The effect of early activity on postoperative patients with lung cancer: a systematic review and meta-analysis

Abstract

Background:

Early activity is recognized as a safe and effective therapeutic approach that offers benefits in accelerating the recovery of patients with lung cancer after surgery.

Objectives:

Data from studies that met the inclusion criteria were pooled to assess the impact of early activity on the prognosis of postoperative lung cancer patients, including duration of chest tube retention, length of hospital stay (LOS), incidence of complications, lung function, and 6-minute walking distance (6MWD).

Methods:

Electronic databases, including Web of Science, CINAHL, the Cochrane Library, EMBASE, PubMed, the Chinese BioMedical Literature Service System (SinoMed), WANFANG, CNKI, VIP databases, and Clinical Trial Register Platform were systematically searched from inception to March 11, 2026. Two researchers independently assessed study eligibility. Titles and abstracts were initially screened, followed by a full-text review of potentially eligible articles. Data extraction and risk of bias (RoB) assessment were performed for all studies meeting the eligibility criteria. Pooled outcomes were presented as mean differences (MDs) or risk ratios (RRs) with corresponding 95% confidence intervals (CIs).

Results:

Twenty-three studies involving 2,234 participants were included in the meta-analysis. The results demonstrated that early activity significantly improved postoperative outcomes in patients with lung cancer. It notably reduced the incidence of pulmonary complications, LOS, and duration of chest tube retention. Subgroup analysis of lung function outcomes showed that early activity significantly improved forced expiratory volume in the first second (FEV1), whereas no significant effect was observed for FEV1%. Regarding exercise capacity, early in-hospital activity alone significantly improved 6MWD; however, combining it with post-discharge programs yielded no significant benefit and showed substantial heterogeneity.

Conclusions:

This study’s findings underscore the significant role of early activity in the recovery of postoperative patients with lung cancer. While early in-hospital activity effectively reduced complications, chest tube duration, and LOS and improved FEV1, its effects on FEV1% and long-term exercise capacity remain uncertain due to inconsistent results and high heterogeneity in existing studies. Further large-scale, multicenter, randomized controlled trials (RCTs) are needed to strengthen these findings.

Systematic Review Registration:

https://www.crd.york.ac.uk/prospero/, identifier CRD42022333696.

1 Introduction

Lung cancer remains one of the most prevalent malignant tumors worldwide. According to Global Cancer Statistics 2022, it is the most frequently diagnosed cancer and ranked first in cancer-related mortality (1). For patients with early-stage lung cancer, surgery is the most effective treatment (2, 3). However, postoperative pulmonary problems, including respiratory failure, pneumonia, myocardial infarction, and arrhythmias, frequently occur (4, 5). Early postoperative symptoms such as pain and impaired respiratory function, coupled with complications like pulmonary infection and atelectasis, significantly hinder patient rehabilitation. Addressing these issues is essential to accelerate pulmonary recovery following thoracic surgery. Furthermore, lung resection surgery inherently diminishes exercise capacity (4, 6). Existing national and international enhanced recovery guidelines emphasize that early postoperative exercise reduces pulmonary complications and shortens the length of hospital stay (LOS) (7–10). Consequently, exercise training is increasingly recognized as an essential component of postoperative rehabilitation in lung cancer care.

The 2019 guidelines from the Enhanced Recovery After Surgery (ERAS) define early activity as getting out of bed within 24 hours after surgery (8). This immediate postoperative period represents a clinically important and time-sensitive window for recovery after lung cancer surgery. Mobilization within the first 24 hours may promote lung re-expansion, facilitate sputum clearance, improve circulation, reduce the risk of postoperative pulmonary complications, and support earlier chest tube removal and hospital discharge (11). Therefore, evidence specifically focused on activity initiated within this early postoperative window is important for guiding immediate postoperative nursing and rehabilitation practice.

To avoid conceptual ambiguity, we distinguished between “exercise”, “physical activity”, and “activity” in this review. Exercise generally refers to planned, structured, repetitive, and purposeful physical activity aimed at improving or maintaining physical fitness, whereas physical activity is a broader concept that includes bodily movement during daily living or rehabilitation (12). In contrast, the term “activity” or “early activity” in the present review refers to postoperative mobilization or activity-based interventions initiated within 24 hours after surgery.

In clinical practice, early activity interventions vary and may encompass respiratory training, ambulation, muscle strengthening, and aerobic exercise. Previous research indicates that exercise training improves postoperative outcomes for people with lung cancer (13). Systematic reviews of perioperative exercise therapies suggest that exercise significantly enhances functional capacity following pulmonary resection (14–17). However, findings in the literature remain inconsistent. For instance, a review conducted by Sommer et al. found that while postoperative exercise programs improved quality of life, their impact on exercise capacity remained inconclusive due to the limited scope of randomized controlled trials (RCTs) interventions (primarily strength and aerobic training) (18). Furthermore, other clinical studies have demonstrated that early activity can reduce postoperative complications (19), shorten the duration of chest drain retention (20), and improve lung function (21, 22).

Although early activity is recommended in ERAS pathways, the effectiveness of specific early activity interventions initiated within 24 hours after lung cancer surgery remains unclear (7–10). Furthermore, there is a lack of evidence synthesis specifically focusing on this immediate postoperative activity window (19–22). Therefore, this systematic review aimed to evaluate the effects of early activity—defined as structured postoperative activity initiated within 24 hours after surgery—on key postoperative recovery outcomes, including chest tube retention time, LOS, postoperative complications, pulmonary function, and exercise capacity.

2 Methods

The protocol for this systematic review was registered in the PROSPERO database (registration number: CRD42022333696). This review followed the methodological guidance of the Cochrane Handbook for Systematic Reviews of Interventions (Version 6.5) (23) and was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (24).

2.1 Information sources

A comprehensive literature search was conducted from database inception to 11 March 2026 across 10 electronic databases: Web of Science, CINAHL, the Cochrane Library, EMBASE, PubMed, the Chinese BioMedical Literature Service System (CBM), WANFANG, CNKI, VIP databases, and the Clinical Trial Register Platform. To identify additional eligible studies, we manually screened the reference lists of relevant systematic reviews and included studies. Where necessary, corresponding authors were contacted via email to retrieve missing data or clarify study details.

2.2 Search strategy

Prior to the formal literature search, an initial scoping search was conducted to identify relevant keywords and Medical Subject Headings (MeSH) contained in the titles and abstracts of relevant articles. The search strategy was developed by the first author in collaboration with an experienced medical librarian to ensure methodological rigor. The final search utilized a combination of MeSH terms and keywords, including “early rehabilitation”, “aerobic exercise”, “respiratory training”, “early exercise”, “lung tumors”, “lung cancer”, and combinations thereof. All eligible studies were included regardless of publication status or language (Supplementary Appendix 1).

2.3 Eligibility criteria

This review included RCTs featuring at least one control or comparison group. The specific inclusion criteria were as follows:

• Participants: patients with lung cancer undergoing curative-intent surgery, regardless of gender, age, ethnicity, or country;

• Interventions: early activity interventions, defined as any structured exercise or mobilization protocol initiated within 24 hours post-surgery, encompassing early ambulation, breathing exercises, aerobic activity, and muscle strength training, either alone or in combination. To account for variability, details of the interventions were extracted;

• Comparators: control groups that did not receive early activity interventions or received only conventional postoperative care;

• Outcomes: the primary outcomes included lung function and duration of chest tube retention. Secondary outcomes included LOS, incidence of complications, and six-minute walk distance (6MWD).

Exclusion criteria included: 1) duplicate publications identified across different databases; 2) studies with unavailable, incomplete or non-comparable outcome data; 3) studies including patients with severe comorbidities or coexisting conditions that could independently affect postoperative recovery, pulmonary function, exercise capacity, or the ability to participate in early activity, such as severe cardiopulmonary disease, serious musculoskeletal or neurological disorders, other malignancies, or cognitive impairment; and 4) studies including patients who received preoperative radiotherapy, because radiotherapy may independently affect pulmonary function, postoperative complications, and recovery outcomes, thereby confounding the effect of early activity.

2.4 Selection process

All retrieved records from the ten databases were imported into EndNote X9 for reference management and deduplication. The titles and abstracts of all records were then screened by two independent reviewers according to predefined eligibility criteria. Full-text articles of potentially eligible studies were subsequently assessed independently by both reviewers to confirm final inclusion. Any disagreements were resolved through discussion or, if necessary, consultation with a third reviewer.

2.5 Data collection process and data extraction

A standardized data extraction form, adapted from the Cochrane Handbook for Systematic Reviews of Interventions, was used to guide data collection (23). The adaptations primarily involved adding specific information regarding early activity interventions, such as the timing of the first postoperative activity (in hours), the specific surgical approaches, and the incidence of postoperative complications, etc. Two reviewers independently extracted the data, and any unresolved discrepancies were addressed by consulting a third reviewer. The form was pilot-tested on two included studies and subsequently refined to better align with this review’s requirements.

2.6 Quality assessment

The risk of bias of the included RCTs was assessed using the Cochrane risk of bias tool 2 (25). The assessment covered five domains: bias arising from the randomization process, bias due to deviations from intended interventions, bias due to missing outcome data, bias in measurement of the outcome, and bias in selection of the reported result. Each domain was judged as “low risk of bias”, “some concerns”, or “high risk of bias” according to the RoB 2 guidance, and an overall risk-of-bias judgement was assigned for each study. Two independent reviewers evaluated the overall quality of the evidence using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework. The evidence was ultimately categorized as high, moderate, low, or very low quality based on an assessment of five core domains: risk of bias, inconsistency, indirectness, imprecision, and publication bias (25). Any disagreements were resolved through discussion or, if necessary, consultation with a third reviewer.

2.7 Synthesis methods

Meta-analysis was performed using RevMan 5.2. A narrative synthesis was adopted for studies that could not be quantitatively pooled. Dichotomous outcomes were expressed as risk ratios (RRs) with 95% confidence intervals (CIs). Continuous outcomes were reported as mean differences (MDs) when the same measurement unit was used across studies (e.g., days for length of stay, meters for walking distance), and as standardized mean differences (SMDs, Hedges’g) when different scales or units were reported (e.g., lung function measured as FEV1 or FEV1%.

For model selection, given the clinical and methodological heterogeneity among the included studies (e.g., variations in specific early activity protocols), a random-effects model was selected a priori to pool the effect sizes. Heterogeneity was visually assessed using forest plots and further evaluated using the Cochrane’s Q test and I² statistics. The degree of heterogeneity was interpreted as follows: <25% indicated no heterogeneity, 25–50% low heterogeneity, 50–75% moderate heterogeneity, and ≥75% high heterogeneity. Subgroup analyses were predefined a priori to explore potential sources of heterogeneity. The predefined grouping variables included the timing of early activity initiation, the specific surgical approaches, and the types of intervention. Sensitivity analysis was performed by sequentially omitting individual studies to evaluate the robustness of the pooled results. Potential publication bias was evaluated when a minimum of 10 studies were included for a specific outcome (23), utilizing a combination of visual inspection through funnel plots and Egger’s test.

3 Results

3.1 Search results

The PRISMA flow chart of study selection is presented in Figure 1.

Figure 1

The initial search yielded 7,141 records from nine databases. After the removal of 2,742 duplicates, 4,399 records were remained for titles and abstracts screening, which resulted in the exclusion of 4,290 irrelevant records. Of the 109 articles assessed via full-text review, 86 were excluded: 84 due to inappropriate study design, irrelevant patient participants, or other mismatched criteria; and two due to inaccessible data. Ultimately, 23 studies met the inclusion criteria.

3.2 Characteristics of the included studies

The key characteristics of the 23 included studies are summarized in Table 1. The studies were published between 2004 and 2025 and included a total of 2,234 patients with lung cancer, with 1,119 allocated to early activity interventions and 1,115 to usual care. Most studies were conducted in China, while others were from the UK, Denmark, Australia, and Sweden. The sample sizes ranged from 15 to 300 participants. The included patients mainly underwent thoracoscopic surgery, thoracotomy, or lobectomy, although cancer stage and preoperative treatment were not consistently reported. Early activity interventions varied and included early ambulation, breathing exercises, respiratory muscle training, limb or resistance exercise. The main outcomes included chest tube duration, LOS, postoperative complications, lung function, and 6MWD.

3.3 Quality assessment of the included studies

Table 2 presents the risk-of-bias assessment of the 23 included studies using the ROB 2 tool. Overall, none of the studies were judged to be at low risk of bias. Four studies were rated as having a high overall risk of bias, mainly because of high risk in the randomization process, while the remaining 19 studies were judged as having some concerns. For the randomization process, five studies were rated as low risk, four as high risk, and the others as having some concerns. All studies were judged as having some concerns regarding deviations from intended interventions. Most studies had low risk for missing outcome data, but concerns remained in several studies. In addition, most studies were rated as having some concerns in the measurement of outcomes and selection of the reported results, largely because blinding and prespecified reporting information were insufficiently described. The GRADE assessment results are presented in Table 3. The evidence for the incidence of complications was rated as high quality, while the evidence for lung function and 6MWD was considered very low quality due to concerns regarding inconsistency.

3.4 Effectiveness of early activity intervention among patients with lung cancer

3.4.1 Lung function

Among the included studies, only seven trials reported the effect of early activity on lung function in patients with lung cancer (27, 33, 36, 37, 44, 46, 47). Specifically, five studies (36, 37, 44, 46, 47) used forced expiratory volume in the first second (FEV1), while two used FEV1%. Because the measurement units varied, the SMD was selected as the effect measure. Given the significant heterogeneity among studies (I² = 81%, p<0.001), subgroup analyses were performed. The results showed that early activity significantly improved FEV1 compared with the control group (SMD = 0.95, 95% CI: 0.60 to 1.30, p < 0.001). In contrast, the pooled effect for FEV1% was not statistically significant (SMD = 0.15, 95% CI: –0.20 to 0.50, p = 0.39) (Figure 2).

Figure 2

3.4.2 Duration of chest tube retention

Seven studies (28, 31, 39, 40, 42, 44, 45) analyzed the effect of early postoperative activity on chest tube duration, involving 911 patients (456 in the intervention group and 455 in the control group). As pre-planned, a random-effects model was used for the analysis. Substantial statistical heterogeneity was observed among the included studies (I² = 83%, p<0.001). Meta-analysis showed that the early postoperative activity group had a significant shorter chest tube duration than the routine activity group (MD=-1.28, 95% CI: -1.54 to -1.03, p<0.001) (Figure 3). To explore potential sources of heterogeneity, subgroup analyses were performed based on the timing of intervention initiation (6h vs. 24h) and surgical method (thoracoscopic vs. not mentioned), but no significant subgroup differences were observed (Supplementary Appendix 3, Supplementary e-Figures 1, 2).

Figure 3

3.4.3 LOS

Thirteen studies (28–32, 37–41, 43–45) analyzed the effect of early postoperative activity on LOS. Due to the presence of substantial heterogeneity (I² = 97%, p<0.001), a random effects model was employed. Meta-analysis showed that early postoperative activity significantly reduced patients’ LOS by an average of 3.22 days. (MD=-3.22, 95% CI: -4.05 to -2.38, p<0.001) (Figure 4).

Figure 4

Subgroup analyses were conducted to explore potential sources of heterogeneity. When stratified by the timing of early activity initiation, both the 6-hour subgroup (MD = –2.20, 95% CI: –2.75 to –1.65) and the 24-hour subgroup (MD = –4.03, 95% CI: –6.02 to –2.04) showed significant reductions in LOS, although the effect appeared more pronounced in the 24-hour subgroup.

Stratification by surgical approach indicated that studies involving thoracoscopic surgery (MD = –2.20, 95% CI: –2.75 to –1.65), those that did not specify the approach (MD = –4.03, 95% CI: –6.02 to –2.04), and those including both open and thoracoscopic surgery (MD = –5.50, 95% CI: –7.59 to –3.41) all favored early activity. Significant subgroup differences were observed (p = 0.003).

Additionally, analysis by type of intervention revealed that walking alone (MD = –4.76, 95% CI: –5.72 to –3.80), walking combined with breathing exercises (MD = –2.13, 95% CI: –2.41 to –1.85), and integrated intervention programs (defined as multi-component protocols combining three or more distinct modalities, such as early ambulation and limb resistance exercises) (MD = –3.05, 95% CI: –4.10 to –2.00) were all effective. Furthermore, significant subgroup differences (p<0.001) were found (Supplementary Appendix 3, Supplementary e-Figures 3–5).

Sensitivity analysis was performed by sequentially excluding individual studies and reanalyzing the data. The I² values did not change significantly, and the pooled effect sizes remained consistent with those of the original meta-analysis. These findings indicate that the results are robust and not driven by any single study. However, further high-quality trials are warranted to strengthen these conclusions.

3.4.4 Incidence of complications

Fifteen studies (27–32, 35, 37–39, 41–43, 45, 46) reported postoperative complication rates, specifically investigating the incidence of pneumonia and atelectasis. The result showed a significant difference between the intervention and control groups, confirming that early postoperative activity significantly reduced the incidence of pulmonary complications (RR = 0.33, 95% CI: 0.25 to 0.44, p<0.001) (Figure 5).

Figure 5

3.4.5 6MWD

The 6MWD is an essential indicator of exercise capacity in patients with lung cancer. Five studies reported the 6MWD following the interventions (22, 27, 31, 37, 38). Subgroup analyses were performed based on the duration and setting of the intervention: short-term interventions (solely in-hospital early activity) and long-term interventions (in-hospital early activity combined with post-discharge home exercise).

For the subgroup receiving in-hospital early activity alone, the difference in 6MWD between the two groups was statistically significant (p = 0.02, I² = 77%). However, when in-hospital early activity combined with home exercise, the difference in 6MWD between the two groups was not statistically significant (p = 0.22, I² = 95%) (Figure 6).

Figure 6

3.5 Publication bias

Publication bias was not detected through the visual evaluation of funnel plots (Figure 7) and this was further confirmed by Egger’s test for both LOS (p=0.092) and incidence of complications (p = 0.397).

Figure 7

4 Discussion

4.1 Main findings

To determine the effect of early activity on the prognosis of postoperative lung cancer patients, this study analyzed 23 RCTs with 2,234 patients. The main findings were that early activity reduced chest tube duration and LOS, reduced the incidence of pulmonary complications, and improved lung function and exercise capacity, effectively improving patient prognosis.

The results of this study are not entirely consistent with previous research (48–50). Specifically, previous literature has reported mixed or inconclusive effects regarding postoperative interventions. For instance, while Ahn et al. demonstrated that structured inpatient exercise significantly reduced LOS, their study was limited to colon cancer patients whose primary recovery metric was bowel motility. More notably, a recent meta-analysis by Xu et al. investigating lung cancer concluded that while preoperative interventions were effective, short-term postoperative rehabilitation alone did not significantly reduce postoperative pulmonary complications or LOS. Similarly, the systematic review by Castelino et al. found conflicting and insufficient evidence to confirm that early mobilization protocols significantly improved outcomes or reduced complications across general abdominal and thoracic surgeries. These discrepancies may be explained by several factors. First, there is heterogeneity in outcome definitions (e.g., complications are classified differently across studies). Second, there is variation in the operational definition of “early activity”, ranging from ambulation alone to combined respiratory and strength training. Third, differences exist in study populations, including baseline functional status and comorbidities. Finally, geographic distribution may play a role, as 16 of the 23 studies in our review were conducted in Asian countries, where clinical practice patterns and perioperative care pathways may differ from those in Western countries. Taken together, these contextual differences likely contribute to the variability in reported outcomes across studies and should be considered when interpreting our findings.

4.2 Effects on lung function

Although early postoperative activity improves lung function, the effects are not uniform across different indicators. Subgroup analysis revealed that early activity significantly improved absolute FEV1, indicating a meaningful enhancement in ventilatory capacity; however, no statistically significant improvement was observed for FEV1%. The lack of effect on FEV1% may be attributed to inherent variability in the prediction equations used, alongside differences in individual baseline characteristics (e.g., age, sex, and height). These confounding factors limit cross-study comparability and consequently reduce the sensitivity of this metric in detecting subtle changes during postoperative rehabilitation.

Notably, one study (36) reported a particularly large effect size for FEV1, which was greater than those of the other included studies. This unusually large effect may be explained by the specific intervention design, which focused on systematic early respiratory function training. Compared with the simple ambulation protocols employed in other trials, this targeted approach may have led to greater short-term improvements in FEV1. Additionally, the study was conducted in a single center with high intervention adherence, which could have amplified the observed benefit. While these findings support the potential value of structured respiratory training, they also contributed substantially to the statistical heterogeneity in the pooled analysis and should be interpreted with caution.

4.3 Effects on chest tube duration and LOS

Early activity after lung cancer surgery reduces chest tube duration and LOS. Chest tube duration is universally recognized as an essential indicator of postoperative recovery in patients with lung cancer. Prolonged retention can lead to complications such as infection, subcutaneous emphysema, and pulmonary atelectasis (51). The results of this study showed that early activity after lung cancer surgery significantly shortened chest tube duration and decreased LOS, which was crucial for promoting rapid postoperative recovery.

Subgroup analyses further indicated that early initiation within 6 hours was associated with particularly consistent benefits and minimal heterogeneity, while significant effects were also observed at 24 hours and in thoracoscopic cases, though with greater variability between studies. Moreover, subgroup analyses of LOS further revealed that both very early (within 6 hours) and early (within 24 hours) mobilization significantly reduced LOS, with more pronounced effects observed in the 24-hour subgroup. Benefits were also consistent across different surgical approaches (thoracoscopic, open plus thoracoscopic, or not reported) and across various intervention types (walking alone, walking plus breathing exercises, or integrated programs), though the magnitude of effect varied. These findings suggest that both the timing and the content of early activity, as well as the surgical approach, may influence recovery outcomes and partly explain the heterogeneity among studies.

Physiologically, early postoperative physical activity programs can facilitate the expulsion of fluid and gas from the chest cavity and promote lung re-expansion, thereby shortening chest tube duration. However, from a psychological perspective, getting out of bed within 24 hours poses a considerable challenge. Patients often express a strong preference for bed rest, driven by conventional beliefs, incisional pain, and fears of accidentally dislodging their chest drainage tubes during movement (52). To overcome these barriers, clinical practice must adopt a comprehensive approach. Nurses should provide robust preoperative education detailing the specific exercises, frequency, and overall importance of early physical activity to enhance compliance. Simultaneously, raising awareness among families, implementing effective pain management strategies, and equipping hospital wards with appropriate mobility aids are essential steps to alleviate patient fears and facilitate safe, effective early postoperative mobilization (53).

4.4 Effects on pulmonary complications

Although surgical resection remains the primary curative treatment for lung cancer, postoperative pulmonary complications such as pneumonia, arrhythmia, and pulmonary atelectasis are not uncommon and affect patient prognosis. The results of this study show that early activity after lung cancer surgery can effectively reduce the incidence of these postoperative complications, which aligns with the findings reported by Zhang (44). Specifically, multi-component interventions that combined early ambulation with structured respiratory exercises proved to be highly effective. The potential mechanisms contributing to these positive effects likely include the enhanced clearance of airway secretions, improved ventilation-perfusion matching, and the recruitment of collapsed alveoli, which directly counteract the respiratory impairments caused by surgical trauma and anesthesia. Clinically, these findings highlight the necessity of moving beyond traditional bed rest by implementing standardized, early mobilization protocols that pair breathing exercises with walking within the first 24 hours. Future research should focus on determining the optimal dose-response relationship, evaluating the specific intensity, frequency, and duration of early activity required to maximize the reduction of these postoperative complications.

4.5 Effects on exercise capacity

Exercise capacity in this review was mainly assessed using the 6MWD. Overall, the included studies suggested that early activity may help preserve or improve postoperative exercise capacity; however, the findings were not completely consistent across studies. Some trials reported improvements in 6MWD after early activity or rehabilitation-based interventions, whereas others found no significant between-group difference. This inconsistency may be explained by differences in intervention content, intensity, supervision, duration, follow-up time, baseline physical function, and surgical approach.

The 6MWD is a simple and widely used measure of functional exercise capacity, reflecting the patient’s ability to perform daily physical activity. A change in 6MWD is clinically relevant because previous lung cancer research has suggested that the minimal important difference for deterioration in 6MWD is approximately 22–42 m, or about 9.5% (54). Therefore, improvements or smaller postoperative declines in 6MWD may indicate better functional recovery, although statistical significance alone should not be interpreted as clinical significance.

Based on the included studies, interventions that may be more likely to improve exercise capacity include multicomponent programs combining early ambulation, respiratory training, progressive walking, limb or resistance exercises, and continued supervised or semi-supervised rehabilitation after discharge. In contrast, brief low-intensity mobilization during hospitalization alone may be insufficient to produce a measurable improvement in 6MWD, especially when the intervention duration is short or patients have relatively good baseline exercise capacity.

Clinically, these findings suggest that early activity should not be limited to simply encouraging patients to get out of bed. Instead, postoperative activity should be individualized, progressive, supervised when possible, and integrated with respiratory and strength-based components. Future studies should standardize the reporting of intervention dose, intensity, supervision, adherence, and follow-up duration, and should report whether changes in 6MWD exceed clinically meaningful thresholds.

5 Strengths and limitations

The primary strength of this meta-analysis is its focus on early activity in the context of ERAS. Additionally, to comprehensively evaluate the impact of early mobilization on patient prognosis following lung cancer surgery, we searched both English and Chinese electronic databases and analyzed five outcomes. Moreover, our review was conducted strictly following the PRISMA guideline.

However, this meta-analysis has certain limitations. First, the majority of the included studies were single-center trials with relatively small sample sizes, which may have resulted in an overestimation of effect sizes. Most studies were conducted in China, and clinical practices, perioperative care pathways, discharge policies, and patient characteristics may differ across countries and healthcare systems. Therefore, the generalizability of these findings to other clinical settings and populations may be limited. In addition, some outcomes were supported by only a small number of studies. For example, the analysis of exercise capacity, assessed using 6MWD, included only five studies with limited sample sizes. Therefore, the findings for 6MWD should be interpreted with particular caution and should be considered exploratory rather than definitive.

Second, the potential impact of performance and detection bias should be considered. Because early activity interventions are difficult to blind, most included studies did not blind participants, healthcare providers, or outcome assessors. This may have influenced patient behavior, provider encouragement, co-interventions, and outcome assessment, particularly for subjective or judgement-based outcomes such as complications, pain, quality of life, and functional recovery. Even relatively objective outcomes, such as LOS and chest tube duration, may still be affected by clinical decision-making and institutional practice. Therefore, the observed benefits may have been overestimated and should be interpreted with caution.

Third, significant clinical and statistical heterogeneity was observed among the included studies, particularly for LOS, chest tube duration, and 6MWD. Importantly, the definition and implementation of “early activity” varied substantially across studies, which may have influenced the pooled results. Although all interventions were initiated within the first 24 postoperative hours, the intervention components varied considerably, ranging from simple ambulation to combined respiratory training, strength training, and aerobic exercise. Additional variability arose from differences in sample size, baseline patient characteristics, surgical techniques, perioperative ERAS pathways, intervention duration, supervision, adherence, and outcome measurement methods. For LOS and chest tube duration, heterogeneity may also have been influenced by institutional discharge policies, chest tube removal criteria, and local clinical practice patterns. For 6MWD, the small number of included studies and differences in follow-up duration and post-discharge exercise protocols further limited the certainty of the findings. Although subgroup analyses and random-effects models were used to explore or account for heterogeneity, these approaches could not fully explain the observed variability. Therefore, the pooled estimates for these outcomes should be interpreted cautiously, especially regarding the magnitude of effect rather than only the direction of benefit. Additionally, although we used two independent reviewers for study selection, data extraction, and risk of bias assessment to improve the reliability and consistency of the review process and to minimize reviewer errors, the pooled results should nevertheless be interpreted with caution given the overall risk of bias and substantial heterogeneity among the included studies.

Future research should focus on large-scale, multicenter RCTs with more rigorous designs and standardized early mobilization protocols to validate the clinical benefits of this approach.

6 Conclusion

In conclusion, this systematic review demonstrates that early activity significantly reduces the incidence of pulmonary complications, shortens chest tube duration, and decreases LOS in patients recovering from lung cancer surgery. Furthermore, early activity also improves lung function, particularly absolute FEV1, while no significant effect was observed for FEV1%.

Regarding exercise capacity, limited evidence from five studies suggests that short-term early in-hospital activity may be associated with improved 6MWD, whereas the combination of early in-hospital activity and home exercise programs did not show a significant benefit and was accompanied by substantial heterogeneity. Therefore, conclusions regarding exercise capacity should be interpreted with caution. These results suggest that while in-hospital mobilization is beneficial, the long-term effects of combined programs remain uncertain, largely due to variability in intervention protocols and patient adherence. Future large-scale, multicenter RCTs with standardized definitions and protocols for early activity are needed to provide more robust evidence and to clarify both the isolated and long-term effects of these interventions in this patient population.

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