Transforming post-surgical lung cancer recovery: app-based approach to telerehabilitation

Lung cancer is the leading cause of malignancy-related death in men and the second leading cause in women globally (1). Although surgery often provides a curative treatment approach for early-stage lung cancer, patients may face limitations in functional capacity and quality of life post-operatively (2).

Post-operative rehabilitation is crucial for lung cancer patients, addressing declines in lung function, respiratory muscle strength and exercise capacity (3,4). Improving lung function helps patients regain strength and perform daily activities, enhancing overall health and quality of life (5,6). Additionally, rehabilitation improves psychological well-being such as anxiety and depression by providing structured support (7,8). Rehabilitation programs are also essential for managing post-operative symptoms such as pain, shortness of breath, and fatigue, thus enhancing functional recovery (9,10).

Despite the clear benefits of rehabilitation, access to in-person programs remains low due to issues related to accessibility and resources at some centers (10,11). Telerehabilitation refers to the use of digital platforms such as telephone support, videoconferencing, or mobile applications to provide support, assessment, or instruction for rehabilitation services remotely (12). Telerehabilitation offers a promising solution to the limitations of in person programs, improving rehabilitation accessibility, and helping patients optimize recovery and long-term health outcomes post-operatively (13).

The POPPER study published in the International Journal of Surgery in January of 2025 represents a significant advancement in the field of post-surgical telerehabilitation for lung cancer patients (14). Lv et al. [2025] conducted a single blinded randomized controlled trial, analyzing 136 lung cancer patients, 68 in the usual care and 68 in the intervention group, who underwent video-assisted thoracoscopy (VATS) lobectomy for stage I–II non-small cell lung cancer, comparing the effectiveness of a smartphone-based rehabilitation app.

The app in the POPPER study included daily symptom reporting, aerobic and respiratory exercises, and educational materials (14). Using a Delphi approach, the app’s core symptoms including pain, cough, shortness of breath, and fever, were identified through a combination of patient-reported data from 201 patient surveys and expert consensus from thoracic surgeons and registered nurses (14). Other components of the app included instructions on respiratory exercises through abdominal breathing techniques, aerobic exercises (i.e., stair climbing, walking), and educational materials on lung cancer care, rehabilitation, and nutrition. In the usual care group, participants had access to an app with a single document providing post-discharge instructions, but the three core app components (symptom reporting, exercises, and educational materials) were unavailable.

The POPPER study demonstrated that patients using the rehabilitation app had significantly higher pulmonary function recovery ratios (PFRR) compared to those receiving usual care (79.3% vs. 75.7%, P=0.04), which was the primary outcome measure in this study. PFRR assesses lung function recovery, as it is the ratio of current post-operative percentage of forced expiratory volume in the first second (FEV1%) (predicted value based on age, sex, and height) to pre-operative FEV1%. Symptom burden was also notably lower in the app group, with reduced reports of pain, fatigue, coughing, and sleep disturbance at both one-week and one-month post-discharge (P<0.05). Additionally, patients in the app group demonstrated greater daily function with general activities and work (P<0.05). They engaged in higher-intensity aerobic exercises, as reflected by greater 10-Borg dyspnea scores on days 21 and 28 post-operatively. Furthermore, about 40% of app users triggered symptom alerts and these participants demonstrated greater motivation and interaction with educational materials, along with exercising at a higher intensity than those who did not. Although emergency department visits (8.8% vs. 2.9%) and 30-day readmission rates (4.4% vs. 1.5%) were higher in the app group, possibly suggesting greater attentiveness to symptoms in those using the app, they were not statistically significant. Further, the app had a very good safety profile and excellent satisfaction ratings, with 71% of participants expressing interest in continuing to use the app until 3 months post-operatively (14).

Several strengths are important to highlight in this study. The POPPER trial is the first randomized controlled trial (RCT) to evaluate the efficacy of a smartphone app to facilitate rehabilitation after VATS lobectomy with inclusion of all three domains, reporting of symptoms, training, and education. The comprehensive approach of the smartphone application facilitated recovery by actively engaging patients, as 74 (97%) used the app in the intervention arm. In addition, the study’s single-blinded design is a key strength that minimizes bias with outcome assessments. While clinicians administering the app intervention were aware of the group assignments, all outcome assessors, statisticians, and spirometry testers were blinded. This approach strengthens the study’s validity, particularly in measuring subjective outcomes like symptoms. Moreover, the study’s use of patient-specific data and expert consensus to identify the most relevant symptoms demonstrates its unique approach to symptom monitoring and aligns with those reported in existing literature on post-surgical recovery (15).

A unique feature of the smartphone app used in the POPPER study was its symptom alert system, which most likely played an important role in enhancing patient engagement and motivation. The app allowed patients to report symptoms in real-time, triggering alerts that prompted timely interactions with healthcare providers. This system not only ensured that symptoms were managed promptly, but also appeared to motivate patients to participate in their rehabilitation programs. The study found that patients who triggered symptom alerts engaged in their exercises more frequently and at higher intensities. Lv et al. suggested that self-driven awareness, prompted by alerts, encouraged participants to actively monitor and follow their rehabilitation, improving their recovery (14). This is in line with another telerehabilitation study that demonstrated mobile apps motivated participants, who underwent gastrointestinal and lung cancer operations, to be more physically active by allowing them to set goals and experience a greater sense of responsibility for their recovery (16).

The POPPER study acknowledges several limitations. Firstly, it was a single-center trial with a modest sample size analyzed (n=136), possibly limiting the generalizability of the results to other centers. The authors noted that participants in the usual care group might have been indirectly influenced by answering daily exercise questions, which may have enhanced their daily activity levels. Additionally, only four core symptoms (pain, cough, shortness of breath, and fever) and short-term outcomes in the first month were ascertained, potentially overlooking other postoperative symptoms or long-term effects. Furthermore, there were no direct comparisons between types of exercises, frequency, or duration between groups, which could have provided further insight into the app’s effectiveness to improve physical function.

There are several areas that are important to highlight that were not discussed in the study. Most notably, it still remains unclear the underlying mechanisms by which the app improved outcomes beyond the suggestions from study investigators that greater exercise intensity and follow-up may have played a role. Additionally, while the intervention aimed at improving exercise adherence and recovery, exercise capacity was not directly evaluated using objective measures such as the 6-minute walk test, leaving some uncertainty about the functional benefits of the program (17). Furthermore, the 30-day readmission rates were low in this study and observed in only 3 patients in the app group and 1 in the usual care group, with no severe complications or deaths. This is reassuring, but an important point to highlight is the exclusion of patients with severe post-operative complications or those hospitalized for more than 14 days post-operatively. Moreover, it is somewhat difficult to appreciate what usual care entailed in this study as not fully described, which makes it difficult to assess the full impact of the app compared to standard post-operative care. Finally, this study defines post-operative complications as Clavien-Dindo grade III or higher, whereas many previous studies have used grade II or higher as the threshold (18,19). This higher threshold may have overlooked some patients with less severe but clinically significant complications.

Telerehabilitation offers several advantages including variation, increased adherence and scalability. Synchronous video sessions, such as remote consultations, provide real-time interaction with healthcare professionals, replicating in-person therapy remotely. Asynchronous communication allows patients to follow app-based exercise instructions and log symptoms at their own pace, as seen in the POPPER study, where patients independently tracked their exercises and symptoms. Moreover, telerehabilitation can help engage patients in their recovery by integrating personalized feedback systems, which enhances motivation and adherence with rehabilitation protocols. Finally, telerehabilitation offers scalable solutions by reducing health system costs, expanding access to rehabilitative services, and reducing barriers of transportation costs and travel time for the patient (20,21). Integrating these programs into public healthcare systems to reach underserved populations could maximize their impact, reducing costs and increasing accessibility.

While the benefits of telerehabilitation are promising, it is equally important to acknowledge several barriers. One of the challenges of telerehabilitation is the reduction of in-person interaction between patients and healthcare providers. For some patients, the lack of face-to-face interaction can lead to feelings of dissatisfaction or discomfort, as they may miss the personal connection that is often a key component of comprehensive care (22). Moreover, there is a concern that telehealth may not fully capture the non-verbal communication that occurs during in-person visits—such as body language and emotional expressions (22). Furthermore, limited digital infrastructure, insufficient resources or poor technological literacy, particularly for older adults and rural communities, risks exacerbating existing health disparities (23).

To optimize the effectiveness of telerehabilitation services, addressing these limitations is important. Limitations to telerehabilitation can be improved with investments in reliable internet connectivity, private space to complete online consults, and comprehensive training programs for both healthcare providers and patients (23,24). Addressing accessibility challenges could involve designing user friendly apps specific to the population being served, implementing hybrid models that combine in-person and online rehabilitation, and equipping healthcare providers to assist patients with limited technological literacy (25,26). While implementing these recommendations entails additional costs, increased funding may be worthwhile to ensure equitable access and broad scalability of telerehabilitation services.

Telerehabilitation, particularly through smartphone apps as seen in the POPPER study, offers a promising approach for post-surgical recovery by improving accessibility and providing variety while maintaining patient adherence with rehabilitation. The POPPER study exemplifies these benefits, demonstrating how an app-based intervention not only improves lung function recovery and exercise adherence, but also empowers patients to take an active role in their recovery. Importantly, telerehabilitation has proven particularly beneficial, providing flexible and accessible care for patients in remote areas while reducing costs (22). This makes telerehabilitation a valuable tool in expanding access to post-surgical care. However, telerehabilitation should be integrated into multiple models, with synchronous and asynchronous approaches complementing in-person care to optimize patient outcomes (26). Further research should explore long-term outcomes, propose assessment indicators such as improvements in quality of life measures, and investigate the underlying mechanisms through which these interventions improve patient health to fully understand their potential in post-surgical recovery within the lung cancer population.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, AME Clinical Trials Review. The article has undergone external peer review.

Peer Review File: Available at https://actr.amegroups.com/article/view/10.21037/actr-24-184/prf

Funding: This editorial was funded by Ontario Graduate Scholarship (to R.R.A.), Sandra Faire and Ivan Fecan Professorship (to R.R.A.), Ajmera Transplant Center (to R.R.A.), CIHR (No. PJM 185763; to R.R.A.), and Sandra Faire and Ivan Fecan Professorship in Rehabilitation Medicine and Temerty Faculty of Medicine (to D.R.).

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://actr.amegroups.com/article/view/10.21037/actr-24-184/coif). D.R. reports funding from Sandra Faire and Ivan Fecan Professorship in Rehabilitation Medicine and Temerty Faculty of Medicine. R.R.A. reports funding from Ontario Graduate Scholarship, Sandra Faire and Ivan Fecan Professorship, Ajmera Transplant Center, and CIHR (No. PJM 185763). The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Bray F, Laversanne M, Sung H, et al. Global cancer statistics 2022: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin 2024;74:229-63. [Crossref] [PubMed]
2. Bendixen M, Jørgensen OD, Kronborg C, et al. Postoperative pain and quality of life after lobectomy via video-assisted thoracoscopic surgery or anterolateral thoracotomy for early stage lung cancer: a randomised controlled trial. Lancet Oncol 2016;17:836-44. [Crossref] [PubMed]
3. Huang CY, Hsieh MS, Hsieh PC, et al. Pulmonary rehabilitation improves exercise capacity, health-related quality of life, and cardiopulmonary function in patients with non-small cell lung cancer. BMC Cancer 2024;24:211. [Crossref] [PubMed]
4. Ichikawa T, Yokoba M, Horimizu Y, et al. Recovery of respiratory muscle strength, physical function, and dyspnoea after lobectomy in lung cancer patients undergoing pulmonary rehabilitation: A retrospective study. Eur J Cancer Care (Engl) 2022;31:e13663. [Crossref] [PubMed]
5. Şahin H, Naz İ, Aksel N, et al. Outcomes of pulmonary rehabilitation after lung resection in patients with lung cancer. Turk Gogus Kalp Damar Cerrahisi Derg 2022;30:227-34. [Crossref] [PubMed]
6. Cesario A, Ferri L, Galetta D, et al. Post-operative respiratory rehabilitation after lung resection for non-small cell lung cancer. Lung Cancer 2007;57:175-80. [Crossref] [PubMed]
7. Sui Y, Wang T, Wang X. The impact of WeChat app-based education and rehabilitation program on anxiety, depression, quality of life, loss of follow-up and survival in non-small cell lung cancer patients who underwent surgical resection. Eur J Oncol Nurs 2020;45:101707. [Crossref] [PubMed]
8. Mehnert A, Veers S, Howaldt D, et al. Effects of a physical exercise rehabilitation group program on anxiety, depression, body image, and health-related quality of life among breast cancer patients. Onkologie 2011;34:248-53. [Crossref] [PubMed]
9. Li XH, Zhu JL, Hong C, et al. Effects of systematic rehabilitation programs on quality of life in patients undergoing lung resection. Mol Clin Oncol 2013;1:200-8. [Crossref] [PubMed]
10. Erlik M, Timm H, Larsen ATS, et al. Reasons for non-participation in cancer rehabilitation: a scoping literature review. Support Care Cancer 2024;32:346. [Crossref] [PubMed]
11. IJsbrandy C, Hermens RPMG, Boerboom LWM, et al. Implementing physical activity programs for patients with cancer in current practice: patients' experienced barriers and facilitators. J Cancer Surviv 2019;13:703-12. [Crossref] [PubMed]
12. Fong KNK, Kwan R. Telerehabilitation (Remote Therapy). In: Gu D, Dupre ME. editors. Encyclopedia of Gerontology and Population Aging. Cham: Springer International Publishing; 2021:4956-62.
13. Chang P, Zheng J. Updates in Cancer Rehabilitation Telehealth. Curr Phys Med Rehabil Rep 2022;10:332-8. [Crossref] [PubMed]
14. Lv C, Lu F, Zhou X, et al. Efficacy of a smartphone application assisting home-based rehabilitation and symptom management for patients with lung cancer undergoing video-assisted thoracoscopic lobectomy: a prospective, single-blinded, randomised control trial (POPPER study). Int J Surg 2025;111:597-608. [Crossref] [PubMed]
15. Avery KNL, Blazeby JM, Chalmers KA, et al. Impact on Health-Related Quality of Life of Video-Assisted Thoracoscopic Surgery for Lung Cancer. Ann Surg Oncol 2020;27:1259-71. [Crossref] [PubMed]
16. de Leeuwerk ME, Botjes M, van Vliet V, et al. Self-monitoring of Physical Activity After Hospital Discharge in Patients Who Have Undergone Gastrointestinal or Lung Cancer Surgery: Mixed Methods Feasibility Study. JMIR Cancer 2022;8:e35694. [Crossref] [PubMed]
17. Wesolowski S, Orlowski TM, Kram M. The 6-min walk test in the functional evaluation of patients with lung cancer qualified for lobectomy. Interact Cardiovasc Thorac Surg 2020;30:559-64. [Crossref] [PubMed]
18. Saetang M, Kunapaisal T, Wasinwong W, et al. Predictors associated with Clavien-Dindo complications in lung cancer surgery: A retrospective cohort study. PLoS One 2024;19:e0316214. [Crossref] [PubMed]
19. Shinohara S, Kobayashi K, Kasahara C, et al. Long-term impact of complications after lung resections in non-small cell lung cancer. J Thorac Dis 2019;11:2024-33. [Crossref] [PubMed]
20. Nizeyimana E, Joseph C, Plastow N, et al. A scoping review of feasibility, cost, access to rehabilitation services and implementation of telerehabilitation: Implications for low- and middle-income countries. Digit Health 2022;8:20552076221131670. [Crossref] [PubMed]
21. Snoswell CL, Taylor ML, Comans TA, et al. Determining if Telehealth Can Reduce Health System Costs: Scoping Review. J Med Internet Res 2020;22:e17298. [Crossref] [PubMed]
22. O'Neill L, Brennan L, Sheill G, et al. Moving Forward With Telehealth in Cancer Rehabilitation: Patient Perspectives From a Mixed Methods Study. JMIR Cancer 2023;9:e46077. [Crossref] [PubMed]
23. Dennett A, Harding KE, Reimert J, et al. Telerehabilitation's Safety, Feasibility, and Exercise Uptake in Cancer Survivors: Process Evaluation. JMIR Cancer 2021;7:e33130. [Crossref] [PubMed]
24. Fioratti I, Fernandes LG, Reis FJ, et al. Strategies for a safe and assertive telerehabilitation practice. Braz J Phys Ther 2021;25:113-6. [Crossref] [PubMed]
25. Jaswal S, Lo J, Howe A, et al. The Era of Technology in Healthcare-An Evaluation of Telerehabilitation on Client Outcomes: A Systematic Review and Meta-analysis. J Occup Rehabil 2024; Epub ahead of print. [Crossref] [PubMed]
26. Nicolas B, Leblong E, Fraudet B, et al. Telerehabilitation solutions in patient pathways: An overview of systematic reviews. Digit Health 2024;10:20552076241294110. [Crossref] [PubMed]