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M. Missel

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    MS 19 - Global Nursing Issues in Lung Cancer (ID 37)

    • Event: WCLC 2015
    • Type: Mini Symposium
    • Track: Nursing and Allied Professionals
    • Presentations: 1
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      MS19.04 - The Importance of Pre- and Early Postoperative Rehabilitation in NSCLC Patient (Design and Rationale for the PROLUCA Study) (ID 1934)

      14:15 - 15:45  |  Author(s): M. Missel

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      Background Exercise has been introduced to improve physical capacity (VO~2peak~ and 1RM) and quality of life and to reduce symptoms and side-effects of treatment in patients with cancer, mostly investigated in patients with breast cancer (1,2). Against this background a feasibility study was developed to investigate the safety and feasibility of a preoperative and postoperative exercise program in patients undergoing surgery for lung cancer (3). The study concluded that the preoperative exercise program was not feasible. However, initiation of exercise two weeks postoperatively for patients with NSCLC was safe and feasible. A randomized clinical trial (PROLUCA) was therefore developed to investigate the efficacy of a postoperative exercise intervention in a non-hospital setting. Objectives The objective of the presented study was to explore operable lung cancer patient experiences with the postoperative exercise intervention from a longitudinal perspective according to patient motivation and patient perceived benefits and barriers of exercise. Methods This qualitative component formed part of the randomized control trial (PROLUCA) comparing the efficacy of early initiated postoperative exercise (initiated two weeks after surgery) with the effect of exercise initiated 14 weeks after surgery (usual care). NSCLC patients referred for surgery at the Department of Thoracic Surgery, Copenhagen University Hospital, were recruited for the exercise intervention. More details on the RCT study can be found in the published protocol by Sommer et al. (3). Nineteen patients enrolled in the exercise intervention two weeks post-surgery participated in qualitative interviews at three time points; the day after surgery, 7 weeks post-surgery and 4 months post-surgery. An analysis based on Ricoeur’s theory of interpretation was conducted in a phenomenological hermeneutical approach (4). Results The patient sample’s mean age was 63 years (range 48–75). Patients underwent video-assisted thoracoscopic surgery (VATS) with intent to cure. The majority (79 %) had comorbidities, including chronic obstructive pulmonary disease (26 %), cardiovascular disease (26 %) and hypertension (26%). Pre-illness physical activity levels of the patients showed that 47 % had not met the national recommendation for physical activity. Patients started exercising 15 days following surgery (median) (range 14–41 days). Delay was due to postoperative complications (pain, pneumothorax, pneumonia, atrial fibrillation, general discomfort). Eight participants dropped out of the intervention. Reasons for non-adherence included chemotherapy side effects (nausea, fatigue) (n=3), other reasons (n=1), fractured arm (n=1), work (n=1), terminally ill husband (n=1) and death (n=1). The mean attendance rate for the 11 participants who completed the intervention was 82 % (range 58–100 %). No patients experienced severe adverse events (e.g. heart- or respiration stop) during or following exercise. The interview findings are organized into three themes reflecting the timespan related to the patients’ treatment trajectory: 1) Pre-intervention motivation for participation; 2) Benefits and barriers of the intervention; 3) Overall experiences with the intervention. Motivation for participation included patients’ expectations of physical benefits and the security of having professionals present. Patients experienced physical and emotional benefits and affirmed their social identity, including improved breathing and increased well-being and energy level. Group training had social benefits and the patients experienced a sense of belonging. Exercising with others in a similar circumstance was meaningful to the patients and created a sense of community. Barriers were primarily related to side-effects of chemotherapy. The intervention put the patients on track to a healthier lifestyle regarding physical activity and smoking, and regaining vitality and energy increased the participants’ faith in the future. The patients were satisfied with the exercise intensity level, contents and variation and felt that after 12 weeks of two 60-min weekly sessions they had regained a good amount of strength and energy. Two of the eight patients who were undertaking adjuvant chemotherapy started training on completion of their treatment, while three other patients exercised while being treated. Discussion To our knowledge, this is the first study that addresses operable NSCLC patient perspectives on participating in an exercise intervention during the immediate post-surgical period and subsequent chemotherapy. The sample of the 19 patients included in the interview study appears to be a select group of operable lung cancer patients. So far it has not been possible to compare the interview sample with the larger sample of the trial and therefore not possible to discuss representativeness of the selected sample. However, when comparing the interview study sample with other operable lung cancer patients, it appears that the study patients are a little younger, better educated, have early stage disease, good performance status and are used to physical activity. Although this sample is comparable with other lung cancer exercise samples (5), this suggests social inequality related to the intervention’s design. This might also explain why the operable lung cancer patients consented to participate in the intervention and changed their behaviour—a finding that is not comparable with the general lung cancer population reported to have particularly low levels of physical activity during the post-treatment period (6) and with patients engaged in light physical activity (7). Despite the fact that the studied sample might be a select group, the diagnosis appears to represent “a teachable moment” as discussed by Demark-Wahnefried and colleagues (8), and the intervention seem to assist the patients by increasing their physical function and energy, their well-being and improve their social capital. Eleven of the patients completed the intervention with a mean attendance rate of 82 %, which is comparable with other exercise intervention studies (9). This result underscores the patients’ desire and ability to complete the intervention. Reasons for dropping out of the intervention were due to external conditions unrelated to the intervention or due to chemotherapy side effects. Conclusion This study contributes to the literature by taking into account patient perspectives of exercise interventions. The supervised intervention was undertaken safely by operable lung cancer patients initiated 2 weeks after surgery. This select group of lung cancer patients experienced physical and emotional benefits and affirmed their social identity. This qualitative study indicates that exercise is beneficial for lung cancer patients in the postsurgical trajectory and especially for those who were physically active and motivated pre-illness. References 1. Adamsen L, Quist M,Andersen C, Moller T, Herrstedt J, Kronborg D et al (2009) Effect of a multimodal high intensity exercise intervention in cancer patients undergoing chemotherapy: randomised controlled trial. BMJ 339:b3410 2. Mishra SI, Scherer RW, Snyder C, Geigle PM, Berlanstein DR, Topaloglu O (2012) Exercise interventions on health-related quality of life for people with cancer during active treatment. Clin Otolaryngol 37(5):390–392 3. Sommer MS, Trier K, Vibe-Petersen J, Missel M, Christensen M, Larsen KR et al (2014) Perioperative rehabilitation in operation for lung cancer (PROLUCA)—rationale and design. BMC Cancer 14:404-2407–14-404 4. Ricoeur P (1976) Interpretation Theory. Discource and the surplus of meaning. TCU Press, Texas 5. Jones LW, Eves ND, Spasojevic I,Wang F, Il'yasova D (2011) Effects of aerobic training on oxidative status in postsurgical non-small cell lung cancer patients: a pilot study. Lung Cancer 72(1):45–51 6. Coups EJ, Park BJ, Feinstein MB, Steingart RM, Egleston BL, Wilson DJ et al (2009) Physical activity among lung cancer survivors: changes across the cancer trajectory and associations with quality of life. Cancer Epidemiol Biomarkers Prev 18(2):664–672 7. Lin YY,Wu YC, RauKM, Lin CC (2013) Effects of physical activity on the quality of life in Taiwanese lung cancer patients receiving active treatment or off treatment. Cancer Nurs 36(4):E35–E41 8. Demark-Wahnefried W, Aziz NM, Rowland JH, Pinto BM (2005) Riding the crest of the teachable moment: promoting long-term health after the diagnosis of cancer. J Clin Oncol 23(24):5814–5830 9. Kjaer TK, Johansen C, Ibfelt E, Christensen J, Rottmann N, Hoybye MT et al (2011) Impact of symptom burden on health related quality of life of cancer survivors in a Danish cancer rehabilitation program: a longitudinal study. Acta Oncol 50(2):223–232

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