Evaluation of an early exercise intervention after thoracotomy for non-small cell lung cancer (NSCLC), effects on quality of life, muscle strength and exercise tolerance: Randomised controlled trial
Introduction
Annually, around 18,200 men and 13,125 women are diagnosed with lung cancer, which account for 14.8% and 11.3% of all cancers respectively in England. Of those 1 in 5 patients will be suitable for surgery. Statistics for 2007 showed that lung cancer accounted for 21% of all cancer deaths and 6% of all deaths [1]. Of those diagnosed with lung cancer only 7% of men and 9% of women will survive at 5 years [2]. Surgery aims to prolong life and improve quality of life for people with lung cancer. Increasingly, in this population, long-term survivor issues [3] and risk of disability associated with surgery have been highlighted as important patient focussed outcomes [4]. Unfortunately there are few strategies presently available that address long-term functional capacity.
Handy et al. in a longitudinal study of 139 patients undergoing lung resection showed significant decline in physical functioning, role and social functioning and mental health 6 months post-surgery [5]. Compared with previously published normative data from the Short Form 16 (SF16), pain and quality of life were significantly worse in the lung cancer patients. Respiratory symptoms remain problematic for many survivors of lung cancer, dyspnoea in particular is associated with impairment in quality of life at 5 years post-surgery [6]. Rehabilitation strategies in people with dyspnoea due to chronic obstructive pulmonary disease (COPD) have shown positive effects on quality of life, exercise capacity and muscle strength [7] and yet there are few trials testing this approach post-lung resection.
Spruit et al. [8] in an uncontrolled trial, examined the role of an in patient 8 week programme of exercise 3 months after surgery. Their encouraging pilot data results support the notion of positive impact of rehabilitation in people with non-small cell lung cancer (NSCLC). Similarly Cesario et al., in an observational study, showed reductions in breathlessness after a 4 week in-patient exercise programme for self selected subjects immediately post-operatively [9]. Exercise programmes facilitate improvements in quality of life via a number of mechanisms; improvements in fatigue [10], in breathlessness [9]; exercise tolerance and muscle strength will contribute to improved role and social functioning [11]. Furthermore since deterioration in quality of life after lung resection is associated with deterioration in cardio-respiratory fitness [12]. There is a strong rationale for the development of further rehabilitation support post-surgery.
The aim of this randomised controlled trial therefore is to test the effectiveness of a strength and mobility training programme provided early after lung resection on quality of life, exercise tolerance and muscle strength.
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Patients
Full ethical approval was received from Wandsworth Ethics Committee. Sixty-seven patients undergoing lung resection for NSCLC were invited to take part in the study, 53 of these accepted and gave written and oral consent.
Inclusion criteria
Patients with NSCLC referred for lung resection via open thoracotomy or Visual Assisted Thoracotomy (VATs).
Exclusion criteria
Patients undergoing thoracotomy procedure where no lung resection is carried out (e.g. pleurectomy), patients undergoing pneumonectomy, admission greater than 48 h to
Results
Two participants were lost after randomisation (Fig. 1), data is therefore analysed on 51 subjects. Table 1 shows the baseline characteristics for the participants. There were no significant differences in baseline measures between groups at the start of the study. Of the active, 15 were categorised at stages 1, 6 were stages 2, 2 at stages 3, 3 data unavailable (other diagnosis on surgical intervention). Of the control patients, 10 were at stages 1, 6 at stages 2, 5 at stages 4 and 4 other.
Discussion
This is the first randomised controlled trial to evaluate the effects of additional exercise therapy after lobectomy on quality of life. In this study patients were randomised to additional exercise after surgery with once monthly home follow up to 12 weeks. For quality of life, using a disease specific validated tool, we found no change pre-operative to 12 weeks post-operative either over time or between groups. Like others who used EORTC [22] we were reassured to see little deterioration in
Acknowledgments
We gratefully acknowledge the support of the Physiotherapy Department and of the Medical and Nursing Staff of Caroline Ward St George's Healthcare NHS Trust. We are grateful to St George's Hospital Therapies Charitable Funding and the Faculty of Health and Social Care Sciences for salary costs associated with this study.
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