Survival in relation to time to start of curative treatment of colon cancer: A national register-based observational noninferiority study

Prehabilitation in surgery - an update with a focus on nutrition

PURPOSE OF REVIEW

Since the introduction of the prehabilitation concept for optimizing functional capacity before surgery 20 years ago, evidence and interest has grown considerably. This review summarizes the recent evidence and proposes questions for prehabilitation with special regard to the nutritional component.

RECENT FINDINGS

Several meta-analyses of multimodal prehabilitation (exercise, nutrition, and psychological support) have been published recently. These reviews suggest that preoperative conditioning can improve functional capacity and reduce the complication rate for many patient groups (risk of bias: moderate to low). A prerequisite is the identification of high-risk patients using suitable screening and assessment tools. Additionally, there are currently no standardized, clear recommendations for the organization and implementation of prehabilitation programs. The programs vary greatly in duration, content, and outcome measurement. Although the preoperative nutrition interventions enhanced outcomes consistently, there was no clear evidence for which nutritional intervention should be applied to whom over consistent time frame four to six weeks (timeframe consistent with most prehabilitation programs).

SUMMARY

To advance our understanding of which prehabilitation interventions work best, how they work, and for whom they work best, additional low risk of bias and adequately powered trials are required. Nevertheless, our review presents evidence that prehabilitation should be offered before major surgery on a risk-stratified basis.

Nutritional Prehabilitation in Patients Undergoing Abdominal Surgery-A Narrative Review

Malnutrition plays a crucial role as a risk factor in patients undergoing major abdominal surgery. To mitigate the risk of complications, nutritional prehabilitation has been recommended for malnourished patients and those at severe metabolic risk. Various approaches have been devised, ranging from traditional short-term conditioning lasting 7-14 days to longer periods integrated into a comprehensive multimodal prehabilitation program. However, a significant challenge is the considerable heterogeneity of nutritional interventions, leading to a lack of clear, synthesizable evidence for specific dietary recommendations. This narrative review aims to outline the concept of nutritional prehabilitation, offers practical recommendations for clinical implementation, and also highlights the barriers and facilitators involved.

Long-term results of a short-term home-based pre- and postoperative exercise intervention on physical recovery after colorectal cancer surgery (PHYSSURG-C): a randomized clinical trial

AIM

The aim of this work was to assess the effect of a short-term, home-based exercise intervention before and after colorectal cancer surgery on 12-month physical recovery within a previously reported randomized control trial (RCT).

METHOD

PHYSSURG-C is an RCT in six participating hospitals in Sweden. Patients aged ≥20 years planned for elective colorectal cancer surgery were eligible. The intervention consisted of unsupervised moderate-intensity physical activity 2 weeks preoperatively and 4 weeks postoperatively. Usual care was control. The primary outcome measure in PHYSSURG-C was self-assessed physical recovery 4 weeks postoperatively. The predefined long-term follow-up outcomes included: self-assessed physical recovery 12 months postoperatively and reoperations and readmissions 91-365 days postoperatively. The statistical models were adjusted with tumour site (colon or rectum), neoadjuvant therapy (none, radiotherapy or chemo/radiotherapy) and type of surgery (open or laparoscopic).

RESULTS

A total of 616 participants were available for the 12-month follow-up. Groups were balanced at baseline regarding demographic and treatment variables. There was no effect from the intervention on self-reported physical recovery [adjusted odds ratio (OR) 0.91, p = 0.60], the risk of reoperation (OR 0.97, p = 0.91) or readmission (OR 0.88, p = 0.58).

CONCLUSION

The pre- and postoperative unsupervised moderate-intensity exercise intervention had no effect on long-term physical recovery after elective colorectal cancer surgery. There is still not enough evidence to support clinical guidelines on preoperative exercise to improve outcome after colorectal cancer surgery.

Treatment interval in curative treatment of colon cancer, does it impact (cancer free) survival? A non-inferiority analysis

BACKGROUND

In treatment of colon cancer, strict waiting-time targets are enforced, leaving professionals no room to lengthen treatment intervals when advisable, for instance to optimise a patient's health status by means of prehabilitation. Good quality studies supporting these targets are lacking. With this study we aim to establish whether a prolonged treatment interval is associated with a clinically relevant deterioration in overall and cancer free survival.

METHODS

This retrospective multicenter non-inferiority study includes all consecutive patients who underwent elective oncological resection of a biopsy-proven primary non-metastatic colon carcinoma between 2010 and 2016 in six hospitals in the Southern Netherlands. Treatment interval was defined as time between diagnosis and surgical treatment. Cut-off points for treatment interval were ≤35 days and ≤49 days.

FINDINGS

3376 patients were included. Cancer recurred in 505 patients (15.0%) For cancer free survival, a treatment interval >35 days and >49 days was non-inferior to a treatment interval ≤35 days. Results for overall survival were inconclusive, but no association was found.

CONCLUSION

For cancer free survival, a prolonged treatment interval, even over 49 days, is non-inferior to the currently set waiting-time target of ≤35 days. Therefore, the waiting-time targets set as fundamental objective in current treatment guidelines should become directional instead of strict targets.