Henke, C.C., Cabri, J., Fricke, L., Pankow, W., Kandilakis, G., Feyer, P.C., & de Wit, M. (2014). Strength and endurance training in the treatment of lung cancer patients in stages IIIA/IIIB/IV. Supportive Care in Cancer, 22, 95–101.

To test the effects of a specially designed strength and endurance training on the independence and quality of life (QOL) in patients with stages III/IV lung cancer while undergoing chemotherapy

Endurance training and breathing techniques were performed five days per week, and strength training was performed every other day while patients received three cycles of inpatient chemotherapy (platinum based). Endurance training consisted of walking and stair exercises. Strength training consisted of four different endurance exercises (trunk stability, leg, arm, and abdominal musculature), as well as breathing techniques (active cycle of breathing) combined with conventional physiotherapy. Control arm received conventional physiotherapy. Evaluations were conducted at baseline and after three cycles of chemotherapy.

• N = 46; only 29 completed (of the 17 withdrawals, 6 withdrew due to death, 10 from noncompliance, and 1 from switching hospitals). 18 were in the intervention group, 11 in the control.
• AGE: 18 years or older
• MALES (%): Unknown 
• FEMALES (%): Unknown 
• CURRENT TREATMENT: Chemotherapy 
• KEY DISEASE CHARACTERISTICS: Patients with stage IIIA/IIIB or IV lung cancer undergoing platinum-based inpatient chemotherapy regimens 
• OTHER KEY SAMPLE CHARACTERISTICS: Includes patients with non-small cell lung cancer and small cell lung cancer

• SITE: Single Site       
• SETTING TYPE: Hospital (inpatient)   
• LOCATION: Germany

PHASE OF CARE: Active anti-tumor treatment

Randomized controlled trial

6 minute walk test, staircase walking (number of steps), Barthel Index (primary outcome measure), European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core-30, Modified Borg Scale

After intervention, the intervention group had a significantly higher Barthel Index (p = 0.003), indicating higher independence with ADLs. In the single scores of the EORTC QLQ-C30, the intervention group reported higher physical functioning (p = 0.025), lower hemoptysis (p = 0.019), lower pain in the arms/shoulders (p = 0.048), peripheral neuropathy (p = 0.05) and cognitive functioning (p = 0.05). There were significant differences in ability on 6 minute walk test and stair walking as well as strength capacity (all p < 0.05). The level of dyspnea decreased significantly in the intervention group while performing submaximal walking activities.

This study shows both feasibility and effects of a strength and endurance program during chemotherapy for lung cancer. The effects were significantly positive for the intervention group in every area (strength, endurance, QOL, independence). There were many issues with the study, however, making it difficult to apply to other populations. One huge issue is that it is unclear how many of the patients were SCLC versus NSCLC. These populations would have a wide difference in the natural history of disease on platinum regimen for the first few cycles; therefore, not knowing the content of each group is problematic. There were also large differences at baseline, so the effects are harder to evaluate. There was a very small sample size and large dropout rate. The intervention was feasible, but only given inpatient, so it is unclear if it is feasible for an outpatient population and these regimens are currently most typically administered outpatient in the United States. Although promising, it would need to be repeated to be generalizable.

• Small sample (< 30)
• Baseline sample/group differences of import
• Risk of bias (sample characteristics)
• Key sample group differences that could influence results
• Findings not generalizable
• Subject withdrawals 10% or greater  
• Other limitations/explanation: This study was conducted on an inpatient basis. At least in the United States, current chemotherapy for these diseases even at this stage would be outpatient, so feasibility not applicable. Also, there was a large difference between groups at baseline in physical capacity and strength. The dropout rate was high, but also different between groups. The study was conducted as inpatient for what is an outpatient regimen in the United States.

Nurses should take away from this study that there is the possibility that endurance, strength, and QOL are improved by a program of strength and endurance training during chemotherapy. The results are not generalizable and would need further studies to confirm. There was no harm, but it cannot be recommended based solely on this study at this time.