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. 2025 Jul 28;15(7):e091749. doi: 10.1136/bmjopen-2024-091749

Pulmonary rehabilitation for patients receiving lung cancer radiotherapy: a scoping review

Yan Sisi 1, Chen Yao 1, Kuang Yajuan 1, Song Suting 1, Jiayi Du 1, Hu Qu 1, Lei Xuejiao 1, Zhaoli Zhang 1,*, Wang Chunyu 1,✉
PMCID: PMC12306476  PMID: 40730391

Abstract

Objective

Radiotherapy (RT) can cause a range of negative impacts in addition to the intended treatment impacts. Pulmonary rehabilitation (PR) may improve the physical and psychological conditions of patients with lung cancer receiving RT, but specific evidence is lacking. This review mapped the evidence on PR in patients with lung cancer receiving RT for intervention characteristics and outcome assessments.

Data sources

PubMed, EMBASE, CINAHL, Proquest, Web of Science, CNKI and WanFang were searched for studies from January 2003 to April 2025.

Eligibility criteria

We included randomised controlled trials and non-randomised comparative intervention studies that included centre-based PR in patients ≥18 years with lung cancer who were receiving RT. PR was defined as any type of exercise, respiratory training, or both and/or at least one additional component (eg, psychological support). Studies were excluded if they were not available in English, were not full-text articles or were non-peer-reviewed.

Data extraction and synthesis

Two reviewers independently screened titles, abstracts and full texts for inclusion and extracted data. PR components and the typology of outcome assessments used were mapped at the final data synthesis level.

Results

Out of 3120 records, nine studies were investigated in the final data synthesis. In these studies, in addition to exercise or respiratory training, psychological support and disease education were the most common components of PR. Pulmonary function, quality of life, symptom assessment and exercise performance were commonly assessed outcomes in these included studies. Although the effectiveness of PR is difficult to synthesise, the evidence for improvements in exercise performance and symptoms of dyspnoea and anxiety/depression is promising.

Conclusions

Evidence on PR in patients with lung cancer receiving RT is sparse, and there is a heterogeneous understanding of PR. The development of standardised PR protocols and investigation of the capabilities of PR in this growing and under-represented patient population are essential.

Keywords: RADIOTHERAPY, Exercise, Pulmonary Disease

Strengths and limitations of this study.

  • The evidence of pulmonary rehabilitation (PR) was systematically mapped in patients with lung cancer receiving radiotherapy (RT).

  • PR-related outcomes, including pulmonary function, quality of life, symptom assessment and exercise performance, were considered.

  • Implications for future clinical trials addressing the research gap regarding PR in the growing population of patients with lung cancer during RT are discussed.

  • Only nine trials were included in the scoping review, some of which did not use RT exclusively for cancer treatment, highlighting the fragmentary evidence for PR in patients with lung cancer during RT.

Background

According to the latest global cancer research report, lung cancer was the leading cause of cancer morbidity and mortality worldwide, with 2.5 million new cancer cases and 1.8 million deaths in 2022.1 2 A significant proportion (77%) of all patients with lung cancer have an evidence-based indication for radiotherapy (RT) at some point in their cancer journey.3 RT is the standard therapy for those who are unwilling or unsuitable for surgery due to age, multiple comorbidities and/or poor physical function.4

Despite advancements in technology, many patients undergoing RT for cancer experience radiation-associated side effects that negatively impact their quality of life (QoL), particularly when RT is administered with concomitant chemotherapy.5 6 In the short term, more than 69% of patients with lung cancer undergoing RT experience fatigue, with a significant decline in functional ability.7 Low levels of activity and a reduced tolerance to exercise have frequently been cited as salient factors by patients.8 9 Psychosocial functions are also negatively impacted by RT in 30% of RT patients.10 Depressive symptoms worsen during RT and may persist after RT completion.11 Acute site-specific toxicities include radiation-induced lung injury (RILI) and radiation-induced oesophagitis in patients with lung cancer.12,14 RILI incidence has been reported to range from 5% to 58%, typically manifesting 2–3 months post-RT12 and can lead to fatal respiratory disorders and chronic respiratory distress caused by pulmonary fibrosis.12 13 Radiation-induced oesophagitis is associated with clinical symptoms, including dysphagia, odynophagia and substernal pain, which can cause malnutrition and frailty.14 15

Pulmonary rehabilitation (PR) is a comprehensive intervention endorsed by respiratory societies worldwide for managing chronic lung diseases.16 17 PR should include, but is not limited to, exercise training, respiratory training, psychological support, nutrition management, disease education and behaviour change.16 The primary objective of this approach is to improve the physical and psychological conditions of people with chronic respiratory disease and to promote long-term adherence to health-enhancing behaviours.16 18

Despite two decades of accumulating evidence supporting the feasibility and safety of PR in patients with lung cancer receiving RT,19 20 most RT recipients present with unresectable or advanced malignancies characterised by rapid progression and poor prognosis, creating inherent barriers to standardised PR protocols. While approximately 20 reviews have been written on PR of lung cancer in the past decade, much work has focused on the surgical setting or across all treatment settings.21,25 Despite demonstrating potential value for PR,1826,29 other non-surgical settings, such as radiation therapy, remain significantly understudied.

The appropriate design and characteristics of PR for enhancing physical and psychological functioning, along with their corresponding outcome measures, remain uncertain, particularly in the context of lung cancer during RT.18 19 This area is under-investigated. Given this situation, it is crucial, from a practical standpoint, to furnish practitioners with comprehensive details regarding PR interventions and to elucidate their effectiveness. Therefore, we conducted a scoping review of PR in patients with lung cancer receiving RT. We aimed to systematically map the available information pertaining to PR characteristics, outcome assessments and clinical application effectiveness. To this end, we catalogued the components of PR and categorised the types of outcome assessments employed in order to derive insights for future PR development, evaluation and implementation research projects.

Methods

The study followed a scoping review design, adhering to the framework set out by Arksey and O’Malley.30 Furthermore, the study was reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR)31 guidelines (see online supplemental material 1). Moreover, the scoping review followed a protocol that was registered a priori on the Open Science Framework (https://osf.io/dzmvg).

Identifying the research question

The research questions were as follows:

  • (1) What are the characteristics of the published studies?

  • (2) What are the intervention details of the published intervention studies?

  • (3) What are the outcome assessments of PR for patients with lung cancer undergoing RT?

  • (4) What evidence is available for the acceptability and effectiveness of PR for patients with lung cancer undergoing RT?

Search strategy

A broad search strategy was employed for scoping reviews, with the objective of identifying all essential literature pertaining to the research subject. A comprehensive review of the literature revealed a notable increase in the utilisation of RT in patients with cancer over the past two decades. Consequently, following extensive deliberation, the study group reached a consensus to include articles published from January 2003 to the end of April 2025. A systematic literature search was conducted in the following databases: PubMed, EMBASE, CINAHL, Proquest, Web of Science, CNKI and WanFang. Additionally, the reference lists of all the included studies and relevant review articles were checked for additional studies.

The search strategy was conducted in each database on the basis of the following criteria:

  • Population: patients with lung cancer who received RT.

  • Intervention: PR (eg, exercise training, respiratory training, psychological support, nutrition management, disease education, behaviour change).

  • Study type: randomised controlled trials (RCTs) or non-randomised comparative intervention studies.

Using refined search phrases with search words and the PubMed database as an example, the specific search strategy is shown in online supplemental material 2.

Eligibility criteria

Inclusion criteria

Types of studies

RCTs and non-randomised comparative intervention studies that examined the effects of PR in patients with lung cancer undergoing RT were included. We included only studies whose full texts are described in detail.

Types of participants

The study population included patients aged ≥16 years with histologically confirmed non-small cell lung cancer (NSCLC) or small cell lung cancer(SCLC) who were receiving RT with curative, adjuvant or palliative intent, either as monotherapy or in combination with chemotherapy and/or surgery.

Types of interventions

In accordance with American Thoracic Society/European Respiratory Society (ATS/ERS) guidelines, PR was defined as exercise/respiratory training alone or combined with at least one additional component (eg, psychological support, nutrition management, disease education or behaviour change). These interventions were delivered by qualified healthcare professionals (eg, thoracic surgeons, chest physicians, physiotherapists or nurses). Other intervention characteristics, such as duration or frequency, were not specified.

To evaluate the effectiveness of PR in patients with lung cancer undergoing RT, we included studies with the following comparisons: (1) PR versus no intervention (ie, no intervention of any type) and (2) PR versus usual care (as operationalised by individual study protocols). Studies were excluded if they included a comparison with other active lifestyle interventions unless they were classified as usual care. Investigations assessing pulmonary function, QoL, exercise performance or RT-related symptoms after PR completion and follow-up were considered.

Exclusion criteria

We excluded studies that were not available in English, were not full-text articles (ie, conference abstracts only) and were not peer-reviewed articles (eg, magazine articles, letters, editorials, newspaper and commentary articles).

Study selection

All the articles identified by the electronic database searches were imported into EndNote V.X9, which was developed by Thomson ResearchSoft (web application). Once imported, the duplicate removal function within EndNote V.X9 was used to remove duplicate articles. Following the removal of duplicates, a single reviewer independently screened the titles and abstracts of the search results for studies that met the inclusion criteria. The reviewer then used EndNote V.X9 software to categorise the studies into labelled folders. A second reviewer then independently screened studies that were initially categorised as undecided. Once screening of titles and abstracts was completed (establishing includes and excludes), the full texts of the articles deemed eligible after initial screening were retrieved and uploaded onto EndNote V.X9. Two reviewers independently screened the full texts of all potentially eligible studies within the software (using the blinding function). Following the completion of the full-text screening, the two reviewers convened to determine the eligibility of the articles, and any disagreements were resolved through discussion with a third researcher. Following the determination of eligible full texts, both reviewers independently conducted citation screenings of the articles to identify any further studies meeting the inclusion criteria. The full-text articles that met the inclusion criteria were then charted to summarise the findings. The study selection process was recorded in sufficient detail using a PRISMA31 flow diagram.

Data charting and analysis

One reviewer independently extracted data for the included studies using a piloted data extraction form. A second reviewer independently checked and verified all the data extracted by the first reviewer. Information regarding the study (design, author’s name, year of publication, country), analysed population (total number of participants and each subgroup, number of patients with different treatment options (n), RT technology), characteristics of the PR programme (eg, setting, type of components, duration, number of sessions per week), usual care (eg, type of care, duration, frequency), outcome measures (follow-up period, outcome assessments), effectiveness evaluation and drop-out rate (%) were extracted. A narrative synthesis was employed to synthesise the data, prioritising and ordering the data to meet the study’s objectives.

Results

Search results

The database searches identified 3120 articles. After duplicates were removed, a total of 2608 titles and abstracts were screened for eligible studies. During the screening process, 2576 studies were deemed ineligible for inclusion, and 32 studies were extracted for full-text screening. During the full-text screening, the majority of the records (n=23) were excluded due to not having lung cancer with RT (n=6), not having full-text original articles (n=1), not being PR-based (n=4), having a population other than those with lung cancer with RT (n=7), not experiencing lung cancer during RT (n=1) or being of poor quality (n=4). Overall, nine articles were included, as detailed in the PRISMA diagram (see figure 1).

Figure 1. PRISMA flow diagram. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Figure 1

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Among the 9 studies (total n=407), 5 were RCTs,24 27 28 32 33 and 4 were non-randomised intervention studies.2 18 20 26 Studies were conducted across six countries (China, n=520 24 27 28 33; Italy, n=126; South Korea, n=22 18; Denmark, n=132). Seven of the nine studies were published between 2019 and 2024,2 18 24 26 32 33 while two studies were published between 2011 and 2016.20 27 Interventions were conducted primarily in hospital settings (n=6),2 18 20 24 32 33 with additional interventions conducted at home (n=1)26 or through hybrid models (n=2)27 28 combining home-based and hospital-based components. Therapeutic approaches included RT alone (n=4)18 24 27 33 and concurrent chemoradiotherapy or perioperative RT in five studies.2 20 26 28 32 The detailed study characteristics are displayed in online supplemental table.

Characteristics of PR

The PR programmes lasted between 4 and 24 weeks, with a median duration of 7 weeks. Interventions were largely conducted face to face (n=5)2 18 20 24 32 33 or as hybrids (n=3: face to face and telephone/online)26,28. The interventions were delivered by nurses, medical doctors, physiotherapists, psychologists and dietitians. The PR programmes lasted between 4 and 24 weeks, with a median duration of 7 weeks. In addition to exercise training and respiratory training (which were set as inclusion criteria), disease education20 27 28 and psychological management27 28 33 were the most common PR components included in the PR programmes of three studies. One study used nutrition management,28 and another study applied behaviour change to promote self-care27 (see online supplemental table).

Exercise training included warm-up routines, endurance exercises (cycling,2 18 28 32 walking/running on ground/treadmill,18 20 26 28 boxing34) and resistance exercises (upper18 26/lower limb2 19 20 26 34 and trunk (ventral/dorsal)2 35 training). The frequency of training sessions ranged from 2 to 5 times per week in patients.218 20 24 26,28 32 33 The duration of a single exercise session varied between 20 min and 60 min.2 18 24 26 28 32 33 Studies implementing endurance training reported its intensity in different ways: 65%–85% of the maximum heart rate,2 at an intensity equal to 80% of the patient’s Ippo,32 3–5 out of 10 points on the modified Borg Scale26 or, respectively, 11–13 out of 20 points on the Borg Scale.24 Studies that implemented resistance training provided 13–15 out of 20 points on the Borg scale18 or 60% of the maximum frequency achieved at the baseline exercise test.28

Respiratory training focused on breathing pattern optimisation (eg, diaphragmatic and pursed-lip breathing),20 27 28 33 respiratory muscle training18 20 and airway clearance techniques (eg, cough training).20 Each session lasted approximately 10 min.

Outcomes of PR

A range of outcome assessments were summarised into the following categories: pulmonary function, QoL, symptom assessment and exercise performance (see figure 2 and online supplemental table).

Figure 2. Assessment tools of pulmonary rehabilitation for patients receiving lung cancer radiotherapy. 100 mm VAS, 100 mm Visual Analogue Scale; 6-MWT, 6 min walking distance; CDS, Cancer Dyspnoea Scale; CET, constant-load exercise test; CFS, Cancer Fatigue Scale; CPET, cardiopulmonary exercise test; EORTC QLQ C-30, The European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 30; EORTC QLQ LC-13, The European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Lung Cancer 13; FACT-L, the Functional Assessment of Cancer Therapy-Lung; GAD-7, Generalised Anxiety Disorder; HADS, the Hospital Anxiety and Depression Scale; m-Borg: modified Borg Scale; MRC, Medical Research Council Dyspnoea scale; MSAS, Memorial Symptom Assessment Scale; PFS, Piper Fatigue Scale; PFT, pulmonary function test; SF-36, Short Form 36 Health Survey.

Figure 2

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Pulmonary function was assessed by specialised pulmonary function testers, usually in terms of PFT (eg, forced expiratory volume in the first second% (FEV1%),18 20 26 28 32 34 forced vital capacity% (FVC%), FEV1/FVC%18 20 26 28 33 34 diffusing capacity of the lungs for carbon monoxide20 26 or cardiopulmonary exercise test (eg, peak oxygen uptake).32 34 QoL was assessed using patient-reported outcome measures such as the 36-item Short-Form Questionnaire (SF-36)24 27 or the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ C-30).2 18 28 Five of the nine studies assessed exercise capacity using the 6 min walk test (6-MWT)2 18 26 32 because of its convenience, speed and widespread availability. Symptom assessment was performed via patient-reported outcome measures, which generally assess dyspnoea26,28 (eg, the Dysponea scale), fatigue27 28 (eg, the Piper Fatigue Scale), anxiety and depression (eg, the Hospital Anxiety and Depression Scale)24 27 or adverse effects of RT.2 32

In general, outcomes of exercise performance improved in patients who participated in PR, with significant changes in the 6-MWT,2 18 26 knee extensor test18 and knee flexor test,18 with no significant difference in strength (eg, grip strength)2 18; however, a trend towards improvement was observed compared with the control group. Symptomatic benefits of PR were evident across studies, with marked reductions in dyspnoea,27 33 fatigue27 28 33 and anxiety/depression scores.24 27 The impact of PR on QoL remains inconclusive: one study reported statistically improved SF-36 scores at 4 weeks versus baseline18 26; however, six studies revealed mixed outcomes, demonstrating partial improvements in specific QoL subdomains without consistent benefits across all dimensions.2 18 24 28 32 Contradictory effects were observed for pulmonary function: four studies revealed no differences between the PR group and the control group,18 24 26 32 whereas three20 24 33 reported beneficial effects of PR on pulmonary function. Sample attrition rates ranged from 7% to 34% across 6 studies reporting dropout metrics.2 14 24 26 27 32 33

Discussion

In this scoping review, the extant evidence of the effects of PR on existing intervention details and the related outcomes of patients mapped. In the narrative synthesis of the nine studies in the full-text analysis, in addition to exercise training and respiratory training (which were set as inclusion criteria), disease education and psychological management were the most common PR components, with nutrition management and behaviour change only being applied in one study. These interventions were primarily delivered face to face by healthcare professionals, predominantly within hospital settings, and ranged from two to five sessions per week, with each session lasting between 20 and 70 min over 7 weeks. Instrument-based metrics, objective performance tests and patient-reported measures were used to assess intervention effectiveness. Pulmonary function, QOL, symptom assessment and exercise performance were most frequently assessed. It is difficult to determine the effectiveness of PR. Some evidence suggests that PR during RT can lead to improvements in exercise performance and symptoms of dyspnoea, fatigue and depression/anxiety.

Under-representation of patients with lung cancer undergoing RT in PR intervention studies: challenges and barriers

Based on our screening results, most studies were excluded due to the inclusion of ineligible populations. The population of patients with lung cancer receiving RT remains under-represented in interventional studies.36 37 For example, in their scoping review, Flores et al comprehensively examined 30 prehabilitation intervention studies in patients with cancer receiving RT and reported that only one of these studies focused on patients receiving lung cancer RT.37 A more recent systematic review of physical activity in patients with cancer revealed that almost all of the included studies recruited cancer patients before and after surgery.38 The authors observed an exclusion quota of more than 75% of patients with RT due to strict exclusion criteria such as an age limit or multimorbidity.32 For both the researcher and the participant, several identified barriers lead to the frequent exclusion of patients with lung cancer during RT. Psychological factors (eg, fear of physical exertion) or treatment-related pulmonary functional impairment may represent obstacles in RT patients with lung cancer.16 32 39 From the researcher’s perspective, the uncertainty of efficacy, complexity of advanced disease progression, heterogeneity of comorbidities and difficulty in risk‒benefit assessment frequently lead to the decision to exclude patients with lung cancer undergoing RT.16 40

RT may be viewed critically. The provision of PR services to people with lung cancer for RT should be based on symptoms and functional status limitations rather than solely on the severity of lung function impairment or advanced cancer.16 41 42 A useful approach is to recommend that patients be assessed for rehabilitation tolerance by pulmonary function testing, exercise capacity assessment and comprehensive physical examination to be included in the PR population.16 To address existing gaps in clinical practice, there is a clear need for enhanced and more standardised exposure to PR within existing healthcare professionals’ training programmes, which could facilitate dialogue between healthcare professionals and their patients with lung cancer during RT, thereby increasing referrals to PR.16 43

Content of PR

Our definition of PR follows the ATS/ERS recommendations, which should be provided by a multidisciplinary team.29 We considered exercise and respiratory training to be key components of PR because lung cancer is a chronic respiratory disease, and respiratory training, given as an adjunct to whole-body exercise training, has an additional benefit on respiratory muscle strength and endurance.44 45 In all the studies included in the final data synthesis, exercise training consisted mainly of several sessions of endurance and resistance training per week. The overall quality of reporting on exercise intervention parameters, such as method (eg, no mention of unusual care, cannot be compared) or target intensity (eg, % of 1 repetition maximum), varied widely, with studies providing fragmentary information or no details other than the type and frequency of exercise (eg, ‘endurance training’). The details of respiratory training, such as the time, intensity, frequency and specific methods and devices of training, were less frequently reported. Nutrition management and behaviour change strategies were mentioned in only one study. In fact, nutritional support is crucial for patients with lung cancer undergoing RT. Radiation-induced oesophagitis and dysphagia increase the risk of malnutrition in patients.14 15 Behaviour change strategies promote long-term adherence to healthy behaviours.16 29 Relevant attention should be given to the dropout rates of some studies, which were over 20% (eg, Wang et al=34%),24 underscoring the importance of behavioural management to maintain PR. For example, in a recent nationwide survey of 513 patients with orthopaedic diseases, over 50% of the respondents expressed the belief that actively participating in a rehabilitation programme promoted behavioural change and led to the maintenance of beneficial behaviours.46

Our observations illustrate a heterogeneous understanding of PR among the screened studies. The differences in the implementation of PR interventions are likely due to the different healthcare systems in the countries, the updating of healthcare providers’ policies and definitions of PR, study-related aspects or the lack of specific standards such as medical guidelines.16 17 42 47 In fact, before 2006, the ATS/ERS did not emphasise the importance of behaviour change, but after 2013, behaviour change became an important part of PR.29 The use of a standardised rehabilitation definition, as provided by the ATS/ERS, is strongly recommended to develop and evaluate PR interventions for tailored care of patients with lung cancer for RT and to generate sufficient evidence.29 Moreover, we strongly recommend that some model frameworks of health behaviour change, such as the theory of implementation, should be used to support the high-quality implementation of PR, promote its long-term maintenance and improve treatment adherence.48

Reported outcome measurements

We observed that certain aspects of outcomes, such as pulmonary function, QOL, exercise performance and RT-related symptoms, were most frequently assessed after PR. However, synthesising the effectiveness of PR intervention is difficult. It appears that PR enhances exercise performance and treating symptoms (eg, fatigue, dyspnoea, anxiety/depression), and a review of perioperative PR in patients with lung cancer revealed analogous findings.21 Nevertheless, it is worth noting that the effectiveness of PR on pulmonary function remains inconclusive. While preliminary cohort studies have suggested the potential of PR to mitigate QoL declines and improve pulmonary function,20 these findings are at odds with rigorously conducted RCTs showing no difference in outcomes in QoL metrics, respiratory parameters or functional capacity.32 Critical methodological limitations and follow-up times may underlie these discrepancies: (1) underpowered sample sizes in RCTs (the PR group and no-PR group were both less than 10 cases), which may have resulted in a selective, more strongly motivated group32; (2) enrolment bias towards advanced NSCLC populations, whose progressive symptom burden may mask PR-related benefits19; (3) the predominance of exploratory, single-arm studies lacking comparator groups, which may inflate perceived efficacy through regression to the mean and placebo effects2 18 20 26 and (4) RT has been associated with lung cell death or irreversible DNA damage.49 Consequently, improving lung function parameters and repairing tissue cells solely through short-term PR training is challenging.18 20 This difference was preliminarily explored in the 7-week32 and 24-week28 follow-up observations in both studies. To examine the effects of PR, it is necessary to conduct a large, multicentre, randomised controlled study. This study should include the number of patients in the sample size calculation and the results of long-term follow-up surveys.

Limitations

The restrictive nature of the inclusion criteria may have been a limiting factor for study inclusion. In particular, setting the population of interest to RT might have limited the number of eligible studies. Of the 32 studies considered initially, 14 studies were excluded during the full-text screening stage because of an ineligible population, mostly due to the RT population criterion. A further limitation of this review is that it included only RCTs and non-randomised intervention studies. Consequently, studies with alternative designs would not have been included, despite their potential relevance to the findings of this review. Additionally, participants included in five studies were not exclusively administered RT for cancer treatment; instead, they received concurrent chemoradiotherapy or perioperative RT. These combinations of treatments likely influenced the results, although they more closely reflect the reality of lung cancer treatment guidelines.

Conclusions

This review identified five key components of PR for patients with lung cancer undergoing RT, in addition to exercise or respiratory training, psychological support and disease education were the most commonly reported components. The primary outcomes of the studies included in the review focused on pulmonary function, QoL, symptom management and exercise performance. Although synthesising the effectiveness of PR is challenging, the evidence improvements in exercise performance and symptom management (eg, fatigue, dyspnoea, anxiety/depression) are promising. However, the review also highlights several critical gaps in the existing literature. Evidence on the application of PR in patients with lung cancer receiving RT remains limited, and there is considerable variability in how PR is defined and implemented across studies. Methodological limitations and inconsistencies in follow-up times contribute to discrepancies in the results. These variations further complicate efforts to draw definitive conclusions. There is a pressing need for future research to develop standardised PR programmes specifically tailored for patients with lung cancer undergoing RT. High-quality, well-designed trials are essential to assess the impact of PR on this patient population and to better understand its long-term physical and psychological benefits.

Supplementary material

online supplemental material 1
bmjopen-15-7-s001.pdf (111.9KB, pdf)
DOI: 10.1136/bmjopen-2024-091749
online supplemental material 2
bmjopen-15-7-s002.pdf (50.9KB, pdf)
DOI: 10.1136/bmjopen-2024-091749
online supplemental table 1
bmjopen-15-7-s003.pdf (268.9KB, pdf)
DOI: 10.1136/bmjopen-2024-091749

Footnotes

Funding: This work is supported by grants from the Key joint project of Chongqing Health Commission and Science and Technology Bureau (2025ZDXM022) and Technology Innovation Project, Chongqing, Shapingba District (2024176).

Prepublication history and additional supplemental material for this paper are available online. To view these files, please visit the journal online (https://doi.org/10.1136/bmjopen-2024-091749).

Provenance and peer review: Not commissioned; externally peer reviewed.

Patient consent for publication: Not applicable.

Ethics approval: Not applicable.

Patient and public involvement: Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

Data availability statement

Data sharing is not applicable to this article as no new data beyond the presented were generated in this study.

References

  • 1.Bray F, Laversanne M, Sung H, et al. Global cancer statistics 2022: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA A Cancer J Clinicians . 2024;74:229–63. doi: 10.3322/caac.21834. [DOI] [PubMed] [Google Scholar]
  • 2.Ahn HJ, Jeon JY, Kim SS, et al. Feasibility of an outpatient-based pulmonary rehabilitation program for lung cancer patients during radiation therapy. Thorac Cancer. 2021;12:2241–6. doi: 10.1111/1759-7714.14061. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 3.Delaney GP, Barton MB. Evidence-based Estimates of the Demand for Radiotherapy. Clin Oncol. 2015;27:70–6. doi: 10.1016/j.clon.2014.10.005. [DOI] [PubMed] [Google Scholar]
  • 4.Postmus PE, Kerr KM, Oudkerk M, et al. Early and locally advanced non-small-cell lung cancer (NSCLC): ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol . 2017;28:iv1–21. doi: 10.1093/annonc/mdx222. [DOI] [PubMed] [Google Scholar]
  • 5.Fan G, Hadi S, Chow E. Symptom clusters in patients with advanced-stage cancer referred for palliative radiation therapy in an outpatient setting. Support Cancer Ther. 2007;4:157–62. doi: 10.3816/SCT.2007.n.010. [DOI] [PubMed] [Google Scholar]
  • 6.van der Weijst L, Bultijnck R, Van Damme A, et al. Patient-reported outcomes and functional exercise capacity in a real-life setting in non-small cell lung cancer patients undergoing stereotactic body radiotherapy: the Lung PLUS study. Front Oncol. 2023;13:1220248. doi: 10.3389/fonc.2023.1220248. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 7.Thanthong S, Kotronoulas G, Johnston B. Descriptors and factors affecting patients’ symptom experiences for symptom self-management throughout palliative radiotherapy for advanced lung cancer: A systematic review. Asia Pac J Oncol Nurs. 2024;11:100577. doi: 10.1016/j.apjon.2024.100577. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 8.Vena C, Parker K, Cunningham M, et al. Sleep-wake disturbances in people with cancer part I: an overview of sleep, sleep regulation, and effects of disease and treatment. Oncol Nurs Forum. 2004;31:735–46. doi: 10.1188/04.ONF.735-746. [DOI] [PubMed] [Google Scholar]
  • 9.Segal R, Zwaal C, Green E, et al. Exercise for people with cancer: a systematic review. Curr Oncol. 2017;24:e290–315. doi: 10.3747/co.24.3619. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 10.Hess CB, Chen AM. Measuring psychosocial functioning in the radiation oncology clinic: a systematic review. Psychooncology. 2014;23:841–54. doi: 10.1002/pon.3521. [DOI] [PubMed] [Google Scholar]
  • 11.Piraux E, Caty G, Aboubakar Nana F, et al. Effects of exercise therapy in cancer patients undergoing radiotherapy treatment: a narrative review. SAGE Open Med. 2020;8:2050312120922657. doi: 10.1177/2050312120922657. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 12.Fujimoto D, Kato R, Morimoto T, et al. Characteristics and Prognostic Impact of Pneumonitis during Systemic Anti-Cancer Therapy in Patients with Advanced Non-Small-Cell Lung Cancer. PLoS One. 2016;11:e0168465. doi: 10.1371/journal.pone.0168465. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 13.Arroyo-Hernández M, Maldonado F, Lozano-Ruiz F, et al. Radiation-induced lung injury: current evidence. BMC Pulm Med. 2021;21:9. doi: 10.1186/s12890-020-01376-4. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 14.Yu Y, Guan H, Dong Y, et al. Advances in dosimetry and biological predictors of radiation-induced esophagitis. Onco Targets Ther. 2016;9:597–603. doi: 10.2147/OTT.S97019. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 15.De Ruysscher D, Faivre-Finn C, Nackaerts K, et al. Recommendation for supportive care in patients receiving concurrent chemotherapy and radiotherapy for lung cancer. Ann Oncol. 2020;31:41–9. doi: 10.1016/j.annonc.2019.10.003. [DOI] [PubMed] [Google Scholar]
  • 16.Rochester CL, Vogiatzis I, Holland AE, et al. An Official American Thoracic Society/European Respiratory Society Policy Statement: Enhancing Implementation, Use, and Delivery of Pulmonary Rehabilitation. Am J Respir Crit Care Med. 2015;192:1373–86. doi: 10.1164/rccm.201510-1966ST. [DOI] [PubMed] [Google Scholar]
  • 17.Alison JA, McKeough ZJ, Johnston K, et al. Australian and New Zealand Pulmonary Rehabilitation Guidelines. Respirology. 2017;22:800–19. doi: 10.1111/resp.13025. [DOI] [PubMed] [Google Scholar]
  • 18.Do J, Lee SH, Kim SA, et al. The effects of inspiratory muscle training with pulmonary rehabilitation on NSCLC patients during radiation therapy: A pilot clinical study. Thorac Cancer. 2023;14:1567–73. doi: 10.1111/1759-7714.14899. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 19.Choi MG, Lee HY, Song SY, et al. The Effects of Simultaneous Pulmonary Rehabilitation during Thoracic Radiotherapy in the Treatment of Malignant Diseases. Tuberc Respir Dis (Seoul) 2021;84:148–58. doi: 10.4046/trd.2020.0135. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 20.Tarumi S, Yokomise H, Gotoh M, et al. Pulmonary rehabilitation during induction chemoradiotherapy for lung cancer improves pulmonary function. J Thorac Cardiovasc Surg. 2015;149:569–73. doi: 10.1016/j.jtcvs.2014.09.123. [DOI] [PubMed] [Google Scholar]
  • 21.Yang L, Azam A, Friedenreich CM. Physical activity for cancer prehabilitation: A scoping review. Crit Rev Oncol Hematol. 2024;196:104319. doi: 10.1016/j.critrevonc.2024.104319. [DOI] [PubMed] [Google Scholar]
  • 22.Su X-E, Hong W-P, He H-F, et al. Recent advances in postoperative pulmonary rehabilitation of patients with non‑small cell lung cancer (Review) Int J Oncol. 2022;61:156. doi: 10.3892/ijo.2022.5446. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 23.Chen Z, Cai R, Liao X, et al. The efficacy of pulmonary rehabilitation exercise training on complications and mortality after lung cancer resection: a systematic review and meta-analysis. Transl Cancer Res TCR. 2022;11:1321–9. doi: 10.21037/tcr-22-978. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 24.Wang L, Yu M, Ma Y, et al. Effect of Pulmonary Rehabilitation on Postoperative Clinical Status in Patients with Lung Cancer and Chronic Obstructive Pulmonary Disease: A Systematic Review and Meta-Analysis. Evid Based Complement Alternat Med. 2022;2022:1–9. doi: 10.1155/2022/4133237. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 25.Mao X, Ni Y, Niu Y, et al. The Clinical Value of Pulmonary Rehabilitation in Reducing Postoperative Complications and Mortality of Lung Cancer Resection: A Systematic Review and Meta-Analysis. Front Surg. 2021;8 doi: 10.3389/fsurg.2021.685485. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 26.Borghetti P, Branz J, Volpi G, et al. Home-based pulmonary rehabilitation in patients undergoing (chemo)radiation therapy for unresectable lung cancer: a prospective explorative study. Radiol Med. 2022;127:1322–32. doi: 10.1007/s11547-022-01562-w. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 27.Chan CWH, Richardson A, Richardson J. Managing symptoms in patients with advanced lung cancer during radiotherapy: results of a psychoeducational randomized controlled trial. J Pain Symptom Manage. 2011;41:347–57. doi: 10.1016/j.jpainsymman.2010.04.024. [DOI] [PubMed] [Google Scholar]
  • 28.Ting-ting H, Yan-ping B, Guo-dong X. Effect of comprehensive lung rehabilitation training on lung function and syndrome in patients with lung cancer undergoing radiotherapy. Chinese Journal of General Practice. 2021;19:120–3. doi: 10.16766/j.cnki.issn.1674-4152.001746. [DOI] [Google Scholar]
  • 29.Spruit MA, Singh SJ, Garvey C, et al. An Official American Thoracic Society/European Respiratory Society Statement: Key Concepts and Advances in Pulmonary Rehabilitation. Am J Respir Crit Care Med. 2013;188:e13–64. doi: 10.1164/rccm.201309-1634ST. [DOI] [PubMed] [Google Scholar]
  • 30.Arksey H, O’Malley L. Scoping studies: towards a methodological framework. Int J Soc Res Methodol. 2005;8:19–32. doi: 10.1080/1364557032000119616. [DOI] [Google Scholar]
  • 31.Tricco AC, Lillie E, Zarin W, et al. PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation. Ann Intern Med. 2018;169:467–73. doi: 10.7326/M18-0850. [DOI] [PubMed] [Google Scholar]
  • 32.Egegaard T, Rohold J, Lillelund C, et al. Pre-radiotherapy daily exercise training in non-small cell lung cancer: A feasibility study. Rep Pract Oncol Radiother . 2019;24:375–82. doi: 10.1016/j.rpor.2019.06.003. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 33.Yumei S, Jingui H, Zhen X, et al. Effect of mindfulness decompression therapy combined with respiratory function training on dyspnea-fatigue-anxiety symptom clusters and lung function in lung cancer patients with radiotherapy. Medicine and Clinic. 2024;21:991–5. doi: 10.3969/j.issn.1672-9455.2024.07.028. [DOI] [Google Scholar]
  • 34.Dan W, Gin L, Ming Z, et al. A clinical study of the impact of exercise training on cardiorespiratory fitness and quality of life among advanced lung cancer patients under radiation therapy. Chin J Rehabil Med. 2022;37:501–9. doi: 10.3969/j.issn.1001-1242.2022.04.011. [DOI] [Google Scholar]
  • 35.Pasqua F, D’Angelillo R, Mattei F, et al. Pulmonary rehabilitation following radical chemo-radiation in locally advanced non surgical NSCLC: Preliminary evidences. Lung Cancer (Auckl) 2012;76:258–9. doi: 10.1016/j.lungcan.2012.01.015. [DOI] [PubMed] [Google Scholar]
  • 36.Zheng X, Peng P, Wang Y, et al. The impact of exercise during radiotherapy on treatment-related side effects in breast cancer patients: A systematic review and meta-analysis. Int J Nurs Stud. 2025;163:104990. doi: 10.1016/j.ijnurstu.2024.104990. [DOI] [PubMed] [Google Scholar]
  • 37.Flores LE, Westmark D, Katz NB, et al. Prehabilitation in radiation therapy: a scoping review. Support Care Cancer . 2024;32 doi: 10.1007/s00520-023-08262-9. [DOI] [PubMed] [Google Scholar]
  • 38.Michael CM, Lehrer EJ, Schmitz KH, et al. Prehabilitation exercise therapy for cancer: A systematic review and meta-analysis. Cancer Med. 2021;10:4195–205. doi: 10.1002/cam4.4021. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 39.Keating A, Lee A, Holland AE. What prevents people with chronic obstructive pulmonary disease from attending pulmonary rehabilitation? A systematic review. Chron Respir Dis. 2011;8:89–99. doi: 10.1177/1479972310393756. [DOI] [PubMed] [Google Scholar]
  • 40.Qiao Y, Qiu X, Zhou Q. Pulmonary rehabilitation in the management of patients with lung cancer. Zhongguo Fei Ai Za Zhi. 2011;14:744–8. doi: 10.3779/j.issn.1009-3419.2011.09.09. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 41.Ries AL, Bauldoff GS, Carlin BW, et al. Pulmonary Rehabilitation: Joint ACCP/AACVPR Evidence-Based Clinical Practice Guidelines. Chest. 2007;131:4S–42S. doi: 10.1378/chest.06-2418. [DOI] [PubMed] [Google Scholar]
  • 42.Nici L, Donner C, Wouters E, et al. American Thoracic Society/European Respiratory Society statement on pulmonary rehabilitation. Am J Respir Crit Care Med. 2006;173:1390–413. doi: 10.1164/rccm.200508-1211ST. [DOI] [PubMed] [Google Scholar]
  • 43.Marciniuk DD, Brooks D, Butcher S, et al. Optimizing pulmonary rehabilitation in chronic obstructive pulmonary disease--practical issues: a Canadian Thoracic Society Clinical Practice Guideline. Can Respir J. 2010;17:159–68. doi: 10.1155/2010/425975. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 44.Gosselink R, Troosters T, Decramer M. Peripheral muscle weakness contributes to exercise limitation in COPD. Am J Respir Crit Care Med. 1996;153:976–80. doi: 10.1164/ajrccm.153.3.8630582. [DOI] [PubMed] [Google Scholar]
  • 45.Similowski T, Yan S, Gauthier AP, et al. Contractile properties of the human diaphragm during chronic hyperinflation. N Engl J Med. 1991;325:917–23. doi: 10.1056/NEJM199109263251304. [DOI] [PubMed] [Google Scholar]
  • 46.Lee H, Moon JY, Min KH. Real-World Clinical Studies to Understand the Current Status and Future Improvements of Pulmonary Rehabilitation in Chronic Lung Diseases. Chest. 2024;165:e125. doi: 10.1016/j.chest.2023.10.045. [DOI] [PubMed] [Google Scholar]
  • 47.Southard DR, Cahalin LP, Carlin BW, et al. Clinical Competency Guidelines for Pulmonary Rehabilitation Professionals American Association of Cardiovascular and Pulmonary Rehabilitation Position Statement. J Cardiopulm Rehabil. 1995;15:173–8. doi: 10.1097/00008483-199505000-00001. [DOI] [PubMed] [Google Scholar]
  • 48.Nilsen P. Making sense of implementation theories, models and frameworks. Implement Sci . 2015;10:53. doi: 10.1186/s13012-015-0242-0. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 49.Kuipers ME, van Doorn-Wink KCJ, Hiemstra PS, et al. Predicting Radiation-Induced Lung Injury in Patients With Lung Cancer: Challenges and Opportunities. Int J Radiat Oncol Biol Phys. 2024;118:639–49. doi: 10.1016/j.ijrobp.2023.10.044. [DOI] [PubMed] [Google Scholar]

Associated Data

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    Supplementary Materials

    online supplemental material 1
    bmjopen-15-7-s001.pdf (111.9KB, pdf)
    DOI: 10.1136/bmjopen-2024-091749
    online supplemental material 2
    bmjopen-15-7-s002.pdf (50.9KB, pdf)
    DOI: 10.1136/bmjopen-2024-091749
    online supplemental table 1
    bmjopen-15-7-s003.pdf (268.9KB, pdf)
    DOI: 10.1136/bmjopen-2024-091749

    Data Availability Statement

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