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Whey Protein

Multimodal prehabilitation strategy includes physical exercise (moderate aerobic exercise combined with resistance exercise and respiratory training ), nutritional suggestion and optimization(whey protein supplement), and psychological therapy, as well as conventional guidance (including preoperative anesthesia assessment, drug treatment recommendations for chronic disease, quit smoking and abstinence). Patients are advised to record daily exercises and adherence to nutritional, psychological and other recommendations. Short message interviews are sent to patients twice a week to optimize adherence and promote feedback.

Aerobic training strategy includes the same guided individualized moderate aerobic exercise as the multimodal prehabilitation group, as well as the conventional guidance. Patients are advised to record daily exercises. Short message interviews are sent to patients twice a week to optimize adherence and promote feedback.

Multimodal prehabilitation group

Aerobic training group

Yuguang HUANG, M.D.

Zijia Liu, MD

In recent years, many studies have shown that prehabilitation based on aerobic training strategies could have a positive effect on the recovery of postoperative functional capacity in patients undergoing lung cancer surgery. Investigators are proposing a prospective randomized controlled trial to compare the impact of a short home-based multimodal prehabilitation strategy to preoperative aerobic training on patients scheduled for video-assisted thorascopic lobectomy for lung cancer. The multimodal prehabilitation strategy includes guided aerobic and resistance exercise, breathing exercises, nutrition supplement and physiology management preoperatively, while the aerobic strategy offers the same aerobic training guidance without the other parts. The prehabilitation lasts 2-3 weeks in our center. Investigators follow-up patients until 30 days after surgery, to investigate whether multimodal prehabilitation strategy differs from aerobic training program in postoperative functional capability improvement, health-related quality of life scorings, incidence of postoperative complications and other outcomes.

This is a randomized controlled trial comparing the impact of a short home-based multimodal prehabilitaiton strategy to preoperative aerobic training program on patients undertaking video-assisted thoracoscopic (VATS) lobectomy for lung cancer.

The purpose of prehabilitation is to enhance an individual's functional capacity to reach the optimal physiological state before surgery, helping them withstand the stress of surgery and receive an enhanced recovery post operation. Recent studies have shown that trimodal or multimodal prehabilitation strategy including exercise, diet and psychologic guidance could improve postoperative functional recovery for patients undergoing colorectal resection. However, researches regarding to the effect of multi-modal prehabilitation in other types of operations remain scarce.

Studies have shown that the postoperative functional capacity decreases in patients undergoing lung cancer surgery. Therefore, many clinical trials were designed to explore the impact of prehabilitation on these patients, and many of them yielded positive results, showing preoperative exercise for patients undergoing lung cancer surgery is safe and beneficial in postoperative functional capacity recovery. However, the majority of the trials conducted adopted preoperative exercises, specifically aerobic exercises, as the sole means of prehabilitation. In 2017, our team conducted a randomized controlled trial (registration number NCT03068507) to examine the efficacy of a 2-week multimodal home-based prehabilitation strategy in patients undergoing VATS lobectomy for lung cancer. The preliminary results indicate that patients who received the short multimodal home-based prehabilitation have a significantly higher 6-minute walk distance (6MWD) perioperatively.

Investigators are proposing a new randomized controlled trial to compare the efficacy of a short multimodal home-based prehabilitation with the sole aerobic prehabilitation strategy adopted by the previous studies.

A total of 100 patients scheduled to have elective VATS lobectomy for primary lung cancer will be recruited in this research at Peking Union Medical College Hospital. After informed consent is obtained, the patients will be evenly assigned to two groups randomly based on computer-generated sequence, the multimodal prehabilitation group and the aerobic prehabilitation group. The random allocation will be concealed using sealed opaque envelops.

The multimodal group will receive an individualized prehabilitation strategy after a complete assessment, including aerobic and resistance exercise, nutritional optimization, and psychological therapy, as well as conventional guidance. All patients will receive an instruction booklet with details in text and pictures, and will be asked to complete standard diaries in the booklet. The length of prehabilitation will be 2-3 weeks, determined by the waiting time till surgery alone.

For the multimodal group, prehabilitation strategy is as follows: 1) a 30-minute aerobic exercise at least 3 times a week, in the form of jogging, power walking or cycling, according to the patients' individual choice; 2) a guided resistance exercise at least twice a week, using a pull strap distributed by investigators to accomplish 4 pre-set resistance posture; 3) breathing exercise at least 3 times per day, lasting over 10 minutes, in the form of guided effective coughing, blowing up a small balloon or using the respiratory exerciser distributed by investigators; 4) nutritional advice and whey protein supplement 1hour prior to exercising (20g/day for male and 15g/day for female patients); 5) psychological therapy by listening to soothing music or radio and other relaxing activities. Patients are advised to record daily exercises and adherence to nutritional, psychological and other recommendations in a prehabilitation journal distributed by investigators. Standardized short message interviews are sent to patients twice a week to optimize adherence and promote timely feedback.

The aerobic group will receive the same guidance in the individualized home-based aerobic exercise strategy as the multimodal group, but not in the other aspects. These patients are also advised to keep a prehabilitation journal recording daily exercises and will receive the same short message interviews twice a week.

All patients enrolled will receive the conventional guidance, including preoperative anesthesia assessment, drug treatment recommendations for chronic disease, quit smoking and abstinence. And patients are also provided some useful information about anesthesia and surgery process.

The patients and trial personnel will not be blinded to the allocation regarding to the nature of the intervention. The outcome assessors will independently collect the outcome data without the knowledge of the allocation.

The primary outcome will be post-operative 6-minute walk distance (6MWD), measured as functional walking capacity, at 30 days postoperatively). The secondary outcomes include perioperative 6MWD (1 day before surgery, 30 days postoperatively), pulmonary function (1 day before surgery, 30 days postoperatively), hospital anxiety and depression scale (HADS), World Health Organization disability assessment schedule II (WHODAS 2.0) score, postoperative quality of recovery score -15 (QoR-15) score and prognosis information (mortality and morbidity, length of hospital stay, ICU stay time, duration of chest tube, etc.).

Comparing the Impact of Multimodal Prehabilitation to Aerobic Training on Patients Undergoing Thoracoscopic Lobectomy

The Comparison of a Short Home-based Multimodal Prehabilitation Strategy to Preoperative Aerobic Training Program on the Perioperative Functional Capacity and Outcomes in Patients Undergoing Thoracoscopic Lobectomy

Use 6-minute walk distance (6MWD) to evaluate the physical functional capability objectively. The primary outcome will be analyzed after stratification by age and baseline functional capacity.

Evaluate the impact of prehabilitation on functional capability before surgery.

Evaluate the recovery of pulmonary capacity. Forced expiratory volume in 1 s (FEV1) and forced vital capacity (FVC) will be measured in liters, and FEV1/FVC will be calculated with the FEV1 and FVC value and reported in percentage.

The HADS is a questionnaire composed of 14 questions to screen for anxiety and depression. The questionnaire features 7 questions on anxiety and seven on depression. The maximum score for either anxiety or depression is 21 and the minimum for either is 0. The severity of anxiety and depression correlates with the scoring. HADS will be used to evaluate the mental capability recovery after surgery.

WHODAS 2.0 is a patient self-report assessment tool that evaluates the patient's ability to perform activities in six domains of functioning over the previous 30 days. Each item from the six domains is rated using a 5-point Likert scale (1 = no difficulty, 2 = mild difficulty, 3 = moderate difficulty, 4 = severe difficulty, 5 = extreme difficulty). These are then calculated to get a score representing global disability. WHODAS 2.0 will be adopted to make the the global evaluation of patients' disability before and after surgery.

QoR-15 is an easy-to-use score for assessing the quality of post-operative recovery. It is a questionnaire featuring 15 items, each of which has a scale of 0 to 10. Higher scores of QoR-15 indicate better recovery quality after surgery. QoR-15 will be used in this study to evaluate the intermediate phase of recovery.

Evaluate postoperative all-cause mortality, reported in percentage.

Evaluate the incidence of major postoperative complications including atelectasis, pneumonia, respiratory failure, sepsis, septic shock, which will be all reported in percentage.

Evaluate postoperative length of hospital stay, reported in days.

Evaluate postoperative ICU stay time, reported in days.

Evaluate duration of chest tube placement, reported in days.

Peking Union Medical College Hospital

Skin and Connective Tissue Diseases

Behaviors and Mental Disorders

Breast Neoplasms

Breast Diseases

Skin Diseases

Quality of Life

Three sessions per week during 4-6-months according to each individual treatment plan. Participants allocated in this group will perform moderate-intensity cycling exercise.

Three sessions per week during 4-6-months according to each individual treatment plan. Participants allocated in this group will perform weight-machine strength exercises of the upper and lower body.

One session per week of relaxation/stretching.

The participants will perform continuous cycling at 30%-35% of their heart rate reserve for one month (phase 1: adaptive phase). Then, the intensity will increase every 4-5 weeks (± 5%) up to a maximum of 64% of heart rate reserve (moderate intensity), depending on the participant's tolerance. An individualized equation establishing the relationship between heart rate, oxygen consumption, and power output will be determined during the cardiorespiratory fitness assessment and used to determine exercise intensity.

Aerobic Training Group

Initially, and during the first two weeks of the adaptive phase (1-month), the resistance training group will perform one set of 8-12 repetitions (40%-repetition maximum) of 8 exercises for upper and lower body (squat, leg extension, leg curl, deadlift, plank, dead bug, seated row, shoulder press). Then, in the last two weeks, the participants will perform 2 sets of each exercise (45%-repetition maximum). After the adaptive phase, three sets of each exercise will be performed. The initial load will be 50% -repetition maximum increasing up to a maximum of 70%-repetition maximum at the end of the study. Every 4-5 weeks the load will be reviewed and adjusted according to individual.

Resistance Training Group

The control group will perform a weekly stretching/relaxation session for 45 minutes.

Control group

Maria-João Cardoso, MD

Luís B Sardinha, Ph.D.

Maria João Cardoso, MD

André Valente, Ph.D.

Inês R. Correia, MSc

A recent consensus study suggested that understanding the impact of exercise on the tumor microenvironment and therapy effectiveness is paramount and should be considered as a research priority. Therefore, the research team intends to address some of the scientific challenges proposed, which represent clear gaps in the current knowledge.

The investigators propose a randomized controlled trial conducted during all neoadjuvant treatment duration that aims to evaluate and compare the effects of two different exercise protocols (aerobic and resistance training) against a relaxation control group on Ki-67% changes as the main outcome in breast cancer patients. Secondary outcomes will be body composition; resting metabolic rate; physical fitness; quality of life, fatigue, depression/anxiety; accelerometry data (physical activity levels, sedentary time); sleep quality; tumor biology (size, hypoxia, and immune profile); glycemic, lipid, and inflammatory profile.

This project will help not only researchers with the design of future exercise intervention protocols but will also help exercise physiologists in the decision-making process when defining training programs. Moreover, the investigators expect that this research program will encourage more cancer patients to exercise. The team expects that patients with breast cancer engaging in structured exercise will show a more marked decrease in Ki-67, tumor size, and hypoxia and increase the tumor-infiltrating lymphocytes (TILs) compared to controls. The investigators anticipate a more noticeable decrease in the preoperative endocrine prognostic index (PEPI) score and in the Residual Breast Cancer (RCB) in both training groups (respectively with hormonal and chemotherapy). Also, frequent declines in physical fitness are expected to be mitigated in exercisers. It is hypothesize that aerobic training will ameliorate cardiorespiratory fitness and fat mass, while the effects of resistance training will be more relevant for muscle strength, muscle mass, and bone health. Both exercise groups will show greater improvements in quality of life, fatigue, depression, anxiety, and sleep quality. Regarding glycemic, lipid, and inflammatory profiles, the investigators expect to see more favorable changes in both training groups, with a more evident decrease in fasting glucose and insulin, HbA1c%, total and LDL-cholesterol, and triglycerides, and the increase in HDL-cholesterol. The increase in C-reactive protein (CRP), tumor necrosis factor -α (TNF-α), interleukin-6 (IL-6), IL-8, IL-1β, IL-1ra, and insulin-like growth factor-1 (IGF-1) and the decrease in brain-derived neutrotophic factor (BDNF), IL-12p70, IL-10, oncostatin M will be smaller in exercise groups.

Exercise plays a crucial role in breast cancer prevention and more recently it appears as a safe, non-pharmacological, and cost-effective adjuvant therapy for cancer. Indeed exercise improves the quality of life, fatigue, physical fitness, and also has a positive impact on tumor intrinsic characteristics.

Most of the studies regarding the effects of exercise in breast cancer patients were performed after surgery or in survivors. Despite being a window of opportunity to study the impact of exercise on biological properties of the tumor, namely on proliferation markers, the investigations conducted during the neoadjuvant period are still scarce and most of the literature derives from animal studies. Although originating from pilot investigations, the initial human-based evidence suggests that exercise interventions are feasible during neoadjuvant therapy and can potentially reduce some proliferation markers such as Ki-67 (i.e. a widely used prognostic marker), induce favorable changes in tumor-related genes, and increase survival.

Power and sample calculations (G-Power, Version 3.1.9.2) are based on an effect size of 0.25 for KI-67 while using ANOVA - repeated measures within-between interactions, a power of 0.80, a significance of 0.05, and an expected dropout of 40%. The calculation yielded a total sample size of 120 participants (60 undergoing chemotherapy and 60 undergoing hormone therapy: 20 participants per group per each treatment). The power and sample calculations were performed using a study that reported the effect of medication on KI-67 since no study has evaluated the effects of an exercise intervention on that variable and has obtained significant results.

Participants will be recruited to take part in an intervention study for breast cancer patients undergoing neoadjuvant treatment. The recruitment will take place at Champalimaud Clinical Center Breast Unit / Champalimaud Foundation.

To improve exercise adherence, the following strategies will be implemented:

* Thematic sessions about several topics such as physical activity (PA) guidelines, active lifestyle, nutrition, the benefits of exercise for breast cancer patients, etc. Each session will last 1-hour (30 minutes presentation + 30 minutes discussion/questions) and will occur once a month. These thematic sessions are mandatory.
* Group activities: once a month, a group activity will be promoted (exercise outdoor sessions, group walk, group dinner, etc.). In these group activities, participants may invite family members to participate.
* The NEO-program website presenting the mission/goals, team members, activities, news and events, contacts, etc.
* Facebook and Instagram account (share information and photos); before the intervention, written consent for image collection will be requested.

The investigator records clinical data, using a paper or electronic case report form (CRF), all data is collected in an online database that is available through the Champalimaud Clinical Center intranet. Participating physicians have a personal account to log in to the registration page and access the electronic CRF. They will have permanent access to their series of patients.

The participating physician ensures the confidentiality, accuracy, completeness, legibility, and timeliness of the data recorded. Data handling and statistical analysis will be done anonymously by the investigator, with the subject identification code list only available to the local investigator (and research nurse if applicable) working in the local center. The code will be based on the birth date and center abbreviation (and not patient initials). The Sponsor will be the owner of the data. Data will be kept for 20 years.

The Participating Investigator and the Participating Site shall treat all information and data relating to the Study disclosed to Participating Site and/or Investigator in this study as confidential and shall not disclose such information to any third parties or use such information for any purpose other than the performance of the Study.

The collection, processing, and disclosure of personal data, such as patient health and medical information are subject to compliance with applicable personal data protection and the processing of personal data legislation (including but not limited to the European Union Directive 95/46/EC).

Champalimaud Foundation takes out the appropriate insurance.

Participants will be followed in a randomized controlled trial conducted during the full duration of neoadjuvant treatment (i.e. 4- to 6-months, depending on patient treatment plan) and two cohorts will be defined: A - breast cancer patients undergoing chemotherapy; B - breast cancer patients undergoing endocrine therapy. Within each cohort, the participants will be divided into three groups: 1) aerobic training; 2): resistance training; 3): control group.

The intervention is designed to have equal energy expenditure throughout the exercise sessions in both exercise groups (10 kcal/kg/week). All training groups will complete 3 sessions/week. To ensure that both exercise groups are isoenergetic, a portable gas analyzer will be used and blood lactate will be collected.

Mandatory thematic sessions about several topics such as physical activity guidelines, active lifestyle will be implemented.

Resistance vs. Aerobic Training on Breast Cancer Patients Undergoing Neoadjuvant Treatment

Effects of Resistance vs. Aerobic Training on Ki-67 and Other Health-Related Biomarkers: The NEO-Program, a Randomized Controlled Trial on Breast Cancer Patients Undergoing Neoadjuvant Treatment

Fatigue will be assessed using the 13-item FACIT-fatigue scale for the assessment of fatigue in cancer patients.24 The FACIT-Fatigue is a validated questionnaire that was originally developed for the precise evaluation of fatigue levels in cancer patients with anemia. It consists of 13 questions using a 5 point scale (0=not at all; 1 = a little bit, 2 = somewhat, 3 = quite a bit and 4 = very much). It has been used frequently in the clinical trial setting. Responses to each question are added with equal weight to obtain a total score. The range of possible scores is 0-52, with 0 corresponding to the highest level of fatigue and 52 corresponding to the lowest level of fatigue.

T1 and T2 depend on each participant's treatment plan: T1, middle of the intervention; T2, end of the intervention.

Depression and anxiety will be assessed through The Hospital Anxiety and Depression Scale (HADS), which is a 14-item scale composed of two 7-item subscales. Each item could be answered by the patient on a four-point (0-3) response category, which means that each subscale score could range from 0 to 21. Scores below 7 indicate the absence of mood disorder; scores between 8 and 10 suggest a possible mood disorder; scores of 11 or higher indicate problem presence

T1 and T2 depend on each participant's treatment plan: T1, middle of the intervention; T2, end of the intervention.

Sleep quality will be subjectively assessed through The Pittsburgh Sleep Quality Index. Self-reported usual sleep habits for the majority of days and nights during the past month only. The 19 self-rated and 5 non-self rated questions combined to form seven component scores, with a range of 0-21 points, "0" indicating no difficulty and "21" indicating severe difficulties.

T1 and T2 depend on each participant's treatment plan: T1, middle of the intervention; T2, end of the intervention.

Sleep quality and efficiency will be objectively and continuously measured by a ballistocardiography through a bed sensor (Emfit Corp., Kuopio, Finland) placed under the mattress at the thoracic level. Sleep score (range 0 to 100) will be determined indicating the quality of sleep. A score higher or around 80 determines a good sleep quality.

Furthermore, wrist actigraphy will be used.Sleep latency (minutes), sleep efficiency (%), total time in bed (minutes), total time sleeping (minutes), wake before sleep onset (minutes), number of awakenings, and average awakening length (minutes) will be recorded.

Sedentary time and physical activity levels will be assessed by accelerometry (ActiGraph, GT3X model, Fort Walton Beach, FL). All participants will be asked to wear the accelerometer on the right hip, close to the iliac crest. The devices will be activated on the first day (in the morning) and data will be recorded in 60-second epochs. The cut-off values that will be used to define the intensity of physical activity will be as follows: sedentary: \< 150 counts·min-1; light: 151-2689 counts·min-1; moderate: 2690-6166 counts·min-1 (corresponding to 3-5.9 Mets); vigorous: ≥ 6867 counts·min-1 (corresponding to ≥ 6 Mets)

T moments depend on each participant's treatment plan: T1, T2, T3, T4, T5 correspond to 1-, 2-, 3-, 4-, 5-months after the beginning of the intervention, respectively; T6, end of the intervention. On those that will undergo a 4-months treatment plan, only T1, T2, T3, and T4 will be performed.

To measure tumor size, radiological techniques (breast magnetic resonance and mammography) will be used. These assessments will be performed at the moment of the diagnosis and before the mammary surgery.

The time frame depends on each participant's treatment plan.

Tumor hypoxia will be assessed using magnetic resonance imaging (MRI) that is already scheduled before and after neoadjuvant therapy. All MRI examinations will be performed on a 3 Tesla clinical scanner equipped with a standard 16-channel breast coil. In addition to a state-of-the-art MRI protocol with T2-weighted, diffusion-weighted (DWI) and dynamic contrast-enhanced (DCE) MR imaging, the following additional sequences will be performed: 1. a multi-echo gradient-echo (GE) sequence for T2\*-mapping and a multi-echo spin-echo (SE) sequence for T2-mapping; 2. a dynamic susceptibility contrast (DSC) bolus-tracking perfusion MRI sequence combined with a hybrid single-shot gradient-echo spin-echo (GESE) echo-planar imaging (EPI) readout. These additional sequences will take only more 10 minutes than the standard MRI (30 minutes).

The time frame depends on each participant's treatment plan.

Initial tumor biopsy and the post-neoadjuvant surgical specimen will be evaluated. Tissue microarray blocks, with a sampling of the tumor-infiltrating lymphocytes hotspots from the initial biopsy and surgical specimen material, will be constructed. An immunohistochemical study with CD8+, CD4+, and CD56+ will be performed on the tissue microarray blocks.

The time frame depends on each participant's treatment plan.

A certified health care professional will perform all blood sample collections. The participants will be in a seated position and blood samples will be collected from the antecubital vein into dry tubes containing ethylenediaminetetraacetic acid (i.e. anticoagulant). Fasting glucose will be measured.

The time frame depends on each participant's treatment plan.

A certified health care professional will perform all blood sample collections. The participants will be in a seated position and blood samples will be collected from the antecubital vein into dry tubes containing ethylenediaminetetraacetic acid (i.e. anticoagulant). Lipid profile (total cholesterol, HDL-cholesterol, LDL-cholesterol, and triglycerides) will be measured.

The time frame depends on each participant's treatment plan.

A certified health care professional will perform all blood sample collections. The participants will be in a seated position and blood samples will be collected from the antecubital vein into dry tubes containing ethylenediaminetetraacetic acid (i.e. anticoagulant). Inflammatory marker CRP will be measured. Moreover, the cytokine and immune profile (leptin, adiponectin, BDNF, TNF-α, IL-6, IL-8, IL-10, IL-1ra, IGF-1, oncostatin M) will be assessed using flow cytometry (FACS Calibur, BD Biosciences) with a Cytometric Bead Array technique and ELISA kits.

The time frame depends on each participant's treatment plan.

Arterial function assessment will be performed on the right carotid artery using an ultrasound scanner (MyLab One, Esaote, Genova, Italy) and implemented with a previously validated radiofrequency-based tracking of the arterial wall. Pulse wave velocity will be measure using applanation tonometry using the Complior Analyse software (ALAM Medical, Paris, France).

The time frame depends on each participant's treatment plan.

Cardiotoxicity will be evaluated through the assessment of resting left ventricular ejection fraction that could be determined using a two- and three-dimensional electrocardiogram. The time frame depends on each participant's treatment plan.

For mitochondrial respiration, the tissue samples will be collected using biopsies at the moment of diagnosis and following the exercise intervention at the moment of surgery (surgical specimen). Mitochondrial respiration assays will be performed using the Oxygraph-2k high-resolution respirometer (Oroboros Instruments, Innsbruck, Austria) at 37º loaded with mitochondrial respiration medium MiR05, and in the range of 200-400 nmol O2/ml.

The time frame depends on each participant's treatment plan.

Initial tumor biopsy and the post-neoadjuvant surgical specimen will be evaluated. Pathology evaluation will include the Ki67 assessment.

The time frame depends on each participant's treatment plan.

To calculate BMI (kg/m2), Weight and height will be measured on an electronic scale with a stadiometer without shoes wearing minimal clothing to the nearest 0.01 kg/0.1 cm (Seca, Hamburg, Germany). T1 and T2 depend on each participant's treatment plan: T1, middle of the intervention; T2, end of the intervention.

Waist circumference will be assessed according to the NIH (horizontal plane at the level of the iliac crest) and World Health Organization (WHO) protocol (midpoint between the lower margin of the last palpable rib and the top of the iliac crest). Hip circumference will be taken around the widest portion of the buttocks. Two measurements (to the nearest 0.1 cm) will be performed and a mean value will be calculated. If the two measurements differ by more than 0.5 cm, a third one will be performed and the two closest measurements will be considered.T1 and T2 depend on each participant's treatment plan: T1, middle of the intervention; T2, end of the intervention.

Dual-energy X-ray absorptiometry (GE Lunar Prodigy Primo Hologic, Wisconsin, USA) will be used to estimate bone mineral content/density. T1 and T2 depend on each participant's treatment plan: T1, middle of the intervention; T2, end of the intervention.

Dual-energy X-ray absorptiometry (GE Lunar Prodigy Primo Hologic, Wisconsin, USA) will be used to estimate percentage of lean body mass. T1 and T2 depend on each participant's treatment plan: T1, middle of the intervention; T2, end of the intervention.

The participants will undergo bioelectrical impedance analysis (BIA) (single frequency, 50 kilohertz (kHz) ± 1%, NutriLAB, Akern) to determine the PhA and body water compartments (total, extracellular, and intracellular). The participants will be measured in a lying position, with legs apart from each other and arms apart from the trunk, so that the medial surface of the limbs will not touch the rest of the body. Four electrodes (2 in each limb) will be placed on the hand and foot of the dominant side, with a distance of 5 cm between both.

T moments depend on each participant's treatment plan: T1, T2, T3, T4, T5 correspond to 1-, 2-, 3-, 4-, 5-months after the beginning of the intervention, respectively; T6, 6-months (end of the intervention). On those that will undergo a 4-months treatment plan, only T1, T2, T3, and T4 will be performed.

Resting metabolic rate will be measured using indirect calorimetry using a gas analyzer (QUARK resting metabolic rate (RMR) w/ Cardio Pulmonary Exercise Test (CPET), version 9.1, Cosmed, Rome, Italy). The participants will be in a lying position for 30-minutes while using a mask. The first 5-minutes of gas measurement will be discarded. A steady-state period of 5-minutes for oxygen and carbon dioxide volumes (coefficient of variation ≤ 5%) will be used for analyses.

The time frame depends on each participant's treatment plan.

Peak oxygen uptake (VO2 peak) will be determined by an incremental supervised CPET performed on a cycle ergometer. The assessment will start at 20 Watts and then the workloads will increase 10 Watts/min. Cadence: 60-70 rpm. All tests will be monitored using a 12-lead electrocardiogram PC-based acquisition module by a certified cardiologist, and heart rate will be recorded using Omnia software. After the calibration, inspired and expired gases will be continuously analyzed through a gas analyzer (QUARK RMR w/CPET, version 9.1, Cosmed, Rome, Italy). Participants will exercise until at least two of the following test termination criteria are reached: (1) volitional fatigue; (2) respiratory exchange ratio reached 1.1 or higher; (3) predicted maximal heart rate; (4) oxygen uptake do not increase despite increasing workload. Peak oxygen will be determined as the highest 20 seconds average of the last minute.

The time frame depends on each participant's treatment plan.

The handgrip strength test (hydraulic calibrated hand dynamometer - JAMAR) as defined by the American Society of Hand Therapists will be performed to assess upper limb strength. 3 isometric repetitions (separated by 1-minute recovery) will be performed in a seated position. The shoulder joint should be adducted and neutrally rotated; the elbow flexed at 90º, and the forearm in midprone neutral position. The mean of the three trials will be calculated. Verbal encouragement will be provided.

T1 and T2 depend on each participant's treatment plan: T1, middle of the intervention; T2, end of the intervention.

To evaluate lower limb strength, an isometric mid-thigh pull will be performed while using a force sensor (Chronojump). 3 maximal voluntary repetitions will be performed for 4-5 seconds while receiving a verbal stimulus, with 3 minutes recovery between trials. The bar will be positioned near the thigh and the knees should be positioned at 120º.

T1 and T2 depend on each participant's treatment plan: T1, middle of the intervention; T2, end of the intervention.

The EORTC-QLQ-C30 is a 30-item questionnaire composed of 5 multi-item functional subscales (physical, role, emotional, cognitive , and social functioning), three multi-item symptom scales (fatigue, nausea/vomiting, and pain), a global quality of life (QOL) subscale, and 6 single item symptom scales assessing other cancer-related symptoms . The questionnaire employs 28 4-point Likert scales with responses from "not at all" to "very much" and two 7-point Likert scales for global health and overall QOL. Responses to all items are then converted to a 0 to 100 scale. For functional and global QOL scales, higher scores represent a better level of functioning/QOL. For symptom-oriented scales, a higher score represents more severe symptoms. T1 and T2 depend on each participant's treatment plan: T1, middle of the intervention; T2, end of the intervention.

The EORTC-QLQ-BR23 is a 23-item breast cancer-specific companion module to the EORTC-QLQ-C30 and consists of four functional scales (body image, sexual functioning, sexual enjoyment, future perspective) and four symptom scales (systemic side effects, breast symptoms, arm symptoms, upset by hair loss). QLQ-BR23 questionnaire employs 4-point scales with responses from 'not at all' to 'very much'. All scores are converted to a 0 to 100 scale. For functional scales, higher scores represent a better level of functioning. T1 and T2 depend on each participant's treatment plan: T1, middle of the intervention; T2, end of the intervention.

Study title	NCT ID	Conditions	Interventions	Eligibility	Organization
Comparing the Impact of Multimodal Prehabilitation to Aerobic Training on Patients Undergoing Thoracoscopic Lobectomy	NCT04049942	Perioperative Recovery Prehabilitation Thoracoschisis Lobectomy Lung Cancer	Multimodal preh... Aerobic trainin...	18 Years - 70 Years	Peking Union Medical College Hospital
Resistance vs. Aerobic Training on Breast Cancer Patients Undergoing Neoadjuvant Treatment	NCT05297773	Breast Cancer	Aerobic Trainin... Resistance Trai... Control group	18 Years -	Fundacao Champalimaud
Comparing the Impact of Multimodal Prehabilitation to Aerobic Training on Patients Undergoing Thoracoscopic Lobectomy	NCT04049942	Perioperative Recovery Prehabilitation Thoracoschisis Lobectomy Lung Cancer	Multimodal preh... Aerobic trainin...	18 Years - 70 Years	Peking Union Medical College Hospital

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