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Pulmonary Rehabilitation and QoL in Lung Malignancy Patients


(Abstract):The grade of life in patients with lung tumor is determined both by factors related to the individual (stage of disease, comorbidities) and the factors related to treatment (surgery, chemotherapy, radiotherapy). Since the impact of treatment on survival of patients with lung canceris quite low, standard of living is a goal increasingly important. Until now, quality oflife was properly evaluated in few studies and the results can be influenced through non- validated methods. Probably the most usedtools designed for measuring the quality of life for lung tumor are the European Group for Research and Treatment of Tumors (EORTC) LC-13 questionnaire, the Functional Assessment of Cancer Remedy (FACT-L) questionnaire and the Lung Cancer tumor Symptom Scale (LCSS).


Lung tumors is one of the most common types of cancers, with a 5-time survival rate of approximately 15 %. Given the advancement of long asymptomatic lung cancer in contrast to other tumor types, it is often diagnosed at a sophisticated stage. Symptoms include cough, hemoptysis, dyspnea, chest pain, weakness, lack of desire for food. Therefore, treatment goals for these patients are comfort of symptoms and increased overall success [1]. Therapies that improve the survival rate are often associated with severe side results. Due to the increasing range of substitute lines of remedy and treatment, the decrease dissimilarities in the scientific effectiveness and medicine development costs, the importance of estimating the parameters of standard of living (QOL) raises both health and economical reasons. So short amount of time, the inclusion of these parameters in lung cancer clinical tests was generally neglected [1-3].

During 2001-2011, there have been 43 studies conducted to measure health-related quality of life (HRQoL) of patients with lung tumors, 27 which possessed as main purpose HRQoL.

Most publicationsillustrate the results of phase III clinical tests, 38 included patients with locally advanced non-small cell lung tumors (NSCLC), especially in level III/IV, two studies included patients with small cell lung malignancy (SCLC) in every stages and three studies included both patients with NSCLC and SCLC.

Most studies have investigated the impact of platinum structured medication combinations, 6 studies have investigated the result of gefitinib and 2 studies concerns of erlotinib.

Between the questionnaires used to evaluate quality of life in patients with lung cancer tumor are brought up questionnaire of the European Company for Research and Treatment of Malignancy (EORTC QLQ - C30) questionnaire, Functional Examination of Tumor Therapy-General (FACT - G) questionnaire, FACT-L (Lung) questionnaire, Lung Cancers Symptom Scale (LCSS), Nervousness and Depression Scale (HADS), Quick Pain Index (BPI).

The mostly used is the EORTC QLQ-C30 has 30 requirements, available in 60 languages №№[4]. FACT-G questionnaire containing 27 physical elements, psychological, social, practical, available in more than 50 languages №№[5] and the FACT-L is well suited for lung cancer possesses 37 items examining standard of living [6].

Due to the homogeneity characteristics of the patients and treatment regimens, it isn't possible to compare every one of the studies on the HRQoL.

Most studies include evaluating different chemotherapy regimens didn't show significant distinctions in HRQoL between treatment biceps and triceps [7, 8, 9, 10, 11, 12, 13, 14].

Another group of studies report mindful assumptions to boost HRQoL [15, 16, 17].

Only Belani et al. and Reck et al. implies HRQoL superiority of paclitaxel or docetaxel compared with vincristine or vinorelbine/cisplatin [18, 19].

Regarding EGFR inhibitors, Gelibter et al. , Mu et al. , And Zhang et al. been shown to improve HRQoL in patients with highly advanced NSCLC cared for with gefitinib [20, 21, 22]. Cella et al. and Natale et al. reported advancements in HRQoL after administration of gefitinib and correlate these improvements with tumor response [23, 24].

Regarding erlotinib, Lilenbaum et al. cannot demonstrate significant improvement in progression-free success, median survival and HRQoL compared to standard chemotherapy strategy [25].

Bezjak et al. HRQoL proved significant improvement, where erlotinib is given in the next line of treatment [26].

LUX- Lung 3 study conducted over a people of patients with advanced NSCLC with EGFR mutation positive, revealed an unprecedented improvement in cancer-related symptoms and increase quality of life when cured first lines with afatinib, an irreversible inhibitor of the ErbB receptor family, compared to chemotherapy with pemetrexed and cisplatin, considered the typical of good care in this society of patients with NSCLC [27].

Lung cancer tumor or lung metastases frequently have symptoms that palliative radiotherapy works well [28, 29] and increases or maintains quality of life, for approximately one-third of afflicted patients [30].

There are forty-three studies that are evaluated in at least one arm of the analysis, use of palliative thoracic radiotherapy that evaluated QOL or symptoms palliation female or secondary. Thirty studies have examined the treatment of patients with NSCLC. Four studies engaged patients who have been treated with endobronchial brachytherapy only or in mixture with exterior radiotherapy. Other nine studies have examined the use of palliative radiotherapy in patients with lung cancer apart from NSCLC histological type.

Clinical trials that likened different regimens of palliative radiotherapy fractionation demonstrated improved quality of life and success in patients with good performance position who received high doses of radiation (TD = 30Gy/10fractions/3Gy/small fraction) compared with lower doses (TD = 20Gy/5fractions/4Gy/fraction, 17Gy/2fractions, 10Gy/1fraction), that happen to be mainly used in patients with reduced performance status and could be interspersed between your group of chemotherapy without causing delay in chemotherapy supervision [31, 32].

Impact of new radiotherapy techniques (IMRT - level modulated radiotherapy, IGRT - led radiotherapy imaging) and PET -CT imaging integration in the palliative treatment of patients with pulmonary cancers is not evidently defined.

Relative to the palliative role of endobronchial brachytherapy, recent evaluation of 13 medical trials figured external radiotherapy is superior endobronchial brachytherapy and brachytherapy put into external radiation has no advantages over exterior radiotherapy exclusively [33].

So way, not proven an benefit of concomitant radio - chemotherapy to sequential administration for symptoms palliation in patients with lung cancer tumor [34, 35, 36, 37].

First programs of pulmonary treatment have been developed in The United States of America in the 1970's. Since that time, several specialists tried out to identify better the word of "pulmonary treatment ":

''Pulmonary rehabilitation is a multi-dimensional continuum of services directed to

persons with pulmonary disease and their own families, usually by an interdisciplinary team of specialists, with the goal of achieving and keeping the individual's maximum degree of independence and functioning within the community''(1)

"Pulmonary treatment may be thought as an art of medical practice wherein an

individually customized, multidisciplinary program is developed which through appropriate diagnosis, therapy, psychological support, and education, stabilizes or reverses both physio and psychopathology of pulmonary diseases and tries to return the patients to optimum useful capacity allowed by his pulmonary handicap and overall life situation. "(2)

The definition distributed by the American University of Chest Health professionals (ACCP), the North american Relationship of Cardiovascular and Pulmonary Rehabilitation (AACVPR), the North american Thoracic Culture (ATS) and European Respiratory Population (ERS) -

" an evidence-based, multi-disciplinary, and detailed intervention for patients with serious respiratory diseases who are symptomatic and often have decreased lifestyle activities. Built-into the individualized treatment of the patient, pulmonary rehabilitation was created to reduce symptoms, optimize functional status, increase participation, and reduce health care costs through stabilizing or reversing systemic manifestations of the disease. "(3)

The latest definition "Pulmonary rehabilitation is a comprehensive intervention based on a thorough patient assessment accompanied by patient-tailored therapies such as, but aren't limited to, exercise training, education, and patterns change, made to increase the physical and mental condition of people with chronic respiratory disease and also to promote the long-term adherence to health-enhancing behaviors. "(4)

To understand better the importance of the rehabilitation programs, here are some statements of some patients with pulmonary diseases:

-"It could be extremely upsetting because I can't find the breath of life that people all need. "

-"My feet ached, my shoulders ached, my arms ached. I couldn't continue with my pastimes. I lost desire completely. I virtually wanted to pass away. "

-" This is very depressing ; this makes me very troubled!"

Over time pulmonary rehabilitation has been an important part in the management of COPD and of other chronic lung diseases.

Rehabilitation in lung tumors has not been studied so thoroughly as the treatment in COPD however the results from various studies suggest clearly the value of pre and post surgery treatment.

Patients who possessed or have to go through a lung cancer tumor surgery may have breathlessness, pain, exhaustion, anxiety, poor physical condition and low quality of life. For oncology patients, pulmonary treatment is not simply about how the patient learns to inhale properly and breathing strength-training, but a multitude of factors that mutually help the patient to support more easily the surgery or chemo-radiotherapy, to have an early recovery and increase standard of living.

Judging by the motto" There are no diseases, but ill people", pulmonary treatment for patients with lung tumor, also needs to be personalized. It may be regarded as the tailoring of the treatment program to the patient's needs and characteristics and also, to the progression of his oncological disease.

How pulmonary treatment helps people with lung cancers?

-helps the patient to handle his daily activities

-increases the quality of life - helps to improve general health -decrease the number of postsurgical difficulties -hastens the postoperative recovery

-prevents respiratory tract infections

Pulmonary treatment is a complicated process and may include the following: - Respiration techniques (diaphragmatic deep breathing, pursed-lip deep breathing) - Energy conservation techniques - Aerobic (to increase pulmonary capacity) - Respiratory system muscle strengthening techniques - Nourishment tips - Guidance and relaxation techniques

- Group therapy

Before establishing a pulmonary treatment program must be identified that baseline - what the individual can do easily, the type of day to day activities is able to do and the type of activities are finished with difficulty.

Pulmonary treatment can and pre and post surgical. Treatment period is decided by an interdisciplinary team consisting of pneumologist, oncologist and thoracic medical expert. Preoperative rehabilitation can decrease the number of postoperative complications, speed recovery and could also have an economic impact, reducing the number of times of hospitalization, postoperative morbidity.

Studies show that postoperative rehabilitation is good to be began after about 3 or 4 4 weeks after surgery.

The minimum length of time of a pulmonary treatment exercise program hasn't yet been broadly established.

Pulmonary rehabilitation should be studied into consideration for all the patients with lung tumor regardless of what stage. Rehabilitation is beneficial for all stages of lung cancers, even for inoperable cases. Moreover, we're able to say that pulmonary rehabilitation is an essential aspect of the palliative methods in patients with lung tumor.

Pulmonary rehabilitation also offers it's riscks, for example, it can cause arrhythmias or cardiac arrest in patients with cardiac pathology, it can cause bone lessions or muscle injury.

Education The individual must learn what he must do to care for himself better and to maximize quality of life. The main thing is the fact the patient must practice and continue for a lifetime everything he learnt during the medical rehabilitation program conducted at a healthcare facility.

Nutrition is an essential requirement of the treatment programs because, generally, lung tumors patients already have a poor healthy status that can be brought on by the consumptive symptoms, the treatment or as a result of depressive symptoms that is often experienced in patients with malignancy. The consequences of malnutrition in patients with lung cancers: - increased fatigue

- vulnerability to infections -decreases compliance to treatment -delay recovery -influences quality of life

Recommendations on nourishment in lung cancers:

-eat consistent small portions

-eat high-protein and high-calorie foods

-avoid fast food and carbonated drinks

-do not take vitamin supplements without doctor recommendation

- use spices to get an improved style of the food

-the beef will be cooked at high temperatures

-no fried foods

-cooking will be achieved in stringent conditions of cleanliness

-adequate hydration, at least 2 liters of substance per day

Counseling Finding the diagnosis of malignancy, the condition and the large number of investigations and treatments put on patients with cancers are resources of psycho-emotional stress. Through subconscious counseling, the patient confirms new ways to adopt a lifestyle as healthy as it could and receives the necessary power to replace negative feelings. . Oncology patients are special patients that require special attention and support from the complete multidisciplinary team and also from their own families.

In the conditions where palliative attention is the only solution, the pulmonary rehabilitation team must prepare the patient for a dignified end.

Pulmonary treatment is the opportunity for individuals with lung cancer tumor to get help, to get a better quality life, to comprehend better their disease and feel much confident.

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