Table 2.
Prioritization of Research Questions Using Delphi Process
| All Research Questions Identified from ATS Workshop | Round 1 Delphi | Round 2 Delphi | Round 3 Delphi | |
|---|---|---|---|---|
| Number of questions | 32 | 31 | 7 | Rank |
| Section II: General considerations for research in CRF in lung cancer | ||||
| 1. How does CRF in lung cancer differ from other cancer types regarding prevalence, severity, and course? | ✓ | ✓ | ✓ | 1 |
| 2. How do tumoral factors (i.e., location, histology, and stage) and treatment modalities (i.e., surgery, radiation, chemotherapy, and immunotherapy) affect the development, severity, and progression of CRF? | ✓ | ✓ | ✓ | 2 |
| 3. Beyond individual patient data and biomarkers, can other available metrics help clarify mechanisms and diagnosis of CRF: population-based studies, machine learning, imaging (CT, PET, MRI), or tissue samples? | ✓ | ✓ | ||
| 4. Does the pathophysiology of CRF in patients with lung cancer elucidate potential therapeutic targets? | ✓ | ✓ | ||
| 5. Which symptom clusters are associated with the greatest degree of CRF severity? | ✓ | ✓ | ||
| Section III: detection and diagnostic evaluation of CRF in lung cancer | ||||
| 1. What are the roles of multidisciplinary teams in a patient-driven care model for recognizing and treating CRF in patients with lung cancer? | ✓ | ✓ | ||
| 2. What is the optimal screening tool and score cutoff for CRF in patients with lung cancer? | ✓ | ✓ | ||
| 3. What assessments can be used for CRF identification and surveillance: symptom scores, biomarkers, circadian disruption, sleep fragmentation? | ✓ | ✓ | ✓ | 3 |
| 4. How do patient factors (socioeconomic status, race, sex, functional status, comorbidities, medications, nutrition) affect the diagnosis and treatment of CRF in patients with lung cancer? | ✓ | ✓ | ✓ | 5 |
| Section IV: timing, goals, and implementation of physical activity, rehabilitation, and exercise training | ||||
| 1. How do multidisciplinary teams optimize delivery of physical activity programs (dose, timing, location) to improve CRF for patients with lung cancer? | ✓ | ✓ | ✓ | 6 |
| 2. Do comorbid conditions (e.g., COPD, ILD, CAD, heart failure) predict benefit from physical activity programs for patients with lung cancer? | ✓ | ✓ | ||
| 3. What is the effect of physical activity programs, including frequency, intensity, duration, and type, on CRF in patients with lung cancer, before, during, and after treatment? | ✓ | ✓ | ✓ | 7 |
| 4. What are the associated biological and physiological mechanisms relating to physical activity programs and potential impact of CRF for patients with lung cancer? | ✓ | ✓ | ||
| 5. What is the optimal timing to commence physical activity programs to prevent or treat CRF along the lung cancer treatment continuum (before treatment, during treatment, after treatment, palliative care)? | ✓ | ✓ | ||
| 6. Is there effect modification of physical activity programs along the lung cancer treatment course (e.g., before treatment; within 1, 3, or 6 mo after treatment)? | ✓ | ✓ | ||
| 7. What are the effects of physical activity programs in combination with psychological and/or symptom management on CRF and HRQoL in patients with lung cancer along their life course (i.e., before, during, and after treatment, including specific time intervals after treatment)? | ✓ | ✓ | ||
| 8. Are there predictors of the benefit of multidisciplinary rehabilitation for patients with lung cancer and CRF (e.g., older or younger age, presence or absence of comorbid cardiopulmonary disease, early or advanced stage, curative-intent or non–curative-intent therapy)? | ✓ | ✓ | ||
| 9. How are physical activity programs being used clinically for patients with lung cancer, and what are the cost implications for these services? | ✓ | ✓ | ||
| 10. What factors (e.g., patient, socioenvironmental, health care organization) are associated with referrals and uptake of physical activity programs among patients with lung cancer that may identify subgroups of patients with high needs and/or low uptake? | ✓ | ✓ | ||
| 11. What is the optimal strategy to increase access to and uptake of physical activity programs to reduce CRF and improve HRQoL among patients with lung cancer? | ✓ | ✓ | ||
| 12. How can multidisciplinary teams disseminate the importance of physical activity programs for patients with lung cancer? | ✓ | ✓ | ||
| 13. How can multidisciplinary teams incorporate patient-relevant goals and integrate physical activity services to manage patients with lung cancer? | ✓ | ✓ | ||
| 14. What is the relationship between nutritional health and the ability to undertake physical activity and reduce fatigue in lung cancer? | ✓ | ✓ | ||
| 15. How do multidisciplinary teams facilitate participation and adherence in appropriate patient-centered physical activity programs to alleviate symptoms and improve HRQoL among patients with lung cancer? | ✓ | ✓ | ||
| 16. Does e-health enhance strategies for adherence to maintenance of physical activity? | ✓ | |||
| Section V: evaluation of sleep disruption and underlying sleep disorders in lung cancer survivors and CRF | ||||
| 1. What factors contribute to sleep disturbance: biomarkers, genetics, nocturnal hypoxemia, sleep-disordered breathing? | ✓ | ✓ | ||
| 2. What is the prevalence of different sleep disorders (sleep-disordered breathing, insomnia, circadian dysregulation, movement disorders)? | ✓ | ✓ | ✓ | 4 |
| 3. How do symptom clusters affect sleep disruption in patients with lung cancer affect CRF? | ✓ | ✓ | ||
| 4. Which diagnostic modalities (nocturnal oximetry, home sleep testing, polysomnography, actigraphy, wearables) can uncover underlying sleep disorders? | ✓ | ✓ | ||
| 5. How do sleep disorders and their treatments (chronotherapy, positive airway pressure therapy, cognitive-behavioral therapy, oxygen) affect quality of life and response to therapies in patients with lung cancer and CRF? | ✓ | ✓ | ||
| 6. What strategies can multidisciplinary groups use to raise awareness of sleep health, reduce sleep disruption, and emphasize sleep hygiene? | ✓ | ✓ | ||
| 7. What is the role of integrative or complementary therapies (yoga, acupuncture, herbal medication) to address sleep disruption in patients with lung cancer and CRF? | ✓ | ✓ | ||
Definition of abbreviations: ATS = American Thoracic Society; CAD = coronary artery disease; CRF = cancer-related fatigue; COPD = chronic obstructive pulmonary disease; CT = computed tomography; HRQoL = health-related quality of life; ILD = interstitial lung disease; MRI = magnetic resonance imaging; PET = positron emission tomography.
Questions in boldface type represent the seven questions ranked “extremely important” or “important” presented in round 3 of the survey.