Exercise training improves physical capacity after lung cancer surgery

NIHR | September 2019| Exercise training improves physical capacity after lung cancer surgery

A new NIHR Signal showcases the findings of a Cochrane update which reviewed eight trials which combined aerobic and resistance exercise after lung cancer surgery. Although the trials were small in terms of participants (450 participants in total), they demonstrated consistent and meaningful improvements in exercise capacity. 

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Plain Language Summary

Exercise training after lung surgery for people with non‐small cell lung cancer

Review question

We updated the evidence about the effect of exercise training after lung surgery for non‐small cell lung cancer (NSCLC) on fitness level; adverse events; quality of life; strength of the leg, hand, and breathing muscles; breathlessness; fatigue; feelings of anxiety and depression; and lung function.

Background

After lung surgery for NSCLC, people’s fitness levels and quality of life decrease. We know that exercise training improves these outcomes in people with chronic lung disease and in those with prostate and breast cancer. In the 2013 version of this review, we demonstrated that exercise training improved fitness level (distance walked on the six‐minute walk test) in people after lung surgery for NSCLC. Due to the limited number of studies, the effect of exercise training on quality of life and other outcomes was unclear.

Search date

The evidence is current to February 2019.

Study characteristics

We included three studies from the 2013 review and an additional five new studies from the current review, for a total of eight studies with 450 participants (180 women). The number of participants in the included studies ranged between 17 and 131; the mean age of participants was between 63 and 71 years. Six studies explored the effects of combined aerobic and strengthening exercises; one explored the effects of combined aerobic exercise and inspiratory muscle training; and one explored the effects of combined aerobic exercise, strengthening exercise inspiratory muscle training and balance training. The length of the exercise programmes ranged from four to 20 weeks, with exercises performed twice to five days a week.

Key results

Our results showed that people with NSCLC who exercised after lung surgery had better fitness level (measured using both a cycling test and the six‐minute walk test) and strength in their leg muscles compared to those that did not exercise. We also showed initial evidence for better quality of life and less breathlessness in those who exercised. One adverse event (hip fracture) related to the intervention was reported in one study. The effect of exercise training after lung surgery on grip strength, fatigue, and lung function was uncertain. We found insufficient evidence for improvements in the strength of breathing muscles or feelings of anxiety and depression.

Quality of evidence

Overall the quality (certainty) of evidence for the outcomes was moderate, ranging between very low (for breathlessness) and high (for fitness level measured via the six‐minute walk test).

Full reference: Cavalheri, V. et al | 2019| Exercise training undertaken by people within 12 months of lung resection for non-small cell lung cancer | Cochrane Database Syst Rev|  Vol. 6 | doi/10.1002/14651858.CD009955.pub3/epdf/full

The full article is available to read from Cochrane 

Background: Decreased exercise capacity and health-related quality of life (HRQoL) are common in people following lung resection for non-small cell lung cancer (NSCLC). Exercise training has been demonstrated to confer gains in exercise capacity and HRQoL for people with a range of chronic conditions, including chronic obstructive pulmonary disease and heart failure, as well as in people with prostate and breast cancer. A programme of exercise training may also confer gains in these outcomes for people following lung resection for NSCLC. This systematic review updates our 2013 systematic review.

Objectives: The primary aim of this review was to determine the effects of exercise training on exercise capacity and adverse events in people following lung resection (with or without chemotherapy) for NSCLC. The secondary aims were to determine the effects of exercise training on other outcomes such as HRQoL, force-generating capacity of peripheral muscles, pressure-generating capacity of the respiratory muscles, dyspnoea and fatigue, feelings of anxiety and depression, lung function, and mortality.

Search Methods: We searched for additional randomised controlled trials (RCTs) in the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library 2019, Issue 2 of 12), MEDLINE (via PubMed) (2013 to February 2019), Embase (via Ovid) (2013 to February 2019), SciELO (The Scientific Electronic Library Online) (2013 to February 2019), and PEDro (Physiotherapy Evidence Database) (2013 to February 2019).

Selection Criteria: We included RCTs in which participants with NSCLC who underwent lung resection were allocated to receive either exercise training, which included aerobic exercise, resistance exercise, or a combination of both, or no exercise training.

Data collection and analysis: Two review authors screened the studies and identified those eligible for inclusion. We used either postintervention values (with their respective standard deviation (SD)) or mean changes (with their respective SD) in the meta-analyses that reported results as mean difference (MD). In meta-analyses that reported results as standardised mean difference (SMD), we placed studies that reported postintervention values and those that reported mean changes in separate subgroups. We assessed the certainty of evidence for each outcome by downgrading or upgrading the evidence according to GRADE criteria.

Main results: Along with the three RCTs included in the original version of this review (2013), we identified an additional five RCTs in this update, resulting in a total of eight RCTs involving 450 participants (180 (40%) females). The risk of selection bias in the included studies was low and the risk of performance bias high. Six studies explored the effects of combined aerobic and resistance training; one explored the effects of combined aerobic and inspiratory muscle training; and one explored the effects of combined aerobic, resistance, inspiratory muscle training and balance training. On completion of the intervention period, compared to the control group, exercise capacity expressed as the peak rate of oxygen uptake (VO2peak) and six-minute walk distance (6MWD) was greater in the intervention group (VO2peak: MD 2.97 mL/kg/min, 95% confidence interval (CI) 1.93 to 4.02 mL/kg/min, 4 studies, 135 participants, moderate-certainty evidence; 6MWD: MD 57 m, 95% CI 34 to 80 m, 5 studies, 182 participants, high-certainty evidence). One adverse event (hip fracture) related to the intervention was reported in one of the included studies. The intervention group also achieved greater improvements in the physical component of general HRQoL; improved force-generating capacity of the quadriceps muscle; and less dyspnoea. We observed uncertain effects on the mental component of general HRQoL, disease-specific HRQoL, handgrip force, fatigue, and lung function. There were insufficient data to comment on the effect of exercise training on maximal inspiratory and expiratory pressures and feelings of anxiety and depression. Mortality was not reported in the included studies.

Authors’ Conclusions: Exercise training increased exercise capacity and quadriceps muscle force of people following lung resection for NSCLC. Our findings also suggest improvements on the physical component score of general HRQoL and decreased dyspnoea. This systematic review emphasises the importance of exercise training as part of the postoperative management of people with NSCLC.

Full details from NIHR 

Meaningful increases in physical activity levels after cancer can be sustained for three months or more, finds Systematic Review

NIHR | July 2019 | Meaningful increases in physical activity levels after cancer can be sustained for three months or more

An NIHR-funded review is the first review of physical activity maintenance across cancer types. The review pooled 19 studies which measured the effect of interventions for physical activity on 5,792 adult cancer survivors. 

Interventions which were included in the review included supervised group exercise sessions, telephone coaching, education and encouragement to do home-based exercise. Providers included physiotherapists, counsellors and health coaches. Control groups were mostly given printed exercise leaflets.

Patients who received only printed materials also achieved modest increases in physical activity, suggesting low-intensity interventions may be sufficient in promoting small changes in behaviour for some motivated groups. By contrast, the results suggest that more intensive and costly interventions with support could be targeted at groups such as older people with physical limitations (Source: NIHR).

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Full details from NIHR

Grimmett, C., et al | 2019| Systematic review and meta-analysis of maintenance of physical activity behaviour change in cancer survivors | International Journal of Behavioural Nutrition and Physical Activity| 16| 37 | https://doi.org/10.1186/s12966-019-0787-4

Abstract

Background

Physical activity can improve health and wellbeing after cancer and may reduce cancer recurrence and mortality. To achieve such long-term benefits cancer survivors must be habitually active. This review evaluates the effectiveness of interventions in supporting maintenance of physical activity behaviour change among adults diagnosed with cancer and explores which intervention components and contextual features are associated with effectiveness.

 

Methods

Relevant randomised controlled trials (RCTs) were identified by a search of Ovid Medline, Ovid Embase and PsychINFO. Trials including adults diagnosed with cancer, assessed an intervention targeting physical activity and reported physical activity behaviour at baseline and more than or equal to 3 months post-intervention were included. The behaviour change technique (BCT) taxonomy was used to identify intervention components and the Template for Intervention Description and Replication to capture contextual features. Random effect meta-analysis explored between and within group differences in physical activity behaviour. Standardised mean differences (SMD) describe effect size.

 

Results

Twenty seven RCTs were included, 19 were pooled in meta-analyses. Interventions were effective at changing long-term behaviour; SMD in moderate to vigorous physical activity (MVPA) between groups 0.25; 95% CI = 0.16–0.35. Within-group pre-post intervention analysis yielded a mean increase of 27.48 (95% CI = 11.48-43.49) mins/wk. of MVPA in control groups and 65.30 (95% CI = 45.59–85.01) mins/wk. of MVPA in intervention groups. Ineffective interventions tended to include older populations with existing physical limitations, had fewer contacts with participants, were less likely to include a supervised element or the BCTs of ‘action planning’, ‘graded tasks’ and ‘social support (unspecified)’. Included studies were biased towards inclusion of younger, female, well-educated and white populations who were already engaging in some physical activity.

 

Conclusions

Existing interventions are effective in achieving modest increases in physical activity at least 3 months post-intervention completion. Small improvements were also evident in control groups suggesting low-intensity interventions may be sufficient in promoting small changes in behaviour that last beyond intervention completion. However, study samples are not representative of typical cancer populations. Interventions should consider a stepped-care approach, providing more intensive support for older people with physical limitations and others less likely to engage in these interventions.

Link to full text article:

NIHR Signal Meaningful increases in physical activity levels after cancer can be sustained for three months or more

BMC Systematic review and meta-analysis of maintenance of physical activity behaviour change in cancer survivors

Prehabilitation for people with cancer

Prehabilitation for people with cancer: principles and guidance for prehabilitation within the management and support of people with cancer | The Royal College of Anaesthetists, Macmillan Cancer Support, and the National Institute for Health Research (NIHR) Cancer and Nutrition Collaboration

This document calls for changes to the delivery of cancer care across the UK, with a greater focus on prehabilitation including nutrition, physical activity and psychological support.

What is prehabilitation?

Prehabilitation supports people living with cancer to prepare for treatment. It promotes healthy behaviours and prescribes exercise, nutrition and psychological interventions based on a person’s needs, to help them find their best way through.

When should it be implemented?

Prehabilitation should be implemented in the early stages of the patient pathway, ideally soon after diagnosis and well in advance of treatment for maximum benefit. It should be seen as part of the rehabilitation pathway, as a way to optimise a person’s health and wellbeing, maximising their resilience to treatment throughout the cancer journey.

What are the benefits?

Prehabilitation offers patients and care givers three main benefits:

  • Personal empowerment: A sense of control and purpose, which prepares people for treatment and improves their quality of life
  • Physical and psychological resilience: An opportunity to improve physiological function and psychological wellbeing, which offers resilience to the effects of cancer treatment, enhances the quality of recovery and helps people to live life as fully as they can
  • Long-term health: An opportunity to reflect on the role of healthy lifestyle practices after a cancer diagnosis, to promote positive health behaviour change.

Further detail at Macmillan Cancer Support

Full document: Prehabilitation for people with cancer: principles and guidance for prehabilitation within the management and support of people with cancer

Low levels of exercise are beneficial for adults

Even low levels of leisure-time physical activities are beneficial for adults, whilst doing more vigorous exercise has additional health benefits in terms of reducing mortality.  Authors call for the promotion of any amount and intensity of physical activity, to reduce mortality risk in the general population | British Journal of Sports Medicine

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Abstract
Background:  Evidence on the role of very low or very high volumes of leisure time physical activity (PA) on the risk of all-cause and cause-specific mortality is limited. We aimed to examine the associations of different levels of leisure time PA with the risk of all-cause, cardiovascular disease (CVD) and cancer-specific mortality.

Methods:  Data were from 12 waves of the National Health Interview Surveys (1997–2008) linked to the National Death Index records through 31 December 2011. A total of 88 140 eligible participants aged 40–85 years were included.

Results:  Compared with inactive individuals, those performing 10–59 min/week of PA had 18% lower risk of all-cause mortality. Those who reported 1–2 times (150–299 min/week) the recommended level of leisure time PA had 31% reduced risk of all-cause mortality. Importantly, the continued benefits were observed among those performing leisure time PA 10 or more times the recommended minimum level. In addition, there was a larger reduction in all-cause and cause-specific mortality for vigorous vs. moderate intensity PA.

Conclusions: We found that beneficial association between leisure time PA and mortality starts from a low dose. Doing more vigorous exercise could lead to additional health benefits.

Full abstract at British Journal of Sports Medicine

Full reference: Zhao M, Veeranki SP, Li S, et al | Beneficial associations of low and large doses of leisure time physical activity with all-cause, cardiovascular disease and cancer mortality: a national cohort study of 88,140 US adults | British Journal of Sports Medicine | Published Online First: 19 March 2019

See also: Even low amounts of exercise are beneficial | OnMedica

How diet, nutrition and physical activity affect cancer risk

The World Cancer Research Fund have published an interactive infographic summarising risk factors for certain cancers.

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The full report summarises the wealth of evidence on how diet, nutrition and physical activity can influence the biological processes that underpin the development and progression of cancer.

The report contains the following 10 exposure sections, covering definitions and background information, issues relating to interpretation of the evidence, the evidence itself ( and judgements on the evidence.

View the Interactive Cancer Risk Matrix

Full report: Diet, Nutrition, Physical Activity and Cancer: a Global Perspective

Changes to diet and exercise could avoid 26,000 cases of cancer a year in women

Around 500 cases of cancer in women every week in the UK could be prevented by keeping a healthy weight and increasing exercise | British Journal of Cancer | story via Cancer Research UK

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The latest figures, calculated from 2015 cancer data, found that whilst smoking remains the biggest preventable cause of cancer, everyday changes to live a little more healthily can have a large impact.

By keeping a healthy weight, drinking less alcohol, eating more fibre, cutting down on processed meat and being more active, more than 26,000 cancer cases in women could be avoided each year.

This equates to 15% of all cancers diagnosed in women each year in the UK. More than 24,000 cases of cancer in men could also be avoided with the same approach.

Full story at Cancer Research UK

Full reference: Brown, K. et al. | The fraction of cancer attributable to known risk factors in England, Wales, Scotland, Northern Ireland, and the UK overall in 2015 | British Journal of Cancer 2018 | Vol. 118 p1130–1141

Physical activity in the community improves mobility for cancer survivors

Programmes to encourage physical activity for people with cancer at home or in local communities have a positive impact on physical function | NIHR Signal

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The changes were generally small to moderate, for example those receiving rehabilitation could walk on average 28 metres further in six minutes. The studies mostly included older people with breast cancer, in whom these small improvements may be important.

Cancer survivors experience changes to their physical function resulting from cancer and its treatments. Restoring function can help people maintain independence.

This review looked at a range of interventions. Those delivered in people’s homes or nearby community settings may be more convenient for people with reduced physical function, and might enable more people to attend. Further research would help to confirm these findings in the UK and to explore implementation issues.