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 

New lung cancer treatment option approved by NICE

NICE | August 2019| New lung cancer treatment option approved by NICE

NICE has approved another new life-extending treatment for some people with lung cancer is to be made available on the Cancer Drugs Fund (CDF) following its approval by NICE in draft guidance

The immunotherapy drug pembrolizumab (also known as Keytruda) used with chemotherapy drugs carboplatin and paclitaxel will now be an option for adults with squamous non-small-cell lung cancer (NSCLC) which has spread to other parts of the body and who haven’t had any previous treatments.

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Evidence from an ongoing clinical trial suggests that people who have pembrolizumab combination therapy could live longer than those who have standard chemotherapy. It also suggests people could have additional time without their cancer progressing compared with standard chemotherapy.

However, because the clinical evidence is immature, the cost-effectiveness estimates for pembrolizumab combination therapy are very uncertain. The committee recognised that it has the potential to be cost-effective, and therefore recommended it for use on the CDF. This will allow more evidence to be collected to address the uncertainties around overall survival.

Director of the NICE Centre for Health Technology Evaluation Meindert Boysen, said: ““The committee heard from the patient experts that people with squamous non-small-cell lung cancer often have a poor quality of life, and that treatments that have the potential to extend life would be of great importance.” (Source: NICE)

Full press release available from NICE

Read the draft guidance on pembrolizumab here

Lancet Study: Whole-body MRI scans are as accurate as standard imaging pathways for lung cancer staging

NIHR | July 2019 | Whole-body MRI scans are as accurate as standard imaging pathways for lung cancer staging

The latest Signal from the National Institute for Health Research (NIHR) highlights the findings of a study that reports using whole-body magnetic resonance imaging (MRI) in the initial investigation pathway is as good as standard pathways for detecting metastatic disease in adults with non-small-cell lung cancer. This NIHR-funded study also found that WB-MRI used for diagnosis and staging is quicker, cheaper and requires fewer other investigations than standard pathways.

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Although patients reported that having whole-body MRI was a greater burden than standard imaging, they generally preferred whole-body MRI if it reduced staging times. In theory, it may also reduce radiation exposure, as most people would not need to have a positron-emission tomography CT scan.

Current NICE guidance recommends a sequence of investigations for staging – assessing the extent of cancer in order to plan appropriate treatment. MRI of different areas of the body is only recommended after other imaging investigations. This study suggests that whole-body MRI could have a role earlier in the pathway (Source: NIHR).

Read the full Signal from NIHR

Full reference:

Taylor, S. et al | 2019|  Diagnostic accuracy of whole-body MRI versus standard imaging pathways for metastatic disease in newly diagnosed non-small-cell lung cancer: the prospective Streamline L trial| The Lancet Respiratory Medicine|523-532 | https://doi.org/10.1016/S2213-2600(19)30090-6

Background

Whole-body magnetic resonance imaging (WB-MRI) could be an alternative to multi-modality staging of non-small-cell lung cancer (NSCLC), but its diagnostic accuracy, effect on staging times, number of tests needed, cost, and effect on treatment decisions are unknown. We aimed to prospectively compare the diagnostic accuracy and efficiency of WB-MRI-based staging pathways with standard pathways in NSCLC.

Methods

The Streamline L trial was a prospective, multicentre trial done in 16 hospitals in England. Eligible patients were 18 years or older, with newly diagnosed NSCLC that was potentially radically treatable on diagnostic chest CT (defined as stage IIIb or less). Exclusion criteria were severe systemic disease, pregnancy, contraindications to MRI, or histologies other than NSCLC. Patients underwent WB-MRI, the result of which was withheld until standard staging investigations were complete and the first treatment decision made. The multidisciplinary team recorded its treatment decision based on standard investigations, then on the WB-MRI staging pathway (WB-MRI plus additional tests generated), and finally on all tests. The primary outcome was difference in per-patient sensitivity for metastases between standard and WB-MRI staging pathways against a consensus reference standard at 12 months, in the per-protocol population. Secondary outcomes were difference in per-patient specificity for metastatic disease detection between standard and WB-MRI staging pathways, differences in treatment decisions, staging efficiency (time taken, test number, and costs) and per-organ sensitivity and specificity for metastases and per-patient agreement for local T and N stage. This trial is registered with the International Standard Randomised Controlled Trial registry, number ISRCTN50436483, and is complete.

Findings Between Feb 26, 2013, and Sept 5, 2016, 976 patients were screened for eligibility. 353 patients were recruited, 187 of whom completed the trial; 52 (28%) had metastasis at baseline. Pathway sensitivity was 50% for WB-MRI and 54% (41–67) for standard pathways, a difference of 4%. No adverse events related to imaging were reported. Specificity did not differ between WB-MRI (93% [88–96]) and standard pathways. Agreement with the multidisciplinary team’s final treatment decision was 98% for WB-MRI and 99% for the standard pathway. Time to complete staging was shorter for WB-MRI (13 days [12–14]) than for the standard pathway (19 days [17–21]); a 6-day (4–8) difference. The number of tests required was similar WB-MRI (one [1–1]) and standard pathways (one [1–2]). Mean per-patient costs were £317 (273–361) for WBI-MRI and £620 (574–666) for standard pathways.

RFT Library& Knowledge Service can provide this article to Rotherham NHS staff, contact us here 

Most-At-Risk Residents Of South Kirkby Reap The Benefits Of New Lung MOT​

West Yorkshire and Harrogate Cancer Alliance | July 2019 | Most-At-Risk Residents Of South Kirkby Reap The Benefits Of New Lung MOT​

Residents in South Kirby and Hemsworth between the age of 55 and 74 who smoke or used to smoke are being invited to be part of a targeted lung health check pilot programme led by the West Yorkshire and Harrogate Cancer Alliance, in partnership with Yorkshire Cancer Research.

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This ‘Lung MOT’ involves patients receiving a half hour checkup where specially trained nurses at a GP Surgery assess their breathing and overall lung health, measure their height and weight; and may also conduct a breathing test to identify any problems that may need further attention. Patients are also given a six-year risk score calculation for developing lung cancer. Current smokers are then offered the opportunity to access the stop smoking service.

As part of this service a number of patients have also taken up the opportunity to access free advice and help to quit smoking which is being provided on site by specialist advisors. Evidence has shown that access to such support gives smokers the best possible chance of giving up (Source: West Yorkshire and Harrogate Cancer Alliance).

Read the full news story at West Yorkshire and Harrogate Cancer Alliance

 

 

National Lung Cancer Audit

National Lung Cancer Audit annual report 2018  | The Healthcare Quality Improvement Partnership 

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Image source: http://www.hqip.org.uk

This report represents the culmination of nearly two years of patient care and follow up, data collection, data analysis and interpretation. Its purpose is to understand the current quality of care and outcomes for patients with lung cancer, to celebrate good practice and to highlight variability, to ensure that all patients have access to the best care.

The results demonstrate improving data quality, higher rates of surgical treatment, and higher rates of systemic anti-cancer treatment across both small cell lung cancer (SCLC) and non-small cell lung cancer (NSCLC), such that four out of our five key auditable measures have been achieved. Additionally, continuing improvements in data completeness can be observed with 85% completeness seen for performance status (PS), 96% for stage and 64% for recording of lung function in patients potentially suitable for curative treatment, as compared to 82%, 96% and 56% respectively in the previous reporting period.

[NICE Technology Appraisal Guidance] Durvalumab for treating locally advanced unresectable non-small-cell lung cancer after platinum-based chemoradiation

NICE | April 2019 | Durvalumab for treating locally advanced unresectable non-small-cell lung cancer after platinum-based chemoradiation Technology appraisal guidance [TA578]

Evidence-based recommendations on durvalumab (Imfinzi) for treating locally advanced unresectable non-small-cell lung cancer after platinum-based chemoradiation in adults.

More evidence on durvalumab is being collected, until September 2021. After this NICE will decide whether or not to recommend it for use on the NHS and update the guidance. It will be available through the Cancer Drugs Fund until then.

Full details from NICE