Cancer is, for many, a long-term condition, as advances in new cancer treatments mean that survival rates are increasing,1 with half of people diagnosed in England and Wales surviving for 10 years or more.2 However, cancer survivors' psychological and physical well-being can be negatively affected postcancer because of the multitude of symptoms and adverse effects they incur from cancer and its treatment.3
There are approximately 47 000 new cases of lung cancer in the United Kingdom each year2; many of these people have significant smoking-related comorbidities,2 which can negatively impact on their activities of daily living and subsequent quality of life. Lung cancer patients may undergo curative treatment procedures, including surgery, chemotherapy, and radiotherapy; these treatments, although potentially life-giving, are associated with a number of frequently reported and connected symptoms, such as fatigue, dyspnea, and depression, which can be long-lasting and debilitating.4–6
Fatigue is the most prevalent and disruptive symptom posttreatment in cancer patients, affecting between 57% and 100%, whereas depression is present in approximately one-third.6 In addition, dyspnea can substantially add to the onset of fatigue.6 The presence of these symptoms, which can be made worse by surgery and/or adjuvant radiotherapy and chemotherapy, can have negative implications on the psychological and physical well-being of lung cancer survivors.6 The presence of fatigue, dyspnea, and/or depression can inhibit lung cancer survivors' activities of daily living, increase their social isolation, decrease their health and fitness levels, and impair their return to work ability,6–9 making them more likely to access healthcare services for support and management of their condition.
Lung cancer patients have been reported to experience more symptom distress compared with patients with other types of cancer, with profound effects on their emotional and physical well-being.10,11 Fatigue, depression, and dyspnea are among the most common symptoms in lung cancer patients and are often interrelated, with many patients experiencing a combination of symptoms.12,13 This can interfere with patients' activities of daily living, with more interference occurring as symptom severity increases.10
Growing appreciation of the extent to which the mind and body are linked10,11 indicates that depressive symptoms may exacerbate symptoms of fatigue and dyspnea, and vice versa. This supports the hypothesis that depression may be either the sequela or the precursor to uncontrolled physical symptoms such as fatigue and dyspnea.10,11 Poor psychological health is associated with lower physical functioning, suggesting that psychological and physical health outcomes are interrelated.12,13 Hence, strategies aimed at improving any one of the symptoms of depression, fatigue, or dyspnea may incur benefits across all 3.10
Lung cancer survivors use a variety of coping strategies to help to control their symptoms.14 Exercise is one such strategy, helping lung cancer survivors to regain or maintain physical fitness following their cancer diagnosis.11 This is illustrated by evidence that lung cancer patients with higher performance statuses have better physical and psychological outcomes compared with those with lower performance statuses.11 Recent guidelines recommend that individuals with cancer should be as physically active as possible and “avoid inactivity”15,16 and that any prescribed exercise should be individualized in accordance with cancer survivors' pretreatment fitness levels and symptom burdens.15
Research has suggested that exercise is the most common form of self-management practice used after cancer treatment,17 with people using it for a variety of reasons, including to regain health and fitness, improve treatment adverse effects, relax the mind and body, and regain a sense of normality postcancer.9 Many self-management programs including an exercise component have shown improvements in cancer patients' levels of self-efficacy, empowerment, quality of life, coping mechanisms, healthy behaviors, and symptoms such as fatigue, dyspnea, and depression.18–25 In addition, exercise has been found to be a protective factor for fatigue.6,26,27 These findings are strengthened by 2 recent meta-analyses that hich recommend physical exercise in the management of several cancers, including lung cancer.22,23 In addition, the National Institute for Health and Care Excellence recommends that people with mild to moderate depression and chronic physical health problems undertake physical activity programs,28 emphasizing the role of exercise in improving health outcomes for those living with long-term conditions. Similarly, the American Cancer Society25 and the National Comprehensive Cancer Network24 both recommend routine physical activity in lung cancer patients.
Although much research has focused on the effects of exercise in improving the health outcomes and quality of life in cancer patients,21,29 the majority has focused on breast cancer survivors and has been conducted during treatment.30 Despite similarities existing between lung cancer patients and those diagnosed with other types of cancer, there is a need to examine literature focusing specifically on lung cancer survivors. Lung cancer survivors may experience greater symptom distress compared with survivors of other types of cancer10,11 and have distinct characteristics, with lung cancer rates consistently higher among men, older people, smokers, and those with lower socioeconomic statuses.31 Hence, research into the most suitable exercise interventions for lung cancer survivors is required, to ensure that their symptoms are better controlled and that tailored exercise interventions are designed to meet their specific needs.
One systematic review exploring noninvasive interventions in improving well-being and quality of life in patients with lung cancer found exercise to have beneficial effects on self-empowerment and physical strength but no improvement in quality of life.32 Another review examining the effect of exercise training on lung cancer patients within 12 months of lung resection found that exercise training may increase the exercise capacity of this population group.33 No studies, to our knowledge, have examined the effects of different types of exercise interventions on fatigue, dyspnea, and depression in lung cancer survivors, despite these symptoms being commonly experienced by them,4,5,34 highlighting an important gap in the literature. This is an important area to examine because less than a third of lung cancer survivors meet recommended physical activity guidelines,35 indicating that more must be done to uncover which exercise interventions may be useful to them. A comprehensive literature review can help determine whether certain exercise types are more effective than others in managing symptoms for lung cancer survivors.36
Thus, this systematic review aims to examine the evidence on the effects of exercise-based interventions on fatigue, dyspnea, and/or depression in lung cancer survivors. Although the term “cancer survivor” can be associated with people living with cancer at different stages of the cancer pathway, for the purpose of this study “cancer survivor” refers to lung cancer patients who have finished their active treatment for cancer. A quantitative narrative synthesis was undertaken to help describe, explain, and interpret the study findings and to attempt to find explanations for these findings.37
The PRISMA guidelines and flow diagram were followed.38 Ethical approvals were not required.
Criteria for Considering Studies for This Review
TYPES OF STUDIES/INTERVENTIONS
All randomized or quasi–randomized controlled trials (RCTs), observational studies, and qualitative studies were considered for inclusion if they focused on the effectiveness of exercise interventions in improving symptoms of fatigue, dyspnea, and/or depression in lung cancer survivors. Lung cancer survivors must have received the exercise intervention for the study to be eligible for inclusion.
TYPES OF PARTICIPANTS
Studies were excluded if the majority of participants in the study were cancer patients, rather than survivors. Participants were considered to be cancer patients if they were still undergoing active treatment (surgery, chemotherapy, radiotherapy) for cancer at the time of undertaking the study intervention. Studies reporting on exercise interventions in cancer survivors were excluded if none of the participants were lung cancer survivors or if participants were younger than 18 years.
Search Methods for Identification of Studies
The databases CINAHL, MEDLINE, EMBASE, and the Cochrane Database were searched between January and May 2017. Both text and indexed terms (MeSH) were used in line with the relevant database search engine systems. The search strategy used is outlined in the Figure. Google and Google Scholar were also searched for any relevant unpublished studies, and reference lists of all full-text articles included in the review were checked in case they identified any potentially relevant articles. Any relevant systematic reviews were also examined to see if any articles making up the reviews were eligible for inclusion.
Searches were limited to articles published in the English language from the year 2000 onward as developments in cancer treatments have evolved in the last 2 decades,39 as such the symptoms experienced by lung cancer patients may be of a different nature and severity, affecting the impact of any subsequent exercise interventions and limiting the relevance of studies published before this time.
Selection of Studies
All of the studies were screened for inclusion in the review, based on the eligibility criteria outlined previously. Studies were included in the review if some (or all) of the participants were lung cancer survivors.
Data Extraction and Risk of Bias
Data from the included studies were extracted independently, discussed and summarized by 2 researchers (C.L.H., H.A.) using a study-specific extraction form, which was designed to collect all the relevant study data. The characteristics of the studies are summarized in Table 1. The quality of the included studies was assessed by C.L.H. and discussed with H.A., using the appropriate Critical Appraisal Skills Programmes checklist.50 Any uncertainty about the level of bias attributed to an individual study was discussed until a consensus was reached. It was not necessary to contact the authors of the included studies to obtain any more detailed study information.
All of the studies included in the review were quantitative, and these data were descriptively summarized. However, because of the different study designs and the varying quality of the statistical data in many studies, it was not appropriate to undertake meta-analyses of the data set, as pooling of results across the studies was not possible.
Characteristics of Studies
Eight hundred fifty-two records, titles, and abstracts were initially screened for inclusion in the review, of which 797 were excluded, leaving 54 remaining after the exclusion of any duplicates (n = 14). Of these, 44 were excluded once the full articles were assessed for eligibility, leaving 10 for inclusion in the final review40–49 (Figure).
Characteristics of the 10 studies included in the review are shown in Table 1. Seven studies included only lung cancer survivors,42–45,47–49 whereas 3 studies also included other cancer types.40,41,46 In total, 516 cancer survivors were included in the review, of which 298 (58%) were lung cancer survivors. The number of participants in the studies ranged from 10 to 162. The cumulative dropout rate across the studies was 74 (14%). Seven studies had prospective, single-site, pretest/posttest designs,40,42,44,45,47–49 whereas 3 studies were RCTs.41,43,46 Of these, 2 studies were single site,41,43 and 1 study was multisite,46 taking place at 3 hospital outpatient departments. The studies took place in a range of settings including hospital inpatient and outpatient departments and community- and home-based settings. All study participants had previously received cancer treatment consisting of either surgery, radiotherapy, chemotherapy, or a combination of these. The age of participants ranged from 30 to 80 years (age range was not reported in 1 study42). Five studies were carried out in Europe, 3 in North America, 1 in Canada, and 1 study in Australia. All studies were published between 2004 and 2017.
Risk of Bias in Included Studies
Overall, 7 studies were deemed to have a high risk of bias,40–42,44,47–49 2 had an unclear risk of bias,43,45 and 1 study had low risk of bias.46 Common reasons for this high level of bias were related to flaws in the study design, such as selection bias, small sample sizes, lack of blinding and randomization methods, and a lack of rigor in data analysis techniques, such as not accounting for confounding factors and a lack of reporting of confidence intervals (CIs). The substantial proportion of studies with a high or unclear risk of bias was deemed sufficient to affect the interpretation of the results from the review.
Description of Studies
PRETEST/POSTTEST STUDY DESIGNS
Seven studies used single-site, pretest/posttest designs. One of these studies measured depression as an outcome measure,47 whereas 4 measured dyspnea,42,47–49 and 6 studies measured fatigue.40,44,45,47–49 The first of these studies aimed to measure the extent exercise impacted on fatigue, physical and psychosocial well-being, and the quality of life of female cancer survivors.40 The exercise intervention consisted of an oncology community outreach program offering a “Get Fit, Stay Fit” program, with twice-weekly low-impact aerobics, toning, flexibility exercises, and relaxation techniques. The second study42 explored the effects of an inpatient multidisciplinary team pulmonary rehabilitation program on dyspnea, pulmonary function, and exercise capacity. The rehabilitation program included a 5-hour educational seminar by a qualified health professional that incorporated chest physiotherapy and breathing techniques for dyspnea, 30-minute respiratory physiotherapy sessions 5 times per week, 25-minute supervised cycling sessions 3 to 5 times per week, and 30-minute gymnastics daily that focused on general mobilization and flexibility. Participants were also instructed to walk for 1 hour per day.
The third study44 also examined the outcome of a pulmonary rehabilitation program and measured its effects on fatigue, quality of life, and exercise capacity in lung cancer survivors. The exercise program was supervised by a physiotherapist and took place 3 times a week for 12 weeks. It included two 90-minute resistance and endurance training sessions on cycle ergometers and treadmills. In week 3, participants trained for 60 minutes, using activities of daily living, such as walking up stairs, regulating breathing during different postures and activities, playing tennis, or cycling. The program additionally included 5 sessions of relaxation exercises and breathing-regulation techniques.
The fourth study45 examined the effects of supervised aerobic exercise training on fatigue and aerobic fitness among lung cancer survivors who had undergone surgery. The program was individually tailored to each participant, and all sessions were supervised by sports medicine exercise specialists. Exercise consisted of 3 aerobic cycle ergometry sessions per week on nonconsecutive days for 14 weeks.
The fifth study47 aimed to evaluate the feasibility and efficacy of a progressive resistance exercise training program in lung cancer survivors, which included leg and chest presses, seated rows, leg extensions, leg curls, shoulder presses, lateral pull-downs, and abdominal exercises, with 90- to 120-second rest between each exercise. The sessions were supervised by a qualified exercise physiologist, and depression, fatigue, and dyspnea were measured.
The sixth study48 aimed to assess changes in dyspnea, fatigue, exercise capacity, and quality of life of lung cancer survivors before and after a 28-day inpatient rehabilitation training program, which included cycle ergometer exercises in intervals of 3 to 5 minutes for 30 minutes daily. This was complemented by oncological rehabilitation measures including health education techniques. In addition, clinical counseling and medical supervision, drug-based therapies, and psychological support were offered.
Finally, the last study49 aimed to examine the effects of an inpatient multidisciplinary rehabilitation program on dyspnea, fatigue, pulmonary function, and exercise capacity in lung cancer survivors. The program was supervised by a physiotherapist and took place over 8 weeks, for 1 to 2 hours per day. It consisted of ergonomic cycling, treadmill walking, weight training, and gymnastics.
RANDOMIZED CONTROLLED TRIALS
All 3 RCTs measured fatigue as an outcome measure,41,43,46 1 measured dyspnea,41 and 1 study measured depression.46 The first RCT aimed to compare the effect of aerobic exercise and progressive relaxation training on dyspnea, fatigue, quality of life, and the physical performance of cancer patients recovering from surgical treatment.41 It consisted of 30-minute cycle ergometer training for 5 days per week, over 3 weeks. The relaxation training consisted of a systematic program of contraction and relaxation of different muscle groups.
The second RCT43 aimed to investigate the effects of an exercise and balance program compared with normal medical care on cancer-related fatigue severity and fatigability in lung cancer survivors. The intervention group involved a nurse-supported (via phone calls and home visits) home exercise intervention using the Nintendo Wii Fit Plus and consisted of light-intensity walking and balance exercises that corresponded to usual activities of daily living. Wii walking was self-paced and comfortable. Exercise duration started at 5 minutes per day and built by 5 minutes each week with the goal of walking 30 minutes per day by week 6. Balance exercises were also undertaken each day from weeks 1 to 6. Participants self-reported their activity levels. The control group received usual medical follow-up care from their medical providers. In addition, they received phone visits from a nurse to control for staff interaction and data collection.
Finally, the third RCT46 evaluated the use of medical qigong compared with usual care to improve symptoms of fatigue, depression, and quality of life of cancer patients. The intervention group consisted of two 90-minute medical qigong sessions per week for 10 weeks, and participants were also encouraged to undertake home practice each day for 30 minutes. The medical qigong program was devised by an experienced, qualified medical qigong instructor and was modified by the instructor to specifically target the needs of cancer patients to control their emotions and stress, as well as to improve their physical function. Each session included a 15-minute discussion of health issues, 30-minute gentle stretching and body movement in standing postures, 15-minute movement in seated positions, and 30-minute meditation including breathing exercises, relaxation, and visualization. A self-report diary was used to document home practice. The control group received usual care, which was appropriate medical intervention. Control group participants were advised to undertake normal activities but refrain from joining an outside medical qigong class.
Table 2 provides a narrative summary of the effects of the exercise interventions on fatigue, dyspnea, and/or depression across the studies. Fatigue was reported on in 9 studies,40,41,43–49 dyspnea in 5 studies,41,42,47–49 and depression in 2 studies.46,47
Six41,43–46,48 of the 9 studies reporting on fatigue found statistically significant reductions in fatigue postintervention. Three were RCTs,41,43,46 and 3 were pretest/posttest studies.44,45,48 Of the RCTs, 1 study41 showed statistically significant improvements in fatigue in both the aerobic exercise (6% ± 33%; P = .009) and relaxation training groups (9% ± 25%; P = .02) at 3 weeks after interventions. The reduction of fatigue scores did not differ significantly between groups, and there was no significant association between increase of maximal physical performance and reduction of fatigue scores. A second RCT43 showed statistically significant improvements in fatigue in the exercise and balance program group compared with the control group (P < .001; 95% CI, −3.3 to −2.1; d = 1.8) at 6 weeks postintervention. In addition, the study found that fatigue was restored to lower than presurgery levels in the exercise and balance group (P > .001). The third RCT46 found statistically significant improvements in fatigue in the medical qigong group compared with the control group (mean difference, 5.70 [95% CI, 3.32–8.09]) at 10 weeks postintervention. Participants in the medical qigong group also reported a clinically significant change in their levels of fatigue.
Of the 3 pretest/posttest studies,44,45,48 1 study showed statistically significant improvements in fatigue at 12 weeks after the exercise intervention (P ≤ .01; mean difference, 9.19 [95% CI, 6.18-12.14]; effect size, 1.11).44 In addition, 64% of participants reached the minimally important clinical difference for fatigue. The second study45 showed statistically significant improvements in fatigue 14 weeks postintervention (P = .03; mean difference, −7 [95% CI, −1 to −17]). It also found statistically significant improvements in fatigue postintervention for participants who had not received chemotherapy (P = .03; mean difference, −10 [95% CI, −18 to −2]), whereas no statistically significant improvements in fatigue postintervention were found in participants (P = .62; mean difference, −2 [95% CI, −10 to 7]) who had received chemotherapy. Finally, the third study48 found statistically significant reductions in fatigue at 4 weeks postintervention (P < .001).
The remaining 3 studies40,42,49 showed no statistically significant changes in fatigue before or after intervention.
Of the 5 studies reporting on dyspnea, 2 studies42,48 found statistically significant improvements in dyspnea at 4 weeks postintervention, compared with baseline. Glattki et al42 showed statistically significant improvements in dyspnea postintervention (mean difference, −0.26 ± 0.61; P = .007) compared with baseline; Riesenberg and Lubbe48 also found statistically significant improvements in dyspnea postintervention (mean difference, −13.7; P < .001) compared with baseline. Of the 3 remaining studies, 1 study was an RCT and showed no statistically significant differences between aerobic exercise and relaxation training groups at 3 weeks postintervention,41 whereas the 2 pretest/posttest studies found no differences in dyspnea at 8 weeks49 and 10 weeks47 postintervention, compared with baseline.
Of the 2 studies reporting on depression, one was an RCT,46 and the other was a pretest/posttest design.47 The RCT showed a statistically significant reduction in depression in the medical qigong group compared with the control group at 10 weeks postintervention (mean difference, −2.56 [95% CI, −5.14 to 0.01]; P = .029).46 The pretest/posttest study found no statistically significant differences in depression preintervention (3.8 ± 4.2) or postintervention (4.4 ± −5.6).47 However, mean depression scores did move in a positive direction postintervention.
One of the studies reported 3 adverse events relating to the exercise intervention; these were an exacerbation of shoulder arthritis, lower back pain, and shoulder pain.47 All were reported to successfully resolve.
This review examined the effects of exercise interventions on lung cancer survivors' fatigue, dyspnea, and depression levels. The findings suggest there is some evidence that exercise interventions can improve symptoms of fatigue, dyspnea, and depression in this population group. The interventions appear feasible and acceptable, but more rigorous, larger-scale RCT study designs are needed to determine their effectiveness. This would help identify whether certain types of exercise interventions can be used to improve multiple symptoms simultaneously or whether specific exercises are better targeted to specific symptoms.
Our review adds to existing systematic reviews in this area because it includes all studies reporting on any type of exercise intervention. In addition, it focuses on lung cancer survivors, a cancer group who is largely underrepresented in research studies compared with other cancer types.30 The review highlights the need for more robust research to be undertaken in this area to provide informed and credible information and facilitate improved outcomes for lung cancer survivors. In addition, the review has focused on whether exercise specifically improves symptoms of fatigue, dyspnea, and depression in lung cancer survivors. All of these symptoms commonly feature in lung cancer survivors' day-to-day life, and this review sheds light on potential exercise interventions and techniques that might help to alleviate some of these problems posttreatment.
Many of the included studies showed statistically significant improvements in fatigue, dyspnea, and/or depression. These studies included a wide range of exercise interventions, with varying levels of intensity, in a number of different locations, over different lengths of time. Furthermore, 1 study41 found that there was no significant association between an increase of maximal physical performance and reduction of fatigue scores. This suggests that there are a variety of different exercise interventions that may be beneficial to lung cancer survivors and that there is no “one-size-fits-all” approach; instead, customized exercise screening and treatment plans are required.6 Lung cancer survivors who may feel overwhelmed at the prospect of undertaking high levels of resistance training or aerobic exercise can be reassured that gentler exercises such as breathing techniques or medical qigong may also be effective ways of improving their symptom control. Similarly, those people who are keen to get back to their precancer fitness levels can have confidence that by engaging in high levels of physical activity they can achieve positive results and may improve their symptoms of fatigue, dyspnea, and/or depression in the process.
The lack of reporting of adverse events in the majority of the studies infers that, although there is mixed evidence as to the benefits of exercise in improving symptoms of fatigue, dyspnea, and depression in lung cancer survivors, undertaking exercise is unlikely to cause any sustained harm. This is important to note as some cancer survivors may be deterred from exercising posttreatment because of fears they may do further damage to their already fragile bodies.51 Thus, patients can be reassured that undertaking exercise postcancer is safe and is unlikely to cause any untoward, long-term health effects, something that has been verified in other literature on this topic.15,16 The low dropout rate across the studies also suggests that exercise, at all levels, is generally acceptable to lung cancer survivors and can be maintained and incorporated into their daily lives. This contrasts with a recent study52 that found a diagnosis of lung cancer was negatively associated with participating in physical activity programs, although the study focused on people with metastatic disease. Lung cancer survivors may have different attitudes and abilities regarding undertaking exercise compared with those with more advanced disease.
The review also identified that relaxation and mind-based therapies may serve as important adjuncts46 or alternatives41 to exercise-based interventions for improving both depression and fatigue in lung cancer survivors. Previous research9 has indicated that cancer survivors place value in both mind- and body-based practices as a way of providing symptomatic relief, relaxation, and a sense of control over their cancer. This review adds credence to these findings and suggests that both mind- and body-based interventions, when used alone or in conjunction with one another, can be effective ways of improving fatigue and depression in lung cancer survivors. Thus, it is important to consider the use of exercise alongside other supportive care interventions, such as mindfulness, meditation, and other psychosocial therapies, for effective patient outcomes.30
Finally, 1 study45 included in the review found statistically significant improvements in fatigue postintervention in participants who had not received chemotherapy, but these improvements were not found among participants who had received chemotherapy. This indicates that the gruelling impact of chemotherapy on the body53,54 may be hard for lung cancer survivors to recover from, as the intensity of cancer-related fatigue experienced increases during this time6,55 and may, in addition, make exercise regimens difficult to adhere to.30 Nurses should consider the treatment pathways of lung cancer survivors when assessing which exercise or mind-based therapies might be useful to them. It may be that patients who have undergone chemotherapy may require more specialist input and resources to help them manage their fatigue in the long term.
Limitations of the Review
While the researchers endeavored to conduct a thorough, comprehensive, and systematic review of the existing literature on this topic, it is possible that some relevant studies may not have been captured in the study selection and screening process because of the diversity of exercise interventions being examined and because fatigue, dyspnea, or depression may not have been identified as one of the main outcomes being measured in some studies. In addition, the review does not allow for a comparison between the different types of exercise interventions and their effectiveness in improving fatigue, dyspnea, and/or depression because of the limited information provided.
This review has identified that exercise interventions may be effective and are unlikely to cause harm for lung cancer survivors who wish to improve their symptoms of fatigue, dyspnea, and depression. However, the quality of the evidence provided is limited, and more rigorous study designs are required to explore this important area further in order to provide lung cancer survivors with useful advice and guidance about which exercise interventions may be the most beneficial to help them self-manage these symptoms in survivorship.
The National Institute for Health and Care Excellence56 recommends that the opinions and experiences of lung cancer patients and carers should be collected to improve the delivery of lung cancer services. The findings from this review will be used to inform a larger-scale focus group study with lung cancer patients, carers, nurses, and other health professionals to explore which types of exercise and or/mind-based interventions are useful in improving symptoms of fatigue, dyspnea, and depression in lung cancer survivors. This information will be used to develop a self-management app for lung cancer survivors that will be used to provide patient centred, customized, and tailored exercise recommendations to improve their symptom control.
Implications for Practice
The review highlighted the need for nurses to use a patient-focused approach when considering which types of exercise interventions might be suitable for lung cancer patients in survivorship. The one-size-fits-all approach is inappropriate here; instead, customized exercise screening and treatment plans are required to enable nurses to provide lung cancer survivors with tailor-made, patient-focused exercise activities that complement their lifestyle needs, interests, abilities, and requirements. Psychological and mind-based therapies may also be used alongside, or as an alternative to, exercise to improve symptom control for lung cancer survivors; this should be considered by nurses and other health professionals when providing survivorship advice and support to lung cancer patients. Nurses need to carry out holistic, individualized care plans to ensure comprehensive assessments are conducted and appropriate self-management recommendations are communicated to lung cancer survivors.
C.L.H. acknowledges the support of the NIHR Oxford Cognitive Health Clinical Research Facility.
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