Prehabilitation is feasible in patients with rectal cancer undergoing neoadjuvant chemoradiotherapy and may minimize physical deterioration: results from the REx trial

Physical activity levels after low anterior resection for rectal cancer: one-year follow-up

Background

Overall survival rates after rectal cancer have increased. Therefore, functional outcomes rightly deserve more interest. The aims of this study were to assess progression in total, sports, occupational and household physical activity levels of rectal cancer survivors, from preoperatively to 12 months after surgery/stoma closure and to explore predictive factors.

Methods

Multi-center prospective study with 125 patients who underwent low anterior resection for rectal cancer. The Flemish Physical Activity Computerized Questionnaire was completed concerning all physical activity levels at baseline (past preoperative year) and at 1, 4, 6 and 12 months after surgery/stoma closure. At these timepoints, questionnaires (LARS−/ COREFO-questionnaire) regarding bowel symptoms were also filled out. Results were analyzed using linear mixed models for repeated measures.

Results

Total physical activity levels up to 12 months remained significantly lower than preoperative. Occupational and sports physical activity levels remained significantly lower until 6 and 4 months postoperative, respectively. Predictive factors for decreased physical activity levels at a specific timepoint were: younger age and no stoma (total physical activity, 1 month), low/mid rectal tumor, no stoma, non-employed status (total, 4 months), higher COREFO-scores (occupational, 4 months) and non-employed status (total, 12 months). At all timepoints, lower COREFO-scores were associated with higher total physical activity levels; male gender and lower educational levels with higher occupational levels; younger age, normal BMI, employed status and adjuvant therapy with higher sports levels; and female gender, lower educational level and unemployed status with higher household levels.

Conclusions

One year after rectal cancer treatment, total physical activity levels were still not recovered. Rectal cancer patients, especially those at risk for decreased physical activity levels and with major bowel complaints, should be identified and guided to increase their activities.

Trial registration

This trial has been registered at Netherlands Trial Register (NTR6383, 23/01/2017).

Effects of exercise during and after neoadjuvant chemoradiation on symptom burden and quality of life in rectal cancer patients: a phase II randomized controlled trial

PURPOSE

We previously demonstrated that exercise during and after neoadjuvant chemoradiation (NACRT) for rectal cancer may improve the rate of pathologic complete/near complete response. Here, we report the effects of exercise on symptom management and quality of life (QoL).

METHODS

Rectal cancer patients (N = 36) were randomized to a supervised high-intensity interval training program during NACRT followed by unsupervised continuous exercise after NACRT or usual care. Patient-reported outcomes were assessed at baseline, post-NACRT, and presurgery including symptom burden (M.D. Anderson Symptom Inventory) and QoL (European Organisation for Research and Treatment of Cancer QLQ- C30 and -CR29).

RESULTS

During NACRT, exercise significantly worsened stool frequency (adjusted between-group difference, 25.8; 95% CI, 4.0 to 47.6; p = 0.022), role functioning (adjusted between-group difference, -21.3; 95% CI, -41.5 to -1.1; p = 0.039), emotional functioning (adjusted between-group difference, -11.7; 95% CI, -22.0 to -1.4; p = 0.028), and cognitive functioning (adjusted between-group difference, -11.6; 95% CI, -19.2 to -4.0; p = 0.004) compared to usual care. After NACRT, exercise significantly worsened diarrhea (adjusted between-group difference, 1.2; 95% CI, 0.1 to 2.3; p = 0.030) and embarrassment (adjusted between-group difference, 19.7; 95% CI, 7.4 to 32.1; p = 0.003) compared to usual care.

CONCLUSIONS

Exercise exacerbated some symptoms and worsened QoL during NACRT; however, most negative effects dissipated after NACRT. Larger trials are necessary to confirm these findings.

IMPLICATIONS FOR CANCER SURVIVORS

If the clinical benefit of exercise is confirmed, then the modest symptom exacerbation during NACRT may be considered tolerable. However, in the absence of any clinical benefit, exercise may be contraindicated in this clinical setting.

Prehabilitation before surgery: Is it for all patients?

PURPOSE

To evaluate the role of prehabilitation interventions in adult patients before elective major surgery.

RECENT FINDINGS

Exercise training before elective adult major surgery is feasible and safe. Efficacy has been determined but the clinical effectiveness remains uncertain. Early data suggest a reduction in morbidity, length of stay, and an improvement in the quality of life. Nutritional and psychological interventions are less well evaluated, and when they are, it is often in combination with exercise interventions as part of multimodal prehabilitation.

SUMMARY

Studies evaluating multimodal prehabilitation interventions before elective major surgery in adults are producing encouraging early results, but definitive clinical effectiveness is currently very limited. Future research should focus on refining interventions, exploring mechanisms, establishing minimum dosage, interrogating interactions between therapies, and urgent implementation of large-scale clinical effectiveness studies.

Preoperative assessment and optimisation for pelvic exenteration in locally advanced and recurrent rectal cancer: A review

The pre-operative phase in planning a pelvic exenteration or extended resections is critical to optimising patient outcomes. This review summarises the key components of preoperative assessment and planning in patients with locally advanced rectal cancer (LARC) and locally recurrent rectal cancer (LLRC) being considered for potential curative resection. The preoperative period can be considered in 5 key phases: 1) Multidisciplinary meeting (MDT) review and recommendation for neoadjuvant therapy and surgery, 2) Anaesthetic preoperative assessment of fitness for surgery and quantification of risk, 3) Shared decision making with the patient and the process of informed consent, 4) Prehabilitation and physiological optimisation 5) Technical aspects of surgical planning. This review will focus on patients who have been recommended for surgery by the MDT and have completed neoadjuvant therapy. Other important considerations beyond the scope of this review are the various neoadjuvant strategies employed which in this patient group include Total Neo-adjuvant Therapy and reirradiation. Critical to improving perioperative outcomes is the dual aim of achieving a negative resection margin in a patient fit enough for extended surgery. Advanced, realistic communication is required pre-operatively and should be maintained throughout recovery. Optimising patient's physiological and psychological reserve with a preoperative prehabilitation programme is important, with physiotherapy, psychological and nutritional input. From a surgical perspective, image based technical preoperative planning is important to identify risk points and ensure correct surgical strategy. Careful attention to the entire patient journey through these 5 preoperative phases can optimise outcomes with the accumulation of marginal gains at multiple timepoints.

Prehabilitation for medically frail patients undergoing surgery for epithelial ovarian cancer: a cost-effectiveness analysis

Objective

To assess the potential cost-effectiveness of prehabilitation in medically frail patients undergoing surgery for epithelial ovarian cancer (EOC).

Methods

We created a cost-effectiveness model evaluating the impact of prehabilitation on a cohort of medically frail women undergoing primary surgical intervention for EOC. Cost was assessed from the healthcare system perspective via (1) inpatient charges from 2018–2019 institutional Diagnostic Related Grouping data for surgeries with and without major complications; (2) nursing facility costs from published market surveys. Major complication and non-home discharge rates were estimated from the literature. Based on published pilot studies, prehabilitation was determined to decrease these rates. Incremental cost-effectiveness ratio for cost per life year saved utilized a willingness-to-pay threshold of $100,000/life year. Modeling was performed with TreeAge software.

Results

In a cohort of 4,415 women, prehabilitation would cost $371.1 Million (M) versus $404.9 M for usual care, a cost saving of $33.8 M/year. Cost of care per patient with prehabilitation was $84,053; usual care was $91,713. When analyzed for cost-effectiveness, usual care was dominated by prehabilitation, indicating prehabilitation was associated with both increased effectiveness and decreased cost compared with usual care. Sensitivity analysis showed prehabilitation was more cost effective up to a cost of intervention of $9,418/patient.

Conclusion

Prehabilitation appears to be a cost-saving method to decrease healthcare system costs via two improved outcomes: lower complication rates and decreased care facility requirements. It represents a novel strategy to optimize healthcare efficiency. Prospective studies should be performed to better characterize these interventions in medically frail patients with EOC.

Prehabilitation cost-effectiveness analysis was performed for medically frail epithelial ovarian cancer patients undergoing surgery. It was cost-saving for the healthcare system via lower complication rates and discharge care requirements. Prehabilitation was cost effective up to a cost of $9,418/patient.

Impact of prehabilitation on objectively measured physical activity levels in elective surgery patients: a systematic review

OBJECTIVE

To systematically review the impact of prehabilitation on objectively measured physical activity (PA) levels in elective surgery patients.

DATA SOURCES

Articles published in Web of Science Core Collections, PubMed, Embase (Ovid), CINAHL (EBSCOHost), PsycInfo (EBSCOHost) and CENTRAL through August 2020.

STUDY SELECTION

Studies that met the following criteria: (1) written in English, (2) quantitatively described the effect(s) of a PA intervention among elective surgery patients prior to surgery and (3) used and reported objective measures of PA in the study.

DATA EXTRACTION AND SYNTHESIS

Participant characteristics, intervention details, PA measurement, and clinical and health-related outcomes were extracted. Risk of bias was assessed following the revised Cochrane risk of bias tool. Meta-analysis was not possible due to heterogeneity, therefore narrative synthesis was used.

RESULTS

6533 unique articles were identified in the search; 21 articles (based on 15 trials) were included in the review. There was little evidence to suggest that prehabilitation is associated with increases in objectively measured PA, but this may be due to insufficient statistical power as most (n=8) trials included in the review were small feasibility/pilot studies. Where studies tested associations between objectively measured PA during the intervention period and health-related outcomes, significant beneficial associations were reported. Limitations in the evidence base precluded any assessment via meta-regression of the association between objectively measured PA and clinical or health-related outcomes.

CONCLUSIONS

Additional large-scale studies are needed, with clear and consistent reporting of objective measures including accelerometry variables and outcome variables, to improve our understanding of the impact of changes in PA prior to surgery on surgical and health-related outcomes.

PROSPERO REGISTRATION NUMBER

CRD42019151475.

Perioperative exercise training for patients with gastrointestinal cancer undergoing surgery: A systematic review and meta-analysis

Exercise training is emerging as a supportive treatment strategy in surgical oncology, but its effects remain uncertain in patients with gastrointestinal cancer. The primary objective of this systematic review and meta-analysis was to evaluate the effects of perioperative exercise training on gastrointestinal cancer-specific mortality, recurrence, and surgical outcomes (postoperative complications, hospitalization, surgical stress) in patients with gastrointestinal cancer. Randomized or quasi-randomized controlled trials evaluating the effects of perioperative exercise training versus control in patients with GI cancer were eligible. MEDLINE, EMBASE, CENTRAL, CINAHL, PEDro, and SPORTDiscus were systematically searched on June 20, 2020. Data were synthesized using random-effects meta-analyses. Risk of bias was assessed using the Cochrane risk of bias tool 2, and the certainty of evidence was assessed using GRADE. Study selection, data extraction, risk of bias, and GRADE assessments were performed independently by two authors. Ten randomized controlled trials comprising 448 participants with gastrointestinal cancer were eligible. Meta-analyses indicated no statistical effects of exercise on postoperative complications (risk ratio: 1.11, 95% CI: 0.84; 1.47), readmissions (risk ratio: 2.76; 95% CI: 0.00, 9394.76), or postoperative length of stay (difference in means: -0.47, 95% CI: -17.2; 16.2 days). None of the eligible studies assessed gastrointestinal cancer-specific mortality or recurrence. Overall risk of bias was high or of some concerns in all studies, and the certainty of evidence was very low. The effects of perioperative exercise on cancer-specific and surgical outcomes are unknown in patients with gastrointestinal cancer due to lack of studies and very low certainty of evidence.

The effects of neoadjuvant chemoradiotherapy and an in-hospital exercise training programme on physical fitness and quality of life in locally advanced rectal cancer patients: a randomised controlled trial (The EMPOWER Trial)

BACKGROUND

The EMPOWER trial aimed to assess the effects of a 9-week exercise prehabilitation programme on physical fitness compared with a usual care control group. Secondary aims were to investigate the effect of (1) the exercise prehabilitation programme on psychological health; and (2) neoadjuvant chemoradiotherapy (NCRT) on physical fitness and psychological health.

METHODS

Between October 2013 and December 2016, adults with locally advanced rectal cancer undergoing standardised NCRT and surgery were recruited to a multi-centre trial. Patients underwent cardiopulmonary exercise testing (CPET) and completed HRQoL questionnaires (EORTC-QLQ-C30 and EQ-5D-5L) pre-NCRT and post-NCRT (week 0/baseline). At week 0, patients were randomised to exercise prehabilitation or usual care (no intervention). CPET and HRQoL questionnaires were assessed at week 0, 3, 6 and 9, whilst semi-structured interviews were assessed at week 0 and week 9. Changes in oxygen uptake at anaerobic threshold (VO2 at AT (ml kg-1 min-1)) between groups were compared using linear mixed modelling.

RESULTS

Thirty-eight patients were recruited, mean age 64 (10.4) years. Of the 38 patients, 33 were randomised: 16 to usual care and 17 to exercise prehabilitation (26 males and 7 females). Exercise prehabilitation significantly improved VO2 at AT at week 9 compared to the usual care. The change from baseline to week 9, when adjusted for baseline, between the randomised groups was + 2.9 ml kg -1 min -1; (95% CI 0.8 to 5.1), p = 0.011.

CONCLUSION

A 9-week exercise prehabilitation programme significantly improved fitness following NCRT. These findings have informed the WesFit trial (NCT03509428) which is investigating the effects of community-based multimodal prehabilitation before cancer surgery.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01914068 . Registered 1 August 2013.

Feasibility, Safety, and Preliminary Efficacy of Exercise During and After Neoadjuvant Rectal Cancer Treatment: A Phase II Randomized Controlled Trial

BACKGROUND

Neoadjuvant chemoradiation (NACRT) improves outcomes for patients with rectal cancer; however, there are dose-limiting toxicities and only a 15% to 27% pathologic complete response (pCR) rate. Exercise may help manage toxicities and improve treatment response, but feasibility and early efficacy have not been established. EXERT was a phase II trial designed to establish the feasibility and safety of exercise and provide the first evidence of efficacy.

MATERIALS AND METHODS

Patients with rectal cancer scheduled to receive NACRT were randomly assigned to usual care (n = 18) or exercise (n = 18) involving supervised exercise during NACRT and unsupervised exercise after NACRT. The primary outcome was cardiorespiratory fitness (VO₂ peak). Clinical outcomes included treatment toxicities, treatment completion, and treatment response.

RESULTS

Median attendance at supervised exercise sessions during NACRT was 82%, and median self-reported exercise after NACRT was 90 min/wk. From baseline to post-NACRT, VO₂ peak increased by 0.4 mL·kg^-1·min^-1 in the exercise group and decreased by 0.8 mL·kg^-1·min^-1 in the usual care group (P = .47). There were no significant differences between groups for grade 3/4 toxicities or treatment completion. Of 18 patients in the exercise group, 10 (56%) achieved pCR/near pCR compared with 3 of 17 (18%) in the usual care group (P = .020).

CONCLUSION

Exercise during and after NACRT is feasible for many patients with rectal cancer and may improve pCR despite limited fitness improvements. Larger trials are warranted to confirm if exercise is an effective intervention for improving treatment outcomes in this clinical setting.

Adherence to Pre-operative Exercise and the Response to Prehabilitation in Oesophageal Cancer Patients

BACKGROUND

Prehabilitation is thought to reduce post-operative respiratory complications by optimising fitness before surgery. This prospective, single-centre study aimed to establish the effect of pre-operative exercise on cardiorespiratory fitness in oesophageal cancer patients and characterise the effect of adherence and weekly physical activity on response to prehabilitation.

METHODS

Patients received a personalised, home-based pre-operative exercise programme and self-reported their adherence each week. Cardiorespiratory fitness (pVO2max and O2 pulse) was assessed at diagnosis, following completion of neoadjuvant chemotherapy (NAC) and immediately before surgery. Study outcomes included changes in fitness and post-operative pneumonia.

RESULTS

Sixty-seven patients with oesophageal cancer underwent prehabilitation followed by surgery between January 2016 and December 2018. Fitness was preserved during NAC and then increased prior to surgery (pV02max Δ = +2.6 ml min-1, 95% CI 1.2-4.0 p = 0.001; O2 pulse Δ = +1.4 ml beat-1 95% CI 0.5-2.3 p = 0.001). Patients with higher baseline fitness completed more physical activity. Regression analyses found adherence was associated with improvement in fitness immediately before surgery (p = 0.048), and the amount of physical activity completed was associated with the risk of post-operative pneumonia (p = 0.035).

CONCLUSION

Pre-operative exercise can maintain cardiorespiratory fitness during NAC and facilitate an increase in fitness before surgery. Greater exercise volumes were associated with a lower risk of post-operative pneumonia, highlighting the importance progressing exercise programmes throughout prehabilitation. Patients with high baseline fitness completed more physical activity and may require less supervision to reach their exercise goals. Further research is needed to explore stratified approaches to prehabilitation.

Defining standards in colorectal optimisation: a Delphi study protocol to achieve international consensus on key standards for colorectal surgery prehabilitation

INTRODUCTION

Prehabilitation in colorectal surgery is evolving and may minimise postoperative morbidity and mortality. With many different healthcare professionals contributing to the prehabilitation literature, there is significant variation in reported primary endpoints that restricts comparison. In addition, there has been limited work on patient-related outcome measures suggesting that patients with colorectal cancer needs and issues are being overlooked. The Defining Standards in Colorectal Optimisation Study aims to achieve international consensus from all stakeholders on key standards to provide a framework for reporting future prehabilitation research.

METHODS AND ANALYSIS

A systematic review will identify key standards reported in trials of prehabilitation in colorectal surgery. Standards that are important to patients will be identified by a patient and public involvement (PPI) event. The longlist of standards generated from the systematic review and PPI event will be used to develop a three-round online Delphi process. This will engage all stakeholders (healthcare professionals and patients) both nationally and internationally. The results of the Delphi will be followed by a face-to-face interactive consensus meeting that will define the final standards for prehabilitation for elective colorectal surgery.

ETHICS AND DISSEMINATION

The University of Glasgow College of Medical, Veterinary and Life Sciences Ethics Committee has approved this protocol, which is registered as a study (200190120) with the Core Outcome Measures in Effectiveness Trials Initiative. Publication of the standards developed by all stakeholders will increase the potential for comparative research that advances understanding of the clinical application of prehabilitation.

PROSPERO REGISTRATION NUMBER

CRD42019120381.

Efficacy of Prehabilitation Including Exercise on Postoperative Outcomes Following Abdominal Cancer Surgery: A Systematic Review and Meta-Analysis

Objectives: This systematic review set out to identify, evaluate and synthesise the evidence examining the effect of prehabilitation including exercise on postoperative outcomes following abdominal cancer surgery. Methods: Five electronic databases (MEDLINE 1946-2020, EMBASE 1947-2020, CINAHL 1937-2020, PEDro 1999-2020, and Cochrane Central Registry of Controlled Trials 1991-2020) were systematically searched (until August 2020) for randomised controlled trials (RCTs) that investigated the effects of prehabilitation interventions in patients undergoing abdominal cancer surgery. This review included any form of prehabilitation either unimodal or multimodal that included whole body and/or respiratory exercises as a stand-alone intervention or in addition to other prehabilitation interventions (such as nutrition and psychology) compared to standard care. Results: Twenty-two studies were included in the systematic review and 21 studies in the meta-analysis. There was moderate quality of evidence that multimodal prehabilitation improves pre-operative functional capacity as measured by 6 min walk distance (Mean difference [MD] 33.09 metres, 95% CI 17.69-48.50; p = <0.01) but improvement in cardiorespiratory fitness such as preoperative oxygen consumption at peak exercise (VO2 peak; MD 1.74 mL/kg/min, 95% CI -0.03-3.50; p = 0.05) and anaerobic threshold (AT; MD 1.21 mL/kg/min, 95% CI -0.34-2.76; p = 0.13) were not significant. A reduction in hospital length of stay (MD 3.68 days, 95% CI 0.92-6.44; p = 0.009) was observed but no effect was observed for postoperative complications (Odds Ratio [OR] 0.81, 95% CI 0.55-1.18; p = 0.27), pulmonary complications (OR 0.53, 95% CI 0.28-1.01; p = 0.05), hospital re-admission (OR 1.07, 95% CI 0.61-1.90; p = 0.81) or postoperative mortality (OR 0.95, 95% CI 0.43-2.09, p = 0.90). Conclusion: Multimodal prehabilitation improves preoperative functional capacity with reduction in hospital length of stay. This supports the need for ongoing research on innovative cost-effective prehabilitation approaches, research within large multicentre studies to verify this effect and to explore implementation strategies within clinical practise.

Feasibility and acceptability of a preoperative exercise program for patients undergoing major cancer surgery: results from a pilot randomized controlled trial

Objective

To establish the feasibility and acceptability of a preoperative exercise program, and to obtain pilot data on the likely difference in key surgical outcomes to inform the sample size calculation for a full-scale trial.

Design

Pilot randomized controlled trial.

Setting

Royal Prince Alfred Hospital, Sydney, Australia.

Subjects

We included patients undergoing elective pelvic exenteration or cytoreductive surgery aged 18 to 80 years, who presented to the participating gastrointestinal surgeon at least 2 weeks prior to surgery. Patients presenting cognitive impairment, co-morbidity preventing participation in exercise, inadequate English language, currently participating in an exercise program or unable to attend the exercise program sessions were excluded.

Methods

Participants were randomized to a 2–6 weeks preoperative, face-to-face, individualised exercise program or to usual care. Feasibility was assessed with consent rates to the study, and for the intervention group, retention and adherence rates to the preoperative exercise program. Acceptability of the exercise program was assessed with a semi-structured questionnaire exploring the advice received and the amount, duration and intensity of the exercise program. In addition, postoperative complication rates (Clavien-Dindo), length of hospital stay and self-reported measures of health-related quality of life (SF-36v2) were collected at baseline, day before surgery and in-hospital up to discharge from hospital.

Results

Of 122 patients screened, 26 (21%) were eligible and 22 (85%) accepted to participate in the trial and were randomized to the intervention (11; 50%) or control group (11; 50%). The median age of the include participants was 63 years. Adherence to the preoperative exercise sessions was 92.7%, with all participants either satisfied (33%) or extremely satisfied (67%) with the overall design of the preoperative exercise program. No significant differences in outcomes were found between groups.

Conclusions

The results of our pilot trial demonstrate that a preoperative exercise program is feasible and acceptable to patients undergoing major abdominal cancer surgery. There is an urgent need for a definite trial investigating the effectiveness of a preoperative exercise program on postoperative outcomes in patients undergoing major abdominal cancer surgery. This could potentially reduce postoperative complication rates, length of hospital stay and subsequently overall health care costs.

Trial registration

ACTRN12617001129370. Registered on August 1, 2017, https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=373396&showOriginal=true&isReview=true

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-021-00765-8.

An exercise trial for adults undergoing neoadjuvant chemoradiotherapy for rectal cancer proves not feasible: recommendations for future trials

Background

The aim of this paper is to share the methodological problems of an unsuccessful prospective single-arm feasibility trial conducted to evaluate the safety and feasibility of a 12-week progressive exercise intervention for adults undergoing neoadjuvant chemoradiotherapy for rectal cancer, as well as offer recommendations for future trials.

Methods

The initial plan was to recruit adults diagnosed with rectal cancer and scheduled for neoadjuvant chemoradiotherapy over a 12-month period. The exercise intervention was to consist of supervised exercise sessions delivered three times per week by a trained exercise specialist. Feasibility (i.e., recruitment, adherence, and compliance rates) and safety (i.e., adverse events) were to be assessed throughout the trial, and patient-reported and physical health outcomes were to be assessed pre- and post-intervention. After 8 months of open recruitment, we had been unable to successfully enroll patients into our trial. We therefore modified our eligibility criteria to increase the number of patients that could be recruited into our trial, and in turn increase our recruitment rate. We also amended our recruitment procedures to ensure we could reach patients who were either awaiting treatment, receiving treatment, or had completed treatments in the past 5 years. In doing so, we added a research objective, namely to determine the optimal timing of conducting an exercise intervention with adults diagnosed with rectal cancer (i.e., during neoadjuvant treatment, after surgery, during adjuvant treatment, or post-treatment).

Results

Many problems continued to hinder the progress of our trial, particularly the low recruitment rate and the failure to enroll the required sample size that would make our results reliable.

Conclusion

This led us to conclude that our trial was not feasible and that it is advisable to consider some elements carefully (e.g., recruitment strategies, communication, and trial location) before designing and conducting future trials. If one or more of these elements still proves to be problematic, trial results risk being compromised and alternative approaches should be considered.

Trial registration

ClinicalTrials.gov NCT03049124. Registered on 02 September 2017

Prehabilitation for the Anesthesiologist

Prehabilitation aims at enhancing patient’s preoperative functional capacity to better withstand the stress of surgery and recovery.

Effect of Exercise on Physical Function and Psychological Well-being in Older Patients With Colorectal Cancer Receiving Chemotherapy-A Systematic Review

The incidence of colorectal cancer (CRC) increases with older age. Cancer and treatment-related side effects often lead to physical decline, poor treatment adherence, and a lower quality of life. The aim of the present systematic review and meta-analysis was to evaluate the effects of exercise reported by randomized controlled trials (RCTs) on physical function, physical fitness (ie, aerobic capacity, muscle strength) physical activity, and psychological well-being in older patients with CRC undergoing chemotherapy. Eight RCTs with 552 participants were included in the meta-analysis. The mean age across the RCTs was 58.5 years, and 2 RCTs excluded patients aged > 80 years. The meta-analyses showed a low level of evidence for a small beneficial effect of exercise on self-reported physical function (standardized mean difference [SMD], 0.26; 95% confidence interval [CI], 0.04-0.48) and global quality of life (SMD, 0.22; 95% CI, 0.02-0.43) and low level of evidence for a moderate effect of exercise reducing fatigue (SMD, -0.49; 95% CI, -0.79 to -0.19) for patients receiving chemotherapy for CRC. We found no evidence for a beneficial effect of exercise on physical fitness. No adverse events related to the exercise interventions were reported. The evidence for the effect of exercise on physical outcomes and psychological well-being during chemotherapy for patients with CRC and especially for older patients is sparse. However, exercise during chemotherapy for patients with CRC is feasible and safe. We found a moderate to high risk of bias in most of the included studies, small sample sizes, and a low number of included patients. Moreover, all studies had excluded patients with comorbidities or walking impairment, a group of patients who would probably benefit the most from exercise. This positive result requires verification in larger trials of older and frail patients receiving chemotherapy for CRC.

Effects of exercise therapy in cancer patients undergoing radiotherapy treatment: a narrative review

Despite its beneficial effects, radiotherapy still results in a range of side effects that negatively impact quality of life of patients. Exercise has been shown to counteract the side effects induced by cancer treatment. This narrative review aims to provide an up-to-date review of the effects of an exercise intervention in cancer patients during radiotherapy. A literature search was performed on PubMed to identify original articles that evaluated the effects of an exercise programme to alleviate treatment-related side effects in cancer patients undergoing radiotherapy with or without other cancer treatments. Benefits related to exercise training have been shown in breast, prostate, rectal, lung, head and neck cancer patients undergoing radiotherapy. Therefore, exercise should be considered as a concurrent treatment alongside radiotherapy to alleviate treatment-related side effects and facilitate effective recovery. Due to the onset and progress of treatment-related side effects throughout radiotherapy, a regular clinical evaluation seems strongly advisable in order to continuously adapt the exercise programme depending on symptoms and side effects. An exercise professional is needed to personalize exercise training based on the medical condition and tailor it throughout the intervention according to progress and the patient’s medical status. Future studies are needed to confirm the potential benefits of exercises observed on treatment-related side effects. Furthermore, because of the narrative design of this study, a systematic review is required to evaluate the strength of the evidence reported.

Prehabilitative Exercise for the Enhancement of Physical, Psychosocial, and Biological Outcomes Among Patients Diagnosed with Cancer

PURPOSE OF REVIEW

This review summarizes the effects of prehabilitative exercise interventions on the physical, psychosocial, and biological outcomes among patients with cancer. Current gaps and future directions in prehabilitative exercise research will be addressed.

RECENT FINDINGS

Prehabilitative exercise mitigates the detrimental impact of cancer surgery on physical fitness, noted by increases in maximal oxygen consumption and 6-min walk distance. Beneficial effects on psychosocial and biological outcomes remain inconclusive. Aerobic exercise interventions were often prescribed and included low-, moderate-, or high-intensity exercise. Resistance exercise interventions were often performed in conjunction with aerobic exercise. Prehabilitative exercise elicits robust improvements in physical fitness; however, effect on psychosocial and biological outcomes remains inconclusive. Exercise prescription parameters varied greatly by frequency, intensity, time, and type across multiple cancer diagnoses. Future investigations are needed to systematically dose exercise for a wider variety of outcome measures, with an overall goal to set forth pre-operative exercise guidelines.

Prehabilitation: finally utilizing frailty screening data

The elderly colorectal cancer patients tend to be frail, at nutrition risk with multiple comorbidities. In view of the stress on the body by surgery and recovery, it makes sense if patients are prepared before appropriately so that they can recover earlier and better. Prehabilitation prior to major surgery has attracted the attention of clinicians recently, and this review highlights the steps that need to be taken to implement a multidisciplinary program. Such programs requires a paradigm shift in the sense that all players need to be working in team for the benefit of patinets' outcome.

Functional recovery in senior adults undergoing surgery for colorectal cancer: Assessment tools and strategies to preserve functional status

Colorectal cancer is a widely-recognized aging-associated disease. Recent advances in the care of senior colorectal cancer patients has led to similar cancer-related life expectancy for older patients when compared to their younger counterparts. Recent data suggests that onco-geriatric patients place as much value on maintenance of functional independence and quality of life after treatment as they do on the potential improvements in survival that a treatment might offer. As a result, there has been significant interest in the geriatric literature surrounding the concept of "functional recovery," a multidimensional outcome metric that takes into account several domains, including physical, physiologic, psychological, social, and economic wellbeing. This review introduces the concept of functional recovery and highlights a number of predictors of post-treatment functional trajectory, including several office-based tools that clinicians can use to help guide informed decision making surrounding potential treatment options. This review also highlights a number of validated metrics that can be used to assess a patient's progress in functional recovery after surgery. While the timeline of each individual's functional recovery may vary, most data suggests that if patients are to return to their pre-operative functional status, this could occur up to 6 months post-surgery. For those patients identified to be at risk for post-operative functional decline this review also delineates strategies for prehabilitation and rehabilitation that may improve functional outcomes.

Does prehabilitation modify muscle mass in patients with rectal cancer undergoing neoadjuvant therapy? A subanalysis from the REx randomised controlled trial

BACKGROUND

Patients with rectal cancer who present with sarcopenia (low muscle mass) are at significantly greater risk of postoperative complications and reduction in disease-free survival. We performed a subanalysis of a randomised controlled study [the REx trial; www.isrctn.com ; 62859294] to assess the potential of prehabilitation to modify muscle mass in patients having neoadjuvant chemoradiotherapy (NACRT).

METHODS

Patients scheduled for NACRT, then potentially curative surgery (August 2014-March 2016) had baseline physical assessment and psoas muscle mass measurement (total psoas index using computed tomography-based measurements). Participants were randomised to either the intervention (13-17-week telephone-guided graduated walking programme) or control group (standard care). Follow-up testing was performed 1-2 weeks before surgery.

RESULTS

The 44 patients had a mean age of 66.8 years (SD 9.6) and were male (64%); white (98%); American Society of Anesthesiologists class 2 (66%); co-morbid (58%); overweight (72%) (body mass index ≥ 25 kg/m²). At baseline, 14% were sarcopenic. At follow-up, 13 (65%) of patients in the prehabilitation group had increased muscle mass versus 7 (35%) that experienced a decrease. Conversely, 16 (67%) controls experienced a decrease in muscle mass and 8 (33%) showed an increase. An adjusted linear regression model estimated a mean treatment difference in Total Psoas Index of 40.2mm²/m² (95% CI - 3.4 to 83.7) between groups in change from baseline (p = 0.07).

CONCLUSIONS

Prehabilitation improved muscle mass in patients with rectal cancer who had NACRT. These results need to be explored in a larger trial to determine if the poorer short- and long-term patient outcomes associated with low muscle mass can be minimised by prehabilitation.

The relationship between sarcopenia and survival at 1 year in patients having elective colorectal cancer surgery

Background

Colorectal cancer remains a common cause of cancer death in the UK, with surgery being the mainstay of treatment. An objective measurement of the suitability of each patient for surgery, and their risk–benefit calculation, would be of great utility. We postulate that sarcopenia (low muscle mass) could fulfil this role as a prognostic indicator. The aim of this study was to determine the relationship between sarcopenia and long-term outcomes in patients undergoing elective bowel resection for colorectal cancer.

Methods

One hundred and sixty-three consecutive patients who had elective curative colorectal resection for cancer were eligible for inclusion in the study. Psoas muscle mass was assessed on preoperative computed tomography scan at the level of the L3 vertebra and standardised for patient height (total psoas index, TPI). Sarcopenia (low muscle mass) was defined as < 524 mm²/m² in males and 385 mm²/m² in females. In addition to clinical–pathological parameters, postoperative complications were recorded and patients were followed up for mortality for 1 year after surgery.

Results

Sarcopenia was present in 19.6% of the study participants and was significantly related to body mass index (p = 0.007), 30-day mortality (p = 0.042) and 1-year mortality (p = 0.046). In univariate analysis, American Society of Anesthesiologists grade (p = 0.016), tumour stage (p = 0.018) and sarcopenia (p = 0.043) were found to be significant independent predictors of 1-year mortality.

Conclusions

This study has found sarcopenia to be prevalent in patients with colorectal cancer having elective surgery. Independent of age, sarcopenia was associated with poorer 30-day mortality and survival at 1 year. Measurement of muscle mass preoperatively could be used to stratify a patient’s risk, allowing targeted strategies such as prehabilitation, to be implemented to modify sarcopenia and improve long-term outcomes for patients.