Incentive Spirometry to Improve Outcomes in Lung Cancer Patients Undergoing Concurrent Chemotherapy and Radiation Therapy

The INSPIRE-LUNG-CRT trial is a prospective, pilot study investigating the efficacy of incentive spirometry on the incidence and severity of pneumonitis in lung cancer patients undergoing concurrent chemotherapy and radiation therapy with immunotherapy maintenance. Despite advancements in treatment modalities, pulmonary complications remain a significant challenge, often leading to diminished functional capacity and quality of life. The trial aims to establish incentive spirometry as a non-pharmacological intervention to reduce these complications, thereby improving clinical outcomes and patient well-being. Lung cancer treatments are frequently associated with pulmonary toxicities, such as radiation-induced pneumonitis and fibrosis, immunotherapy induced pneumonitis, significantly impacting patient outcomes. Incentive spirometry, a device that encourages deep breathing and lung expansion, has shown promise in postoperative settings but is underutilized in oncology.

The pilot, prospective trial will enroll 100 patients diagnosed with advanced, unresectable non-small-cell lung cancer, candidates will receive concurrent chemotherapy and radiation therapy. Inclusion criteria includes a confirmed diagnosis of advanced non-small-cell lung cancer, good performance status (ECOG 0-1), and eligibility for concurrent chemotherapy and radiation. Exclusion criteria includes previous lung or thoracic surgery, enrollment in another pulmonary intervention trial, home oxygen usage prior to enrollment, radiological evidence of pleural effusion, pneumothorax, bullous emphysema, or pneumonitis, active respiratory tract infection, uncontrolled nausea and vomiting, prior exposure to certain drugs, and inability to give informed consent.

The primary endpoint is to determine the impact of incentive spirometry on the incidence and severity of pneumonitis. Secondary endpoints include evaluating the impact on overall survival and patients\' quality of life using the EORTC QLQ-C30 questionnaire. Patients will use the incentive spirometer 10 times (10 breaths) every hour while awake, starting as soon as they are enrolled in the study. The use will continue daily during chemoradiation and up to three months post-treatment. The study duration for each subject is approximately six months, including the use of incentive spirometry during the concurrent chemoRT phase (6-8 weeks) and continued use for up to three months post-treatment.

Inclusion Criteria:

• Confirmed diagnosis of advanced non-small-cell lung cancer
• Performance status (ECOG 0-1)
• Eligible for concurrent chemotherapy and radiation
• 18 years or older.

Exclusion Criteria:

• Previous lung or thoracic surgery
• Enrollment in another pulmonary intervention trial
• Home oxygen usage prior to enrolment
• Radiological evidence of pleural effusion, pneumothorax, bullous emphysema, or pneumonitis on staging imaging
• Presence of active respiratory tract infection
• Uncontrolled nausea and vomiting
• Prior exposure to drugs such as amiodarone, bleomycin, or immunotherapy
• Inability or unwillingness of individual to give written informed consent

Interventions The study will have one intervention group of patients using incentive spirometry in addition to standard of care treatment, including chemo/radiation and immunotherapy maintenance. Patients will undergo procedures for diagnostic and treatment purposes. Standard procedures for lung cancer patients includes, but is not limited to, routine diagnostic tests such as imaging (CT scans, PET scans, MRI scan), blood tests, and pulmonary function tests (PFTs), diagnostic biopsies. For research purposes, patients will be asked to use incentive spirometry. Patients will use the incentive spirometer 10 times (10 breaths) every hour they are awake. Patients will be asked to start using the incentive spirometer as soon as they are enrolled in the study. Patients will be asked to continue to use incentive spirometry daily, including the duration of chemoradiation and up to three months post-treatment. Patients will be asked to monitoring adherence to the spirometry regimen through patient logs and periodic check-ins.

Duration of Participation. The study duration for each subject is approximately 12 months, including: Use of incentive spirometry during the concurrent chemoRT phase (approximately 6-8 weeks). Continued use of the spirometer for up to three months post-treatment. Quality of life assessments and pulmonary function tests at 3-, 6- and 12 months post-treatment.