Introduction
Lung cancer remains one of the most significant global health challenges. Despite considerable advancements in diagnostics and treatment in recent years, many cases are still diagnosed at advanced stages, and treatment outcomes remain suboptimal [1]. The best chance for a cure lies in early detection, which is increasingly feasible due to wider implementation of lung cancer screening programs [2]. Surgical intervention remains the most effective treatment modality, particularly in the early stages of the disease [3]. Recent developments in oncological treatment, namely pre- and perioperative chemo-immunotherapy protocols, have expanded the eligibility criteria for resection to patients with more advanced disease, thereby increasing the number of candidates for surgery [4].
Significant progress has also been made in surgical techniques. Minimally invasive approaches, such as video-assisted thoracoscopic surgery (VATS), have been shown to offer superior short- and long-term outcomes compared to thoracotomy [5]. Segmentectomies, previously considered insufficient in terms of completeness of resection, have proven non-inferior to lobectomy in selected patient groups – particularly those with small, favorably located nodules [6]. Innovations such as indocyanine green fluorescence imaging, three-dimensional visualization and image-guided techniques for intraoperative pulmonary nodules identification have been introduced to facilitate surgical procedures [7, 8]. The next step in advancing surgical precision, especially in systematic lymph node dissection and in complex cases, such as sleeve resections, is robotic-assisted thoracic surgery [9]. Collectively, these innovations contribute to improved outcomes in lung cancer treatment.
Beyond surgical technique, comprehensive patient assessment, preparation, and perioperative care are equally critical. In Central and Eastern Europe, patients undergoing lung cancer surgery are predominantly smokers with significant comorbidities [10]. Numerous studies have demonstrated a high prevalence of conditions that substantially increase surgical risk, such as chronic obstructive pulmonary disease (COPD), coronary artery disease, and cerebrovascular disease [11]. For such patients, thorough preoperative evaluation and the implementation of strategies aimed at optimizing preoperative status are essential to ensure surgical safety and favorable outcomes [12]. These efforts fall under the broad concept of rehabilitation – all activities aimed at restoring health – which, in the surgical context, aligns with the Enhanced Recovery After Surgery (ERAS) program [13].
Aim
The aim of this review is to summarize current literature on the role of ERAS, with a focus on the preoperative phase in patients undergoing lung cancer surgery, and to present the organizational model of prehabilitation at one high-volume academic thoracic surgery center.
Methods
This narrative review was conducted to summarize current evidence regarding the role of prehabilitation within the Enhanced Recovery After Surgery (ERAS) program for patients undergoing lung cancer surgery. A comprehensive literature search was performed using electronic databases, including PubMed, Scopus, Web of Science, and the Cochrane Library, focusing on studies published up to April 2025. Keywords included “ERAS” , “Enhanced Recovery After Surgery”, “prehabilitation”, “lung cancer surgery”, and “thoracic surgery”. Studies relevant to the topic were selected and included in the manuscript. In addition to the literature review, we presented a real-world organizational model of a prehabilitation program implemented at a high-volume academic thoracic surgery center.
ERAS – principles, evidence, and key elements
The ERAS concept was introduced by the Danish surgeon Henrik Kehlet [14]. It integrates holistic medical principles with fast-track surgical care. This approach emerged from a critical analysis of standard surgical procedures, prompted by questions such as: How can postoperative complications be reduced? How can hospital stays be shortened? How can outcomes be improved? ERAS protocols aim to incorporate multiple evidence-based interventions across all phases of the surgical process – pre-, peri-, and postoperative – to enhance recovery [15]. The philosophy draws on the concept of the “aggregation of marginal gains”, where small, incremental improvements across numerous areas combine to produce significant overall benefits [16]. ERAS programs have been successfully implemented across multiple surgical specialties, including general surgery, gynecology, otolaryngology, pediatric surgery, and cardiac and thoracic surgery [13, 17–20]. Studies have demonstrated that ERAS implementation can lead to reductions in complication rates, intensive care unit and total hospital stays, treatment costs, and hospital readmission rates [18–20].
The ERAS pathway is typically divided into preoperative, perioperative, and postoperative phases. Within the preoperative phase, further distinction is made between the pre-hospital and in-hospital periods. The specific elements of ERAS protocols in thoracic surgery, according to the guidelines, are summarized in Table I [13]. This review focuses on the pre-hospital phase and presents the structure and functioning of the prehabilitation program conducted at the ERAS Clinic within one center.
Table I
Components of Thoracic Enhanced Recovery after Surgery Programs
Preoperative components of ERAS
The primary objectives of preoperative preparation within the ERAS protocol include smoking cessation, enhancement of physical activity, nutritional assessment with supplementation if indicated, diagnosis and management of anemia, reduction in alcohol consumption, and comprehensive patient education regarding the disease and its treatment.
A significant proportion of patients undergoing lung cancer surgery are smokers [21]. Scientific studies have shown that quitting smoking before surgery reduces postoperative morbidity and mortality rates [22]. However, smoking cessation remains challenging [23]. The most effective strategies combine evidence-based motivational techniques, behavioral therapy, and pharmacotherapy, followed by close follow-up [24, 25]. Alcohol abuse is also associated with an increased risk of postoperative complications [26]. During preoperative visits, alcohol abuse should also be addressed, and interventions aimed at reducing alcohol consumption should be implemented [27].
Patients scheduled for lung cancer surgery frequently exhibit reduced exercise capacity, range of motion, and muscle strength [28]. These impairments can lead to delayed postoperative rehabilitation and an increased risk of postoperative complications [29]. Studies suggest that the inclusion of moderate-intensity aerobic exercise [30] and respiratory muscle training [31] may improve functional capacity and reduce postoperative morbidity. Although complex, intensive pulmonary rehabilitation programs may be more effective than standard care, patient compliance may present a challenge.
Another critical component of preoperative preparation is the assessment of nutritional status and implementation of appropriate interventions. Malnutrition may affect up to 60% of lung cancer patients [32]. Although patients eligible for surgical treatment are typically in earlier stages of disease and better functional condition than the overall lung cancer population, a significant proportion still remains at risk of malnutrition [33]. Malnutrition has been associated with lower quality of life and increased morbidity and mortality following lung cancer resection [32, 34]. Therefore, all patients undergoing lung cancer surgery should be screened for malnutrition, and tailored nutritional interventions should be implemented when indicated [35].
Patient education plays a pivotal role in preoperative ERAS protocols for lung cancer. Providing patients with clear and comprehensive information enhances their adherence to prehabilitation regimens, reduces preoperative anxiety and influences pain perception [36, 37]. Effective education ensures that patients understand the benefits of prehabilitation in reducing postoperative complications and promoting faster recovery, particularly among high-risk or frail individuals [38]. The most objective and effective way to deliver this information is through a multidisciplinary team, including physicians, nurses, dietitians, psychologists, and physiotherapists. Although this requires multiple visits and careful organization, it has the potential to achieve the best outcomes.
Patients’ pathway at the center
The treatment pathway for patients with lung cancer typically includes several key stages: pulmonary and thoracic diagnostics, determination of eligibility through a multidisciplinary team meeting (MDT), preoperative preparation within the ERAS Clinic, interventions during pre- and postoperative hospitalization, and the post-discharge recovery period.
Pulmonary diagnostics – including imaging studies and invasive procedures – are performed by the pulmonology departments across the region and the Thoracic Surgery Department at the Center according to the guidelines [39]. Subsequently, all patients are evaluated for surgical eligibility within the framework of an MDT. There is substantial scientific evidence supporting the use of MDTs in the evaluation process, as this approach enables a more comprehensive patient assessment and facilitates therapeutic decisions, ultimately leading to improved treatment outcomes [40].
Following the MDT consultation, patients are scheduled for admission to the ERAS Clinic – typically within one week – and given a planned date of admission to the Thoracic Surgery Department. Patients are informed by telephone about the appointment date and how to prepare for the visit. They are instructed to prepare a list of their current medications, to arrive fasting, and to bring a 3-day food diary detailing what they have eaten. Patients are also informed that the visit will last several hours but that, thanks to this arrangement, they will complete all consultations in a single day.
Preoperative assessment and preparation in the ERAS Clinic
Preoperative preparation at the ERAS Clinic is carried out during a single comprehensive visit, during which the patient meets with a multidisciplinary team including a thoracic surgeon, anesthesiologist, nurse, physiotherapist, rehabilitation specialist, dietitian, and psychologist. The purpose of this visit is to assess the patient’s health status and readiness for surgery, and to initiate interventions that reduce perioperative risk and improve postoperative outcomes.
The thoracic surgeon is the first team member the patient consults and plays a central role in evaluating the patient’s overall condition and the risks associated with the planned procedure. This specialist also confirms or revises the surgical eligibility assessment, explains the nature of the disease and available treatment options, and provides detailed information about the course of surgery, potential complications, and expected outcomes. Additionally, comorbidities are reviewed and, if necessary, treatment is optimized in coordination with other specialists. The thoracic surgeon also emphasizes the importance of collaboration with other members of the ERAS team, highlighting that each is an expert in their respective field, and explains the concept of a patient-centered approach, stressing that the patient shares responsibility for preoperative preparation and surgical outcomes.
During the anesthesiology consultation, a detailed medical history is taken, anesthetic risk is assessed, and recommendations regarding premedication are documented. This step ensures that the patient is safely prepared from an anesthetic standpoint and that any modifiable risk factors are addressed in advance.
The ERAS nurse coordinates the logistics during the entire visit. Responsibilities include ordering laboratory and imaging tests, arranging additional specialist consultations if needed, and conducting a thorough nursing assessment. This assessment includes reviewing vital signs, conducting a detailed medical interview, inspecting the oral cavity, and evaluating thromboembolic risk using the Caprini scale. The nurse also records the patient’s current medications and dosages, recommends compression therapy when indicated, and provides educational materials about the ERAS protocol. After the test results are obtained, the nurse performs an initial review and issues partial recommendations, such as suggesting vitamin D supplementation or referring for diabetic assessment if glucose or HbA1c levels are elevated. Regarding the educational and informational aspect of the visit, the nurse discusses all matters related to nursing care during hospitalization and conducts a motivational conversation about pre- and perioperative procedures.
In all patients, consultation with a psychologist is also provided. The psychological assessment focuses on offering emotional support and helping the patient cope with the stress of the diagnosis. Common goals include reducing anxiety related to surgery and hospitalization, and providing psychoeducation to promote adaptive coping strategies. The psychologist also supports smoking cessation and may offer brief crisis interventions if required.
The dietitian evaluates the patient’s nutritional status based on anthropometric measures (e.g., body mass index, BMI), screening tools (e.g., nutritional risk scale, NRS), body composition measurements, and laboratory test results. The goal is to identify malnutrition and, where necessary, introduce oral nutritional supplements. Patients are educated on proper dietary strategies. Follow-up monitoring is supported using digital tools such as food diaries and mobile applications.
The physiotherapy consultation focuses on preparing the patient physically for surgery. The physiotherapist introduces the role of physiotherapy in the perioperative period and explains the structure of the prehabilitation process. A functional assessment is performed using the 6-minute walk test or cardiopulmonary exercise testing (if required) to evaluate physical capacity. The physiotherapist proposes an exercise program aimed at improving overall fitness and thoracic mobility. The recommended exercises focus on enhancing the range of motion in the chest and shoulder girdle, improving respiratory function, and increasing general endurance. Simple daily activities – such as 20–40 minutes of walking at a moderate pace – are encouraged. The target intensity should be sufficient to raise heart and respiratory rates, while still allowing the patient to hold a conversation. Alternatives such as Nordic walking or outdoor/indoor cycling may be suggested, depending on the patient’s preference. In addition to aerobic training, the physiotherapist provides a structured set of thoracic mobility exercises (Table II), which are recommended to be performed 2–3 times per day. These exercises are simple, safe, and adapted to each patient’s capabilities. Regular practice before surgery ensures that patients become familiar with the movements, which facilitates their implementation in the early postoperative period. As a result, patients are more confident and engaged in their recovery, contributing to enhanced postoperative rehabilitation. The guiding principles of physiotherapy in the ERAS setting include clarity, consistency, and adaptability – ensuring that the exercises are easy to integrate into the patient’s daily routine without the need for excessive individualization.
Table II
Preoperative exercise protocol for ERAS: instructions for patients
The entire preoperative assessment concludes with a second meeting with the thoracic surgeon. During this final discussion, the results of all consultations are reviewed, any remaining questions are addressed, and the patient receives clear, personal recommendations for the preoperative period.
Throughout the entire process, the role of the administrative coordinator of the program is also important. In accordance with the recommendations of the MDT, the coordinator informs patients about the planned procedures, including the dates of their ERAS visit and hospital admission. In cases where inpatient rehabilitation is required for patients with poorer functional status, the coordinator arranges the necessary appointments and informs the patients accordingly. Additionally, the coordinator reminds patients of their upcoming visits shortly before the scheduled date, which improves patient flow and reduces missed appointments, thereby minimizing empty visit slots.
Self-preparation at home and in-hospital procedures
The period between the visit to the ERAS Clinic and surgical treatment is approximately two to three weeks. During this time, the patient is expected to follow the recommendations provided by the multidisciplinary team. If needed, additional consultations at the ERAS Clinic can be arranged, either in person or by telemedicine tools. Upon admission to the hospital, selected consultations and diagnostic tests are repeated, as necessary. The in-hospital phase of preoperative preparation is then carried out, followed by surgery and the early stages of postoperative care, as outlined previously in Table II. The entire ERAS pathway is subject to periodic audit and quality control, ensuring adherence to protocol standards and enabling continuous improvement in patient care.
Difficulties and limitations of the ERAS Clinic
The ERAS Clinic is a valuable component of preoperative preparation within the ERAS pathway. However, there are several limitations and challenges associated with its implementation.
Firstly, patients are required to attend the clinic in person, which may be difficult for those living far from the hospital. In such cases, remote (telemedicine) consultations may offer at least a partial solution.
Secondly, the visit to the ERAS Clinic can take several hours, which may be physically or emotionally demanding for some patients. Nevertheless, if the patient is properly informed in advance about the structure of the visit, the rationale for combining multiple consultations in a single day, and the overall benefits of the ERAS program, the visit is well accepted.
Thirdly, the clinic requires the coordinated involvement of multiple healthcare professionals. While this represents a logistical and organizational challenge, the benefits for patients – such as improved outcomes and reduced postoperative complications – justify the effort.
Lastly, in the context of the Polish healthcare system, ERAS Clinics are currently not reimbursed by the national health insurer. As a result, hospitals must cover most of the associated costs themselves. Given the proven benefits of ERAS programs, consideration should be given to including such clinics in standard insurance coverage.
Conclusions
Recent advances in thoracic surgery and oncology have had a significant positive impact on the outcomes of surgical treatment for lung cancer. The next step toward further improving results is the implementation of Enhanced Recovery After Surgery (ERAS) programs. The effectiveness of ERAS protocols has been well established across various surgical disciplines. In thoracic surgery specifically, studies have demonstrated that ERAS implementation leads to better early outcomes, including a lower rate of complications, shorter hospital stays, and reduced treatment costs.
Preoperative ERAS programs, delivered on an outpatient basis by a multidisciplinary team, enable optimal assessment and preparation for surgery. Although challenges exist — such as coordinating a multi-specialist team, the logistical demands of completing evaluations within a single day, and issues related to reimbursement — preoperative ERAS proves beneficial for both patients and healthcare institutions.
