Preoperative Maximum Oxygen Consumption Is Associated With Prognosis After Pulmonary Resection in Stage I Non-Small Cell Lung Cancer

doi:10.1016/j.athoracsur.2014.04.029

The Annals of Thoracic Surgery

Volume 98, Issue 1, July 2014, Pages 238-242

Presented at the Poster Session of the Fiftieth Annual Meeting of The Society of Thoracic Surgeons, Orlando, FL, Jan 25–29, 2014.

https://doi.org/10.1016/j.athoracsur.2014.04.029 Get rights and content

Background

The objective of this investigation was to evaluate whether maximum oxygen consumption (VO_2max) is a reliable prognostic factor after lung resection for pathologic stage I non-small cell lung cancer (NSCLC).

Methods

Observational analysis of 157 patients undergoing pulmonary lobectomy or segmentectomy for pathologic stage I (T1 or T2-N0 only) NSCLC, with preoperative measurement of Vo₂max and complete follow-up (2006–2011). Survival was calculated by the Kaplan-Meier method. The log-rank test was used to assess differences in survival between groups. The relationships between survival and several baseline and clinical variables were determined by Cox multivariate analyses.

Results

The median follow-up time was 40 months. The average preoperative Vo₂max was 16.1 mL/kg · min and 69% of predicted value. Sixty-two (40%) patients had a Vo₂max below 60%. The median and 5-year overall survivals of patients with preoperative Vo₂max above 60% were significantly longer than in those with Vo₂max below 60% (median not reached vs 48 months: 73% vs 40%, p = 0.0004). Cox regression model showed that an age older than 70 years (p = 0.005, hazard ratio 2.3) and Vo₂max below 60% (p = 0.001, hazard ratio 2.4) were independent prognostic factors significantly associated with overall survival. Cancer-specific survival was also longer in patients with Vo₂max above 60% (81% vs 61%, p = 0.01).

Conclusions

Exercise tolerance may influence the physiologic outcomes associated with cancer that can potentially affect survival. Physical rehabilitation aimed at improving exercise tolerance can possibly improve the long-term prognosis after operations for lung cancer.

Section snippets

Patients and Methods

This was a single-center observational analysis performed on a prospective database. The local institutional review board approved the study, and all patients gave their informed consent to participate in the institutional prospective database and have their data used for research and clinical purposes.

All patients undergoing pulmonary lobectomy or segmentectomy for pathologic stage I (pT1 or pT2-N0 only) NSCLC and who performed a preoperative cardiopulmonary exercise test as part of their

Results

Table 1 summarizes the patients' characteristics. During the same period, 140 patients with early-stage NSLC did not perform CPET because they did not meet the criteria or were unable to perform the test because of physical or mental limitations. They had similar 5-year survival rates compared with those who performed the exercise test (60% vs 65%, p = 0.2). The median follow-up time was 40 months. The average preoperative Vo₂max was 16.1 mL/kg · min or 69% of predicted value. Testing for a

Background and Rationale

A growing body of literature is showing an association between better physical fitness and long-term survival in lung cancer patients.

In other types of cancers, improving fitness through regular exercise has been shown to be associated with a 30% to 50% reduction in risk of cancer-specific mortality and all-cause mortality 9, 10, 11, 12.

In lung cancer patients, some authors have found that impaired physical condition at preoperative exercise testing 5, 6, 13 and the patient's perception of

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Percent predicted peak oxygen uptake is superior to weight-indexed peak oxygen uptake in risk stratification before lung cancer lobectomy
2024, Journal of Thoracic and Cardiovascular Surgery
To improve preoperative risk stratification in lung cancer lobectomy by identifying and comparing optimal thresholds for peak oxygen uptake (VO_2peak) presented as weight-indexed and percent of predicted values, respectively.
This was a longitudinal cohort study including national registry data on patients scheduled for cancer lobectomy that used available data from preoperative cardiopulmonary exercise testing. The measured VO_2peak was indexed by body mass (mL/kg/min) and also compared with 2 established reference equations (Wasserman-Hansen and Study of Health in Pomerania, respectively). By receiver operating characteristic analysis, a lower 90% specificity and an upper 90% sensitivity threshold were determined for each measure, in relation to the outcome of any major complication or death. For each measure and based on these thresholds, patients were categorized as low risk, intermediate risk, or high risk. The frequency of complications was compared between groups using χ².
The frequency of complications differed significantly between the proposed low-, intermediate-, and high-risk groups when using % predicted Study of Health in Pomerania (5%, 21%, 35%, P = .007) or % predicted Wasserman-Hansen (5%, 25%, 35%, P = .002) but not when using the weight-indexed VO_2peak groups (7%, 23%, 15%, P = .08). Nonsignificant differences were found using the threshold <15 mL/kg/min (P = .34).
This study showed that weight-indexed VO_2peak was of less use as a marker of risk at the lower range of exercise capacity, whereas % predicted VO_2peak was associated with a continuously increasing risk of major complications, also at the lower end of exercise capacity. As identifying subjects at high risk of complications is important, % predicted VO_2peak is therefore preferable.
Validity of Estimated Cardiorespiratory Fitness in Patients With Primary Breast Cancer
2022, JACC: CardioOncology
Citation Excerpt :
Poor Vo2peak is prevalent across the breast cancer continuum (ie, from diagnosis to survivorship)10,29,30 and correlates with heightened symptom burden.31 Vo2peak is also a significant predictor of all-cause10,32 and cause-specific mortality,33 even after adjustment for important clinical covariates. Despite the importance of accurate assessment of Vo2peak in the large and rapidly growing population of patients with cancer,34 prediction equations are commonly used in oncology clinical and research settings.13
Estimated peak oxygen consumption (Vo₂peak) is widely used in oncology; however, estimated Vo₂peak equations were developed in noncancer settings.
The aim of this study was to evaluate the validity of estimated Vo₂peak in women with primary breast cancer and to develop oncology-specific estimated Vo₂peak equations.
Vo₂peak was directly measured (TrueOne 2400, Parvo Medics) during 380 cardiopulmonary exercise tests in women previously treated for breast cancer (mean age: 59 ± 10 years; 3.1 ± 1.2 years post-therapy). The American College of Sports Medicine (ACSM), the Fitness Registry and the Importance of Exercise National Database (FRIEND), and heart failure (HF)-FRIEND equations were used to estimate Vo₂peak. New equations were developed using patient and peak (Onc_peak) or submaximal (Onc_sub) exercise test characteristics.
The median differences between measured and estimated Vo₂peak were 7.0 mL O₂·kg⁻¹·min⁻¹, 3.9 mL O₂·kg⁻¹·min⁻¹, and −0.2 mL O₂·kg⁻¹·min⁻¹ for ACSM, FRIEND, and HF-FRIEND, respectively. The number of estimated Vo₂peak values within ±3.5 mL O₂·kg⁻¹·min⁻¹ of the measured values was 70 (18%), 164 (43%), and 306 (81%) for ACSM, FRIEND, and HF-FRIEND, respectively. The Onc_peak and Onc_Sub models included body mass index, age, a history of chemotherapy or radiation, the peak measured heart rate, and the treadmill grade and/or speed. The median differences between measured and estimated Vo₂peak were 0.02 mL O₂·kg⁻¹·min⁻¹ (Onc_peak) and −0.2 mL O₂·kg⁻¹·min⁻¹ (Onc_sub). Eighty-six percent (n = 325) and 76% (n = 283) estimated Vo₂peak values were within ±3.5 mL O₂·kg⁻¹·min⁻¹ of the measured Vo₂peak values for Onc_peak and Onc_sub, respectively.
HF-FRIEND or oncology-specific equations could be applied to estimate Vo₂peak in patients previously treated for breast cancer in settings where cardiopulmonary exercise tests are not available. (Trial Comparing the Effects of Linear Versus Nonlinear Aerobic Training in Women With Operable Breast Cancer [EXCITE]; NCT01186367
Recommendations of the Society of Thoracic Surgery and the Section of Cardiothoracic and Vascular Surgery of the Spanish Society of Anesthesia, Resuscitation and Pain Therapy, for patients undergoing lung surgery included in an intensified recovery program
2022, Revista Espanola de Anestesiologia y Reanimacion
En los últimos años se están implementando programas multidisciplinares que incluyen diferentes actuaciones durante el periodo pre, intra y postoperatorio, encaminadas a disminuir el estrés perioperatorio y, por tanto, a mejorar los resultados de los pacientes sometidos a intervenciones quirúrgicas. Inicialmente, estos programas se desarrollaron para cirugía colorrectal y de ahí se han ido extendiendo a otras cirugías. La cirugía torácica, considerada de elevada complejidad, al igual que otras cirugías con una alta tasa de morbimortalidad postoperatoria, puede ser una de las especialidades que más se beneficien de la implantación de estos programas. En esta revisión se presentan las recomendaciones elaboradas por diferentes especialidades implicadas en los cuidados perioperatorios de los pacientes que requieren la resección de un tumor pulmonar. Para la elaboración de las recomendaciones presentadas en esta guía se han tenido en cuenta los metaanálisis, las revisiones sistemáticas, los estudios controlados aleatorizados y no aleatorizados y los estudios retrospectivos realizados en pacientes sometidos a este tipo de intervenciones. Para la clasificación de las recomendaciones se ha empleado la escala GRADE, valorando, por un lado, el nivel de evidencia publicado sobre cada aspecto concreto, y por otro, la fuerza de la recomendación con la que los autores proponen su aplicación. Las recomendaciones consideradas más importantes para este tipo de cirugía son las que se refieren a la prehabilitación, a la minimización de la agresión quirúrgica, a la excelencia en el manejo del dolor perioperatorio y a los cuidados postoperatorios encaminados a proporcionar una rápida rehabilitación postoperatoria.
In recent years, multidisciplinary programs have been implemented that include different actions during the pre, intra and postoperative period, aimed at reducing perioperative stress and therefore improving the results of patients undergoing surgical interventions. Initially, these programs were developed for colorectal surgery and from there they have been extended to other surgeries. Thoracic surgery, considered highly complex, like other surgeries with a high postoperative morbidity and mortality rate, may be one of the specialties that most benefit from the implementation of these programs. This review presents the recommendations made by different specialties involved in the perioperative care of patients who require resection of a lung tumor. Meta-analyses, systematic reviews, randomized and non-randomized controlled studies, and retrospective studies conducted in patients undergoing this type of intervention have been taken into account in preparing the recommendations presented in this guide. The GRADE scale has been used to classify the recommendations, assessing on the one hand the level of evidence published on each specific aspect and, on the other hand, the strength of the recommendation with which the authors propose its application. The recommendations considered most important for this type of surgery are those that refer to pre-habilitation, minimization of surgical aggression, excellence in the management of perioperative pain and postoperative care aimed at providing rapid postoperative rehabilitation.
“Fit for Surgery? What's New in Preoperative Assessment of the High-Risk Patient Undergoing Pulmonary Resection”
2021, Journal of Cardiothoracic and Vascular Anesthesia
Advances in perioperative assessment and diagnostics, together with developments in anesthetic and surgical techniques, have considerably expanded the pool of patients who may be suitable for pulmonary resection. Thoracic surgical patients frequently are perceived to be at high perioperative risk due to advanced age, level of comorbidity, and the risks associated with pulmonary resection, which predispose them to a significantly increased risk of perioperative complications, increased healthcare resource use, and costs. The definition of what is considered “fit for surgery” in thoracic surgery continually is being challenged. However, no internationally standardized definition of prohibitive risk exists. Perioperative assessment traditionally concentrates on the “three-legged stool” of pulmonary mechanical function, parenchymal function, and cardiopulmonary reserve. However, no single criterion should exclude a patient from surgery, and there are other perioperative factors in addition to the tripartite assessment that need to be considered in order to more accurately assess functional capacity and predict individual perioperative risk.
In this review, the authors aim to address some of the more erudite concepts that are important in preoperative risk assessment of the patient at potentially prohibitive risk undergoing pulmonary resection for malignancy.
Exercise prehabilitation in lung cancer: Getting stronger to recover faster
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Despite several recent advances, lung cancer surgery is still associated with potentially severe postoperative complications. It has been suggested that preoperative exercise training could render patients with borderline functional parameters eligible for surgery, improve perioperative outcomes and that these benefits might reduce healthcare costs. Nevertheless, given the substantial heterogeneity of the available studies, no specific guidelines for preoperative exercise training have been released so far.
This narrative review aims to provide an overview of the potential benefits of exercise training in the preoperative period as a central intervention for lung cancer patients. In detail, the effects of exercise (with different regimens) were evaluated in terms of physical functions, patients’ eligibility for curative surgery, postoperative complications and length of stay, with an exploratory focus on healthcare costs and long-term outcomes. Furthermore, a feasible approach for every-day clinical practice is proposed in order to increase the expected benefit deriving from a more extensive and methodical application of prehabilitation exercise, ideally in the context of a comprehensive approach to lung cancer patients, including nutritional and psychological support.
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A total of 100 studies with patients treated for clinical stage I non–small-cell lung carcinoma were included. Long-term overall and disease-free survival after LR was superior over SBRT in all comparisons, and for most comparisons, SR was superior to SBRT. Noncomparative studies showed superior long-term overall and disease-free survival for both LR and SR over SBRT. Although the papers were heterogeneous and of low quality, results remained essentially the same throughout a large number of stratifications and sensitivity analyses.
Results of this systematic review and meta-analysis showed that LR has superior outcomes compared to SBRT for cI non–small-cell lung carcinoma. New trials are underway evaluating long-term results of SBRT in potentially operable patients.

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Original articleGeneral thoracicPreoperative Maximum Oxygen Consumption Is Associated With Prognosis After Pulmonary Resection in Stage I Non-Small Cell Lung Cancer

Background

Methods

Results

Conclusions

Section snippets

Patients and Methods

Results

Background and Rationale

Chest

J Thorac Oncol

Ann Thorac Surg

Ann Thorac Surg

Lung Cancer

Lung Cancer

Thorac Surg Clin

Chest

ERS/ESTS clinical guidelines on fitness for radical therapy in lung cancer patients (surgery and chemo-radiotherapy)

Eur Respir J

Guidelines on the radical management of patients with lung cancer

Thorax

CALGB 140803-Association between cardiorespiratory fitness and overall survival in operable lung cancer patients: ancillary analysis of protocol 9238

J Clin Oncol

A nondivided intercostal muscle flap further reduces pain of thoracotomy: a prospective randomized trial

Ann Thorac Surg

Original article
General thoracic
Preoperative Maximum Oxygen Consumption Is Associated With Prognosis After Pulmonary Resection in Stage I Non-Small Cell Lung Cancer