved by optimising treatment for comorbidities, potentially tipping the balance between a patient being deemed not fit enough for surgery and being considered a surgical candidate | The prehabilitation programme was based around the mainstays of COPD management: optimising inhaled therapy, smoking cessation and pulmonary rehabilitation (including progressive muscle resistance and aerobic training) | Oncology outpatient physiotherapy team, local community respiratory team or cardio-respiratory physiotherapy team depending on patient choice, need and availability | Information not provided | One-to-one or group sessions depending on patient choice, need and availability | Referral was made as early as possible. For the majority of patients, the duration was driven by the pragmatic constraints of the 62-day lung cancer pathway. The pragmatic approach around location, nature and duration of programme led to significant variation in the nature of individual patients programmes | Tailored according to patient choice, need and availability | Median number of sessions for 35 patients seen purely by the outpatient oncology physiotherapy team was three over a median of 22 days. Eight patients (16%) underwent inpatient prehabilitation, with a median duration of eight days. This variance was predominantly driven by the scheduled surgical date. 13 patients (26%) were unnecessary or inappropriate referrals Improvement in surgical rates from 12.8% at the inception of the study to 29.8% at the end | |||||||||||
A feasibility study of an unsupervised, pre-operative exercise program for adults with lung cancer (Feasibility study) [59] | • Exercise No model or theory base reported | Patients received a verbal and written exercise prescription from their surgeon: “Do any moderately-intense aerobic physical activity (e.g., walking, jogging, stair climbing, upper body ergometer, stationary bicycle) for 30 min a day and for 5 days each week. While doing the activity, you should be working hard enough that it is difficult to speak more than a few words at a time. You may need to start slowly (e.g., 5–10 min at a time), but as you get stronger you can increase your activity so that you exercise for 30 min at a time.” | Surgeon and a project co-ordinator | Each patient was given a Garmin Vivoactive heart rate device. Patients were assigned an email address and password which was used as a login for the Garmin Connect Mobile App. The project coordinator downloaded the application onto patient phones and activated the fitness device during enrolment Patients were asked to synchronise and charge the device daily and wear the device at all other times including showering and sleeping Patients recorded their aerobic exercise sessions within a paper-based log | Home based | Pre-operatively 30 min 5 × week | Patients were allowed to choose the type of activity that they found most feasible or enjoyable | 81% recruitment rate with 79% completing the pre-operative assessments. Only 29% completed the exercise log and 14% experience adverse events related to the device 79% reported at least one aspect of the fitness device that they disliked and 29% reported at least one thing they did not understand regarding the device | |||||||||||
Pre-radiotherapy daily exercise training in non-small cell lung cancer: A feasibility study (Feasibility study) [60] | • Exercise No model or theory base reported | Structured exercise training immediately prior to radiotherapy. This consisted of three exercise phases. Phase one and three: interval training. Phase two: continuous cycling | An exercise physiologist or physiotherapist | Supervised, individualised exercise using an ergometer cycle. All patients wore heart rate monitors during the exercise sessions and were given Garmin® vívosmart® heart rate activity trackers to use during the course of radiotherapy | Next to the accelerator when a patient attended for radiotherapy treatment | The intervention period was equal to the patient’s number of radiotherapy sessions over a seven week period, with each session lasting 20 min | The exercise sessions were tailored to the patient’s fitness level | The intervention comprised of 31 prescribed exercise sessions over the seven-week period. Overall attendance rate to exercise was 90%. Of the 90% attendance, the adherence rate to full exercise participation was 88.1% and was performed by a modified program due to early exhaustion, pause during the exercise session or practical reasons (e.g. earlier start of radiotherapy on a given day) 2 patients were hospitalised due to chemotherapy adverse events. No adverse events were observed during the exercise sessions | |||||||||||
Patients’ and healthcare professionals’ views on a pre-and post-operative rehabilitation programme (SOLACE) for lung cancer: A qualitative study (Qualitative study) [61] | • Exercise • Nutrition • Wellbeing Not based on a model or theory, but based on a previous pre and post-surgical intervention study in pulmonary rehabilitation which demonstrated a reduction in post-operative complications and hospital readmissions | No specific information provided. Services provided in the SOLACE programme include patient education / written information on recovery from lung cancer surgery, smoking cessation, nutritional advice, information on thoracic surgical pathways, psychological support, pain management, financial help, links to other NHS, Macmillan and external support agencies, pre-and post-operative rehabilitation exercise classes, local exercise referrals and rehabilitation DVDs | A Macmillan lung cancer survivorship Advanced Nurse Practitioner (ANP) and a Macmillan lung cancer survivorship Advanced Therapist Practitioner (ATP) | Through the provision of personalised support depending on a patient’s support requirements, Interventions informed by the Macmillan guidance | Hospital and/or community based | Information not provided | Provision of personalised support | Pre and post-operative rehabilitation services can help improve patients’ perceived physical and psychological health and build self-confidence in their ability to self-manage There is a need to consider ways to enable prolonged access to rehabilitation services for lung cancer patients entering the follow-up stages of their care | |||||||||||
Attitudes and perceptions to prehabilitation in lung cancer (Online cross-sectional survey) [62] | • Exercise No model or theory base reported | 24 item survey sent to 198 fellows of the Royal Australasian College of Cardiothoracic Surgeons | Information not provided | Via email, college newsletters, digital press and in printed format | Throughout Australia and New Zealand | Information not provided | Information not provided | > 90% of cardio-thoracic surgeons surveyed would delay surgery for prehabilitation in order to optimise ‘high risk’ patients (those with multiple comorbidities, advanced age, positive smoking status / respiratory disease, and/or obesity) preoperatively, particularly in patients with borderline fitness for surgery. The main barriers to prehabilitation reported were patient comorbidities and access to allied health professionals | |||||||||||
Potential effectiveness of a surgeon-delivered exercise prescription and an activity tracker on pre-operative exercise adherence and aerobic capacity of lung cancer patients (Proof of concept study) [63] | • Exercise Not based on a model or theory, but based on the hypothesis that pre-operative exercise can improve functional outcomes for lung cancer patients, but barriers associated with cost, resources, and burden make it challenging to deliver pre-operative exercise programs | Patients received a verbal and written exercise prescription from their surgeon: “Do any moderately-intense aerobic physical activity (e.g., walking, jogging, stair climbing, upper body ergometer, stationary bicycle) for 30 min a day and for 5 days each week. While doing the activity, you should be working hard enough that it is difficult to speak more than a few words at a time. You may need to start slowly (e.g., 5–10 min at a time), but as you get stronger you can increase your activity so that you exercise for 30 min at a time.” | Surgeon and a project co-ordinator | The project co-ordinator provided a written copy of the prescription on enrolment. Each patient was given a Garmin Vivoactive heart rate device. Patients were assigned an email address and password which was used as a login for the Garmin Connect Mobile App. The project coordinator downloaded the application onto patient phones and activated the fitness device during enrolment. Patients were asked to synchronise and charge the device daily and wear the device at all other times including showering and sleeping | Home based | Pre-operatively 30 min 5 × week | Patients were allowed to choose the type of activity that they found most feasible or enjoyable | Proof of concept was achieved as nearly half of the study sample achieved the minimal clinically meaningful improvement in aerobic capacity prior to surgery as a result of participation in the intervention. However, approximately 50% did not achieve this and the majority of patients fell short of achieving the prescribed weekly MVPA goal. Future work should involve the use of a triage system to identify patients who can successfully adhere to the pre-operative exercise prescription with only “low-touch” support and those who could benefit from additional resources and high-touch forms of support | |||||||||||
Prehabilitation in thoracic cancer surgery: From research to standard of care (Quality Improvement Project) [64] | • Exercise • Nutrition • Wellbeing No model or theory base reported | The prehabilitation program included 3 steps: (1) Screening, (2) Assessment and (3) Intervention. Screening identified high-risk patients with at least one functional, nutritional, or psychological impairment. Assessment quantified the severity of the impairment to help tailor the intervention. The intervention was tailored based on specific physical, nutritional, or psychological impairments identified during the assessment phase. High-risk patients with a mild impairment received a low-intensity prehabilitation program, whereas high-risk patients with severe impairments were given a high-intensity prehabilitation program | Exercise: Kinesiologist Nutrition: Dietitian Wellbeing: Nurse specialist with specific training in psycho-social support for patients with cancer | Exercise: Screening—6MWT and the Duke Activity Status Index (DASI). Assessment—CPET Nutrition: Screening—Involuntary weight loss > 10% in 6 months and/or reduced dietary intake < 50% over the previous weeks and/or nutrition related symptoms (poor appetite, dysphagia, vomiting or and constipation over the last weeks) and/or low handgrip strength: < 20th percentile of normative value. Assessment: PG-SGA Wellbeing: HADS questionnaire | Hospital based | Information not provided | All interventions were tailored to each individual | 58 patients showed at least one or more physical, nutritional, or mental impairment and progressed onto the assessment phase of the program. 23 patients were categorised as low risk. 45 high-risk patients received a one-month personalised prehabilitation program. 16 of these received a trimodal program and 22 received a nutrition and exercise program The median duration of prehabilitation was 30 days |