Lung cancer is the most common cause of cancer death in the UK. Our study aims to assess whether early prehabilitation is feasible in these patients. Many patients aren’t fit for anticancer treatment, due to a combination of burden of disease, patient fitness and comorbidities. These issues affect energy levels and performance status, which results in anticancer treatment becoming less tolerable. Currently, the most common treatment for locally advanced and metastatic lung cancer is best supportive care.
All patients with likely locally advanced or metastatic thoracic malignancy were seen by a district general hospital in South East Scotland. Patients were invited to participate in the project if they had involved mediastinal lymph nodes, or over metastatic disease on a CT scan.
A range of assessments followed, including the PG Subjective Global Assessment, EORTC Quality of Life Questionnaires C30 and LC13, Eastern Cooperative Oncology Group Performance Status, and the Charlson Comorbidity Index. Each patient was given three specialist personalised interventions, one from each of: palliative care physician, physiotherapist, and a dietitian. The purpose of this plan was to bridge the gap between diagnosis and start of treatment and the aim was to have the first prehabilitation consultation within 10 days of their new patient appointment.
Four key outcomes were identified for tracking throughout: weight change, active treatment rates, admission rates, and overall survival.
94% of patients attended at least one of the three assessments, with all three assessments being completed by 84%. Palliative care involved 47 patients, 20 required follow-up via telephone, 8 of whom needed more than one contact. Medication changes were made in 25 consultations, and specific symptom advice given on 16 occasions. Results showed that pain was the dominant symptom, followed by coughing and a shortness of breath. Only 3 of 49 patients had no dominant symptom. Dietic assessments had 46 patients reviewed, 19 required one follow-up appointment, while a further 19 patients required more than one. Results broadly fell into 3 topics: need for oral nutritional supplements, need for food first fortification advice, and general dietary advice. Physiotherapy assessments reviewed 44 patients, who received 89 interventions. 6 patients were assessed without follow-up, 9 had one follow-up, whilst 29 had more than one. The dominant theme in area was the number of patients who experienced breathlessness. Only 2 out of 42 patients were suitable for reference to join a gym. Palliative care results showed that pain was the dominant symptom to discussion within palliative care consultation, followed by coughing and a shortness of breath. Only 3 of 49 patients did not have an obvious dominant symptom.
Figure 1. Patient flow for patients who were offered prehabilitation within the EPIC project.
Figure 2. The major themes of the consultations in those attending prehabilitation.
Figure 3. Resource Implications for the EPIC project.
In conclusion, it is clear to see that early prehabilitation is feasible alongside the investigation of locally advanced and metastatic lung cancer. Patients joined their assessments in high rates too (84%). Although it is difficult to establish if some uptake in patients’ follow ups may be linked to the COVID pandemic, further work will aim to assess its impact on admission to hospitals, survival, and treatment rates. Patients with lung cancer are often comorbid with a high system burden, and support must be put forward for them. One of the aims of this project was to help identify endpoints for a prehabilitation clinical trial, with possible end points including; treatment rates, overall survival, and a reduction of hospital admissions following prehabilitation. We hope to explore this at the project enfolds.
As demonstrated by the results of this study, we know that prehabilitation can successfully be delivered in parallel with the investigation of a likely diagnosis in lung cancer.