Breathing Easier: Pulmonary Rehabilitation Can Improve Function for Some With Lung Cancer

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CURE, Lung Cancer Special Issue, Volume 1, Issue 1

Pulmonary rehabilitation is a medical program designed for people facing chronic lung disease. It was first implemented for patients with COPD, and since has expanded to include patients with other diagnoses such as pulmonary fibrosis and even lung cancer.

Imagine a therapy free of drugs and side effects, one that allows you to be surrounded by people facing similar diagnoses while promoting camaraderie, time to ask questions, a change in behavior to promote health and an enhancement of your quality of life. This treatment, known as pulmonary rehabilitation, is not a cure, but many people with chronic lung diseases are given the recommendation to participate with good reason.

Pulmonary rehabilitation (aka pulmonary rehab, or PR) is a medical program designed for people facing chronic lung disease. It was first implemented for patients with chronic obstructive pulmonary disease (COPD), and since has expanded to include patients with other diagnoses such as pulmonary fibrosis (lung scarring) and even lung cancer. The program is multidisciplinary, and includes the input of physicians, respiratory therapists, physical therapists, occupational therapists, psychologists, dieticians and/or nutritionists.

What does PR entail?

Patients start the program with a thorough medical assessment, followed by tailored, individualized sessions focused on exercise training, education, breathing techniques and behavioral change.

Supervised exercise training can increase upper and/or lower body strength using a combination of cyclers, treadmills and/or free weights. Educational sessions can help patients better understand their chronic lung disease; the reason for, and proper use of, any medications they may be taking for these conditions; the benefits of smoking cessation; and the relationship between disease and symptoms. Commonly taught breathing techniques are pursed-lips breathing and/or diaphragmatic breathing.

After completing the program, patients are encouraged to implement their learning and perform home exercises to help enhance long-term health. The program typically lasts four to 12 weeks, consisting of two to three sessions per week. In patients with chronic lung disease, PR has been shown to improve symptom burden (including shortness of breath) and exercise capacity, increase participation in everyday activities, promote autonomy, enhance quality of life and affect long-term behaviors that boost health.

Which patients with lung cancer may be eligible for PR?

Chronic lung diseases commonly considered for PR include COPD, interstitial lung disease (ILD)/pulmonary fibrosis, cystic fibrosis, bronchiectasis and pulmonary hypertension. Patients with lung cancer, partly due to their tendency to present at late (advanced) stages, are not traditionally considered to be good candidates for PR. However, there is emerging evidence that PR in lung cancer can lead to improved outcomes.

In addition, some chronic lung diseases, notably COPD and pulmonary fibrosis, are linked to lung cancer. Therefore, it is not uncommon for patients with lung cancer to have other co-existing chronic lung diseases that, in turn, benefit from PR. For instance, in one 2006 study that appeared in the journal Chest, COPD was found to be present in approximately 70 percent of men and 50 percent of women newly diagnosed with lung cancer.

Moreover, while lung cancer itself is highly challenging as both a chronic and frequently fatal illness, it is treatable and even curable in a subset of patients that are diagnosed at a relatively early stage. Yet, in some patients with early-stage lung cancer, where surgery and radiotherapy are commonly employed with curative intent, the chronic impact of lung resection or radiation can significantly impair functional status and lung function. PR may be appropriate in this subset of patients. What are the benefits of PR in lung cancer?

The most common settings in which PR is used in lung cancer are before and/or after surgery. Before surgery, participation in PR can potentially lower the risk of having complications related to the procedure, a benefit that can lead to decreased time on life support, shorter duration of hospitalization and/or lower chances of acquiring hospital-associated infections. When used in this setting, the duration of PR is typically shortened so as to not delay the time to treatment (it’s abbreviated to between two and four weeks, instead of the typical eight to 10 weeks).

After lung cancer surgery, patients usually experience a decline in lung function, since portions of their lungs have been removed. As a result, some can develop exercise limitations and experience persistent symptoms (including shortness of breath and fatigue) and decreased quality of life. According to a 2009 German study, these effects are known to be most evident at three months after surgery, but can persist beyond one year. In such circumstances, PR can reduce some of the residual effects of lung cancer surgery, restore exercise capacity and improve symptoms, quality of life and long-term health.

In patients with advanced lung cancer (not typically surgical candidates), the effects of the disease itself, including shortness of breath, fatigue, deconditioning, muscle weakness, muscle wasting and anxiety, can be very limiting and disabling. Many patients with advanced lung cancer, therefore, are unable to participate in the traditional PR programs. Instead, home-based and less-intensive exercise programs have been designed to be better tolerated and feasible. In recent studies, these programs have been shown to potentially reduce symptoms and improve sleep quality and quality of life. In those undergoing chemotherapy and/or targeted therapy, the programs can also improve patients’ ability to tolerate those treatments.

Is it safe?

In clinical practice, some clinicians have recommended limited activity in cancer patients to avoid making symptoms worse. Patients, sometimes at the encouragement of supporting family members, have also been known to limit their activities to prevent “getting worse.” Loved ones might ask: “Should you be exercising? After all, shouldn’t you rest and take it easy since your cancer is already limiting you so much?” Not according to medical evidence. For all but those with severe musculoskeletal and/or neurologic deficits that limit physical activity, exercise is encouraged.

Inactivity can compound symptoms of lung cancer, resulting in a “downward spiral” of declining health, in which symptoms such as shortness of breath and fatigue lead to more inactivity, in turn accelerating the worsening of symptoms. Stopping such a downward spiral is a goal of PR and/or exercise programs. When symptoms are controlled through exercise, patients experience fewer symptoms on a day-to-day basis, improving their work capacity and endurance, and are thus able to do more. The result is better quality of life and improved overall health. Exercise and physical activity, especially through a guided (PR) protocol, are therefore safe, encouraged, and can provide clinical benefits in lung cancer.

How do I enroll in pulmonary rehabilitation?

To be considered for PR, you will need a referral from your health care provider (such as your local pulmonologist or primary care physician). Insurance coverage varies according to the specific disease and disease severity. Currently, PR is covered by Medicare for patients with COPD; other chronic lung diseases may also be covered, but this varies by regions of the country. Private insurance coverage also varies greatly. The coordinator of any pulmonary rehabilitation program you are considering joining can tell you if you qualify and what the cost will be.

PR programs are available at both teaching/academic and private institutions. To search for a program in your area, visit here and here.

What can I do on my own?

Exercise is a key component of PR. CURE previously published an article on the benefits of exercise in lung cancer. In this article, recommendations were to start off with short periods of moderate activity several times a day, such as 10- to 15-minute walks three times a day, with the goal of exercising for at least 30 minutes a day, at least five times a week. However, these recommendations were meant to serve as a starting point. The key is to find what you’re able to do physically and build on it. Some exercise, at any duration or intensity, is likely to be better than no exercise at all.

Duc Ha, MD, Philippe Montgrain, MD, and Mark Fuster, MD, are from the University of California San Diego and VA San Diego Healthcare System