Supervised exercise training with multimodal pre-habilitation leads to earlier functional recovery following colorectal cancer resection

Multimodal Prehabilitation in Colorectal Cancer: Improving Fitness, Lifestyle, and Post-Surgery Outcomes

Objectives: This study aimed to analyze the effect of a multimodal prehabilitation program for colorectal cancer patients in body composition, physical and cardiorespiratory fitness as well as its ability to reduce postoperative complications. Methods: A longitudinal observational study evaluated the efficacy of a prehabilitation intervention based on four components: (a) health education and self-care, (b) nutritional counseling, (c) psychological support, and (d) supervised physical exercise. Body composition was determined through bioelectrical impedance analysis; physical fitness variables such as strength was measured by a handgrip dynamometer for upper limbs, and a squat-jump test, countermovement jump test using a contact platform, and a chair-stand test for lower limbs. Flexibility was assessed with the sit-and-reach test. Cardiorespiratory fitness was assessed with the 6 min walking test (6MWT). Moreover, we measured lifestyles related to the amount of physical exercise by accelerometry. Results: The final cohort included 30 patients. Patients completed an average of 9.90 ± 5.26 exercise sessions. Statistically significant changes with varying effect sizes were observed in the following outcomes: SJ values in cm and W for both sexes (p = 0.021/d = 0.14 and p = 0.043/d = 0.10, respectively), SJ in W for women (p = 0.023/d = 0.21), all chair-stand test values (p = 0.021/d = 0.65 for men, p = 0.004/d = 2.08 for women, and p = 0.000/d = 0.84 for both sexes), and sit-and-reach for both sexes (p = 0.005/d = 0.12) and for men (p = 0.044/d = 0.08). All 6MWT values had statistically significant changes (p = 0.001/0.46). Women reduced the weekly minutes spent in sedentary behavior (p = 0.037/d = 0.65) and increased the minutes spent performing light physical activity (p = 0.037/d = 0.63). With regard to surgical outcomes, there was a tendency towards a decrease in postoperative complications and hospitalization days, as well as minutes in postoperative REA (p = 0.009/d = 0.69) in relation to the control group. Conclusions: Participation in a multimodal prehabilitation program improves several aspects of physical condition and lifestyles related to the amount of physical exercise and reduces both days of hospitalization and several complications post-surgery.

The effects of psychological intervention on negative emotions, pain, and sleep in patients with advanced colon cancer

OBJECTIVE

To investigate the effectiveness of psychological interventions in improving negative emotions, pain, and sleep quality among patients with advanced colon cancer.

METHODS

From March 2021 to March 2023, a total of 218 patients with advanced colon cancer were selected from the First Affiliated Hospital of Soochow University based on strict inclusion and exclusion criteria. Patients were randomly assigned to either the control group or the observation group (109 patients each) using a random number table. The control group received standard medical care, while the observation group received psychological interventions. Both groups were assessed for anxiety and depression levels [using the Self-Rating Anxiety Scale (SAS) and the Self-Rating Depression Scale (SDS)], sleep quality [measured by the Pittsburgh Sleep Quality Index (PSQI)], pain intensity [using the Visual Analog Scale (VAS)], and overall quality of life. Inter-group comparisons were conducted.

RESULTS

Post-intervention assessments showed a decrease in SAS and SDS scores for both groups, with the observation group demonstrating a more significant reduction (P < 0.05). Additionally, the observation group reported significantly lower pain levels (VAS scores) and improved sleep quality (PSQI scores) compared to the control group, along with a markedly higher quality of life as measured by the Quality of Life Core Questionnaire (QLQ-30) (P < 0.05).

CONCLUSION

This study demonstrates that psychological interventions effectively alleviate anxiety, depression, pain, and sleep disturbances in patients with advanced colon cancer, thereby improving their overall quality of life. However, further studies are required to explore the long-term impact on prognosis.

Supervised Home-Based Exercise Intervention in Colorectal Cancer Patients Following Surgery: A Feasibility Study

This pilot study aimed to assess the feasibility and preliminary effects of a supervised, home-based exercise program in patients recovering from laparoscopic colorectal cancer surgery. A total of 23 patients were included, with 13 participating in the exercise intervention and 10 receiving standard postoperative care. The exercise group (intervention group) followed a two-month structured program, while the control group received no structured exercise. Feasibility was demonstrated by 98% adherence in the intervention group and no reported adverse events. At T1, the intervention group showed significant improvements in role function, cognitive function, and reduced fatigue compared to the control group. At T2, a significant difference was observed in physical function. Functional capacity, assessed by the Six-Minute Walk Test, was significantly better in the intervention group at T1, T2, and T3, as was physical performance measured by the Short Physical Performance Battery (SPPB) at T1, T2, and T3. No significant differences were observed between the groups in anxiety, depression, sleep quality, or body composition parameters. This study highlights the feasibility of a supervised home-based exercise program in the early postoperative phase, demonstrating positive effects on Quality of Life, functional recovery, and fatigue in colorectal cancer patients.

Predictive Power of the Fried Phenotype in Assessing Postoperative Outcomes in Patients Undergoing Craniotomy for Tumor Resection

BACKGROUND AND OBJECTIVES

Compared with the modified Frailty Index-11 (mFI-11) frailty tool, reflective of patient comorbidities, the Fried phenotype weighs functional patient variables. This study examined using the Fried phenotype in predicting postoperative outcomes in craniotomy for patients with tumor.

METHODS

This retrospective cohort analysis included patients with Current Procedural Terminology codes for supratentorial/infratentorial tumor resections and preoperative frailty scores. Chart review collected the remaining variables for the primary outcome, length of stay (LOS), and secondary outcomes, discharge disposition and postoperative complications. Basic descriptive statistics summarized patient demographics, clinical parameters, and postoperative outcomes. χ 2 tests, t -tests, and ANOVA examined associations and mean differences. Logistic and Poisson regressions explored predictor-outcome relationships.

RESULTS

Over 7 years, these 153 patients underwent Fried assessments. The Fried score was biased toward females being more frail (nonfrail 38.0% female, prefrail 50.0% female and frail 65.6% female, P = .027) but not by age, body mass index, or tumor type. The mFI-11 was biased by age (nonfrail 67.8 years vs frail 72.3 years, P < .001) and body mass index (nonfrail 27.5 vs frail 30.8, P < .001) but not sex or tumor type. The Fried score was significantly correlated with increased LOS's (odds ratio [OR] = 5.92, 95% CI = 1.66-21.13, P < .001) but the mFI-11 was not (OR = 0.82, 95% CI = 0.35-1.93, P = .64). The Fried phenotype was significantly correlated with discharge disposition location ( P = .016), whereas the mFI-11 was not ( P = .749). The Fried score was significantly correlated with postoperative complications (OR = 1.36, 95% CI = 1.08-1.71, P = .01), whereas the mFI-11 was not (OR = 1.10, 95% CI = 0.86-1.41, P = .44).

CONCLUSION

The Fried phenotype more accurately correlates with postoperative outcomes including LOS, discharge disposition location, and complications than does the mFI-11 score. These findings can be used to guide preoperative planning, inform consent, and potentially identify patients who may benefit from functional optimization in the preoperative period to improve postoperative outcomes.

Impact of mindfulness-based tri-modal prehabilitation on functional recovery and selected surgical outcomes of patients with colorectal cancer admitted to surgical hospital wards: the first international randomised control trial for mindfulness-based tri-modal prehabilitation

INTRODUCTION

Colorectal cancer (CRC) is the third most common and second most deadly cancer worldwide, with significant morbidity and mortality risks. Despite advancements in surgical care, postoperative complications and recovery challenges persist. The severity of these issues is linked to preoperative functional capacity and emotional distress. Mindfulness, known for enhancing emotional well-being, is being considered as a promising intervention in cancer care. This study investigates the effectiveness of mindfulness-based tri-modal prehabilitation in improving functional recovery and surgical outcomes for patients with CRC.

METHODS AND ANALYSIS

The sample size of this prospective, randomised controlled trial was calculated based on the primary outcome, which is the detection of the clinically significant difference in a 6 min walk test (6MWT). With our population variables, the size of the sample was estimated for an α level of 0·05 (two-sided) and 80% power to detect a clinically meaningful difference between groups at postsurgical follow-up of 32 m, with an estimated variability of 64 m based on previous studies. The final sample size is 72 patients, in both arms. Both groups will receive a 4-week standard tri-modal prehabilitation. The intervention group will receive a mindfulness practice module. Outcomes will be measured at four different time intervals for each patient. Secondary outcome measures cover nutritional status, psychological status and selected biomarker status. Patient recruitment to the study started in April 2022.

ETHICS AND DISSEMINATION

This study was approved by the Ethics Review Committee of the Faculty of the Medical Sciences University of Sri Jayewardenepura (Registration No: FMC/ USJP ERC 29/19) and the Ethics Review Committee of Colombo South Teaching Hospital (Reference number 915). The research results will be published in peer-reviewed publications and presented at international conferences.

TRIAL REGISTRATION NUMBER

SLCTR/2020/022.

Patient attitudes and experiences towards exercise during oncological treatment. A qualitative systematic review

PURPOSE

Exercise and physical activity (PA) during oncological treatment have many benefits. However, PA levels and adherence are often low. This systematic review of qualitative literature aims to explore the experience and the perceived barriers and facilitators to exercise and physical activity during treatment.

METHODS

A systematic search of the published literature was carried out in the Embase and Medline databases; full details for the protocol can be found in the Prospero database (CRD42022371206). Studies eligible for inclusion were qualitative and included participants that were either currently undergoing oncological treatment or had finished treatment within the last 6 months. The findings from each study were tabulated and synthesised into analytical themes.

RESULTS

Eighteen full texts from 309 studies met inclusion criteria with a total of 420 participants including both curative and palliative treatment intents. Four overarching themes were generated: (1) Facilitators; (2) Barriers; (3) Experience of PA/exercise and (4) Transforming attitudes. Sub-themes that showed perceptions of PA or exercise during treatment were positive, and seeing personal positive change was highly motivating, especially in a group class setting. Barriers included lack of support or guidance from healthcare professionals (HCPs), environmental challenges and disease burden/fear or worsening symptoms.

CONCLUSIONS

Despite having positive perceptions of exercise and PA during oncological treatment, there are significant barriers impacting participation. Lack of support from HCPs and fear of worsening symptoms were significant barriers. Future research should focus on impacting these barriers to ultimately improve PA and exercise levels in those undergoing oncological treatment.

Multimodal Prehabilitation for Patients with Crohn's Disease Scheduled for Major Surgery: A Narrative Review

Approximately 15-50% of patients with Crohn's disease (CD) will require surgery within ten years following the diagnosis. The management of modifiable risk factors before surgery is essential to reduce postoperative complications and to promote a better postoperative recovery. Preoperative malnutrition reduced functional capacity, sarcopenia, immunosuppressive medications, anemia, and psychological distress are frequently present in CD patients. Multimodal prehabilitation consists of nutritional, functional, medical, and psychological interventions implemented before surgery, aiming at optimizing preoperative status and improve postoperative recovery. Currently, studies evaluating the effect of multimodal prehabilitation on postoperative outcomes specifically in CD are lacking. Some studies have investigated the effect of a single prehabilitation intervention, of which nutritional optimization is the most investigated. The aim of this narrative review is to present the physiologic rationale supporting multimodal surgical prehabilitation in CD patients waiting for surgery, and to describe its main components to facilitate their adoption in the preoperative standard of care.

Retrospective analysis of preoperative application of triple-modal pre-rehabilitation on postoperative recovery of colorectal cancer patients

PURPOSE

To retrospectively analyze the difference between triple-modal pre-rehabilitation and common treatment in patients with colorectal cancer (CRC).

METHODS

A total of 145 patients with CRC diagnosed by pathology and admitted to our hospital for surgery between June 2020 and June 2022 were included in the study. All patients were divided into two groups: the triple-modal pre-rehabilitation group (pre-rehabilitation group) and the common treatment group. The triple-modal pre-rehabilitation strategy included exercise (3-5 times per week, with each session lasting more than 50 min), nutritional support, and psychological support. The study was designed to assess the potential of the pre-rehabilitation intervention to accelerate postoperative recovery by assessing the 6-min walk test, nutritional indicators, and HADS score before and after surgery.

RESULTS

The pre-rehabilitation intervention did not reduce the duration of initial postoperative recovery or the incidence of postoperative complications, but it did increase the patients' exercise capacity (as determined by the 6-min walk test), with the pre-rehabilitation group performing significantly better than the common group (433.0 (105.0) vs. 389.0 (103.5), P < 0.001). The study also found that triple-modal pre-rehabilitation was beneficial for the early recovery of nutritional status in surgical patients and improved anxiety and depression in patients after surgery, especially in those who had not received neoadjuvant therapy.

CONCLUSION

The triple-modal pre-rehabilitation strategy is of significant importance for reducing stress and improving the functional reserve of patients with colorectal cancer (CRC) during the perioperative period. The results of our study provide further support for the integration of the triple-modal pre-rehabilitation strategy into the treatment and care of CRC patients.

Prescribing pre- and post-operative physical activity interventions for people undergoing breast cancer surgery: A qualitative systematic review

INTRODUCTION

Undertaking physical activity, pre- and post-operatively, can benefit recovery time and improve post-surgical outcomes. One cohort of patients that have reported these benefits are those undergoing surgery for breast cancer. Yet, what remains unclear is the level to which physical activity interventions are implemented into standard surgical care for patients with breast cancer.

AIMS

This systematic review aimed to examine existing qualitative evidence focusing on pre- and post-operative physical activity interventions to better understand the benefits and shortcomings of physical activity within the surgical journey.

METHODS

A systematic literature search was undertaken in November 2022, across five databases: MEDLINE, PsycINFO, Embase, CINAHL, and Scopus. Qualitative studies involving people with breast cancer who had undertaken a physical activity intervention, either pre- and/or post-operatively, were included for analysis. The review was registered on PROSPERO: CRD42022372466 and performed according to PRISMA guidelines. The Critical Appraisal Skills Programme qualitative study checklist was used to assess study quality.

RESULTS

Fourteen studies were included, comprising the perspectives of 418 people receiving surgery for breast cancer. One study implemented preoperative physical activity interventions; the remaining studies focused on post-operative interventions. A narrative systematic review was undertaken due to heterogeneity in reported results. Four themes were developed by thematic analysis, centring on: (1) factors promoting engagement with physical activity interventions; (2) factors preventing engagement with physical activity interventions; (3) the impact of pre- and post-operative interventions on physical and psychological health; and (4) participant recommendations for pre- and post-operative interventions.

CONCLUSION

Pre- and post-operative physical activity interventions were well-accepted. Patients recognised factors which promoted or prevented engagement with interventions, as well as pre- and post-operative physical and psychological benefits that arose as a result. Evidence based co-design studies may further inform successful implementation of prescribed physical activity into standard care for surgical breast cancer patients.

Everything or Nothing: Supervised High-intensity Exercise is the Only Way to Achieve Meaningful Results

Prehabilitation exercise should be performed via supervised, high-intensity exercise training regimens. This type of training is preferred by patients, increases exercise accountability, leads to emotional and social benefits, and ensures that exercises are performed in a safe and efficient manner.

A systematic review of the impact of postoperative aerobic exercise training in patients undergoing surgery for intra-abdominal cancers

INTRODUCTION

Enhanced recovery after surgery (ERAS) programmes which advocate early mobility after surgery have improved immediate clinical outcomes for patients undergoing abdominal cancer resections with curative intent. However, the impact of continued physical activity on patient-related outcomes and functional recovery is not well defined. The aim of this review was to assess the impact of postoperative aerobic exercise training, either alone or in conjunction with another exercise modality, on patients who have had surgery for intra-abdominal cancer.

METHODS

A literature search was performed of electronic journal databases. Eligible papers needed to report an outcome of aerobic capacity in patients older than 18 years of age, who underwent cancer surgery with curative intent and participated in an exercise programme (not solely ERAS) that included an aerobic exercise component starting at any point in the postoperative pathway up to 12 weeks.

RESULTS

Eleven studies were deemed eligible for inclusion consisting of two inpatient, one mixed inpatient/outpatient and eight outpatient studies. Meta-analysis of four outpatient studies, each reporting change in 6-min walk test (6MWT), showed a significant improvement in 6MWT with exercise (MD 74.92 m, 95% CI 48.52-101.31 m). The impact on health-related quality of life was variable across studies.

CONCLUSION

Postoperative exercise confers benefits in improving aerobic function post surgery and can be safely delivered in various formats (home-based or group/supervised).

Assessing real-world implementability of a multimodal group-based tele-prehabilitation program in cancer care: a pragmatic feasibility study

Introduction

Multimodal prehabilitation is intended to optimize a patient's mental and physical health prior to surgery. Most multimodal prehabilitation interventions are delivered on a one-on-one format, which may limit benefits associated with social interactions that can be achieved in a group context, and are delivered in-person, which may limit the accessibility. The purpose of this study was to develop a group-based, multimodal, tele-prehabilitation intervention for individuals diagnosed with cancer (iACTIF) and assess its implementability in a "real-world" clinical setting by measuring feasibility, acceptability, fidelity, and preliminary effects.

Methods

A prospective, single-group, pragmatic feasibility study was conducted with assessments at baseline, pre-surgery, and 12-weeks post-surgery. iACTIF consisted of three 90-min live videoconference sessions per week, including exercise and educational components. Descriptive statistics were used to document feasibility, acceptability, and fidelity indicators. Paired t-test, Wilcoxon test, and Cohen's D-test were conducted to assess changes in health-related outcomes.

Results

A total of 25 participants (mean age ± SD= 60.2 ± 14.0) were recruited. The feasibility assessment revealed a low referral rate (31.4%) and a high study retention (98%) and program attendance [session attended/possible session] (70.2%), with a prehabilitation window of 32.7 days (SD= 20.9, median= 28). Acceptability was high (84%-100%) according to satisfaction, utility and safety, delivery modality, and intention to continue physical activity and to recommend iACTIF to a relative. Pre-post-intervention assessments suggest positive changes on physical functional capacity based on the 2-min step test (mean difference= +18.9 steps, p=0.005), the 30-s sit-to-stand (mean difference= +1.1 repetition, p=0.011), and volume of moderate intensity physical activity per week (mean difference= +104.8 min, p<0.001). Fidelity was supported by conformity and coherence, with only minimal adjustments required to meet participants' needs.

Discussion

iACTIF implementability in a "real-world" clinical setting is promising, and preliminary outcomes suggest moderate benefits on physical health and small increase in mental health indicators.

Exercise effects on functional capacity and quality of life in older patients with colorectal cancer: study protocol for the ECOOL randomized controlled trial

BACKGROUND

Surgery and treatment for colorectal cancer (CRC) in the elderly patient increase the risk of developing post-operative complications, losing functional independence, and worsening health-related quality of life (HRQoL). There is a lack of high-quality randomized controlled trials evaluating the potential benefit of exercise as a countermeasure. The primary aim of this study is to evaluate the effectiveness of a home-based multicomponent exercise program for improving HRQoL and functional capacity in older adults undergoing CRC surgery and treatment.

METHODS

This randomized, controlled, observer-blinded, single-center trial aims to randomize 250 patients (>74 years) to either an intervention or a control group (i.e., usual care). The intervention group will perform an individualized home-based multicomponent exercise program with weekly telephone supervision from diagnosis until three months post-surgery. The primary outcomes will be HRQoL (EORTC QLQ-C30; CR29; and ELD14) and functional capacity (Barthel Index and Short Physical Performance Battery), which will be assessed at diagnosis, at discharge, and one, three, and six months after surgery. Secondary outcomes will be frailty, physical fitness, physical activity, inspiratory muscle function, sarcopenia and cachexia, anxiety and depression, ambulation ability, surgical complications, and hospital length of stay, readmission and mortality.

DISCUSSION

This study will examine the effects of an exercise program in older patients with CRC across a range of health-related outcomes. Expected findings are improvement in HRQoL and physical functioning. If proven effective, this simple exercise program may be applied in clinical practice to improve CRC care in older patients.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT05448846.

Prehabilitation versus no prehabilitation to improve functional capacity, reduce postoperative complications and improve quality of life in colorectal cancer surgery

BACKGROUND

Surgery is the cornerstone in curative treatment of colorectal cancer. Unfortunately, surgery itself can adversely affect patient health. 'Enhanced Recovery After Surgery' programmes, which include multimodal interventions, have improved patient outcomes substantially. However, these are mainly applied peri- and postoperatively. Multimodal prehabilitation includes multiple preoperative interventions to prepare patients for surgery with the aim of increasing resilience, thereby improving postoperative outcomes.

OBJECTIVES

To determine the effects of multimodal prehabilitation programmes on functional capacity, postoperative complications, and quality of life in adult patients undergoing surgery for colorectal cancer.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and PsycINFO in January 2021. We also searched trial registries up to March 2021.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) in adult patients with non-metastatic colorectal cancer, scheduled for surgery, comparing multimodal prehabilitation programmes (defined as comprising at least two preoperative interventions) with no prehabilitation. We focused on the following outcomes: functional capacity (i.e. 6-minute walk test, VO2peak, handgrip strength), postoperative outcomes (i.e. complications, mortality, length of hospital stay, emergency department visits, re-admissions), health-related quality of life, compliance, safety of prehabilitation, and return to normal activities.

DATA COLLECTION AND ANALYSIS

Two authors independently selected studies, extracted data, assessed risk of bias and used GRADE to assess the certainty of the evidence. Any disagreements were solved with discussion and consensus. We pooled data to perform meta-analyses, where possible.

MAIN RESULTS

We included three RCTs that enrolled 250 participants with non-metastatic colorectal cancer, scheduled for elective (mainly laparoscopic) surgery. Included trials were conducted in tertiary care centres and recruited patients during periods ranging from 17 months to 45 months. A total of 130 participants enrolled in a preoperative four-week trimodal prehabilitation programme consisting of exercise, nutritional intervention, and anxiety reduction techniques. Outcomes of these participants were compared to those of 120 participants who started an identical but postoperative programme. Postoperatively, prehabilitation may improve functional capacity, determined with the 6-minute walk test at four and eight weeks (mean difference (MD) 26.02, 95% confidence interval (CI) -13.81 to 65.85; 2 studies; n = 131; and MD 26.58, 95% CI -8.88 to 62.04; 2 studies; n = 140); however, the certainty of evidence is low and very low, respectively, due to serious risk of bias, imprecision, and inconsistency. After prehabilitation, the functional capacity before surgery improved, with a clinically relevant mean difference of 24.91 metres (95% CI 11.24 to 38.57; 3 studies; n = 225). The certainty of evidence was moderate due to downgrading for serious risk of bias. The effects of prehabilitation on the number of complications (RR 0.95, 95% CI 0.70 to 1.29; 3 studies; n = 250), emergency department visits (RR 0.72, 95% CI 0.39 to 1.32; 3 studies; n = 250) and re-admissions (RR 1.20, 95% CI 0.54 to 2.65; 3 studies; n = 250) were small or even trivial. The certainty of evidence was low due to downgrading for serious risk of bias and imprecision. The effects on VO2peak, handgrip strength, length of hospital stay, mortality rate, health-related quality of life, return to normal activities, safety of the programme, and compliance rate could not be analysed quantitatively due to missing or insufficient data. The included studies did not report a difference between groups for health-related quality of life and length of hospital stay. Data on remaining outcomes were not reported or were reported inadequately in the included studies.

AUTHORS' CONCLUSIONS

Prehabilitation may result in an improved functional capacity, determined with the 6-minute walk test both preoperatively and postoperatively. A solid effect on the number of omplications, postoperative emergency department visits and re-admissions could not be established. The certainty of evidence ranges from moderate to very low, due to downgrading for serious risk of bias, imprecision and inconsistency. In addition, only three heterogeneous studies were included in this review. Therefore, the findings of this review should be interpreted with caution. Numerous relevant RCTs are ongoing and will be included in a future update of this review.

Remote and Unsupervised Exercise Strategies for Improving the Physical Activity of Colorectal Cancer Patients: A Meta-Analysis

Colorectal cancer (CRC) burden across the world is expected to increase by ~2.2 million new cases and ~1.1 million deaths by 2030. Regular physical exercise is recommended to prevent CRC, but the myriad of protocols preclude further discussion on how to manage its variables for this population. Home-based exercise guided by remote monitoring provides an alternative to surpass the barriers of supervised exercise. However, no meta-analysis was conducted to verify the effectiveness of this intervention for improving physical activity (PA). We performed a systematic review of remote and unsupervised strategies imposed on CRC patients for improving PA and compared, via a meta-analysis, their effectiveness against CRC patients submitted to usual care or no intervention. The databases PubMed, Scopus, and Web of Science were searched on 20 September 2022. Eleven studies attained the criteria for eligibility in the qualitative approach, and seven were included in the meta-analysis. No significant effect (p = 0.06) of remote and unsupervised exercise intervention was observed. However, a sensitivity analysis including three studies that only considered CRC patients was performed, demonstrating a significant effect in favor of exercise (p = 0.008). Based on our sensitivity analysis, remote and unsupervised exercise strategies were effective to improve the PA of CRC patients.

Patient characteristics and preferences for a surgical prehabilitation program design: results from a pilot survey

PURPOSE

Surgical prehabilitation aims to reduce a decline in the functional capacity thereby optimising health and fitness before surgery. One of the major barriers in successfully implementing a prehabilitation program in hospitals has been poor patient adherence. In our pilot survey on surgical patients, we sought to explore patient preferences regarding the program design, the barriers and enablers to patient participation in a multimodal prehabilitation program.

METHODS

The survey was administered to patients undergoing major abdominal surgery in the preoperative period. The first two parts of the instrument mainly included questions on demographics, social history, activity levels, interest towards prehabilitation program and their involvement in co-design, preferences towards the components of the program, the barriers and enablers. The last part of survey included symptom and physical assessments.

RESULTS

The survey was completed by 24 patients undergoing major abdominal surgery. The median age of our cohort was 71 (range 35-91) years and 75% were retired. 75% of our participants were extremely interested in improving health and fitness and 63% were very keen to co-design their program when explained. Home-based programs were preferred by most participants and among exercises, walking was preferred by 71% of the participants. One third of the participants were interested in professional dietary counselling. There were only two participants who preferred group psychological therapy while 25% preferred individual psychological counselling sessions.

CONCLUSION

Our survey highlighted a need to design a personalised program with tailored interventions due to the wide variation in the interest and preferences among surgical patients.

Lifestyle Interventions with Mind-Body or Stress-Management Practices for Cancer Survivors: A Rapid Review

This rapid review examined current evidence on lifestyle interventions with stress-management or mind-body practices that assessed dietary and/or physical activity outcomes among cancer survivors. Searches were conducted in PubMed, Embase, and PsycINFO based on Cochrane Rapid Reviews Methods Group rapid review recommendations using the keywords "diet," "physical activity," "mind-body," "stress," and "intervention." Of the 3624 articles identified from the initial search, 100 full-text articles were screened, and 33 articles met the inclusion criteria. Most studies focused on post-treatment cancer survivors and were conducted in-person. Theoretical frameworks were reported for five studies. Only one study was tailored for adolescent and young adult (AYA) cancer survivors, and none included pediatric survivors. Nine studies reported race and/or ethnicity; six reported that ≥90% participants were White. Many reported significant findings for diet and/or physical activity-related outcomes, but few used complete, validated dietary intake methods (e.g., 24-h recall; n = 5) or direct measures of physical activity (e.g., accelerometry; n = 4). This review indicated recent progress on evaluating lifestyle interventions with stress-management or mind-body practices for cancer survivors. Larger controlled trials investigating innovative, theory-based, personalized interventions that address stress and health behaviors in cancer survivors-particularly racial/ethnic minority and pediatric and AYA populations-are needed.

Home-based physical activity after treatment for esophageal cancer-A randomized controlled trial

BACKGROUND

The treatment of most esophageal cancer patients includes chemo(radio)therapy and extensive surgery, causing physical decline with loss of muscles. This trial aimed to test the hypothesis that a tailored home-based physical activity (PA) intervention improves muscle strength and mass in patients having undergone curative treatment for esophageal cancer.

METHODS

Patients operated for esophageal cancer 1 year earlier were included in a nationwide randomized controlled trial in Sweden in 2016-2020. The intervention group was randomized to a 12-week home-based exercise program, while the control group was encouraged to maintain routine daily PA. The primary outcomes were changes in maximal/average hand grip strength measured with hand grip dynamometer and lower extremity strength measured using 30-second chair stand test and muscle mass measured using a portable bio-impedance analysis monitor. Intention-to-treat analysis was used, and results were presented as mean differences (MDs) with 95% confidence intervals (CIs).

RESULTS

Among 161 randomized patients, 134 completed the study, 64 in the intervention group and 70 in the control group. Compared with the control group (MD 2.73; 95% CI 1.75-3.71), patients in the intervention group (MD 4.48; 95% CI 3.18-5.80) had statistically significantly (p = 0.03) improved lower extremity strength. No differences were seen for hand grip strength or muscle mass.

CONCLUSION

A home-based PA intervention 1 year after surgery for esophageal cancer improves lower extremity muscle strength.

Perspectives on the Direction of Cancer Prehabilitation in the Pandemic and Beyond

Growing attention has been placed on cancer prehabilitation in the recent years as the number of publications increase. The real-world application of prehabilitation remains heterogeneous and its implementation has been challenging during the COVID-19 pandemic. However, the pandemic has also provided impetus for change-leveraging technology and digitalization. This paper will discuss the pre-existing models of care, adaptations that had taken place in the pandemic, the model of care in the author's institution, and the future direction of cancer prehabilitation.

Prehabilitation versus no prehabilitation to improve functional capacity, reduce postoperative complications and improve quality of life in colorectal cancer surgery

BACKGROUND

Surgery is the cornerstone in curative treatment of colorectal cancer. Unfortunately, surgery itself can adversely affect patient health. 'Enhanced Recovery After Surgery' programmes, which include multimodal interventions, have improved patient outcomes substantially. However, these are mainly applied peri- and postoperatively. Multimodal prehabilitation includes multiple preoperative interventions to prepare patients for surgery with the aim of increasing resilience, thereby improving postoperative outcomes.

OBJECTIVES

To determine the effects of multimodal prehabilitation programmes on functional capacity, postoperative complications, and quality of life in adult patients undergoing surgery for colorectal cancer.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and PsycINFO in January 2021. We also searched trial registries up to March 2021.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) in adult patients with non-metastatic colorectal cancer, scheduled for surgery, comparing multimodal prehabilitation programmes (defined as comprising at least two preoperative interventions) with no prehabilitation. We focused on the following outcomes: functional capacity (i.e. 6-minute walk test, VO2peak, handgrip strength), postoperative outcomes (i.e. complications, mortality, length of hospital stay, emergency department visits, re-admissions), health-related quality of life, compliance, safety of prehabilitation, and return to normal activities.

DATA COLLECTION AND ANALYSIS

Two authors independently selected studies, extracted data, assessed risk of bias and used GRADE to assess the certainty of the evidence. Any disagreements were solved with discussion and consensus. We pooled data to perform meta-analyses, where possible.

MAIN RESULTS

We included three RCTs that enrolled 250 participants with non-metastatic colorectal cancer, scheduled for elective (mainly laparoscopic) surgery. Included trials were conducted in tertiary care centres and recruited patients during periods ranging from 17 months to 45 months. A total of 130 participants enrolled in a preoperative four-week trimodal prehabilitation programme consisting of exercise, nutritional intervention, and anxiety reduction techniques. Outcomes of these participants were compared to those of 120 participants who started an identical but postoperative programme. Postoperatively, prehabilitation may improve functional capacity, determined with the 6-minute walk test at four and eight weeks (mean difference (MD) 26.02, 95% confidence interval (CI) -13.81 to 65.85; 2 studies; n = 131; and MD 26.58, 95% CI -8.88 to 62.04; 2 studies; n = 140); however, the certainty of evidence is low and very low, respectively, due to serious risk of bias, imprecision, and inconsistency. After prehabilitation, the functional capacity before surgery improved, with a clinically relevant mean difference of 24.91 metres (95% CI 11.24 to 38.57; 3 studies; n = 225). The certainty of evidence was moderate due to downgrading for serious risk of bias. Prehabilitation may also result in fewer complications (RR 0.95, 95% CI 0.70 to 1.29; 3 studies; n = 250) and fewer emergency department visits (RR 0.72, 95% CI 0.39 to 1.32; 3 studies; n = 250). The certainty of evidence was low due to downgrading for serious risk of bias and imprecision. On the other hand, prehabilitation may also result in a higher re-admission rate (RR 1.20, 95% CI 0.54 to 2.65; 3 studies; n = 250). The certainty of evidence was again low due to downgrading for risk of bias and imprecision. The effect on VO2peak, handgrip strength, length of hospital stay, mortality rate, health-related quality of life, return to normal activities, safety of the programme, and compliance rate could not be analysed quantitatively due to missing or insufficient data. The included studies did not report a difference between groups for health-related quality of life and length of hospital stay. Data on remaining outcomes were not reported or were reported inadequately in the included studies.

AUTHORS' CONCLUSIONS

Prehabilitation may result in an improved functional capacity, determined with the 6-minute walk test both preoperatively and postoperatively. Complication rates and the number of emergency department visits postoperatively may also diminish due to a prehabilitation programme, while the number of re-admissions may be higher in the prehabilitation group. The certainty of evidence ranges from moderate to very low, due to downgrading for serious risk of bias, imprecision and inconsistency. In addition, only three heterogeneous studies were included in this review. Therefore, the findings of this review should be interpreted with caution. Numerous relevant RCTs are ongoing and will be included in a future update of this review.

Successes and challenges of implementing teleprehabilitation for onco-surgical candidates and patients' experience: a retrospective pilot-cohort study

This study documents the implementation of a multimodal teleprehabilitation program (e.g., completion rate, exercise metrics, and program successes and challenges) for cancer patients undergoing surgery. It also documents the patients’ experience of the program. This pilot-cohort study included adults scheduled for elective thoracic and abdominal cancer resection surgery, referred to the prehabilitation clinic to engage in physical activity, and received a teleprehabilitation program between August 1st, 2020, and February 28th, 2021. The technology platform provided to the patients included a tablet and a wearable device to facilitate communication and data collection. Data collected for this article were acquired through virtual physical activity monitoring in addition to patient charts. Qualitative data collected comprised of successes and challenges of implanting a teleprehabilitation program, in addition to patients’ perspectives of the program. Quantitative data collected comprised of the exercise metrics, perioperative functional outcomes, in addition to the surgical and postoperative outcomes. Ten patients (8 males and 2 females; mean age: 68.3 years, SD 11.96) diagnosed with various thoracoabdominal malignancies were included in the current descriptive study. The successes identified were related to recruitment and assessment, improvement in functional capacity, clinic scheduling and interventions, and optimal medical follow-up. The challenges identified were related to the adoption of the technologies by patients and the multidisciplinary team, the accurate acquisition of patient physical activity data, and the initial costs to acquire the new technologies. Patients were satisfied with the teleprehabilitation program (i.e., services delivered; average appreciation: 96%), and they perceived the technologies provided to be 90% user-friendly. The findings of the current study highlight important concepts in view of the current international health paradigm changes prioritizing remote interventions facilitated through digital communication technologies. It provides important insight into the clinical application of telehealth in elderly populations, notably in the context of acute preoperative cancer care. This article may provide guidance for other cancer care facilities aiming to implement teleprehabilitation programs.

Prehabilitation for Vascular Surgery Patients: Challenges and Opportunities

Global demand for major surgery is rising as a consequence of a growing, ageing population and clinically applicable approaches to perioperative risk reduction have never been needed more. Prehabilitation aims to optimise aerobic capacity and address modifiable risk factors prior to surgery to improve postoperative outcomes. Given the inherently high-risk nature of vascular surgery and the frequently high-acuity, frail, vascular surgical population, the potential to introduce an intervention into the surgical pathway that may reduce postoperative complications cannot be overlooked. The aim of this article is to examine the current evidence base for prehabilitation in patients awaiting vascular surgery, and to summarise the potential benefits, pitfalls, and practicalities of this emerging perioperative intervention. There is a paucity of high-quality research specifically aimed at prehabilitation for patients undergoing vascular surgery, both peripheral and aortic, making it difficult to draw definitive conclusions upon which to base a change in practice. Currently, evidence is taken from small, often single-centre heterogenous studies that vary significantly from each other, meaning that the optimal exercise regimen for patients awaiting vascular surgery has yet to be defined. Establishing the impact of prehabilitation on outcomes for vascular patients is important as the effectiveness of preoperative exercise training is likely to vary between surgical interventions and patient populations. However, extrapolation from other cohorts is possible and indeed forms the basis of many current prehabilitation programmes. Given the success of prehabilitation in other surgical groups, it has potential to become an important future research target for patients awaiting vascular surgery.

Feasibility of a novel mixed-nutrient supplement in a multimodal prehabilitation intervention for lung cancer patients awaiting surgery: A randomized controlled pilot trial

OBJECTIVE

To investigate, in lung cancer patients awaiting elective surgery, the feasibility of delivering a novel four-week multimodal prehabilitation intervention and its effects on preoperative functional capacity and health-related quality of life (HRQoL), compared to standard hospital care.

METHODS

Adult patients awaiting elective thoracotomy for lung cancer stages I, II or IIIa, were approached to participate in an open-label, randomized controlled trial of two parallel arms: multimodal prehabilitation combining a mixed-nutrient supplement with structured supervised and home-based exercise training, and relaxation-strategies (Prehab) or standard hospital care (Control). Feasibility was assessed based on recruitment and adherence rates to the intervention and study outcome assessment. Functional capacity, measured by the 6-min walk test (6MWT), and HRQoL were measured at baseline and after four weeks (preoperative).

RESULTS

Within 5 months, 34 patients were enrolled and randomized (2:1) to Prehab (n = 24; median age = 67 years) or Control (n = 10; median age = 69 years); recruitment rate of 58.6%. The study was interrupted by the COVID-19 pandemic. Adherence to the prescribed intensity of the supervised exercise program was 84.1% (SD 23.1). Self-reported adherence to the home-based exercise program was 88.2% (SD 21) and to the nutritional supplement, 93.2% (SD 14.2). Adherence to patients' preoperative assessment was 82% and 88% in Prehab and Control, respectively. The mean adjusted difference in 4-week preoperative 6MWT between groups was 37.7 m (95% CI, -6.1 to 81.4), p = 0.089. There were no differences in HRQoL between groups.

CONCLUSION

Within a preoperative timeframe, it was feasible to deliver this novel multimodal prehabilitation intervention in lung cancer patients awaiting surgery.

Functional capacity of prediabetic patients: effect of multimodal prehabilitation in patients undergoing colorectal cancer resection

BACKGROUND

Prehabilitation is the process of increasing functional capacity (FC) before surgery. Poor glycemic control is associated with worse outcomes in patients undergoing surgery. Therefore, prediabetic patients could particularly benefit from prehabilitation.

METHODS

This is a pooled analysis of individual patient data from three multimodal prehabilitation trials in colorectal cancer surgery. Following a baseline assessment using the 6-minute walking test (6MWT), subjects were randomized to multimodal prehabilitation or to a control group. Participants were reassessed 24 h before surgery and 4 weeks after surgery. Prediabetes (PreDM) was defined as HbA1c 5.7%-6.4%. Multivariable logistic regression was used to adjust for potentially confounding variables.

RESULTS

Participation in a prehabilitation program was the most important predictive factor of clinical improvement in FC prior to surgery (Adjusted OR 2.42, 95% CI 1.18, 4.94); prediabetes was not a statistically significant predictor of improvement in FC after adjustments for covariates. Prehabilitation attenuated the loss of FC in unadjusted analyses after surgery in prediabetic patients (PreDM Control: median change -6 m [IQR -50-20] vs PreDM Prehab: median change +25 m [IQR -20-53], p = 0.045). Adjusted analyses also suggested the protective effect against loss of FC after surgery was stronger in prediabetic patients (PreDM Prehab vs PreDM Control: OR 5.5, 95% CI: 1.2-25.8; Normo Prehab vs Normo Control: OR 1.5, 95% CI: 0.53-4.52).

CONCLUSIONS

Multimodal prehabilitation favored clinical recovery of FC after surgery in CRC patients, especially prediabetic patients.

Rethinking Telerehabilitation: Attitudes of Physical Therapists and Patients

COVID-19 has accelerated the adoption of telehealth among various specialties, including rehabilitation. The fast-paced implementation of telerehabilitation has laid bare its challenges, providing an opportunity for innovation in order to enhance the experience of remote care. The purpose of this study sought to understand the attitudes toward telerehabilitation from physical therapist (PT) and patient perspectives. Two surveys administered to PTs, and the general patient population explored beliefs regarding telerehabilitation. There were a total of 289 participant responses in this study. There were 228 PT respondents and 61 patients who responded to the patient survey. Qualitative results describe current attitudes toward telerehabilitation. Results indicated both groups were receptive to virtual therapy sessions; however, some challenges were also reported. Current challenges and trends in utilizing telerehabilitation are further discussed.

Perioperative and oncologic outcomes in young and octogenarian patients with colorectal cancer: a comparison at the extremes

INTRODUCTION

In colorectal cancer (CRC), surgical outcomes in the young (< 50) and octogenarian populations are believed to be poor due to an aggressive phenotype in the former, and increased frailty in the latter. Given that age-related effects are inversely related between groups, we compared short- and long-term outcomes of young and octogenarian patients with CRC to determine the dominance of one age-related factor over another.

METHODS

A prospectively collected database from 2015 to 2020 of all CRC was analyzed. Cases were divided into metastatic and non-metastatic groups.

RESULTS

Among non-metastatic cases, there were 34 young and 113 octogenarian patients. Mean CEA was higher among octogenarians (11.2 vs 32.8 units/ml; p = 0.041). Octogenarians suffered from more comorbidities than younger counterparts, with increased rates of postoperative UTI (3.3% vs 10.3%; p = 0.246) and pneumonia (3.1% vs 8.8%; p = 0.331). There was no increased rate of reintervention or Clavien-Dindo scores. We noticed a statistically significant higher proportion of extramural vascular invasion (EMVI) (8.8% vs 32.3%; p = 0.003) among the young. When excluding octogenarians who had declined surgery, Kaplan-Meier analysis showed no difference in disease-free (p = 0.290) or overall survival (p = 0.111). Among metastatic cases, there were 21 young and 19 octogenarian patients. Young patients were treated more aggressively with chemotherapy (55.6% vs 12.5%; p = 0.040). There was however no difference in overall survival between groups (p = 0.610).

CONCLUSIONS

Octogenarians may have more comorbidities, but can achieve similar surgical outcomes with younger patients. There is no reason to suspect a more aggressive phenotype in younger patients.

Exercise recommendations and referral patterns of oncology professionals

BACKGROUND

Exercise physiologists and physiotherapists can provide exercise interventions for cancer survivors; however, many do not access this support. Our primary aim explored referral habits to exercise professionals and attitudes of oncology professionals. Secondary aims explored fitness levels of oncology professionals and the relationship between fitness and exercise referral habits.

METHODS

Oncology professionals (n = 67) attending a national cancer conference in Australia participated in this cross-sectional study (23% doctors, 11% nurses, 25% allied health, and 41% other). A subgroup (n = 49) completed a fitness assessment measuring aerobic fitness (3-minute step test), muscle strength (handgrip dynamometry), and body composition (waist-to-hip ratio). Oncology professionals in a position to refer patients to exercise professionals were assessed on their history of patient referrals.

RESULTS

Sixty-seven of 750 eligible conference delegates participated (9% recruitment rate), of which 73% completed fitness assessments. Participants displayed above average physical activity and fitness levels with 60% meeting exercise guidelines. The majority (92%) agreed that exercise is important among cancer survivors to attenuate treatment-associated symptoms. Most understand the role of exercise physiologists (61%) and physiotherapists (64%) in cancer care. Seventy-three percent reported that referral to exercise professionals is optimal to increase exercise participation. Most (82%) oncology professionals who are able to refer patients to exercise professionals have self-reported doing so, while 91% recommended exercise themselves. Sixty-two percent were aware of evidence-based exercise guidelines. Fitness levels (p = 0.25), strength (p = 0.88), and physical activity (p = 0.33) did not impact referrals made to exercise professionals.

CONCLUSION

There was high awareness exercise-oncology benefits and evidence-based guidelines existed among sampled participants. Oncology professionals understand the role of exercise professionals, reflected by high self-reported referral rates. Implementing referral pathways to exercise professionals in cancer care may facilitate improved patient outcomes.

What matters to you? An investigation of patients' perspectives on and acceptability of prehabilitation in major cancer surgery

OBJECTIVE

To understand perspectives on and acceptability of prehabilitation among patients undergoing complex abdominal cancer surgery (cytoreductive surgery with or without hyperthermic intraperitoneal chemotherapy).

METHODS

Seventy-nine patients admitted to a Danish colorectal or ovarian cancer centre participated in qualitative semi-structured interviews and/or registered their prehabilitation activities based on preoperative recommendations presented in a leaflet. Malterud's principles of systematic text condensation were used to analyse the interview data, and descriptive statistics were used to describe the activity registrations.

RESULTS

Five domains clarify central aspects of the patients' perspectives on and acceptability of prehabilitation: the preoperative period, attitudes towards prehabilitation, the actual prehabilitation performed, motivation to take action and the need for support.

CONCLUSION

Patients undergoing major abdominal cancer surgery are interested in and positive towards prehabilitation, but it has to be on their terms. The patients need support and supervision, but it has to be provided in a setting and in a way that are in line with the patient's preferences, resources and values. Thus, patient involvement is necessary to create prehabilitation programmes that are feasible and fit into patients' everyday lives.

Colorectal Cancer in Elderly Patients with Surgical Indication: State of the Art, Current Management, Role of Frailty and Benefits of a Geriatric Liaison

Six out of every 10 new colorectal cancer (CRC) diagnoses are in people over 65 years of age. Current standardized surgical approaches have proved to be tolerable on the elderly population, although post-operative complications are more frequent than in the younger CRC population. Frailty is common in elderly CRC patients with surgical indication, and it appears to be also associated with an increase of post-operative complications. Fast-track pathways have been developed to assure and adequate post-operative recovery, but comprehensive geriatric assessments (CGA) are still rare among the preoperative evaluation of elderly CRC patients. This review provides a thorough study of the effects that a CGA assessment and a geriatric intervention have in the prognosis of CRC elderly patients with surgical indication.

Evaluation of a Post-Operative Rehabilitation Program in Patients Undergoing Laparoscopic Colorectal Cancer Surgery: A Pilot Study

This pilot study explores the effects of a post-operative physical exercise program on the quality of life (QoL) and functional and nutritional parameters of patients that underwent laparoscopic colorectal cancer surgery, compared to usual care alone. The intervention group (IG) attended a 2-month-long supervised and combined exercise–training program during the post-operative period. Both IG and control group (CG) participated in the QoL, functional, and nutritional assessments before exercise training (T0), 2 months after the beginning of the exercise (end of treatment) (T1), and 2 (T2) and 4 (T3) months from the end of treatment. Eleven patients with colorectal cancer that underwent laparoscopic surgery were enrolled (six intervention; five control). The IG showed significant improvements compared to the CG in “Physical functioning” (PF2) (p = 0.030), “Cognitive functioning” (CF) (p = 0.018), and “Fatigue” (FA) (p = 0.017) of the European Organization for Research and Treatment of Cancer Quality of Life-C30 Questionnaire (EORTC QLQ-C30) at T1; in SMWT (p = 0.022) at T1; in PF2 (p = 0.018) and FA (p = 0.045) of EORTC QLQ-C30 at T2, in phase angle (PhA) of bioelectrical impedance analysis (p = 0.022) at T3. This pilot study shows that a post-operative, combined, and supervised physical exercise program may have positive effects in improving the QoL, functional capacity, and nutritional status in patients that undergo laparoscopic colorectal cancer surgery.

Teleprehabilitation during COVID-19 pandemic: the essentials of "what" and "how"

In view of the COVID-19 pandemic and recent global events, the healthcare system and its services have been negatively affected, contributing towards extensive surgical backlogs. Oncological surgical candidates have been the most impacted by these changes and recommended self-isolation practices, which could result in emotional distress, sedentary behavior, and poor lifestyle habits. Preoperative supportive intervention, prehabilitation, has been proven to improve patients' functional status and clinical trajectories. Presently, there is a critical need for prehabilitation to optimize patient health, as they experience extended wait times. However, in-hospital delivery may not be an ideal approach due to public health and safety measures. Telehealth is a field of research and practice, which has grown and evolved significantly in the last two decades, allowing for the remote delivery of health services. Therefore, the current commentary addresses the different modalities of telehealth delivery in perspective of their known feasibility and potential application in prehabilitation.

The Potential of Prehabilitation in Radical Cystectomy Pathways: Where Are We Now?

OBJECTIVE

The growing recognition of prehabilitation has caused an emerging paradigm shift in surgical cancer care and an integrated component of the cancer care continuum. This narrative review aims to update and inform the urological community of the potential of prehabilitation before radical cystectomy.

DATA SOURCES

A nonsystematic narrative review was performed through a database search in PubMed, and CINAHL using the following search terms: enhanced recovery after surgery (ERAS); Frailty; Prehabilitation and/or Rehabilitation; Physical Activity and/or exercises; Nutrition; Nutritional Care; Smoking cessation; Alcohol cessation; Prevention; Supportive Care; and combined with Radical Cystectomy.

CONCLUSION

A multimodal and multi-professional approach during the preoperative period may offer an opportunity to preserve or enhance physiological integrity and optimize surgical recovery. Studies indicate a positive effect of prehabilitation on postoperative functional capacity and earlier return to daily activities and health related quality of life. Meaningful outcomes that reflect recovery from a patient's perspective and clinical outcome measures, as well as validating metrics, are necessary to establish whether prehabilitation diminish the risk of developing long-term disability in high-risk patients.

IMPLICATIONS FOR NURSING PRACTICE

Uro-oncology nurses are at the forefront in every ERAS program and vital in screening patients ahead of surgery for common risk factors, current impairments, and limitations that can compromise baseline functional capacity. The growing movement to standardize clinical implementation of prehabilitation, indicate there is a clear need for further investigation, optimization of a multimodal approach and an open discussion between health care providers from different areas of expertise who might best support and promote these initiatives.

Multimodal Prehabilitation for Lung Cancer Surgery: A Randomized Controlled Trial

BACKGROUND

The study was conducted to determine whether a multimodal prehabilitation program enhances postoperative functional recovery compared with multimodal rehabilitation.

METHODS

Patients scheduled for non-small cell lung cancer resection were randomized to 2 groups receiving home-based moderate-intensity exercise, nutritional counseling with whey protein supplementation, and anxiety-reducing strategies for 4 weeks before the operation (PREHAB, n = 52) or 8 weeks after (REHAB, n = 43). Functional capacity (FC) was measured by the 6-minute walk test (6MWT) at baseline, immediately before the operation, and 4 and 8 weeks after operation. All patients were treated according to enhanced recovery pathway guidelines.

RESULTS

There was no difference in FC at any point during the perioperative period between the 2 multimodal programs. By 8 weeks after operation, both groups returned to baseline FC, and a similar proportion of patients (>75%) in both groups had recovered to their baseline.

CONCLUSIONS

In patients undergoing surgical resection for lung cancer within the context of an enhanced recovery pathway, multimodal prehabilitation initiated 4 weeks before operation is as effective in recovering FC as multimodal rehabilitation.

Effect of Multimodal Prehabilitation vs Postoperative Rehabilitation on 30-Day Postoperative Complications for Frail Patients Undergoing Resection of Colorectal Cancer: A Randomized Clinical Trial

Importance

Research supports use of prehabilitation to optimize physical status before and after colorectal cancer resection, but its effect on postoperative complications remains unclear. Frail patients are a target for prehabilitation interventions owing to increased risk for poor postoperative outcomes.

Objective

To assess the extent to which a prehabilitation program affects 30-day postoperative complications in frail patients undergoing colorectal cancer resection compared with postoperative rehabilitation.

Design, Setting, and Participants

This single-blind, parallel-arm, superiority randomized clinical trial recruited patients undergoing colorectal cancer resection from September 7, 2015, through June 19, 2019. Patients were followed up for 4 weeks before surgery and 4 weeks after surgery at 2 university-affiliated tertiary hospitals. A total of 418 patients 65 years or older were assessed for eligibility. Of these, 298 patients were excluded (not frail [n = 290], unable to exercise [n = 3], and planned neoadjuvant treatment [n = 5]), and 120 frail patients (Fried Frailty Index,≥2) were randomized. Ten patients were excluded after randomization because they refused surgery (n = 3), died before surgery (n = 3), had no cancer (n = 1), had surgery without bowel resection (n = 1), or were switched to palliative care (n = 2). Hence, 110 patients were included in the intention-to-treat analysis (55 in the prehabilitation [Prehab] and 55 in the rehabilitation [Rehab] groups). Data were analyzed from July 25 through August 21, 2019.

Interventions

Multimodal program involving exercise, nutritional, and psychological interventions initiated before (Prehab group) or after (Rehab group) surgery. All patients were treated within a standardized enhanced recovery pathway.

Main Outcomes and Measures

The primary outcome included the Comprehensive Complications Index measured at 30 days after surgery. Secondary outcomes were 30-day overall and severe complications, primary and total length of hospital stay, 30-day emergency department visits and hospital readmissions, recovery of walking capacity, and patient-reported outcome measures.

Results

Of 110 patients randomized, mean (SD) age was 78 (7) years; 52 (47.3%) were men and 58 (52.7%) were women; 31 (28.2%) had rectal cancer; and 87 (79.1%) underwent minimally invasive surgery. There was no between-group difference in the primary outcome measure, 30-day Comprehensive Complications Index (adjusted mean difference, -3.2; 95% CI, -11.8 to 5.3; P = .45). Secondary outcome measures were also not different between groups.

Conclusions and Relevance

In frail patients undergoing colorectal cancer resection (predominantly minimally invasive) within an enhanced recovery pathway, a multimodal prehabilitation program did not affect postoperative outcomes. Alternative strategies should be considered to optimize treatment of frail patients preoperatively.

Trial Registration

ClinicalTrials.gov identifier: NCT02502760.

Preliminary Results of an Exercise Program After Laparoscopic Resective Colorectal Cancer Surgery in Non-Metastatic Adenocarcinoma: A Pilot Study of a Randomized Control Trial

Background and objectives: Performing physical exercise after a colorectal cancer diagnosis is associated with lower mortality related to the tumor itself. In order to improve physical recovery after elective surgery, there are no specific exercise protocols after discharge from the hospital. The purpose of this study is to show the preliminary results of an exercise program after colorectal cancer surgery. Materials and Methods: Six patients with non-metastatic colorectal adenocarcinoma addressed to respective laparoscopic were randomly assigned to a mixed supervised/home-based exercise program for six months and compared to a control group without exercise. To assess the effectiveness of the program, functional and body composition parameters were evaluated. Results: Three months after surgery, the exercise group increased flexibility (p <0.01, ES = 0.33), strength of lower limbs (p <0.01, ES = 0.42) and aerobic capacity (p <0.01, ES = 0.28). After surgery, the six patients experienced a significant reduction in body mass index (BMI) and free fat mass. More specifically, fat mass reached the lowest values, with a concomitant increase in cell mass after six months (p <0.01, ES = 0.33). This did not occur in the control group. Conclusions: Colorectal cancer treatment induces a reduction in physical function, particularly during the first six months after treatment. A mixed exercise approach appears promising in countering this process after colorectal cancer surgery.

Application of Exercised-based Pre-rehabilitation in Perioperative Period of Patients with Gastric Cancer

Objective

To analyze the difference between exercised-based pre-rehabilitation and postoperative rapid rehabilitation of gastric cancer patients.

Methods

The clinical data of 120 patients who underwent surgical treatment between 2016 and 2018 in our hospital with pathologically confirmed gastric cancer were retrospectively reviewed. According to the different treatments during the perioperative period, they were divided into exercised-based pre-rehabilitation group and postoperative rapid rehabilitation group. Factor analysis was used to analyze pre-rehabilitation and postoperative rehabilitation of patients with gastric cancer after stress response, nutritional status, insulin resistance, and inflammatory response in patients with gastric cancer, and to further evaluate the value of pre-recovery accelerated postoperative recovery.

Results

The postoperative stress response, insulin resistance, and inflammatory response in the pre-rehabilitation group were lower than the conventional treatment group. The nutritional status was improved faster than the traditional treatment group. Exercised-based pre-rehabilitation for the rapid recovery of postoperative gastrointestinal function in patients with gastric cancer surgery has significant value.

Conclusion

Exercised-based pre-rehabilitation has great significance for the accelerated rehabilitation of patients with gastric cancer during perioperative period.

Compliance, adherence and effectiveness of a community-based pre-operative exercise programme: a pilot study

BACKGROUND

Pre-operative exercise training improves HR components of fitness and HRQoL following hospital-based programmes.

OBJECTIVE

To assess compliance and adherence of a pragmatic community-based preoperative exercise programme and its effect on health-related (HR) components of fitness and health-related quality of life (HRQoL).

METHODS

Thirty-two surgical oncological participants (15 prostate cancer and 17 colorectal cancer (CRC)) were recruited and assessed to measure HR components of fitness (strength and functional exercise capacity) and HRQoL. An exercise programme was prescribed in the time available prior to surgery with repeat assessments pre-operatively.

RESULTS

Twenty-four participants (14 prostate cancer and 10 CRC) completed the full study (75% compliance). Exercise training was delivered over a median interquartile range (IQR) of 4 (3-4) weeks and 2 (1-3) weeks for the prostate cancer and CRC participants, with > 80% adherence. From baseline to post-exercise intervention, there were significant improvements in lower body strength in the prostate cancer group (p = 0.045), the CRC group (p = 0.001), and in both groups overall (p = .001). Additionally, there were statistically significant improvements in HRQoL: global health status for CRC group (p = 0.025) and for both groups overall (p = 0.023); emotional health subscale for the prostate cancer group (p = 0.048) and for both groups overall (p = 0.027); nausea/vomiting/pain subscale for the CRC group (p = 0.005) and for both groups overall (p = 0.030); and for health scale status for the prostate cancer group (p = 0.019) and for both groups overall (p = 0.006).

CONCLUSION

This community-based pre-operative exercise programme showed acceptable compliance and adherence rates, and significantly increased upper and lower body strength and HRQoL. Pre-operative exercise training should be considered as early as possible in the surgical-oncology pathway and respected within patient scheduling.

You Are Only as Frail as Your Arteries: Prehabilitation of Elderly Surgical Patients

Purpose of Review

To discuss the concept of prehabilitation for the elderly frail surgical patient as well as strategies to improve preoperative functional capacity and vascular function to decrease postoperative complications.

Recent Findings

Frailty is associated with poor surgical outcomes yet there is no consensus on how frailty should be measured or mitigated in the preoperative period. Prehabilitation, or improving functional capacity prior to surgery typically through exercise, has been shown to be an effective strategy to decrease preoperative frailty and improves surgical outcomes. Use of remote ischemic preconditioning (RIPC) may serve as an alternative to exercise in this fragile patient population.

Summary

Prehabilitation programs using strategies targeted at improving vascular function may decrease frailty in the preoperative period and improve surgical outcomes in the elderly population.

Prehabilitation for esophagectomy

Esophagectomy remains the mainstay treatment of esophageal cancer (EC). Combined with neoadjuvant therapies, the management of EC has deleterious effects on body composition, functional capacity and psychological well-being. Preoperative patient optimisation known as prehabilitation is a novel intervention aimed at reducing morbidity and mortality associated with the trajectory of EC care. There is emerging evidence to suggest that prehabilitation is safe, feasible and efficacious. In addition, there is strong data to infer that prehabilitation has a positive effect on functional capacity through exercise. Nutritional and psychological interventions are less well evaluated. Furthermore, no convincing relationship between prehabilitation and oncological outcomes has been demonstrated. Early studies evaluating prehabilitation are promising however further large scale research is required in order to assess the clinical effectiveness.