Adding Mindfulness: Innovation for an Optimal Preoperative Rehabilitation Before Lung Cancer Resection

Surgical resection appears to be the most effective treatment for early stage non-small cell lung cancer. New research shows that patients with lung cancer facing a curative surgery may be able to help themselves ensure a better outcome with simple perioperative — care before, during and after surgery — rehabilitation techniques, including a slow exercise routine and breathing awareness exercises.

In fact, several recent studies determined that perioperative pulmonary rehabilitation improves ultimate functional capacity and reduces postoperative complications, as well as enhances recovery in operated patients. However, the optimal intervention tailored to patients with lung cancer, either pre- or post-surgery, has yet to be established.

For patients undergoing lung resection for cancer, it has been shown that stress, anxiety, depression and fear are associated with worsening quality of life following the surgery. Those same risk factors have been found to be associated with poorer outcomes in patients with chronic obstructive pulmonary disease (COPD) — a lung disease related to cigarette smoking that usually coexists with lung cancer.

There is an urgent need for additional high-quality studies to identify comprehensive rehabilitation interventions that can target not only the physical but also the emotional aspects of surgically treated patients with non-small cell lung cancer and COPD.

With that knowledge gap in mind, we completed a pilot study of a feasible two-week preoperative intervention that included an intervention intended for emotional balance: mindfulness.

Mindfulness is the awareness that arises from paying attention to the present moment. The practice of mindfulness has been associated with emotional well-being and better control of pain, which are two attributes known to be important in postoperative recovery. The intervention results suggested an improvement in important postoperative outcomes such as length of hospital stay and accelerated lung re-expansion, or less time with chest drainage.

The emphasis was not on the exercises used, per se — in fact, they were similar to those done in traditional rehabilitation programs — but on the level of awareness of the body and the breath while doing them. In other words, mindfulness.

Adding stress reduction to rehabilitation programs is not unique to preoperative rehabilitation; recent reports have indicated its beneficial effects in cardiac rehabilitation. But it is a relatively novel concept for lung surgery rehabilitation.

With funding from the National Institutes of Health and the National Cancer Institute in collaboration with the Alliance for Clinical Trials in Oncology, we are launching a large study that tests a mindfulness-based preoperative rehabilitation for patients undergoing lung cancer resection. Outcomes of the study will be daily quality of life after surgery, which will be measured by validated tools, as well as the length of hospital stay and number of postoperative complications.

With recruitment targeted at 200 patients, the study will be large enough to provide answers about how to promote wellness in the preoperative and postoperative states, as well as how to help reduce the burden of surgery. The intervention will include six to ten visits to the center in a two to three-week period before a patient’s lung resection.

Simple mind-body practices like meditation and body awareness will be part of the rehabilitation routine, as will walking and upper extremity exercises done in a very slow, attentive way. Patients will follow a dedicated video as they exercise to assure not only compliance but also uniformity of the intervention across the many sites — both small and large hospitals will be participating.

In essence, we are seeking to innovate by adding mindfulness to exercise rehabilitation. We hypothesize that it will improve overall wellness during and beyond the operative intervention, and that the comprehensiveness and patient-centeredness of the approach will also affect health care outcomes and become an accepted intervention prior to curative lung resection. We hope that this simple, yet profound, intervention becomes standard of care once rigorous science proves it to be beneficial.