Speaker's Highlight

• Don Sin University of British Columbia, St. Paul Hospital (Canada)
  Kenneth R. Chapman Toronto General Hospital Research Institute (Canada)
• Parameswaran Nair McMaster University (Canada)
  Carolyn Calfee UCSF (U.S.A.)
• Gregory P. Downey University of Colorado School of Medicine (U.S.A.)
  David A. Schwartz University of Colorado School of Medicine (U.S.A.)
• Neil Schluger Tuberculosis Control Branch, California Department of Public Health (U.S.A.)
  Nick Kim Critical Care & Sleep Medicine, University of California San Diego (U.S.A.)
• Nicola Hananiah Baylor College of Medicine (U.S.A.)
  Jae-Joon Yim Seoul National University College of Medicine (Republic of Korea)
• Koichiro Asano Tokai University School of Medicine (Japan)
  Diahn-Warng Perng Taipei Veterans General Hospital (Taiwan)
• Konstantinos Kostikas University of Ioannina (Greece)
  Karin Klooster University Medical Center Groningen (Kingdom of the Netherlands)

• Restoring Function Through Pulmonary Rehabilitation in Lung Cancer

  Lung cancer remains the leading cause of cancer-related death in Australia, with more than 8,000 deaths recorded each year by the Australian Institute of Health and Welfare. Survival has improved with targeted therapies, immunotherapy and earlier detection, yet many survivors still face chronic breathlessness, fatigue and marked physical decline. These symptoms often linger long after surgery or chemotherapy has finished.

  Pulmonary rehabilitation is a structured programme of exercise training, education and behaviour change, traditionally developed for people with chronic obstructive pulmonary disease. Over the past decade, evidence has expanded to show that people with lung cancer, whether before surgery, after treatment or during survivorship, gain comparable benefits. Programmes typically combine aerobic and resistance work, breathing retraining and psychological support, delivered by a multidisciplinary team.

  In Australia, pulmonary rehabilitation is provided through hospital outpatient services, community programmes and, increasingly, telehealth. The Lung Foundation Australia has championed access, particularly in regional areas of New South Wales, Queensland and Western Australia, where travelling to a tertiary centre can be difficult. Funding through Medicare and private health insurers has supported growth, although gaps remain for patients in very remote locations.

  For clinicians gathering at the APSR 2022 congress, the intersection of respiratory medicine and oncology offers a clear opportunity to embed rehabilitation earlier in the lung cancer pathway. What follows is an outline of the evidence base, the practical components of a programme and the Australian realities of delivering care across vast distances.

  Why Pulmonary Rehabilitation Matters in Lung Cancer

  People diagnosed with lung cancer typically lose 10 to 15 percent of their exercise capacity before treatment even begins, driven by the tumour itself, smoking history, comorbidities and physical deconditioning. After lobectomy or pneumonectomy, this loss deepens for several weeks and many never return to baseline without focused training. Reduced exercise capacity is associated with poorer survival and higher rates of postoperative complications.

  Rehabilitation addresses these losses through measurable improvements in six-minute walk distance, peak oxygen uptake and muscle strength. It also reduces dyspnoea, anxiety and depression, outcomes that matter as much to patients as they do to clinicians. For those with advanced disease, even short programmes can ease the burden of breathlessness and preserve independence for daily activities such as shopping or walking a dog along a Melbourne beach path.

  The economic argument is equally relevant in the Australian context. Keeping people out of hospital and functional in their own homes reduces pressure on public health services. Data from Victorian and New South Wales services suggest fewer readmissions and shorter inpatient stays among participants, a pattern echoed in international trials.

  Core Components of an Effective Programme

  A well-designed programme includes aerobic exercise such as treadmill walking or cycling, performed three to five times weekly at moderate intensity. Resistance training for the major muscle groups complements aerobic work, addressing the cachexia and sarcopenia frequently seen in lung cancer. Breathing retraining, including diaphragmatic and paced techniques, helps patients manage episodes of acute breathlessness.

  Education sessions cover energy conservation, oxygen use, nutrition, smoking cessation and recognition of infection. Many Australian centres partner with dietitians and clinical psychologists, recognising that malnutrition and distress commonly accompany a lung cancer diagnosis. Where available, speech pathologists contribute to voice and swallowing rehabilitation after thoracic surgery.

  Progress is reviewed at regular intervals using validated tools. The six-minute walk test, the Chronic Respiratory Questionnaire and the Hospital Anxiety and Depression Scale are widely used in Australian practice. Adjustments are made to intensity, duration or format based on treatment phase, symptom burden and patient goals, whether that is returning to a building site in Brisbane or simply climbing stairs without stopping.

  Preoperative Rehabilitation Before Surgery

  Prehabilitation, the term used for rehabilitation delivered before surgery, has gathered momentum in lung cancer care. Patients identified as high risk, often due to poor lung function, low fitness or significant comorbidities, are offered two to four weeks of supervised training before their planned resection. The aim is to enter surgery in the best possible condition.

  Studies show reductions in postoperative pulmonary complications, shorter chest drain duration and fewer days in intensive care. Australian centres in Sydney and Perth have built prehabilitation clinics alongside thoracic surgical units, with physiotherapists screening patients at the time of surgical listing. Where surgery is delayed for any reason, training continues, ensuring no opportunity is wasted.

  Prehabilitation also offers a psychological head start. Meeting the rehabilitation team before surgery reduces anxiety, builds trust and gives patients a sense of agency during a turbulent period. For clinicians, it provides a structured window to optimise comorbidities such as diabetes, anaemia and obstructive sleep apnoea.

  Recovery After Surgery and During Treatment

  After lobectomy or pneumonectomy, patients are usually seen within four to six weeks, once surgical healing permits. Early outpatient programmes focus on restoring chest wall mobility, regaining shoulder range of motion and rebuilding aerobic capacity. Walking programmes are progressed carefully, with intensity titrated against dyspnoea and fatigue scores.

  For patients receiving chemotherapy, radiotherapy or immunotherapy, rehabilitation is adjusted around treatment cycles. Fatigue is the main constraint, and programmes often shift towards shorter, more frequent sessions. Exercise has been shown to mitigate treatment-related fatigue and improve completion rates of adjuvant therapy, an effect that matters for both survival and quality of life.

  The role of the specialist cancer nurse and physiotherapist is central here. Coordinated reviews, shared documentation and clear communication with the oncology team keep rehabilitation aligned with the overall treatment plan. For those wishing to share emerging findings with colleagues, reviewing speaker guidelines ahead of abstract submission helps avoid common pitfalls.

  Managing Breathlessness in Advanced Disease

  When cure is no longer possible, the goals of rehabilitation shift towards symptom control and functional independence. Breathlessness is the dominant symptom, often accompanied by cough, fatigue and anxiety. Non-pharmacological strategies, including positioning, fan therapy, paced activity and breathing techniques, are taught alongside pharmacological options such as opioids where appropriate.

  Programmes for advanced disease are typically shorter and delivered closer to home. Some Australian services offer home-based rehabilitation, supported by telehealth check-ins, for patients who are too unwell to attend in person. Equipment such as portable oxygen, mobility aids and small hand weights can be prescribed to support safe activity.

  Family and carers are welcomed into sessions. Learning to pace activities together, to recognise early signs of decompensation and to plan for setbacks helps the whole household cope. Palliative care teams and rehabilitation services increasingly collaborate, particularly in Adelaide and Hobart, to ensure the transition from active treatment to supportive care is seamless.

  Delivering Rehabilitation Across Australia

  Australia's geography shapes how rehabilitation is delivered. Urban centres such as Melbourne and Sydney have well-established hospital-based programmes, often running two to three times weekly for eight weeks. Rural and remote patients face long travel distances, limited local services and fewer specialist staff.

  Telehealth has emerged as a practical solution. Initial assessments, education sessions and supervised exercise reviews can be conducted via video link, with simple home-based programmes filling the gap. The Lung Foundation Australia and several Primary Health Networks have supported pilot programmes in the Northern Territory and western Queensland, where the population is dispersed across enormous distances.

  Cultural safety is essential when working with Aboriginal and Torres Strait Islander patients. Programmes adapted to local languages, delivered by Aboriginal health workers and grounded in community priorities are more successful. Recognising cultural practices around family, country and traditional healing strengthens engagement and improves outcomes.

  Outcomes, Evidence and What Lies Ahead

  The evidence for pulmonary rehabilitation in lung cancer is now strong enough to move from research curiosity to standard practice. Systematic reviews consistently report improvements in exercise capacity, dyspnoea and health-related quality of life across pre-treatment, post-treatment and palliative phases. Cost-effectiveness data from Australian settings are emerging and are likely to support wider funding.

  Future directions include embedding rehabilitation into lung cancer multidisciplinary meetings, integrating wearable technology for remote monitoring and tailoring programmes to molecular subtypes of lung cancer, where treatment side effects differ. Trials underway in Australian tertiary centres are testing whether prehabilitation combined with immunotherapy improves surgical outcomes in borderline-resectable disease.

  Phase of care	Main goals	Typical setting	Australian example
  Preoperative (prehabilitation)	Improve fitness, reduce complications	Hospital outpatient clinic	Sydney and Perth thoracic surgery clinics
  Post-surgical recovery	Restore mobility, rebuild strength	Outpatient rehab or home programme	Community programmes in regional NSW
  During chemotherapy/radiotherapy	Manage fatigue, maintain function	Hospital or telehealth	Telehealth pilots in western Queensland
  Advanced or palliative disease	Ease breathlessness, preserve independence	Home-based or hospice-linked	Adelaide and Hobart palliative rehab

  The practical takeaway is that every patient with lung cancer can benefit from some form of rehabilitation, regardless of stage or treatment intent. Early referral, individualised prescription and culturally appropriate delivery are the foundations of success. When respiratory physicians, oncologists, surgeons and rehabilitation teams work together, the patient moves through treatment with more strength, less breathlessness and a better quality of life. Pulmonary rehabilitation deserves the same urgency in lung cancer care as it has earned in chronic lung disease.

  Richard Russell Nuffield Department of Clinical Medicine, University of Oxford (United Kingdom)
• Mona Bafadhel King’s College London (United Kingdom)
  David Jackson Guy’s and St Thomas’ Hospital, King’s College London (United Kingdom)
• James Chalmers University of Dundee (United Kingdom)
  David Price University of Aberdeen (United Kingdom)