Thoracic Oncology and Surgery

  • Catherine L. GrangerEmail author
  • Gill Arbane


Pulmonary rehabilitation is an important component in the management of lung cancer. It aims to minimise physical and psychological impairments which commonly occur in patients following a diagnosis of lung cancer. There are well-established clinical guidelines regarding exercise for patients with cancer. These recommend at least 150 min of moderate intensity physical activity and two to three resistance training sessions per week, and avoidance of sedentary time. The evidence for exercise specifically in lung cancer is growing rapidly. It shows that pulmonary rehabilitation is associated with improvements in exercise capacity, muscle strength and symptoms, especially when delivered after surgery. Pulmonary rehabilitation before surgery (prehabilitation) is also associated with reduced post-operative complications and hospital length of stay. Pulmonary rehabilitation during chemotherapy or radiotherapy, and for patients with advanced palliative disease appears to be effective at reducing symptoms and improving and/or maintaining exercise capacity and muscle strength. This chapter begins by providing an overview to the topic of thoracic oncology and specifically focuses on lung cancer. The chapter summarises the symptoms of lung cancer, medical treatment and side-effects, common impairments, and the evidence for physical activity and exercise training. It also outlines a number of specific considerations for delivery of pulmonary rehabilitation in the lung cancer setting including patient assessment, exercise prescription, safety, and timing of delivery across the cancer disease trajectory.


  1. 1.
    Australian Institute of Health and Welfare & Australasian Association of Cancer Registries. (2012). Cancer in Australia: an overview 2012. Cancer series no. 74. Cat. no. CAN 70. Canberra: AIHW.Google Scholar
  2. 2.
    Ervik, M., Lam, F., Ferlay, J., Mery, L., Soerjomataram, I., & Bray, F. (2016). Cancer today. Lyon, France: International Agency for Research on Cancer. Cancer Today. Available from:, accessed [27/09/2016].
  3. 3.
    NICE. (2011). National Institute for Health and Clinical Excellence Clinical Guidelines, CG 121 Lung cancer: The diagnosis and treatment of lung cancer.Google Scholar
  4. 4.
    Smith A, Reeve B, Bellizzi K, Harlan L, Klabunde C, Amsellem M, et al. Cancer, comorbidities, and health-related quality of life of older adults. Health Care Financ Rev. 2008;24(9):41–56.Google Scholar
  5. 5.
    Dela Cruz C, Tanoue L, Matthay R. Lung cancer: epidemiology, etiology, and prevention. Clin Chest Med. 2011;32(4):605–44.CrossRefGoogle Scholar
  6. 6.
    NCCN. (2012). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines): Non-small Cell Lung Cancer. National Comprehensive Cancer Network, Version 3; 2012.Google Scholar
  7. 7.
    Loewen G, Watson D, Kohman L, Herndon J, Shennib H, Kernstine K, et al. Preoperative exercise Vo2 measurement for lung resection candidates: results of cancer and leukemia group B protocol 9238. J Thorac Oncol. 2007;2(7):619–25.CrossRefPubMedCentralPubMedGoogle Scholar
  8. 8.
    Granger C. Physiotherapy management of lung cancer. J Physiother. 2016;62(2):60–7.CrossRefPubMedCentralPubMedGoogle Scholar
  9. 9.
    Agostini P, Cieslik H, Rathinam S, Bishay E, Kalkat M, Rajesh P, et al. Postoperative pulmonary complications following thoracic surgery: are there any modifiable risk factors? Thorax. 2010;65:815–8.CrossRefPubMedCentralPubMedGoogle Scholar
  10. 10.
    Lugg S, Agostini P, Tikka T, Kerr A, Adams K, Bishay E, et al. Long-term impact of developing a postoperative pulmonary complication after lung surgery. Thorax. 2016;71(2):171–6.CrossRefPubMedCentralPubMedGoogle Scholar
  11. 11.
    McKenna R, Houck W, Fuller C. Video-assisted thoracic surgery lobectomy: experience with 1100 cases. Ann Thorac Surg. 2006;81(2):425–6.CrossRefGoogle Scholar
  12. 12.
    Reeve J, Nicol K, Stiller K, McPherson K, Birch P, Gordon I, Denehy L. Does physiotherapy reduce the incidence of postoperative pulmonary complications following pulmonary resection via open thoracotomy? A preliminary randomised single-blind clinical trial. Eur J Cardiothorac Surg. 2010;37(5):1158–66.CrossRefPubMedCentralPubMedGoogle Scholar
  13. 13.
    Benzo R, Kelley G, Recchi L, Hofman A, Sciurba F. Complications of lung resection and exercise capacity: a meta-analysis. Respir Med. 2007;101(8):1790–77.CrossRefPubMedCentralPubMedGoogle Scholar
  14. 14.
    Brunelli A, Belardinelli R, Refai M, Salati M, Socci L, Pompili C, Sabbatini A. Peak oxygen consumption during cardiopulmonary exercise test improves risk stratification in candidates to major lung resection. Chest. 2009;135(5):1260–7.CrossRefPubMedCentralPubMedGoogle Scholar
  15. 15.
    Bolliger C, Jordan P, Soler M, Stulz P, Tamm C, Wyser M, et al. Pulmonary function and exercise capacity after lung resection. Eur Respir J. 1996;9:415–21.CrossRefPubMedCentralPubMedGoogle Scholar
  16. 16.
    Granger C, Parry S, Edbrooke L, Denehy L. Deterioration in physical activity and function differs according to treatment type in non-small cell lung cancer - future directions for physiotherapy management. Physiotherapy. 2016;102(3):256–63.CrossRefPubMedCentralPubMedGoogle Scholar
  17. 17.
    Cooley M. Symptoms in adults with lung cancer. A systematic research review. J Pain Symptom Manage. 2000;19(2):137–53.CrossRefPubMedCentralPubMedGoogle Scholar
  18. 18.
    Cheville A, Novotny P, Sloan J, Basford J, Wampfler J, Garces Y, et al. The value of a symptom cluster of fatigue, dyspnea, and cough in predicting clinical outcomes in lung cancer survivors. J Pain Symptom Manage. 2011;42(2):213–21.CrossRefPubMedCentralPubMedGoogle Scholar
  19. 19.
    Degner L, Sloan J. Symptom distress in newly diagnosed ambulatory care patients and as a predictor of survival in lung cancer. J Pain Symptom Manage. 1995;10(6):423–31.CrossRefPubMedCentralPubMedGoogle Scholar
  20. 20.
    Tanaka K, Akechi T, Okuyama T, Nishiwaki Y, Uchitomi Y. Impact of dyspnea, pain, and fatigue on daily life activities in ambulatory patients with advanced lung cancer. J Pain Symptom Manage. 2002;23(5):417–23.CrossRefPubMedCentralPubMedGoogle Scholar
  21. 21.
    Tishelman C, Petersson LM, Degner LF, Sprangers MA. Symptom prevalence, intensity, and distress in patients with inoperable lung cancer in relation to time of death. J Clin Oncol. 2007;25(34):5281–9.CrossRefGoogle Scholar
  22. 22.
    Granger C, McDonald C, Irving L, Clark R, Gough K, Murnane A, et al. Low physical activity levels and functional decline in individuals with lung cancer. Lung Cancer. 2014;83(2):292–9.CrossRefPubMedCentralPubMedGoogle Scholar
  23. 23.
    Rock C, Doyle C, Demark-Wahnefried W, Meyerhardt J, Courneya K, Schwartz A, et al. Nutrition and physical activity guidelines for cancer survivors. CA: Cancer J Clin. 2013;62(4):242–74.Google Scholar
  24. 24.
    Schmitz K, Courneya K, Matthews C, Demark-Wahnefried W, Galvao D, Pinto B, et al. ACSM roundtable on exercise guidelines for cancer survivors. Med Sci Sports Exerc. 2010;42(7):1409–26.CrossRefPubMedCentralPubMedGoogle Scholar
  25. 25.
    Coups E, Park B, Feinstein M, Steingart R, Egleston B, Wilson D, Ostroff J. Physical activity among lung cancer survivors: changes across the cancer trajectory and associations with quality of life. Cancer Epidemiol Biomarkers Prev. 2009;18(2):664–72.CrossRefPubMedCentralPubMedGoogle Scholar
  26. 26.
    Novoa N, Varela G, Jimenez M, Aranda J. Influence of major pulmonary resection on postoperative daily ambulatory activity of the patients. Interact Cardiovasc Thorac Surg. 2009;9(6):934–8.CrossRefPubMedCentralPubMedGoogle Scholar
  27. 27.
    Cavalheri, V., & Granger, C. (2015). Preoperative exercise training for patients with non-small cell lung cancer. Cochrane Database Syst Rev (7).Google Scholar
  28. 28.
    Cavalheri, V., Tahirah, F., Nonoyama, M., Sue Jenkins, S., & Hill, K. (2013). Exercise training for people following lung resection for non-small cell lung cancer. Cochrane Database Syst Rev (7), Art. No.: CD009955.Google Scholar
  29. 29.
    Crandall K, Roma Maguire R, Campbell A, Kearney N. Exercise intervention for patients surgically treated for Non-Small Cell Lung Cancer (NSCLC): a systematic review. Surg Oncol. 2014;23(1):17–30.CrossRefPubMedCentralPubMedGoogle Scholar
  30. 30.
    Granger C, McDonald C, Berney S, Chao C, Denehy L. Exercise intervention to improve exercise capacity and health related quality of life for patients with Non-small cell lung cancer: a systematic review. Lung Cancer. 2011;72(2):139–53.CrossRefPubMedCentralPubMedGoogle Scholar
  31. 31.
    Blum D, Omlin A, Baracos V, Solheim T, Tan B, Stone P, et al. Cancer cachexia: a systematic literature review of items and domains associated with involuntary weight loss in cancer. Crit Rev Oncol Hematol. 2011;80(1):114–44.CrossRefPubMedCentralPubMedGoogle Scholar
  32. 32.
    Morice R, Peters E, Ryan M, Putnam J, Ali M, Roth J. Exercise testing in the evaluation of patients at high risk for complications from lung resection. Chest. 1992;101(2):356–61.CrossRefPubMedCentralPubMedGoogle Scholar
  33. 33.
    Nezu K, Kushibe K, Tojo T, Takahama M, Kitamura S. Recovery and limitation of exercise capacity after lung resection for lung cancer. Chest. 1998;113(6):1511–6.CrossRefPubMedCentralPubMedGoogle Scholar
  34. 34.
    American Cancer Society. Cancer prevention & early detection facts & figures 2012. Atlanta: American Cancer Society Website; 2012.Google Scholar
  35. 35.
    World Health Organization. Global recommendations on physical activity for health. Geneva: World Health Organization; 2010. p. 1–58. ISBN: 9789241599979Google Scholar
  36. 36.
    Friedenreich C. Physical activity and cancer prevention: from observational to intervention research. Cancer Epidemiol Biomarkers Prev. 2001;10(4):287–301.PubMedPubMedCentralGoogle Scholar
  37. 37.
    Biswas A, Oh P, Faulkner G, Bajaj R, Silver M, Mitchell M, Alter D. Sedentary time and its association with risk for disease incidence, mortality, and hospitalization in adults: a systematic review and meta-analysis. Ann Intern Med. 2015;162(2):123–32.CrossRefPubMedCentralPubMedGoogle Scholar
  38. 38.
    Ballard-Barbash R, Friedenreich C, Courneya K, Siddiqi S, McTiernan A, Alfano C. Physical activity, biomarkers, and disease outcomes in cancer survivors: a systematic review. J Natl Cancer Inst. 2012;104(11):815–40.CrossRefPubMedCentralPubMedGoogle Scholar
  39. 39.
    Lee I, Wolin K, Freeman S, Sattlemair J, Sesso H. Physical activity and survival after cancer diagnosis in men. J Phys Act Health. 2014;11(1):85–90.CrossRefPubMedCentralPubMedGoogle Scholar
  40. 40.
    Cavalheri V, Tahirah F, Nonoyama M, Jenkins S, Hill K. Exercise training undertaken by people within 12 months of lung resection for non-small cell lung cancer. Cochrane Database Syst Rev. 2015;7Google Scholar
  41. 41.
    Granger C, Denehy L, Parry S, Oliveira C, McDonald C. Functional capacity, physical activity and muscle strength of individuals with non-small cell lung cancer: a systematic review of outcome measures and their measurement properties. BMC Cancer. 2012;13(135)Google Scholar
  42. 42.
    Arbane G, Tropman D, Jackson D, Garrod R. Evaluation of an early exercise intervention after thoracotomy for non-small cell lung cancer: effects on quality of life, muscle strength and exercise tolerance: Randomised controlled trial. Lung Cancer. 2011;71(2):229–34.CrossRefPubMedCentralPubMedGoogle Scholar
  43. 43.
    Granger C, Chao C, McDonald C, Berney S, Denehy L. Safety and feasibility of an exercise intervention for patients following lung resection: a pilot randomized controlled trial. Integr Cancer Ther. 2013;12(3):213–24.CrossRefPubMedCentralPubMedGoogle Scholar
  44. 44.
    Edvardsen E, Skjonsberg O, Holme I, Nordsletten L, Borchsenius F, Anderssen S. High-intensity training following lung cancer surgery: a randomised controlled trial. Thorax. 2015;70(3):244–50.CrossRefPubMedCentralPubMedGoogle Scholar
  45. 45.
    Cesario A, Ferri L, Galetta D, Pasqua F, Bonassi S, Clini E, et al. Post-operative respiratory rehabilitation after lung resection for non-small cell lung cancer. Lung Cancer. 2007;57(2):175–80.CrossRefPubMedCentralPubMedGoogle Scholar
  46. 46.
    Spruit M, Janssen P, Willemsen S, Hochstenbag M, Wouters E. Exercise capacity before and after an 8-week multidisciplinary inpatient rehabilitation program in lung cancer patients: a pilot study. Lung Cancer. 2006;52(2):257–60.CrossRefPubMedCentralPubMedGoogle Scholar
  47. 47.
    Henke C, Cabri J, Fricke L, Pankow W, Kandilakis G, Feyer P, de Wit M. Strength and endurance training in the treatment of lung cancer patients in stages IIIA/IIIB/IV. Support Care Cancer. 2014;22(1):95–101.CrossRefPubMedCentralPubMedGoogle Scholar
  48. 48.
    Hwang C, Yu C, Shih J, Yang P, Wu Y. Effects of exercise training on exercise capacity in patients with non-small cell lung cancer receiving targeted therapy. Support Care Cancer. 2012;20(12):3169–77.CrossRefPubMedCentralPubMedGoogle Scholar
  49. 49.
    Kuehr L, Wiskemann J, Abel U, Ulrich C, Hummler S, Thomas M. Exercise in patients with non-small cell lung cancer. Med Sci Sports Exerc. 2014;46(4):656–63.CrossRefPubMedCentralPubMedGoogle Scholar
  50. 50.
    Quist M, Rorth M, Langer S, Jones LW, Laursen JH, Pappot H, et al. Safety and feasibility of a combined exercise intervention for inoperable lung cancer patients undergoing chemotherapy: A pilot study. Lung Cancer. 2012;75(2):203–8.CrossRefPubMedCentralPubMedGoogle Scholar
  51. 51.
    Quist M, Adamsen L, Rorth M, Laursen J, Christensen K, Langer S. The impact of a multidimensional exercise intervention on physical and functional capacity, anxiety, and depression in patients with advanced-stage lung cancer undergoing chemotherapy. Integr Cancer Ther. 2015;14(4):341–9.CrossRefPubMedCentralPubMedGoogle Scholar
  52. 52.
    Temel J, Greer J, Goldberg S, Vogel P, Sullivan M, Pirl W, et al. A structured exercise program for patients with advanced non-small cell lung cancer. J Thorac Oncol. 2009;4(5):595–601.CrossRefPubMedCentralPubMedGoogle Scholar
  53. 53.
    Jastrzębski D, Maksymiak M, Kostorz S, Bezubka B, Osmanska I, Młynczak T, et al. Pulmonary rehabilitation in advanced lung cancer patients during chemotherapy. Adv Exp Med Biol. 2015;861:57–64.CrossRefPubMedCentralPubMedGoogle Scholar
  54. 54.
    National Cancer Intelligence Network. Cancer survival in England by stage 2012. London: NCIN; 2014.Google Scholar

Copyright information

© Springer International Publishing AG 2018

Authors and Affiliations

  1. 1.Department of PhysiotherapyUniversity of MelbourneMelbourneAustralia
  2. 2.Department PCCP, Guy’s and St Thomas’ NHS Foundation TrustLondonUK

Personalised recommendations