Effects of Supervised Aerobic Exercise on Biomarkers in Patients With nSCLC Receiving Immunotherapy

A total of 78 patients with NSCLC receiving active immunotherapy and meeting the predefined eligibility criteria will be enrolled. Participants assigned to the intervention group will perform supervised aerobic exercise on a cycle ergometer twice weekly for 24 weeks. Each session will consist of 5 minutes of warm-up, 30 minutes of aerobic exercise, and 5 minutes of cool-down. Exercise intensity will be prescribed based on estimated maximal oxygen consumption (VO₂max) and progressively increased from 60% during weeks 1-6 to 65% during weeks 7-12, 70% during weeks 13-18, and 75% during weeks 19-24. The exercise program will be implemented in accordance with the American College of Sports Medicine (ACSM) recommendations for exercise oncology. Assessments will be performed at baseline, 12 weeks, and at the end of 24 weeks. The primary outcomes will be immune system- and tumor microenvironment-related biomarkers which will be analyzed via ELISA system (CXCL9, CXCL11, CCL2, CCL5, IFN gamma and IL-10). Immune cells (NK cells, T and B lymphocytes, CD3+, CD4+, CD8+, CD19+, CD16/56+) will also be analyzed via flow-cytometry. Secondary outcomes will include handgrip strength, peripheral muscle strength, quality of life, fatigue, and cardiorespiratory capacity. Progression-free survival will also be evaluated as an exploratory clinical outcome. This study aims to provide prospective evidence regarding the potential immunomodulatory and tumor-related effects of structured aerobic exercise during active immunotherapy and to contribute to the development of individualized supportive exercise strategies for patients with NSCLC.

• Exercise (Other), also known as Aerobic stationary resistive cycle ergometer: A resistance-based aerobic exercise program using a stationary bike will be implemented twice a week for a total of 24 weeks. Each session will last a total of 40 minutes, consisting of a 5-minute warm-up, a 30-minute exercise period, and a 5-minute cool-down. The moderate-intensity range (60-75% of VO₂max) is defined as the optimal range that is both safe and conducive to physiological adaptation. Exercise intensity will initially be determined based on the estimated VO2max value calculated from each individual's 6-Minute Walk Test result. Based on the clinical value obtained, the initial exercise intensity will be set, and during exercise, heart rate reserve (Karvonen formula) and the Borg Perceived Exertion Scale (target range of 11-14) will be monitored together; if the intensity becomes intolerable, it will be reduced by 5%. If an immune-related adverse event occurs, the exercise will be temporarily suspended.

Primary outcomes

• Analysis of Serum Biomarkers (Serum CXCL9,CXCL11,CCL2,CCL5,IFN-γ,IL-10 concentration) [Before immunotherapy, week 12 and week 24]: Serum CXCL9,CXCL11,CCL2,CCL5,IFN-γ,IL-10 concentrations will be measured using ELISA. Results will be expressed in pg/mL.
• Assesment of Absolute CD3+ , CD4+ , CD8+ , CD19+ T-lymphocyte counts, CD16/56+ Natural Killer cells [Before immunotherapy, week 12 and week 24]: Absolute CD3+ , CD4+ , CD8+ , CD19+ T-lymphocyte counts, CD16/56+ Natural Killer cells will be assessed by flow cytometry using the BD Multitest™ 6-Color TBNK reagent and BD FACSLyric™ flow cytometer. Absolute counts will be calculated using a dual-platform approach incorporating routine complete blood count data. Results will be expressed in cells/µL.
• Analysis of Handgrip Strength [Before immunotherapy, week 12 and week 24]: Handgrip strength will be evaluated via hand dynamometer while one is upright seated in an armless chair, elbow flexed 90 degree and forearm positioned at midprone. Three repetitions will be collected, the mean of them will be recorded. Handgrip strength will be recorded as kilogram (kg).
• Peripheral muscle strength [Before immunotherapy, week 12 and week 24]: Participants' peripheral muscle strength will be assessed using a digital hand dynamometer (LaFayette Manual Muscle Tester) to measure knee extension of the quadriceps femoris muscle, with three repetitions on each side; measurements will be recorded in Newtons. Peripheral muscle strength will be recorded as Newton (N).
• Cardiorespiratory endurance assessment [Before immunotherapy, week 12 and week 24]: Cardiorespiratory endurance will be evaluated via the six minute walk test and total walking distance will be recorded in meters (m).

Secondary outcomes

• Assessment of Quality of Life [Before immunotherapy, week 12 and week 24]: Participants' quality of life will be assessed using the European Organization for Research and Treatment of Cancer to assess health-related quality of life in patients with lung cancer questionnaire (EORTC-QLQ-LC29), which was developed specifically for lung cancer patients by the European Organization for Research, Treatment and Cancer and has been proven to be valid and reliable. Higher scores indicate worse quality of life. The minimum and maximum values are ranged between 0 and 100.
• Fatigue Assessment [Before immunotherapy, week 12 and week 24]: Fatigue will be assessed using the European Organization for Research and Treatment of Cancer to assess fatigue in patients with cancer (EORTC-QLQ-FA12).Higher scores indicate higher perceived fatigue. The minimum and maximum values are ranged between 0 and 100.
• Body fat percentage [Before immunotherapy, week 12 and week 24]: Body fat percentage will be evaluated via Tanita-BC-420 MA. It will be recorded as %(percentage).
• Skeletal Muscle Mass [Before immunotherapy, week 12 and week 24]: Skeletal Muscle Mass will be evaluated via Tanita-BC-420 MA. It will be recorded as kilogram (kg).
• Fat free mass [Before immunotherapy, week 12 and week 24]: Fat free mass will be evaluated via Tanita-BC-420 MA. It will be recorded as kilogram (kg).
• Mental status assessment [Before immunotherapy, week 12 and week 24]: Mental status assessment will be performed via Mini Mental State Examination test. It consists of five domains: orientation (10 points), registration (3 points), attention and calculation (5 points), recall (3 points), and language and visuospatial abilities (9 points). The total score ranges from 0 to 30, with higher scores indicating better cognitive function. Score interpretation is as follows: 24-30 indicates normal cognitive function; 18-23 indicates mild cognitive impairment; 10-17 indicates moderate cognitive impairment; and 0-9 indicates severe cognitive impairment.
• Analysis of Progression-free survival [From enrollment until the end of the 24-month follow-up period]: Progression free survival will be performed during the study's timeframe.

Sex: All, ages: 18 Years to 75 Years

Inclusion Criteria:

* Be willing to participate in the study
* Have been diagnosed with nSCLC and be a candidate for immunotherapy
* Having ability to read, write, and communicate in Turkish or English

Exclusion Criteria:

* Presence of orthopedic (nerve compression, joint deformity, nerve damage, etc.) and/or neurological (ataxia, history of cerebrovascular events, etc.) deficits or disabilities that would prevent the patient from exercising
* A history of distant metastases diagnosed by a physician and confirmed by imaging studies
* Presence of mental and/or cognitive impairment
* Use of antiepileptic medications
* Pregnancy
* A tendency to bleed (thrombocytopenia)
* Diagnosis of small cell lung cancer

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• Alper Tuğral, Assoc.Prof, Principal investigator, Izmir Bakircay University
• Gözde Kaya Uçar, Assist.Prof, Study chair, Izmir Bakircay University
• Murat Akyol, MD, Prof., Study chair, Izmir Bakircay University
• Melih Zeren, Assoc.Prof, Study chair, Izmir Bakircay University
• Fatma D Arslan, MD, Prof., Study chair, Izmir Bakircay University
• Mutlu O Güçsav, MD, Study chair, Izmir Bakircay University
• Rasime D Kılıçoğlu, MD, Study chair, Izmir City Hospital
• Ezgisu Türker, PT, Study chair, Izmir Bakircay University