Syst Rev. 2026 Jul 10. doi: 10.1186/s13643-026-03258-y. Online ahead of print.
ABSTRACT
OBJECTIVE: Current cardiopulmonary exercise testing (CPET) guidelines for lung cancer surgery rely on expert consensus and scientific statements, lacking robust, graded evidence. This study aimed to provide an evidence-based evaluation of CPET variables for assessing perioperative morbidity and long-term mortality risks.
METHODS: Electronic databases were searched through December 20, 2025, for cohort studies on CPET variables and lung cancer surgery. Quality was assessed using the Newcastle-Ottawa Scale. Heterogeneity was evaluated by the Q-test and I2 statistic, with fixed or random effects models. Publication bias was assessed via funnel plots and Egger's test, with adjustment using the trim-and-fill method when necessary. Effect sizes were pooled, and evidence was evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.
RESULTS: Of 3080 studies, 47 studies involving 11,356 surgeries and 13 CPET variables were included. Meta-analysis and GRADE assessment showed lower peak oxygen uptake (peak O₂) increased the risk of perioperative complications by 2.04-3.02 times (P < 0.001), using a cutoff point of 15 mL/kg/min or peak O2 expressed as %pred. A higher minute ventilation to carbon dioxide production (E/CO₂) slope was associated with a 2.44-fold increased risk (95% CI [1.82-3.27], P < 0.001), with a cutoff point of 35 (high-level). Limited studies suggest peak O₂ (L/min) and E/CO₂ slope relate to cancer-specific and all-cause mortality. Evidence for variables such as O₂ at anaerobic threshold and peak ventilation remains low.
CONCLUSION: Among 13 CPET variables, only peak O₂ (15 mL/kg/min or %pred values) and E/CO₂ slope (35) are supported by high-certainty evidence for perioperative risk. Further studies are needed to establish CPET's role in predicting cancer-specific mortality in lung cancer surgery.
SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42023405083.
PMID:42432773 | DOI:10.1186/s13643-026-03258-y