Letter in response to BJSM Article: Preoperative exercise halves the postoperative complication rate in patients with lung cancer: a systematic review of the effect of exercise on complications, length of stay and quality of life in patients with cancer.

Dear Editor,

It was with great pleasure that I read the recent review article by Steffens et al [1], as the surgical treatment of lung cancer remains the treatment of choice for early stage disease.[2]  Yet the most recent data for England and Wales shows that only 17.5% of lung cancer patients are being treated surgically,[3] which compares poorly to our European neighbours with broad agreement that this contributes to our overall poorer outcomes.[4]  So all efforts aimed at increasing resection rates should be applauded.

However, it is debateable how relevant the studies reviewed are to the UK setting.  A pooled mean length of stay (LOS) is not given, but even in the study with the shortest mean LOS this was 9.66 days in the control group with a pooled mean reduction of 2.86 days (95% CI -5.4 to -0.33) reported in the intervention arms.  The recent Royal College of Physicians Lung Cancer Clinical Outcomes Publication (LCCOP) Report describes a median LOS of only 6 days in England,[5] making it unlikely that such a significant reduction in LOS would be achieved in the UK context.

Furthermore, whilst the LCCOP Report does not specifically comment on complications, given both the short LOS and low mortality rates reported it might be expected that there is a lower complication rate in England than in these studies.  The definition of complications was also debateable with atelectasis deemed a complication in many of the studies.  With minimal, if any, clinical significance, atelectasis is arguably not a true complication, leading to both misleadingly high complication rates and, additionally, as atelectasis is highly amenable to physiotherapy interventions, potentially biasing outcomes in favour of the intervention arms.

Finally, this review describes significant variation in exercise regimens and, whilst not necessarily the place of this review, no description of patient selection is provided.  In the context of the finite resource available in the NHS setting optimal patient selection, exercise intervention and duration are all questions that require answering.

As noted in the review the quality of most included studies was low or very low, although lung cancer faired a little better with two moderate quality studies.  As in our own work,[6] in the studies under review proof of concept has been achieved, but now is the time to ensure that high quality studies, asking the right clinical questions and utilising clinically relevant outcome measures are performed in the future.

Sincerely,

Dr William Ricketts 

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Dr William Martin Ricketts (@tb_doc) is a Consultant Chest Physician at St Bartholomew’s and the Royal London Hospitals with a special interest in Lung Cancer and Complex Breathlessness also works for AFC Wimbledon football club.

Competing interests

None declared

References

1         Steffens D, Beckenkamp PR, Hancock M, et al. Preoperative exercise halves the postoperative complication rate in patients with lung cancer: a systematic review of the effect of exercise on complications, length of stay and quality of life in patients with cancer. Br J Sports Med 2018;52:344–344. doi:10.1136/bjsports-2017-098032

2         National Institute for Health and Clinical Excellence. Lung cancer : diagnosis and management. 2011.

3         The Royal College of Physicians. National Lung Cancer Audit Annual report 2017 (for the audit period 2016). London: 2018.

4         Lim E, Popat S. What exactly are we doing to improve low lung cancer survival in the United Kingdom? Thorax 2013;68:504–5. doi:10.1136/thoraxjnl-2013-203543

5         The Royal College of Physicians. Lung cancer clinical outcomes publication 2017 (for operations performed in 2015). London: 2017.

6         Bollard K, Lau K, De Luca B, et al. 153: Experiences of setting up a pre-operative optimisation ‘pre-hab’ service for patients being considered for lung cancer surgery. Lung Cancer 2017;103:S69. doi:10.1016/S0169-5002(17)30203-9