Lise Tremblay

Feasibility and effectiveness of a home-based exercise training program before lung resection surgery

BACKGROUND Patients with lung cancer often experience a reduction in exercise tolerance, muscle weakness and decreased quality of life. Although the effectiveness of pulmonary rehabilitation programs is well recognized in other forms of cancers and in many pulmonary diseases, few researchers have studied its impact in patients with lung cancer, particularly in those awaiting lung resection surgery (LRS). OBJECTIVES To investigate the feasibility of a short, home-based exercise training program (HBETP) with patients under investigation for non-small cell lung cancer and potential candidates for LRS, and to determine the effectiveness of this program on exercise tolerance, skeletal muscle strength and quality of life. METHODS Sixteen patients with lung cancer awaiting LRS participated in a four-week HBETP including moderate aerobic activities (walking and cycling) and muscle training performed three times weekly. Before and after the intervention, a cardiopulmonary exercise test, a 6 min walk test and the assessment of muscle strength and quality of life were performed. RESULTS Thirteen patients completed the four-week HBETP and all the patients completed >75% of the prescribed exercise sessions. The duration of the cycle endurance test (264±79 s versus 421±241 s; P<0.05) and the 6 min walk test distance (540±98 m versus 568±101 m; P<0.05) were significantly improved. Moreover, the strength of the deltoid, triceps and hamstrings were significantly improved (∆ post-pre training 1.82±2.83 kg, 1.32±1.75 kg and 3.41±3.7 kg; P<0.05, respectively). CONCLUSION In patients with lung cancer awaiting LRS, HBETP was feasible and improved exercise tolerance and muscle strength. This may be clinically relevant because poor exercise capacity and muscle weakness are predictors of postoperative complications.

Exercise-Based Rehabilitation for People with Lung Cancer

Lung cancer is the leading cause of cancer-related death worldwide. Patients living with lung cancer often experience severe physical and psychological symptoms including dyspnea, fatigue, anxiety, decreased exercise tolerance, muscle weakness and compromised health-related quality of life as a direct consequence of the disease or as an indirect consequence of the cancer therapy itself. As both screening and treatment modalities improve, the number of people living with a diagnosis of lung cancer is increasing. Consequently, management of cancer-related symptoms as well as improvement of overall quality of life and functional status become critical issues in lung cancer patients. Thus, during the last decade, a wide range of exercise prescriptions and training modalities has been proposed and an emerging literature has addressed the effects of exercise-based rehabilitation programs along the continuum of the disease. The aim of this review is to address the latest literature regarding the feasibility and effectiveness of exercise-based rehabilitation for patients with lung cancer receiving treatments (perioperative, during chemotherapy/radiation therapy or following them) or for patients with advanced diseases. We also address how the use of new technologies or training modalities such as home-based telerehabilitation or neuromuscular electrical stimulation appears to be a promising approach to improve accessibility and participation in exercisebased rehabilitation programs. Evidence from our review suggests that pre and post-operative exercise-based rehabilitation appear to be safe and effective approaches to use with patients with lung cancer and for those with advanced disease receiving chemotherapy/radiation therapy. Larger randomized controlled trials are needed to confirm the efficacy of exercise interventions in this population.

Pericardiocentesis versus pericardiotomy for malignant pericardial effusion: a retrospective comparison

BACKGROUND Treatment of malignant pericardial effusion remains controversial, because no randomized controlled trials have been conducted to determine the best approach, and results of retrospective studies have been inconsistent. The objective of the present study was to compare pericardiocentesis and pericardiotomy with respect to efficacy for preventing recurrence, and to determine, for those two procedures, diagnostic yields, complication rates, and effects on survival. We also aimed to identify clinical and procedural factors that could predict effusion recurrence. METHODS We retrospectively assessed 61 patients who underwent a procedure for treatment of a malignant pericardial effusion at the Institut universitaire de cardiologie et de pneumologie de Québec between February 2004 and September 2013. RESULTS Pericardiocentesis was performed in 42 patients, and pericardiotomy, in 19 patients. The effusion recurrence rate was significantly higher in patients treated with pericardiocentesis than with pericardiotomy (31.0% vs. 5.3%, p = 0.046). The diagnostic yield of the procedures was not significantly different (92.9% vs. 86.7%, p = 0.6). The overall rate of complications was similar in the two groups, as was the median overall survival (2.4 months vs. 2.6 months, p = 0.5). In univariate analyses, the procedure type was the only predictor of recurrence that approached statistical significance. Age, sex, type of cancer, presence of effusion at the time of cancer diagnosis, prior chest irradiation, tamponade upon presentation, and total volume of fluid removed did not influence the recurrence rate. CONCLUSIONS Compared with pericardiocentesis, pericardiotomy had higher success rate in preventing recurrence of malignant pericardial effusion, with similar diagnostic yields, complication rates, and overall survival.

A Distress Protocol for Respiratory Emergencies in Terminally Ill Patients With Lung Cancer or Chronic Obstructive Pulmonary Disease

A combination of opioid, midazolam, and scopolamine (that we call “distress protocol” [DP]) is used to induce transient sedation when emergencies occur in palliative care. We wished to describe the prescription and administration of DP in terminally ill patients with either lung cancer or chronic obstructive pulmonary disease (COPD). In a retrospective study, 96 of 100 patients with cancer and 85 of 100 patients with COPD had a DP prescribed. Thirty patients with cancer and 29 with COPD received at least 1 DP. All patients receiving a DP for an appropriate indication were sedated within 30 minutes. There was no difference in survival from DP administration among patients who received it and those who did not.

Wait times for diagnosis and treatment of lung cancer: a single-centre experience

Background Multiple clinical practice guidelines recommend rapid evaluation of patients with suspected lung cancer. It is uncertain whether delays in diagnosis and management have a negative effect on outcomes. Methods This retrospective study included 551 patients diagnosed with lung cancer through the diagnostic assessment program at the Institut universitaire de cardiologie et de pneumologie de Québec between September 2013 and March 2015. Median wait times between initial referral, diagnosis, and first treatment were calculated and compared with recommended targets. Analyses were performed to evaluate for specific factors associated with longer wait times and for the effect of delays on the outcomes of progression-free survival (pfs), relapse-free survival (rfs) after primary surgical resection, and overall survival (os). Results Most patients were investigated and treated within recommended targets. Of the entire cohort, 379 patients were treated at our institution. Of those 379 patients, 311 (82%) were treated within recommended targets. In comparing patients within and outside target times, the only statistically significant difference was found in the distribution of treatment modalities: patients meeting targets were more likely to be treated with surgery or chemotherapy rather than with radiation. The pfs on first treatment modality was influenced by clinical stage, but not by time to therapy [hazard ratio (hr): 1.10; p = 0.65]. The os for the entire cohort was also influenced by stage, but not by delays (hr: 1.04; p = 0.87). For the 209 patients treated by surgery with curative intent, a significant reduction in rfs was associated with male sex and TNM stage, but not with delays (hr: 1.11; p = 0.83). The os after primary surgical resection was also associated with TNM stage, but not with delays (hr: 1.82; p = 0.43). Conclusions Recommended targets for wait times in the investigation and treatment of lung cancer can be achieved within a diagnostic assessment program. Compared with radiation treatment, treatment with surgery or chemotherapy is more likely to be completed within targets. Delays in investigation and treatment do not appear to negatively affect the clinical outcomes of os, rfs, and pfs. Prospective studies are needed to evaluate whether efficient work-up and treatment influence other important variables, such as quality of life, cost of care, and access to therapies while performance status is adequate.

Immunotherapy and pseudoprogression in lung adenocarcinoma

A 59-year-old woman with EGFR, ALK and PD-L1 negative metastatic lung adenocarcinoma presented with progressive disease under platinum-based chemotherapy (Figure 1; panel A). Nivolumab, an anti-PD-1 monoclonal antibody, was initiated as second-line therapy and administered at a dose of 3 mg/kg intravenously every 2 weeks. Chest CT scan after 5 cycles showed progressive disease. As an excellent performance status and treatment tolerance were maintained, nivolumab was continued. Imaging after 8 cycles again showed progression (Figure 1; panel B), but the patient remained asymptomatic; hence, treatment was pursued. CT following 11 cycles showed significant tumor regression, thus confirming initial pseudoprogression. Radiologic stability persisted as the patient received her 34 cycle (Figure 1; panel C). Since the introduction of immunotherapy in oncology, cases have been described of initial progression followed by treatment response under the RECIST and WHO criteria. This unique response pattern led to the establishment of immune-related response criteria to better identify responders and non-responders under immunotherapy. However, to date, limited data investigating the usefulness of functional imaging such as PET-CT in monitoring response to immunotherapy are available. As pseudoprogression is infrequent, its underlying pathophysiology remains uncertain. Hypotheses include tumoral immune cell infiltration as part of the enhanced immune response, as biopsies of pseudoprogressive neoplastic lesions revealed the presence of inflammatory cells, including T lymphocytes, as well as necrotic tissue. Following regression, an absence of tumoral cells was also noted. True progression followed by regression of tumoral burden, through a late effective immune response, is considered as another hypothesis. If absence of PD-L1 expression, as in our patient, can contribute to such a delayed antitumoral immune response is another question of interest. Tumor response assessment in the era of immunotherapy is therefore a true challenge. Further studies are needed to better distinguish pseudoprogression from true progression. Alternative approaches must be explored, including functional imaging, biopsy and biomarkers.

L’utilisation des opiacés dans la maladie pulmonaire obstructive chronique sévère

Resume Objectifs La dyspnee est un symptome dominant dans la maladie pulmonaire obstructive chronique severe. Malgre un traitement optimal, la dyspnee demeure difficile a soulager. Les opiaces ont un role dans la prise en charge de la dyspnee refractaire. Methodes Il s’agit d’une etude retrospective de 200 patients decedes entre 1998 et 2004. Les variables suivantes ont ete etudiees : le choix de l’opiace, la duree d’utilisation, les effets secondaires et la severite de la maladie sous-jacente. Resultats Les opiaces ont ete utilises chez 98 % des patients. Dans 70 % des cas, la duree d’utilisation a ete inferieure a 7 jours. Celle-ci a varie entre 1 et 1 030 jours. La morphine a ete l’opiace le plus frequemment utilise (188/192). Les effets secondaires ont ete : nausees (16/192), constipation (61/192). Il y a eu deux cessations d’opiaces pour de la constipation. La Paco 2 moyenne etait de 56 mmHg. Conclusion L’utilisation des opiaces chez les patients avec une maladie pulmonaire obstructive chronique severe est relativement bien toleree. Toutefois, la majorite des patients en recoivent seulement quelques jours avant le deces.