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Cham S, Kumar A, Walter LC, Lichtman S, Tew WP. Understanding frailty and the role of patient-centered care for older adults with gynecologic cancer. Gynecol Oncol 2025; 196:42-53. [PMID: 40179515 DOI: 10.1016/j.ygyno.2025.03.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2025] [Revised: 03/21/2025] [Accepted: 03/25/2025] [Indexed: 04/05/2025]
Abstract
The number of older adults with cancer will significantly grow in the coming decades. 45 % of older adults with gynecologic cancer are estimated to be affected by frailty. Frailty is a state of reduced physiologic reserve and decreased resiliency resulting in increased vulnerability to stressors. Importantly, frailty can exist in conjunction, but is not synonymous, with chronological age and older adults can be a heterogenous population. Routine assessment of frailty can help providers prevent both over- and under-treatment. The purpose of this review to describe the current state of literature on frailty as it relates to gynecologic cancer and draw from other literature including geriatrics, medical oncology, and surgery to suggest approaches to care. Frail patients have increased rates of surgical morbidity and mortality, higher toxicity to systemic therapy, and lower overall survival. Principles of the 5Ms (mobility, multi-complexity, mind, medications, and matters most) can be used in the clinic to guide care for older vulnerable (at risk) or frail adults. Surgical and medical oncology literature consistently indicates improved outcomes when multi-disciplinary approaches are used with routine frailty assessment. Future work is urgently needed to add validated geriatric measurements and outcomes into therapeutic trials and evaluate the impact of treatment choices on outcomes important to older adults such as functional recovery.
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Affiliation(s)
- Stephanie Cham
- Division of Gynecologic Oncology, University of California San Francisco, San Francisco, CA, United States of America.
| | - Amanika Kumar
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN, United States of America
| | - Louise C Walter
- Division of Geriatrics, University of California San Francisco, San Francisco, CA, United States of America
| | - Stuart Lichtman
- Wilmont Cancer Center, Geriatric Oncology, University of Rochester, Rochester, NY, United States of America
| | - William P Tew
- Memorial Sloan Kettering Cancer Center, New York, NY, United States of America
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2
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van der Graaff S, Backhuijs TAM, de Kort FP, Lockhorst EW, Smedts HPM, Schreinemakers JMJ, Nieuwenhuyzen-de Boer GM, Hoogstad-van Evert JS. Feasibility and Effects of Implementing Multimodal Prehabilitation Before Cytoreductive Surgery in Patients with Ovarian Cancer: The Gynofit Multicenter Study. Cancers (Basel) 2025; 17:1393. [PMID: 40361319 PMCID: PMC12070995 DOI: 10.3390/cancers17091393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2025] [Revised: 04/17/2025] [Accepted: 04/19/2025] [Indexed: 05/15/2025] Open
Abstract
Background: Cytoreductive surgery (CRS), in combination with chemotherapy, is the main treatment for advanced-stage ovarian cancer. In vulnerable patients, this extensive surgery has a high complication risk and may lead to clinical decline. There is emerging evidence that prehabilitation could be valuable in optimizing the patient's condition prior to cytoreductive surgery, as is shown in colorectal surgery. However, there is limited evidence in gynecologic oncology. The objective of this study is to evaluate the feasibility and effects of implementing multimodal prehabilitation before cytoreductive surgery in patients with ovarian cancer. Methods: In two Dutch hospitals, 46 patients with ovarian cancer were included during the study period, of whom 32 participated in a multimodal prehabilitation program before CRS. The programs included at least physiotherapy, dietary advice and intoxication cessation. The timing, extent and content of the programs differed. Feasibility was assessed by eligibility and participation rates and adherence to the physiotherapy program. Effectiveness was measured by differences in functional capacity, postoperative outcomes and tolerance to adjuvant chemotherapy. Results: Eligibility rates in both hospitals were 83% and 89%, and participation rates were 68% and 72%. Adherence to the physiotherapy program was moderate and only satisfactory in 55% and 63% of the patients. All fitness endpoint measurements improved compared to the baseline. No significant differences in postoperative outcomes were found between prehabilitation and control patients. Prehabilitation patients appeared to have better tolerance to adjuvant chemotherapy, with fewer dose reductions (21% vs. 73%, p = 0.017) and dose deferrals (39% vs. 46%, not significant) compared to the control group. Conclusions: The implementation of multimodal prehabilitation before CRS is feasible and effective in patients with ovarian cancer with respectable eligibility and participation rates, along with improved functional capacity, even during neoadjuvant chemotherapy.
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Affiliation(s)
- Stella van der Graaff
- Department of Gynecology and Obstetrics, Amphia Hospital, 4818 CK Breda, The Netherlands; (S.v.d.G.); (H.P.M.S.)
| | | | - Frank P. de Kort
- Department of Physiotherapy, Albert Schweitzer Hospital, 3318 AT Dordrecht, The Netherlands;
| | - Elize W. Lockhorst
- Department of Surgery, Amphia Hospital, 4818 CK Breda, The Netherlands; (E.W.L.)
| | - Huberdina P. M. Smedts
- Department of Gynecology and Obstetrics, Amphia Hospital, 4818 CK Breda, The Netherlands; (S.v.d.G.); (H.P.M.S.)
| | | | - Gatske M. Nieuwenhuyzen-de Boer
- Department of Gynecology and Obstetrics, Albert Schweitzer Hospital, 3318 AT Dordrecht, The Netherlands
- Department of Gynecological Oncology, Erasmus Medical Centre, 3015 GD Rotterdam, The Netherlands
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Mancebo G, Sole-Sedeno JM, Fabregó B, Pinto G, Vizoso A, Alvarez M, Sabaté-Garcia RA, Miralpeix E. Influence of Age on Treatment and Prognosis in Ovarian Cancer Patients. Cancers (Basel) 2025; 17:1397. [PMID: 40361324 PMCID: PMC12071169 DOI: 10.3390/cancers17091397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2025] [Revised: 03/30/2025] [Accepted: 04/19/2025] [Indexed: 05/15/2025] Open
Abstract
Background: Ovarian cancer, particularly in advanced stages, requires cytoreductive surgery followed by chemotherapy. A significant proportion of patients are elderly, yet older women are often treated with non-standard regimens despite a lack of consistent evidence linking age to prognosis. The aim of this study is to assess age-specific differences in treatment and survival outcomes for ovarian cancer in women aged 70 years or older. Methods: This retrospective study included ovarian cancer patients treated at the Hospital del Mar, Barcelona, between 2016 and 2022. Patients were stratified into two groups: <70 and ≥70 years. Clinical and pathological data were analyzed, and hazard ratios (HR) for overall survival (OS) and disease-free survival (DFS) were calculated using Cox proportional hazards regression models. Multivariate analysis was performed to compare outcomes. Results: A total of 110 patients were included (73 <70 years, 37 ≥70 years). Among the older group, 80.5% were diagnosed at advanced stages (III-IV), compared to 63% in the younger group (p = 0.012). Patients aged ≥70 were more likely to undergo interval surgery (p = 0.053) and receive non-standard treatment (p = 0.023). Complete cytoreduction was achieved in 95.8% of younger patients versus 81.3% of older patients (p = 0.024). Age ≥70 did not significantly impact DFS (p = 0.091), but OS was significantly worse in the older group (44.4% vs. 67.2%, p = 0.014). Conclusions: Older women (≥70 years) with ovarian cancer are more likely to be diagnosed at advanced stages, receive non-standard treatment, and achieve suboptimal cytoreduction compared to younger patients. While DFS was similar across age groups, older age was associated with worse OS, highlighting the need for age-tailored treatment strategies.
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Affiliation(s)
- Gemma Mancebo
- Department of Obstetrics and Gynecology, Hospital del Mar, 08003 Barcelona, Spain; (J.M.S.-S.); (B.F.); (M.A.); (E.M.)
- Faculty of Medicine and Life Science, Pompeu Fabra University, 08003 Barcelona, Spain
| | - Josep Maria Sole-Sedeno
- Department of Obstetrics and Gynecology, Hospital del Mar, 08003 Barcelona, Spain; (J.M.S.-S.); (B.F.); (M.A.); (E.M.)
- Faculty of Medicine and Life Science, Pompeu Fabra University, 08003 Barcelona, Spain
| | - Berta Fabregó
- Department of Obstetrics and Gynecology, Hospital del Mar, 08003 Barcelona, Spain; (J.M.S.-S.); (B.F.); (M.A.); (E.M.)
| | - Giovanna Pinto
- Faculty of Medicine and Life Science, Pompeu Fabra University, 08003 Barcelona, Spain
| | - Adrián Vizoso
- Department of Epidemiology, Hospital del Mar, 08003 Barcelona, Spain;
| | - Marta Alvarez
- Department of Obstetrics and Gynecology, Hospital del Mar, 08003 Barcelona, Spain; (J.M.S.-S.); (B.F.); (M.A.); (E.M.)
| | | | - Ester Miralpeix
- Department of Obstetrics and Gynecology, Hospital del Mar, 08003 Barcelona, Spain; (J.M.S.-S.); (B.F.); (M.A.); (E.M.)
- Faculty of Medicine and Life Science, Pompeu Fabra University, 08003 Barcelona, Spain
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Renouf T. The Role of Prehabilitation in Oncology Patients Undergoing Complex Systemic Anticancer Therapy. Semin Oncol Nurs 2025; 41:151812. [PMID: 39939205 DOI: 10.1016/j.soncn.2025.151812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2024] [Revised: 01/13/2025] [Accepted: 01/14/2025] [Indexed: 02/14/2025]
Abstract
OBJECTIVES To review the recent literature around the role of patient-centric prehabilitation for oncology patients undergoing complex systemic anticancer therapy (SACT) and the nurse's role in this area. METHOD A narrative review of recent peer-reviewed literature, national guidance, and government strategy for prehabilitation in oncology patients undergoing complex SACT. RESULTS/CONCLUSION Prehabilitation interventions in people receiving complex SACT are feasible and benefit patient outcomes. These results must still be viewed with caution; however, as of now, there are only small-scale studies in this area, although larger-scale studies are now being done. The role of the nurse is key here (as part of the interdisciplinary team) through the establishment of the therapeutic relationship underpinning patient screening, assessment, intervention implementation, and patient reassessment, ensuring care is dynamic, consistent, and tailored to patient needs. IMPLICATIONS FOR NURSING PRACTICE The review has discussed the beneficial patient outcomes from prehabilitation in patients receiving complex SACT, but more research is warranted in the form of larger multisite trials to increase the validity of the prehabilitation interventions. The review advocates for the role of the nurse in the provision of prehabilitation in SACT oncology patients through the provision of personalized patient care.
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Cham S, Pozzar RA, Horowitz N, Feltmate C, Matulonis UA, Lai JC, Wright AA. The pervasive impact of frailty on ovarian cancer care and the role of prehabilitation: Qualitative perspectives of key stakeholders. J Geriatr Oncol 2025; 16:102173. [PMID: 39708401 DOI: 10.1016/j.jgo.2024.102173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2024] [Revised: 10/08/2024] [Accepted: 12/03/2024] [Indexed: 12/23/2024]
Abstract
INTRODUCTION We performed a qualitative study to explore key stakeholders' perspectives about the impact of frailty on ovarian cancer care and evaluate a candidate prehabilitation intervention. MATERIALS AND METHODS We conducted semi-structured interviews with patient-caregiver dyads and multi-disciplinary clinicians. Patients were ≥ 50 years of age with a new diagnosis of advanced stage (III/IV) ovarian cancer who received cancer-directed treatment (chemotherapy and/or surgery) during the past year and met criteria as pre-frail or frail using the FRAIL scale. We used a semi-structured interview guide to elicit participants' views on frailty, nutrition, physical therapy, and a candidate prehabilitation intervention. We used inductive and deductive approaches to code and analyze interviews and identify emergent themes and patterns. RESULTS Ten patients and caregivers (five dyads) and 10 providers were interviewed. We identified four themes: (1) frailty screening is essential to prevent over- and under-treatment, but underused; (2) stakeholders preferred a multidisciplinary approach to providing tailored care for frail patients over a candidate prehabilitation intervention; (3) patient, family caregiver, and clinician stakeholders reported multiple barriers to prehabilitation programs, including concerns about selection bias, and (4) frail patients and family members are vulnerable and require more psychosocial support. DISCUSSION We identified significant barriers to prehabilitation interventions for frail patients with ovarian cancer; initiatives to increase frailty screening and provide tailored multi-disciplinary approaches may have a greater impact.
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Affiliation(s)
- Stephanie Cham
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology & Reproductive Sciences, University of California San Francisco, San Francisco, CA, United States.
| | - Rachel A Pozzar
- Dana Farber Cancer Institute, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Neil Horowitz
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Colleen Feltmate
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Ursula A Matulonis
- Dana Farber Cancer Institute, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Jennifer C Lai
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Alexi A Wright
- Dana Farber Cancer Institute, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
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Kim J, Lee CH, Yim GW. Multimodal Prehabilitation for Gynecologic Cancer Surgery. Curr Oncol 2025; 32:109. [PMID: 39996909 PMCID: PMC11853901 DOI: 10.3390/curroncol32020109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2024] [Revised: 02/11/2025] [Accepted: 02/12/2025] [Indexed: 02/26/2025] Open
Abstract
Surgical treatment is commonly employed to treat patients with gynecologic cancer, although surgery itself may function as a stressor, reducing the patients' functional capacity and recovery. Prehabilitation programs attempt to improve patients' overall health and baseline function prior to surgery, thereby enhancing recovery and lowering morbidity. In recent years, prehabilitation has come to primarily refer to multimodal programs that combine physical activity, nutritional support, psychological well-being, and other medical interventions. However, the specific methods of implementing prehabilitation and measuring its effectiveness are heterogeneous. Moreover, high-level evidence regarding prehabilitation in gynecologic cancer surgery is limited. This review provides a summary of multimodal prehabilitation studies in gynecologic oncologic surgery. Enhanced postoperative recovery, lower postoperative complications, lower rate of blood transfusions, and faster gastrointestinal functional recovery have been reported after multimodal prehabilitation interventions. Patients and healthcare professionals should recognize the importance of prehabilitation in the field of gynecologic oncologic treatment, based on the emerging evidence. In addition, there is a need to establish an appropriate target group and construct a well-designed and tailored prehabilitation program.
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Affiliation(s)
| | | | - Ga Won Yim
- Department of Obstetrics and Gynecology, Dongguk University College of Medicine, Goyang 10326, Republic of Korea; (J.K.); (C.H.L.)
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Prakash Bhandoria G, Guru A, Pawar A, Bhatt A, Kumar N, Kumar R, Patel S, Lal Solanki S, Sukumar V, Rajagopal AK, Somashekhar S. INDEPSO-ISPSM consensus on peritoneal malignancies - Enhanced recovery after surgery in cytoreductive surgery (CRS) with/without hyperthermic intraperitoneal chemotherapy (HIPEC). Gynecol Oncol Rep 2025; 57:101662. [PMID: 39811827 PMCID: PMC11732209 DOI: 10.1016/j.gore.2024.101662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2024] [Revised: 10/28/2024] [Accepted: 12/11/2024] [Indexed: 01/03/2025] Open
Abstract
Background The role of enhanced recovery after surgery (ERAS) in cytoreductive surgery and/or Hyperthermic Intraperitoneal Chemotherapy (HIPEC) is evolving, with promising results that improve patient outcomes. This consensus exercise was carried out to address and standardize components of the ERAS protocol pertinent to the Indian context. Method The modified Delphi method was employed with two rounds of voting. All fifty invited specialists agreed to vote. There were 30 questions addressing the key elements of ERAS protocols. They were broadly distributed across four sections: Prehabilitation, Preoperative, Intraoperative, and Postoperative elements. A consensus was achieved if any one option received > 70 % votes (strong consensus > 90 %). If consensus was not achieved in round 1, the question was moved to round 2. Results After rounds I and II, 48/50 (95.8%) of invited panelists voted for the questions. The highest rate of 'skipped question' was 6% in both rounds. A consensus was obtained for 28/30 (93.33%) questions, and strong consensus was obtained for 5/30 (16.6%) questions. No consensus was obtained for two questions. Some of the panelists' recommendations contradicted the standard ERAS guidelines, such as using intraperitoneal drains in all patients and mechanical bowel preparation for left-sided colonic or rectal resections. Conclusion Despite some limitations, this consensus exercise represents a significant step toward advancement and pioneering efforts to improve patient outcomes by implementing and standardizing ERAS protocols in CRS and/or HIPEC tailored for India.
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Affiliation(s)
| | - Arvind Guru
- Dept of Surgical Oncology, Homi Babha Cancer Hospital and Research Centre (HBCHRC), New Chandigarh, Punjab, India
| | - Ajinkya Pawar
- Dept of Surgical Oncology, The Gujarat Cancer & Research Institute, Ahmedabad, Gujarat, India
| | - Aditi Bhatt
- Dept of Surgical Oncology, Shalby Cancer and Research Institute, Ahmedabad, India
| | - Neha Kumar
- Dept of Gynaecologic Oncology, Amrita Hospital, Faridabad, India
| | - Rohit Kumar
- Dept of Surgical Oncology, Aster International Institute of Oncology, Bangalore, India
| | - Swapnil Patel
- Dept of Surgical Oncology, Upkar Hospital and Cancer Institute, Varanasi, India
| | | | - Vivek Sukumar
- Dept of Surgical Oncology, Specialty Surgical Oncology, Mumbai, India
| | - Ashwin K. Rajagopal
- Dept of Surgical Oncology, Aster International Institute of Oncology, Bangalore, India
| | - S.P. Somashekhar
- Dept of Surgical Oncology, Aster International Institute of Oncology, Bangalore, India
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Miralpeix E, Rodriguez-Cosmen C, Fabregó B, Sole-Sedeno JM, Carazo J, Sadurní M, Corcoy M, Mancebo G. Pre-operative impact of multimodal prehabilitation in gynecologic oncology patients. Int J Gynecol Cancer 2025; 35:100062. [PMID: 39971423 DOI: 10.1016/j.ijgc.2024.100062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2024] [Revised: 12/12/2024] [Accepted: 12/14/2024] [Indexed: 02/21/2025] Open
Abstract
OBJECTIVE Multimodal prehabilitation is a multi-disciplinary program that includes exercise, nutrition, and psychological intervention before surgery to improve pre-operative functional capacity. This study aims to assess the impact of a prehabilitation program on the pre-operative functional status of gynecologic oncology patients. METHODS This single-center, prospective observational study included all consecutive patients diagnosed with gynecologic cancer who were scheduled for surgery and enrolled in a structured prehabilitation program from January 2018 to May 2024. Only patients with both baseline and pre-operative evaluations were included. Functional status data were compared before (baseline) and after (pre-operative) the prehabilitation intervention. The primary outcome measured was functional capacity, as determined by the 6-minute walk test (6MWT). Secondary outcomes included hand grip strength, the Malnutrition Universal Screening Tool (MUST) score, and the Hospital Anxiety and Depression Scale score. The type of training and adherence were also evaluated. RESULTS A total of 77 patients underwent both baseline and pre-operative evaluation at the prehabilitation unit. The median duration of the program was 25.2 days (range; 9-63). Significant pre-operative improvements were observed in 6MWT (baseline: 435.7 m, standard deviation [SD] = 115.9 vs pre-operative: 455.7 m, SD = 118.9, p < .001), hand grip strength (baseline: 19.0 kg, SD = 5.5 vs pre-operative: 20.4 kg, SD = 5.9, p = .012), MUST score (baseline MUST ≥2 in 14.3% patients vs pre-operative 3.9%, p = .03), and Hospital Anxiety and Depression Scale score (baseline anxiety score: 7.4, SD = 4.3 vs pre-operative: 6.3, SD = 3.6, p < .001; and baseline depression score: 5.5, SD = 4.2 vs pre-operative: 4.3, SD = 3.6, p < .001). Among the different training programs, patients participating in supervised CrossFit training showed greater improvement in the 6MWT (33.4 m), compared to the hospital-supervised group (27.1 m), and the non-supervised home training group (14.0 m). CONCLUSIONS A structured multimodal prehabilitation program improves pre-operative functional capacity in gynecologic oncology patients, with the greatest improvements seen in those who participated in supervised high-intensity training, such as CrossFit.
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Affiliation(s)
- Ester Miralpeix
- Hospital del Mar, Department of Obstetrics and Gynecology, Barcelona, Spain; Pompeu Fabra University, Faculty of Medicine and Life Science, Barcelona, Spain.
| | | | - Berta Fabregó
- Hospital del Mar, Department of Obstetrics and Gynecology, Barcelona, Spain
| | - Josep-Maria Sole-Sedeno
- Hospital del Mar, Department of Obstetrics and Gynecology, Barcelona, Spain; Pompeu Fabra University, Faculty of Medicine and Life Science, Barcelona, Spain
| | - Jesus Carazo
- Hospital del Mar, Department of Anesthesiology, Resuscitation and Pain Relief, Barcelona, Spain
| | - Marc Sadurní
- Hospital del Mar, Department of Anesthesiology, Resuscitation and Pain Relief, Barcelona, Spain
| | - Marta Corcoy
- Hospital del Mar, Department of Anesthesiology, Resuscitation and Pain Relief, Barcelona, Spain
| | - Gemma Mancebo
- Hospital del Mar, Department of Obstetrics and Gynecology, Barcelona, Spain; Pompeu Fabra University, Faculty of Medicine and Life Science, Barcelona, Spain
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Heutlinger O, Acharya N, Tedesco A, Ramesh A, Smith B, Nguyen NT, Wischmeyer PE. Nutritional Optimization of the Surgical Patient: A Narrative Review. Adv Nutr 2025; 16:100351. [PMID: 39617150 PMCID: PMC11784791 DOI: 10.1016/j.advnut.2024.100351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2024] [Revised: 11/13/2024] [Accepted: 11/14/2024] [Indexed: 12/18/2024] Open
Abstract
An increasing body of literature supports the clinical benefit of nutritional assessment and optimization in surgical patients; however, this data has yet to be consolidated in a practical fashion for use by surgeons. In this narrative review, we concisely aggregate emerging data to highlight the role of nutritional optimization as a promising, practical perioperative intervention to reduce complications and improve outcomes in surgical patients. This review of the surgical nutrition literature was conducted via large database review. There were no distinct inclusion/exclusion criteria for this review; however, we focused on adult populations using up-to-date literature from high-quality systematic reviews or randomized controlled trials when available. Current perioperative management focuses on the mitigation of intraoperative and immediate postoperative complications. Well-defined risk calculators attempt to stratify patient surgical risk preoperatively to reduce adverse events directly related to surgical procedures, such as hemorrhage, cardiopulmonary compromise, or infection. However, there is a lack of standardization of prognostic tools, nutritional protocols, and guidelines governing the assessment, composition, and administration of nutritional supplementation. Substantial data exist demonstrating the clinical benefit in the operative setting. In this work, we provide a fundamental primer for surgeons to understand the clinical importance of nutritional optimization along with practical prognostic tools and recommendations for use in their practice. While the extent to which nutritional optimization improves patient outcomes is debatable, the evidence clearly demonstrates a clinically meaningful benefit. Evaluating nutritional status differs based on disease severity and etiology of presentation, thus surgeons must select the appropriate prognostic tools to assess their patients during the perioperative period. This information will catalyze subsequent work with a multidisciplinary team to provide personalized dietary plans for patients and spark research to establish protocols for specific presentations.
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Affiliation(s)
- Olivia Heutlinger
- School of Medicine, University of California-Irvine, Irvine, California, United States.
| | - Nischal Acharya
- School of Medicine, University of California-Irvine, Irvine, California, United States
| | - Amanda Tedesco
- School of Medicine, University of California-Irvine, Irvine, California, United States
| | - Ashish Ramesh
- School of Medicine, University of California-Irvine, Irvine, California, United States
| | - Brian Smith
- Department of Surgery, University of California-Irvine, Irvine, California, United States
| | - Ninh T Nguyen
- Department of Surgery, University of California-Irvine, Irvine, California, United States
| | - Paul E Wischmeyer
- Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina, United States; Department of Surgery, Duke University School of Medicine, Durham, North Carolina, United States
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Zębalski MA, Krzywon A, Nowosielski K. Prehabilitation-A Simple Approach for Complex Patients: The Results of a Single-Center Study on Prehabilitation in Patients with Ovarian Cancer Before Cytoreductive Surgery. Cancers (Basel) 2024; 16:4032. [PMID: 39682218 DOI: 10.3390/cancers16234032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2024] [Revised: 11/27/2024] [Accepted: 11/28/2024] [Indexed: 12/18/2024] Open
Abstract
Background/Objectives: Prehabilitation is a low-cost, safe procedure with no side effects, and it may have a positive impact on postoperative outcomes. However, it is not widely implemented. Our study aimed to assess the impact of prehabilitation on postoperative outcomes in patients with ovarian cancer within the field of gynecological oncology. Methods: We analyzed 110 patients with ovarian cancer who participated in a prehabilitation program before cytoreductive surgery. Based on the results of a 6-min walk test (6MWT), patients were divided into two groups: Group A (patients who improved their 6MWT results) and Group B (patients who did not improve their 6MWT results). Results: Patients in Group A demonstrated better postoperative outcomes. The length of hospital stay was significantly shorter in Group A compared to Group B (median 7 [5, 9] vs. 9 [6, 17], p = 0.032). Group A also had a lower overall number of complications and also fewer complications, as summarized by the Clavien-Dindo classification, compared to Group B. Conclusions: Patient adherence to prehabilitation recommendations was adequate. Prehabilitation was associated with improved postoperative outcomes, including shorter hospital stays and fewer complications. These benefits were more pronounced with higher patient compliance with the prehabilitation program and improvements were recorded in preoperative physical capacity.
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Affiliation(s)
- Marcin Adam Zębalski
- Department of Gynecology, Obstetrics and Gynecological Oncology, University Clinical Center of the Medical University of Silesia, 40-752 Katowice, Poland
| | - Aleksandra Krzywon
- Department of Biostatistics and Bioinformatics, Maria Sklodowska-Curie National Research Institute of Oncology, Gliwice Branch, 44-102 Gliwice, Poland
| | - Krzysztof Nowosielski
- Department of Gynecology, Obstetrics and Gynecological Oncology, University Clinical Center of the Medical University of Silesia, 40-752 Katowice, Poland
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11
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Mayer A, Cibula D. Optimizing prehabilitation in gynecologic malignancies: Improving acceptance, overcoming barriers, and managing program complexity. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:108739. [PMID: 39418833 DOI: 10.1016/j.ejso.2024.108739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2024] [Revised: 09/23/2024] [Accepted: 10/01/2024] [Indexed: 10/19/2024]
Abstract
Prehabilitation aims to improve patients' physical condition before a stressful event, such as surgery, and enhance recovery. Despite its potential benefits, many emerging prehabilitation programs face challenges in enrolling or retaining patients. In our prehabilitation study PHOCUS, which aims to prepare ovarian cancer patients for surgery, we have also encountered lower acceptance and retention rates. Particularly the most vulnerable patients, who are old and frail, and may benefit the most from the prehabilitation, decline participation due to the complexity of the proposed program. In our review we discussed obstacles and barriers that prevent patients' participation based on both literature and our experience. Among the main reasons are patient's low motivation, high intensity of the program and a lack of social support. To overcome these challenges, we suggest increasing the program's flexibility, adapting the program according to individual patient's needs and enhancing patients' education about the benefits of prehabilitation.
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Affiliation(s)
- Alexandra Mayer
- Gynecologic Oncology Center, Department of Obstetrics and Gynecology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - David Cibula
- Gynecologic Oncology Center, Department of Obstetrics and Gynecology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic.
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12
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Chen Y, Sebio-García R, Iglesias-Garcia E, Reguart N, Martinez-Palli G, Bello I. Prehabilitation for patients undergoing neoadjuvant therapy prior to cancer resection: a systematic review and meta-analysis. Support Care Cancer 2024; 32:749. [PMID: 39466349 DOI: 10.1007/s00520-024-08941-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Accepted: 10/13/2024] [Indexed: 10/30/2024]
Abstract
PURPOSE To determine the effectiveness of uni- or multimodal prehabilitation on several outcomes in patients undergoing neoadjuvant therapy before cancer surgery. METHODS A systematic search was carried on May 1, 2023, using four major databases (SCOPUS, Web of Science, Medline (Ovid and Pubmed)) and updated monthly until February 2024. Inclusion criteria included (i) any original articles (any design), (ii) adult patients undergoing neoadjuvant therapy (NAT) prior to surgical resection, (iii) participation in uni- or multimodal prehabilitation programs during NAT, and (iv) reporting on any functional, treatment-related, or perioperative outcome. Two reviewers independently conducted the search and screened all records. Risk of bias was assessed using the Johanna Briggs Institute Appraisal Tools independently by two reviewers. A random-effects meta-analysis was performed for all outcomes with two or more studies. RESULTS A total of 30 records met the inclusion criteria and were analyzed. Studies showed that prehabilitation during NAT can be feasible in most settings and increase or prevent the loss of cardiorespiratory fitness (CRF), maintain or improve muscle mass, and improve pathological response and treatment completion compared to no prehabilitation, but the certainty of the evidence is low to moderate. However, according to our findings, prehabilitation has little to no effect on postoperative complications and length of hospital stay as well as in health-related quality of life. CONCLUSIONS Prehabilitation during NAT might be feasible and associated with improvements in cardiorespiratory fitness, muscle mass, and treatment response/completion with low-to-moderate certainty of evidence. Insufficient data on safety is available at this stage.
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Affiliation(s)
- Y Chen
- Physical Medicine and Rehabilitation Department, Hospital Clinic de Barcelona, Casanova 160 Bis. 08036, Barcelona, Spain
| | - R Sebio-García
- Physical Medicine and Rehabilitation Department, Hospital Clinic de Barcelona, Casanova 160 Bis. 08036, Barcelona, Spain.
- Fundació de Recerca Clínic Barcelona - Institut d'Investigacions Biomèdiques August Pi i Sunyer Biomedical Research Institute (FRCB-IDIBAPS), Barcelona, Spain.
| | - E Iglesias-Garcia
- Physical Medicine and Rehabilitation Department, Hospital Clinic de Barcelona, Casanova 160 Bis. 08036, Barcelona, Spain
| | - N Reguart
- Fundació de Recerca Clínic Barcelona - Institut d'Investigacions Biomèdiques August Pi i Sunyer Biomedical Research Institute (FRCB-IDIBAPS), Barcelona, Spain
- Department of Thoracic Oncology, Hospital Clínic de Barcelona, Barcelona, Spain
| | - G Martinez-Palli
- Fundació de Recerca Clínic Barcelona - Institut d'Investigacions Biomèdiques August Pi i Sunyer Biomedical Research Institute (FRCB-IDIBAPS), Barcelona, Spain
- Department of Anaesthesia, Reanimation and Pain Management, Hospital Clínic de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red Enfermedades Respiratorias CIBERES, Madrid, Spain
| | - I Bello
- Fundació de Recerca Clínic Barcelona - Institut d'Investigacions Biomèdiques August Pi i Sunyer Biomedical Research Institute (FRCB-IDIBAPS), Barcelona, Spain
- Department of Thoracic Surgery, Hospital Clinic de Barcelona, Barcelona, Spain
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13
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Sebio-Garcia R, Celada-Castro C, Arguis MJ, Sisó M, Torné A, Tena B, Díaz-Feijoo B, Martinez-Palli G. Multimodal prehabilitation improves functional capacity in patients with advanced ovarian cancer undergoing cytoreductive surgery. Int J Gynecol Cancer 2024:ijgc-2024-005686. [PMID: 39375165 DOI: 10.1136/ijgc-2024-005686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/09/2024] Open
Abstract
OBJECTIVE Prehabilitation, defined as the preparatory intervention to increase patient preparedness in the lead-up to surgery, has shown a decrease in post-operative complications in various types of surgery. However, there is limited evidence in advanced ovarian cancer surgery. This study aimed to evaluate the benefits of multimodal prehabilitation in advanced ovarian cancer patients in terms of improving physical functioning, body composition, and psychological well-being during the pre-operative period. METHODS This single-center, ambispective study included patients with advanced ovarian cancer eligible for primary or interval cytoreductive surgery. Participants attended a multimodal prehabilitation program comprising medical optimization, supervised exercise training, nutritional counseling and supplementation, and psychological support. Functional capacity, nutritional status, and psychological well-being were assessed before the start of the program and before surgery. RESULTS 62 patients were referred for the multimodal prehabilitation program from July 2019 to May 2023. Median adherence to the training program reached 75% (IQR 58-87%). 35 patients (59%) were evaluated pre-operatively. Patients attended a median of 8 (IQR 6-12) supervised exercise training sessions with no differences between those who underwent primary or interval cytoreductive surgery (p=0.80). A significant improvement was observed in functional capacity according to the 6 min walk test (mean 33.1 m, 95% CI 10.5 to 55.5) as well as in the 30 s sit-to-stand test (+3.3 repetitions, 95% CI 1.8 to 4.8), with both being above the minimal clinically important difference of 14 m and two repetitions, respectively. Patients also reported a significant decrease in depression, anxiety, and total scores of the Hospital Anxiety and Depression Scale. CONCLUSIONS Multimodal prehabilitation in patients with advanced ovarian cancer undergoing cytoreductive surgery improves pre-operative physical functioning and decreases emotional distress. Further controlled studies with a larger sample size are warranted to corroborate improvement in functional capacity, body composition, and psychological well-being through prehabilitation programs.
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Affiliation(s)
- Raquel Sebio-Garcia
- Department of Rehabilitation, Hospital Clinic de Barcelona, Barcelona, Catalunya, Spain
| | | | - Maria J Arguis
- Anaesthesiology and Intensive Care, Hospital Clinic de Barcelona, Barcelona, Spain
- IDIBAPS, Barcelona, Catalunya, Spain
| | - Marina Sisó
- Hospital Clinic de Barcelona, Barcelona, Catalunya, Spain
| | - Aureli Torné
- Gynecology Oncology Unit, Hospital Clínic de Barcelona, Barcelona, Spain
- University of Barcelona. IDIBAPS, Barcelona, Spain
| | - Beatriz Tena
- Anaesthesiology and Intensive Care, Hospital Clinic de Barcelona, Barcelona, Spain
- Universidad de Barcelona, Barcelona, Spain
| | - Berta Díaz-Feijoo
- Gynecology Oncology Unit, Hospital Clínic de Barcelona, Barcelona, Spain
- University of Barcelona. IDIBAPS, Barcelona, Spain
| | - Graciela Martinez-Palli
- Anaesthesiology and Intensive Care, Hospital Clinic de Barcelona, Barcelona, Spain
- IDIBAPS, Barcelona, Catalunya, Spain
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14
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Fumagalli D, Sonik R, De Vitis LA, Rossi V, Bazzurini L, McGree ME, Fought AJ, Mariani A, Cliby WA, Kumar A. Evaluating nutrition in advanced ovarian cancer: which biomarker works best? Gynecol Oncol 2024; 188:97-102. [PMID: 38943693 DOI: 10.1016/j.ygyno.2024.06.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Revised: 06/12/2024] [Accepted: 06/24/2024] [Indexed: 07/01/2024]
Abstract
BACKGROUND Advanced epithelial ovarian cancer (OC) patients often present with malnutrition; however, the ideal nutritional evaluation tool is unclear. We aimed to evaluate the role of preoperative albumin, Prognostic Nutritional Index [PNI], neutrophil-to-lymphocyte ratio [NLR], and platelet-to-lymphocyte ratio [PLR] as independent predictors of severe postoperative complications and 90-day mortality in OC patients who underwent primary cytoreductive surgery to identify the ideal tool. METHODS OC patients who underwent surgery at Mayo Clinic (2003-2018) were included; biomarkers were retrospectively retrieved and established cut-offs were utilized. Outcomes included severe complications (Accordion grade ≥ 3) and 90-day mortality. Univariate and multivariable logistic regression models were performed. Biomarkers were evaluated in separate models adjusted for age and American Society of Anesthesiologists (ASA) score for 90-day mortality, and adjusted for age, ASA score, stage, and surgical complexity for severe complications. RESULTS Albumin <3.5 g/dL, PNI < 45, NLR > 6 and PLR ≥ 200 were univariately associated with 90-day mortality (all p < 0.05) in 627 patients that met inclusion criteria. Each marker remained significant in adjusted models with albumin having the highest OR: 6.04 [95% CI:2.80-13.03] and AUC (0.83). Univariately, PNI <45, NLR >6, and PLR ≥200 were significant predictors of severe complications(all p < 0.05), however failed to reach significance in adjusted models. Albumin was not associated with severe complications. CONCLUSION All biomarkers were associated with 90-day mortality in adjusted models, with albumin being the easiest predictor to attain clinically; none with severe complications. Future research should focus less on methods of nutritional assessment and more on strategies to improve nutrition during OC tumor-directed therapy.
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Affiliation(s)
- Diletta Fumagalli
- Division of Gynecologic Surgery, Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN, USA; Department of Medicine and Surgery, University of Milan-Bicocca, Milan, MI, Italy
| | - Roma Sonik
- Mayo Alix School of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Luigi A De Vitis
- Division of Gynecologic Surgery, Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN, USA; Department of Gynecology, European Institute of Oncology (IEO), Milan, MI, Italy
| | - Valentina Rossi
- Department of Medicine and Surgery, University of Milan-Bicocca, Milan, MI, Italy
| | - Luca Bazzurini
- Department of Obstetrics and Gynecology, Manerbio Hospital, ASST Garda, Brescia, BS, Italy
| | - Michaela E McGree
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | - Angela J Fought
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | - Andrea Mariani
- Division of Gynecologic Surgery, Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN, USA
| | - William A Cliby
- Division of Gynecologic Surgery, Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN, USA
| | - Amanika Kumar
- Division of Gynecologic Surgery, Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN, USA.
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Moss E, Taylor A, Andreou A, Ang C, Arora R, Attygalle A, Banerjee S, Bowen R, Buckley L, Burbos N, Coleridge S, Edmondson R, El-Bahrawy M, Fotopoulou C, Frost J, Ganesan R, George A, Hanna L, Kaur B, Manchanda R, Maxwell H, Michael A, Miles T, Newton C, Nicum S, Ratnavelu N, Ryan N, Sundar S, Vroobel K, Walther A, Wong J, Morrison J. British Gynaecological Cancer Society (BGCS) ovarian, tubal and primary peritoneal cancer guidelines: Recommendations for practice update 2024. Eur J Obstet Gynecol Reprod Biol 2024; 300:69-123. [PMID: 39002401 DOI: 10.1016/j.ejogrb.2024.06.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2024] [Accepted: 06/13/2024] [Indexed: 07/15/2024]
Affiliation(s)
- Esther Moss
- College of Life Sciences, University of Leicester, University Road, Leicester, LE1 7RH, UK
| | | | - Adrian Andreou
- Royal United Hospitals Bath NHS Foundation Trust, Combe Park, Bath BA1 3NG, UK
| | - Christine Ang
- Northern Gynaecological Oncology Centre, Gateshead, UK
| | - Rupali Arora
- Department of Cellular Pathology, University College London NHS Trust, 60 Whitfield Street, London W1T 4E, UK
| | | | | | - Rebecca Bowen
- Royal United Hospitals Bath NHS Foundation Trust, Combe Park, Bath BA1 3NG, UK
| | - Lynn Buckley
- Beverley Counselling & Psychotherapy, 114 Holme Church Lane, Beverley, East Yorkshire HU17 0PY, UK
| | - Nikos Burbos
- Department of Obstetrics and Gynaecology, Norfolk and Norwich University Hospital Colney Lane, Norwich NR4 7UY, UK
| | | | - Richard Edmondson
- Saint Mary's Hospital, Manchester and University of Manchester, M13 9WL, UK
| | - Mona El-Bahrawy
- Imperial College London, Hammersmith Hospital, Du Cane Road, London W12 0HS, UK
| | | | - Jonathan Frost
- Gynaecological Oncology, Royal United Hospitals Bath NHS Foundation Trust, Combe Park, Bath, Bath BA1 3NG, UK; University of Exeter, Exeter, UK
| | - Raji Ganesan
- Department of Cellular Pathology, Birmingham Women's Hospital, Birmingham B15 2TG, UK
| | | | - Louise Hanna
- Department of Oncology, Velindre Cancer Centre, Whitchurch, Cardiff CF14 2TL, UK
| | - Baljeet Kaur
- North West London Pathology (NWLP), Imperial College Healthcare NHS Trust, Hammersmith Hospital, Du Cane Road, London W12 0HS, UK
| | - Ranjit Manchanda
- Wolfson Institute of Population Health, Cancer Research UK Barts Centre, Queen Mary University of London and Barts Health NHS Trust, UK
| | - Hillary Maxwell
- Dorset County Hospital, Williams Avenue, Dorchester, Dorset DT1 2JY, UK
| | - Agnieszka Michael
- Royal Surrey NHS Foundation Trust, Guildford GU2 7XX and University of Surrey, School of Biosciences, GU2 7WG, UK
| | - Tracey Miles
- Royal United Hospitals Bath NHS Foundation Trust, Combe Park, Bath BA1 3NG, UK
| | - Claire Newton
- Gynaecology Oncology Department, St Michael's Hospital, University Hospitals Bristol NHS Foundation Trust, Bristol BS1 3NU, UK
| | - Shibani Nicum
- Department of Oncology, University College London Cancer Institute, London, UK
| | | | - Neil Ryan
- The Centre for Reproductive Health, Institute for Regeneration and Repair (IRR), 4-5 Little France Drive, Edinburgh BioQuarter City, Edinburgh EH16 4UU, UK
| | - Sudha Sundar
- Institute of Cancer and Genomic Sciences, University of Birmingham and Pan Birmingham Gynaecological Cancer Centre, City Hospital, Birmingham B18 7QH, UK
| | - Katherine Vroobel
- Department of Cellular Pathology, Royal Marsden Foundation NHS Trust, London SW3 6JJ, UK
| | - Axel Walther
- Bristol Cancer Institute, University Hospitals Bristol and Weston NHS Foundation Trust, UK
| | - Jason Wong
- Department of Histopathology, East Suffolk and North Essex NHS Foundation Trust, Ipswich Hospital, Heath Road, Ipswich IP4 5PD, UK
| | - Jo Morrison
- University of Exeter, Exeter, UK; Department of Gynaecological Oncology, GRACE Centre, Musgrove Park Hospital, Somerset NHS Foundation Trust, Taunton TA1 5DA, UK.
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16
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Miller LJ, Halliday V, Snowden JA, Aithal GP, Lee J, Greenfield DM. Health professional attitudes and perceptions of prehabilitation and nutrition before haematopoietic cell transplantation. J Hum Nutr Diet 2024; 37:1007-1021. [PMID: 38696512 DOI: 10.1111/jhn.13315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 04/20/2024] [Indexed: 05/04/2024]
Abstract
BACKGROUND Nutritional prehabilitation may improve haematopoietic cell transplantation (HCT) outcomes, although little evidence exists. The present study aimed to understand healthcare professional (HCP) perceptions of prehabilitation and nutritional care pre-HCT in UK centres. METHODS An anonymous online survey (developed and refined via content experts and piloting) was administered via email to multidisciplinary HCPs in 39 UK adult centres, between July 2021 and June 2022. Data are presented as proportions of responses. Routine provision denotes that care was provided >70% of time. RESULTS Seventy-seven percent (n = 66) of HCPs, representing 61.5% (n = 24) of UK adult HCT centres, responded. All HCPs supported prehabilitation, proposing feasible implementation between induction chemotherapy (60.4%; n = 40) and first HCT clinic (83.3%; n = 55). Only 12.5% (n = 3) of centres had a dedicated prehabilitation service. Nutrition (87.9%; n = 58), emotional wellbeing (92.4%; n = 61) and exercise (81.8%; n = 54) were considered very important constituents. HCPs within half of the HCT centres (n = 12 centres) reported routine use of nutrition screening pre-HCT with a validated tool; 66.7% of HCPs (n = 36) reported using the malnutrition universal screening tool (MUST). Sixty-two percent (n = 41) of HCPs reported those at risk, received nutritional assessments, predominantly by dietitians (91.6%; n = 22) using the dietetic care process (58.3%; n = 14). Body mass index (BMI) was the most frequently reported body composition measure used by HCPs (70.2%, n = 33). Of 59 respondents, non-dietitians most routinely provided dietary advice pre-HCT (82.4%; n = 28 vs. 68%; n = 17, p = 0.2); including high-energy/protein/fat and neutropenic diet advice. Prophylactic enteral feeding pre-HCT was rare, indicated by low BMI and significant unintentional weight loss. Just under half (n = 25 of 59, 42.4%) HCPs reported exercise advice was given routinely pre-HCT. CONCLUSIONS Nutrition and prehabilitation pre-HCT are considered important and deliverable by HCPs, but current provision in UK centres is limited and inconsistent.
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Affiliation(s)
- Laura J Miller
- Department of Dietetics and Nutrition, Nottingham University Hospitals NHS Trust, Nottingham, UK
- School of Medicine and Population Health, University of Sheffield, Sheffield, UK
| | - Vanessa Halliday
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK
| | - John A Snowden
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- British Society of Blood and Marrow Transplantation & Cellular Therapy (BSBMTCT), London, UK
| | - Guruprasad P Aithal
- School of Medicine and Population Health, University of Sheffield, Sheffield, UK
| | - Julia Lee
- British Society of Blood and Marrow Transplantation & Cellular Therapy (BSBMTCT), London, UK
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Lovey J, Molnar A, Banky B. Long-term nutrition in patients candidate to neoadjuvant and adjuvant treatments. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:106850. [PMID: 36841694 DOI: 10.1016/j.ejso.2023.02.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 02/14/2023] [Indexed: 02/19/2023]
Abstract
To improve outcomes, to decrease the rate of local recurrence and development of distant metastases neoadjuvant and adjuvant therapies are employed in cancer patients in forms of radiation, chemo-, endocrine-, targeted-, and immunotherapy or their combination. Nutrition therapy plays important role in all phases of the cancer journey. From neoadjuvant therapy to prehabilitation, early postoperative nutrition, and long-term nutrition care during the adjuvant phase and survivorship determines the survival and quality of life of cancer patients. During the neoadjuvant phase patients may be in poor nutritional condition which can be aggravated by the applied oncological treatment. Beside this apparent threat this period also gives an excellent opportunity to maintain or even improve the nutritional status of the patients by nutrition therapy. After surgery the burdening effects of the operation may jeopardize the execution of adjuvant therapy. After early postoperative feeding a long-term nutrition strategy should be developed for cancer patients in order to avoid nutritional deterioration during the usually lengthy postoperative therapy. In this narrative review we discuss how preoperative nutritional status and medical nutrition therapy influence the results of surgery and after the operation what is the available evidence about nutritional status and outcome and the potentials to influence them by nutrition therapy.
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Affiliation(s)
- Jozsef Lovey
- National Tumorbiology Laboratory, National Institute of Oncology, Budapest, Hungary; Chair of Oncology, Semmelweis University, Budapest, Hungary.
| | - Andrea Molnar
- Scientific Committee, National Association of Hungarian Dietitians, Budapest, Hungary
| | - Balazs Banky
- Department of Surgery, Transplantation and Gastroenterology, Semmelweis University, Budapest, Hungary
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18
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Daviu Cobián C, Oreskov JO, Blaakaer J, Jespersen E, Jørgensen TL, Ryg J, Herrstedt J, Høgdall C, Lund CM, Seibæk L, Vinther A, Ekmann-Gade AW, Schnack TH. Impact of FRAilty screening and Geriatric assessment and INtervention in older patients with epithelial Ovarian Cancer: A multicenter randomized clinical trial protocol (FRAGINOC). J Geriatr Oncol 2024; 15:101713. [PMID: 38326125 DOI: 10.1016/j.jgo.2024.101713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 01/11/2024] [Accepted: 01/23/2024] [Indexed: 02/09/2024]
Abstract
INTRODUCTION Radical surgery combined with chemotherapy is the only potential curative treatment of patients with advanced epithelial ovarian cancer (EOC). However, 43% of older Danish patients with EOC are not referred to surgery due to frailty, age, or fear of complications. Comprehensive geriatric assessment (CGA) has demonstrated ability to reduce frailty in older patients, but there is a knowledge gap regarding its effect before or during treatment in older adults with EOC. This protocol presents a randomized controlled trial (RCT), which evaluates the effect of CGA-based interventions including individualized physical exercise therapy in older adults with EOC during neoadjuvant chemotherapy (NACT). MATERIALS AND METHODS This RCT will include patients aged ≥70 years with primary EOC referred to NACT. Patients will be randomized 1:1 to intervention or standard of care, along with neoadjuvant antineoplastic treatment. Stratification for performance status and center of inclusion will be performed. In the intervention arm, a geriatrician will perform CGA and corresponding geriatric interventions and patients will undergo an individualized home-based exercise program managed by a physiotherapist. All patients will be evaluated with Geriatric-8, modified Geriatric-8, clinical frailty scale, and physical tests at randomization. Predictive values (positive/negative) will be evaluated for CGA detected impairments. The primary endpoint is the proportion of patients referred to interval debulking surgery (IDS). Secondary endpoints include the proportion who complete oncological treatment, improvements in physical tests, quality of life measured by European Organization for Research and Treatment of Cancer-Quality of Life questionnaires at inclusion, after three cycles of chemotherapy, and at end of chemotherapy treatment. Furthermore, the association between results of geriatric screening tests, CGA, and physical tests with complication rate and progression free survival will be examined. The primary outcome will be analyzed with logistic regression in the intention-to-treat population. Power calculations reveal the need to enroll 216 patients. DISCUSSION The present study examines whether CGA-based interventions including individualized physical exercise can increase the referral rate for potential curative IDS in older patients with EOC. If successful, this will result in more patients undergoing surgery and completing chemotherapy, preventing complications, and ultimately improving quality of life and survival. The study setup may establish the basis for direct clinical implementation if proven effective.
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Affiliation(s)
- Cristina Daviu Cobián
- Department of Gynecology and Obstetrics, Zealand University Hospital, Roskilde, Denmark; Department of Gynecology and Obstetrics, Odense University Hospital, Denmark.
| | - Jakob O Oreskov
- Department of Gynecology, Rigshospitalet, Copenhagen University Hospital, Denmark
| | - Jan Blaakaer
- Department of Gynecology and Obstetrics, Odense University Hospital, Denmark; Department of Clinical Research, University of Southern Denmark, Denmark; Academy of Geriatric Cancer Research (AgeCare), Odense University Hospital, Denmark
| | - Eva Jespersen
- Department of Clinical Research, University of Southern Denmark, Denmark; Department of Oncology, Odense University Hospital, Denmark
| | - Trine L Jørgensen
- Department of Clinical Research, University of Southern Denmark, Denmark; Academy of Geriatric Cancer Research (AgeCare), Odense University Hospital, Denmark; Department of Oncology, Odense University Hospital, Denmark
| | - Jesper Ryg
- Department of Clinical Research, University of Southern Denmark, Denmark; Academy of Geriatric Cancer Research (AgeCare), Odense University Hospital, Denmark; Department of Geriatric Medicine, Odense University Hospital, Denmark
| | - Jørn Herrstedt
- Department of Clinical Oncology and Palliative Care, Zealand University Hospital, Roskilde, Denmark
| | - Claus Høgdall
- Department of Gynecology, Rigshospitalet, Copenhagen University Hospital, Denmark
| | - Cecilia M Lund
- Department of Medicine, Herlev and Gentofte hospital, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, Copenhagen University, Denmark
| | - Lene Seibæk
- Department of Gynecology and Obstetrics, Aarhus University Hospital, Aarhus, Denmark
| | - Anders Vinther
- Department of Physiotherapy and Occupational Therapy, Copenhagen University Hospital, Herlev and Gentofte Hospital, Herlev, Denmark; Hospital Secretariat and Communications, Research, Copenhagen University Hospital, Herlev and Gentofte Hospital, Herlev, Denmark
| | - Anne Weng Ekmann-Gade
- Department of Obstetrics and Gynecology, Herlev University Hospital, Herlev, Denmark
| | - Tine H Schnack
- Department of Gynecology and Obstetrics, Odense University Hospital, Denmark; Department of Clinical Research, University of Southern Denmark, Denmark
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19
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Dhanis J, Strijker D, Drager LD, van Ham M, van Laarhoven CJHM, Pijnenborg JMA, Smits A, van den Heuvel B. Feasibility of Introducing a Prehabilitation Program into the Care of Gynecological Oncology Patients-A Single Institution Experience. Cancers (Basel) 2024; 16:1013. [PMID: 38473372 DOI: 10.3390/cancers16051013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 02/08/2024] [Accepted: 02/28/2024] [Indexed: 03/14/2024] Open
Abstract
Prehabilitation is an upcoming strategy to optimize patient's functional capacity, nutritional status, and psychosocial well-being in order to reduce surgical complications and enhance recovery. This study aims to assess the feasibility of implementing a multimodal prehabilitation program into the standard care of gynecological oncology patients at an academic hospital in terms of recruitment, adherence, and safety, which were assessed by the number of patients eligible, recruitment rate, participation rate, and adherence to individual modalities. Data were derived from the F4S PREHAB trial, a single-center stepped-wedge trial implementing a multimodal prehabilitation program among various surgical specialties. All patients undergoing elective surgery as part of treatment for ovarian, uterine, and vulvar cancer at the Radboudumc, an academic hospital in The Netherlands, between May 2022 and September 2023 were considered eligible for the F4S PREHAB trial and, consequently, were included in this cohort study. The multimodal prehabilitation program comprised a physical exercise intervention, nutritional intervention, psychological intervention, and an intoxication cessation program. A total of 152 patients were eligible and approached for participation of which 111 consented to participate, resulting in a recruitment rate of 73%. Participants attended an average of six exercise sessions and adhered to 85% of possible training sessions. Respectively, 93% and 98% of participants adhered to the prescribed daily protein and vitamin suppletion. Ten participants were referred to a psychologist and completed consultations. Out of nine active smokers, two managed to quit smoking. A total of 59% adhered to alcohol cessation advice. No adverse events were reported. This study demonstrates that introducing a multimodal prehabilitation program into the standard care of gynecological oncology patients is feasible in terms of recruitment and adherence, with no serious adverse events.
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Affiliation(s)
- Joëlle Dhanis
- Department of Obstetrics and Gynecology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
- Department of Operating Rooms, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Dieuwke Strijker
- Department of Surgery, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Luuk D Drager
- Department of Operating Rooms, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Maaike van Ham
- Department of Obstetrics and Gynecology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Cornelis J H M van Laarhoven
- Department of Surgery, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Johanna M A Pijnenborg
- Department of Obstetrics and Gynecology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Anke Smits
- Department of Obstetrics and Gynecology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Baukje van den Heuvel
- Department of Operating Rooms, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
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Chauhan S, Langstraat CL, Fought AJ, McGree ME, Cliby WA, Kumar A. Relationship between frailty and nutrition: Refining predictors of mortality after primary cytoreductive surgery for ovarian cancer. Gynecol Oncol 2024; 180:126-131. [PMID: 38091771 DOI: 10.1016/j.ygyno.2023.11.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 11/13/2023] [Accepted: 11/26/2023] [Indexed: 02/18/2024]
Abstract
OBJECTIVE We aimed to examine the interplay between frailty and nutritional status on 90-day mortality after primary cytoreductive surgery (PCS) for ovarian cancer (OC). METHODS Patients with OC who underwent PCS from 1/2/2006-4/30/2018 at a single institution were identified. Frailty index (FI) includes 30 items and is calculated summing across all the item scores and dividing by the total; frailty was defined as FI ≥0.15. Nutritional status was considered impaired when preoperative serum albumin was <3.5 g/dL. Logistic regression was used to analyze the association between FI (continuous) and albumin status (binary) and 90-day postoperative mortality. RESULTS A total of 533 patients (mean age, 64.4 years) were included, the majority were stage IIIC disease and serous histology. Albumin was <3.5 g/dL in 87 patients (16.3%) and 113 patients (21.2%) were considered frail. Median FI was 0.07 (IQR 0.03, 0.13). Postoperative 90-day mortality occurred in 24 patients (4.5%). Mortality within 90 days was higher amongst patients with low albumin (12/87, 13.8%), regardless of frailty status (13.8% [9/65] non-frail and 13.6% [3/22] frail patients). Ninety-day mortality in patients with normal albumin (n = 446) was over twice as likely in frail versus non-frail patients (5.5% [5/91] vs. 2.0% [7/355], respectively, p = 0.08). A model to assess 90-day mortality that included both FI and low albumin significantly improved the overall discrimination compared to low albumin alone (AUC 0.76 vs. 0.68 p = 0.03). CONCLUSION Our findings suggest that frailty and nutrition are both related to 90-day mortality. Preoperative interventions to improve functional and nutritional characteristics are needed.
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Affiliation(s)
- Shruti Chauhan
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN, United States
| | - Carrie L Langstraat
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN, United States
| | - Angela J Fought
- Department of Quantitative Health Sciences, Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN, United States
| | - Michaela E McGree
- Department of Quantitative Health Sciences, Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN, United States
| | - William A Cliby
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN, United States
| | - Amanika Kumar
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN, United States.
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21
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Laios A, Kalampokis E, Mamalis ME, Thangavelu A, Tan YS, Hutson R, Munot S, Broadhead T, Nugent D, Theophilou G, Jackson RE, De Jong D. Explaining the Elusive Nature of a Well-Defined Threshold for Blood Transfusion in Advanced Epithelial Ovarian Cancer Cytoreductive Surgery. Diagnostics (Basel) 2023; 14:94. [PMID: 38201403 PMCID: PMC10795734 DOI: 10.3390/diagnostics14010094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 12/18/2023] [Accepted: 12/29/2023] [Indexed: 01/12/2024] Open
Abstract
There is no well-defined threshold for intra-operative blood transfusion (BT) in advanced epithelial ovarian cancer (EOC) surgery. To address this, we devised a Machine Learning (ML)-driven prediction algorithm aimed at prompting and elucidating a communication alert for BT based on anticipated peri-operative events independent of existing BT policies. We analyzed data from 403 EOC patients who underwent cytoreductive surgery between 2014 and 2019. The estimated blood volume (EBV), calculated using the formula EBV = weight × 80, served for setting a 10% EBV threshold for individual intervention. Based on known estimated blood loss (EBL), we identified two distinct groups. The Receiver operating characteristic (ROC) curves revealed satisfactory results for predicting events above the established threshold (AUC 0.823, 95% CI 0.76-0.88). Operative time (OT) was the most significant factor influencing predictions. Intra-operative blood loss exceeding 10% EBV was associated with OT > 250 min, primary surgery, serous histology, performance status 0, R2 resection and surgical complexity score > 4. Certain sub-procedures including large bowel resection, stoma formation, ileocecal resection/right hemicolectomy, mesenteric resection, bladder and upper abdominal peritonectomy demonstrated clear associations with an elevated interventional risk. Our findings emphasize the importance of obtaining a rough estimate of OT in advance for precise prediction of blood requirements.
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Affiliation(s)
- Alexandros Laios
- Department of Gynaecologic Oncology, St James’s University Hospital, Leeds LS9 7TF, UK; (A.T.); (Y.S.T.); (R.H.); (S.M.); (T.B.); (D.N.); (G.T.); (D.D.J.)
| | - Evangelos Kalampokis
- Department of Business Administration, University of Macedonia, 54636 Thessaloniki, Greece; (E.K.); (M.-E.M.)
- Center for Research & Technology HELLAS (CERTH), 6th km Charilaou-Thermi Rd, 57001 Thessaloniki, Greece
| | - Marios-Evangelos Mamalis
- Department of Business Administration, University of Macedonia, 54636 Thessaloniki, Greece; (E.K.); (M.-E.M.)
| | - Amudha Thangavelu
- Department of Gynaecologic Oncology, St James’s University Hospital, Leeds LS9 7TF, UK; (A.T.); (Y.S.T.); (R.H.); (S.M.); (T.B.); (D.N.); (G.T.); (D.D.J.)
| | - Yong Sheng Tan
- Department of Gynaecologic Oncology, St James’s University Hospital, Leeds LS9 7TF, UK; (A.T.); (Y.S.T.); (R.H.); (S.M.); (T.B.); (D.N.); (G.T.); (D.D.J.)
| | - Richard Hutson
- Department of Gynaecologic Oncology, St James’s University Hospital, Leeds LS9 7TF, UK; (A.T.); (Y.S.T.); (R.H.); (S.M.); (T.B.); (D.N.); (G.T.); (D.D.J.)
| | - Sarika Munot
- Department of Gynaecologic Oncology, St James’s University Hospital, Leeds LS9 7TF, UK; (A.T.); (Y.S.T.); (R.H.); (S.M.); (T.B.); (D.N.); (G.T.); (D.D.J.)
| | - Tim Broadhead
- Department of Gynaecologic Oncology, St James’s University Hospital, Leeds LS9 7TF, UK; (A.T.); (Y.S.T.); (R.H.); (S.M.); (T.B.); (D.N.); (G.T.); (D.D.J.)
| | - David Nugent
- Department of Gynaecologic Oncology, St James’s University Hospital, Leeds LS9 7TF, UK; (A.T.); (Y.S.T.); (R.H.); (S.M.); (T.B.); (D.N.); (G.T.); (D.D.J.)
| | - Georgios Theophilou
- Department of Gynaecologic Oncology, St James’s University Hospital, Leeds LS9 7TF, UK; (A.T.); (Y.S.T.); (R.H.); (S.M.); (T.B.); (D.N.); (G.T.); (D.D.J.)
| | | | - Diederick De Jong
- Department of Gynaecologic Oncology, St James’s University Hospital, Leeds LS9 7TF, UK; (A.T.); (Y.S.T.); (R.H.); (S.M.); (T.B.); (D.N.); (G.T.); (D.D.J.)
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22
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Veneziani AC, Gonzalez-Ochoa E, Alqaisi H, Madariaga A, Bhat G, Rouzbahman M, Sneha S, Oza AM. Heterogeneity and treatment landscape of ovarian carcinoma. Nat Rev Clin Oncol 2023; 20:820-842. [PMID: 37783747 DOI: 10.1038/s41571-023-00819-1] [Citation(s) in RCA: 54] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/04/2023] [Indexed: 10/04/2023]
Abstract
Ovarian carcinoma is characterized by heterogeneity at the molecular, cellular and anatomical levels, both spatially and temporally. This heterogeneity affects response to surgery and/or systemic therapy, and also facilitates inherent and acquired drug resistance. As a consequence, this tumour type is often aggressive and frequently lethal. Ovarian carcinoma is not a single disease entity and comprises various subtypes, each with distinct complex molecular landscapes that change during progression and therapy. The interactions of cancer and stromal cells within the tumour microenvironment further affects disease evolution and response to therapy. In past decades, researchers have characterized the cellular, molecular, microenvironmental and immunological heterogeneity of ovarian carcinoma. Traditional treatment approaches have considered ovarian carcinoma as a single entity. This landscape is slowly changing with the increasing appreciation of heterogeneity and the recognition that delivering ineffective therapies can delay the development of effective personalized approaches as well as potentially change the molecular and cellular characteristics of the tumour, which might lead to additional resistance to subsequent therapy. In this Review we discuss the heterogeneity of ovarian carcinoma, outline the current treatment landscape for this malignancy and highlight potentially effective therapeutic strategies in development.
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Affiliation(s)
- Ana C Veneziani
- Division of Medical Oncology and Haematology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Eduardo Gonzalez-Ochoa
- Division of Medical Oncology and Haematology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Husam Alqaisi
- Division of Medical Oncology and Haematology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Ainhoa Madariaga
- Medical Oncology Department, 12 De Octubre University Hospital, Madrid, Spain
| | - Gita Bhat
- Division of Medical Oncology and Haematology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Marjan Rouzbahman
- Department of Laboratory Medicine and Pathobiology, Toronto General Hospital, Toronto, Ontario, Canada
| | - Suku Sneha
- Division of Medical Oncology and Haematology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Amit M Oza
- Division of Medical Oncology and Haematology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada.
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
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23
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Morton M, Patterson J, Sciuva J, Perni J, Backes F, Nagel C, O'Malley DM, Chambers LM. Malnutrition, sarcopenia, and cancer cachexia in gynecologic cancer. Gynecol Oncol 2023; 175:142-155. [PMID: 37385068 DOI: 10.1016/j.ygyno.2023.06.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 06/14/2023] [Accepted: 06/18/2023] [Indexed: 07/01/2023]
Abstract
Patients with gynecologic cancers are at risk for malnutrition, cancer cachexia, and sarcopenia. Accumulating data supports that malnourished patients with gynecologic cancer have worse overall survival, increased healthcare utilization and costs, and a higher incidence of postoperative complications and treatment toxicity than those who are not malnourished. Malnutrition is defined as insufficient energy intake, leading to altered body composition and subsequent impaired physical and cognitive function, and can result in sarcopenia and cachexia, defined as the loss of lean body mass and loss of body weight respectively. The etiology of cancer-related malnutrition is complex, resulting from a systemic pro-inflammatory state of malignancy with upregulation of muscle degradation pathways and metabolic derangements, including lipolysis and proteolysis, that may not respond to nutritional repletion alone. Numerous validated scoring systems and radiographic measures have been described to define and quantify the severity of malnutrition and muscle loss in both clinical and research settings. "Prehabilitation" and optimization of nutrition and functional status early in therapy may combat the development or worsening of malnutrition and associated syndromes and ultimately improve oncologic outcomes, but limited data exist in the context of gynecologic cancer. Multi-modality nutrition and physical activity interventions have been proposed to combat the biophysical losses related to malnutrition. Several trials are underway in gynecologic oncology patients to address these aims, but significant gaps in knowledge persist. Pharmacologic interventions and potential immune targets for combating cachexia related to malignancy are discussed in this review and may provide opportunities to target disease and cachexia. This article reviews currently available data regarding the implications, diagnostics, physiology, and intervention strategies for gynecologic oncology patients with malnutrition and its associated conditions.
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Affiliation(s)
- Molly Morton
- Division of Gynecologic Oncology; The Ohio State University Wexner Medical Center, The James Cancer Hospital and Solove Research Institute, Starling Loving Hall, M210, 320 W. 10(th) Avenue, Columbus, OH 43210, United States of America.
| | - Jenna Patterson
- Department of Obstetrics and Gynecology; The Ohio State University Wexner Medical Center, 456 W 10(th) Avenue, Columbus, OH 43210, United States of America
| | - Jessica Sciuva
- The Ohio State University College of Medicine; 370 W. 9(th) Ave, Columbus, OH 43210, United States of America
| | - Jaya Perni
- The Ohio State University; 281 W Lane Ave, Columbus, OH 43210, United States of America
| | - Floor Backes
- Division of Gynecologic Oncology; The Ohio State University Wexner Medical Center, The James Cancer Hospital and Solove Research Institute, Starling Loving Hall, M210, 320 W. 10(th) Avenue, Columbus, OH 43210, United States of America
| | - Christa Nagel
- Division of Gynecologic Oncology; The Ohio State University Wexner Medical Center, The James Cancer Hospital and Solove Research Institute, Starling Loving Hall, M210, 320 W. 10(th) Avenue, Columbus, OH 43210, United States of America
| | - David M O'Malley
- Division of Gynecologic Oncology; The Ohio State University Wexner Medical Center, The James Cancer Hospital and Solove Research Institute, Starling Loving Hall, M210, 320 W. 10(th) Avenue, Columbus, OH 43210, United States of America
| | - Laura M Chambers
- Division of Gynecologic Oncology; The Ohio State University Wexner Medical Center, The James Cancer Hospital and Solove Research Institute, Starling Loving Hall, M210, 320 W. 10(th) Avenue, Columbus, OH 43210, United States of America
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24
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Wardill HR, Da Silva Ferreira AR, Kumar H, Bateman EH, Cross CB, Bowen JM, Havinga R, Harmsen HJM, Knol J, Dorresteijn B, van Dijk M, van Bergenhenegouwen J, Tissing WJE. Whey-based diet containing medium chain triglycerides modulates the gut microbiota and protects the intestinal mucosa from chemotherapy while maintaining therapy efficacy. Cell Death Dis 2023; 14:338. [PMID: 37221162 DOI: 10.1038/s41419-023-05850-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 04/24/2023] [Accepted: 05/02/2023] [Indexed: 05/25/2023]
Abstract
Cytotoxicity (i.e. cell death) is the core mechanism by which chemotherapy induces its anti-cancer effects. Unfortunately, this same mechanism underpins the collateral damage it causes to healthy tissues. The gastrointestinal tract is highly susceptible to chemotherapy's cytotoxicity, resulting in ulcerative lesions (termed gastrointestinal mucositis, GI-M) that impair the functional capacity of the gut leading to diarrhea, anorexia, malnutrition and weight loss, which negatively impact physical/psychological wellbeing and treatment adherence. Preventing these side effects has proven challenging given the overlapping mechanisms that dictate chemotherapy efficacy and toxicity. Here, we report on a novel dietary intervention that, due to its localized gastrointestinal effects, is able to protect the intestinal mucosal from unwanted toxicity without impairing the anti-tumor effects of chemotherapy. The test diet (containing extensively hydrolyzed whey protein and medium chain triglycerides (MCTs)), was investigated in both tumor-naïve and tumor-bearing models to evaluate its effect on GI-M and chemo-efficacy, respectively. In both models, methotrexate was used as the representative chemotherapeutic agent and the diet was provided ad libitum for 14 days prior to treatment. GI-M was measured using the validated biomarker plasma citrulline, and chemo-efficacy defined by tumor burden (cm3/g body weight). The test diet significantly attenuated GI-M (P = 0.03), with associated reductions in diarrhea (P < 0.0001), weight loss (P < 0.05), daily activity (P < 0.02) and maintenance of body composition (P < 0.02). Moreover, the test diet showed significant impact on gut microbiota by increasing diversity and resilience, whilst also altering microbial composition and function (indicated by cecal short and brained chain fatty acids). The test diet did not impair the efficacy of methotrexate against mammary adenocarcinoma (tumor) cells. In line with the first model, the test diet minimized intestinal injury (P = 0.001) and diarrhea (P < 0.0001). These data support translational initiatives to determine the clinical feasibility, utility and efficacy of this diet to improve chemotherapy treatment outcomes.
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Affiliation(s)
- Hannah R Wardill
- Department of Pediatrics, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
- School of Biomedicine, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA, Australia.
- Supportive Oncology Research Group, Precision Cancer Medicine, The South Australian Health and Medical Research Institute, Adelaide, Australia.
| | - Ana Rita Da Silva Ferreira
- Department of Medical Microbiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | | | - Emma H Bateman
- School of Biomedicine, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA, Australia
| | - Courtney B Cross
- Supportive Oncology Research Group, Precision Cancer Medicine, The South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Joanne M Bowen
- School of Biomedicine, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA, Australia
| | - Rick Havinga
- Department of Pediatrics, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Hermie J M Harmsen
- Department of Medical Microbiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jan Knol
- Danone Nutricia Research, Utrecht, the Netherlands
- Laboratory of Microbiology, Wageningen University, Wageningen, The Netherlands
| | | | | | | | - Wim J E Tissing
- Department of Pediatrics, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
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25
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Sole-Sedeno JM, Miralpeix E, Muns MD, Rodriguez-Cosmen C, Fabrego B, Kanjou N, Medina FX, Mancebo G. Protein Supplementation in a Prehabilitation Program in Patients Undergoing Surgery for Endometrial Cancer. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:5502. [PMID: 37107783 PMCID: PMC10139161 DOI: 10.3390/ijerph20085502] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 03/10/2023] [Accepted: 03/16/2023] [Indexed: 05/11/2023]
Abstract
Enhanced recovery after surgery (ERAS) and prehabilitation programs are multidisciplinary care pathways to reduce stress response and improve perioperative outcomes, which also include nutritional interventions. The aim of this study is to assess the impact of protein supplementation with 20 mg per day before surgery in a prehabilitation program in postoperative serum albumin, prealbumin, and total proteins in endometrial cancer patients undergoing laparoscopic surgery. METHODS A prospective study including patients who underwent laparoscopy for endometrial cancer was conducted. Three groups were identified according to ERAS and prehabilitation implementation (preERAS, ERAS, and Prehab). The primary outcome was levels of serum albumin, prealbumin, and total protein 24-48 h after surgery. RESULTS A total of 185 patients were included: 57 in the preERAS group, 60 in the ERAS group, and 68 in the Prehab group. There were no basal differences in serum albumin, prealbumin, or total protein between the three groups. After surgery, regardless of the nutritional intervention, the decrease in the values was also similar. Moreover, values in the Prehab group just before surgery were lower than the initial ones, despite the protein supplementation. CONCLUSIONS Supplementation with 20 mg of protein per day does not impact serum protein levels in a prehabilitation program. Supplementations with higher quantities should be studied.
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Affiliation(s)
- Josep M. Sole-Sedeno
- Department of Obstetrics and Gynecology, Hospital del Mar, E-08003 Barcelona, Spain (G.M.)
- Campus del Mar, Universitat Pompeu Fabra, E-08003 Barcelona, Spain
| | - Ester Miralpeix
- Department of Obstetrics and Gynecology, Hospital del Mar, E-08003 Barcelona, Spain (G.M.)
- Campus del Mar, Universitat Pompeu Fabra, E-08003 Barcelona, Spain
| | - Maria-Dolors Muns
- Department of Endocrinology, Hospital del Mar, E-08003 Barcelona, Spain
| | | | - Berta Fabrego
- Department of Obstetrics and Gynecology, Hospital del Mar, E-08003 Barcelona, Spain (G.M.)
| | - Nadwa Kanjou
- Department of Obstetrics and Gynecology, Hospital del Mar, E-08003 Barcelona, Spain (G.M.)
| | - Francesc-Xavier Medina
- FoodLab & UNESCO Chair on Food, Culture, and Development, Faculty of Health Sciences, Open University of Catalonia, E-08018 Barcelona, Spain
| | - Gemma Mancebo
- Department of Obstetrics and Gynecology, Hospital del Mar, E-08003 Barcelona, Spain (G.M.)
- Campus del Mar, Universitat Pompeu Fabra, E-08003 Barcelona, Spain
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26
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Miralpeix E, Fabregó B, Rodriguez-Cosmen C, Solé-Sedeño JM, Gayete S, Jara-Bogunya D, Corcoy M, Mancebo G. Prehabilitation in an ERAS program for endometrial cancer patients: impact on post-operative recovery. Int J Gynecol Cancer 2023; 33:528-533. [PMID: 36898697 DOI: 10.1136/ijgc-2022-004130] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2023] Open
Abstract
OBJECTIVES Enhanced recovery after surgery (ERAS) and prehabilitation programs are multidisciplinary care pathways that aim to reduce stress response and improve perioperative outcomes. However, literature is limited regarding the impact of ERAS and prehabilitation in gynecologic oncology surgery. The aim of this study was to assess the impact of implementing an ERAS and prehabilitation program on post-operative outcomes of endometrial cancer patients undergoing laparoscopic surgery. METHODS We evaluated consecutive patients undergoing laparoscopy for endometrial cancer that followed ERAS and the prehabilitation program at a single center. A pre-intervention cohort that followed the ERAS program alone was identified. The primary outcome was length of stay, and secondary outcomes were normal oral diet restart, post-operative complications and readmissions. RESULTS A total of 128 patients were included: 60 patients in the ERAS group and 68 patients in the prehabilitation group. The prehabilitation group had a shorter length of hospital stay of 1 day (p<0.001) and earlier normal oral diet restart of 3.6 hours (p=0.005) in comparison with the ERAS group. The rate of post-operative complications (5% in the ERAS group and 7.4% in the prehabilitation group, p=0.58) and readmissions (1.7% in the ERAS group and 2.9% in the prehabilitation group, p=0.63) were similar between groups. CONCLUSIONS The integration of ERAS and a prehabilitation program in endometrial cancer patients undergoing laparoscopy significantly reduced hospital stay and time to first oral diet as compared with ERAS alone, without increasing overall complications or the readmissions rate.
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Affiliation(s)
- Ester Miralpeix
- Department of Obstetrics and Gynecology, Hospital del Mar, Barcelona, Catalunya, Spain
| | - Berta Fabregó
- Department of Obstetrics and Gynecology, Hospital del Mar, Barcelona, Catalunya, Spain
| | | | | | - Sonia Gayete
- Department of Obstetrics and Gynecology, Hospital del Mar, Barcelona, Catalunya, Spain
| | - David Jara-Bogunya
- Family and Community Medicine, Hospital Universitari Germans Trias i Pujol, Badalona, Catalunya, Spain
| | - Marta Corcoy
- Department of Anesthesia, Hospital del Mar, Barcelona, Catalunya, Spain
| | - Gemma Mancebo
- Department of Obstetrics and Gynecology, Hospital del Mar, Barcelona, Catalunya, Spain
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Díaz-Feijoo B, Agusti N, Sebio R, Sisó M, Carreras-Dieguez N, Domingo S, Díaz-Cambronero O, Torne A, Martinez-Palli G, Arguís MJ. A multimodal prehabilitation program for the reduction of post-operative complications after surgery in advanced ovarian cancer under an ERAS pathway: a randomized multicenter trial (SOPHIE). Int J Gynecol Cancer 2022; 32:1463-1468. [PMID: 35793862 DOI: 10.1136/ijgc-2022-003652] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Multimodal prehabilitation programs that combine exercise training, nutritional support, and optimize psychological status have demonstrated efficacy in reducing post-operative complications in non-gynecological abdominal surgeries; however, the benefit in advanced ovarian cancer is unclear. PRIMARY OBJECTIVE To compare the post-operative complications of a multimodal prehabilitation program in patients undergoing cytoreductive surgery for advanced ovarian cancer with standard pre-operative care. STUDY HYPOTHESIS Multimodal prehabilitation reduces post-operative complications in patients undergoing cytoreductive surgery for advanced ovarian cancer and subsequently reduces the length of hospital stay and time to initiation of adjuvant therapy. TRIAL DESIGN This prospective, multi-institutional, randomized clinical trial will randomize candidates for surgery to either the standard of care or multimodal prehabilitation consisting of (1) 2- or 3-weekly supervised high-intensity resistance training sessions and promotion of physical activity through a mobile phone application; (2) respiratory physiotherapy; (3) nutrition counseling with supplementation as needed; and (4) weekly psychological and cognitive behavioral sessions. Baseline, pre-operative and 1 month post-operative data will be collected. An independent blinded evaluator will collect intra- and post-operative surgical data. MAJOR INCLUSION/EXCLUSION CRITERIA Women with advanced ovarian cancer International Federation of Gynecology and Obstetrics (2014) stage III or IV scheduled to undergo primary debulking surgery, interval debulking surgery,or secondary or tertiary cytoreductive surgery will be included. Women are eligible if they are able to undergo a minimum of 2 weeks of prehabilitation prior to surgery. Patients with <75% adherence to the total program will be excluded. PRIMARY ENDPOINT Post-operative complications in patients with advanced ovarian cancer undergoing cytoreductive surgery according to the Comprehensive Complication Index. SAMPLE SIZE 146 patients will be included, 73 in each group. ESTIMATED DATES FOR COMPLETING ACCRUAL AND PRESENTING RESULTS Accrual should be completed in December 2024 with results reported soon thereafter. TRIAL REGISTRATION NUMBER NCT04862325.
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Affiliation(s)
- Berta Díaz-Feijoo
- Hospital Clinic de Barcelona, Barcelona, Spain
- Universitat de Barcelona, Barcelona, Spain
- Department of Gynecologic Oncology, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Nuria Agusti
- Hospital Clinic de Barcelona, Barcelona, Spain
- Department of Gynecologic Oncology, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Raquel Sebio
- Hospital Clinic de Barcelona, Barcelona, Spain
- Department of Rehabilitation, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Marina Sisó
- Hospital Clinic de Barcelona, Barcelona, Spain
- Nutrition and Clinical Dietetics, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Núria Carreras-Dieguez
- Hospital Clinic de Barcelona, Barcelona, Spain
- Department of Gynecologic Oncology, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Santiago Domingo
- Gynaecology, Hospital Politécnico y Universitario La Fe, Valencia, Spain
| | - Oscar Díaz-Cambronero
- Department of Anesthesiology and Critical Care, Hospital Universitari i Politecnic La Fe, Valencia, Spain
| | - Aureli Torne
- Hospital Clinic de Barcelona, Barcelona, Spain
- Universitat de Barcelona, Barcelona, Spain
- Department of Gynecologic Oncology, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Graciela Martinez-Palli
- Hospital Clinic de Barcelona, Barcelona, Spain
- Anaesthesiology and Intensive Care, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Ma José Arguís
- Hospital Clinic de Barcelona, Barcelona, Spain
- Anaesthesiology and Intensive Care, Hospital Clinic de Barcelona, Barcelona, Spain
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28
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Dhanis J, Keidan N, Blake D, Rundle S, Strijker D, van Ham M, Pijnenborg JMA, Smits A. Prehabilitation to Improve Outcomes of Patients with Gynaecological Cancer: A New Window of Opportunity? Cancers (Basel) 2022; 14:3448. [PMID: 35884512 PMCID: PMC9351657 DOI: 10.3390/cancers14143448] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 06/30/2022] [Accepted: 07/11/2022] [Indexed: 12/02/2022] Open
Abstract
The literature evaluating the effect of prehabilitation programmes on postoperative outcomes and quality of life of patients with gynaecological cancer undergoing surgery was reviewed. Databases including Pubmed, Medline, EMBASE (Ovid) and PsycINFO were systematically searched to identify studies evaluating the effect of prehabilitation programmes on patients with gynaecological cancer. Both unimodal and multimodal prehabilitation programmes were included encompassing physical exercise and nutritional and psychological support. Primary outcomes were surgical complications and quality of life. Secondary outcomes were anthropometric changes and adherence to the prehabilitation programme. Seven studies fulfilled the inclusion criteria, comprising 580 patients. Included studies were nonrandomised prospective studies (n = 4), retrospective studies (n = 2) and one case report. Unimodal programmes and multimodal programmes were included. In patients with ovarian cancer, multimodal prehabilitation resulted in significantly reduced hospital stay and time to chemotherapy. In patients with endometrial and cervical cancer, prehabilitation was associated with significant weight loss, but had no significant effects on surgical complications or mortality. No adverse events of the programmes were reported. Evidence on the effect of prehabilitation for patients with gynaecological cancer is limited. Future studies are needed to determine the effects on postoperative complications and quality of life.
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Affiliation(s)
- Joëlle Dhanis
- Department of Obstetrics and Gynaecology, Radboud University Medical Centre, 6525 GA Nijmegen, The Netherlands; (M.v.H.); (J.M.A.P.); (A.S.)
- Faculty of Medical Sciences, Radboud University, 6526 GA Nijmegen, The Netherlands
| | - Nathaniel Keidan
- Department of Gynaecological Oncology, Queen Elizabeth Hospital, Gateshead NE9 6SX, UK; (N.K.); (D.B.); (S.R.)
| | - Dominic Blake
- Department of Gynaecological Oncology, Queen Elizabeth Hospital, Gateshead NE9 6SX, UK; (N.K.); (D.B.); (S.R.)
| | - Stuart Rundle
- Department of Gynaecological Oncology, Queen Elizabeth Hospital, Gateshead NE9 6SX, UK; (N.K.); (D.B.); (S.R.)
| | - Dieuwke Strijker
- Department of Surgery, Radboud University Medical Centre, 6525 GA Nijmegen, The Netherlands;
| | - Maaike van Ham
- Department of Obstetrics and Gynaecology, Radboud University Medical Centre, 6525 GA Nijmegen, The Netherlands; (M.v.H.); (J.M.A.P.); (A.S.)
| | - Johanna M. A. Pijnenborg
- Department of Obstetrics and Gynaecology, Radboud University Medical Centre, 6525 GA Nijmegen, The Netherlands; (M.v.H.); (J.M.A.P.); (A.S.)
| | - Anke Smits
- Department of Obstetrics and Gynaecology, Radboud University Medical Centre, 6525 GA Nijmegen, The Netherlands; (M.v.H.); (J.M.A.P.); (A.S.)
- Department of Gynaecological Oncology, Queen Elizabeth Hospital, Gateshead NE9 6SX, UK; (N.K.); (D.B.); (S.R.)
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