Multimodal Prehabilitation During Neoadjuvant Therapy Prior to Esophagogastric Cancer Resection: Effect on Cardiopulmonary Exercise Test Performance, Muscle Mass and Quality of Life-A Pilot Randomized Clinical Trial

Multimodal Prehabilitation in Major Abdominal Surgery-Rationale, Modalities, Results and Limitations

Recent evidence revealed that an adequate preoperative physiological reserve is crucial to overcome surgical stress response. Consequently, a new concept, called prehabilitation, emerged, aiming to improve the preoperative functional reserve of patients who will undergo major abdominal surgery. During the interval between diagnosis and surgery, a multimodal approach consisting of physical exercise and nutritional and psychological support could be employed to enhance physiologic reserve. Physical activity interventions aim to improve aerobic capacity, muscle strength and endurance. Nutritional support addressing malnutrition and sarcopenia also contributes to the achievement of the above-mentioned goals, particularly in patients undergoing cancer-related procedures. Psychological interventions targeting anxiety, depression and self-efficacy, as well as risk behavior modification (e.g., smoking cessation) seem to enhance recovery. However, there is a lack of standardization regarding these interventions, and the evidence about the impact of this multidisciplinary approach on the postoperative outcomes is still contradictory. This narrative review focuses on the physiological basis of surgical stress response and on the efficacy of prehabilitation, reflected mainly in the length of hospitalization and rates of postoperative complications. Multidisciplinary collaboration between surgeons, nutritionists, psychologists and physiotherapists was identified as the key to the success of prehabilitation programs. Synergizing prehabilitation and ERAS protocols significantly improves short-term surgical outcomes. Recent well-designed, randomized clinical trials revealed that this approach not only enhanced functional reserve, but also decreased the rates of postoperative complications and enhanced patient's overall quality of life, emphasizing the importance of its implementation in routine, elective, surgical care.

Feasibility and Effects of Implementing Multimodal Prehabilitation Before Cytoreductive Surgery in Patients with Ovarian Cancer: The Gynofit Multicenter Study

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.

Changes in CT-derived muscle mass and density during prehabilitation in patients undergoing NACT ahead of esophagectomy

INTRODUCTION

Esophageal adenocarcinoma (EAC) patients routinely undergo neoadjuvant chemotherapy (NACT) and surgery with known deleterious effects on body composition and functional capacity. Prehabilitation has been postulated as a viable way to combat this decline, however, using CT scans to characterize changes has been scarcely studied. The aims were to a) investigate the impact of prehabilitation among patients treated with NACT using CT-derived measurements of muscle mass and quality as compared to control patients and b) determine their impact on post operative outcomes.

MATERIALS AND METHODS

A single-center retrospective cohort study was performed, including 61 patients with EAC, all treated with NACT and surgery between 2019 and 2022 (32 prehabilitation, 29 controls). CT scans at the third lumbar vertebra assessed skeletal muscle index (SMI) and skeletal muscle density (SMD) pre- and post-NACT. Outcome parameters included changes in SMI and SMD, NACT adherence, tumor regression grade, length of stay, and anastomotic leakage. Statistical analyses evaluated differences and correlations between groups.

RESULTS

Prehabilitation patients showed no significant differences in SMI changes compared to controls. While SMD deterioration was significantly blunted (p < .001), SMI decreased significantly in prehab patients (p = .002). Adherence to protein intake correlated with improved SMD (p = .041) and reduced SMD decline (p = .028). SMD preservation was associated with reduced anastomotic leak rates (p = .001) and low SMD was correlated to impaired 6 Minute Walking distance.

CONCLUSIONS

SMD may serve as a prognostic marker for outcomes, highlighting the importance of individualized prehabilitation programs. Future research should refine patient selection and optimize multimodal interventions to improve outcomes.

A national survey of the provision of prehabilitation for oesophagogastric cancer patients in the UK

INTRODUCTION

Studies have demonstrated that prehabilitation in oesophagogastric cancer (OGC) improves body composition, physical fitness and quality of life, and can reduce surgical complications. However, it is not offered in all OGC centres. Furthermore, definitions, funding and access to services vary. We conducted a survey of prehabilitation in OGC centres in England and Wales.

METHODS

OGC centres were identified through the National Oesophago-Gastric Cancer Audit (NOGCA). Survey questions were developed, piloted in two institutions and distributed via email in October 2022. Reminder emails were sent over two months until the survey closed in December 2022.

RESULTS

Responses were received from 28 of 36 centres. There was near-universal agreement that prehabilitation should be considered standard of care for patients on curative pathways (27/28; 96%). Most centres (21/28; 75%) offered prehabilitation. The majority of respondents believed that prehabilitation should commence at diagnosis (27/28; 96%) and consist of at least aerobic training and dietitian input. Most (26/28; 93%) believed access to clinical psychologists should be included; however, only 12 (43%) had access to clinical psychologists. Respondents believed prehabilitation improves quality of life (26/28; 93%), fitness (26/28; 93%), smoking cessation (28/28; 100%), surgical complication rates (25/28; 89.3%), likelihood of proceeding to surgery (25/28; 89.3%) and overall survival (20/28; 71.4%).

CONCLUSIONS

Despite barriers to funding and a lack of best practice guidelines, most units deliver prehabilitation. Units require higher quality evidence, consensus on the most important aspects of the intervention and core outcome sets to support the delivery of services and facilitate audit to assess the impact of their introduction.

The Role of Prehabilitation in Oncology Patients Undergoing Complex Systemic Anticancer Therapy

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.

Exploring the impact of physical exercise regimens on health-related quality of life following oesophageal or gastric cancer surgery: a systematic review and meta-analysis of randomized controlled trials

PURPOSE

To assess the effectiveness and adverse events of postoperative physical exercise on health-related quality of life (HRQL) in patients who have undergone surgery for oesophageal or gastric cancer.

METHODS

We conducted a systematic review and meta-analysis and reported it according to the preferred reporting items for systematic reviews and meta-analyses. (PRISMA) guidelines. Randomised controlled trials (RCT) that investigated HRQL factors following physical exercise interventions in patients undergoing oesophageal or gastric cancer surgery were included. Studies including participants who had undergone oesophagectomy or gastrectomy for cancer, of either sex and were 18 years or older were included. Participants with other cancers were excluded. Medline, Embase, CINAHL, Cochrane Library, PEDro, and trial registries were searched for studies from inception until February 2025. Results were synthesised using meta-analyses. Two independent reviewers assessed the risk of bias using the Cochrane risk of bias tool 2.0, and the grading of recommendations assessment, development and evaluation (GRADE) was used to evaluate the overall certainty of the evidence. PROSPERO ID CRD42022358493.

RESULTS

Three studies enrolling 284 patients undergoing oesophagectomy were included, of which two were assessed at high risk of bias and one at some concerns. The global quality of life score from the European Organisation for Research and Rreatment of Cancer (EORTC) quality of life questionnaire Cancer QLQ-C30 was used to assess HRQL in all the included studies. The score ranges from 0 to 100, with higher scores indicating a better HRQL. Physical exercise therapy had no discernible impact on HRQL compared to the control group (mean difference 0.77 [95% CI -4.36, 5.90]. However, the quality of evidence was very low, which should be considered when interpreting the results as they can differ substantially from the true effects.

CONCLUSION

We found a significant lack of information about the effects of post-surgery physical exercise compared to standard care in patients who have undergone oesophagectomy or gastrectomy for cancer. Based on the current very low certainty evidence, the effectiveness on HRQL and the safety of postoperative physical exercise in patients treated with oesophagectomy for cancer is uncertain. We found no studies investigating gastric cancer and exercise.

Feasibility, safety, and adherence of home-based exercise interventions in people diagnosed with cancer: a systematic review

PURPOSE

This systematic review aims to evaluate the feasibility, safety, and adherence of home-based exercise interventions in people diagnosed with cancer. The primary research question is: Are home-based exercise interventions safe and feasible for people diagnosed with cancer?

METHODS

A comprehensive search of databases including PubMed, EMBASE, and Cochrane Library was conducted in January 2025, focusing on randomized controlled trials (RCTs) that involved home-based exercise interventions people diagnosed with cancer. Studies were included if they reported on safety, feasibility, and health-related outcomes. The Physiotherapy Evidence Database (PEDro) scale was used to assess study quality and risk of bias. Adverse events were categorized by severity, and feasibility which was determined based on recruitment, withdrawal, and adherence rates.

RESULTS

From 127 eligible studies involving 10,562 participants, the review found that home-based exercise interventions are generally safe, with less than 3.2% of participants experiencing exercise-related adverse events, most of which were minor. Feasibility was supported by an average recruitment rate of 50.1%, which was calculated as the proportion of eligible participants who consented to participate across the included studies. Additionally, the review found a withdrawal rate of 13.7%, and an adherence rate of 76.2%. However, significant variability in these rates were observed across the studies, highlighting the challenges in maintaining participant engagement.

CONCLUSIONS

Home-based exercise interventions are feasible and safe for people diagnosed with cancer, with minor adverse events being the most common. However, there is a need for standardized protocols in reporting adverse events and better strategies to improve recruitment and adherence.

IMPLICATIONS FOR CANCER SURVIVORS

These findings support the integration of home-based exercise into standard cancer care, offering a practical and safe option for enhancing the health and well-being of cancer survivors. However, the successful implementation of these programs may require additional support from exercise professionals within primary care or community settings to ensure appropriate guidance and adherence. Personalized exercise programs, developed by qualified exercise professionals such as physiotherapists or clinical exercise physiologists, and improved reporting standards are essential to optimizing these interventions.

Boosting recovery before surgery: The impact of prehabilitation on upper gastrointestinal cancer patients - A quantitative comparative analysis

BACKGROUND

Emerging research presents divergent perspectives on the efficacy of prehabilitation for patients scheduled for surgery due to upper gastrointestinal (GI) cancers, capturing the attention of both the scientific community and surgical professionals. This quantitative comparative analysis seeks to assess the association of prehabilitation to ameliorate postoperative outcomes in individuals with upper GI cancers, thereby providing a comprehensive evaluation of its potential benefits within a surgical context.

MATERIALS AND METHODS

Medline, Embase, Cochrane Library and Web of Science were searched up to February 2024. Studies reporting the association between prehabilitation, and postoperative complications, readmissions or other outcomes of interest were included. Fixed or random effect models were used, and forest plots were applied to show the results of the quantitative comparative analysis.

RESULTS

A total of 198 studies were initially screened based on titles and abstracts, with 129 studies subsequently excluded. Overall, 69 full-text studies were identified, of which 12 studies were finally included for qualitative analysis in the quantitative comparative analysis after determining whether the inclusion and exclusion criteria were met. The pooled results indicated that prehabilitation significantly reduced the overall postoperative complication rates in patients with upper GI cancer undergoing surgical therapy with the pooled OR of 0.59 (95%CI: 0.39-0.88). Moreover, prehabilitation was also shown to be a protective factor of pulmonary complications (OR: 0.54, 95%CI: 0.36-0.80) and ICU readmissions (OR: 0.23, 95%CI: 0.06-0.89).

CONCLUSION

The correlation between prehabilitation and a reduction in overall postoperative complications, pulmonary complications, and ICU readmissions among patients with upper GI cancer is substantiated by significant data. This pivotal finding necessitates further empirical investigation to validate these initial results and ascertain the clinical efficacy of prehabilitation protocols, thereby informing future surgical practice strategies.

Factors influencing exercise rehabilitation behavior in older patients with esophageal cancer: A qualitative study

Exercise rehabilitation programs have been proven to beneficially affect several health-related outcomes for cancer patients. However, adherence is important to achieve optimal effects. This study aimed to investigate the influencing factors of exercise rehabilitation behavior in older esophageal cancer patients participating in pre- and postoperative exercise rehabilitation programs in a hospital setting. A qualitative study with semistructured interviews was conducted based on the capability, opportunity, and motivation as determinants of behavior (COM-B) theoretical framework. Purposeful sampling was used (n = 16), and the interview data were analyzed following thematic analysis. The results revealed ten key themes: capability factors (physical discomfort, limited knowledge, and psychological burden), opportunity factors (grassroots medical and health services support, family support, peer support, and healthcare professionals support), and motivation factors (high exercise self-efficacy, awareness of benefits, and desire for normal life). Understanding these factors can help design more effective exercise rehabilitation programs in clinical practice.

Prehabilitation during neoadjuvant therapy in patients with cancer of the upper gastrointestinal tract and rectum-the study protocol

Aims

The concept of prehabilitation, defined as interventions aimed at enhancing a patient's functional capacity prior to an impending physiological stressor, may contribute to reduced postoperative morbidity and mortality. The study's goal is to verify or refute the feasibility of a prehabilitation programme for two diagnostic patient groups during neoadjuvant chemo(radio)therapy, which is prescribed before the scheduled surgical procedure. This is a single group study design, with all patients enrolled receiving the intervention.

Methods

This is an interventional feasibility study of a prehabilitation programme in the form of physical training conducted at home. The training consists of progressively dosed walking and strength exercises for selected muscle groups. Data will be monitored telemetrically and also through telephone contact with participants. Primary outcomes include: the percentage of patients interested in participating in the study out of all patients indicated for neoadjuvant therapy at University Hospital Ostrava during the observed period, the percentage of patients who complete the prehabilitation programme until the date of surgery and individual patient compliance. Secondary outcomes include physical fitness parameters obtained from cardiopulmonary exercise testing, grip strength measured by a dynamometer, changes in body composition, EORTC QLQ-C30 quality of life questionnaire, and a questionnaire on the subjective perception of the exercise programme. Both primary and secondary outcomes will be compared between study arms (two diagnostic groups). The study is registered at ClinicalTrials.gov, ID: NCT05646043.

Conclusion

The results of this study can serve as a foundation for larger, multicentre, controlled studies in the future.

Effects of Systemic Anticancer Treatment on Cardiorespiratory Fitness: A Systematic Review and Meta-Analysis

BACKGROUND

Poor cardiorespiratory fitness (CRF) is associated with a higher symptom burden and an increased prevalence of long-term treatment-related cardiovascular disease risk factors in cancer survivors. However, the magnitude of systemic therapy-related CRF impairment remains unclear.

OBJECTIVES

The aim of this study was to evaluate the effects of systemic anticancer treatment on CRF and identify physiological determinants underpinning CRF impairment.

METHODS

A systematic literature search was performed in PubMed, Embase, CINAHL, SPORTDiscus, and the Cochrane Library. The primary endpoint was the change in CRF, measured by peak oxygen consumption (Vo2peak), from before to after systemic treatment. Secondary endpoints included post-treatment differences in Vo2peak between cancer survivors and noncancer control subjects, along with physiological determinants of Vo2peak. Two meta-regressions were conducted to examine the association between CRF and cardiac output and arteriovenous oxygen difference.

RESULTS

A total of 44 studies were included, comprising 27 prospective trials (61%; n = 1,234 cancer survivors, median age 52.4 years) and 17 cross-sectional studies (39%; n = 1,372 cancer survivors, median age 54.0 years; n = 1,923 noncancer control subjects, median age 56.0 years). Systemic anticancer treatment was associated with a significant decrease in Vo2peak (weighted mean difference -2.13 mL·kg-1·min-1; 95% CI: -2.76 to -1.50 mL·kg-1·min-1). No significant differences were observed between patient subgroups (esophagogastric, breast, and colon or rectal cancers). At a median follow-up of 2 years (range: 6 weeks to 12 years) post-therapy, cancer survivors had a significantly lower Vo2peak (weighted mean difference -6.39 mL·kg-1·min-1; 95% CI: -7.60 to -5.18 mL·kg-1·min-1) compared with noncancer control subjects. Reduced arteriovenous oxygen difference was associated with lower Vo2peak (β = 2.55; 95% CI: 2.05-3.06; P < 0.001).

CONCLUSIONS

Systemic anticancer treatment leads to substantial and sustained impairments in CRF.

Exercise, cancer, and the cardiovascular system: clinical effects and mechanistic insights

Cardiovascular diseases and cancer are the leading causes of death in the Western world and share common risk factors. Reduced cardiorespiratory fitness (CRF) is a major determinant of cardiovascular morbidity and cancer survival. In this review we discuss cancer- induced disturbances of parenchymal, cellular, and mitochondrial function, which limit CRF and may be antagonized and attenuated through exercise training. We show the impact of CRF on cancer survival and its attenuating effects on cardiotoxicity of cancer-related treatment. Tailored exercise programs are not yet available for each tumor entity as several trials were performed in heterogeneous populations without adequate cardiopulmonary exercise testing (CPET) prior to exercise prescription and with a wide variation of exercise modalities. There is emerging evidence that exercise may be a crucial pillar in cancer treatment and a tool to mitigate cardiotoxic treatment effects. We discuss modalities of aerobic exercise and resistance training and their potential to improve CRF in cancer patients and provide an example of a periodization model for exercise training in cancer.

Prehabilitation Outcomes in Surgical Oncology Patients Undergoing Major Abdominal Surgery: A Meta-analysis of Randomized Control Trials

BACKGROUND

Prehabilitation has been increasingly utilized to optimize perioperative outcomes. In this study, we aim to evaluate the impact of uni- and multimodal prehabilitation on functional capacity and postoperative outcomes among surgical oncology patients undergoing major abdominal surgery.

PATIENTS AND METHODS

Three electronic databases (PubMed, Embase, Cochrane) were systematically searched up until December 2023. We included randomized controlled trials comparing prehabilitation to standard of care in surgical oncology patients undergoing major abdominal surgery. Our primary outcome was functional capacity as measured by the 6-min walk distance (6MWD). Secondary outcomes include postoperative complications, emergency readmissions, and length of stay (LOS). We stratified our findings to determine the impact of uni- versus multimodal prehabilitation on outcomes.

RESULTS

We included 27 studies with 2532 surgical oncology patients. Overall, patients undergoing prehabilitation demonstrated a significant improvement in preoperative functional capacity compared to those without prehabilitation (mean difference in 6MWD 28.32 meters [m], 95% CI 15.26, 41.39, p < 0.01). Prehabilitation was also associated with significantly lower odds of postoperative complications (odds ratio [OR] 0.60, 95% CI 0.46, 0.78, p < 0.01). There was no difference in emergency readmission (OR 0.90, 95% CI 0.59, 1.38, p = 0.61) or LOS (mean difference -0.42 days, 95% CI -1.01, 0.16, p = 0.15). Comparing uni- versus multimodal prehabilitation, multimodal prehabilitation was associated with greater improvements in functional capacity (6MWD 37.35 m versus 13.38 m) and lower odds of postoperative complications (OR 0.61, 95% CI 0.45, 0.82, p < 0.01 versus OR 0.63, 95% CI 0.36, 1.11, p = 0.10) CONCLUSION: Prehabilitation improves functional capacity and reduces postoperative complications among surgical oncology patients undergoing major abdominal surgery.

Prehabilitation of Patients With Oesophageal Malignancy Undergoing Peri-Operative Treatment (Pre-EMPT): Outcomes From a Prospective Controlled Trial

BACKGROUND

The Pre-EMPT study aimed to determine if structured exercise could reduce length of stay, post-operative complications and improve fitness and health-related quality of life (HQRL) in patients undergoing neoadjuvant chemotherapy (NAC) and oesophagectomy.

METHODS

A prospective non-randomised trial compared a standard care pathway (control) to a structured prehabilitation exercise programme (intervention) commenced before NAC and surgery for oesophageal adenocarcinoma. Length of hospital stay and post-operative complications were recorded. Cardiopulmonary exercise testing (CPEX), body composition analyses, lymphocyte levels and HRQL questionnaires were performed at multiple time points.

RESULTS

Median length of stay was similar in both groups. There were 6 versus 11 complications observed (intervention vs control p = 0.086). Cardio-pulmonary fitness (VO2peak) declined after NAC, but less in the intervention group (intervention -13.54% vs control -21.40%, p = 0.02). Body composition improved in the intervention group (FMi/FFMi -5.5% intervention, 10.7% control p = 0.043). Performance, cognitive, sleep and emotional function scores improved following NAC in the intervention group. Lymphocyte subsets increased in the intervention group compared to the control group after chemotherapy (p = 0.034). Chemotherapy response was improved in the intervention group (p = 0.022).

CONCLUSION

A structured exercise programme may mitigate cardiopulmonary deconditioning, reduce sarcopenia and offset lymphopenia, during chemotherapy, in patients undergoing NAC and oesophagectomy.

Short- and long-term outcomes following perioperative ERAS management in patients undergoing minimally invasive radical gastrectomy after neoadjuvant chemotherapy: A single-center retrospective propensity score matching study

INTRODUCTION

Gastric cancer patients receiving neoadjuvant chemotherapy (NACT) are more vulnerable to perioperative stress. Enhanced recovery after surgery (ERAS) is widely used in surgical patients aiming at reducing stress responses. However, whether this approach is safe and feasible for gastric cancer patients received minimally invasive radical gastrectomy after NACT remained determined. So, the objective of this study is to investigate the effects of ERAS for this special group of gastric cancer patients.

MATERIAL AND METHODS

The data of gastric cancer patients who underwent minimally invasive radical gastrectomy after NACT were collected. Patients were divided into an ERAS group and a conventional group based on whether they received perioperative ERAS management. Propensity score matching was conducted to eliminate bias. Pre- and postoperative inflammatory and nutritional marker levels, postoperative complications, recovery indices and 3-year OS and RFS were observed.

RESULTS

A total of 252 patients were analyzed after 1:1 PSM, including 126 patients in the ERAS group and 126 in the conventional group. The results showed that the implementation of ERAS significantly reduced the levels of novel inflammatory indicators, improve nutritional status and accelerate postoperative recovery. We found that the 3-year OS (72.2 % vs. 66.7 %) and RFS (67.5 % vs. 61.9 %) in the ERAS group showed an improvement trend compared to those in the traditional group, especially for stage III patients, although these differences were not significant.

CONCLUSION

The perioperative ERAS program is safe and feasible for gastric cancer patients received minimally invasive radical gastrectomy after NACT.

Association of Preoperative Physical Fitness With Post-Esophagectomy Pneumonia in Older With Locally Advanced Esophageal Cancer: An Exploratory Prospective Study

BACKGROUNDS

Currently, there is a lack of evidence of prehabilitation during neoadjuvant chemotherapy (NAC) to prevent pneumonia of older patients. This study aimed to investigate the association of preoperative physical fitness after NAC with post-esophagectomy pneumonia in older patients with locally advanced esophageal cancer (LAEC).

METHODS

This single-center exploratory prospective cohort study included 80 patients aged ≥ 65 years with LAEC scheduled for curative esophagectomy after NAC between 2021 and 2023. The post-NAC short incremental shuttle walk test (ISWT) by sex was established using the Youden index. The association of the post-NAC short ISWT with postoperative pneumonia was investigated via Firth's penalized logistic regression model with statistical significance set as two-tailed p < 0.05.

RESULTS

A total of 69 patients were analyzed. The mean post-NAC ISWT values were 353.5 m. Short ISWT distance was defined as ≤ 395 and ≤ 195 m for men and women, respectively. Postoperative pneumonia developed in 17 (25%) patients. Short post-NAC ISWT distance was significantly associated with postoperative pneumonia (adjusted odds ratio: 1.840, 95%CI: 1.760-28.440, p = 0.004).

CONCLUSIONS

Decline in physical fitness was associated with post-esophagectomy pneumonia, which may be a key targeted factor of prehabilitation during NAC for older patients with LAEC.

Nutritional Counseling During Chemotherapy Treatment: A Systematic Review of Feasibility, Safety, and Efficacy

Dietary interventions during chemotherapy hold promise for clinical and supportive care outcomes. We systematically investigated the feasibility, safety, and efficacy of nutritional counseling conducted during chemotherapy. Studies prospectively implemented nutrition counseling during chemotherapy. Articles were identified from three databases-EMBASE, Cochrane Library, and SCOPUS-from inception to 1 October 2024. Feasibility, safety, and efficacy of outcome data were extracted. Among 44 publications, 39 studies recruited 98 ± 80 participants (range 15-360); 38/39 (97%) were randomized controlled trials. One-third (31%) were among patients with breast cancer. Interventions were divided into individualized nutritional counseling (n = 21), nutrition counseling plus exercise (n = 13), and nutrient-specific dietary patterns (n = 10). Many had goals to achieve established nutrition guidelines. Feasibility was high based on attendance at counseling sessions, retention, and/or food log analysis. Overall, there were minimal adverse events related to the interventions. Many studies showed between-group differences favoring the intervention group for body weight (8/24, gain or loss, according to goals), nutritional status (8/9), quality of life (3/10 without and 6/9 with exercise), cancer-related fatigue (7/10), chemotherapy tolerance (6/11), and treatment responses (3/13). In conclusion, nutritional interventions were feasible and safe for patients undergoing chemotherapy and demonstrated preliminary efficacy to improve nutritional status, fatigue, chemotherapy tolerance, and other outcomes.

Potential Benefits from Physical Exercise in Advanced Cancer Patients Undergoing Systemic Therapy? A Narrative Review of the Randomized Clinical Trials

DESIGN

The purpose of this review is the analysis of the literature concerning the effects of physical exercise in cancer patients undergoing medical oncologic treatment. Papers were retrieved from the scrutiny of 15 reviews/meta-analyses published in the last 2 years, which, however, pooled different populations of patients (surgical and medical patients, receiving or not an oncologic therapy, harboring a cancer, or being survivors).

RESULTS

We reviewed the data of 35 RCTs on the use of physical exercise in cancer patients, distinguishing well-nourished from malnourished patients. The conclusions of our study are the following: No major difference between well-nourished and malnourished patients as regards compliance/adherence with physical exercise and outcomes. Compliance with physical exercise was reported in about 70% of the studies. Compared with a control group receiving the usual care, in patients who practiced physical exercise, a benefit in some parameters of physical function and quality of life and lean body mass (LBM) was reported in 61%, 47%, and 12%, respectively, of the studies in non-malnourished patients, and in 50%, 100%, and 36%, respectively, of the studies in malnourished patients. The benefit in LBM was more frequently reported in weight-losing patients. There was no strict association among the results of different outcomes (muscle function vs. quality of life vs. LBM). There are still some ill-defined issues, including the optimal physical regimen (with some authors favoring high-intensity interval training and resistance) and the place of exercising (patients usually preferring home exercises, which, however, have been proved less efficacious).

The effectiveness of prehabilitation interventions on biopsychosocial and service outcomes pre and post upper gastrointestinal surgery: a systematic review

PURPOSE

This review synthesised the evidence for the effect of prehabilitation interventions on biopsychosocial and service outcomes.

MATERIALS AND METHODS

A systematic review was conducted. 10 databases were searched to December 2023. Prospective experimental studies exploring prehabilitation interventions in adults undergoing upper gastrointestinal surgery were included. Prehabilitation was any preoperative intervention to improve physical or psychological outcomes. Included studies required a comparator group or alternative preoperative intervention as well as baseline, presurgical and postoperative assessment points. Study quality was assessed using the Cochrane risk of bias tool (v.2). Data synthesis was narrative (SWiM guidance).

RESULTS

6028 studies were screened, with 25 studies included. Prehabilitation interventions were: inspiratory muscle training (five studies n = 450); exercise (nine studies n = 683); psychological (one study n = 400); and nutritional (ten studies n = 487). High quality studies showed preoperative improvements in impairments directly targeted by the interventions. Generally, these did not translate into functional or postoperative improvements, but multimodal interventions were more promising.

CONCLUSION

Current evidence supports prehabilitation as safe to preserve or improve preoperative function. Heterogeneity in outcomes and variable study quality means definitive conclusions regarding interventions are not yet possible, limiting implementation. Agreement of clinical outcomes and cost effectiveness evaluation is required.

Exercise During Chemotherapy for Cancer: A Systematic Review

Exercise prehabilitation may improve the tolerance and effectiveness of anticancer treatments such as chemotherapy. This systematic review assesses the impact of exercise on chemotherapy outcomes and identifies research priorities. Nineteen studies (1418 patients) were reviewed, including 11 randomised controlled trials and eight observational studies. Exercise led to improvements in body composition, fitness, strength and quality of life (QoL) across studies. Exercise can be safely and effectively delivered during chemotherapy. Limited standardisation and small sample sizes highlight the need for larger, better-designed studies to optimise this low-cost intervention.

Multimodal prehabilitation to enhance functional capacity of patients with esophageal cancer during concurrent neoadjuvant chemotherapies-a randomized feasibility trial

Esophageal adenocarcinoma continues to bear high morbidity and mortality. Prehabilitation, using exercise, nutrition, and psychosocial strategies to optimize patients prior to surgical resection, is largely underexplored in this malignancy, especially in patients undergoing neoadjuvant chemotherapy. Objectives of this study were (i) to determine feasibility of prehabilitation during treatment in patients with esophageal cancer and (ii) to establish differences between hospital and home-based exercise. Patients were recruited from August 2019 - February 2023 and blindly randomized to either supervised or homebased exercise, receiving identical nutritional and psychosocial support. The main outcome measures were recruitment, retention, and dropout rates. The secondary outcomes included cardiorespiratory fitness, functional capacity, and quality of life. Forty-four subjects were blindly randomized: 23 to supervised exercise and 21 to home-based exercise (72% recruitment rate). Overall compliance for the supervised group was 72%; home-based group was 77%. Baseline to pre-operative, both groups experienced significant increases in sit-to-stand, arm curls, and amount of weekly moderate-vigorous physical activity. The home-based group experienced an additional considerable decrease in up-and-go test times. Both groups maintained cardiorespiratory fitness and saw substantial increases in some quality-of-life scores. Multimodal prehabilitation is feasible for patients with esophageal cancer undergoing neoadjuvant chemotherapy. In both groups, patient fitness, which is relevant for this patient population given the anticipated decline in functional status during this period, was maintained. This study provides a foundation for future prehabilitation interventions in this patient population.

Prehabilitation for patients undergoing neoadjuvant therapy prior to cancer resection: a systematic review and meta-analysis

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.

Association of Upper Gastrointestinal Surgery of Great Britain and Ireland (AUGIS)/perioperative quality initiative (POQI) consensus statement on prehabilitation in oesophagogastric surgery

BACKGROUND

Prehabilitation is safe, feasible and may improve a range of outcomes in patients with oesophago-gastric cancer (OGC). Recent studies have suggested the potential of prehabilitation to improve body composition, sarcopenia and physical fitness, reduce surgical complications and improve quality of life. Despite this, prehabilitation services are not offered throughout all OGC centres in the UK. Where prehabilitation is offered, delivery and definitions vary significantly, as do funding sources and access.

METHODS

A professional association endorsed series of consensus meetings were conducted using a modified Delphi process developed by the Peri-Operative Quality Initiative (POQI) to identify and refine consensus statements relating to the development and delivery of prehabilitation services for OGC patients. Participants from a variety of disciplines were identified based on a track record of published studies in the field of prehabilitation and/or practice experience encompassing prehabilitation of OGC patients. Approval from the POQI board was obtained and independent supervision provided by POQI.

RESULTS

A total of 20 statements were developed and agreed by 26 participants over a preliminary meeting and 2 semi-structured formal POQI meetings. Ten research themes were identified. In the case of one statement, consensus was not reached and the statement was recorded and developed into a research theme. A strong recommendation was made for the majority of the consensus statements (17 of 20).

DISCUSSION

Consensus statements encompassing the interventions and outcomes of prehabilitation services in oesophago-gastric cancer surgery have been developed to inform the implementation of programmes.

The effect of a pre-operative and post-operative exercise programme versus standard care on physical fitness of patients with oesophageal and gastric cancer undergoing neoadjuvant treatment prior to surgery (the PERIOP-OG trial): a randomized controlled trial

INTRODUCTION

Although the benefits of post-operative rehabilitation in cancer surgery are well established, the role of prehabilitation is less defined. Oesophagogastric cancers present a unique opportunity to study the impact of prehabilitation during the neoadjuvant window, whether with chemotherapy or chemoradiotherapy (NCT) in patients who are frequently nutritionally depleted. This trial examines the impact of a community-based exercise programme on patient fitness during and after the neoadjuvant window.

METHODS

A pragmatic, randomized controlled multicentre trial was undertaken in three centres. Inclusion criteria were patients aged at least 18 years planned for NCT and esophagectomy or gastrectomy. Participants were randomized 1:1 to an exercise prehabilitation group (EX) or to usual care (UC). The primary endpoint was cardiorespiratory fitness between baseline and pre-surgery time point using the 6-minute walk test (MVT). Secondary endpoints included a hand dynamometer, 10-s sit-to-stand, activity behaviour, body mass index, semi-structured interviews, questionnaires assessing the quality of life, surgical fear, general self-efficacy and mastery.

RESULTS

Between March 2019 and December 2020, 71 participants were recruited: EX ( n =36) or UC ( n =35). From baseline to pre-surgery, the difference-in-difference (DID) for EX showed a significant improvement in 6MWT of 50.7 m ( P =0.05) compared to UC [mean (SD): 522.1 m (+/-104.3) to 582.1 m (+/-108) vs. 497.5 m (+/-106.3) to 506.0 m (+/-140.4). There was no statistically significant DID for secondary outcome measures.

CONCLUSIONS

This community exercise prehabilitation programme significantly improves physical fitness for surgery, is feasible and provides a standardized framework for the prescription of exercise in oesophagogastric cancer patients undergoing NCT.

Mitigating disuse-induced skeletal muscle atrophy in ageing: Resistance exercise as a critical countermeasure

The gradual deterioration of physiological systems with ageing makes it difficult to maintain skeletal muscle mass (sarcopenia), at least partly due to the presence of 'anabolic resistance', resulting in muscle loss. Sarcopenia can be transiently but markedly accelerated through periods of muscle disuse-induced (i.e., unloading) atrophy due to reduced physical activity, sickness, immobilisation or hospitalisation. Periods of disuse are detrimental to older adults' overall quality of life and substantially increase their risk of falls, physical and social dependence, and early mortality. Disuse events induce skeletal muscle atrophy through various mechanisms, including anabolic resistance, inflammation, disturbed proteostasis and mitochondrial dysfunction, all of which tip the scales in favour of a negative net protein balance and subsequent muscle loss. Concerningly, recovery from disuse atrophy is more difficult for older adults than their younger counterparts. Resistance training (RT) is a potent anabolic stimulus that can robustly stimulate muscle protein synthesis and mitigate muscle losses in older adults when implemented before, during and following unloading. RT may take the form of traditional weightlifting-focused RT, bodyweight training and lower- and higher-load RT. When combined with sufficient dietary protein, RT can accelerate older adults' recovery from a disuse event, mitigate frailty and improve mobility; however, few older adults regularly participate in RT. A feasible and practical approach to improving the accessibility and acceptability of RT is through the use of resistance bands. Moving forward, RT must be prescribed to older adults to mitigate the negative consequences of disuse atrophy.

The implementation status of prehabilitation during neoadjuvant chemotherapy for patients with locally advanced esophageal cancer: a questionnaire survey to the board-certified facilities in Japan

BACKGROUND

Prehabilitation during neoadjuvant therapy has the potential to improve clinical outcomes. However, information on its global dissemination status is limited. This Japanese nationwide survey investigated the implementation status of and barriers to prehabilitation during neoadjuvant chemotherapy (NAC) for patients with locally advanced esophageal cancer in hospitals.

METHODS

This multicenter nationwide survey was conducted by post. The eligible facilities were 155 Japanese hospitals that had been certified within the last 10 years as authorized institutes for board-certified esophageal surgeons by the Japan Esophageal Society. We administered an original questionnaire to investigate the current status of prehabilitation during NAC.

RESULTS

The response rate was 75% (117/155 facilities). Forty-six facilities (39%) provided prehabilitation during NAC. The most frequently selected reasons for not providing or providing insufficient prehabilitation were lack of human resources, issues with the reimbursement of medical fees, difficulty in providing continuous prehabilitation during repeated inpatient and outpatient care, the lack of established standard prehabilitation programs, challenges in providing multidisciplinary prehabilitation, and difficulty in managing physical symptoms.

CONCLUSION

We observed that the implementation rate of prehabilitation during NAC was low. Critical reasons were not only the lack of medical resources but also the lack of evidence-based standard prehabilitation programs during NAC and the lack of evidence for how to continuously deliver prehabilitation during NAC to patients with physical symptoms.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Age-related and cancer-related sarcopenia: is there a difference?

PURPOSE OF REVIEW

The aim of this review is the attempt to differentiating the pathophysiologic and clinical features of the aging-related sarcopenia from cancer-related sarcopenia. In fact, there is some controversy among the experts mainly regarding two points: is always sarcopenia, even that aging-related one, the expression of a generalized disease or may exist independently and without major alteration of the muscle function? Are always aging-related and cancer-related sarcopenia completely separated entities?

RECENT FINDINGS

Literature shows that sarcopenia, defined as simple skeletal muscle mass loss, may range from a mainly focal problem which is common in many healthy elderly people, to a component of a complex multiorgan syndrome as cancer cachexia. Disuse, malnutrition and (neuro)degenerative processes can account for most of the aging-related sarcopenias while systemic inflammation and secretion of cancer-and immune-related molecules play an additional major role in cachexia.

SUMMARY

A multimodal approach including physical exercise and optimized nutritional support are the key measures to offset sarcopenia with some contribution by the anti-inflammatory drugs in cancer patients. Results are more promising in elderly patients and are still pending for cancer patients where a more specific approach will only rely on the identification and contrast of the key mediators of the cachectic process.

Does All Social Support Work? Examining the Mechanisms of Patient-Reported Symptom Interference after Esophagectomy Affecting Life Satisfaction

Purpose

We intended to explore the chain mediation role of resilience and different sources of social support on the relationship between symptom interference and life satisfaction from the patient-reported perspective.

Patients and Methods

Two hundred and twenty-six patients after esophagectomy were investigated using four validated scales to estimate the symptom interference, resilience, different sources of social support, and life satisfaction. The chain mediation analysis was conducted using SPSS PROCESS Macro Model 6.

Results

Mediation analysis showed that symptom interference indirectly influenced life satisfaction through two significant mediating pathways: (i) resilience (B = -0.138, 95% CI: -0.194 to -0.091); (ii) the chain mediators involving in resilience and family support (B = -0.049, 95% CI: -0.073 to -0.026). Surprisingly, the mediating pathway of family support was not significant.

Conclusion

Interventions for resilience and family support could mitigate the adverse effects of symptom interference in patients after esophagectomy, improving life satisfaction. Of these, resilience may be more critical in terms of the utilization of social resources than family support.

Enhancing Mobility in Oncology: Evidence-Based Practices Across the Care Continuum

OBJECTIVES

Provide an overview of research-derived insights aimed at elucidating best practices for enhancing mobility in patients with cancer throughout the entirety of the care continuum. Highlighting the value of a multidisciplinary approach involving various healthcare professionals to optimize mobility outcomes for patients with cancer and the benefits of different approaches.

METHODS

A literature search was conducted in PubMed/Medline, CINAHL, Scopus, Embase, and on Google Scholar using search terms, mobility, exercise, cancer, nurs*, physical activity, pre-habilitation, rehabilitation, best practices. Systematic reviews, meta-analyses, peer reviewed research studies, exercise, and physical activity recommendations were reviewed to provide a comprehensive overview of strategies aimed at enhancing mobility in patients with cancer.

RESULTS

Twenty-nine references were included in this overview of enhancing mobility in patients with cancer across the care continuum.

CONCLUSIONS

Evidence-based strategies prioritize enhancing mobility for patients with cancer, aiming to boost physical functioning and overall quality of life. Healthcare providers should consider each patient's unique needs and limitations when implementing these evidence-based approaches, emphasizing a multidisciplinary approach involving oncologists, surgeons, nurses, physical therapists, occupational therapists, and other professionals to ensure comprehensive and personalized care focused on improving mobility.

IMPLICATIONS FOR NURSING PRACTICE

Nurses advocate for incorporating exercise into cancer care plans throughout the entire treatment journey, collaborating with healthcare team members to tailor programs to individual patient needs. Working together as an interdisciplinary team, nurses help develop an overall care plan that emphasizes exercise as an important aspect of cancer care, using their expertise to create customized exercise routines to encourage and motivate patients to participate in physical activity.

Nutritional Prehabilitation in Patients Undergoing Abdominal Surgery-A Narrative Review

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

Effectiveness of prehabilitation during neoadjuvant therapy for patients with esophageal or gastroesophageal junction cancer: a systematic review

Progression of the physical weakness during neoadjuvant therapy (NAT) in patients with esophageal or gastroesophageal junction cancer is a serious problem; however, prehabilitation during NAT has the potential to overcome the unmet need. Nevertheless, systematic reviews on this topic have not been summarized. Therefore, this systematic review aimed to determine prehabilitation's effectiveness, acceptability, and safety during NAT for patients with esophageal or gastroesophageal junction cancer. An electronic search was performed in the MEDLINE, Web of Science, CENTRAL, CINAHL, and PEDro databases. A meta-analysis was conducted to assess the effectiveness of prehabilitation during NAT, along with a descriptive analysis of acceptance and safety. This study analyzed data from three randomized controlled trials (RCTs) and nine non-RCTs involving 664 patients. The meta-analysis of two RCTs demonstrated that prehabilitation during NAT may be more effective than usual care in enhancing tolerance to NAT and grip strength; moreover, one RCT and three non-RCTs revealed that prehabilitation may reduce the risk of postoperative complications. The adherence rates for exercise programs in two RCTs and seven non-RCTs were 55-76%. Additionally, two studies reported a 76% adherence rate for multimodal prehabilitation programs, including exercise, dietary, and psychological care. Six studies reported no serious prehabilitation-related adverse events during NAT. Prehabilitation during NAT may be a safe and beneficial intervention strategy for patients with esophageal or gastroesophageal junction cancer. However, the investigation of strategies to enhance adherence is essential. Furthermore, additional high-quality RCTs are needed to examine the effect of prehabilitation during NAT.

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

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

What is the role of physical exercise in the era of cancer prehabilitation? A systematic review

PURPOSE

Exercise before surgery, as part of prehabilitation, aiming to enhance patients' functional and physiological capacity, has become widespread, necessitating an in-depth understanding.

METHODS

A systematic search was conducted on Pubmed, Cochrane, and Scopus to examine the effect of exercise as prehabilitation, alone or in combination with other interventions, in patients with cancer. Interventional studies applying a single-arm, randomized controlled, or nonrandomized design were included.

RESULTS

A total of 96 studies were included, and categorized according to cancer types, i.e., gynecological, breast, urological, gastrointestinal and lung cancer. For each cancer site, the effect of exercise, on physical fitness parameters and postoperative outcomes, including length of hospital stay and postoperative complications, was reported.

CONCLUSION

Exercise as prehabilitation may have an important role in improving physical fitness, postoperative outcomes, and accelerating recovery, especially in certain types of malignancies.

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

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

A Feasibility Randomized Controlled Trial of Prehabilitation During Neoadjuvant Chemotherapy for Women with Breast Cancer: A Mixed Methods Study

BACKGROUND

Limited data exist regarding the role of multimodal prehabilitation during neoadjuvant chemotherapy (NACT) for breast cancer. Determining large trial feasibility and identifying signals of prehabilitation benefit are needed.

PATIENTS AND METHODS

We conducted a randomized controlled feasibility trial of multimodal prehabilitation versus usual care during NACT among women diagnosed with non-metastatic breast cancer. Intervention participants received an individualized exercise program, dietetic support, and stress management counseling during NACT. The trial assessed feasibility via rates of recruitment, attrition, adherence, and study-related adverse events. Physical fitness (Six Minute Walk Test, grip strength, anthropometrics) and patient-reported outcomes were assessed at baseline, after NACT completion, and 6 months after surgery as exploratory outcomes, and analyzed using linear mixed effects models. Qualitative data were collected from a subsample to understand feasibility and acceptability of prehabilitation.

RESULTS

A total of 72 participants were enrolled from the 123 eligible patients (recruitment rate of 53%). There was a 13% attrition rate and no intervention-related adverse events. Participants in the prehabilitation group had better 6-min walk distance at the post-chemotherapy timepoint [between group difference of 49.43 m, 95% confidence interval (CI) - 118.1, 19.2] and at the post-surgery timepoint (27.3, 95% CI -96.8, 42.2) compared with the control group. Prehabilitation participants reported better quality of life, less fatigue, and improved physical activity levels compared with usual care participants. Interviews revealed that the intervention had a positive impact on the treatment experience.

CONCLUSIONS

This study demonstrated feasibility and improvement in physical and psychosocial outcomes. Larger trials assessing intervention efficacy to confirm indications of prehabilitation benefit are warranted.

Physical Prehabilitation in Patients who Underwent Major Abdominal Surgery: A Comprehensive Systematic Review and Component Network Meta-Analysis Using GRADE and CINeMA Approach

BACKGROUND

Physical prehabilitation is recommended before major abdominal surgery to ameliorate short-term outcomes.

METHODS

A frequentist, random-effects network meta-analysis (NMA) was performed to clarify which type of preoperative physical activity among aerobic exercise (AE), inspiratory muscle training (IMT), and resistance training produces benefits in patients who underwent major abdominal surgery. The surface under the P-score, odds ratio (OR), or mean difference (MD) with a 95% confidence interval (CI) were reported. The results were adjusted by using the component network approach. The critical endpoints were overall and major morbidity rate and mortality rate. The important but not critical endpoints were the length of stay (LOS) and pneumonia.

RESULTS

The meta-analysis included 25 studies. The best approaches for overall morbidity rate were AE and AE + IMT (OR = 0.61, p-score = 0.76, and OR = 0.66, p-score = 0.68). The best approaches for pneumonia were AE + IMT and AE (OR = 0.21, p-score = 0.91, and OR = 0.52, p-score = 0.68). The component analysis confirmed that the best incremental OR (0.30; 95% CI 0.12-0.74) could be obtained using AE + IMT. The best approach for LOS was AE alone (MD - 1.63 days; 95% CI - 3.43 to 0.18). The best combination of components was AE + IMT (MD - 1.70; 95% CI - 2.06 to - 1.27).

CONCLUSIONS

Physical prehabilitation reduces the overall morbidity rate, pneumonia, and length of stay. The most relevant effect of prehabilitation requires the simultaneous use of AE and IMT.

Does prehabilitation before esophagectomy improve postoperative outcomes? A systematic review and meta-analysis

Esophagectomy for esophageal cancer is associated with high morbidity. It remains unclear whether prehabilitation, a strategy aimed at optimizing patients' physical and mental functioning prior to surgery, improves postoperative outcomes. A systematic review and meta-analysis was conducted to evaluate the effect of prehabilitation on post-operative outcomes after esophagectomy. Data sources included Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, and PEDro, with information from 1 January 2000 to 5 August 2023. The analysis included randomized controlled trials and observational studies that compared prehabilitation interventions to standard care prior to esophagectomy. A random effects model was used to generate a pooled estimate for pairwise meta-analysis, meta-analysis of proportions, and meta-analysis of means. A total of 1803 patients were included with 584 in randomized controlled trials (RCTs) and 1219 in observational studies. In the randomized evidence, there were no significant differences between prehabilitation and control in the odds of postoperative pneumonia (15.0 vs. 18.9%, odds ratio (OR) 1.06 [95% confidence interval (CI): 0.66;1.72]) or pulmonary complications (14 vs. 25.6%, OR 0.68 [95% CI: 0.32;1.45]). In the observational data, there was a reduction in both postoperative pneumonia (22.5 vs. 32.9%, OR 0.48 [95% CI: 0.28;0.83]) and pulmonary complications (26.1 vs. 52.3%, OR 0.35 [95% CI: 0.17;0.75]) with prehabilitation. Hospital and intensive care unit length of stay (days), operative mortality, and severe complications (Clavien-Dindo ≥ 3) did not differ between groups in both the randomized data and observational data. Prehabilitation demonstrated reductions in postoperative pneumonia and pulmonary complications in observational studies, but not RCTs. The overall certainty of these findings is limited by the low quality of the available evidence.

The Benefit of Exercise in Patients With Cancer Who Are Receiving Chemotherapy: A Systematic Review and Network Meta-Analysis

OBJECTIVE

This study aimed to determine which therapeutic exercise-based intervention is most effective in improving cardiorespiratory fitness (CRF) in patients with cancer receiving chemotherapy.

METHODS

The authors conducted a systematic review with network meta-analysis in MEDLINE (PubMed), Embase, Cumulative Index to Nursing and Allied Health Literature, Scopus, SPORTDiscus, and Web of Science. The authors employed the Physiotherapy Evidence Database and the Revised Cochrane Risk of Bias Tool for Randomized Trials to assess the methodological quality and risk of bias, respectively.

RESULTS

A total of 27 studies were included. Data were pooled using a random-effects model. Adding aerobic training (moderate to high intensity), with or without resistance training, to usual care versus usual care was statistically significant, with a small beneficial effect (aerobic training: standardized mean difference = 0.46; 95% CI= 0.17 to 0.75; aerobic and resistance training: standardized mean difference = 0.26; 95% CI = 0.00 to 0.52) for peak oxygen consumption at the postintervention assessment.

CONCLUSION

Therapeutic exercise-based interventions to improve short-term CRF in patients with cancer receiving chemotherapy should include moderate- to high-intensity aerobic exercise, with or without resistance training.

IMPACT

It is important to improve CRF in the oncological population due to its relationship with mortality. The results showed the benefit of exercise to improve cardiorespiratory fitness in the oncology population receiving chemotherapy treatment.

Effects of unimodal or multimodal prehabilitation on patients undergoing surgery for esophagogastric cancer: a systematic review and meta-analysis

PURPOSE

To evaluate the effects of unimodal or multimodal prehabilitation on patients undergoing surgery for esophagogastric cancer.

METHODS

We conducted a systematic search of the PubMed, Embase, CINAHL, Web of Science, and Cochrane Library (CENTRAL) databases from database inception to May 5, 2023, for randomized controlled trials (RCTs) and cohort studies that investigated prehabilitation in the context of esophagogastric cancer. A random-effects model was used for meta-analysis.

RESULTS

We identified 2,994 records and eventually included 12 studies (6 RCTs and 6 cohort studies) with a total of 910 patients. According to random-effects pooled estimates, prehabilitation reduced the incidence of all complications (RR = 0.79, 95% CI: 0.66 to 0.93, P = 0.006), pulmonary complications (RR = 0.61, 95% CI: 0.47 to 0.79, P = 0.0002), and severe complications (RR = 0.63, 95% CI: 0.47 to 0.84, P = 0.002), and shortened the length of stay (MD = -1.92, 95% CI: -3.11 to -0.73, P = 0.002) compared to usual care. However, there were no statistically significant differences in 30-day readmission rates or in-hospital mortality. Subgroup analysis showed that multimodal prehabilitation was effective in reducing the risk of all complications and severe complications, while unimodal prehabilitation was not.

CONCLUSIONS

Our findings suggested that prehabilitation may be beneficial in reducing postoperative complications and length of stay. We recommend preoperative prehabilitation to improve postoperative outcomes and hasten recovery following esophagogastric cancer surgery, and multimodal prehabilitation seems to be more advantageous in reducing complications. However, further studies are needed to confirm these results.

Effect of home-based prehabilitation on postoperative complications after surgery for gastric cancer: randomized clinical trial

BACKGROUND

Recent studies have demonstrated that prehabilitation improves patients' physical fitness but its impact on postoperative morbidity remains unclear. This study aimed to assess the effect of personalized, multimodal, semisupervised, home-based prehabilitation on postoperative complications after surgery for gastric cancer.

METHODS

This RCT was conducted at two centres in Lithuania. Patients (aged at least18 years) with gastric cancer scheduled to undergo elective primary surgery or surgery after neoadjuvant chemotherapy for gastric cancer were randomized (1 : 1) to prehabilitation or standard care. Prehabilitation included exercise interventions focused on endurance, respiratory muscle strength, stretching, and resistance training as well as nutritional and psychological support. The primary outcome was the proportion of patients with postoperative complications within 90 days after surgery. Secondary outcomes included 90-day mortality rate, physical condition, fitness level, nutritional status, quality of life, anxiety and depression level, and proportion of patients completing neoadjuvant chemotherapy.

RESULTS

Between February 2020 and September 2022, 128 participants were randomized to prehabilitation (64) or standard care (64), and 122 (prehabilitation 61, control 61) were analysed. The prehabilitation group had increased physical capacity before the operation compared with baseline (mean 6-min walk test change +31 (95 per cent c.i. 14 to 48) m; P = 0.001). The prehabilitation group had a decreased rate of non-compliance with neoadjuvant treatment (risk ratio (RR) 0.20, 95 per cent c.i. 0.20 to 0.56), a 60 per cent reduction in the number of patients with postoperative complications at 90 days after surgery (RR 0.40, 0.24 to 0.66), and improved quality of life compared with the control group.

CONCLUSION

Prehabilitation reduced morbidity in patients who underwent gastrectomy for gastric cancer.

REGISTRATION NUMBER

NCT04223401 (http://www.clinicaltrials.gov).

Comparative effects of different types of exercise on health-related quality of life during and after active cancer treatment: A systematic review and network meta-analysis

BACKGROUND

The positive influence of most types of exercise has been reported repeatedly, but what the most effective exercise approaches are for improving health-related quality of life (HRQoL) in people with cancer remains unknown. The aim of this systematic review and network meta-analysis was to synthesize the evidence from intervention studies to assess the effects of different types of exercise on HRQoL during and after cancer treatment.

METHODS

MEDLINE, SPORTDiscus, the Cochrane Library, Web of Science, and Scopus were searched for randomized controlled trials aimed at testing the effects of exercise interventions meant to improve HRQoL in people with cancer. Separate analyses were conducted for HRQoL as measured by general and cancer-specific questionnaires. We also evaluated whether the effects of exercise were different during and after cancer treatment in both the physical and mental HRQoL domains.

RESULTS

In total, 93 studies involving 7435 people with cancer were included. Network effect size estimates comparing exercise intervention vs. usual care were significant for combined exercise (0.35, 95% confidence interval (95%CI): 0.14-0.56) for HRQoL as measured by general questionnaires, and for combined (0.31, 95%CI: 0.13-0.48), mind-body exercise (0.54, 95%CI: 0.18-0.89), and walking (0.39, 95%CI: 0.04-0.74) for HRQoL as measured by cancer-specific questionnaires.

CONCLUSION

Exercise programs combining aerobic and resistance training can be recommended to improve HRQoL during and after cancer treatment. The scarcity and heterogeneity of these studies prevents us from making recommendations about other exercise modalities due to insufficient evidence.

Association between Pre-Treatment Biological Indicators and Compliance to Neoadjuvant/Perioperative Chemotherapy in Operable Gastric Cancer

BACKGROUND AND AIMS

Perioperative treatment is currently the gold standard approach in Europe for locally advanced gastric cancer (GC). Unfortunately, the phenomenon of patients dropping out of treatment has been frequently observed. The primary aims of this study were to verify if routine blood parameters, inflammatory response markers, sarcopenia, and the depletion of adipose tissues were associated with compliance to neoadjuvant/perioperative chemotherapy.

METHODS AND STUDY DESIGN

Blood samples were considered before the first and second cycles of chemotherapy. Sarcopenia and adipose indices were calculated with a CT scan before starting chemotherapy and before surgery. Odds ratios (OR) from univariable and multivariable models were calculated with a 95% confidence interval (95% CI).

RESULTS

A total of 84 patients with locally advanced GC were identified between September 2010 and January 2021. Forty-four patients (52.4%) did not complete the treatment according to the number of cycles planned/performed. Eight patients (9.5%) decided to suspend chemotherapy, seven patients (8.3%) discontinued because of clinical decisions, fourteen patients (16.7%) discontinued because of toxicity and fifteen patients (17.9%) discontinued for miscellaneous causes. Seventy-nine (94%) out of eighty-four patients underwent gastrectomy, with four patients having surgical complications, which led to a suspension of treatment. Sarcopenia was present in 38 patients (50.7%) before chemotherapy began, while it was present in 47 patients (60%) at the CT scan before the gastrectomy. At the univariable analysis, patients with basal platelet to lymphocyte ratio (PLR) ≥ 152 (p = 0.017) and a second value of PLR ≥ 131 (p = 0.007) were more frequently associated with an interruption of chemotherapy. Patients with increased PLR (p = 0.034) compared to the cut-off were associated with an interruption of chemotherapy, while patients with increased monocytes between the first and second cycles were associated with a lower risk of treatment interruption (p = 0.006); patients who underwent 5-fluorouracil plus cisplatin or oxaliplatin had a higher risk of interruption (p = 0.016) compared to patients who underwent a 5-fluorouracil plus leucovorin, oxaliplatin and docetaxel (FLOT) regimen. The multivariable analysis showed a higher risk of interruption for patients who had higher values of PLR compared to the identified cut-off both at pretreatment and second-cycle evaluation (OR: 5.03; 95% CI: 1.34-18.89; p = 0.017) as well as for patients who had a lower PLR than the identified cut-off at pretreatment evaluation and had a higher PLR value than the cut-off at the second cycle (OR: 4.64; 95% CI: 1.02-21.02; p = 0.047). Becker regression was neither affected by a decrease of sarcopenia ≥ 5% (p = 0.867) nor by incomplete compliance with chemotherapy (p = 0.281).

CONCLUSIONS

Changes in PLR values which tend to increase more than the cut-off seem to be an immediate indicator of incomplete compliance with neoadjuvant/perioperative treatment. Fat loss and sarcopenia do not appear to be related to compliance. More information is needed to reduce the causes of interruption.