PM R 8 (2016) 990-996

www.pmrjournal.org

Narrative Review

Pulmonary Rehabilitation in Lung Cancer

Hongmei Wang, MD, Xin Liu, MD, PhD, Shawn J. Rice, MS, Chandra P. Belani, MD

Abstract

Lung cancer remains a challenging disease with high morbidity and mortality despite targeted therapy. Symptom burden
related to cancer impairs quality of life and functional status in patients with lung cancer and in survivors. Pulmonary rehabil-
itation has been recognized as an effective, noninvasive intervention for patients with chronic respiratory disease. It is well
established that pulmonary rehabilitation benefits patients with chronic obstruction pulmonary disease through improved exer-
cise capacity and symptoms. Evidence is increasing that the benefit of pulmonary rehabilitation can be applied to patients with
lung cancer. Comprehensive pulmonary rehabilitation has made its way as a cornerstone of integrated care for patients with lung
cancer.
Level of Evidence: V

Introduction reduced COPD exacerbations [4], and decreased length

Pulmonary rehabilitation is a multidisciplinary inter-
vention for patients with symptoms related to compro-
mised pulmonary function. It has been defined as an
intervention based on a systematic patient assessment
and culminates in patient-tailored therapies [1]. Therapy
options can include exercise training, education, and
behavioral changes. Pulmonary therapy endeavors to
improve the psychological and physical condition of pa-
tients with chronic respiratory disease, which can pro-
mote long-term adherence to healthy behaviors [1]. The
primary goals of pulmonary rehabilitation are to enhance
exercise capacity, functional status, and quality of life,
which can induce behavioral change to facilitate an
active lifestyle. These goals can be attained through ex-
ercise, educating patients and family, and behavioral and
psychosocial interventions facilitated by the collective
input of a multidisciplinary health care team.
Pulmonary rehabilitation is an evidence-based
therapy for patients with respiratory disorders. It is
considered a core element for comprehensive inte-
grated care [2]. The efficacy of pulmonary rehabilita-
tion has been well established in the management of
patients with chronic obstructive pulmonary disease
(COPD). Patients with COPD can achieve benefits from
pulmonary rehabilitation that include increased 6-
minute walk distance [3], improved muscle strength,
of hospital stay [3]. There is also increased recognition
that pulmonary rehabilitation can benefit patients with
other respiratory conditions such as restrictive lung
disease [5,6], pulmonary hypertension [7], and lung
cancer [8,9]. The role of pulmonary rehabilitation in
lung cancer has gained increasing attention with posi-
tive effects on patients, but it hasn’t been well
described because of limited research to date.
Lung cancer is among the most prevalent cancers and
remains the leading cause of cancer-related death
worldwide despite aggressive treatments. The patho-
logic types are classified into small cell lung cancer
(15%) and nonesmall cell lung cancer (NSCLC, 85%) [10].
NSCLC is further divided into adenocarcinoma, squa-
mous cell carcinoma, and large cell carcinoma to guide
the choice of therapies histologically. The clinical
manifestations of primary lung cancer depend on the
location [11]. Local growth of central lesions can cause
cough, dyspnea, hemoptysis, or features of large airway
obstruction. Peripheral tumors, in addition to causing
cough and dyspnea, can lead to pleural effusion and
pain if parietal pleura or the chest wall become
involved. Cancer-induced lipolysis and proteolysis re-
sults in weight loss and muscle wasting [12]. Patients
with lung cancer are often deconditioned with skeletal
muscle weakness, exercise intolerance, and functional
disability. Although targeted therapy continues to

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http://dx.doi.org/10.1016/j.pmrj.2016.03.010
 H. Wang et al. / PM R 8 (2016) 990-996
increase treatment options for lung cancer, few thera-
peutic approaches are available to relieve symptom
burden such as fatigue, dyspnea, cachexia, depression,
and sleep disturbance, which significantly impair the
overall quality of life. Patients with lung cancer also have
a high incidence of concomitant chronic respiratory dis-
ease, which leads to ventilatory impairment or gas ex-
change disturbance. In a recent study of patients with
newly diagnosed lung cancer [13], it was found that 73% of
men and 53% of women presented with clinically signifi-
cant COPD. Performance status determines the thera-
peutic decisions and may exclude patients from receiving
a specific therapy [14]. Low exercise tolerance is associ-
ated with worse outcomes after surgery [14], suboptimal
response to chemotherapy [15], and reduced survival
[16]. Chest physiotherapy along with exercise training has
been shown to reduce symptoms, increase exercise
tolerance, and improve quality of life [17-20].
Cancer rehabilitation is defined by Silver and col-
leagues as “medical care that should be integrated
throughout the oncology care continuum and deliv-
ered by trained rehabilitation professionals who have
it within their scope of practice to diagnose and treat
patients’ physical, psychological and cognitive im-
pairments in an effort to maintain or restore function,
reduce symptom burden, maximize independence and
improve quality of life in this medically complex
population” [21]. Impairment-driven cancer rehabili-
tation has been reported to play a critical role in
minimizing disability and maximizing quality of life
[22]. Pulmonary rehabilitation has also been increas-
ingly recognized as a cost-effective intervention for
patients with chronic lung disease by integrating ex-
ercise training and education into an individualized
program. Studies of patients with lung cancer who
initially were considered nonsurgical candidates
because of poor maximum oxygen uptake (VO2 max)
were conducted [23,24]. Pulmonary rehabilitation
achieved significant improvements in VO2 max, which
allowed the patients who met eligibility criteria for
lung surgery to undergo successful resection. Although
lung cancer type is an important contributor to health
and wellness outcomes for patients with lung cancer
receiving pulmonary rehabilitation, such studies have
not yet been undertaken. A few trials [25-27] suggest
that exercise training is safe and feasible in patients
with advanced stage lung cancer and that increased
physical activity may improve exercise tolerance and
symptom burden; however, the regimens have been
diverse in terms of location, duration, and exercise
intensity. The optimal regimen to be recommended
remains unclear. In this article we review, generally,
how pulmonary rehabilitation can be used with
patients who have lung cancer to improve their quality
of life during and after tumor resection and/or
chemotherapy by focusing on validated approaches for
pulmonary rehabilitation.
991
Principles of Pulmonary Rehabilitation in Patients
With Lung Cancer
Pulmonary rehabilitation for patients with lung can-
cer has 3 key elements: a specific plan for each patient,
a multidisciplinary team, and recognition of all the
elements of the disease (Figure 1). Comprehensive
assessment of the patients for pulmonary rehabilitation
is critical to develop an appropriate, individualized plan
of care. The exercise capacity, quality of life, and dys-
pnea should be assessed by utilizing specific measure-
ment tools to provide information that will guide
exercise prescription and to evaluate the effectiveness
of the rehabilitation program. Physicians and allied
health care professionals including nurses, respiratory
personnel, physical therapists, dietitians, and social
workers all play important roles in the rehabilitation
program. For patients with lung cancer, the important
psychological, emotional, and social aspects of the
disease, in addition to the physical aspects, also need to
be adequately addressed.
Exercise Training
Physical inactivity is common in patients with lung
cancer, especially in advanced stages, because of
disease-related symptoms and treatment adverse ef-
fects. Exercise training under the supervision of reha-
bilitation professionals is the foundation of pulmonary
rehabilitation programs [28]. It involves a set of planned
and structured activities with the goal of improving
strength, endurance, and exercise capacity. Exercise
training is applicable to any stage of lung cancer.
However, it should be prescribed with consideration of
overload, progression, specificity, and reversibility [29].
In patients with NSCLC, 8 weeks of aerobic interval ex-
ercise training has been shown to improve exercise ca-
pacity and alleviate fatigue and dyspnea [19]. Chen et al
[18] found that a 12-week home-based walking exercise
program was effective in managing depression and
anxiety in lung cancer survivors. Quist et al [17] re-
ported that a 6-week structured, supervised hospital-
based and group-based exercise program in patients
with advanced-stage lung cancer, such as NSCLC IIIb-IV
and extensive disease small cell lung cancer, leads to
improved physical and functional capacity, reduced
anxiety level, and uplift in emotional well-being without
any effect on overall health-related quality of life.
Pulmonary complications related to chemotherapy and
radiotherapy are often exacerbated in patients with lung
cancer. Fatigue and loss of appetite/weight are common
complications of chemotherapy and radiotherapy. The
latter will be discussed in the nutritional support section.
Interventions aimed at improving pulmonary function and
exercise tolerance can be achieved in these patients
through pulmonary rehabilitation management [30]. In a
trial of 18 patients with advanced lung cancer (stage IIIA-B
992 Pulmonary Rehabilitation in Lung Cancer
Figure 1. The key components of pulmonary rehabilitation for patients with lung cancer.
and IV) who received intensive chemotherapy and radio-
therapy, an inpatient chest physiotherapy program was
initiated with a focus on breathing control, breathing
exercises, relaxation training, upper and lower extremity
exercises, mobilization, and transcutaneous nerve stim-
ulation. This physiotherapy program was shown to signif-
icantly decrease fatigue and dyspnea and improve
exercise capacity and quality of life [20]. Tarumi et al [31]
reported that in patients with NSCLC who underwent
induction chemoradiotherapy, pulmonary function was
significantly improved after a 10-week pulmonary
rehabilitation program as measured by forced vital ca-
pacity (FVC) and forced expiratory volume in 1 second
(FEV1). Tokarski et al [32] found that pulmonary rehabil-
itation increased partial pressure of oxygen (pO2) and
oxygen saturation (SaO2) in blood along with improved
FEV1 and FVC in patients with NSCLC undergoing first-line
chemotherapy.
Exercise training applied before and after surgery is
proven to improve exercise capacity and quality of life
and reduce symptoms associated with lung cancer in
patients [33-35]. It enhances 6-minute walk distance
and preoperative oxygen consumption. In a randomized
controlled trial, Edvardsen et al [36] conducted a 20-
week high-intensity endurance and strength training in
patients with lung cancer 5 to 7 weeks after surgery.
These investigators found that the exercise regime was
well tolerated and there was substantial improvement
in peak oxygen uptake, carbon monoxide transfer fac-
tor, functional fitness, total muscular mass, and
muscular strength. Additionally, the authors found no
association between improvement in peak oxygen up-
take and pulmonary function, the number of lung seg-
ments removed, and cardiopulmonary comorbidities
[36]. It is also important to note that the reduction in
VO2 peak and lack of improvement 6 months after lung
cancer surgery cannot be explained by the extent of
surgical resection or the amount of tissue resected [37].
For patients who had lung resection surgery, 4 weeks of
aggressive inpatient pulmonary rehabilitation reduced
dyspnea, improved 6-minute walk distance, and
increased FEV1 and FVC [38]. Hoffman et al [39]
enrolled 7 post-thoracotomy patients with NSCLC in a
home-based rehabilitative exercise program immedi-
ately upon hospital discharge. This intervention
improved functional status and quality of life and
reduced cancer-related fatigue. Preoperative pulmo-
nary rehabilitation can also reduce postoperative
morbidity such as incidence of atelectasis [40], facili-
tate a prompt recovery, and decrease the length of
hospital stay. However, it may be challenging to
implement pulmonary rehabilitation in the period
between diagnosing NSCLC and surgical treatment
because patients and health care providers want the
cancer to be surgically removed as soon as possible [41].
The duration of pulmonary rehabilitation in most
studies ranges from 4 to 7 weeks, but further trials are
required to address the minimal effective duration.
Short interventions have been reported to produce
positive outcomes with improved postoperative lung
re-expansion evidenced by shorter chest tube times [41]
and decreased length of hospital stay [42].
 H. Wang et al. / PM R 8 (2016) 990-996
Education
Education is a vital element of comprehensive pul-
monary rehabilitation and is included in nearly all pro-
grams. Structured education in the form of patient
education classes enhances follow-through with thera-
peutic regimens in patients, compared with those who
did not receive classes [43]. Jeong and Yoo [44]
demonstrated that an education program including in-
struction for splint cough, airway clearance techniques,
diaphragm breathing, segmental breathing, and exer-
cises in patients with lung cancer after lung resection
could provide a positive effect on pulmonary function
(ie, increased FVC and FEV1). Most patients with lung
cancer experience fatigue as a result of cancer pathol-
ogy and treatment such as chemotherapy and/or radi-
ation. A randomized controlled trial by Wangnum et al
[45] showed that a multidisciplinary education program
in self-care decreased fatigue in patients with lung
cancer who are receiving chemotherapy. Fatigue, anxi-
ety, and breathlessness are considered cluster symp-
toms, which frequently occur simultaneously in patients
with advanced lung cancer. Radiotherapy often worsens
the clusters [46,47], despite its effectiveness in
reducing pain and large airway obstruction. Chan et al
[48] investigated a psychoeducational intervention in
patients with lung cancer before and after radiotherapy.
The intervention involved educating patients on the use
of progressive muscle relaxation and management of
symptoms. Psychoeducational intervention was also
found to be a favorable treatment for mitigating the
effects of this symptom cluster after palliative RT, and
improved functional ability was also noted in patients.
Patient education can improve postsurgical recovery
for many surgical procedures, including lung tumor
resection. Preoperative teaching can provide beneficial
effects on postoperative outcomes after thoracic sur-
gery [49,50]. Preoperative anesthesia teaching can
enhance patient knowledge of anesthesia care options,
mitigate anxiety and fear, and reduce postoperative
analgesic requirements [51,52]. Additionally, preoper-
ative physiotherapy education can lessen complications
and even shortens hospital stays associated with surgical
procedures [42,53].
Nutritional Support
Malnutrition is associated with a poor prognosis and
infections in patients with lung cancer after surgery
because of suppressed cell-mediated immunity and
impaired wound healing. Cellular effects of malnutrition
involve reduced surfactant production and protein syn-
thesis, and physiologic responses can include reductions
of peripheral muscle function, respiratory muscle force,
exercise tolerance, and health-related quality of life
[54]. Weight loss and muscle wasting are common in
patients with lung cancer. It has been shown that weight
993
loss starts early during chemoradiotherapy for NSCLC
even prior to onset of esophagitis and further body
weight loss occurs despite nutritional supplementation
[55]. It is recommended that these patients receive
intense nutritional intervention, especially in the
background of increased exercise-related energy
expenditure. Nutrition therapy for patients currently
receiving treatment or during recovery centers around
providing missing nutrients and maintaining nutritional
health to mitigate complications such as muscle and
bone loss. A study performed at the Australian Cancer
Center showed that a 2-month cancer nutrition reha-
bilitation program that included individualized nutri-
tional intervention in combination with exercise training
improved mean weight, endurance, and strength in
patients with cancer [56]. Increased caloric intake
during pulmonary rehabilitation resulted in better ex-
ercise performance in patients with COPD [57]. Murphy
et al [58] found that nutritional intervention with 2.2 g
of fish oil daily can maintain weight and muscle mass for
patients with NSCLC during chemotherapy [58]. An oral
nutritional supplement containing n-3 polyunsaturated
fatty acids demonstrated positive effects on quality of
life, performance status, and physical activity in pa-
tients with NSCLC undergoing multimodality treatment
[59]. In another study performed in patients with NSCLC
undergoing chemotherapy, it was reported that an oral
nutritional supplement of eicosapentaenoic acid signif-
icantly improves body composition, energy, and protein
intake while reducing fatigue, loss of appetite, and
neuropathy [60]. Nutritional wellness is important for
patients in remission or whose cancer has been
controlled.
Psychosocial Support
Difficulties in coping, depression, and anxiety are
common in patients with lung cancer. Patients with
advanced COPD are known to experience elevated
depression and anxiety. These psychological effects can
enhance the perceived dyspnea severity and are asso-
ciated with poor social, physical, and quality of life of
patients [61]. Psychosocial and behavioral intervention
in pulmonary rehabilitation can include educational
training, cognitive behavioral therapy, and support
groups focusing on stress management and progressive
muscle relaxation [62]. The benefits of these in-
terventions for patients include a better appreciation of
the physical and psychological changes associated
with lung cancer, better self-management and adher-
ence to the treatment plan, and active participation in
treatments. Additionally, breathing strategies such as
diaphragmatic and pursed-lip breathing, work simplifi-
cation and energy conservation, and advance directives
can be integrated into didactic sessions to accentuate
the patients’ benefit.
994 Pulmonary Rehabilitation in Lung Cancer
Barriers of Pulmonary Rehabilitation in Lung Cancer
Despite evidence supporting the role of rehabilitation
in managing lung cancer symptoms, rehabilitation needs
are inadequately recognized with inadequate referral.
Several factors prevent pulmonary rehabilitation from
being offered to patients with lung cancer. Two signifi-
cant barriers are oncology providers’ lack knowledge of
these services and long waiting times at rehabilitation
centers [63]. Overcoming these 2 barriers could greatly
improve access to pulmonary rehabilitation and quality
of life for patients with lung cancer and survivors. In
addition, symptom burden and comorbidities make it
challenging to complete the pulmonary rehabilitation
program. Temel et al [64] reported that patients with
lung cancer who completed an exercise program experi-
enced improvements in lung cancer symptoms, but they
found that fewer than 50% of these patients were able to
complete their exercise programs [64]. Pulmonary reha-
bilitation provided in the inpatient setting generally has
the same benefits as programs provided in outpatient
hospital-based settings [65]. However, inpatient pulmo-
nary rehabilitation is limited by increased cost, the po-
tential risk of being institutionalized, and the available
number of beds. The duration of programs is defined by
the reimbursement system rather than by the individual
patient’s need. Currently, Medicare and most private
insurance companies cover pulmonary rehabilitation for
beneficiaries with COPD. Despite growing evidence of a
favorable impact, pulmonary rehabilitation for lung
cancer is considered experimental and investigational,
and national coverage has not yet been determined.
Services that make up pulmonary rehabilitation individ-
ually may fall into various applicable benefit categories
and be covered through the local coverage determination
process or on a case-by-case basis.
A study of Australian general practitioners who care
for people with COPD identified 4 categorical barriers to
referral, which include minimal knowledge of pulmo-
nary rehabilitation in the management of people with
COPD, minimal knowledge of the referral process, dif-
ficulties with access to pulmonary rehabilitation by their
patients, and questions about the need to further pro-
mote exercise behavior change in this patient group
[66]. The use of long-term oxygen therapy and living
alone have been identified as independent predictors of
poor attendance in patients with stable COPD, whereas
current smoking, poor shuttle walk distance, and hos-
pitalization are independent predictors of poor adher-
ence to pulmonary rehabilitation [67].
Conclusions
Interest in implementing pulmonary rehabilitation
in patients with lung cancer is gaining momentum.
Comprehensive pulmonary rehabilitation tailored indi-
vidually to patients with lung cancer has been shown to
enhance exercise tolerance, reduce symptoms, and
improve quality of life. Behavioral modification
including smoking cessation, adequate nutrition, and
adherence to physical activities provide sustainable
benefits that extend well beyond program completion.
However, symptom burden, comorbidities, lack of
awareness of benefit, and limited access to rehabilita-
tion center are the major barriers to pulmonary reha-
bilitation in patients with lung cancer and other chronic
respiratory lung diseases. Large randomized controlled
clinical trials are required to validate the efficacy and
improve the quality of pulmonary rehabilitation for
patients with lung cancer and survivors.
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Disclosure
H.W. Department of Physical Medicine & Rehabilitation, Montefiore Medical
Center, Albert Einstein College of Medicine, Bronx, NY
Disclosure: nothing to disclose
X.L. Penn State Hershey Cancer Institute, Pennsylvania State University College
of Medicine, Hershey, PA
Disclosure: nothing to disclose
S.J.R. Penn State Hershey Cancer Institute, Pennsylvania State University
College of Medicine, Hershey, PA
Disclosure: nothing to disclose
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anxiety in patients with chronic obstructive pulmonary disease.
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C.P.B. Penn State Hershey Cancer Institute, Pennsylvania State University
College of Medicine, 500 University Dr, Hershey, PA 17033. Address correspondence
to: C.P.B.; e-mail: cpbelani@hmc.psu.edu
Disclosure: nothing to disclose
Submitted for publication October 27, 2015; accepted March 30, 2016.