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Marisol Arroyo Hern
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IASLC Pre-Conference School of Nursing (ID 3)
- Event: LALCA 2019
- Type: Invited Speaker Session
- Track:
- Presentations: 1
- Moderators:
- Coordinates: 10/17/2019, 09:00 - 15:30, Castillo A 5-6
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PC3.05 - Respiratory Rehab of the Postoperative Patient (ID 30)
09:00 - 15:30 | Author(s): Marisol Arroyo Hern
- Abstract
Lung cancer is the most common cancer and is the leading cause of cancer death worldwide. The most common type of primary lung cancer is non-small cell lung cancer (NSCLC). 67% of patients with lung cancer have 2 or more chronic conditions, the most common one being Chronic Obstructive Pulmonary Disease. Pulmonary rehabilitation programs can be given in three stages: before surgery (prehabilitation), after surgery and in advanced disease (1). The main objective of pulmonary rehabilitation after surgery is to improve or restore impairments associated with the disease and treatment, focused on exercise capacity and muscle strength. Other benefits are to promote a healthy lifestyle, reducing symptoms, and improving quality of life. Patients with lung cancer can have several physical and psychological impairments. These include reduced exercise capacity, peripheral muscle weakness, poor respiratory function, reduced shoulder range of motion (post-surgery), low physical activity levels, poor nutrition, anxiety, depression, distress, and reduced health-related quality of life. All of these impairments are responsive to pulmonary rehabilitation(2).
Lung cancer treatment options are surgery, chemotherapy, radiotherapy, or targeted therapy. These treatments have multiple side-effects, which can cause inactivity to the patient. An exercise training program in non-lung cancer patients has demonstrated a significant impact in controlling symptoms and improving quality of life. In lung cancer patients, there is not enough scientific evidence supporting a standard pulmonary physiotherapy program, assessment of the patients impairments, and individualized exercise prescription. We should take precautions to look for contraindications before prescribing pulmonary rehabilitation to a patient. Some of the contraindications are extreme fatigue, nausea, fever, anemia, thrombocytopenia, neutropenia, lymphedema, cachexia, muscle atrophy, high risk for bone fracture, and cardiorespiratory limitation (3).
In patients who are candidates for surgery, lung resection results in an immediate reduction in VO2 peak by 12% following a lobectomy, and 18% following pneumonectomy. Exercise capacity usually recovers to baseline by six months post-lobectomy, but in the case of pneumonectomy, exercise capacity loss is still evident six months after surgery. These impairments can also be targeted with post-operative pulmonary rehabilitation (2).
The duration of a rehabilitation program varies between 3 to 20 weeks, as well as the time before surgery (4). There is no evidence for the optimal duration and timing for initiation. Although there is an improvement in the patientŽs functional status, and reducing perioperative pulmonary complications and length of stay, ambiguous results have been obtained regarding lung function improvement.
Pulmonary physiotherapy for lung resection candidates focuses on chest expansion, bronchial clearance, postural correction, and inspiratory muscle training which is practiced not only in the preoperative course but also postoperatively as a recovery and maintenance approach. The programs tested in the studies to date predominately involve aerobic and resistance exercises and are delivered as a supervised outpatient training program.
Most research has been focused on operable NSCLC (pre or post-surgery). Growing evidence supports that exercise during chemotherapy, radiotherapy, and advanced/palliative care can be beneficial for patients. Despite the evidence supporting physical activity and exercise training for people with cancer, evidence has not translated effectively into practice, and there has not been a routine integration of exercise/cancer rehabilitation programs for patients in most parts of the world.
References
1. Kendall F, Abreu P, Pinho P, Oliveira J, Bastos P. The role of physiotherapy in patients undergoing pulmonary surgery for lung cancer. A literature review. Rev Port Pneumol (2006). 2017;23(6):343-51.
2. Sebio Garcia R, Yanez Brage MI, Gimenez Moolhuyzen E, Granger CL, Denehy L. Functional and postoperative outcomes after preoperative exercise training in patients with lung cancer: a systematic review and meta-analysis. Interact Cardiovasc Thorac Surg. 2016;23(3):486-97.
3. Clini E. Textbook of pulmonary rehabilitation. New York, NY: Springer Berlin Heidelberg; 2017. pages cm p.
4. Pouwels S, Fiddelaers J, Teijink JA, Woorst JF, Siebenga J, Smeenk FW. Preoperative exercise therapy in lung surgery patients: A systematic review. Respir Med. 2015;109(12):1495-504.
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Session 1: Diagnostic Imaging Innovation (ID 13)
- Event: LALCA 2019
- Type: Invited Speaker Session
- Track:
- Presentations: 1
- Moderators:
- Coordinates: 10/18/2019, 08:30 - 09:30, Castillo A 1-4
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F1.01 - Diagnosis in LATAM Region: Differences in Access to Technology (ID 66)
08:30 - 09:30 | Author(s): Marisol Arroyo Hern
- Abstract
Inequality in service coverage and access to required assistance persist and is strongly determined by socioeconomic characteristics and geographical barriers. In Latin America (LATAM) and the Caribbean, over 30% of the population do not have access to health care for economic reasons, and 21% do not seek care because of geographical barriers. The latest available consensus shows that in 2010 there were about 42 million indigenous people in LATAM, making up nearly 8 percent of the total population. Indigenous people face significant barriers to adequate healthcare due to linguistic differences between patients and healthcare professionals (1). Likewise, indigenous families who must travel long or costly distances to get medical attention experience apathy to search for health services. Furthermore, in urban areas, the population show high levels of dissatisfaction with their health care system, which may explain why a broad population of Latin Americans with sufficient income chose private services over universal public services.
In 2018, over 60% of newly diagnosed patients with lung cancer were located in low and medium-income countries as the ones in LATAM. Therefore two-thirds of the deaths attributed to lung cancer worldwide occur in these countries. In 2009 half of the economic resources destined for cancer were addressed only for pharmacotherapy. Compared to high-income countries, only 0.125% of the per capita income is intended for treatment acquisition (2, 3).
The challenges that face LATAM to make a diagnosis and give treatment are not always related with economic factors. There are other barriers such as a) lack in investment in research, b) limitations with the current established health care services where lung cancer is not considered a priority even though is the leading cause of cancer-related death worldwide, and c) limitations in drug supplies, and its affordability. Also, the low number of cancer specialists per head of population contributes to work overload and restricts them from participating in clinical cancer research(4). This situation is deleterious to the development of clinical trials, and national health authorities should ensure sufficient cancer specialists for the population volume. In this regard, we urge governments to design and implement better public policy and infrastructure for lung cancer prevention, screening, and treatment availability.
In the last decade, lung screening programs have been established in high-income countries. However, only two extensive studies have shown benefit in lung cancer timely detection within the high-risk population. These encourage the incorporation of early lung cancer detection campaigns(5).
The experience in low-income LATAM countries is limited to a Brazilian study in which they screened 800 patients with a high prevalence of granulomatous disease as in the rest of LATAM region. This research exposes LATAM ethnic differences and environmental exposures (wood-smoke exposure) that differs from high-income countries. Screening requires medical equipment and health care personal to obtain good results when detecting a vulnerable population. A Cost-effective lung screening program is subject to demographic characteristics and how the program is designed.
Inequalities in access to health services among and within LATAM countries prevails, which means that we need to ensure equity in both access and quality of services. We need new policies that allow better coverage of human and technological resources for lung cancer patients. Until now, there is insufficient evidence for screening and treatment programs for lung cancer done in LATAM despite being the most common cancer worldwide.
References
1. OECD/CAF/ECLAC. Latin American Economic Outlook 2018: Rethinking Institutions for Development,. Paris; 2018.
2. Raez LE, Cardona AF, Santos ES, Catoe H, Rolfo C, Lopes G, et al. The burden of lung cancer in Latin-America and challenges in the access to genomic profiling, immunotherapy and targeted treatments. Lung Cancer. 2018;119:7-13.
3. Raez LE, Santos ES, Rolfo C, Lopes G, Barrios C, Cardona A, et al. Challenges in Facing the Lung Cancer Epidemic and Treating Advanced Disease in Latin America. Clin Lung Cancer. 2017;18(1):e71-e9.
4. Rolfo C, Caglevic C, Bretel D, Hong D, Raez LE, Cardona AF, et al. Cancer clinical research in Latin America: current situation and opportunities. Expert opinion from the first ESMO workshop on clinical trials, Lima, 2015. ESMO Open. 2016;1(4):e000055.
5. Kielstra P. Lung cancer in Latin America: Time to stop looking away. Economist Intelligence Unit. 2018;1(1):1-65.
