The Role of Pulmonary Rehabilitation Programs in Patients with Lung Cancer: A Narrative Review

Abstract

Background: Pulmonary rehabilitation (PR) is increasingly used across the lung-cancer care pathway, but the scope, effectiveness, and optimal delivery of programmes remain variably reported. Objective: To examine the effectiveness of PR in adults undergoing lung cancer surgery across preoperative perioperative, and post operating settings. Methods: We conducted a narrative synthesis of studies evaluating PR interventions in patients undergoing lung cancer resection. Eligible designs included randomised, non-randomised trials and observational studies published between 2021 and 2025. Interventions were classified by timing (preoperative, perioperative, postoperative) and by completeness of PR content. Full PR was defined as programmes including structured exercise training, at least one respiratory-specific component, and structured education and/or supportive interventions. Outcomes of interest included postoperative pulmonary complications (PPCs), length of stay (LOS), functional capacity, ventilatory function, symptoms and health-related quality of life (HRQoL). Results: Across perioperative phases, PR was feasible and safe, with consistent improvements in functional capacity and patient-reported outcomes. Preoperative PR reliably improved presurgical fitness with reductions in PPCs and LOS most evident in supervised and physiologically targeted programmes. Perioperative PR integrated within enhanced recovery pathways supported early mobilisation and respiratory recovery. Postoperative PR accelerated recovery of exercise capacity, respiratory symptoms, and HRQoL beyond expected natural recovery. Programmes classified as Full PR demonstrated more consistent and broader benefits across outcome domains compared with Partial PR. Substantial heterogeneity in intervention design and outcome measurement was observed. Conclusions: Pulmonary rehabilitation is an effective, multidimensional intervention across the surgical lung cancer continuum. Comprehensive, multimodal programmes appear to confer the greatest clinical benefit. Standardisation of PR content and outcome measurement is needed to strengthen evidence synthesis and guide implementation in perioperative lung cancer care.

1. Introduction

On a global scale lung cancer ranks highest in both incidence and mortality rates among all cancers worldwide [1]. Incidence and mortality remain high in men, and late-stage presentation is common, contributing to poor overall survival despite advances in screening and therapy [2,3,4] Multimorbidity is common in lung cancer, and over half of patients have two or more chronic conditions at diagnosis and respiratory (notably chronic obstructive pulmonary disease, COPD) and cardiovascular diseases are the most frequent. These coexisting conditions amplify symptom burden and complicate treatment decisions [5,6].

Functional decline begins early and is driven by tumour-related deconditioning, systemic inflammation, dyspnoea, cough, pain, fatigue, anxiety, depression, and physical inactivity [7,8]. Objective impairments include reduced cardiopulmonary fitness (lower VO₂peak) and diminished functional capacity (shorter 6 min walk distance, 6MWD), both of which predict poorer tolerance of therapy, higher complication rates, and worse quality of life [9,10,11]. Sarcopenia and cachexia—prevalent across stages—further limit strength and endurance, impede recovery and are associated with inferior survival [12,13].

Complications are common both from disease and treatment. In surgical patients, PPCs—including atelectasis, pneumonia, respiratory failure, prolonged air leak, and pneumothorax—are major drivers of intensive care use, extended length of stay, 30-day readmission, reduced quality of life (QoL), and mortality [14,15]. Risk is amplified by COPD, impaired baseline function and poor ventilatory mechanics after resection (reduced lung volume, diaphragmatic dysfunction) [16,17,18,19]. In non-surgical patients, thoracic radiotherapy and concurrent chemoradiotherapy can worsen dyspnoea and fatigue and may precipitate radiation pneumonitis and later fibrosis [20,21], whereas systemic therapies contribute to anaemia, neuropathy, cardiopulmonary toxicity and cumulative deconditioning [22,23,24]. Across settings, these complications hinder timely treatment delivery, intensify symptom burden, and undermine return to usual activities and independence [24].

As complications accumulate across the care pathway, preserving functional reserve becomes essential. PR provides a targeted goal to sustain exercise tolerance, improve ventilatory mechanics, and mitigate downstream morbidity. PR according to American Thoracic Society and European Respiratory Society (ATS/ERS) definition is a comprehensive, patient-tailored intervention built on a thorough assessment and comprising exercise training, education, and behaviour change to improve the physical and psychological condition of people with chronic respiratory disease and to promote long-term health-enhancing behaviours [25]. Contemporary ERS work reaffirms this definition and details modern delivery models and components [26]. Contemporary lung-cancer PR programmes typically use aerobic and resistance training as the backbone, with inspiratory muscle training (IMT) included in several trials and frequent adjuncts (nutrition, psychology, education). Dosing varies from short, intensive preoperative schedules to multi-week postoperative courses delivered in hospital, community and home.

Lung cancer and its treatments lead to ventilatory impairment, dyspnoea, and fatigue. After thoracoscopic lobectomy, patients experience reduced lung volume and altered ventilatory mechanics. PR targets these deficits to hasten recovery.

2. Materials and Methods

We conducted a narrative literature review to synthesise recent evidence on the role of PR in adults with lung cancer across the surgical pathway (preoperative, perioperative, postoperative). The review emphasises studies published 1 January 2021 through 31 December 2025. Eligibility criteria were first, adults (≥18 years) with lung cancer (non-small cell lung cancer, NSCLC, or small cell lung cancer, SCLC). Mixed-cancer cohorts were eligible only if lung-cancer-specific outcomes were reported or could be extracted. Secondary, intervention PR including supervised or home/tele-PR aerobic and/or resistance training, IMT, breathing/airway-clearance techniques, education and behaviour change, multimodal prehabilitation, perioperative PR bundles (PR plus nutrition/psychological support). We compare the intervention with usual care, no-PR, wait-list/attention control or alternative active components. Finally, our main outcomes were PPCs, LOS, readmission, treatment interruptions, chest-tube duration. Also, the 6 min walk distance (6MWD) or Incremental Shuttle Walking test (ISWT), VO₂peak/cardiopulmonary exercise test (CPET), spirometry (FEV₁, FVC, ratios), ventilatory efficiency (VE/VCO₂ slope), and respiratory-muscle strength (maximal inspiratory pressure-MIP/maximal expiratory pressure-MEP/Pimax/Pemax). Subjective outcomes included dyspnoea (mMRC/Borg), fatigue, HRQoL, anxiety/depression (Hospital Anxiety and Depression Scale, HADS).

2.1. Study Design

Our narrative review comprised randomised clinical and controlled trials, non-randomised controlled studies, prospective/retrospective cohorts and adequately reported pre–post single-arm studies.

2.2. Exclusion Criteria

The exclusion criteria were paediatric populations, non-lung cancer groups, case reports, editorials, commentaries, narrative/systematic reviews (used for context only), protocols with ongoing trials without results (but summarised in Discussion), conference abstracts, and non-English studies.

2.3. Search Strategy

We searched MEDLINE (PubMed), Embase, Scopus, Web of Science, and the Cochrane Central Register of Controlled Trials (CENTRAL) from 1 January 2021 to 31 December 2025. We also searched reference lists of included studies and recent reviews and screened trial registries (e.g., ClinicalTrials.gov) for ongoing or recently completed trials relevant to PR in lung cancer. Key words used were lung neoplasms or lung cancer or NSCLC or SCLC AND pulmonary rehabilitation, PR, breathing exercises or inspiratory muscle training or IMT or prehabilitation AND preoperative/postoperative or surgery or lobectomy or video-assisted thoracoscopic surgery (VATS).

2.4. Study Selection

Titles/abstracts were screened against eligibility criteria, followed by full-text assessment of potentially relevant records. Disagreements (when present) were resolved by discussion. Studies available only as abstracts were considered if PICOS and at least one primary outcome were extractable. These were flagged as such in our data extraction and synthesis notes.

2.5. Data Extraction and Synthesis

For each study we extracted therapy classification (preoperative, perioperative, postoperative), intervention components and dose (Frequency, Intensity, Time, Type (FITT), supervision, delivery, model), comparator, primary/secondary outcomes, adherence and cost/resource metrics if reported. Finally, we conducted a narrative synthesis by perioperative pathway and compared studies primarily on key clinical outcomes (PPCs/LOS, functional capacity, ventilatory function, symptoms/HRQoL), with interpretation informed by intervention completeness, classified as Full or Partial PR.

2.6. Intervention Classification

To describe intervention heterogeneity, we classified programmes by completeness of PR content and by timing relative to surgery using explicit anchors. Preoperative rehabilitation referred to interventions delivered exclusively in the weeks prior to surgery (from programme initiation up to the day before surgery). Perioperative rehabilitation referred to interventions delivered around the time of surgery, spanning the immediate presurgical period and the early postoperative/in-hospital period—operationalised as programmes that started in the days to weeks before surgery and continued into the index admission, and/or protocols initiated immediately after surgery and delivered during the in-hospital phase (post-op days 0–7) as part of perioperative care pathways (ERAS). Postoperative rehabilitation referred to programmes initiated after hospital discharge and delivered in the weeks following surgery (post-discharge recovery). Full PR was defined as a multicomponent programme including (i) structured exercise training (aerobic and/or resistance), (ii) at least one respiratory-specific component (e.g., inspiratory muscle training, breathing retraining, airway clearance techniques), and (iii) structured education/self-management and/or supportive components (e.g., smoking cessation counselling, nutritional or psychological support). The presence of both exercise training and a respiratory-specific component was considered essential to classify an intervention as pulmonary rehabilitation, reflecting international guideline definitions. Partial PR included programmes that contained PR elements but did not meet all Full PR criteria (i.e., missing ≥1 of the above domains). Exercise-only or respiratory-training-only interventions were therefore not classified as Full PR and were not included in the PR completeness synthesis. When reporting was insufficient to confirm domains, classification was conservative (coded as Partial PR) [27].

3. Results

3.1. Preoperative Phase

Across recent trials, prehabilitation programmes remain heterogeneous in content, intensity, and supervision, which likely contributes to variability in effect sizes. Improvements in presurgical status are relatively consistent—particularly for exercise tolerance and patient-reported outcomes—whereas reductions in PPCs appear more context-dependent and are most evident in programmes that are intensive, supervised, and/or risk-targeted. Two contemporary randomised trials illustrate that even short prehabilitation windows (≈2 weeks) can be clinically meaningful. In a recent randomised controlled trial (RCT), a 14-day multimodal programme (with behavioural/support components) reduced PPCs and shortened hospital length of stay, alongside improvements in ventilatory efficiency and peak VO₂ [28]. In prespecified analyses, changes in VE/VCO₂ slope—not changes in peak VO₂—were associated with PPC occurrence, echoing Licker and associates who improved peak VO₂ without lowering early complications, consistent with VE/VCO₂’s superior prognostic value, reinforcing the concept that ventilatory efficiency may be a more sensitive perioperative risk marker than peak VO₂ in this context [28,29]. A second RCT similarly reported fewer short-term complications and shorter length of stay following a brief, supervised preoperative exercise programme, with accompanying improvements in functional and psychological outcomes [30]. Additional supervised, higher-load programmes support the physiological plausibility of benefit. A recent study (2022) demonstrated that delivering a fixed dose of supervised sessions over 3 versus 5 weeks improved cardiopulmonary fitness and related physiological parameters. Although the study was not powered to detect differences in PPCs, the findings support the feasibility of structured training and its short-term physiological benefits [31]. Similarly, a 2023 investigation reported that an intensive, supervised 7-day respiratory-focused regimen—including breathing exercises, incentive spirometry, and BiPAP—reduced overall complication rates, largely driven by fewer prolonged air leaks, and shortened length of stay. However, no clear between-group differences were observed in spirometric outcomes during the early postoperative period [32]. In contrast, more pragmatic home-based programmes tend to show functional and quality-of-life benefits without consistent effects on complications. A 2024 study evaluating a home-based intervention comprising walking and resistance training with weekly telephone supervision reported significant improvements in HRQoL and functional outcomes, including the Incremental Shuttle Walk Test (ISWT) and the 5 min sit-to-stand test (5STS). However, no reductions were observed in length of stay or perioperative endpoints [33]. Moreover, “Move For Surgery” research was associated with a lower incidence of prolonged hospital stay (>5 days) and improvements in Euro Quality of Five Dimensions questionnaire EQ-5D domains, while complication-related outcomes were not clearly reduced [34]. Findings from another study similarly suggest that when baseline recovery is already supported within enhanced recovery after surgery (ERAS) pathways, programme timing and lower-intensity delivery may have less influence on short-term functional recovery [35].

Overall, prehabilitation reliably improves presurgical functional status and patient-reported outcomes (

Table 1. Preoperative studies characteristics.

Study (Year)	Design	Duration	Population	Intervention	Comparator	Main Outcomes	Key Results
[28]	RCT	14 days	High-risk lung resection candidates	Multimodal prehab (RMT/IMT + exercise + education + smoking cessation + psych + nutrition)	Usual care	PPCs, LOS, chest drain, CPET/VE/VCO2	↓ PPCs, ↓ LOS and chest drain ↓ VE/VCO2 slope ↑ QoL
[30]	Prospective RCT	16-days alternate supervised exercise	NSCLC, planned VATS lobectomy	HIIT/MICT	Usual care	PPCs, LOS, QoL	↓ PPCs ↓ LOS before surgery ↑ QoL ↑ functional capacity
[31]	Active-comparator RCT	3 weeks/5 weeks	Adults with NSCLC presurgery	Supervised high-intensity multimodal prehab (interval aerobic + resistance + IMT + education) dense vs. distributed schedules	Active comparator (no usual care arm)	VO2peak, VE/VCO2, MIP, quad strength, QoL, PPCs	Physiology ↑ (VO2peak, MIP, strength), ↓ VE/VCO2, ↑ emotional QoL no diff. dense vs. distributed underpowered for PPCs
[32]	RCT	7 days	Thoracotomy lung resections	Intensive supervised pre-op physio (≈3 h/day): breathing + BiPAP + education	None/usual	ABGs resp function, PPCs, LOS	↓ LOS ↓ PPCs ABGs, respiratory function = ns
[33]	RCT	4 weeks	NSCLC presurgery	Home-based exercise + education + weekly phone supervision	Usual care (+ attention calls)	HRQoL (QLQ-C30), ISWT, 5STS, postop exercise capacity, LOS	↑ Global QoL pre- and post-op better function ↑ postop exercise capacity LOS = ns
[34]	Blinded single-site RCT	3–4 weeks	Early-stage NSCLC for resection (≈51/arm)	Home-based “Move for Surgery” (activity tracker + breathing + lifestyle/education)	Usual care	Prolonged LOS > 5 days, LOS, HRQoL	↓ Prolonged LOS (7% vs. 24%), LOS ↓ (~1.77 days) ↑ EQ-5D-5L pain ↓ POD1
[35]	RCT	4 weeks before the operation (PREHAB, n = 52) or 8 weeks after (REHAB, n = 43).	NSCLC resection	Home multimodal (aerobic + resistance + whey protein + anxiety-reduction)	Same programme delivered post-op	6MWD over time	No between-group diff. recovery to baseline by 8 weeks > 75% regained capacity

↑: improvement/increase, ↓: reduction/decrease, ns: no significant change.

). Reductions in PPCs and LOS are most consistently observed when programmes are supervised and physiologically targeted (e.g., ventilatory efficiency/respiratory muscle loading) and/or delivered with higher training density and clinical oversight.

3.2. Perioperative Phase

Across seven perioperative studies, programmes were delivered as integrated perisurgical bundles (typically combining preoperative elements with early postoperative respiratory training and mobilisation), often positioned within or alongside ERAS pathways. Compared with the preoperative-only literature, perioperative studies more consistently targeted early respiratory mechanics and recovery milestones (e.g., cough effectiveness, ambulation, drainage parameters), which may explain the clearer signal for reductions in short-term complications in several datasets.

PPC reduction emerged as the most consistent perioperative benefit, although effects varied by intensity, content, and comparator. A multicentre ERAS-plus-PR approach of 2023 reported fewer PPCs than ERAS alone, supporting the concept that PR can provide additive benefit beyond standard enhanced recovery pathways [36]. Similarly, a nurse-led perioperative breathing and airway-clearance programme reduced postoperative complication rates and improved EQ-5D outcomes, even though spirometric indices and LOS were not significantly different, suggesting that mechanisms such as secretion clearance, breathing control, and early symptom management may translate into fewer early complications without necessarily altering lung function metrics [37]. Several studies also suggested that perioperative PR may improve recovery efficiency and resource use [38]. A study evaluating a perioperative package that combined pulmonary rehabilitation with individualised nutritional intervention reported broad benefits, including improvements in functional capacity and pulmonary function, alongside reductions in PPCs, LOS and healthcare costs. These findings suggest that integrating rehabilitation with targeted nutritional support may enhance recovery pathways in surgical patients [38]. Real-world matched analyses similarly supported reductions in PPCs and LOS with improved quality of life, reinforcing external validity in routine practice settings [39].

On the contrary, not all perioperative benefits were expressed through complication or LOS endpoints. In a propensity score–matched cohort study, perioperative PR was associated with improvements in exercise capacity, pulmonary function indices (including FEV₁/FVC), symptom burden as measured by the COPD Assessment Test (CAT), and preservation of skeletal muscle mass. However, no differences were observed in PPCs or LOS [40]. These findings suggest that perioperative PR may enhance physiological reserve and functional recovery, even when short-term surgical outcomes remain unchanged.

Functional recovery outcomes showed a more mixed pattern, with some benefits occurring even when PPCs were unchanged. In an ultra-short perioperative regimen (3-day preoperative endurance training plus IMT, with postoperative IMT continued after discharge) no statistically significant reduction was found in PPCs or LOS, but the study demonstrated improved cough strength and early walking distance, highlighting that very short interventions may preferentially influence early functional milestones rather than complication rates [41]. Another study also reported improvements in exercise capacity and pulmonary function tests, while PPCs, LOS, Quality of Life (QoL) and mood outcomes were largely unchanged, suggesting that certain perioperative bundles may enhance functional recovery without consistently affecting “hard” surgical endpoints [42] (

Table 2. Characteristics of perioperative studies.

Study (Year)	Design	Population	Intervention	Comparator	Main outcomes	Key Results
[36]	RCT	Patients scheduled for VATS	ERAS + PR nursing programme	ERAS alone	PPCs, chest drain removal time, LOS	↓ PPCs, drain time and LOS ns
[37]	RCT	Older adults undergoing thoracoscopic surgery	Nurse-led peri-op breathing + airway clearance + education	Usual care	PPCs, EQ-5D, spirometry, LOS	PPCs ↓ (11.9%→3.7%) EQ-5D ↑ spirometry/LOS ns
[38]	Single-centre RCT	NSCLC scheduled thoracoscopic resection (n = 169)	Peri-op PR + individualised nutrition (start 2 weeks preop, restart 2 weeks postop; breathing trainer + walking + diet)	Usual care	FACT-L, spirometry, 6MWD, nutrition indices, PPCs, LOS, costs	Better QoL + improved pulmonary function/6MWD and nutritional indices ↓ PPCs/LOS/costs
[39]	PSM cohort	Lung cancer surgery patients receiving PR vs. not	PR (programme details in study)	Usual care	PPCs, LOS, QoL	↓ PPCs ↓ LOS ↑ QoL
[40]	Cohort + PSM	NSCLC surgery cohort (n = 420 PSM 46 vs. 46)	PR (aerobic + strength + flexibility + IMT + education)	No PR	CPET, spirometry, HRQoL, muscle loss	FEV1/FVC and fitness ↑ less muscle loss symptoms/CAT better
[41]	Randomised prospective single-centre controlled trial	Smokers ≥ 20 pack-years candidates for lobectomy (n = 194)	Pre-op 3 days endurance + IMT postop IMT until discharge (ERAS in both)	ERAS only	PPCs, LOS/cost, drainage; cough strength, pain/fatigue walking distance POD1–2	PPCs ns (24.5% vs. 33.0%), LOS, fatigue ns ↑ cough strength ↑ walking distance
[42]	Single-centre RCT (PUREAIR)	Thoracic surgery patients	Perioperative “rehab bundle” (early mobilisation, cough/breathing training etc.)	Usual care	Exercise capacity 1 m/6 m 6MWT, PFTs, PPCs, LOS, QoL, HADS	↑ 6MWT PFTs, PPCs, LOS, QoL, HADS = ns

↑: improvement/increase, ↓: reduction/decrease, ns: no significant change.

).

Notably, outcome selection and measurement varied across the perioperative studies (PPC definitions, functional tests, QoL tools, spirometric endpoints), which limits direct comparison and may contribute to apparently discordant findings. Nevertheless, when considered together, the perioperative evidence indicates that adding PR components to perisurgical care—particularly structured breathing/airway clearance training, IMT, mobilisation support, and where appropriate nutritional optimisation—can reduce PPCs in several contexts and may shorten LOS, with additional benefits in symptom control and early functional recovery.

3.3. Postoperative Phase

Across seven postoperative studies pulmonary rehabilitation was delivered either as inpatient programmes soon after resection, structured outpatient PR or combined hospital–home exercise packages typically over 2–12 weeks. Despite differences in delivery setting and programme components, the overall pattern of findings was consistent; postoperative PR most reliably improves functional recovery and patient-reported symptoms/quality of life, while effects on surgical endpoints (PPCs, LOS) are less consistent and often not the primary focus of postoperative trials (Table 3).

3.3.1. Functional Recovery and Exercise Capacity

The strongest and most reproducible postoperative signal was improvement in exercise capacity, usually measured with walking-based functional outcomes. Outpatient PR in a real-world setting demonstrated clinically meaningful gains in functional performance alongside improvements in symptom burden [43]. Similar improvements were reported in other postoperative programmes [44,45,46], supporting the conclusion that structured PR accelerates functional recovery beyond routine postoperative care or spontaneous recovery alone. Collectively, these data suggest that postoperative PR helps reverse the combined deconditioning effects of surgery, pain, altered breathing mechanics, and reduced physical activity.

3.3.2. Pulmonary Function and Respiratory Mechanics

Pulmonary function outcomes were more heterogeneous than functional outcomes. Some studies demonstrated improvements in respiratory mechanics and airflow-related variables, particularly when PR included breathing training, airway clearance strategies, or manual techniques. For example, Zhou & Sun reported improvements in measures such as peak expiratory flow (PEF) and spirometry indices in the group receiving conventional PR plus manual techniques compared with conventional PR alone, alongside shorter chest tube duration and LOS [47] (Table 4). Another study similarly focused on postoperative recovery of lung volume and respiratory muscle function, reporting improvements in respiratory muscle-related outcomes and recovery markers [46]. In contrast, other studies reported limited or non-significant spirometric change despite clear improvements in exercise capacity and symptoms [44,48]. This pattern suggests that postoperative PR may improve recovery primarily through breathing efficiency, inspiratory muscle performance, and overall conditioning, rather than producing uniform changes in standard spirometric volumes in the early months after surgery.

3.3.3. Symptoms of Dyspnoea and Cough

Postoperative PR consistently improved symptom burden, especially dyspnoea and cough-related outcomes. One study demonstrated reductions in CAT score, reflecting improvement in respiratory symptoms and activity limitation during outpatient PR [43]. Another study addressed a specific and common postoperative problem—persistent cough—and reported improvements in cough-related outcomes and cough-related quality of life over follow-up, indicating that targeted PR breathing strategies can be effective for symptom clusters that meaningfully impact recovery [49]. Additionally, evidence indicates that reductions in dyspnoea occur alongside physiological recovery, supporting a coherent relationship between respiratory muscle performance, breathing retraining, and perceived symptom relief [46].

3.3.4. Health-Related Quality of Life and Psychological Outcomes

Postoperative PR was consistently associated with improvements in HRQoL, particularly in disease-specific and symptom-related domains. One study demonstrated significant gains in both disease-specific (St. George’s Respiratory Questionnaire-SGRQ) and generic (SF-36) QoL measures, alongside reductions in anxiety and depression, highlighting the multidimensional benefits of structured postoperative PR [45]. Importantly, another study also reported significant improvements in SGRQ total scores following a 3-week inpatient PR programme, indicating better disease-specific quality of life despite the absence of significant spirometric change [44]. These findings reinforce that postoperative PR can meaningfully improve patient-perceived health status even when conventional pulmonary function indices remain unchanged.

Consistent with this pattern, recent research observed improvements in HRQoL in patients undergoing structured postoperative PR, accompanying gains in inspiratory muscle strength and cardiorespiratory fitness, while spirometric measures remained largely stable [48]. Improvements in symptom burden were also reflected in reductions in CAT scores following outpatient PR in another study [43] suggesting better control of dyspnoea and activity limitation during recovery. Collectively, these findings indicate that postoperative PR improves HRQoL primarily through enhanced functional capacity, symptom relief, and psychological adaptation to recovery, rather than through uniform improvements in lung volumes [43,48].

3.3.5. Postoperative Complications and Length of Stay

In contrast to the preoperative/perioperative literature, postoperative PR showed less consistent effects on PPCs and LOS. Many postoperative programmes are designed primarily for recovery optimisation, and several did not demonstrate significant between-group differences in complications. Where LOS or tube duration were reported, benefits appeared context-specific: two studies reported shorter recovery-related time endpoints (including chest tube duration and/or LOS), suggesting that some postoperative protocols—especially those that intensively target respiratory mechanics and secretion clearance—may accelerate early clinical milestones [46,47]. Overall, however, the postoperative evidence supports PR mainly as an intervention for functional restoration and symptom/QoL improvement, rather than a uniformly effective strategy for preventing PPCs once surgery has occurred.

Table 3. Postoperative studies characteristics.

Study (Year)	Design	Duration	Population	Intervention	Comparator	Main Outcomes	Key Results
[43]	Retrospective outpatient	6 weeks	Post resection (n = 57 referred 52 completed)	PR (3–4 h, 3 days/week): endurance + strength + IMT + education	None	6MWT, Wmax, PiMax, strength, CAT	↑ 6MWT ↓ CAT no Aes 91% completion
[44]	Retrospective cohort	3 weeks	Post-lobectomy NSCLC ± COPD	3-week inpatient PR (6 days/week: breathing + cycling+ airway clearance + relaxation + education + psych + nutrition)	Basic postoperative physiotherapy and control standard care	6MWT, SGRQ, spirometry,	↑ 6MWT ↓ SGRQ spirometry ns
[45]	Prospective non-randomised cohort	8 weeks	Post-resection NSCLC (n = 66)	Outpatient PR (2×/week) + home exercises	Breathing exercises only	6MWD, dyspnoea, SGRQ/SF-36,HADS spirometry	PR: ↑ FVC ↑ 6MWD ↓ dyspnoea ↑ QoL control: small symptom gains only
[46]	RCT	3 months	Post-VATS lobectomy (n = 88)	PR + albuterol nebuliser for 3 months	Albuterol only	PFTs, 6MWT, dyspnoea, chest-tube time, LOS	↑ PF, ↓ dyspnoea ↓ LOS and tube time ↑ 6MWT
[47]	Prospective randomised controlled study	14 days	NSCLC post-VATS lobectomy (n = 86)	Conventional PR + manual techniques (14 days)	Conventional PR only	PEF/FEV1/FEV1/FVC, 6MWT, PPCs, tube time, LOS	↑ FEV1 and PEF ↓ tube time and LOS 6MWT/PPCs similar
[48]	Prospective cohort	12 weeks	NSCLC post-treatment PR (mostly post-surgical) (n = 56)	Supervised PR (aerobic + resistance + RMT + education)	None	CPET (VO2peak etc.), RM strength, HRQoL, Borg	↑ MIP PFTs ns HRQoL improved
[49]	Retrospective comparative cohort	Not mentioned	NSCLC post-VATS lobectomy (PR 81 vs. 195)	Post-op hospital + home PR (breathing + airway clearance + stretching + aerobic)	“Traditional rehab”	Cough + LCQ6-mo PFTs complications/LOS	↓ Cough (day 3 and 6 months) ↑ LCQ6-mo ↑ PFTs complications/ LOS: ns

↑: improvement/increase, ↓: reduction/decrease, ns: no significant change.

Table 3. Postoperative studies characteristics.

Study (Year)	Design	Duration	Population	Intervention	Comparator	Main Outcomes	Key Results
[43]	Retrospective outpatient	6 weeks	Post resection (n = 57 referred 52 completed)	PR (3–4 h, 3 days/week): endurance + strength + IMT + education	None	6MWT, Wmax, PiMax, strength, CAT	↑ 6MWT ↓ CAT no Aes 91% completion
[44]	Retrospective cohort	3 weeks	Post-lobectomy NSCLC ± COPD	3-week inpatient PR (6 days/week: breathing + cycling+ airway clearance + relaxation + education + psych + nutrition)	Basic postoperative physiotherapy and control standard care	6MWT, SGRQ, spirometry,	↑ 6MWT ↓ SGRQ spirometry ns
[45]	Prospective non-randomised cohort	8 weeks	Post-resection NSCLC (n = 66)	Outpatient PR (2×/week) + home exercises	Breathing exercises only	6MWD, dyspnoea, SGRQ/SF-36,HADS spirometry	PR: ↑ FVC ↑ 6MWD ↓ dyspnoea ↑ QoL control: small symptom gains only
[46]	RCT	3 months	Post-VATS lobectomy (n = 88)	PR + albuterol nebuliser for 3 months	Albuterol only	PFTs, 6MWT, dyspnoea, chest-tube time, LOS	↑ PF, ↓ dyspnoea ↓ LOS and tube time ↑ 6MWT
[47]	Prospective randomised controlled study	14 days	NSCLC post-VATS lobectomy (n = 86)	Conventional PR + manual techniques (14 days)	Conventional PR only	PEF/FEV1/FEV1/FVC, 6MWT, PPCs, tube time, LOS	↑ FEV1 and PEF ↓ tube time and LOS 6MWT/PPCs similar
[48]	Prospective cohort	12 weeks	NSCLC post-treatment PR (mostly post-surgical) (n = 56)	Supervised PR (aerobic + resistance + RMT + education)	None	CPET (VO2peak etc.), RM strength, HRQoL, Borg	↑ MIP PFTs ns HRQoL improved
[49]	Retrospective comparative cohort	Not mentioned	NSCLC post-VATS lobectomy (PR 81 vs. 195)	Post-op hospital + home PR (breathing + airway clearance + stretching + aerobic)	“Traditional rehab”	Cough + LCQ6-mo PFTs complications/LOS	↓ Cough (day 3 and 6 months) ↑ LCQ6-mo ↑ PFTs complications/ LOS: ns

↑: improvement/increase, ↓: reduction/decrease, ns: no significant change.

3.4. Full Versus Partial Pulmonary Rehabilitation

Across perisurgical phases, intervention completeness appeared to influence the consistency and breadth of observed benefits. Programmes classified as Full PR—incorporating structured exercise training, a respiratory-specific component and education/support—were more consistently associated with improvements across multiple outcome domains, including functional capacity, health-related quality of life, and, in several studies, postoperative pulmonary complications and LOS [43,44,47,48]. These effects were observed in preoperative, perioperative and postoperative settings, particularly in supervised or structured programmes (Table 4 and Table 5).

In contrast, Partial PR interventions—typically lacking either a respiratory-specific component or structured education/support—demonstrated more selective benefits, most commonly confined to functional or patient-reported outcomes, with less consistent effects on clinical endpoints such as PPCs or hospital LOS [45,46,49]. This pattern was especially evident in pragmatic or home-based interventions, where gains in exercise tolerance and quality of life were observed without parallel reductions in postoperative complications.

In our study, Full PR is highest in the perioperative phase [38,39,40,41,42] and remains relatively high postoperatively while partial PR is highest preoperatively [30,32,33,35,37] and lowest during the perioperative phase (Figure 1). The latter may happen because the time window before surgery in often limited and workflow is highly interrupted, allowing only some components to be delivered. Also, patients’ factors such as anxiety, pain or reduced ability to engage can constrain full implementation. Overall, while both Full and Partial PR interventions were associated with meaningful improvements in presurgical or recovery-related outcomes, greater intervention completeness was associated with more robust and clinically comprehensive effects, supporting the importance of multimodal programme design in perisurgical pulmonary rehabilitation [27,50].

Table 4. Summary of effects across key outcome domains.

Study	Category	Exercise Capacity	Pulmonary Function	Symptoms (Dyspnoea/Cough/Fatigue)	HRQoL	PPCs	LOS/Recovery
[28]	Pre-op	—	↑ DLCO ↓ VE/VCO2	↑ mood/↓ stress	↑	↓	↓
[33]	Pre-op	↑ ISWT ↑ 5STS (better physical performance)	—	↓ pre-op dyspnoea	↑ global QoL fewer patients with QoL deterioration	—	ns
[34]	Pre-op	↑ capacity	—	—	↑	—	↓ LOS
[31]	Pre-op	↑ performance	—	—	↑	ns	—
[30]	Pre-op	↑ functional capacity	—	—	↑	↓	↓
[35]	Pre-op	ns recovery to baseline	—	↑	↑	—	→
[44]	post-op	↑ 6MWD	ns	—	↑	—	—
[48]	Pre-op	↑ exercise tolerance	↑ ventilatory indices	↑	↑	—	→
[38]	Peri-op	↑ 6MWD	↑ FEV1/FVC	↑	↑ nutrition	↓	↓
[40]	Peri-op	↑ 6MWD	↑ FEV1/FVC	—	—	↓	↓
[41]	Peri-op	—	—	↑ cough strength	—	ns	ns
[36]	Peri-op	—	—	—	—	↓	ns
[39]	Peri-op	—	—	↓ (QoL domain)	↑	↓	↓
[32]	Peri-op	—	ns	—	—	↓	↓
[46]	Peri-op	↑ 6MWD	↑	↓ dyspnoea index	—	—	—
[37]	Peri-op	—	ns	—	↑	↓	ns
[42]	Post-op	↑ walking capacity	ns	ns	ns	ns	ns
[43]	Post-op	↑ 6MWD	↑ PiMax spirometry ns	↓ CAT (improved respiratory symptoms incl. dyspnoea item)	—	—	—
[45]	Post-op	↑ 6MWD	—	↓ dyspnoea (mMRC)	↑	—	—
[47]	Post-op	ns	↑ PEF, FEV1, FEV1/FVC	↓ dyspnoea (Borg)	—	ns	↓
[49]	Post-op	—	↑ lung function	↓ cough	—	ns	ns

↑: improvement/increase, ↓: reduction/decrease, ns: no significant change, —: not measured.

Table 4. Summary of effects across key outcome domains.

Study	Category	Exercise Capacity	Pulmonary Function	Symptoms (Dyspnoea/Cough/Fatigue)	HRQoL	PPCs	LOS/Recovery
[28]	Pre-op	—	↑ DLCO ↓ VE/VCO2	↑ mood/↓ stress	↑	↓	↓
[33]	Pre-op	↑ ISWT ↑ 5STS (better physical performance)	—	↓ pre-op dyspnoea	↑ global QoL fewer patients with QoL deterioration	—	ns
[34]	Pre-op	↑ capacity	—	—	↑	—	↓ LOS
[31]	Pre-op	↑ performance	—	—	↑	ns	—
[30]	Pre-op	↑ functional capacity	—	—	↑	↓	↓
[35]	Pre-op	ns recovery to baseline	—	↑	↑	—	→
[44]	post-op	↑ 6MWD	ns	—	↑	—	—
[48]	Pre-op	↑ exercise tolerance	↑ ventilatory indices	↑	↑	—	→
[38]	Peri-op	↑ 6MWD	↑ FEV1/FVC	↑	↑ nutrition	↓	↓
[40]	Peri-op	↑ 6MWD	↑ FEV1/FVC	—	—	↓	↓
[41]	Peri-op	—	—	↑ cough strength	—	ns	ns
[36]	Peri-op	—	—	—	—	↓	ns
[39]	Peri-op	—	—	↓ (QoL domain)	↑	↓	↓
[32]	Peri-op	—	ns	—	—	↓	↓
[46]	Peri-op	↑ 6MWD	↑	↓ dyspnoea index	—	—	—
[37]	Peri-op	—	ns	—	↑	↓	ns
[42]	Post-op	↑ walking capacity	ns	ns	ns	ns	ns
[43]	Post-op	↑ 6MWD	↑ PiMax spirometry ns	↓ CAT (improved respiratory symptoms incl. dyspnoea item)	—	—	—
[45]	Post-op	↑ 6MWD	—	↓ dyspnoea (mMRC)	↑	—	—
[47]	Post-op	ns	↑ PEF, FEV1, FEV1/FVC	↓ dyspnoea (Borg)	—	ns	↓
[49]	Post-op	—	↑ lung function	↓ cough	—	ns	ns

↑: improvement/increase, ↓: reduction/decrease, ns: no significant change, —: not measured.

Table 5. Intervention components and PR classification (all included studies).

Study (Year)	Exercise Training (A)	Respiratory Component (B)	Education/Behaviour (C)	Nutrition/Psych (D)	Category (Final)
[28]	✖	✔	✔	✔	Partial PR
[33]	✔	✖	✔	✖	Partial PR
[34]	✔	✔	✔	✖	Full PR
[31]	✔	✔	✔	✖	Full PR
[32]	✖	✔	✔	✖	Partial PR
[35]	✔	✖	✔	✔	Partial PR
[30]	✔	✔	✖	✖	Partial PR
[41]	✔	✔	✔	✖	Full PR
[40]	✔	✔	✔	✖	Full PR
[38]	✔	✔	✖	✔	Full PR
[42]	✔	✔	✔	✖	Full PR
[39]	✔	✔	✔	✖	Full PR
[37]	✖	✔	✔	✖	Partial PR
[27]	✔	✔	✔	✖	Full PR
[44]	✔	✔	✔	✔	Full PR
[43]	✔	✔	✔	✖	Full PR
[45]	✔	✔	✖	✖	Partial PR
[47]	✔	✔	✔	✖	Full PR
[49]	✔	✔	✖	✖	Partial PR
[48]	✔	✔	✔	✖	Full PR
[46]	✔	✔	✖	✖	Partial PR

✔: Component included in the intervention; ✖: component not included in the intervention.

Table 5. Intervention components and PR classification (all included studies).

Study (Year)	Exercise Training (A)	Respiratory Component (B)	Education/Behaviour (C)	Nutrition/Psych (D)	Category (Final)
[28]	✖	✔	✔	✔	Partial PR
[33]	✔	✖	✔	✖	Partial PR
[34]	✔	✔	✔	✖	Full PR
[31]	✔	✔	✔	✖	Full PR
[32]	✖	✔	✔	✖	Partial PR
[35]	✔	✖	✔	✔	Partial PR
[30]	✔	✔	✖	✖	Partial PR
[41]	✔	✔	✔	✖	Full PR
[40]	✔	✔	✔	✖	Full PR
[38]	✔	✔	✖	✔	Full PR
[42]	✔	✔	✔	✖	Full PR
[39]	✔	✔	✔	✖	Full PR
[37]	✖	✔	✔	✖	Partial PR
[27]	✔	✔	✔	✖	Full PR
[44]	✔	✔	✔	✔	Full PR
[43]	✔	✔	✔	✖	Full PR
[45]	✔	✔	✖	✖	Partial PR
[47]	✔	✔	✔	✖	Full PR
[49]	✔	✔	✖	✖	Partial PR
[48]	✔	✔	✔	✖	Full PR
[46]	✔	✔	✖	✖	Partial PR

✔: Component included in the intervention; ✖: component not included in the intervention.

4. Discussion

4.1. Overview of Main Findings

Across the lung cancer treatment continuum, PR consistently emerges as a valuable intervention that counteracts functional decline associated with tumour burden, surgery, systemic therapy and radiotherapy. Across twenty-one studies, spanning preoperative, perioperative and postoperative settings, PR was associated with improvements in physiologic capacity, dyspnoea, respiratory mechanics, mood, and HRQoL. Several studies also demonstrated reductions in PPCs and improved early recovery trajectories. Despite variation in programme structure and delivery, the direction of effect was remarkably consistent, aligning with recent reviews emphasising the expanding role of rehabilitation in lung cancer care [50,51].

As documented by the current findings, outcome measures differ substantially in their sensitivity to PR effects. Functional exercise capacity, most commonly assessed using the 6MWD or ISWT, appears to be among the most responsive outcomes across preoperative, perioperative, and postoperative settings, consistently improving even after short or pragmatic interventions [33,40,45,46]. Similarly, patient-reported outcomes, including dyspnoea scales and HRQoL instruments, demonstrate reliable responsiveness to PR reflecting improvements in symptom burden, physical functioning, and emotional well-being [28,30,33,34,35,39,44,47]. In contrast, spirometric indices such as FEV₁ and FVC are less consistently affected, with changes often modest or absent, particularly in the early postoperative period, suggesting limited sensitivity to rehabilitation-induced functional adaptations rather than absence of clinical benefit [32,42,43,44]. Also, several interventions did not assess spirometry as an outcome. Emerging outcomes may better capture PR-related physiological and clinical effects, including ventilatory efficiency indices (e.g., VE/VCO₂ slope), which have shown closer associations with postoperative risk and complication rates than traditional spirometry in preoperative populations [28,29] Measures of respiratory muscle strength, cough effectiveness, and early functional recovery trajectories have also been proposed as clinically meaningful adjuncts, alongside prioritisation of patient-centred domains within recently proposed core outcome sets [52,53].

In evaluating the impact of PR across these studies, it is critical to weigh statistical significance against clinical meaningfulness, especially regarding functional capacity and patient-centred metrics. Several trials reported statistically significant improvements in exercise capacity measures such as walking distance or shuttle walk performance [33,42,43], yet the magnitude of change varied and did not always reach thresholds typically considered clinically meaningful. Conversely, some interventions demonstrated clinically relevant improvements in functional capacity or HRQoL despite modest or non-significant between-group differences, suggesting meaningful benefits at the individual patient level [34,49]. This pattern was also evident for symptom-based outcomes, where reductions in dyspnoea or cough burden were frequently reported and perceived as beneficial by patients, even when spirometric changes were minimal or absent [37,43,44,45]. In contrast, improvements in hard clinical endpoints—most notably PPCs and, less consistently, LOS—were observed in a limited number of studies and were both statistically and clinically relevant when present. These effects were predominantly reported in more comprehensive or perioperative programmes, as well as in intensive preoperative interventions targeting high-risk patients [28,39].

4.2. PR Completeness and Intervention Heterogeneity

A major source of heterogeneity across the included studies was the variability in PR programme content. Using the framework proposed by Zhong, interventions were classified across four domains—structured exercise, respiratory training, education/self-management, and nutritional or psychological support—and categorised as Fully PR or Partial PR depending on completeness [50].

This classification proved highly informative. Fully PR programmes, incorporating exercise plus a respiratory-specific component and at least one educational or supportive element, consistently produced the most robust improvements in functional capacity, ventilatory mechanics, dyspnoea, and HRQoL. These findings reflect the synergistic physiological and behavioural benefits of multicomponent rehabilitation. In contrast, several interventions—though labelled as “PR” in their respective studies—delivered modified or Partial PR models. Many perioperative bundles emphasised respiratory training or mobilisation without structured education [38,46,49]. Some programmes emphasised respiratory muscle training and supportive components without structured exercise training [28,37]. These programmes produced meaningful benefits but do not meet the comprehensive PR definition endorsed by international societies (British Thoracic Society-BTS 2022). Recognizing this heterogeneity is important when interpreting effect sizes and assessing comparability across trials.

4.3. Effects Across the Perioperative Continuum

The preoperative period represents a critical window to optimise physiological reserve and reduce surgical vulnerability. Across included studies, even brief prehabilitation programmes (few days to 2 weeks) improved presurgical functional capacity, ventilatory efficiency and patient-reported outcomes, with reductions in PPCs and LOS most evident in supervised, higher-intensity interventions [28,30]. Likewise, a previous study of Lai demonstrated that participation in an intensive seven-day preoperative PR program was associated with shorter hospital stays and a lower incidence of PPCs compared with controls [52]. Consistent with prior reviews [53,54,55], the evidence supports prehabilitation as beneficial, yet substantial heterogeneity limits firm guidance on the optimal duration, intensity, structure, and patient selection. Although there have been concerns that preoperative PR could delay cancer-specific treatment, multiple studies have shown that postponements of less than one month do not result in significant negative effects on clinical outcomes [56,57,58]. Perioperative PR, often embedded within ERAS pathways provided additive benefits, particularly in early mobilisation, cough effectiveness and respiratory mechanics, with observational data suggesting improvements in spirometry, nutritional indices and complication rates.

Postoperatively, PR consistently supported recovery of exercise capacity and symptoms, accelerating return toward baseline functional status and improving HRQoL compared with usual care alone. In a meta-analysis, the postoperative rehabilitation programs were initiated at least two weeks after surgery and yield superior outcomes compared with those started within the first two postoperative weeks [58]. Likewise, another study reported that postoperative exercise programs were initiated at a median of 15 days after surgery, primarily due to the presence of postoperative complications [59]. This finding underscores the importance of allowing sufficient recovery before commencing PR, with a minimum recovery period of approximately two weeks. In our review studies reporting significant postoperative benefits, the duration of PR programs has generally ranged from 4 to 12 weeks, delivered across diverse settings and with varying levels of intensity. Nevertheless, conclusive evidence regarding the optimal postoperative PR regimen remains lacking. Consequently, the duration of PR should be individualised according to the patient’s care plan and the chosen mode of delivery.

4.4. Outcome Measurement Challenges and the Need for Standardisation

A persistent barrier in lung cancer rehabilitation research is the heterogeneity of outcome measures. Studies used diverse endpoints including spirometry, walk tests, ventilatory efficiency indices, dyspnoea scales and various HRQoL instruments. A recent study highlighted wide variability in outcome selection, prioritisation and timing across studies, limiting comparability and evidence synthesis [53]. This variability complicates synthesis and limits the comparability of findings across trials. The recently developed Core Outcome Set (COS) for lung cancer rehabilitation defines six minimum domains—breathlessness, activities of daily living, physical function, HRQoL, emotional wellbeing and pain—and recommends the 6MWT and the European Organisation for the Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30) as core instruments [60]. Adoption of this COS would align future studies with patient-relevant priorities, facilitate meta-analysis, and enable benchmarking across PR services. This responds directly to earlier reviews highlighting outcome inconsistency as a major barrier to evidence consolidation [27].

4.5. Barriers to Implementation of Pulmonary Rehabilitation

Despite growing evidence of benefit, several barriers continue to limit the uptake and scalability of PR in lung cancer care:

• Patient-related factors, including symptom burden, fatigue, anxiety and reduced motivation.
• Disease-related factors, such as advanced stage, comorbidities and treatment-related toxicity.
• Accessibility and distance, particularly for centre-based programmes.
• Adherence challenges, especially in unsupervised or home-based models.
• Organisational and resource constraints, including staffing and funding limitations.
• Lack of standardisation in PR content and outcome measurement.

These barriers are consistently reported across contemporary reviews and highlight the need for flexible, patient-centred delivery models [27,50,53].

4.6. Study Limitations

Several limitations should be considered when interpreting these findings. Although we sought to improve comparability by organising studies across the surgical pathway (pre-, peri- and postoperative periods) and by classifying interventions as Full versus Partial PR, additional clinically important sources of heterogeneity could not be incorporated into the synthesis because of inconsistent reporting in the primary literature. In particular, tumour stage (Tumour, Node, and Metastasis-TNM) was not reported uniformly across studies. Some trials provided detailed stage distributions [33,43], whereas others reported no staging information or used non-comparable summaries [28,44], which precluded reliable grouping or subgroup comparisons by cancer stage. Similarly, major comorbidities (including respiratory comorbidities such as COPD and interstitial lung disease) were variably reported and rarely analysed in a way that would allow stratified interpretation, despite their substantial impact on baseline pulmonary function and exercise capacity and their potential to confound or modify rehabilitation effects. As a result, the review could not determine whether intervention effects differed meaningfully by TNM stage or comorbidity burden, limiting interpretability and generalisability to specific clinical subgroups. Future studies should therefore report TNM stage and key comorbidities systematically (with clear definitions and distributions) and, where feasible, stratify or adjust outcome analyses accordingly.

4.7. Clinical Implications and Future Directions

The accumulated evidence positions PR as a safe, multidimensional intervention capable of improving physiological reserve, functional capacity, symptoms and recovery across all stages of lung cancer treatment. When initiated preoperatively, PR may reduce PPCs and LOS. When delivered postoperatively, it accelerates recovery and improves HRQoL. Programmes should ideally be Fully PR, incorporating exercise training, respiratory-specific training and structured education/support. Future research should prioritise standardisation of PR content, adoption of the COS, stratification of interventions by baseline risk, evaluation of mechanistic outcomes such as ventilatory efficiency, and expansion of hybrid and tele-rehabilitation models to address real-world barriers to access. As we know PR can be delivered through multiple modalities, including inpatient, outpatient, home-based, or hybrid models. Facility-based programs, such as inpatient and outpatient PR, offer advantages related to standardised care delivery and the social support inherent in group-based settings. In contrast, home-based PR programs reduce transportation-related barriers and overall time burden for patients. However, home-based PR lacks the communal and motivational elements of traditional site-based programs, which may contribute to lower adherence rates, partly due to the absence of peer engagement and group accountability. Furthermore, several studies have indicated that home-based PR may be associated with less pronounced improvements in patient outcomes when compared with facility-based approaches. Considering the heterogeneous needs of patients across different stages of lung cancer the modality of pulmonary rehabilitation should be individualised to align with each patient’s specific needs and logistical circumstances.

Embedding PR within multidisciplinary perioperative pathways and ensuring flexible delivery models may narrow the persistent gap between proven benefit and underutilisation in clinical practice. Taken together, these findings underline the emerging role of PR as an essential component of perioperative lung cancer care. Standardisation of intervention content and outcome measurement will be critical for strengthening the evidence base and supporting widespread, high-quality implementation.

5. Conclusions

This review highlights PR as a safe, feasible, and clinically meaningful intervention across the perioperative continuum of lung cancer care. Prehabilitation programmes, particularly those that are structured, supervised, and multimodal, are associated with improvements in functional capacity and ventilatory efficiency, with more consistent reductions in postoperative pulmonary complications and length of stay when respiratory-specific training and education are included. Perioperative and postoperative rehabilitation further support recovery of exercise capacity, symptom burden, and health-related quality of life. Collectively, the evidence suggests that more comprehensive, “Full PR” models—integrating exercise training, respiratory interventions, and educational or supportive components—tend to produce more robust and consistent benefits than partial or single-component approaches. However, heterogeneity in programme content, patient populations, and outcome measurement continues to limit comparability across studies. Future research should prioritise standardisation of rehabilitation components and outcome measures, adoption of core outcome sets, and development of flexible, personalised delivery models to facilitate broader implementation and optimise patient-centred outcomes in lung cancer surgery.