Treating breathlessness in lung cancer patients: the potential of breathing training

Three-quarters of people with lung cancer have breathlessness at presentation and nearly all experience this distressing and limiting symptom by the time they have advanced disease [1,2]. Five-year lung cancer survival remains low worldwide (10–20%) in both resource-rich and resource-challenged nations [3]. Many people with lung cancer will also have experienced long-term breathlessness due to their co-existing chronic obstructive pulmonary disease (COPD). Palliation is therefore the goal of care for the majority from the time of diagnosis.

A prospective observational study showed that while hemoptysis and chest pain were well palliated in just over 70%, breathlessness was controlled adequately in only 35% of people [1]. The importance of breathlessness as a predictor of mortality [4], quality of life, and ability to pursue active cancer therapy has been highlighted [5]. Management of the cancer and its complications is the pivotal to survival but this requires excellent symptom control including the management of breathlessness. In this setting, breathlessness remains an overlooked therapeutic target in its own right.

Breathlessness is a multidimensional subjective experience with distinct perceptions of intensity and unpleasantness. It engenders an emotional response and functional consequences which manifest as physical and social restriction [6]. In the field of respiratory disease, interventions such as pulmonary rehabilitation (PR) address many of these domains using techniques which include self-management, cognitive support, physical conditioning and exercise, and group interaction. PR has a strong evidence base and has become part of standard therapy for people with COPD [7]. However, despite such a robust evidence base and its acceptance by policymakers and funders, implementation is low [8,9]. In the field of heart failure, another common cause of chronic breathlessness, the value of similar approaches (cardiac rehabilitation) for symptom management are likewise evidenced [10]. Likewise, they are implemented on an ad hoc basis rather than systematically [11]. Reasons for poor implementation include (i) poor knowledge of the intervention by both patients and clinicians, (ii) poor clinicians’ knowledge of how, when, and where to refer, (iii) access difficulties for patients, and (iv) clinicians’ lack of engagement with interventions which promote exercise behavior change [9,12].

So what about other non-pharmacological approaches for the management of breathlessness in people with lung cancer? Complex interventions using a similar approach to PR, but tailored to people of poorer performance status, have been developed, piloted, and tested in trials which include people with lung cancer [13–19]. Three adequately powered randomized controlled trials (RCTs) [15,17,18] confirmed benefit in terms of reduced breathlessness intensity [15], reduced distress due to breathlessness [17], and improved mastery over breathlessness [18]. An earlier systematic review found at least moderate evidence for several non-pharmacological interventions for reducing breathlessness due to a variety of diseases [20]. Emerging work also recognizes that breathlessness may be part of a symptom ‘cluster’ alongside fatigue and/or cough, for which non-pharmacological approaches are helpful [21].

Despite Level 1 evidence for non-pharmacological interventions, the situation is far worse for people with lung cancer. Lung cancer management guidelines give brief, if any, mention of interventions for breathlessness other than the use of interventions treating the cancer or its complications. Where guidelines do have a section regarding breathlessness management [22], the evidence cited is limited, omitting such studies as the 1999 study by Bredin et al. [15]; the other two trials were only published in the last 2 years. More recently, the European Society of Medical Oncology guidelines erroneously claimed a lack of evidence for such interventions, referencing the abovementioned systematic review, which provided evidence in favor [23]. The general impression conveyed is that non-pharmacological interventions are of less importance; relegating supportive care to be the ‘Cinderella’ of cancer services despite demonstrable benefits [24].

An Ontario-wide program to roll out a systematic approach to breathlessness management for people with lung cancer, involving seven pilot sites of breathlessness management programs led by nurses or allied health professionals, confirmed that patients benefitted, but that uptake was relatively low [25]. Clinicians who referred patients to the program valued the expertise of the resource, and the education provided for them, leading to improved confidence in assessment and management. Problems with uptake included patients declining the service due to feeling too unwell, or not seeing it as a priority. The challenge is delivering a balance: more severe breathlessness is more likely with advanced disease where modifying the course of the cancer is less likely to be successful and symptom control takes a more prominent role in treatment plans. However, although the burden of cancer treatments is recognized at this stage, we must not assume that supportive care carries none. An adequately powered RCT demonstrated that, for patients with lung cancer, a single hour’s session of breathing training was of equal benefit (worst breathlessness over the past 24 hours) to the standard three sessions at weekly intervals, and patients receiving three sessions experienced worse distress due to their breathlessness [19]. The authors suggested that this could be because the burden of visits to clinic, or even home visits from clinic staff, outweighed the benefits of additional sessions.

Poor implementation of non-pharmacological interventions for breathlessness could also be a consequence of the configuration of the multidisciplinary team and funding of cancer services. While the traditional model of medical leadership has modified over past decades, nevertheless, the doctor remains the lead in most service delivery models. In addition, provision of direct, rather than supportive, cancer treatments has greater priority for funding. A new drug, or chemotherapy regime, has more simplicity and face validity for clinicians, service funders, and patients than does a complex intervention typically provided by nurses and allied health professionals, even though such interventions are cost-effective [17]. Within the current structure of the cancer multidisciplinary team, provision of non-pharmacological interventions for breathlessness requires the doctor to be convinced of its benefit, and pass this conviction to service funders and patients: especially given the need for patients to engage with such interventions. Furthermore, a successful, embedded service also requires that appropriately trained staff are maintained in post.

Symptom control in lung cancer is vitally important but has too little focus from clinicians. Treatments for lung cancer and its complications alone will not manage breathlessness adequately. There are excellent evidence-based non-pharmacological treatments available which are under-funded and under-utilized. It is time for cancer services to address this suboptimal service provision.

Financial and competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.