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Surviving Lung Cancer Is Just The Beginning

More than 14,000 cases of lung cancer were diagnosed in Australia in 2022. Survival rates are the worst of all cancers, with just 22% surviving five years after diagnosis.

The best survival is seen in people with early-stage, localized disease—people who may not even feel unwell at the time of diagnosis. Australia is planning to introduce a National Lung Cancer Screening Program by July 2025, and so we expect to see many more lung cancers detected early, more people able to be treated with curative surgery and improvements in survival.

This is great news but it's just the first step. It is essential that we consider how we can maximize survivorship outcomes both now and in the future for people receiving lung cancer surgery.

Concerningly, a study recently found the prevalence of "functional limitations" in cancer survivors has rapidly risen over the last 20 years. Functional limitations are difficulties with physical activities like walking, standing up or carrying objects.

Very few people are limitation-free even years after treatment for cancer. Lung cancer survivors are the second most vulnerable (after pancreatic cancer)—with 76% reported living with functional limitations.

Cancer-related fatigue and breathlessness are also common and often continue long after surgery. This leads to a worsening pattern of difficulty moving, reduced fitness and muscle strength, and poor quality of life.

This comes with an associated economic burden as patients require extra care and other support like adapting their houses to accommodate their limitations.

The positive news for patients is exercise training has huge potential to address these limitations in people with lung cancer.

Strong research evidence has been produced over the last decade and we are now convinced that exercise is safe and highly effective in lung cancer therapy. We see consistent improvements in functional limitations, cancer symptoms, fitness, strength and quality of life for those who participate in an exercise program.

Surgery is the preferred treatment for people with early-stage lung cancer. This is usually delivered very close to diagnosis. In Australia, two-thirds of people undergo surgery within 14 days of a lung cancer diagnosis.

Fourteen days. Is that enough time to make a difference with exercise training before surgery? Our research published in the Cochrane Database of Systematic Reviews, in collaboration with Curtin University, suggests yes.

We found that exercise training results in a 55% reduction in the risk of lung complications after surgery. One extra person will be saved from a lung complication, like pneumonia, for every five people who exercise before surgery (compared to those not exercising).

Exercise programs as short as 14 days long are beneficial. People who exercise before surgery, compared to those who do not, stay in hospital shorter after their surgery and improve their fitness levels.

More research is needed to understand the long-term benefits of pre-surgery exercise and we are continuing to monitor patients after surgery to complete this picture.

Exercise training after surgery is also critically important and associated with excellent outcomes, including improved fitness, strength, breathlessness and quality of life. These exercise programs are longer, often six to 20 weeks in duration, as they are not restricted to the short timeframe before surgery.

The exercise programs are often delivered in a hospital gymnasium for a group of people with lung cancer. They usually run for 60 minutes and typically include aerobic exercises like stationary bike riding and treadmill walking, performed at a moderate "brisk" intensity. Other elements can include muscle strength training, balance exercises and stretches.

The strength of evidence now challenges us to consider how all Australians living with lung cancer can be supported to exercise.

People with lung cancer have significant barriers to exercise and we cannot expect most people to exercise without the support of health professionals. The exercise programs that we know work—because they have been tested in clinical trials—are supervised by health professionals, mostly physiotherapists.

It is important for patients to be screened for safety and given a careful, tailored exercise prescription. Yet despite the complexity of care required, we found that in Australia there are very few exercise programs available for people with lung cancer.

This is partly because we have only gathered the evidence to understand the efficacy of exercise for lung cancer in recent years and clinical practice has not yet caught up.

Similar exercise programs are already well established nationally and internationally for other conditions, including hospital or community-based Pulmonary Rehabilitation. The evidence supporting exercise for people with chronic obstructive pulmonary disease "COPD' was initially generated decades ago.

Many of the pulmonary rehabilitation programs have now expanded to include people with "other" respiratory diseases like lung cancer. However, demand is very high and waitlists are long.

Our team are currently trialing a remotely delivered exercise program, using physiotherapy support through weekly phone calls for 12 weeks after lung cancer surgery. The trial was outlined in a preliminary article published in BMJ Open Respiratory Research.

Whether or not such a hands-off home-based program can achieve the same magnitude of patient gains is the big question we hope to answer.

Certainly, the exercise program is less resource intensive for patients as they don't need to travel to a hospital gymnasium to see the physiotherapist and exercise. If shown to be effective, the program could be scaled up nationally in time for the introduction of the National Lung Cancer Screening Program.

There are promising times ahead for the management of lung cancer. We are finally at a point where we truly understand the benefits, and safety, of exercise.

For many people, exercise is a positive activity, that they can control, in an otherwise terrible time in their lives.

More information: Preoperative exercise training for people with non-small cell lung cancer, Cochrane Database of Systematic Reviews (2022). DOI: 10.1002/14651858.CD012020.Pub3

Catherine L Granger et al, Effect of a postoperative home-based exercise and self-management programme on physical function in people with lung cancer (CAPACITY): protocol for a randomised controlled trial, BMJ Open Respiratory Research (2022). DOI: 10.1136/bmjresp-2021-001189

Citation: Surviving lung cancer is just the beginning (2023, July 31) retrieved 13 August 2023 from https://medicalxpress.Com/news/2023-07-surviving-lung-cancer.Html

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Study Shows Gap In Care For Millions Of Smokers With Lung Disease

Among folks who smoked at least one pack of cigarettes a day for 20 or more years, half had persistently high respiratory symptoms. Photo by Myriams-Fotos/Pixabay

Millions of American smokers suffer from a potentially serious lung disease that's not technically chronic obstructive pulmonary disease (COPD), a new study finds.

They would benefit from a clear diagnosis, though, and the new findings demonstrate a major gap in care for people with a history of tobacco use, the researchers said.

Among folks who smoked at least one pack of cigarettes a day for 20 or more years, half had persistently high respiratory symptoms, including shortness of breath, daily cough and phlegm, and decreased ability to exercise, although they did well in the breathing tests used to spot COPD.

The researchers call the condition "tobacco exposure preserved spirometry" (TEPS).

"We first described TEPS in 2016. What we're showing here is the long-term follow up, and it's not like an early COPD. It stays persistent the way it is over time," said lead researcher Dr. Prescott Woodruff, division chief of pulmonology at the University of California, San Francisco.

Right now, there is no treatment for TEPS, he said. "It does improve in many people when they stop smoking, but not everyone," Woodruff said.

Woodruff's team tried treating patients with bronchodilators used to treat COPD. The drugs improved lung function but not the symptoms, he said.

"TEPS may be due to abnormal mucus production, so therapies that could control mucus might be the best therapies," Woodruff said. "We think it's a form of chronic bronchitis."

TEPS can occur in smokers as young as 35, he noted. And the researchers don't know the long-term prognosis of the condition. Some of these patients may go on to develop COPD.

But the study shows that "the number of people with smoking-related lung disease is bigger than we used to think," Woodruff said. "Only 50% of smokers get COPD, but if you count this disease, it's a much bigger percentage that has chronic problems."

The findings underscore the need to broaden the definition of smoking-related lung disease so new treatments can be developed, he added.

Dr. Jamie Garfield, a professor of thoracic medicine and surgery at Temple University School of Medicine in Philadelphia, thinks many patients with TEPS will develop COPD.

Someone might say, "I smoke, but I don't have any symptoms ... I'm doing fine." But that person is just as likely to progress to COPD "as the other person who has lots of symptoms of cough and sputum and trouble breathing and trouble sleeping and decreased energy," said Garfield, who is also a volunteer medical spokesperson for the American Lung Association.

For the study, Woodruff and his colleagues analyzed data on nearly 1,400 heavy smokers aged 40 to 80 who took part in the Subpopulations and Intermediate Outcome Measures In COPD Study (SPIROMICS I). They were compared with people who had never smoked.

Participants had spirometry, a test that diagnoses COPD, as well as a six-minute walk distance test, an assessment of respiratory symptoms, and CT scans of their lungs, each year for three to four years. Many participants also completed a round of testing five to 10 years after their original assessment.

Based on these tests, some people were diagnosed with COPD, but others with similar symptoms were not. Their symptoms, however, persisted throughout the years of the study.

Like folks with COPD, people with TEPS also had high rates of respiratory problems and shortness of breath that limited their ability to be active.

Participants with TEPS symptoms did not have increased incidence of COPD compared to people without TEPS symptoms, or a faster rate of lung function decline over time. Participants with COPD did have a more rapid decline in lung function.

The researchers also found that TEPS was more common among Black smokers, compared with white smokers. And the risk for COPD was greater among Black patients than white patients. These differences may be due to occupational and environmental exposures, socioeconomic status and structural racism, the researchers noted.

One expert stressed that most smokers develop serious health conditions.

"There are smokers that don't develop COPD, but they can develop other problems like heart disease and cancer," said Dr. Len Horovitz, a pulmonologist at Northwell Lenox Hill Hospital in New York City. "Very few people get off completely free with smoking."

Jennifer Sidi, director of the Northwell Health Center for Tobacco Control in New Hyde Park, N.Y., added that smoking causes inflammation that damages lung cells. This can cause COPD and other chronic conditions.

"This goes for vaping, too," she said. "Anything inhaled causes inflammation, and we just don't know exactly how some people are going to react long-term to the smoke exposure. Some people may smoke for several years, and then they stop and reverse themselves, but it doesn't take away the fact that the longer you smoke the more likely you're going to have permanent damage and risk for cancers and COPD."

The report was published Tuesday in the Journal of the American Medical Association.

More information

For more on smoking and lung disease, head to the U.S. Centers for Disease Control and Prevention.

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