Abstract
Abstract
Introduction
Lung cancer surgery is a cornerstone of curative treatment for resectable disease, but postoperative recovery is often prolonged and may be complicated by impaired pulmonary function, reduced physical activity, symptom burden and delayed functional restoration. Wearable devices may support perioperative physical activity through objective monitoring and activity promotion; however, existing evidence remains fragmented and has not been synthesised in a focused review. This protocol describes a systematic review and meta-analysis to evaluate the association of wearable device-based perioperative physical activity with recovery outcomes in patients undergoing lung cancer surgery.
Methods and analysis
We will include randomised controlled trials, non-randomised interventional studies and prospective or retrospective cohort studies involving adults undergoing surgery for suspected or confirmed primary lung cancer. Eligible studies must examine wearable device-based perioperative physical activity during the preoperative period, postoperative period or both. The primary outcomes will be postoperative pulmonary complications, length of hospital stay and physical function or exercise capacity. Secondary outcomes will include overall postoperative complications, pulmonary function, symptom burden, health-related quality of life, chest tube duration, readmission and postoperative mortality. We will search PubMed, EMBASE, Web of Science, CINAHL and the Cochrane Library from inception to the final search date, supplemented by reference screening, forward citation tracking, grey literature and trial registry searches. Two reviewers will independently perform study selection, data extraction and risk-of-bias assessment. Where appropriate, meta-analysis will be performed using random-effects models; otherwise, findings will be synthesised narratively.
Ethics and dissemination
Ethical approval is not required because this review will use data from published studies and publicly accessible sources only and will not involve individual participants or identifiable personal data. The findings will be disseminated through publication in a peer-reviewed journal and presentation at relevant academic or professional conferences.
PROSPERO registration number
CRD420261375254.
Keywords: Chronic Disease, Digital Technology, eHealth, Lung Neoplasms
STRENGTHS AND LIMITATIONS OF THIS STUDY.
This review will provide a focused synthesis of evidence on wearable device-based perioperative physical activity and recovery after lung cancer surgery.
Major databases will be searched from inception, supplemented by reference screening, citation tracking, grey literature and trial registry searches.
Both interventional and cohort studies will be included due to limited randomised trial evidence, but these study designs will be synthesised separately to avoid inappropriate pooling.
Heterogeneity in wearable devices, activity measures and recovery outcomes may limit study comparability and the feasibility of meta-analysis.
As non-randomised evidence will be included, causal inferences should be made cautiously.
Introduction
Lung cancer remains a major global health challenge and is both the most commonly diagnosed cancer and the leading cause of cancer-related death worldwide.1 For patients with resectable disease, surgery remains a cornerstone of curative treatment. However, postoperative recovery after lung cancer surgery is often complex and prolonged. Patients commonly experience declines in pulmonary function, reduced exercise tolerance, lower levels of physical activity, persistent symptoms and impaired health-related quality of life, with recovery in some domains extending for several months after surgery.2,4 These postoperative challenges may delay functional recovery, increase the risk of complications and place a substantial burden on patients, families and healthcare systems.5,7
Perioperative physical activity is increasingly recognised as an important and modifiable component of recovery after lung cancer surgery.8 Current enhanced recovery guidance for lung surgery emphasises the importance of prehabilitation for selected high-risk patients and early mobilisation after surgery as part of a systematic perioperative care pathway.9,12 In patients recovering from lung cancer surgery, wearable devices such as pedometers, accelerometers, smartwatches and activity trackers may support activity-based recovery by enabling objective monitoring of postoperative physical activity and self-monitoring after discharge. Through feedback, goal setting and activity tracking, these devices may help patients maintain or increase physical activity during the transition from hospital to home.13,15 Accordingly, wearable device-based approaches may represent a practical strategy for improving perioperative activity management and postoperative recovery in patients undergoing lung cancer surgery.
Recent clinical research has suggested that perioperative exercise interventions supported by wearable devices may improve daily step counts, moderate-to-vigorous physical activity and patient-reported dyspnoea after lung cancer surgery.16,18 Broader recent reviews have also indicated that commercial wearable activity monitors may improve activity levels, physical function and quality of life during lung cancer treatment, while digital pulmonary rehabilitation programmes may reduce postoperative pulmonary complications and chest tube duration and may improve physical capacity and other patient-reported outcomes in patients undergoing lung cancer surgery.19,22 Nevertheless, the current evidence base remains difficult to interpret because studies vary considerably in device type, intervention content, perioperative timing, activity metrics, outcome definitions and follow-up duration. This heterogeneity highlights the need for a focused systematic review to clarify the available evidence on wearable device-based perioperative physical activity and recovery outcomes after lung cancer surgery, determine whether quantitative synthesis is appropriate for specific outcomes and inform future perioperative rehabilitation research and practice.16 23 24
Therefore, a focused and methodologically transparent systematic review is warranted. This protocol describes a systematic review and meta-analysis that will evaluate the association of wearable device-based perioperative physical activity with recovery outcomes in patients undergoing lung cancer surgery. Specifically, this review will synthesise evidence on whether wearable-supported or wearable-measured perioperative physical activity is associated with postoperative complications, pulmonary recovery, functional recovery, symptom burden, hospital stay and health-related quality of life. Where data permit, the magnitude of these associations will also be estimated quantitatively. Such evidence may help clarify the role of wearable devices in perioperative recovery pathways and inform future clinical practice, rehabilitation design and research in lung cancer surgery.
Materials and methods
Study registration
This protocol has been registered in the International Prospective Register of Systematic Reviews (PROSPERO). The planned start date of this systematic review and meta-analysis is 1 July 2026, and the planned end date is 31 December 2026. The review protocol was prepared with reference to the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) 2015 statement; the completed PRISMA-P checklist is available as online supplemental file S1.25 The final systematic review and meta-analysis will be reported in accordance with the PRISMA 2020 statement. Any important changes made to the methods after registration will be documented in the PROSPERO record and described in the completed review.
Ethics and dissemination
As this study is a systematic review and meta-analysis based exclusively on data from published literature and publicly accessible sources, no direct involvement of human participants will occur and no identifiable personal information will be collected. Therefore, formal ethical approval is not required for this review. The findings will be disseminated through publication in a peer-reviewed journal and presentation at relevant academic or professional conferences.
Patient and public involvement
Patients and/or the public were not involved in the design, conduct, reporting or dissemination plans of this research.
Eligibility and exclusion criteria
Participants
We will include studies involving adults (≥18 years) who are scheduled to undergo, are undergoing, or have undergone surgery for suspected or confirmed primary lung cancer. Eligible surgical procedures will include wedge resection, segmentectomy, lobectomy, bulbectomy, sleeve resection and pneumonectomy, performed via video-assisted thoracoscopic, robotic-assisted or open approaches. No restrictions will be placed on sex, ethnicity, tumour stage, histological subtype or receipt of neoadjuvant or adjuvant therapy. Studies involving mixed populations will be eligible only if data for patients undergoing surgery for primary lung cancer are reported separately or can be obtained from study authors. If separate data for this target population cannot be obtained, the study will be excluded. We will exclude studies focusing exclusively on non-surgical management, diagnostic procedures without lung resection or surgery for non-primary lung malignancies or other non-lung cancer conditions.
Exposure
Eligible studies must examine wearable device-based perioperative physical activity. In this review, this refers to physical activity undertaken during the preoperative period, postoperative period or both, in which a body-worn device is used to objectively measure, monitor, promote or support activity behaviour. Eligible wearable devices will include pedometers, accelerometers, smartwatches, fitness bands and other wearable activity trackers capable of recording indicators such as step count, walking time, activity intensity, energy expenditure or sedentary time. Studies will be eligible whether the wearable is used to characterise naturally occurring activity levels or as part of a perioperative intervention aimed at increasing physical activity, exercise participation or early mobilisation. Multicomponent perioperative rehabilitation programmes will be included if wearable-supported physical activity is a clearly described core component of the programme. We will exclude studies in which devices are used solely for physiological monitoring unrelated to physical activity, studies based only on self-reported activity without wearable-derived data and digital rehabilitation programmes that do not include a wearable-based physical activity component.
Outcomes
The outcomes of interest in this review will be postoperative recovery outcomes following lung cancer surgery. The primary outcomes will be postoperative pulmonary complications, length of hospital stay and physical function or exercise capacity. Postoperative pulmonary complications may include pneumonia, atelectasis, respiratory failure, prolonged air leak or other pulmonary events as defined by the original study authors. Physical function or exercise capacity may be assessed using measures such as the 6 min walk test, sit-to-stand performance or other validated functional indicators. Secondary outcomes will include overall postoperative complications, pulmonary function, symptom burden, health-related quality of life, chest tube duration, readmission, postoperative mortality and other reported recovery-related outcomes. We will include studies reporting outcomes during hospitalisation or after discharge, provided that at least one postoperative recovery outcome is evaluated in relation to wearable device-based perioperative physical activity.
Study designs and setting
Given the limited randomised trial evidence identified in preliminary searches, we will include randomised controlled trials, non-randomised interventional studies and prospective or retrospective cohort studies that examine wearable device-based perioperative physical activity in relation to recovery outcomes after lung cancer surgery. Because interventional and cohort studies address different questions, these types of evidence will be analysed separately to avoid inappropriate pooling. Analytical cross-sectional studies and case-control studies will be excluded because these designs are less able to establish a clear temporal relationship between perioperative physical activity and postoperative recovery outcomes. We will also exclude case reports, case series, qualitative studies, reviews, study protocols, editorials and conference abstracts without sufficient data. Studies conducted in hospital, outpatient, home and community-based or hybrid perioperative care settings will be eligible. No restrictions will be placed on country or region.
Search strategy
A comprehensive literature search will be conducted in PubMed, EMBASE, Web of Science, CINAHL and the Cochrane Library from database inception to the date of the final search. The search will be conducted without restrictions on publication date, and the final search will be completed within the planned study period from 1 July 2026 to 31 December 2026, with the actual final search date documented in the completed review. To improve the completeness of the evidence base, we will also screen the reference lists of all included studies and relevant reviews and perform forward citation tracking through Google Scholar or other citation databases where available. In addition, grey literature sources and trial registries will be searched, where feasible, to identify potentially eligible unpublished or ongoing studies. The search strategy will combine controlled vocabulary terms and free-text terms related to three main concepts: lung cancer surgery, wearable devices and perioperative physical activity and recovery. The search terms will be adapted to the indexing system and search functions of each database, with appropriate use of Boolean operators, truncation and phrase searching. No restrictions will be placed on language. Non-English records will be screened using translated titles and abstracts where available, and potentially eligible full texts will be translated or summarised using language-proficient reviewers or validated translation tools, with key eligibility and extraction decisions checked by two reviewers. The detailed search strategies for all databases are presented in online supplemental file S2.
Study selection
All retrieved records will be imported into reference management software (EndNote V.X9), and duplicate records will be removed before screening. Two reviewers (JS and YH) will independently screen titles and abstracts according to the predefined eligibility criteria, followed by full-text assessment of potentially eligible studies. Any disagreements between the two reviewers will be resolved through discussion and, if necessary, consultation with a third reviewer (FS). Reasons for exclusion at the full-text stage will be recorded. The study selection process will be presented in a PRISMA flow diagram (online supplemental figure S1).
Data extraction
Two reviewers (JS and YH) will independently extract data from all included studies using a standardised and pilot-tested Microsoft Excel data extraction form. The extracted information will include: (1) general study characteristics, including first author, year of publication, country, study setting, study design, recruitment period and funding source where reported; (2) participant and surgical characteristics, including sample size, age, sex, tumour type or stage where available, surgical approach and procedure; (3) wearable-related exposure or intervention characteristics, including, for interventional studies, the type of wearable device, intervention components, co-intervention components, intervention intensity, duration, frequency, timing within the perioperative pathway and comparator characteristics, and, for cohort studies, the exposure definition, measurement period, timing in relation to surgery, duration of monitoring and any available information on baseline or historical physical activity; (4) comparator characteristics, where applicable; (5) outcome-related information, including outcome definitions, measurement tools and follow-up time points and (6) statistical data required for evidence synthesis, including effect estimates, summary statistics, measures of variance, sample sizes, event numbers and total numbers for dichotomous outcomes, and means, SD or other statistics that can be converted into a common effect measure for continuous outcomes, where available.
For interventional studies, we will additionally extract details of the intervention content, delivery format and adherence information where available. For cohort studies, we will preferentially extract adjusted effect estimates and the covariates included in the adjusted analyses. If multiple reports are based on the same study population or trial, we will collate the available information across reports and retain the most complete dataset for each outcome to avoid double counting. Duplicate publications from the same study will not be treated as separate studies in the analysis. Any discrepancies between the two reviewers will be resolved through discussion and, if necessary, consultation with a third reviewer (FS). When essential information is missing or unclear, we will attempt to contact the corresponding authors for clarification. If additional data cannot be obtained, the study will be synthesised using the available information, and the possible impact of missing data will be considered when interpreting the findings.
Assessment of risk of bias
Two reviewers (JS and YH) will independently assess the risk of bias of all included studies using design-specific tools. Randomised controlled trials will be evaluated using the Cochrane Risk of Bias 2 tool.26 For non-randomised interventional studies, studies with a concurrent comparator will be assessed using Risk Of Bias In Non-randomised Studies of Interventions27 whereas eligible quasi-experimental studies without random allocation will be appraised using the revised Joanna Briggs Institute (JBI) critical appraisal tool28 for quasi-experimental studies. Prospective and retrospective cohort studies will be assessed using the revised JBI critical appraisal tool for cohort studies.29 Any disagreements between the two reviewers will be resolved through discussion and, if necessary, consultation with a third reviewer (FS). The assessment results will be summarised in tables and figures and will be considered in the interpretation of the findings. Where feasible, sensitivity analyses will be conducted by excluding studies judged to be at high risk of bias.
Strategy for data synthesis
We will first undertake a structured descriptive synthesis of all included studies and summarise their main characteristics in tables. The unit of analysis will be the study rather than the article; multiple publications from the same study or trial will be collated and treated as a single study in the synthesis and meta-analysis, where applicable. Studies will be grouped according to study design, the role of the wearable device in the study (eg, objective activity monitoring only or activity-support intervention), the perioperative timing of the exposure or intervention and the outcome domain assessed. Quantitative synthesis will be considered only when studies are sufficiently comparable in terms of participants, wearable-based exposure or intervention, comparator, outcome definition and follow-up time point. Interventional studies will be used to evaluate the effects of wearable device-based perioperative physical activity interventions, whereas cohort studies will be used to examine associations between wearable-measured perioperative physical activity and recovery outcomes. These two types of evidence will not be combined in the same meta-analysis. This approach is intended to enhance the clinical and methodological interpretability of the findings and is consistent with guidance in the Cochrane Handbook for preparing and analysing evidence syntheses.30
For randomised controlled trials and non-randomised interventional studies, meta-analysis will be performed, where appropriate, using a random-effects model. Randomised and non-randomised interventional studies will be pooled together only when they are sufficiently comparable in design, intervention characteristics, comparator, outcome definition and follow-up time point; otherwise, they will be synthesised separately. For dichotomous outcomes, risk ratios with 95% CIs will be calculated; for continuous outcomes, mean differences or standardised mean differences with 95% CIs will be used, as appropriate. For cohort studies, adjusted effect estimates will be preferentially extracted, and pooled analyses will be undertaken only when the reported effect measures, exposure definitions, outcome definitions and follow-up time points are sufficiently comparable. Interventional and cohort data will not be combined in the same meta-analysis. Statistical heterogeneity will be assessed using the χ2 test and the I2 statistic. Where meta-analysis is not appropriate because of substantial clinical or methodological heterogeneity, limited data or inconsistency in outcome reporting, findings will be synthesised narratively using a structured approach informed by Synthesis Without Meta-analysis guidance.31 The narrative synthesis will consider study characteristics, the direction and consistency of findings, outcome reporting, follow-up time points and risk of bias when interpreting the evidence. Statistical analyses will be conducted using Review Manager 5.4.
Quality of evidence and publication biases assessment
Two reviewers (JS and YH) will independently assess the certainty of evidence for each primary outcome, and for secondary outcomes where quantitative synthesis is performed. For evidence derived from randomised controlled trials and non-randomised interventional studies, the certainty of evidence will be evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach and rated as high, moderate, low or very low across the domains of risk of bias, inconsistency, indirectness, imprecision and publication bias; within GRADE, randomised evidence starts as high-certainty evidence, whereas non-randomised intervention evidence starts as low-certainty evidence and may be rated down or up as appropriate.32 For prospective and retrospective cohort studies examining associations between wearable device-based perioperative physical activity and postoperative recovery outcomes, the certainty of evidence will be assessed using GRADE guidance for prognostic factor evidence.33 Certainty ratings will be undertaken separately for interventional evidence and cohort evidence. Any disagreements will be resolved through discussion and, if necessary, consultation with a third reviewer (FS).
Publication bias and small-study effects will be explored for each meta-analysis that includes a sufficient number of studies. When at least 10 studies are available for a pooled analysis, funnel plots will be inspected visually and Egger’s regression test will be performed where appropriate.34 When fewer than 10 studies are available, formal tests for funnel plot asymmetry will not be undertaken because such tests have low statistical power and may be misleading in small meta-analyses.35 In these circumstances, the possibility of publication bias will be considered qualitatively on the basis of study size, direction and consistency of findings and the completeness of outcome reporting. The final certainty judgments will be presented in summary tables and considered in the interpretation of the review findings.
Subgroup analysis
Where sufficient data are available, subgroup analyses will be conducted to explore potential sources of heterogeneity. Interventional studies and cohort studies will be synthesised separately and will not be combined in subgroup analyses or meta-analyses. For studies considered sufficiently comparable for meta-analysis, subgroup analyses may be undertaken, where data permit, according to intervention components, timing and duration of the physical activity exposure or intervention, baseline or historical physical activity, surgical approach (minimally invasive vs open surgery) and outcome measurement time point. All subgroup analyses will be considered exploratory and interpreted cautiously.
Sensitivity analysis
Where sufficient data are available, sensitivity analyses will be performed to examine the robustness of the main findings. We will repeat the primary analyses after excluding studies judged to be at high risk of bias. Where appropriate, additional sensitivity analyses may be conducted by excluding studies with poorly defined exposure or outcome measures and by performing leave-one-out analyses to assess the influence of individual studies on the pooled estimates.
Discussion
Recovery after lung cancer surgery remains a clinically important issue. Although surgery is a cornerstone of treatment for resectable lung cancer, postoperative recovery is often affected by impaired pulmonary function, reduced physical activity, symptom burden and delayed functional restoration.36 Current enhanced recovery guidance for lung surgery also emphasises prehabilitation for selected high-risk patients and early mobilisation after surgery as key components of perioperative care, highlighting the clinical relevance of physical activity across the surgical pathway.36 In this context, wearable devices may offer practical advantages by enabling objective activity monitoring and by supporting behavioural strategies that extend beyond the inpatient setting. Therefore, a focused synthesis of the evidence on wearable device-based perioperative physical activity and postoperative recovery is warranted.
A dedicated review is particularly needed because this topic cannot be fully addressed by broader reviews of digital rehabilitation or general wearable monitoring in lung cancer. Recent evidence suggests that wearable-supported perioperative exercise may improve daily step counts, moderate-to-vigorous physical activity and patient-reported dyspnoea after lung cancer surgery.16 At the same time, broader reviews have reported potentially beneficial effects of commercial wearable activity monitors during lung cancer treatment and of digital pulmonary rehabilitation after lung cancer surgery.37,39 However, these earlier syntheses have generally addressed wider questions, such as overall digital support, wearable use during treatment or digital pulmonary rehabilitation programmes, rather than specifically examining wearable device-based perioperative physical activity in relation to postoperative recovery outcomes after lung cancer surgery.18 20 21 This distinction is important because the perioperative setting has particular clinical features, including rapid transitions from hospital to home, short-term recovery targets and outcome measures such as pulmonary complications, length of stay and early functional recovery.
This review may therefore provide both methodological and practical value. By synthesising evidence from interventional studies and cohort studies in a structured manner, it may help clarify the extent to which wearable device-based perioperative physical activity is associated with postoperative pulmonary complications, hospital stay, functional recovery and patient-reported outcomes after lung cancer surgery. The findings may help identify important gaps in the current literature, including variation in device type, activity metrics, intervention content, follow-up time points and outcome definitions. In turn, this may inform the design of future studies and support the development of more consistent perioperative rehabilitation pathways that incorporate wearable technologies in clinically meaningful ways.
Limitation
This review may have several limitations. First, clinical and methodological heterogeneity may limit the comparability of the included studies and, in some cases, the feasibility of quantitative synthesis. Second, this review will include both interventional studies and cohort studies; however, these designs address different questions and will be synthesised separately, so causal inferences will be made cautiously according to study design. Third, differences in the definition and measurement of wearable device-based physical activity and recovery outcomes may affect the consistency of evidence synthesis and interpretation.
Supplementary material
Footnotes
Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
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-2026-121526).
Provenance and peer review: Not commissioned; externally peer reviewed.
Patient consent for publication: 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.
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