Surgery offers a potential cure for certain lung cancers, yet it is physiologically stressful and associated with considerable morbidity. Reduced physical functioning (e.g., difficulty performing chores, walking, climbing stairs) can persist for months (Handy et al., 2002) to years (Kenny et al., 2008) following surgery. Reduced physical functioning can affect a patient’s quality of life (Francesco Carli & Scheede-Bergdahl, 2015), likelihood of returning to work (Silver, Baima, Newman, Galantino, & Shockney, 2013), ability to tolerate further cancer treatment (Silver & Baima, 2013), and overall survival (Franco Carli & Zavorsky, 2005).

The paradigm of pre-operative exercise as a neoadjuvant therapy to reduce morbidity is increasingly promoted within general surgery (Francesco Carli & Scheede-Bergdahl, 2015; Santa Mina, Scheede-Bergdahl, Gillis, & Carli, 2015) and surgical oncology (Armstrong, Bravo-Iñiguez, Jacobson, & Jaklitsch; Singh, Newton, Galvão, Spry, & Baker, 2013). Pre-operative exercises generally involve breathing exercises and aerobic exercise at least five times a week (Sebio Garcia, Yáñez Brage, Giménez Moolhuyzen, Granger, & Denehy, 2016). Patients with lung cancer who participate in pre-operative exercise have better aerobic capacity (Crandall, Maguire, Campbell, & Kearney, 2014; Pouwels et al., 2015) and pulmonary function (Sebio Garcia et al., 2016), and shorter hospital length-of-stay after surgery (Crandall et al., 2014; Sebio Garcia et al., 2016).

While highly supervised, on-site exercise programs could be considered the gold standard for research and clinical care, (Crandall et al., 2014; Singh et al., 2013) these are labor-intensive for staff and often inaccessible for patients who live in rural communities. In order to translate promising research findings into sustainable clinical practice, some places and patients may need pragmatic and effective home-based exercise protocols. The main challenge of this translational research (Kleinman & Mold, 2009) is to identify efficient ways to ensure patients safely engage in and adhere to the prescribed amount of preoperative exercise while at home.

Wearable fitness devices offer a way to approximate the supervision that occurs in laboratory-based exercise research by allowing for synchronous and asynchronous monitoring of physical activity and vital signs during home-based exercise. To explore the feasibility of this approach, we conducted a single arm pilot study of an unsupervised, pre-operative exercise prescription augmented by a wearable fitness device. The study was designed to answer these questions: To what degree do participants enroll and comply with the study procedures? To what degree do the fitness devices successfully transmit data? To what degree do participants perceive the wearable fitness device and the exercise program as useful in supporting their preparation for and recovery from lung cancer surgery?

The purpose of the present study was to explore the feasibility and acceptability of the study procedures, the exercise program, and the use of a commercially available fitness device to provide information regarding exercise engagement in order to inform subsequent effectiveness trials. Our results demonstrate reasonably high engagement with the devices and study assessments in the pre-operative period, with a decline in participation after surgery. Our enrollment rate was similar to another pilot study (Granger et al., 2018) for lung cancer patients, where 89% of the patients approached enrolled, similar to our enrollment rate of 81%. However, in that study, only 16% of the sample participated in the pre-operative portion of the study, primarily because they were recruited relatively close to the date of surgery. In another recent pilot study (Sommer et al., 2016) of perioperative exercise, 32% of eligible patients enrolled and pre-operative exercise was deemed not feasible due to a short time between enrollment and surgery. Our average pre-operative period was approximately one month, which could increase the feasibility of pre-operative exercise engagement.

A common reason for enrolling in this study was a desire to augment motivation and monitoring of exercise engagement after the direct exercise prescription from the surgeon. A recent systematic review reinforced this idea, noting that recommendation from healthcare providers influences the adoption of exercise habits (Granger et al., 2017). Similar to a recent qualitative study (Granger et al., 2019), the participants showed variation in their type of preferred exercise and personal barriers to exercise. This suggests that tailored feedback and behavioral support might be needed to maximize adherence to home-based exercise (Granger et al., 2019).

Excluding the people who actively withdrew from the study, 71% of the sample were able to synchronize their device and provide data in the pre-operative period. This is a higher usage rate than seen in the pilot study by Granger and colleagues (Granger et al., 2018), where only 50% of the sample wore the fitness device provided by the study. Participants were reasonably consistent with keeping it charged and synchronized. We generally received information for a little more than two-thirds of the days and we received heart rate data for a little less than two-thirds of the days in the pre-operative period. The device use is somewhat impressive when considering more participants had negative versus positive comments and impressions regarding the device. While not perfect, the fitness device was utilized more than the exercise logs, which many people explicitly stated they felt unmotivated to utilize.

Enrollment procedures were completed in less than one hour. However, a greater investment of time may be warranted as a number of participants voiced confusion as to how to use the device. More education regarding the functions of the device and the advantages of self-monitoring one’s exercise is warranted in future trials. This echoes research that indicates while an aging population is growing more comfortable and savvy with technology, many people still need extra information to adopt technology into lives and routines (Batsis et al., 2019; Chun, Dey, Lee, & Kim, 2017).

Use of the device and participation in the study assessments dropped off after surgery. Patients often voiced fatigue and disinclination to extend time at the hospital for assessments, particularly if they were traveling a distance. Further, more people reported shortness of breath, illness or surgical complications, and being busy/working as barriers to exercising in the post-operative period compared to the pre-operative period. It is possible that more active or tailored support may be needed to promote exercise in the post-operative period. This may include reinforcement of device use as they are being discharged from the hospital as well as when they are contacted 2-4 days after discharge from the clinic nursing staff for their standard post-discharge phone calls.

One limitation of the study is that we are unable to determine the cause of missing device data. For example, four of the eight participants with missing device data in the pre-operative period indicated that they were wearing and/or interacting with the devices when they were interviewed at T2. We are unable to determine whether the missing data indicates a device malfunction versus a choice not to wear, charge, or synchronize the device versus an inability to successfully operate the device. In future research, we plan to monitor the device data in real time so that we can determine the cause of any missing data and intervene accordingly (e.g., troubleshoot technical problems or initiate motivational interviewing to address disinterest) to maximize study retention.

Sampling issues should be considered when interpreting these findings. It is difficult to determine the degree to which this sample is representative of the population of patients scheduled for lung cancer surgery (N = 153) because the project coordinator was only alerted by the surgeons when a patient expressed interest in the study. We do not have documentation regarding reasons the project coordinator was not alerted, though we know they include things like not having the requisite WiFi or cellular service, incompatible mobile phone, or patient’s lack of interest. Less frequently, unavailability of the project coordinator or a surgeon forgetting to mention the study occurred as well. People who were willing to enroll in the study may be more active than the average lung cancer patient. Though most of our participants have some pulmonary or cardiac co-morbidities, they do not appear to be grossly debilitated, as their PROMIS physical functioning scores are only slightly lower than the general population (Reeve et al., 2007), their grip strength scores do not indicate the presence of frailty (Studenski et al., 2014), and they report a considerable amount of baseline minutes of physical activity (i.e., above the 300 minutes of exercise recommended for a two-week period). For example, our sample’s self-reported physical activity was higher than the amount of pre-operative exercise participation reported in another study (Granger et al., 2014), which found patients with lung cancer were less physically active than healthy controls. However, it is important to note (1) our baseline assessment asked about any physical activity as opposed to moderate to vigorous exercise and includes things like golf and gardening and (2) physical activity assessed via self-report is frequently overestimated (Fukuoka, Haskell, & Vittinghoff, 2016; Prince et al., 2008).

This pilot study demonstrated the feasibility and acceptability of a pre-operative exercise program for patients scheduled to undergo surgery for lung cancer. Semi-structured interviews revealed participant endorsement of the potential for the fitness device to provide motivation and monitor exercise engagement; however, more thorough instruction and consideration of a less “bulky” device might increase use and acceptability of the device. A strength of this study was the ability to enroll participants weeks (as opposed to days) before surgery; such a window could promote adoption and/or reinforcement of exercise habits. Future research will explore the potential effectiveness of this approach and the potential to augment post-operative exercise engagement thorough tailored support that addresses each participant’s idiosyncratic barriers to and facilitators of exercise.