Prehabilitation in colorectal cancer surgery improves outcome and reduces hospital costs

Fit4Surgery app: Home-based prehabilitation app for older patients undergoing elective colorectal cancer surgery

BACKGROUND

Supervised multimodal prehabilitation prior to colorectal cancer (CRC) surgery is associated with reduced complications and enhanced recovery. However, it is labor intensive and expensive. In an aging population with increasing demand and costs on healthcare and staff shortages, home-based prehabilitation (HBP) with an app could be of interest. This study assessed the effectiveness of a Fit4Surgery app in CRC surgery.

METHOD

The app was effectuated in a prospective cohort study of 100 CRC patients ≥60 years from October 2021-December 2022. The primary outcome was preservation or improvement of the 6-minute walking test (6MWT) six weeks postoperative, compared to baseline. Secondary outcomes were 90-day complication and mortality rate, 90-day readmission, length of stay, 6MWT and Short Performance Physical Battery (SPPB) at different timepoints and total costs.

RESULTS

Three patients needed urgent surgery, remaining 97 patients (mean age 72) using the app for at least three weeks. The 6MWT was preserved in 74.7 % with a 12.1 m higher mean six weeks postoperative, compared to baseline (p = 0.194). A significant higher 6MWT was observed after prehabilitation and one year postoperative, compared to baseline (p=<0.001). The SPPB was significant higher at all timepoints. Overall 90-day complication rate was 25.8 %, readmission rate 6.3 % and mortality occurred in 2.1 %. Total costs were €518.50 per patient.

CONCLUSION

This is the first study of multimodal HBP by an app for CRC surgery patients with high compliance. Results show promising results regarding functional capacity and a low occurrence of complications, in line with multimodal supervised prehabilitation. This by reducing costs by half.

Study protocol for a multicentre randomised controlled trial using music prehabilitation to reduce preoperative anxiety before oncological colorectal surgery: the MU-PRIOR trial

INTRODUCTION

Prehabilitation aims to improve preoperative health before surgery to reduce complications. Reducing anxiety helps prevent postoperative pain, stress and sleep disturbances. Listening to music through headphones or earpieces in the hospital directly preoperatively, intraoperatively and postoperatively has been shown to ameliorate anxiety, stress, pain and sleep disorders. This randomised controlled trial will investigate the effect of active music listening at home 1 week before surgery as a prehabilitation modality on preoperative anxiety compared with standard care.

METHODS AND ANALYSIS

This study is a multicentre randomised controlled trial that will include 116 patients. The study population consists of adults undergoing elective oncological colorectal surgery. The intervention group will be advised to listen to recorded music three times per day for 20 min, starting 1 week prior to surgery, using headphones or earpieces. Both groups will receive standard care during hospitalisation. The primary outcome is patient-reported preoperative anxiety using the State-Trait Anxiety IndexInventory 6. Secondary outcomes are patient-reported stress, delirium incidence, medication usage, postoperative pain, complication rate, length of stay, adherence to the intervention, quality of life and healthcare-related costs.

ETHICS AND DISSEMINATION

This study protocol has been approved by the Medical Ethical Review Board of Erasmus Medical Center on 15 December 2022 (MEC-2022-9415). The trial will be carried out following the updated Declaration of Helsinki principles and Good Clinical Practice guidelines. Study results will be published and reported in a peer-reviewed journal according to the Consolidated Standards of Reporting Trials guidelines.

TRIAL REGISTRATION NUMBER

NCT05982184.

Multimodal Prehabilitation in Head and Neck Cancer Patients Undergoing Surgery: A Feasibility Study

BACKGROUND

Head and neck cancer (HNC) incidence is increasing, and surgery is frequently indicated as curative treatment. Unfortunately, complications and long-term functional impairment are common. Recent promising results of multimodal prehabilitation in colorectal cancer surgery show improved recovery and functional outcomes. The objective of this study is to assess the feasibility of multimodal prehabilitation, which is composed of high-intensity training, a protein-enriched diet, cessation of intoxications, mental support and speech support therapy, in HNC surgery.

METHODS

A feasibility study was conducted at a large teaching hospital, Northwest Clinics, Alkmaar, the Netherlands, between July 2022 and December 2023. The primary outcome was feasibility, defined as participation, dropout and adherence rate. The secondary outcome was functional capacity 6 weeks postoperatively.

RESULTS

The participation rate was 60% (30 of 50 patients), mainly limited due to the travel distance to the physiotherapist. A dropout rate of 7% was present, as two patients discontinued prehabilitation. Of the remaining 28 patients, 27 patients (96%) attended at least six sessions at the community physiotherapist practice. All functional tests increased by prehabilitation, with the 6-min walking test being significant (p ≤ 0.05). Six weeks postoperatively, all but steep ramp tests remained higher than baseline.

CONCLUSION

Feasibility of multimodal prehabilitation in HNC surgery patients in this study is limited by its participation rate of 60%. Addressing participation, a widespread network of oncologic physiotherapists or home-based multimodal prehabilitation by an app could possibly potentiate participation. More studies are needed to assess the optimal form of multimodal prehabilitation in this challenging population.

Changes in nutritional status and effectiveness of the dietary intervention of multimodal prehabilitation for patients with colorectal cancer: A secondary analysis of the PREHAB randomized clinical trial

BACKGROUND & AIMS

Prehabilitation is a preoperative multimodal program including exercise, nutritional, and psychological support. Little is known about changes in nutritional status during prehabilitation.

METHODS

This secondary analysis of the PREHAB trial aims to assess changes in nutritional status and explore the effectiveness of a four-week nutritional intervention. Data were collected at baseline and preoperatively (end of the program), including body composition with bioelectrical impedance analysis (single frequency, 50 kHz), muscle strength (indirect 1RM leg press), three-day food diaries and the scored PG-SGA. Protein requirements were set at 1.5 g/kg body weight.

RESULTS

Sixty-seven participants were enrolled, 34 to standard care and 33 to four-week prehabilitation. Nutritional status improved in both groups: -1 point change in the standard care group (p = , 0.027), and -1.5 point in the prehabilitation group (p = 0.015). Those who received prehabilitation statistically increased fat free mass (0.9 kg, p = 0.017) and appendicular skeletal muscle mass (0.5 kg, p = 0.007. In contrast, an increase in fat mass (0.6 kg, p = 0.016) was observed within the standard care group only. Participants in the prehabilitation group had a substantial increase of 27 % muscle strength (p = <0.001). Optimal protein intake was more often achieved within the prehabilitation group (47 %, p = <0.001).

CONCLUSION

Our study provides evidence for the positive impact of multimodal prehabilitation on preoperative nutritional status in adult patients with CRC, especially in body composition and muscle strength. Achieving optimal protein intake was challenging, both dietary counseling and supplements are recommended to improve intake.

TRIAL REGISTER

PREHAB RCT: NTR5947.

Development and implementation of a home-based prehabilitation app for older patients undergoing elective colorectal cancer surgery. A Prospective Cohort Study

Background

Prehabilitation optimizes colorectal cancer patients' health during the preoperative waiting period, by increasing functional capacity, reducing postoperative complications, and speeding recovery. However, challenges in implementation include patients' willingness to attend multiple hospital visits, and hospitals needing trained personnel, facilities, and financial resources. An app-based prehabilitation program could address these issues by allowing patients to participate from home with remote support from healthcare professionals.

Objective

To develop and evaluate the feasibility of a digital application to offer multimodal home-based prehabilitation for older patients undergoing surgery for colorectal cancer.

Materials and Methods

This single-center prospective cohort study at Northwest Clinics (Alkmaar and Den Helder, The Netherlands) included patients scheduled for elective surgery for the curative treatment of colorectal cancer. The Patient Journey App was used to deliver prehabilitation. The primary outcome was the number of patients who downloaded and activated the app. Secondary outcomes included usage information, videos viewed, questionnaires answered, and signals triggered.

Results

Ninety-seven patients were included in the study (age 72.1 [SD 0.8], 62.9% male). All patients used the app daily for a median of 29 days (IQR 23-28). Exercise videos were viewed most. Ninety-five patients activated daily exercise and protein shake reminders. Patients provided 1367 answers, triggering 79 signals related to smoking cessation, nutrition, and exercise. Response rates to in-app questionnaires were high, up to 90.5%.

Conclusions

Home-based prehabilitation via an app for older colorectal cancer surgery patients is feasible. Given the effectiveness of prehabilitation programs, the scarcity of healthcare professionals, and patients' reluctance for frequent in-person visits, home-based prehabilitation programs via an app could become a valuable added modality for offering these programs.

Trial Registration

2020.0600 (VU University Medical Center).

Prehabilitation-A Simple Approach for Complex Patients: The Results of a Single-Center Study on Prehabilitation in Patients with Ovarian Cancer Before Cytoreductive Surgery

Background/Objectives: Prehabilitation is a low-cost, safe procedure with no side effects, and it may have a positive impact on postoperative outcomes. However, it is not widely implemented. Our study aimed to assess the impact of prehabilitation on postoperative outcomes in patients with ovarian cancer within the field of gynecological oncology. Methods: We analyzed 110 patients with ovarian cancer who participated in a prehabilitation program before cytoreductive surgery. Based on the results of a 6-min walk test (6MWT), patients were divided into two groups: Group A (patients who improved their 6MWT results) and Group B (patients who did not improve their 6MWT results). Results: Patients in Group A demonstrated better postoperative outcomes. The length of hospital stay was significantly shorter in Group A compared to Group B (median 7 [5, 9] vs. 9 [6, 17], p = 0.032). Group A also had a lower overall number of complications and also fewer complications, as summarized by the Clavien-Dindo classification, compared to Group B. Conclusions: Patient adherence to prehabilitation recommendations was adequate. Prehabilitation was associated with improved postoperative outcomes, including shorter hospital stays and fewer complications. These benefits were more pronounced with higher patient compliance with the prehabilitation program and improvements were recorded in preoperative physical capacity.

Prehabilitation for Chilean frail elderly people - pre-surgical conditioning protocol - to reduce the length of stay: randomized control trial

BACKGROUND

Frail elderly patients have a higher risk of postoperative morbidity and mortality. Prehabilitation is a potential intervention for optimizing postoperative outcomes in frail patients. We studied the impact of a prehabilitation program on length of stay (LOS) in frail elderly patients undergoing elective surgery.

METHODS

An RCT study was conducted. Frail patients scheduled for elective surgery were randomized to receive either pre-surgical conditioning protocol (PCP) or standard preoperative care. PCP included nursing, anesthetic, and geriatric assessment, nutritional intervention, and physical training for 4-weeks preoperatively. A nurse followed both groups until discharge criteria were met. The primary outcome was postoperative LOS. Secondary outcomes were nutritional status, preoperative frailty status (frailty phenotype-FP) after PCP, and postoperative complications up to three months categorized according to the Clavien-Dindo Classification. Means and medians between the control and intervention groups were compared, with statistical significance set at α=5%.

RESULTS

Thirty-four patients were to intervention and Thirty-seven to the control group. In the intervention group, adherence to prehabilitation was 90%. The median LOS after surgery was three days in both groups, without finding statistically significant differences between groups (P=0.754), although there was a trend towards lower LOS in the urologic surgery subgroup. We found a significant reduction in frailty status after PCP (FPpre=2.4±0.5 and FPpost=1.7±0.5, P<0.001). Nutritional status significantly improved in frail patients after prehabilitation (MNAbasal=9.0±2.5 and MNApost=10.6±2.6), P=0.028. The intervention group had less severe postoperative complications, which were not statistically significant.

CONCLUSIONS

The PCP conducted both in-person and online, for older frail patients undergoing elective colorectal and urological surgery was not associated with shorter LOS. However, frailty status significantly improved after completing PCP.

Stakeholders' perspectives on capturing societal cost savings from a quality improvement initiative: A qualitative study

BACKGROUND

Besides improving the quality of care, quality improvement initiatives often also intend to produce cost savings. An example is prehabilitation, which can reduce complication rates and the length of stay in the hospital. However, the process from utilization reductions to actual societal cost savings remains uncertain in practice. Our aim was to identify barriers and facilitators throughout this process. We used the implementation of prehabilitation in a Dutch hospital as a test case.

METHODS

We held 20 semi-structured interviews between June and November 2023. Eighteen stakeholders were affiliated with the hospital and two with different health insurers. Nine interviews were held face-to-face and 11 via Microsoft Teams. The interviews were recorded and transcribed. The first transcripts were inductively coded by two authors, the subsequent transcripts by one and checked by another. Differences were resolved through discussion.

RESULTS

We identified 20 barriers and 23 facilitators across four stages: reducing capacity, reducing departmental expenses, reducing hospital expenses and reducing insurer expenses. All participants expected that the excess capacity will be used for other priorities. This was perceived as highly valuable and as an efficiency gain. Other barriers to capture savings included the fear of losing resilience, flexibility, status and revenue. Misalignment between service contracts among hospitals and insurers can hinder the ability to financially incentivize cost reductions. Additionally, some contract types can hinder the transfer of hospital savings to insurers. Identified facilitators included shared savings agreements, an explicit strategy targeting all stages, and labor shortage, among others.

CONCLUSION

This study systematically describes barriers and facilitators that prevent translating quality improvement initiatives into societal cost savings. Stakeholders expect that any saved capacity will be used for other priorities, including providing care due to the increasing demand. Capturing any cash savings does not occur automatically, emphasizing the need for a strategy targeting all stages.

Effect of prehabilitation programmes on functional capacity in patients awaiting oncological resections: a systematic review and meta-analysis of randomised controlled trials

PURPOSE

To investigate the effects of prehabilitation on the perioperative functional capacity of patients awaiting oncological resections.

METHODS

A systematic review and meta-analysis were performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) checklist and within the databases Cochrane Library, EBSCOhost, Google Scholar, MEDLINE PubMed, and Web of Science. The eligibility criteria were set to include peer-reviewed randomised control trials including only adult (≥ 18 years old) patients undergoing any type of prehabilitation (PREHAB) prior to any type of oncological resection. The studies had to feature at least one control group undergoing standard care (SC) and had to assess functional capacity by means of a 6-min walk distance (6MWD) or peak oxygen uptake (VO2Peak) at different stages pre- and post- operatively.

RESULTS

Twenty-seven randomised controlled trials involving 1994 patients were included. After processing the data, the number of patients was 1889. Studies featured different cancer specialties: lung (11), colorectal (5), urological (4), abdominal (3), esophagogastric (2), liver (1), and gastrointestinal (1). Overall, PREHAB enhanced both 6MWD (g = 0.273, 95% CI 0.174 to 0.371, Z = 5.406, p < 0.001) and VO2Peak (g = 0.615, 95% CI 0.243 to 0.987, Z = 3.240, p = 0.001) compared with SC. The 6MWD subgroup analysis revealed a small mean effect size favouring both unimodal and multimodal PREHAB interventions.

CONCLUSION

These findings support that prehabilitation, whether implemented as unimodal or multimodal format, elicits small preoperative improvements in functional capacity in patients awaiting oncological resections. PROSPERO registration number CRD42023428676.

Perioperative management of sarcopenia in patients undergoing major surgeries in Singapore: a modified Delphi consensus

BACKGROUND

Ageing population is a worldwide phenomenon with correspondingly higher proportion of older patients being treated in the hospital setting. Sarcopenia, which increases with age, has serious negative implications on health, hospitalisation, and overall postoperative recovery. There is no mutual consensus on perioperative management of sarcopenia in surgical patients in Singapore. The purpose of this study is to create greater clarity pertaining to the recognition of sarcopenia, the application of assessment criteria of sarcopenia and perioperative management of surgical patients in Singapore.

METHODS

A modified Delphi consensus consisting of a panel of experts from Singapore forming a multidisciplinary team, including surgeons, geriatricians, anesthesiologists, physiotherapists, and dieticians. Eight recommendations were proposed by the steering committee. Literature search from MEDLINE, Embase, and Scopus for articles up till June 2023 were performed to support recommendation statements. The expert panel voted on agreement to recommendation statements and graded the level of evidence supporting each statement through surveys to achieve consensus, set at 85% a priori.

RESULTS

The panellists underwent two rounds of anonymized, independent voting before reaching consensus for all eight statements. After the first round, seven statements reached consensus, including the corresponding grading for level of evidence. The statement which did not achieve consensus was revised with supporting literature and after the second round of survey, all eight statements and level of evidence reached consensus, completing the Delphi process. These eight statements covered themes to (1) encourage the identification of sarcopenia, (2) guide preoperative, and (3) postoperative management of sarcopenia.

CONCLUSION

With the varying approaches in perioperative management, poor understanding of and identification of sarcopenia can result in suboptimal management of sarcopenia in surgical patients. Given the abundance of evidence linking beneficial impact on recovery and postoperative complications with prudent management of sarcopenia, it is imperative and urgent to achieve awareness and consensus.

Multimodal prehabilitation in elective oncological colorectal surgery enhances postoperative functional recovery: A secondary analysis of the PREHAB randomized clinical trial

INTRODUCTION

Colorectal cancer (CRC) ranks as the second leading cause of cancer-related deaths. The PREHAB trial revealed that prehabilitation in colorectal surgery leads to a reduction of severe complications and enhanced functional capacity. Nevertheless, risk selection for prehabilitation and the potential benefits for patients without postoperative complications remains unclear. This study aims to assess postoperative functional capacity, also in patients without postoperative complications.

MATERIALS & METHODS

This study was a secondary analysis of the PREHAB trial. Functional capacity tests, including cardiopulmonary exercise testing (CPET), steep ramp test (SRT), 6-min walking test (6MWT), stair climb test (SCT), 30" sit-to-stand test (STS), timed-up-and-go test (TUG), and muscle strength assessments, were conducted at baseline (T0) and 4 weeks postoperatively (T3). The primary outcome was the relative change in functional capacity from baseline to postoperative (ΔT0-T3) per group (i.e., prehabilitation vs control). Secondary, identical analysis were performed for patients without postoperative complications in each group.

RESULTS

Intention-to-treat analysis included 251 patients. For postoperative functional capacity, prehabilitation patients showed improvements in VO2peak (p = 0.024), VO2AT (p = 0.017), SRT (p = 0.001), 6MWT (p = 0.049), SCT (p = 0.012), and STS (p = 0.001) compared to the control group. Regarding muscle strength, prehabilitation patients showed improvements in estimated 1RM lateral pull down (p = 0.016), 1RM chest press (p = 0.001), 1RM leg press (p = 0.001) and HGS (p = 0.005) compared to controls. Additionally, prehabilitation patients more often reached baseline levels at T3 in VO2AT (p = 0.037), SRT (p = 0.008), 6MWT (p = 0.013), STS (p = 0.012), estimated 1RM lateral pull down (p = 0.002), 1RM chest press (p = 0.001) and 1RM leg press (p = 0.001) compared to controls. Moreover, even patients without postoperative complications in the prehabilitation group showed better postoperative functional capacity and more often reached baseline levels at T3, compared to controls.

CONCLUSION

Multimodal prehabilitation in CRC surgery is associated with improved postoperative functional capacity, even in patients without postoperative complications.

Access, acceptance and adherence to cancer prehabilitation: a mixed-methods systematic review

PURPOSE

The purpose of this systematic review is to better understand access to, acceptance of and adherence to cancer prehabilitation.

METHODS

MEDLINE, CINAHL, PsychINFO, Embase, Physiotherapy Evidence Database, ProQuest Medical Library, Cochrane Library, Web of Science and grey literature were systematically searched for quantitative, qualitative and mixed-methods studies published in English between January 2017 and June 2023. Screening, data extraction and critical appraisal were conducted by two reviewers independently using Covidence™ systematic review software. Data were analysed and synthesised thematically to address the question 'What do we know about access, acceptance and adherence to cancer prehabilitation, particularly among socially deprived and minority ethnic groups?' The protocol is published on PROSPERO CRD42023403776 RESULTS: Searches identified 11,715 records, and 56 studies of variable methodological quality were included: 32 quantitative, 15 qualitative and nine mixed-methods. Analysis identified facilitators and barriers at individual and structural levels, and with interpersonal connections important for prehabilitation access, acceptance and adherence. No study reported analysis of facilitators and barriers to prehabilitation specific to people from ethnic minority communities. One study described health literacy as a barrier to access for people from socioeconomically deprived communities.

CONCLUSIONS

There is limited empirical research of barriers and facilitators to inform improvement in equity of access to cancer prehabilitation.

IMPLICATIONS FOR CANCER SURVIVORS

To enhance the inclusivity of cancer prehabilitation, adjustments may be needed to accommodate individual characteristics and attention given to structural factors, such as staff training. Interpersonal connections are proposed as a fundamental ingredient for successful prehabilitation.