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Dr. Jack West is a medical oncologist and thoracic oncology specialist, and Executive Director of Employer Services at the City of Hope Comprehensive Cancer Center in Duarte, CA.

Exercise in Lung Cancer
Tue, 02/26/2008 - 22:32
Howard (Jack) West, MD, Associate Clinical Professor, Medical Oncology, Executive Director, Employer Services, Founder, President and CEO of GRACE

Several users on a recent thread have raised questions about whether exercise after surgery or chemo and radiation is harmful, beneficial, or has no effect on outcomes among people with lung cancer. Unfortunately, this field has so few answers that it's easy to imagine doctors filling in the void with half-truths or less. I explained that I had seen so little information on this subject that I couldn't shed much light, but I'd try to dig up some information.

There is really little to nothing out there on exercise programs for patients with lung cancer specifically. The American College of Chest Physicians put out a set of guidelines ten years ago (article here) that really focused on the value of exercise programs for patients with chronic obstructive pulmonary disease (COPD), or emphysema, but not cancer. Overall, the findings of various trials suggest that lower extremity exercise (ambulating) is beneficial, in terms of improved exercise tolerance, but no significant improvement in pulmonary function, and no detrimental effects appreciated. Many of these programs also include some upper extremity (or, you may know it as the arm) training, and breathing training, with some support for increased arm function in these exercise programs, but no improvement in breathing function. So these studies in aggregate show convincing improvement in exercise capacity, in activity levels, but also psychological benefits with improved quality of life as activity levels increase. A summary table of results from the article is shown here (grade of evidence summarizes the strength of the evidence, from A for very strong to C for rather sketchy and only suggestive):

ACCP Pulm Rehab Guidelines, COPD

(click on image to enlarge)

And yet, we really don't have information on exercise in the setting of lung cancer.

The Southwest Oncology Group has actually been trying to run a clinical trial (called SWOG 0229) that tests the value of a supervised exercise program for patients with stage III, locally advanced NSCLC who have received chemo and radiation. In addition, the study is also assessing the health-related quality of life for participating patients. The trial actually randomizes patients to an educational program about the value of exercise or the same educational program along with a supervised 12-week exercise program. Participants undergo testing in the form of a six minute walk in which the total distance is recorded, as well as lung function tests and quality of life surveys.

Great idea, but unfortunately this concept just hasn't captured the lung cancer community. The trial was opened in September of 2004, but as of an update several months ago, just a single patient had been enrolled (by one of the lead investigators of the study). The trial was designed to enroll 82 patients per arm, for a total of 164 patients. At this rate, we should get some answers in about 500 years.

Some of the problem may be a lack of interest among potential patients, but I also suspect that most oncologists forget about it and don't mention it to their patients in the middle of their busy clinic days, where they are more focused on scan results and chemo plans (and since I wasn't the one who enrolled the only patient on this study, consider me guilty as charged). Unfortunately, this suggests that it may be a long, long time before physicians and patients prioritize exercise programs in lung cancer enough to answer questions about the potential contribution(s) of exercise on physical and psychological well being. The study has liberalized its entry criteria, but it may well be closed down if interest in it doesn't pick up dramatically. I'll have to remember to offer it to my eligible patients.

Until then, I can tell you that I support people pursuing an exercise program and don't see any evidence of a harmful effect, but there is precious little information to address how much it adds.

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