1 Introduction

Lung cancer is the leading cause of cancer mortality and morbidity in Australia [1]. High symptom burden in people with lung cancer contributes to functional decline and reduced quality of life, with unmet physical and psychological care needs linked to worse outcomes compared to unmet emotional, informational, and spiritual needs [2, 3]. Exercise interventions have been shown to decrease symptom burden, minimize treatment side effects, and improve physical functioning and health-related quality of life across the lung cancer-care continuum [4]. Heterogeneity in exercise modalities, intensity, frequency, and duration complicates the ability to draw consistent conclusions across studies [4]. Data on exercise interventions provided in surgical lung cancer patients suggest that this heterogeneity also exists in clinical practice [5]. Data are not currently available for non-surgical lung cancer patients.

Optimal Lung Cancer Care Pathways are evidence-based standards of care developed to ensure the provision of standardized person-centered care for people with lung cancer. These pathways recommend pre- and rehabilitation to enhance the patient experience and performance status across the cancer care continuum [6]. Despite recommendations, Australian survey data show a gap between what is recommended in the evidence base and clinical practice [5]. A survey conducted with oncology physiotherapy services in Australia reports low availability across all cancer types, with approximately half (54%) of surveyed services accepting referrals for people with lung cancer [7]. More specifically in lung cancer, a recent survey reports that 11% (n = 8) and 55% (n = 39) of 70 responding services in Australia or New Zealand offered an exercise program to people with lung cancer in the pre- and postoperative setting, respectively [5]. Although these studies offer valuable insights into available exercise programs, they lack comprehensive reporting of the uptake of community-based exercise services by lung cancer patients across the cancer continuum. In addition to limited services, lung cancer clinical trials and qualitative research show that physical activity levels and exercise engagement in people with lung cancer are influenced by program cost support from caregivers and relatives, in addition to exercise program location and method of delivery, that is, home or clinic visit [8, 9].

Significant variation and gaps in lung cancer care and outcomes exist both internationally and within Australia. Social determinants of health are nonmedical factors that influence a person's health outcomes [10]. Current data show that people living in remote or rural locations, with lower socioeconomic status and identifying as Indigenous, are more likely to be diagnosed with lung cancer and have poorer outcomes, including reduced 5-year survival [1, 11]. Longitudinal data collected from national surveys of the general population report that lower income, unemployment, a lower education level, and living in a lower sociodemographic area are associated with lower levels of physical activity [12, 13]. Participant social determinants of health and the impact of these factors on physical activity or exercise program engagement are rarely reported in exercise clinical trials in lung cancer.

To date, there has been no point–prevalence audit of Australian exercise services for people with thoracic cancer, managed surgically or nonsurgically, across all stages of the care continuum (from prehabilitation to survivorship). Point-prevalence surveys are cross-sectional and capture the prevalence of an intervention over a specific period of time, minimizing the potential for recall bias; hence, are more likely to provide a more accurate representation of prevalence compared to studies with extended timeframes [14]. Data are required to identify current care gaps and variations in exercise service delivery for patients with thoracic cancer to inform areas in need of future service implementation.

The aim of this study was to describe the current Australian exercise services available to people with thoracic cancers. Secondary aims were to understand the characteristics of the health professionals providing these services, the characteristics of people with thoracic cancers attending an exercise program, and the outcomes and interventions used within these services.

2 Methods

3 Results

3.1 Exercise Health Services

A total of 402 healthcare services were contacted, and 199 responded (50%). Overall, 69% (n = 137) of responding healthcare services accepted thoracic cancer referrals, and 78% (n = 107) of thoracic cancer exercise services completed the survey (see Figure 1). No significant differences were observed between responding and non-responding services when comparing remoteness area (p = 0.064) or center funding type (p = 0.056) using the chi-square test.

Exercise health services that participated in the point-prevalence survey all delivered exercise interventions in the outpatient clinic or community center setting. Virtual modes were employed by less than half of the services (videoconferencing 40%, n = 42; telephone 37%, n = 40), whereas home visits were offered by approximately one-quarter (26%, n = 28) (Table 1).

TABLE 1. Exercise health services.

Characteristics	n (%)
Location
New South Wales	32 (30)
Victoria	31 (29)
Queensland	16 (15)
South Australia	12 (11)
Western Australia	5 (5)
Tasmania	5 (5)
Northern Territory	4 (4)
Australian Capital Territory	2 (2)
Service remoteness
Major city	62 (58)
Inner regional	27 (25)
Outer regional	13 (12)
Remote	4 (4)
Very remote	1 (1)
Service type
Public hospital	59 (55)
Private hospital	8 (8)
Private clinic	10 (9)
Community based rehab	26 (24)
Other	4 (4)
Intervention settings offered
Outpatient clinic, community center, or gym	107 (100)
Home visits	28 (26)
Telehealth—video	43 (40)
Telehealth—phone	40 (37)
Timepoint on cancer care continuum service offered
Prior to receiving treatment for cancer	87 (81)
During treatment	85 (79)
First 6 months after treatment	88 (81)
Greater than 6 months after treatment	77 (70)
Other	14 (13)

Most exercise health services were targeted to patients with general respiratory diseases and included people with lung cancer (58%, n = 60) compared with 31% cancer-specific (n = 33) and 5% lung cancer-specific (n = 5) programs. The majority of responding sites (n = 82, 77%) accepted referrals at all stages of the cancer care continuum.

3.4 Interventions and Outcomes of the Exercise Programs

During the point-prevalence survey, 12 different exercise interventions were delivered in 45 combinations for 67 patients. Most patients completed aerobic (n = 58, 87%) and resistance training (n = 57, 85%) at a moderate intensity (Table 3). Approximately half received a home-based exercise program and airway clearance instruction. A total of 51 different combinations of 18 different outcomes were recorded for 70 patients. The most commonly collected outcomes were fatigue (86%, n = 60), breathlessness (84%, n = 59), and cardiovascular fitness (70%, n = 49) (Figure 2).

4 Discussion

This point-prevalence survey is the first study to report on the prevalence of exercise programs available to people with thoracic cancer and to report on the sociodemographic characteristics of people with thoracic cancer attending Australian exercise programs across all treatment types and stages of disease.

The number of exercise services that reported offering a service for people with thoracic cancer was low. With 137 exercise services for people with thoracic cancer identified, our findings indicate that there is 1 exercise service per 108 predicted new lung cancer diagnoses in 2023 [1] and 1 exercise service per 274 people living with lung cancer in Australia, based on 2018 prevalence data [21]. Considering these services are not solely for people with lung cancer but also for those with chronic diseases such as chronic obstructive pulmonary disease (COPD) (n = 60, 56%) or other cancers (n = 33, 31%), our results indicate that current service availability is not able to meet the needs of people with lung cancer in Australia.

The number of people accessing services during the study period was also low, with attendance of 74 people. These data indicate that this study included 0.2% of people in Australia with thoracic cancer who were attending an exercise program during the survey time period. Similarly low exercise program attendance levels are reported for people with comparable chronic diseases that involve lung tissue damage and result in respiratory symptoms such as those with COPD [22]. Multimorbidity is common for people with lung cancer, and a prior diagnosis of COPD, emphysema, chronic bronchitis, asthma, pneumonia, or tuberculosis approximately doubles a person's risk of being diagnosed with lung cancer [23]. Almost 50% of people with lung cancer have a concurrent diagnosis of COPD [24]. It has been reported that only 3% of people with COPD who are hospitalized access a pulmonary rehabilitation program within 1 year of hospital discharge [22]. This is despite pulmonary rehabilitation being recommended in COPD clinical practice guidelines with the highest level of evidence (Level 1) [22]. Lower attendance in pulmonary rehabilitation for people with COPD is reported for people with a higher comorbidity index and with increased numbers of hospitalizations [22]. This may partially account for lower attendance in exercise programs in the lung cancer population when compared to COPD, as lung cancer is associated with higher comorbid burden [25] and hospitalization rates [26].

Over 80% of exercise services and health professionalswere located in metropolitan or inner regional areas; by comparison, 96% of people accessing an exercise service during the point prevalence period were from metropolitan or inner regional areas. This indicates that although the proportion of services available to people with thoracic cancer in remote areas is comparable to the distribution of the Australian population, uptake of exercise programs in these areas is disproportionately low. Although telerehabilitation is a safe and feasible method of delivering exercise programs to people with lung cancer living a greater distance from an exercise program, our research indicates that use of this technology is low. Despite nearly half of services offering exercise interventions via telehealth (videoconferencing or telephone), only six patients (6%) engaged with exercise therapy via virtual mode. Low recruitment and attendance rates with telerehabilitation are observed in randomized controlled trials conducted with people with lung cancer [27], suggesting further research is needed to enable the uptake and implementation of telerehabilitation to overcome barriers to accessing care for people living in remote and outer regional areas.

Sociodemographic factors and geographical distance from an exercise service are reported to impact a person's attendance and engagement with exercise programs in COPD and breast cancer populations [12, 22]. Although Australian age-standardized lung cancer incidence is 76% higher in lower socioeconomic status areas, our study shows the reverse relationship where one-quarter (24%, n = 17) of patients who attended an exercise service lived in the most socioeconomically disadvantaged area [1]. A similar relationship is seen with remoteness area, where the age-standardized incidence rate is 21% higher in remote and very remote areas than metropolitan areas, and yet 3% (n = 2) of patients who attended an exercise service in this study lived in remote areas, and no participants lived in very remote areas [1]. Although low participation from people living in outer regional or remote areas may be attributed to geographical distance from services [28], the relationship between remoteness area and sociodemographic factors should not be ignored, as the most advantaged areas in Australia are commonly located around metropolitan areas and inner regional areas [16]. Cigarette smoking is another factor that may impact exercise participation, linked to geographical area and socioeconomic status [29]. Smoking is associated with delayed medical help-seeking behavior [30] and lower adherence with exercise programs in an oncology population following completion of treatment [31]. Although Australian data show that over one-third of Australians with lung cancer are current smokers [32], our results show that 7% (n = 5) of people attending exercise services were current smokers.

Social determinants of health, such as level of education and social supports, are linked to low service utilization, lower access to treatment, and poorer overall outcomes [33]. In this study, all patients with a known level of education had completed either a secondary or tertiary level qualification. Higher education levels may lead to increased awareness of educational needs and benefits of supportive care interventions [34]. This may also be linked to geographical area, as people living in metropolitan areas are more than twice as likely to have a tertiary education compared with people living in regional and remote areas in Australia [35].

Culturally adapted exercise programs are likely to improve engagement and uptake for Indigenous Australians and people from CALD backgrounds; however, access to these resources remains low [36, 37]. There were no patients recorded as identifying as Aboriginal and/or Torres Strait Islander attending an exercise program, and only three identified as CALD during the point-prevalence period. Common barriers to exercise include transport difficulties, lack of access to optimal care pathways, and lack of culturally appropriate care and education [38, 39]. An additional barrier for people from CALD backgrounds may be the lack of awareness of services and lack of interpreting services available when attending exercise services [40, 41]. Research conducted with Aboriginal health workers and exercise physiologists found that using co-design principles to develop culturally adapted COPD resources promoted participation and collaboration [42]. Highlighting the need for implementation research conducted with CALD and Indigenous Australian lung cancer populations to improve understanding and uptake of culturally safe exercise programs.

The high heterogeneity in exercise interventions and outcome measures observed in our study is analogous to the heterogeneity observed in clinical trials of exercise and lung cancer [4]. High heterogeneity in the prescription of exercise interventions in research limits the capacity of clinicians to translate findings into their clinical practice and may lead to ineffective exercise interventions being delivered to patients. When compared with cross-sectional data in a surgical lung cancer population, variability in exercise intervention type is comparable; however, the number of outcomes reported is increasingly variable when not limited to a surgical cohort [5]. Variability in medical treatment side effects and disease burden experienced by people with unresectable lung cancer may impact these differences. Limited standardization of outcome collection in clinical practice may lead to the collection of less relevant and patient-centered outcomes and limit the ability of health services to evaluate clinical programs [43]. Furthermore, the lack of consensus restricts the development of clear recommendations for exercise prescription and outcome measure collection in lung cancer, hindering clinicians’ ability to design and implement a consistent model of care.

5 Conclusion and Future Research

Despite a high level of evidence for the benefits of exercise for people with lung cancer, the results of our point-prevalence survey indicate that both the availability of exercise services for and attendance levels at exercise programs by people with lung cancer in Australia are low.

Future research should aim to understand and overcome service and patient barriers to providing and accessing exercise services for a thoracic cancer population. This research should be leveraged to design and implement exercise interventions to support CALD populations and Indigenous Australians, as well as people with lower levels of education and those who live alone. Future research should explore methods for leveraging telehealth exercise programs for people who are unable to access center-based pre- or rehabilitation.

To standardize clinical practice, a core-outcome set with rehabilitation outcomes should be developed and implemented. Furthermore, additional interventional studies should be conducted to compare the impact of different exercise interventions on outcomes for people with lung cancer.