Lung cancer was the second most prevalent cancer worldwide in 2020, as well as the leading cause of cancer-related death (Sung et al., 2021). Several treatment options are available for this disease; however, surgical resection is an intervention with a favorable prognosis when patients are eligible (Goldsmith et al., 2021; Machado et al., 2023). The indication for surgery in lung cancer cases is expected to increase by approximately 60% by 2040 (Perera et al., 2021). The goal of the surgical procedure is to achieve adequate tumor resection while preserving viable lung tissue (Rotman et al., 2015; Tegegne et al., 2021). Although pulmonary resection improves survival rates, it is associated with significant postoperative complications that affect the quality of life, including physical limitations such as pain, fatigue, and dyspnea (Machado et al., 2023; Motono et al., 2021; Pu et al., 2021; Van et al., 2018). These complications are the primary causes of morbidity and mortality, leading to prolonged hospitalization and increased healthcare costs (Tegegne et al., 2021; Fernandes et al., 2019).

International Enhanced Recovery After Surgery (ERAS) guidelines were established to minimize complications associated with surgical procedures (Batchelor et al., 2019). These guidelines incorporate multimodal, evidence-based interventions during the preoperative, intraoperative, and postoperative periods to shorten hospital stays, reduce postoperative complications, and lower associated healthcare costs (Machado et al., 2023; Van et al., 2018; Batchelor et al., 2019; Mendes et al., 2018). According to these recommendations, in the preoperative period, which is the focus of this review, the ERAS program emphasizes patient education, stress reduction, pain management optimization, physical exercise, nutrition, and improving functional status (Batchelor et al., 2019; Mendes et al., 2018; Haywood et al., 2020; Montagne et al., 2021). This approach is referred to as prehabilitation.

Prehabilitation, an emerging concept, can involve either unimodal or multimodal approaches tailored to each person’s individual needs (Silver, 2015; Silver and Baima, 2013; Carli et al., 2017). It is a process within the continuum of care between the moment of diagnosis and the initiation of treatment. This process includes physical and psychological assessments to establish baseline functional levels, identify needs, and provide specific interventions to improve the person’s health. The goal is to reduce the incidence and severity of current and future health issues (Silver, 2015; Silver and Baima, 2013; Carli et al., 2017). In the surgical context, prehabilitation aims to enhance preoperative functional reserve, leading to improved and faster postoperative recovery and a reduction in complications (Pu et al., 2021; Carli et al., 2017).

By enhancing individuals' functional capacity and encouraging active involvement in their own care, prehabilitation has demonstrated positive outcomes for both patients and healthcare systems. This proactive approach not only prepares people physically and psychologically for surgery but also contributes to more efficient hospital management—facilitating smoother patient flow, reducing the need for critical care beds, and shortening hospital stays.

Recent studies have reported improved postoperative outcomes, including in individuals undergoing cancer surgery, highlighting benefits at multiple levels, such as reduced complication rates, quicker recoveries, more efficient care transitions, and a significant reduction in hospital length of stay (Daniels et al., 2020; Gillis et al., 2018; Hughes et al., 2019; Moran et al., 2016).

Two recent syntheses have consolidated the evidence base: a review of exercise-based prehabilitation in people with non-small cell lung cancer (Granger and Cavalheri, 2022) and an overview of reviews focusing on exercise across the lung cancer care continuum (Edbrooke et al., 2023). Building on these contributions, this scoping review adopts a complementary, practice-oriented lens to map preoperative prehabilitation components in adults with lung cancer scheduled for thoracic surgery, detailing what is delivered and how it is delivered, so that readers can clearly understand the interventions in practice. Accordingly, this review aims to identify preoperative rehabilitation interventions for individuals with lung cancer undergoing thoracic surgery and to describe their content and delivery to inform clinical implementation.

Scoping reviews are most appropriate when the aim is to identify and map characteristics or concepts across studies and to report and discuss these features, rather than to answer a single, narrowly framed question (Munn et al., 2018). In line with this, we selected a scoping review to map what is delivered and how it is delivered in preoperative prehabilitation for lung cancer surgery across different studies and reporting formats, enabling comprehensive charting of the literature to inform implementation.

This scoping review was conducted using the methodology of Arksey and O’Malle (2007), which comprises five stages. This approach was chosen for its flexibility and adaptability, allowing tailoring to the review’s specific aims (Arksey and O’Malley, 2007). Methods are reported in accordance with the PRISMA-ScR statement (Haddaway et al., 2022). No protocol for this scoping review was publicly registered.

This scoping review systematically mapped preoperative prehabilitation interventions in adults with lung cancer undergoing thoracic surgery, detailing what is delivered and how it is delivered. The included studies most often described multimodal programs combining aerobic endurance training and resistance training with respiratory training (Lai et al., 2017a; Lai et al., 2017b; Liu et al., 2020; Ferreira et al., 2021a; Ferreira et al., 2021b; Sebio et al., 2017; Licker et al., 2017). In contrast, Yang et al. (2018), Huang et al. (2024), Wang et al. (2020), and Kökez et al. (2023) referred only to respiratory exercise as a training component.

Within these programs, aerobic endurance training aims to increase aerobic capacity by improving the cardiovascular, respiratory, and musculoskeletal systems (Machado et al., 2021). On the other hand, resistance training focuses on improving muscle contraction against external resistance, enhancing muscular endurance (Machado et al., 2021). Respiratory training aims to increase maximum inspiratory pressure, helping to control dyspnea and improve alveolar ventilation (Ordem dos Enfermeiros, 2018).

Regarding intensity prescription, most authors (Lai et al., 2017a; Lai et al., 2017b; Wang et al., 2020; Chen et al., 2023; Ferreira et al., 2021b; Sebio et al., 2017; Gravier et al., 2022; Machado et al., 2024) used the relationship between perceived effort and the load applied, employing the Borg scale, which is a valid and reliable indicator for monitoring exercise tolerance (Machado et al., 2021). However, in the study by Licker et al. (2017), it was determined that exercise power using power meters in watts allowed for measuring instantaneous changes and controlling effort more specifically (Robinson et al., 2011). This type of device is costly, which was reported as a limitation. When compared to measuring intensity by heart rate, Robinson et al. (2011) argued that there were no significant advantages in using power meters for average recreational performance, suggesting that low-cost heart rate monitors are equally capable of functioning as training monitoring devices.

The respiratory training interventions (Lai et al., 2017a; Huang et al., 2024; Sebio et al., 2017; Fernández-Blanco et al., 2023; Tenconi et al., 2021; Kökez et al., 2023) aligned with the goals of respiratory functional reeducation (Dias et al., 2022). These goals include improving ventilation and lung re-expansion, clearing the airways through the mobilization and expulsion of secretions, enhancing oxygenation and gas exchange, increasing thoracic mobility, re-educating respiratory muscles, and boosting muscular strength and endurance. These effects contribute to the prevention of complications and promote pulmonary recovery. Notably, Fernández-Blanco et al. (2023), mentioned aerosol sessions, although they did not specify the rationale or outcomes. Additionally, Kökez et al. (2023) noted the application of BiPAP within the scope of the preoperative rehabilitation program, which was aimed at improving pulmonary mechanics.

Consistent with prior reviews (Granger and Cavalheri, 2022; Edbrooke et al., 2023; Voorn et al., 2023), the evidence supports prehabilitation as beneficial, yet substantial heterogeneity limits firm guidance on the optimal duration, intensity, structure, and patient selection. This heterogeneity spans procedure, program design, exercise prescription and outcome definitions. Together, these differences likely dilute pooled effects and make cross-study comparisons difficult.

Relaxation strategies and emotion-regulation interventions were identified across several studies (Liu et al., 2020; Chen et al., 2023; Liu et al., 2024; Ferreira et al., 2021a; Ferreira et al., 2021b; Brat et al., 2025), Mindfulness was examined by Liu et al. (Chen et al., 2023), who compared a stand-alone conscious breathing protocol with a combined approach that also included rehabilitation guidelines. Although the rehabilitation guidelines were not specified, both approaches demonstrated a reduction in anxiety, improvement in emotional resilience, and optimization of postoperative recovery. However, the combined group was not more effective than the isolated group. This type of training allowed for establishing respiratory rhythms, regulating respiratory disturbances, and improving gas exchange.

These observations are consistent with previous syntheses, which note that many lung-cancer prehabilitation packages include psychoeducational and anxiety-reduction components—for example, guided breathing/relaxation, mindfulness, or brief coping skills—although reporting of dose and delivery is often limited (Edbrooke et al., 2023). This is likely important because preoperative anxiety is common and prognostically relevant, being associated with higher postoperative pain, poorer quality of life, and longer recovery; brief psychological modules are low-cost, feasible in short preoperative windows, and may enhance adherence to exercise and nutrition. Consequently, embedding a minimum psychological bundle (clear education plus a simple relaxation/breathing routine and basic coping guidance) within multimodal prehabilitation is justified, while future trials should specify content and dose, monitor fidelity, and test mediators such as anxiety or self-efficacy to clarify mechanisms of benefit.

Nutrition remains under-reported in operational terms despite its prominence in ERAS (Batchelor et al., 2019). Malnutrition and/or preoperative weight loss are important predictors of postoperative complications (Batchelor et al., 2019; Asakawa et al., 2024; Campbell et al., 2023). Accordingly, nutritional and rehabilitation interventions, the goal is to reduce the incidence of postoperative complications and improve prognosis (Asakawa et al., 2024; Campbell et al., 2023). Where specified, teams used screen-and-treat pathways that triggered targeted supplementation and individualized dietetic plans. Liu et al. (2020), Ferreira et al. (2021a), and Gravier et al. (2022) incorporated formal nutritional assessment with supplement adjustments as indicated. Liu et al. (2020) recommended the intake of whey protein at 1.5 g/kg/day, which aligns with recommendations from other international studies; however, the dosage should be tailored to the individual’s needs, based on prior assessment, with a range of 1.0–1.6 g/kg/day (Asakawa et al., 2024; Campbell et al., 2023; Deutz et al., 2014).

The importance of preoperative education was also emphasized in previous studies (Mendes et al., 2021) stated that through preoperative nursing consultations, change is promoted by improving processes and outcomes. This leads to better preparation, more information, and greater collaboration. Several studies also mentioned this practice as part of the rehabilitation process (Liu et al., 2020; Huang et al., 2024; Chen et al., 2023; Ferreira et al., 2021a; Fernández-Blanco et al., 2023; Kökez et al., 2023), an integral component of the preoperative plan.

It is also noteworthy that several studies (Liu et al., 2020; Huang et al., 2024; Chen et al., 2023; Ferreira et al., 2021a; Gravier et al., 2022; Licker et al., 2017) advocated for smoking cessation and alcohol abstinence, which aligns with international recommendations (Mendes et al., 2018). These guidelines emphasize that both alcohol consumption and smoking are associated with increased morbidity and mortality risk and should be discontinued, ideally 4 weeks before surgery (Batchelor et al., 2019).

The analysis of the selected articles also demonstrates that prehabilitation plans can be implemented at the rehabilitation center and home or even simultaneously. Considering the assumptions of the training, it is understood that the included studies used their interventions to improve functional capacity and aerobic function, as well as to reduce fatigue (Lai et al., 2017a; Liu et al., 2020; Chen et al., 2023; Sebio et al., 2017; Fernández-Blanco et al., 2023; Tenconi et al., 2021; Licker et al., 2017). Furthermore, studies by Lai et al. (2017b), Tenconi et al. (2021), Sommer et al. (2016), and Kökez et al. (2023) demonstrated a reduction in postoperative complications. In the interventions established by Lai et al. (2017a), Lai et al. (2017b), Fernández-Blanco et al. (2023), and Kökez et al. (2023), a reduction in hospitalization time was demonstrated, as well as a decrease in hospital costs (Lai et al., 2017b; Yang et al., 2018). In addition to physical benefits, studies identified improvements in both quality of life (Lai et al., 2017a; Wang et al., 2020; Gravier et al., 2022; Machado et al., 2024) and a reduction in anxiety (Liu et al., 2020; Huang et al., 2024; Chen et al., 2023; Machado et al., 2024). However, Sommer et al. (2016) reported no benefits from their preoperative intervention. This was due to the reduced sample size and the fact that the program lasted 4 weeks, while the country’s guidelines required people to be operated on within 2 weeks, making it unfeasible to meet the proposed timeframe.

Overall, our map of preoperative prehabilitation components accords with prior syntheses showing benefit signals for prehabilitation in lung cancer while highlighting operational details that earlier reviews did not emphasize. Previous reviews also concluded that prehabilitation is promising yet heterogeneous, making optimal duration, intensity, structure, and patient selection uncertain. Our findings complement these conclusions by describing how interventions have been delivered in recent trials, thereby addressing a recognized gap in implementation-oriented reporting.

This review has clear implications for clinical practice. It shows that prehabilitation should be included as a routine part of care for individuals with lung cancer undergoing thoracic surgery. The evidence suggests combining physical training (aerobic endurance, resistance, and respiratory training), nutritional support, preoperative education, and relaxation/emotion-regulation can improve outcomes. This means developing personalized exercise programs to increase physical capacity, offering preoperative consultations to reduce anxiety and improve patient engagement, and assessing nutritional needs with appropriate supplementation. It is also recommended to support smoking cessation and alcohol abstinence ideally 4 weeks before surgery. Psychological support, including breathing training and mindfulness, should be considered to reduce anxiety and support emotional resilience. Depending on patients’ needs and available time, these interventions can be implemented at hospital, at home, or both. Applying these measures in a structured and interdisciplinary way can help reduce postoperative complications, shorten hospital stays, and improve recovery and quality of life.

Practical and tailored prehabilitation protocols can reduce postoperative complications, shorten the length of stay, and consequently lower associated costs, ultimately improving survival outcomes in treating the disease. This is an important area for future research, aiming at developing and modifying programs and protocols. This review sought to identify which prehabilitation interventions applicable in the preoperative period of thoracic surgery could provide more significant benefits to the therapeutic process and enhance long-term quality of life after the completion of this treatment modality.

The recommendations from this review are that rehabilitation programs should encompass both aerobic endurance training and resistance training, as well as respiratory training, including functional respiratory rehabilitation and inspiratory muscle training. As well, preoperative education is a key component, with the encouragement of alcohol abstinence and smoking cessation serving as a cornerstone. Nutritional counseling and relaxation/emotion-regulation strategies should also be considered, aligning with international guidelines, where personalization is essential to make the intervention individualized. With the knowledge synthesis in this review, rehabilitation nurse specialists can establish prehabilitation intervention plans aimed at caring for, empowering, and maximizing patients' potential. However, further research is needed to demonstrate the potential of prehabilitation in postoperative recovery and the prevention and/or reduction of postoperative complications.