Advocating for prehabilitation for patients undergoing gynecology-oncology surgery

All Wales Ovarian Cancer Prehabilitation Project (AWOCPP)

Over 50% of patients with ovarian cancer are diagnosed with advanced disease (stage 3+) in Wales when treatment typically involves chemotherapy, combined with cytoreductive surgery. Postoperative morbidity is common resulting in prolonged hospital stays and delays in returning to chemotherapy. Patients with advanced ovarian cancer commonly have modifiable risk factors that can be targeted for improvement with personalised prehabilitation. Multimodal personalised prehabilitation has been shown to have a positive impact on perioperative outcomes and length of stay (LOS).Quality improvement methods were used to implement a multimodal prehabilitation programme for all patients with advanced ovarian cancer planned for surgery in Wales. A unique approach to determining an individual patient's modifiable risk factors was devised that enabled a personalised prehabilitation programme to be created including exercise, smoking cessation, medical and nutritional optimisation and emotional support. Data were collected to enable future health economic evaluation of the programme in anticipation of national role out as standard of care. To evaluate if the prehabilitation intervention was impacting the quality of care, the following outcome measures were assessed: LOS, postoperative complications and surgery to chemotherapy interval (SCI). These measures were compared with a historical Welsh data set from 2018 to 2019 when access to prehabilitation was not available.Following the implementation of prehabilitation for ovarian cancer, the median LOS reduced from 6 to 5 days (p=0.29). There was a reduction in postoperative complications: from 16.9% to 12.7% (Grade 2), 4.4% to 1.8% (Grade 3), 0.6% to 0% (Grade 4+5). The median SCI following prehabilitation was 43.5 days (range 27-91) compared with 40 days (range 15-182 (p=0.65)).Prehabilitation has had a positive impact on the treatment pathways for advanced ovarian cancer in Wales. Means of improving patient engagement and establishing cost-effective delivery need to be developed to make this intervention standard of care.

Pre-operative impact of multimodal prehabilitation in gynecologic oncology patients

OBJECTIVE

Multimodal prehabilitation is a multi-disciplinary program that includes exercise, nutrition, and psychological intervention before surgery to improve pre-operative functional capacity. This study aims to assess the impact of a prehabilitation program on the pre-operative functional status of gynecologic oncology patients.

METHODS

This single-center, prospective observational study included all consecutive patients diagnosed with gynecologic cancer who were scheduled for surgery and enrolled in a structured prehabilitation program from January 2018 to May 2024. Only patients with both baseline and pre-operative evaluations were included. Functional status data were compared before (baseline) and after (pre-operative) the prehabilitation intervention. The primary outcome measured was functional capacity, as determined by the 6-minute walk test (6MWT). Secondary outcomes included hand grip strength, the Malnutrition Universal Screening Tool (MUST) score, and the Hospital Anxiety and Depression Scale score. The type of training and adherence were also evaluated.

RESULTS

A total of 77 patients underwent both baseline and pre-operative evaluation at the prehabilitation unit. The median duration of the program was 25.2 days (range; 9-63). Significant pre-operative improvements were observed in 6MWT (baseline: 435.7 m, standard deviation [SD] = 115.9 vs pre-operative: 455.7 m, SD = 118.9, p < .001), hand grip strength (baseline: 19.0 kg, SD = 5.5 vs pre-operative: 20.4 kg, SD = 5.9, p = .012), MUST score (baseline MUST ≥2 in 14.3% patients vs pre-operative 3.9%, p = .03), and Hospital Anxiety and Depression Scale score (baseline anxiety score: 7.4, SD = 4.3 vs pre-operative: 6.3, SD = 3.6, p < .001; and baseline depression score: 5.5, SD = 4.2 vs pre-operative: 4.3, SD = 3.6, p < .001). Among the different training programs, patients participating in supervised CrossFit training showed greater improvement in the 6MWT (33.4 m), compared to the hospital-supervised group (27.1 m), and the non-supervised home training group (14.0 m).

CONCLUSIONS

A structured multimodal prehabilitation program improves pre-operative functional capacity in gynecologic oncology patients, with the greatest improvements seen in those who participated in supervised high-intensity training, such as CrossFit.

Optimizing prehabilitation in gynecologic malignancies: Improving acceptance, overcoming barriers, and managing program complexity

Prehabilitation aims to improve patients' physical condition before a stressful event, such as surgery, and enhance recovery. Despite its potential benefits, many emerging prehabilitation programs face challenges in enrolling or retaining patients. In our prehabilitation study PHOCUS, which aims to prepare ovarian cancer patients for surgery, we have also encountered lower acceptance and retention rates. Particularly the most vulnerable patients, who are old and frail, and may benefit the most from the prehabilitation, decline participation due to the complexity of the proposed program. In our review we discussed obstacles and barriers that prevent patients' participation based on both literature and our experience. Among the main reasons are patient's low motivation, high intensity of the program and a lack of social support. To overcome these challenges, we suggest increasing the program's flexibility, adapting the program according to individual patient's needs and enhancing patients' education about the benefits of prehabilitation.

Prehabilitation Consultation on Self-Care and Physical Exercise in Patients Diagnosed with Abdominopelvic Cancer: Protocol of the Study

BACKGROUND

Introduction: Prehabilitation in the field of oncology has been defined as "the process in the continuum of care that occurs between diagnosis and the start of treatment involving physical and psychological measures that determine the patient's baseline functional status."

AIM

To determine the effectiveness of a Prehabilitation consultation on self-care and targeted physical exercise for patients diagnosed with abdominopelvic cancer.

DESIGN

An observational study that will evaluate the pre-post efficacy of an ad-hoc designed Prehabilitation intervention. The study population consists of patients diagnosed with colon or gynecological cancer with a surgical indication as part of their therapeutic plan from the General Surgery Services. It is configured around four key interventions: (a) health education and self-care, (b) specific nutritional counseling, (c) initial psychological assessment, and (d) directed physical exercise intervention. Health education, self-care interventions, and physical exercise will be carried out weekly from diagnosis to the scheduled surgery day.

RESULTS

Aspects such as self-care capacity or agency, perioperative anxiety, aerobic capacity, strength and flexibility, postoperative complications, and recovery time to adjuvant treatment will be measured using tools such as Appraisal of self-care agency scale (ASA), State Trait Anxiety Inventory (STAI), walking test, sit and Reach, Hand Grip or Squad Jump.

CONCLUSION

Utilizing validated tools for analyzing selected variables will contribute to refining and expanding care guidelines, ultimately enhancing support for both patients and their caregivers.

The impact of short-term multimodal prehabilitation on functional capacity in patients with gynecologic malignancies during the perioperative period: A prospective study

PURPOSE

To explore the effect of a short-term, hospital-based, multimodal preoperative prehabilitation intervention on perioperative functional ability of patients with gynecological malignant tumors.

METHODS

According to the order in which they underwent surgery, 97 patients were divided into the control group (48 cases) and the intervention group (49 cases). The control group was given routine preoperative guidance, whereas the intervention group was given short-term multimodal prehabilitation guidance on the basis of the control group intervention. The 6-min walk test was performed on the day of admission to the hospital, the day before surgery, and the 30th day after surgery.

RESULTS

Compared with the control group, the intervention group had significantly better 6-min walk distance and superior physical and psychological status on the day before surgery and the 30th day after surgery (P < 0.001). For three consecutive days after surgery, the quality of recovery in the intervention group was significantly higher than that in the control group (P < 0.001), and the first ambulation time and exhaust time were achieved earlier in the intervention group than in the control group (P < 0.05).

CONCLUSION

The preoperative intervention group showed improved preoperative exercise ability and reduced anxiety in patients with gynecological cancer. Furthermore, this intervention improved the overall health of patients and accelerated their postoperative recovery.

Health-Related Quality of Life after Hysterectomy for Endometrial Cancer: The Impact of Enhanced Recovery after Surgery Shifting Paradigm

OBJECTIVES

Enhanced recovery after surgery (ERAS) protocols provide well-known benefits in the immediate recovery with a shorter length of stay (LOS) and also in gynecological surgery. However, the impact of ERAS has not been clearly showed yet regarding long-term consequences and health-related quality of life (HRQL). The aim of this study was to investigate the impact of ERAS on HRQL after hysterectomy for endometrial cancer.

DESIGN

An observational retrospective study with propensity score matching (PSM) was performed.

PARTICIPANTS

We administered the SF-36 validated questionnaire to women underwent hysterectomy and lymph nodal staging before and after introducing ERAS protocol, getting, respectively, a standard practice (SP) and ERAS group.

SETTINGS

The study was conducted at the academic hospital.

METHODS

We collected demographic, clinical, surgical and postoperative data and performed a PSM of the baseline confounders. We administered the questionnaire 4 weeks after the surgery. The SF-36 measures HRQL using eight scales: physical functioning (PF), role physical (RLP), bodily pain (BP), general health (GH), vitality (Vt), social functioning (SF), role emotional (RLE) and mental health (MH).

RESULTS

After PSM, we enrolled a total of 154 patients, 77 in each group (SP and ERA). The two groups were similar in terms of age, BMI, anesthetic risk, Charlson comorbidity index (CCI), and surgical technique (minimally invasive vs. open access). Median LOS was shorter for ERAS group (5 vs. 3 days; p = 0.02), while no significant differences were registered in the rates of postoperative complications (16.9% vs. 17.4%; p = 0.66). Response rates to SF-36 questionnaire were 89% and 92%, respectively, in SP and ERAS group. At multivariate analyzes, the mean scores of SF-36 questionnaire, registered at 28 days weeks after surgery (range 26-32 days), were significantly higher in ERAS group for PF (73.3 vs. 91.6; p < 0.00), RLP (median 58.3 vs. 81.2; p = 0.02), and SF (37.5 vs. 58.3; p = 0.01) domains, when compared to SP patients.

LIMITATIONS

Further follow-up was not possible due to the anonymized data derived from clinical audit.

CONCLUSIONS

ERAS significantly increases the HRQL of women who underwent surgery for endometrial cancer. HRQL assessment should be routinely implemented in the ERAS protocol.

Robotic-assisted surgery in high-risk surgical patients with endometrial cancer

Many patients diagnosed with an endometrial cancer are at high-risk for surgery due to factors such as advanced age, raised body mass index or frailty. Minimally-invasive surgery, in particular robotic-assisted, is increasingly used in the surgical management of endometrial cancer however, there are a lack of clinical trials investigating outcomes in high-risk patient populations. This article will review the current evidence and identify areas of uncertainty where future research is needed.

Frailty and Preoperative Palliative Care in Surgical Oncology

In this paper, we discuss surgical palliative care for patients with cancer through the lens of frailty and the preoperative context. Historically, palliative care principles such as complex symptom management, high-risk decision-making and communication have played an important role in preoperative discussions of oncologic surgery for both palliative and curative intent. There is increasing motivation among surgeons to integrate palliative care into the perioperative period in order to more effectively and comprehensively address potential adverse functional and quality of life outcomes. We discuss how the concept of frailty, and various instruments to measure frailty, have impacted perioperative decision-making, review the roots of surgical risk stratification and counseling on acceptable perioperative risk, and explore the preoperative setting as a possible avenue by which primary and specialty palliative care integration may have beneficial impact for patients considering oncologic resections.

Prehabilitation in an ERAS program for endometrial cancer patients: impact on post-operative recovery

OBJECTIVES

Enhanced recovery after surgery (ERAS) and prehabilitation programs are multidisciplinary care pathways that aim to reduce stress response and improve perioperative outcomes. However, literature is limited regarding the impact of ERAS and prehabilitation in gynecologic oncology surgery. The aim of this study was to assess the impact of implementing an ERAS and prehabilitation program on post-operative outcomes of endometrial cancer patients undergoing laparoscopic surgery.

METHODS

We evaluated consecutive patients undergoing laparoscopy for endometrial cancer that followed ERAS and the prehabilitation program at a single center. A pre-intervention cohort that followed the ERAS program alone was identified. The primary outcome was length of stay, and secondary outcomes were normal oral diet restart, post-operative complications and readmissions.

RESULTS

A total of 128 patients were included: 60 patients in the ERAS group and 68 patients in the prehabilitation group. The prehabilitation group had a shorter length of hospital stay of 1 day (p<0.001) and earlier normal oral diet restart of 3.6 hours (p=0.005) in comparison with the ERAS group. The rate of post-operative complications (5% in the ERAS group and 7.4% in the prehabilitation group, p=0.58) and readmissions (1.7% in the ERAS group and 2.9% in the prehabilitation group, p=0.63) were similar between groups.

CONCLUSIONS

The integration of ERAS and a prehabilitation program in endometrial cancer patients undergoing laparoscopy significantly reduced hospital stay and time to first oral diet as compared with ERAS alone, without increasing overall complications or the readmissions rate.

Intraoperative Assessment of Surgical Stress Response Using Nociception Monitor under General Anesthesia and Postoperative Complications: A Narrative Review

We present a narrative review focusing on the new role of nociception monitor in intraoperative anesthetic management. Higher invasiveness of surgery elicits a higher degree of surgical stress responses including neuroendocrine-metabolic and inflammatory-immune responses, which are associated with the occurrence of major postoperative complications. Conversely, anesthetic management mitigates these responses. Furthermore, improper attenuation of nociceptive input and related autonomic effects may induce increased stress response that may adversely influence outcome even in minimally invasive surgeries. The original role of nociception monitor, which is to assess a balance between nociception caused by surgical trauma and anti-nociception due to anesthesia, may allow an assessment of surgical stress response. The goal of this review is to inform healthcare professionals providing anesthetic management that nociception monitors may provide intraoperative data associated with surgical stress responses, and to inspire new research into the effects of nociception monitor-guided anesthesia on postoperative complications.

Preoperative exercise and prehabilitation

PURPOSE OF REVIEW

The purpose of this narrative review is to give an overview about the effects of multimodal prehabilitation and current existing and prospectively planned studies. The potential efficacy of exercise in the context of prehabilitation ranges from preoperatively improving patients' functional capacity to inducing cellular mechanisms that affect organ perfusion via endothelial regeneration, anti-inflammatory processes and tumour defense.

RECENT FINDINGS

Current studies show that prehabilitation is capable of reducing certain postoperative complications and length of hospital stay in certain patient populations. These findings are based on small to mid-size trials with large heterogeneity, lacking generalizability and evidence that prehabilitation has positive effects on long term survival.

SUMMARY

The concept of prehabilitation contains the features, namely preoperative exercise, nutritional intervention and psychological support. Preoperative exercise holds potential molecular effects that can be utilized in the perioperative period in order to improve patients' postoperative outcome. Future multimodal prehabilitation trials must specifically clarify the clinical impact of this concept on patients' quality of life after major cancer surgery and cancer-specific survival.