Pulmonary Rehabilitation for People With Lung Cancer

Rehab may be helpful for any stage of the disease

Male person performing lung function test by using a triflow
Can pulmonary rehabilitation help people with lung cancer?. Jan-Otto / Getty Images

Pulmonary rehabilitation for people with lung cancer is relatively new and infrequently prescribed, but the reason isn't a lack of effectiveness. It's thought that pulmonary rehabilitation prior to lung cancer surgery may reduce complications by 50%, but it's been argued that rehab should be standard of care for those with stage 4 lung cancer (metastatic lung cancer) as well, due to its positive effects on quality of life. It may also be beneficial in reducing shortness of breath and improving exercise tolerance.

While rehabilitation is an expected part of the recovery process for many medical conditions, and has recently become recognized as an essential part of a COPD treatment plan, it is greatly underutilized with lung cancer. In fact, many lung cancer survivors have had to request the service themselves. We will look at what you might expect during pulmonary rehabilitation, how it has been found to help people with lung cancer in studies to date, and what to do if you believe you could benefit.

Defining Pulmonary Rehabilitation

Pulmonary rehabilitation is a coordinated approach to improving quality of life that uses the expertise of several specialties. Some of these include respiratory therapists, physical therapists, occupational therapists, nutritionists, psychologists, exercise physiologists, and more. Even though "breathing easier" might be one goal of rehab, there are many factors that work together to improve or impede quality of life in people with cancer.

Pulmonary rehabilitation is different than chest physical therapy (also called chest physiotherapy). Chest physical therapy involves techniques used to remove excess mucus from the lungs.

What Happens During Pulmonary Rehabilitation

There are several components to pulmonary rehabilitation, though a mainstay of this treatment is education. This may include information about your cancer, nutritional information, breathing techniques, and methods for coping with the stress of a cancer diagnosis. Sessions with a pulmonary rehab specialist may include:

A Walk Test

Before beginning rehab, a therapist will often check your baseline lung function tests. She may also do something called a 6-minute walk test which will look at the distance you can walk on a firm surface for 6 minutes comfortably (if you are able to do so).

Instruction in Breathing Techniques/Strategies

There are a number of techniques that can improve breathlessness, even without an improvement in lung volumes or performance. For example, the technique known as diaphragmatic breathing can strengthen the diaphragm and decrease the fatigue of breathing. The technique of pursed-lip breathing may help decrease the sensation of shortness of breath.

Energy Conserving Techniques

There are actually many ways to be more active while reducing shortness of breath. For example, a pulmonary rehab specialist may provide instruction that includes tips for avoiding shortness of breath while eating, or tips on how to avoid reaching and bending. (Extension arms or grabbers can be priceless.)

Assistance with Medications and/or Oxygen

Instruction in the use of medications to help breathing, such as inhalers and nebulizers, can be extremely beneficial as improper use can result in less than optimal improvement in symptoms. A pulmonary rehab specialist may also help by providing education for the proper use of oxygen.

Exercise Therapy

Exercise therapy can make a significant different for many people with lung cancer, though the specific type of exercise will vary based on a person's limitations. For those who are active, aerobic exercise (such as walking on a treadmill or using an exercise bike) may improve endurance and/or increase lung capacity. Yet there are many options even for those who are unable to participate in these activities.

Respiratory Muscle Training/Weightlifting

Therapists may instruct people in training respiratory muscles to assist respiration, or encourage weightlifting to built strength in the muscles that control respiration.

Education About Airborne Triggers

Education can be helpful in helping people understand indoor air and outdoor air pollutants that can worsen their symptoms. Many people are surprised to learn that indoor air can often be more detrimental than outdoor air when it comes to breathing. This is sometimes as simple as recommending a few houseplants known to purify indoor air.

Certainly, when needed, help with smoking cessation is offered as well.

Counseling

Many people living with lung cancer struggle with anxiety and/or depression, and even those who do not can often benefit from counseling. (With breast cancer, counseling has actually been linked with improved survival.)

Counselors can be invaluable in not only helping people develop coping strategies as they face their cancer, but to understand how emotions and psychological stress can affect breathing.

Even if you find you are coping as well as you think you can, and stress isn't affecting your breathing, talking with a therapist can have benefits. Researchers are learning that people with cancer often experience posttraumatic growth, or that having cancer results in positive changes in a person's life. Talking with a counselor may help you maximize the growth you experience during your journey.

Nutrition Counseling

Weight loss is far too common among people living with lung cancer, and cancer cachexia, a syndrome that includes unintentional weight loss and muscle wasting, is thought to be the direct cause of 20 percent of cancer deaths. Shortness of breath can also interfere with eating, and counselors can offer instruction in techniques to reduce dyspnea while eating.

As an added benefit, exercise alone, though counterintuitive, appears to be one of the few ways that cachexia can be remedied or prevented.

Benefits of Pulmonary Rehabilitation With Lung Cancer

Though it hasn’t been studied as extensively for lung cancer as it has for COPD, studies have found that pulmonary rehabilitation (in the right situations and at the right time during treatment) may:

  • Improve the ability to exercise and do day to day activities
  • Lessen complications of lung cancer surgery (see below)
  • Improve pulmonary function
  • Improve quality of life
  • Lessen shortness of breath
  • Improve lower extremity strength
  • Improve co-existing medical conditions: It’s not uncommon for people with lung cancer to also have emphysema and/or chronic bronchitis. Studies have found that in these people, pulmonary rehab results in less shortness of breath, better exercise performance, and better health-related quality of life.

Pulmonary Rehabilitation Before Lung Cancer Surgery

Research is just beginning to look into the role of preoperative pulmonary rehabilitation on surgery outcomes, though a 2013 pilot study found that people who underwent a program prior to surgery had both improved functional capacity going in to surgery and fewer complications during the postoperative period.

A 2017 review of studies to date indicates that pulmonary therapy prior to lung cancer surgery may actually be helpful in a number of ways. What we are learning so far is that rehabilitation may:

  • Decrease complications following surgery: Complications from lung cancer surgery are common and may include prolonged ventilator dependence, infections, bleeding, heart problems, blood clots, post-thoracotomy pain syndrome, and more.
  • Improve breathing so that potentially curative lung cancer surgery can be done
  • Possibly improve outcomes after lung cancer surgery
  • A few small studies found that people who had rehab before surgery had shorter hospital stays, less morbidity (that means sickness) near the time of surgery, and had a shorter duration of needing a chest tube following surgery.

Evidence for preoperative rehabilitation continues to expand, with a 2018 study finding that preoperative exercise therapy alone could halve the risk of post-surgical complications as well as reduce hospital stays and improve quality of life.

When Pulmonary Rehabilitation Should Be Started

Your oncologist, thoracic surgeon, or pulmonologist will need to work with you to determine the best time for pulmonary rehabilitation. There is some evidence that rehab shortly after thoracotomy results in increased pain, and some surgeons suggest that it might be better to wait 3 months to 4 months after major chest surgery to begin rehab.

Pulmonary Rehabilitation and Advanced Lung Cancer

Even people with advanced lung cancer may benefit from pulmonary rehabilitation. In addition, many people with stage 4 disease do not have surgery and therefore may be able to begin a rehabilitation program right away without waiting for surgical incisions to heal. Not only can pulmonary rehabilitation be beneficial for people with stage 4 lung cancer, but it should be considered for anyone coping with the disease.

A 2015 review published in the journal Respiratory Medicine notes that it can be considered standard of care for maximizing the quality of life for people living with advanced lung cancer.

A 2015 study looking at pulmonary rehabilitation in people with advanced lung cancer undergoing chemotherapy identified a few areas in which the therapy made a difference. These included:

  • Improved ability to get around (better mobility)
  • Improved forced expiratory volume in one second (FEV1), a rough measure of how strong your lungs are
  • Improved quality of life

How to Get Started

If you are wondering if you may benefit from pulmonary rehabilitation, the best place to begin is by talking to your lung cancer doctors regarding pulmonary rehabilitation programs in your area. Many of the larger cancer centers offer these services on an outpatient as well as an inpatient basis. If your physicians are not aware of programs, you can check:

  • In California, the California Society for Pulmonary Rehabilitation has a list you can search for providers
  • In Canada, the Canadian Lung Association has a list of pulmonary rehab programs
  • In the U.K., you can check with the British Lung Foundation regarding rehab sources

Risks

Risks associated with pulmonary rehabilitation are primarily the risks inherent with any exercise program. If someone has unstable heart disease, exercise can increase the risk of abnormal heart rhythms or heart attacks. For people with osteoporosis, the risk of bone injury should be considered. This is also important to consider if you have bone metastases. For those on chemotherapy, the risk of infection when in contact with others should be considered. For people who have had surgery, it’s important that the surgical site be well healed to avoid the risk of a surgical incision opening.

Insurance Coverage

It’s important to check with your insurance provider to see what will be covered by your particular plan. If treatment is not covered, you may want to consider entering one of the clinical trials that are studying the benefit of pulmonary rehab for people with lung cancer. If you aren’t sure where to start, there is the Lung Cancer Clinical Trial Matching Service that provides free help in searching clinical trials available worldwide.

If you have copays for rehab, or if you will need to pay for pulmonary rehabilitation out of pocket, keep in mind that the expense is likely deductible on your taxes. Many people are discouraged to learn that medical expenses must exceed 10% of adjusted gross income, but when expenses related to cancer are added up (including travel to and from treatment), including expenses incurred by other family members, it's surprising how often this number is reached and exceeded.

Why Haven't You Heard About Pulmonary Rehabilitation?

Part of the reason many people with lung cancer may not have heard about pulmonary rehabilitation is a lack of awareness about these services even by physicians. Research has also cited long waiting lists as one reason. Another major reason is that the benefits of rehabilitation for people with lung cancer has only recently been studied to the degree it has been for other conditions such as COPD.

It could also be that the stigma of lung cancer being a "smoker's disease" (which it isn't, and anyone who has lungs can get lung cancer even if they've never touched a cigarette) has placed less emphasis on quality of life issues.

A Word From Verywell

With many medical conditions we're learning that rehabilitation can make a tremendous difference in quality of life. For those who have had a heart attack, stroke, or hip replacement, it's become almost routine. But we are only begin to learn about the possible benefits for people with lung cancer. When done before lung surgery, it appears that pulmonary rehabilitation can reduce some of the common complications. Even those who have advanced lung cancer have been found to benefit. If you haven't been offered rehab, talk to your physicians. You may need to be your own advocate and bring up the possibility at this stage, though it's likely that rehabilitation will become much more routine in the future.

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Article Sources

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