Multimodal prehabilitation to improve the clinical outcomes of frail elderly patients with gastric cancer: a study protocol for a multicentre randomised controlled trial (GISSG+2201)

Multimodal prehabilitation to improve functional abilities and reduce the chronic inflammatory response of frail elderly patients with gastric cancer: A prospective cohort study

BACKGROUND

Population ageing and cancer burden are important global public health problems that pose unprecedented threats to health systems worldwide. Frailty is a common health problem among elderly patients with cancer. In recent years, the use of prehabilitation to improve frailty has received widespread attention. Few studies have addressed the specific physiologic effects of prehabilitation on patients undergoing surgery.

METHODS

Frail elderly patients (aged at least 65 years) who underwent elective primary surgery for gastric cancer between September 2022 and October 2023 were included in this single-centre prospective cohort study and were categorized into multimodal prehabilitation or ERAS standard care groups. Prehabilitation, including physical and respiratory training, nutritional support and psychosocial treatment, was provided at least two weeks before gastrectomy. The primary outcome was functional status. Secondary outcomes included changes in indices of lipid metabolism, oxidative stress and chronic inflammation.

RESULTS

Over a 13-month period, 137 participants were assessed for eligibility, and 110 patients (prehabilitation 55, ERAS 55) were analysed. Compared with the baseline, patients in the prehabilitation group exhibited increased physical capacity before the operation (mean 6-min walk test change +28 m; P < 0.001). After prehabilitation intervention, inflammation-related indicators (NLR, PLR, SII and CRP) improved, and proinflammatory cytokine production (IL-5, IL-6, IL-1β, IL-10 and TNF-α) decreased. After surgery, the increase in IL-6 was reduced in the prehabilitation group (P = 0.036). Moreover, prehabilitation was associated with alleviating oxidative stress as determined by the levels of MDA (P = 0.005).

CONCLUSION

Multimodal prehabilitation can play a beneficial role in improving functional abilities by reducing chronic inflammation, improving lipid metabolism, and attenuating oxidative stress.

Prevalence and factors influencing preoperative frailty in elderly patients with gynecologic oncology surgery: A cross-sectional study

BACKGROUND

Frailty is an important predictor of poor postoperative outcomes in elderly patients with gynaecologic cancer. However, the prevalence and risk factors for frailty in this population remain unclear.

METHODS

This cross-sectional study was conducted simultaneously in three gynecology departments of a tertiary hospital in China between January and March 2024. The study recruited 126 hospitalised patients with gynaecologic malignancies who underwent surgery. The demographic and clinical characteristics and biochemical laboratory parameters of all patients were collected. The Edmonton Frailty Scale was used to assess the patient's frailty. Multivariate logistic regression model analysis was used to identify the influencing factors of frailty.

RESULTS

The prevalence of preoperative frailty was 31 %. Univariate analysis showed significant differences between frail and non-frail groups in terms of age, body mass index, menopausal status, self-management ability, nutritional risk and activities of daily living (ADL) (all p < 0.05). Multiple logistic regression analysis identified older age (odds ratio [OR] = 1.27, 95%CI: 1.068-1.511, p = 0.007), ADL disability (OR = 3.184, 95%CI: 2.294-4.833, p = 0.010) and high nutritional risk (Nutritional Risk Screening 2002 score ≥ 3) (OR = 4.823, 95%CI: 1.422-16.816, p = 0.031) as risk factors for frailty. High self-management ability (OR = 0.918, 95%CI: 0.844-0.998, p = 0.046) was a protective factor against frailty.

CONCLUSION

Nutritional support, activity exercise and improvement of patient self-management are potential intervention goals, and nurses should develop targeted prevention strategies based on identified risk factors to protect patient health.

The impact of preoperative skeletal muscle loss on the completion of S-1 adjuvant chemotherapy for gastric cancer

PURPOSE

Body weight loss after surgery for gastric cancer is related to S-1 compliance and it also affects the prognosis. However, it is unclear whether the preoperative skeletal muscle mass affects S-1 completion for gastric cancer. We investigated the impact of preoperative skeletal muscle mass loss on the completion of S-1 adjuvant chemotherapy for gastric cancer.

METHODS

We retrospectively analyzed data from 53 patients who underwent curative gastrectomy followed by adjuvant S-1 monotherapy for pStage II-III gastric cancer between 2012 and 2021 at our hospital. The psoas muscle mass index (PMI) was used as the index for preoperative skeletal muscle mass.

RESULTS

Thirty-six patients completed S-1 treatment and 17 discontinued treatment. The patients who completed S-1 treatment had a longer overall survival than those who discontinued treatment (log-rank test, p = 0.043). According to a univariate analysis, the patients in the discontinuation group had a significantly lower preoperative body mass index (< 22.9 kg/m2, p = 0.005) and a higher rate of adverse events (grade 2 or higher, p < 0.001) than those in the completion group. According to a multivariate analysis, preoperative PMI (HR 3.563, p = 0.030) was an independent predictive factor for S-1 completion.

CONCLUSION

Preoperative skeletal muscle loss might therefore prevent the completion of adjuvant chemotherapy S-1 in patients with gastric cancer.

Effect of Intensive Nursing Management on Quality of Life and Mental Health in Elderly Gastric Cancer Patients Undergoing Chemotherapy: A Retrospective Study

Aims/Background Implementing effective nursing management is particularly critical in the case of elderly gastric cancer (GC) patients receiving chemotherapy, who are more vulnerable to risk events. Therefore, this study explored the effect of intensive nursing management on quality of life (QoL) and mental health in elderly GC patients receiving chemotherapy. Methods A total of 155 elderly patients with GC undergoing chemotherapy in Central Hospital Affiliated to Shandong First Medical University from July 2021 to July 2023 were selected as the study subjects. The sample was divided into two groups according to different nursing methods: 74 patients who received intensive nursing management were classified in the observation group, while 81 patients treated with routine nursing management were classified under the reference group. The QoL, mental health and adverse reactions to chemotherapy were compared between the two groups. Results Before nursing management was implemented, there was no significant difference in the scores of the quality of life questionnaire-core 30 (QLQ-C30), patient health questionnaire-9 items (PHQ-9), and the Chinese version of the M.D. Anderson Symptom Inventory (MDASI-C) (p > 0.05). After management, in comparison with the reference group, the observation group showed significantly higher scores in each dimension of QLQ-C30, as well as significantly lower scores in PHQ-9 and MDASI-C (p < 0.001). The incidences of gastrointestinal reaction, myelosuppression, neurotoxicity, and hepatorenal damage were lower in the observation group than in the reference group (45.95% vs 70.37%, 40.54% vs 65.43%, 35.14% vs 53.09%, and 33.78% vs 51.25%, respectively; p < 0.05). Conclusion The application of intensive nursing management in treating elderly GC patients during chemotherapy effectively improves their physical and mental states, ameliorates clinical symptoms and enhances the QoL, showing certain clinical application value.

Nutritional status and related factors in gastric cancer patients after gastrectomy: a cross-sectional study

<b>Introduction: </b> Gastrectomy due to gastric cancer induces metabolic changes in body composition, directly affecting nutritional status. <br><br><b>Aim:</b> The aim of this cross-sectional study was to investigate the nutritional status and related factors in gastric cancer patients after total and subtotal gastrectomy.<br><br><b>Materials and methods:</b> A total of 41 patients who underwent gastrectomy due to gastric cancer were included: 20 patients (48.8%) with total gastric resection and 21 patients (51.2%) with subtotal resection were enrolled. The evaluation was performed over a follow-up period ranging from two to four years after surgery during routine oncological monitoring visits. The laboratory tests, bioimpedance parameters, physical activity, and quality of life were evaluated.<br><br><b>Results:</b> The only statistically significant differences included BMI, fat percentage, fat mass, and metabolic age in the subtotal gastrectomy group. Overall, post-gastrectomy patients showed suboptimal vitamin D concentration and low physical activity level and were found to be at risk of malnutrition assessed with prealbumin concentration and total lymphocyte count.<br><br><b>Discussion:</b> The nutritional status and life quality do not significantly differ between total and subtotal gastric cancer patients.<br><br><b>Conclusions:</b> The nutritional status and life quality do not significantly differ between total and subtotal post-gastrectomy patients in long-term follow-up. The analysis of selected parameters suggests that post-gastrectomy patients are at risk of malnutrition.<br><br><b>Study significance:</b> The presented study brings better insight into the nutritional status of gastric cancer patients after gastrectomy in long-term follow-up.

Effect of preoperative immunonutrition on postoperative short-term clinical outcomes in patients with gastric cancer cachexia: a prospective randomized controlled trial

BACKGROUND

Although current guidelines(ESPEN guideline: Clinical nutrition in surgery and other guidelines) recommend preoperative immunonutrition for cachectic gastric cancer patients, the strength of the recommendation is weak, and the level of evidence is low. The benefits of preoperative immunonutrition still remain controversial.

PATIENTS AND METHODS

112 patients with gastric cancer cachexia were enrolled in the study and randomly assigned in a 1:1 ratio to receive either preoperative enteral immunonutrition support (IN, n = 56) or standard enteral nutrition support (SEN, n = 56). The primary endpoint was the incidence of infectious complications, and the secondary endpoints included the nutritional indicators, inflammatory markers, immune parameters, postoperative recovery and complications and gastrointestinal intolerance reactions.

RESULTS

The incidence of postoperative infectious complications(P = 0.040) and overall complications (P = 0.049)was significantly lower in the IN group compared to the SEN group. In terms of laboratory inflammatory indexes, patients in the IN group demonstrated significantly lower levels of white blood cells (WBC), C-reactive protein (CRP), and interleukin-6 (IL-6), as well as higher levels of lymphocytes (LYMPH) and immunoglobulin A (IgA), compared to patients in the SEN group, with statistically significant differences. In terms of clinical outcomes, the IN group had a shorter duration of antibiotic use (P = 0.048), shorter hospital stay (P = 0.018), and lower total hospital costs (P = 0.034) compared to the SEN group. The IN group also experienced significantly less weight loss after surgery (P = 0.043).

CONCLUSION

Preoperative administration of immunonutrition formula has a positive impact on the incidence of infectious complications in patients with gastric cancer cachexia after surgery. It improves patients' inflammatory and immune status, shortens hospital stays, and reduces healthcare costs. Preoperative use of immunonutrition may contribute to the improvement of prognosis in this high-risk population.

Prehabilitation in Adults Undergoing Cancer Surgery: A Comprehensive Review on Rationale, Methodology, and Measures of Effectiveness

Cancer surgery places a significant burden on a patients' functional status and quality of life. In addition, cancer surgery is fraught with postoperative complications, themselves influenced by a patient's functional status. Prehabilitation is a unimodal or multimodal strategy that aims to increase a patient's functional capacity to reduce postoperative complications and improve postoperative recovery and quality of life. In most cases, it involves exercise, nutrition, and anxiety-reducing interventions. The impact of prehabilitation has been explored in several types of cancer surgery, most commonly colorectal and thoracic. Overall, the existing evidence suggests prehabilitation improves physiological outcomes (e.g., lean body mass, maximal oxygen consumption) as well as clinical outcomes (e.g., postoperative complications, quality of life). Notably, the benefit of prehabilitation is additional to that of enhanced recovery after surgery (ERAS) programs. While safe, prehabilitation programs require multidisciplinary coordination preoperatively. Despite the existence of numerous systematic reviews and meta-analyses, the certainty of evidence demonstrating the efficacy and safety of prehabilitation is low to moderate, principally due to significant methodological heterogeneity and small sample sizes. There is a need for more large-scale multicenter randomized controlled trials to draw strong clinical recommendations.

Society for Surgery of the Alimentary Tract State-of-the-Art Session 2022: Frailty in Surgery

Given the exponentially aging population and rising life expectancy in the United States, surgeons are facing a challenging frail population who may require surgery but may not qualify based on their general fitness. There is an urgent need for greater awareness of the importance of frailty measurement and the implementation of universal assessment of frail patients into clinical practice. Pairing risk stratification with stringent protocols for prehabilitation and minimally invasive surgery and appropriate enhanced recovery protocols could optimize and condition frail patients before, during, and immediately after surgery to mitigate postoperative complications and consequences on patient function and quality of life. In this paper, highlights from the 2022 Society for Surgery of the Alimentary Tract State-of-the-Art Session on frailty in surgery are presented. This work aims to improve the understanding of the impact of frailty on patients and the methods used to augment the outcomes for frail patients during their surgical experience.