The role of pulmonary rehabilitation in lung cancer has been systematically reviewed in the literature and it has been recommended as part of the pre-operative management to enhance recovery after thoracic surgery.1,2 However, few studies have focused on patients undergoing video-assisted thoracic surgery (VATS). To fill this research gap, we designed a pilot study to investigate the effects of a preoperative pulmonary rehabilitation program in patients awaiting VATS for lung cancer.

From February 2013 to June 2013, 23 patients were screened at the University Hospital of A Coruna. Patients who agreed to participate gave written informed consent before any formal testing. The research protocol was approved by the local ethics committee.

The rehabilitation program consisted of one and a half hour sessions, 3–5 times per week during the preoperative period, including: (1) interval aerobic training on a cycloergometer for 30–40minutes; (2) resistance training with elastic bands and body-weight exercises for 3 sets of 15 repetitions each; and (3) breathing exercises with an incentive spirometer twice daily.

Participants were evaluated at 4 time points: at baseline (T0); prior to surgery (T1); at hospital discharge (T2); and 3 months after surgery (T3). Functional capacity measured with the 6-minute walking test (6MWT) was the main study endpoint. Other outcomes included muscle strength measured with the Senior Fitness Test (SFT),3 health-related quality of life (HRQoL) measured with the Short-Form 36 Health Survey (SF36), and postoperative outcomes (incidence of postoperative complications and hospital stay).

Non-parametric tests were used to examine difference across time in the main outcomes. Univariate and multivariate regression analyses were used to identify the potential risk factors associated with a decrease in postoperative functional capacity. Analyses were performed using SPSS for Windows.

Twelve patients met the inclusion criteria and entered the rehabilitation program. Two patients withdrew and another was excluded because surgery was brought forward, leaving 9 patients (mean age was 68.5±10.4 years, 8 men), who attended a median of 21 sessions (range 11–27; mean adherence: 125.7%). Six patients underwent lobectomy and 3 had wedge resection. Postoperative complications occurred in 2 patients (prolonged air leak in 2 and 1 with pneumothorax).

Main outcomes are summarized in Table 1. An almost significant increase was found in the 6MWT after rehabilitation (P=.050). The 2 SFT items were also significantly improved (P<.05). HRQoL was less than normal at baseline. No significant changes were observed in any domain of the SF36 except for the Mental Health Subscale (P=.041). After surgery, all items decreased, especially the physical role (P=.012). Univariate analysis indicated that postoperative 6MWT was highly correlated with baseline FEV1, baseline physical functioning, and baseline physical summary component (PCS) of the SF36. The multivariate analysis confirmed that the PCS was a strong, independent factor for postoperative decline in the 6MWT (R2=.581).

The results of this pilot study suggest that a preoperative pulmonary rehabilitation program for patients undergoing VATS is feasible and appears to improve functional capacity and muscle strength. This finding is consistent with earlier studies in individuals undergoing thoracotomy4 and should be considered as a method for optimizing patients’ status before surgery and for increasing the number of candidates for surgical resection. The borderline improvement found in the 6MWT could be explained by the ceiling effect observed in individuals who are already fit (defined as baseline 6MWT 124.6% predicted) and the lack of responsiveness of the test in this scenario. Even so, it achieved the minimal clinically important difference reported for the lung cancer population.5 Our results also confirm earlier findings in sedentary and elderly populations,6 suggesting that in the absence of more sophisticated equipment, elastic bands are an effective way of improving muscle strength in individuals with lung cancer. Unfortunately, no significant changes were found in HRQoL after training. Further studies are required in larger series to address this issue. A randomized controlled trial is also needed to investigate whether these functional improvements can lead to a reduction in postoperative complications and length of stay, in comparison to standard care.