PULMONARY REHABILITATION IN LUNG CANCER

Dr. Tuğba GÖKTALAYCelal Bayar University

Department of PulmonologyManisa

Conflict of interest

Support for participation in the congress and the course (last 3 years)› Deva › GSK› Bayer

Presentation Plan

Rationale of pulmonary rehabilitation in lung cancer

Goals of pulmonary rehabilitation in lung cancer

Pre-post operative pulmonary rehabilitation in lung cancer

Pulmonary rehabilitation approaches

Cancer-related fatigue and pulmonary rehabilitation

Conclusion

Pulmonary rehabilitation;

Exercise capacity, Functional status, Improve health-related quality of life

(HRQOL) In patients with chronic lung problems

Chronic dyspnea and fatigue

  a multidisciplinary intervention.

Cancer Rehabilitation;

Restoration of the individual to the fullest physical, social, physicological and occupational potential of which the person is capable with the limitations of the disease and therapies.

Rationale Cancer Rehabilitation;

Cancer-related fatigue

Mobility

Self-care disability

Pain

Dyspnea

Malnutrition

Psycho-social problems

Goals of Cancer Rehabilitation;

Improve health-related quality of life

Increase the functional capacity

Enhance the efficacy of treatment

Increase the oxygen consumption

Reduce chemotherapy-related fatigue

To achieve targets;

Multidisciplinary health care team,Exercise training,Patient and family education, Psycho-social and behavioral interventions

5-year survival 15.6% in lung cancer

A small amount of patients eligible for surgery curative (25%)

Cardiopulmonary comorbidities

The coexistence of COPD-Lung cancer

Males 73%, females 53%

• Loganathan R, Stover DE, Shi W, Venkatraman E. Chest 2006; 129:1305– 1312.

n=100

Lobectomy for Lung cancer

Patient with COPD

Similar postoperative DLCO and VO2max

• Greater decline in FEV1 (p=0.0002)• Increased

cardiopulmonary morbidity (p=0.04)• Lower postoperative FEV1

(p=0.0001)

• Pompili C, Brunelli A, Refai M et al. Eur. J Cardio-thoracic Surg 2010; 525-530

Postoperative effects of COPD patients undergoing lobectomy due to lung cancer

Preoperative pulmonary rehabilitation, leads to a significant increase exercise capacity, dyspnea and health-related quality of life in this patients.

Shannon VR. Current Opinion in Pulmonary Medicine 2010;16:334–339

PR for patients with advanced NSCLC

n=11

Pulmonary rehabilitation; 2 times/week, 8week Aerobic and strengthening

exercises

• Reduction in symptoms

• Temel JS, Greer JA, Goldberg S et al. J Thorac Oncol 2009 (4): 595-601

Survival was negatively affected?

≤48 day is not the predictor of survival*

The Swedish Cancer Study Group Proposal for Lung Cancer;**Consultation and investigations to be

completed within 4 wk, treatment should start within the next 2 weeks

*Bozcuk H, Martin C. Lung Cancer 2001; 34:243– 252.

**Myrdal G, Lambe M, Hillerdal G, et al. Thorax 2004; 59:45–49.

Prepeoperatif pulmonary rehabilitation, many patients in the window period of 4-6 weeks can be done without adversely affecting survival.

Poor performance status and exercise capacity morbidity and mortality*

Exercise capacity is a modifiable risk factor!!**

*Oga T, Nishimura K, TsukinoM, et al. Am J Respir Crit Care Med 2003; 167:544–549.

*Baser S, Shannon VR, Eapen GA, et al. Clin Lung Cancer 2006; 5:344–349.

*Brunelli A, Salati M. Curr Opin Pulm Med 2008; 14:275–281.

**Fishman A, Martinez F, Nauheim K, et al. N Engl J Med 2003; 348: 2059–2073

CPET the main outcome

SFT predictive value is not clear

Pre-operative interventions aimed at improving VO2 peak, post-operative results improve and increase surgical candidacy.*

6MWT, CPET to be used as an alternative. **

*Brunelli A, Belardinelli R, Refai M, et al. Chest 2009; 135:1260–1267.

**Cote C, Pinto-Plata V, Kasprzyk K, et al. Chest 2007; 132:1778–1785.

Efficacy of Preoperative Pulmonary

Rahabilitation in Patients

with Lung Cancer

Complete surgical resection is the most effective treatment method

Preoperative PR, recommended to reduce surgical morbidity.

Fishman A, Martinez F, Nauheim K, et al. N Engl J Med 2003; 348: 2059–2073

PR before surgery for cancer; n=19

The standard and non-standard arm

Pulmoneary rehabilitation;

Short-term(4w)A) Standard arm Accordance

with guidelines

B) Patient-based Self-

sufficiency Inspiratory

muscle training

Slow breathing training

• Benzo R, Wigle D, Novotny P, et al. Lung Cancer 2011 Dec;74(3):441-5

•Shorter duration of hospital stay of at least 3 days (p=0.058), •The number of days for chest tube was less than (p = 0.04), •The need for prolonged chest tube drainage was less than (p = 0.03).•Can be applied to the patient-based PR

The Effects of cardiorespiratory training prior to surgery

•There is a significant increase in peak VO2 and 6MWT (respectively 21%, 13%)

• Jones L. Cancer Chemother Pharmacol 2007; 110:590–598

n=13 Preoperatively and 30 days after the assessment

Pulmonary Rehabilitation;

Short-termConsecutive days from the operation1-4 week

• Peripheral muscle exercise (endurance

The effect of preoperative pulmonary rehabilitation in NSCLC

n=12 akciğer

Pulmonary Rehabilitation;

• In hospital

• Short term(1.5 h, 5day/ 4 week süreli

• Patient education;

› Smoking cessation Effective coughing Controlled breathing

techniques

• Peripheral muscle training (Endurance)

•The average increase in peak VO2 2.8mL/kg/min•Increase in exercise performance•Positive effects of cardiopulmonary

• Bobbio A, Chetta A, Ampollini L, et al. Eur J Cardio-thoracic Surg 2008;33:95–98

Preoperative PR in patients with limited performance

n=8

Candidates for surgery, patients with limited respiratory function and performance

Pulmonary Rehabilitation; Short term(4

week) Aerobic

exercise, Controlled

breathing techniques

Training sessions

• Cesario A, Ferri L, Galetta D, et al. Lung Cancer 2007; 57:118–119.

•Increase in 6MWT (47%)•Increase in PaO2 (7,2mmHg)•Increase in Pulmonary function (FEV1, FVC)

Cost-effectiveness of PR before lobectomy

n=119

• Reduction of postoperative atelectasis (p= 0.003)• Reduction in length of hospital stay• Cost reduction

• Varela G, Ballesteros E, Jimenez MF et al. Eur J Cardio-thoracic Surg 2006; 216-220

•Exercise capacity improved•Shorter duration of hospital stay•Reduces postoperative pulmonary complications•Preserved lung function after surgery in patients with COPD

Preoperative PR is useful?

• Nagarajan K, Bennerr A, Agostini P et al. Interact Cardiovascular Thorac Surg 2011; 300-302

The benefits of preoperative pulmonary rehabilitation;

Shorten length of hospital stay, Improves postoperative complications,

reduces complications, Improves exercise capacity after surgery, Creates a positive impact on the post-

operative period of cardiopulmonary, Borderline patients eligible for surgery

makes Cost-effective

Efficacy of Postoperative Pulmonary

Rahabilitation in Patients with Lung

Cancer

Pulmonary rehabilitation after surgery, 6-9 weeks is continued.

PR in patients undergoing radical treatment

n=16

12 week multidisciplinary PR program

Pulmonary Rehabilitation;

Resistance and endurance exercise

Nutritional assessment Dyspnea and fatigue

assessment (CRDQ)

• Salhi B, Demedts I, Simpelere A et al. Rehabilitation Research and Practice 2010, Article ID 481546, 7 pages, doi:10.1155/2010/481546

•Improved exercise capacity•Increased muscle strength •Improved Quality of life (dyspnea and fatigue)

The effect of postoperative PR in NSCLC

Cesario A, Ferri L, Galetta D, et al. Lung Cancer 2007; 57:175–180

• Improvement in respiratory function• Improvement in exercise capacity

Postoperative PR in NSCLC

n=103

Patients undergoing surgery for NSCLC

• Cesario A, Dall’Armi V, Cusumano G et al. Lung Cancer November 2009, 66(2); 268–269

• Improvement in exercise capacity•  Improvement in respiratory function•  Improvement in the perception of dyspnea•  Improvement in SaO2•  Improvement in BODE index

Effect on exercise capacity in postoperative PR

n=10

Surgery, Surgery + RT, Surgery + RT+ KT

Pulmonary rehabilitation; 8 week Multidisciplinary

Increase the capacity of doing work

• Spruit M, Janssen PP, Willemsen SC, et al. Lung Cancer 2006; 52:257–260.

(P=0.0020) (P=0.0078)

•Increase in 6MWT (43%) and peak work load (34%)

The benefits of postoperative pulmonary rehabilitation;;

Increases exercise capacity

Increases muscle strength

Provides symptom control

Improves quality of life

Shorten length of hospital stay

Pre-Post operative Pulmonary Rehabilitation Approaches

Smoking cessation Assessments of patients;

Functional limitations Exercise capacity

Airway clearance and pulmonary expansion techniques Assisted coughing Insentive spirometry NIMV

Energy conservation strategies Transfer-mobility Prevention of venous thromboembolism Pain control Stress and anxiety management Nutritional evaluation / support

The effect of fast-track PR after lobectomy

n=109

Avoidance of long-term preoperative benzodiazepine

Early extubation

Patient-controlled analgesia

Early ambulation

Oral nutrition

•Shortening length of hospital stay •Reduction in complication

• Das-Neves-Pereira JC, Bagan P, Coimbra-Israel AP et al. Eur J Cardio-thoracic Surg 2009; 383-392

Cancer Related Fatigueand

Pulmonary Rehabilitation

Fatigue

Shortness of breath

Involuntary weight

loss

Cancer Related Fatigue (CRF)

70-100 % *

CRF during or after treatment

Decrease in activity participation and life**

*Mock V. Cancer. 2001;92(6 suppl):1699–1707 **Curt GA, Breitbart W, Cella D, et al. Oncologist.

2000;5:353–360

CRF

Cancer- related fatigue is a distressing persistent, subjective sense of physical, emotional and/or cognitive tiredness or exhaustion to cancer or cancer treatment that is not proportional to recent activity and interferes with unusual functioning.

NCCN Practice Guidlines in Oncology-1.2012, Cancer Related Fatigue

CRF

May be isolated or accompanied by other symptoms such as pain, distress, anemia, and sleep disorders

Patient-specific systematic assessment should be performed

Guides should be approached with a multidisciplinary applied

Rehabilitation should begin with the cancer diagnosis

• NCCN Practice Guidlines in Oncology-1.2012, Cancer Related Fatigue

• Wagner LI, Cella D. British Journal of Cancer (2004) 91, 822 – 828

Causes of cancer-related fatigue

Approach to cancer-related fatigue

Non-pharmacologic

Activity enhancement Maintain optimal level of activity /Exercise prescription/ Exercise training Energy conservation techniques

Education Psychosocial interventions

Assessment/support (Stress management /Relaxation ) Nutritional assessment /support Sleep assesment Cautions:

Bone metastasis Immunosuppression / neutropenia Thrombocytopenia Anemia Fever Limitations due to metastasis or co-morbidities

• NCCN Practice Guidlines in Oncology-1.2012, Cancer Related Fatigue

CRF CRF is associated with muscle mass and strength. *

The most common symptom, fatigue Increased fatigue, associated with low physical

activity levels. Physical activity level, regardless of age,

significant in predicting the level of fatigue.

Physical activity level, a factor that can be changed in CRF.**

• *Kilgour RD, Vigano A, Trutschnigg B et al. J Cachexia Sarcopenia Muscle (2010) 1:177–185

**Luctkar-Flude M, Groll D, Woodend K, et al. Oncol Nurs Forum. 2009 Mar; 36 (2):194-202

•Exercise; reduces fatigue, increases walking, improves the quality of life

• Wagner LI, Cella D. British Journal of Cancer (2004) 91, 822 – 828

The benefits of pulmonary rehabilitation in CRF;

Reduces fatigue

Provides symptom control

Increases the functional capacity

Improves the quality of life

Pulmonary Rehabilitation;

Makes it ready for surgery patients with borderline

Shorten length of hospital stay, cost-effective

Reduce the complication rates Accelerate recovery after surgery Provides symptom control Improves cancer-related fatigue and

quality of life

THANKS