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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Effects of multimodal prehabilitation on muscle size, myosteatosis, and dietary intake of surgical patients with lung cancer - a randomized feasibility study

Many patients with lung cancer undergo surgery, which can increase the risk for muscle loss, leading to worsened outcomes. A multimodal prehabilitation intervention integrating dietary and muscle assessment may help clinicians better understand changes in these outcomes. This pilot assessed feasibility of multimodal prehabilitation in early-stage surgical lung cancer patients and explored relationships between body composition, muscle characteristics and dietary intake, as well as muscle changes due to prehabilitation. Patients were randomized to one of two groups: multimodal prehabilitation including nutritional supplements (fish oil with vitamin D3 + whey protein with leucine), exercise and relaxation, or standard of care. Physical function, dietary intake and muscle were evaluated at 0 and 4 weeks pre-operatively. Of 87 patients assessed for eligibility, 34 (39%) were randomized and 3 (9%) were lost to follow-up. Median age was 69 years and baseline protein intake was 1.0 g/kg/d. Adherence to exercise (86%) and supplements was high (93%); 3 patients (16%) reported side effects. Supplements significantly increased protein, omega-3 fatty acid, leucine and vitamin D intake. There were no significant changes in muscle characteristics. Multimodal prehabilitation with dietary and muscle analyses proved to be feasible. An adequately powered randomized controlled trial is warranted. ClinicalTrials.gov registration no: NCT04610606. Novelty: • Multimodal prehabilitation incorporating dietary assessment and muscle analysis is feasible for early-stage surgical lung cancer patients. • An adequately powered randomized controlled trial is warranted to further explore functional and post-operative outcomes.

Neoadjuvant prehabilitation therapy for locally advanced non-small-cell lung cancer: Optimizing outcomes throughout the trajectory of care

e20545

Background: Prehabilitation is well established for improving outcomes in cancer surgery. Combining prehabilitation with neoadjuvant treatments may provide an opportunity to rapidly initiate cancer-directed therapy while improving functional status in preparation for local consolidation. In this proof-of-concept study, we analyzed non-small-cell lung cancer patients who underwent simultaneous prehabilitation and neoadjuvant therapy. Methods: We retrospectively analyzed all patients who underwent neoadjuvant treatment for non-small-cell lung cancer followed by curative intent surgery at the McGill University Health Center between 2015-2020. Patients who were screened for the prehabilitation program were identified. Screening included assessment of physical performance, nutritional status and signs for anxiety and depression. 6-minute-walk test was used as a functional outcome parameter of prehabilitation. Results: We identified a total of 93 patients who underwent neoadjuvant therapy. Of these, 12 patients were screened to undergo a prehabilitation program. For 1 patient surgical intervention was too soon to complete the program, 1 patient dropped out after the first and another patient was deemed fit to undergo surgery without intervention. Thus, 9 patients completed full neoadjuvant prehabilitation therapy. Postoperative median length of stay was 2 days (IQR 1-5) and there were no mortalities. We found major complications in 1 patient and minor complications (prolonged air leak) in 2 cases. Patients improved their 6-minute-walk test despite undergoing neoadjuvant treatment by a mean of 35 meters (SD 39). Conclusions: Neoadjuvant prehabilitation therapy is feasible and associated with encouraging results. The performance of all measures remains a logistic challenge. With multimodal strategies for lung cancer treatment becoming key to optimal outcomes, neoadjuvant prehabilitation therapy is a concept worthy of prospective multi-center evaluation.

Colorectal cancer patients with malnutrition suffer poor physical and mental health before surgery

BACKGROUND

To determine whether there is an association between preoperative nutritional status and preoperative physical function, patient-reported quality of life, and body composition in colorectal cancer patients awaiting elective surgery.

METHODS

We conducted a pooled analysis of individual baseline patient data (n = 266) collected from 5 prehabilitation trials in colorectal cancer surgery. All data were collected approximately 4 weeks before surgery. Each patient's nutritional status was evaluated using the Patient-Generated Subjective Global Assessment: scores 4-8 indicated need for nutritional treatment, whereas ≥9 indicated critical need for a nutrition intervention. Physical function was measured with the 6-minute walk test; patient-reported quality of life was captured with the SF-36; body mass and composition were determined using multifrequency bioelectrical impedance.

RESULTS

Mean Patient-Generated Subjective Global Assessment score was 5.3 (standard deviation: 3.9). Approximately two-thirds of patients had a Patient-Generated Subjective Global Assessment of 4-8 or ≥9 (n = 162/266). The 6-minute walk test was progressively worse with higher Patient-Generated Subjective Global Assessment scores (PG-SGA <4: 471(119) m; PG-SGA 4-8: 417(125) m; PG-SGA ≥9: 311(125) m, P < .001). Every component of the SF-36 was lower in those with a Patient-Generated Subjective Global Assessment ≥9 compared to Patient-Generated Subjective Global Assessment <4, indicating that malnourished patients suffer worse quality of life. Interestingly, only the male patients with a Patient-Generated Subjective Global Assessment ≥9 presented with statistically significant lower body mass, reduced fat-free mass index, and a lower percent body fat relative to those with Patient-Generated Subjective Global Assessment <4, in part due to the higher variability among the females.

CONCLUSION

The consequences of malnutrition are far-reaching and are strongly associated with the physical and mental health of colorectal cancer patients awaiting elective resection.

Virtual Prehabilitation in Surgical Cancer Patients During the Covid-19 Pandemic: A Prospective Feasibility Study (Preprint)

Background

Since the beginning of the COVID-19 pandemic, preoperative care, also termed prehabilitation, has become increasingly relevant due to the decreasing functional and psychosocial health of patients with cancer, which is a result of the pandemic restrictions. Concurrently, access to telehealth has improved; telehealth comprises all remote care delivery facilitated by information technologies (ie, virtually).

Objective

The aim of this protocol is to describe the rationale and methodology for a major trial investigating the feasibility and safety of multimodal virtual prehabilitation services (ie, teleprehabilitation).

Methods

This single-arm feasibility trial aims to recruit 100 patients with cancer to receive teleprehabilitation throughout their preoperative period. The inclusion criteria are as follows: (1) 18 years of age or older, (2) scheduled for elective cancer surgery and referred by a surgeon, (3) medically cleared by the referring physician to engage in physical activity, and (4) have a good comprehension of the English or French language. Feasibility will be assessed by documenting recruitment, adherence, and retention rates, in addition to patients’ motives for not participating in the trial, low participation, or discontinuation. The secondary outcome of safety will be assessed by reporting program-related adverse events.

Results

The Montreal General Hospital Foundation funded the project in August 2020. The protocol was then approved by the Research Ethics Board of the McGill University Health Centre in January 2021 (ID No. 2021-6730). The first patient was recruited in March 2021, and recruitment is expected to end in September 2022. As of March 2022, 36 patients have been recruited, including 24 who have completed their participation. No adverse events have been reported. Data collection is expected to conclude in November 2022. Data analysis will be performed, and the results will be published by the beginning of 2023.

Conclusions

This trial will provide guidance on the use of telehealth in the administration of prehabilitation services. The trial will provide a large amount of information that will respond to gaps in the literature, as there are minimal reports on the use of telehealth rehabilitation and prehabilitation services among elderly populations and in acute contexts, such as the preoperative period.

Trial Registration

ClinicalTrials.gov NCT0479956; https://clinicaltrials.gov/ct2/show/NCT04799561

International Registered Report Identifier (IRRID)

DERR1-10.2196/29936

Current Landscape of Nutrition Within Prehabilitation Oncology Research: A Scoping Review

Background: Prehabilitation aims to improve functional capacity prior to cancer treatment to achieve better psychosocial and clinical outcomes. Prehabilitation interventions vary considerably in design and delivery. In order to identify gaps in knowledge and facilitate the design of future studies, we undertook a scoping review of prehabilitation studies to map the range of work on prehabilitation being carried out in any cancer type and with a particular focus on diet or nutrition interventions. Objectives: Firstly, to describe the type of prehabilitation programs currently being conducted. Secondly, to describe the extent to which prehabilitation studies involved aspects of nutrition, including assessment, interventions, implementation, and outcomes. Eligibility Criteria: Any study of quantitative or qualitative design that employed a formal prehabilitation program before cancer treatment ("prehabilitation" listed in keywords, title, or abstract). Sources of Evidence: Search was conducted in July 2020 using MEDLINE, PubMed, EMBASE, EMCARE, CINAHL, and AMED. Charting Methods: Quantitative data were reported as frequencies. Qualitative nutrition data were charted using a framework analysis that reflects the Nutrition Care Process Model: assessment, intervention, and monitoring/evaluation of the nutrition intervention. Results: Five hundred fifty unique articles were identified: 110 studies met inclusion criteria of a formal prehabilitation study in oncology. prehabilitation studies were mostly cohort studies (41%) or randomized-controlled trials (38%) of multimodal (49%), or exercise-only (44%) interventions that were applied before surgery (94%). Nutrition assessment was inconsistently applied across these studies, and often conducted without validated tools (46%). Of the 110 studies, 37 (34%) included a nutrition treatment component. Half of these studies provided the goal for the nutrition component of their prehabilitation program; of these goals, less than half referenced accepted nutrition guidelines in surgery or oncology. Nutrition interventions largely consisted of counseling with dietary supplementation. The nutrition intervention was indiscernible in 24% of studies. Two-thirds of studies did not monitor the nutrition intervention nor evaluate nutrition outcomes. Conclusion: Prehabilitation literature lacks standardized and validated nutritional assessment, is frequently conducted without evidence-based nutrition interventions, and is typically implemented without monitoring the nutrition intervention or evaluating the intervention's contribution to outcomes. We suggest that the development of a core outcome set could improve the quality of the studies, enable pooling of evidence, and address some of the research gaps identified.

Malnourished lung cancer patients have poor baseline functional capacity but show greatest improvements with multimodal prehabilitation

OBJECTIVE

The objective is to characterize the presence of malnutrition, examine the association between malnutrition and baseline functional capacity (FC), and the extent to which patients benefit from preoperative multimodal prehabilitation in patients undergoing lung resection for cancer.

METHODS

Data from 162 participants enrolled in multimodal prehabilitation or control before lung cancer surgery were analyzed. Malnutrition was measured using the Patient-Generated Subjective Global Assessment (PG-SGA) according to triage levels: low-nutrition-risk (PG-SGA 0-3), moderate-nutrition-risk (4-8) and high-nutrition-risk (≥9). Baseline differences in FC, measured by the 6-minute walk test (6MWT), were compared. Factorial analysis of covariance (ANCOVA) was conducted to examine the effect of nutrition status and intervention on mean change in 6MWT preoperatively.

RESULTS

51.2% patients were considered low-nutrition-risk, 37.7% moderate-nutrition-risk, and 11.1% high-nutrition-risk. Low-nutrition-risk patients had significantly higher 6MWT at baseline (mean of 484 m [standard deviation (SD) = 88]) compared with moderate-nutrition-risk (432 m [SD = 107], P = .005) and high-nutrition-risk groups (416 m [SD = 90], P = .022). The adjusted mean change in 6MWT between prehabilitation vs control was 18.1 (95% confidence interval, 3.8 to 32.3) vs 5.6 m (-14.1 to 25.4) in low-nutrition-risk (P = .309), 28.5 (11 to 46) vs -4 m (-31.3 to 23.4) in moderate-nutrition-risk (P = .053), and 58.9 (16.7 to 101.2) vs -39.7 m (-80.2 to 0.826) in high-nutrition-risk group (P = .001).

CONCLUSIONS

Lung cancer patients at high-nutrition-risk awaiting surgery had significantly lower baseline FC compared with low-nutrition-risk patients but experienced significant improvements in preoperative FC upon receiving multimodal prehabilitation.

Prehabilitation in Thoracic Cancer Surgery: From Research to Standard of Care

OBJECTIVE

To determine whether personalized, stepped prehabilitation care is a feasible, safe, and effective implementation strategy.

DESIGN

Quality improvement project. Data collected prospectively from August 2018 to December 2019 were analyzed retrospectively to describe the clinical implementation of a prehabilitation care program for elective lung cancer surgery.

SETTING

Single center, tertiary university hospital.

PARTICIPANTS

Eighty-one consecutive adult patients living in the metropolitan area of Montreal were included if an elective resection of suspected or confirmed lung cancer was planned.

INTERVENTIONS

At the earliest contemplation of surgery, the whole cohort was screened for impaired physical, nutritional, and/or psychological status. Patients screened at higher risk received dedicated assessment and personalized prehabilitation care upon specific needs.

MEASUREMENTS AND MAIN RESULTS

Patients' specific needs and their access and flow through the different services were described. Prehabilitation effectiveness was evaluated using walking and exercise tests, and adverse events were monitored. Eighty-one patients were screened for functional impairments. Forty patients showed reduction of physical function, seven of them refused the specific assessment, one refused in-hospital exercise; 48 patients showed nutritional risk, eight of them refused or did not comply with nutritional therapy. Overall, 45 high-risk patients received a one-month personalized prehabilitation program: 16 partook in a trimodal program (exercise, nutrition, and psychological), and 22 received a program with both nutrition and exercise. No adverse events occurred during the study period. After prehabilitation, six-minute waking distance improved by 29.9 meters (standard deviation 47.3 m) (n = 35; p = 0.001) and the oxygen uptake at the anaerobic threshold improved by 1.6 (1.7) mL/kg/min (n = 13; p = 0.004). Length of hospital stay was two (interquartile range one-four) days in prehabilitated patients versus three (two-seven) days in the usual care group (p = 0.101).

CONCLUSIONS

A personalized, stepped prehabilitation program targeting high-risk patients undergoing elective lung cancer surgery was feasible, safe, and effective.

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

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

Artificial intelligence-based prediction of transfusion in the intensive care unit in patients with gastrointestinal bleeding

Objective

Gastrointestinal (GI) bleeding commonly requires intensive care unit (ICU) in cases of potentialhaemodynamiccompromise or likely urgent intervention. However, manypatientsadmitted to the ICU stop bleeding and do not require further intervention, including blood transfusion. The present work proposes an artificial intelligence (AI) solution for the prediction of rebleeding in patients with GI bleeding admitted to ICU.

Methods

A machine learning algorithm was trained and tested using two publicly available ICU databases, the Medical Information Mart for Intensive Care V.1.4 database and eICU Collaborative Research Database using freedom from transfusion as a proxy for patients who potentially did not require ICU-level care. Multiple initial observation time frames were explored using readily available data including labs, demographics and clinical parameters for a total of 20 covariates.

Results

The optimal model used a 5-hour observation period to achieve an area under the curve of the receiving operating curve (ROC-AUC) of greater than 0.80. The model was robust when tested against both ICU databases with a similar ROC-AUC for all.

Conclusions

The potential disruptive impact of AI in healthcare innovation is acknowledge, but awareness of AI-related risk on healthcare applications and current limitations should be considered before implementation and deployment. The proposed algorithm is not meant to replace but to inform clinical decision making. Prospective clinical trial validation as a triage tool is warranted.

Multimodal Prehabilitation for Lung Cancer Surgery: A Randomized Controlled Trial

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

Importance

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

Objective

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

Design, Setting, and Participants

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

Interventions

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

Main Outcomes and Measures

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

Results

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

Conclusions and Relevance

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

Trial Registration

ClinicalTrials.gov identifier: NCT02502760.

Combined Exercise and Nutrition Optimization for Peripheral Arterial Disease: A Systematic Review

BACKGROUND

Patients with peripheral arterial disease (PAD) who suffer from claudication have a low exercise capacity, poor quality of life, and often severe disability. Exercise and healthy nutrition have been shown to be important factors to prevent disease progression. This systematic review aims to assess the evidence supporting the use of combined nutrition and structured exercise in patients with intermittent claudication.

METHODS

Publications that included a combination of structured exercise (SE) and a nutritional intervention and that reported quality of life, exercise capacity, pain-free walking distance, limb blood flow hemodynamics, need for revascularization surgery, or surgical outcomes were systematically searched. Publications were screened, selected, and reviewed by 2 independent reviewers.

RESULTS

Four publications were found reporting the effects of combined SE and nutrition programs. Pooled statistical analysis across trials was not performed because of the heterogeneity of study designs and type of interventions. Only 2 randomized controlled trials were found, reporting conflicting results with regard to the effects of combined SE and nutrition on exercise capacity. Only one trial reported quality of life measures. Blood flow was increased in the intervention involving inorganic nitrate in addition to SE.

CONCLUSIONS

There are conflicting results and lack of quality data proving the benefit of nutrition and SE programs on patient-centered outcomes and limb blood flow. There are no data on the effects of combined nutrition and exercise on the need for revascularization surgery or postrevascularization outcomes. More randomized controlled trials are needed to assess the effects of multimodal interventions on patient-centered outcomes and clinical outcomes of PAD.

Third-Variable Effects: Tools to Understand Who, When, Why, and How Patients Benefit From Surgical Prehabilitation

Prehabilitation is a new field of research that aims to optimize modifiable surgical risk factors before surgery to improve patient-oriented outcomes preoperatively and postoperatively. As with any new intervention, the pressing questions that arise include what interventions work, for whom they work, and when do they work best? Given that prehabilitation can be resource intensive, and that preoperative patient characteristics are likely to produce variation in response to treatment, establishing answers to these questions is critical for successful implementation of prehabilitation in clinical practice. The objective of this review article is to describe the illuminating potential of including "third-variable effects" into the integration of research design; by planning for and including measurements of mediators, moderators, and confounders in the design and analysis of prehabilitation research, we can begin to answer practical, clinically relevant questions.

Older frail prehabilitated patients who cannot attain a 400 m 6-min walking distance before colorectal surgery suffer more postoperative complications

INTRODUCTION

Recent efforts to prehabilitate intermediately frail and frail (Fried frailty criteria ≥2) elective colorectal cancer patients did not influence clinical nor functional outcomes. The objective of this secondary analysis was to describe the subset of intermediately frail and frail prehabilitated patients who could not attain a minimum 400 m (a prognostic cut-point used in other patient populations) 6-min walking distance (6MWD) before elective surgery.

MATERIALS AND METHODS

Secondary analysis of a randomized controlled trial. Patients participated in multimodal prehabilitation at home and in-hospital for approximately four weeks before colorectal surgery. Primary outcome was incidence of postoperative complications within 30 days of hospital discharge.

RESULTS

Sixty percent of the patients who participated in prehabilitation did not reach a minimum walking distance of 400 m in 6 min before surgery. Compared to the group that attained ≥400 m 6MWD (n = 19), the <400 m group (n = 28) were older, had higher percent body fat, lower physical function, lower self-reported physical activity, higher American Society of Anesthesiologists (ASA) classification, and twice as many were in critical need of a nutrition intervention at baseline. No group differences were observed regarding frailty status (P = 0.775). Sixty-one percent of the <400 m 6MWD group experienced at least one complication within 30 days of surgery compared to 21% in the ≥400 m group (P = 0.009).

CONCLUSION

Several preoperative characteristics were identified in the <400 m 6MWD group that could be useful in screening and targeting future prehabilitative treatments. Future trials should investigate use of a 400 m standard for the 6MWD as a minimal treatment target for prehabilitation.

From preoperative assessment to preoperative optimization of frail older patiens

Physiological and mental reserve decreases with age and the ability to mount a response to a stress like surgery can represent a burden to the frail and sarcopenic patient. It is necessary to evaluate the cardiorespiratory capacity and muscle strength before surgery in the older persons and prepare adequately to the same extent the marathon runner prepares before a full marathon. Assessment and stratification of risk are necessary for decision-making, but also for planning interventions aimed at improving the functional and emotional status in anticipation of surgery. Prehabilitation can improve the physiological reserve by optimizing cardiorespiratory capacity, muscle strength, and mental resiliency. Patients with low reserve and chronic medical conditions at high risk can benefit.

Making Patients Fit for Surgery: Introducing a Four Pillar Multimodal Prehabilitation Program in Colorectal Cancer

BACKGROUND

Considering the relation between preoperative functional capacity and postoperative complications, enhancing patients' functional capacity before surgery with a prehabilitation program may facilitate faster recovery and improve quality of life. However, time before surgery is short, mandating a multimodal and high-intensity training approach. This study investigated feasibility and safety of a prehabilitation program for colorectal cancer.

METHODS

Multimodal prehabilitation was offered to patients eligible for participation and they were assigned to an intervention or control group by program availability. The prehabilitation program consisted of the following four interventions: in-hospital high-intensity endurance and strength training, high-protein nutrition and supplements, smoking cessation, and psychological support. Program attendance, patient satisfaction, adverse events, and functional capacity were determined.

RESULTS

Fifty patients participated in this study (prehabilitation 20, control 30). Program evaluation revealed a high (90%) attendance rate and high level of patient satisfaction. No adverse events occurred. Endurance and/or strength were improved. Eighty-six percent of patients with prehabilitation recovered to their baseline functional capacity 4 weeks postoperatively, 40% in the control group (P < 0.01).

CONCLUSIONS

Multimodal prehabilitation including high-intensity training for colorectal cancer patients is feasible, safe, and effective. A randomized controlled trial (NTR5947) was initiated to determine whether prehabilitation may lower morbidity and mortality rates in colorectal surgery.

Prehabilitation: finally utilizing frailty screening data

The elderly colorectal cancer patients tend to be frail, at nutrition risk with multiple comorbidities. In view of the stress on the body by surgery and recovery, it makes sense if patients are prepared before appropriately so that they can recover earlier and better. Prehabilitation prior to major surgery has attracted the attention of clinicians recently, and this review highlights the steps that need to be taken to implement a multidisciplinary program. Such programs requires a paradigm shift in the sense that all players need to be working in team for the benefit of patinets' outcome.

Effect of Exercise and Nutrition Prehabilitation on Functional Capacity in Esophagogastric Cancer Surgery: A Randomized Clinical Trial

Importance

Preserving functional capacity is a key element in the care continuum for patients with esophagogastric cancer. Prehabilitation, a preoperative conditioning intervention aiming to optimize physical status, has not been tested in upper gastrointestinal surgery to date.

Objective

To investigate whether prehabilitation is effective in improving functional status in patients undergoing esophagogastric cancer resection.

Design, Setting, and Participants

A randomized clinical trial (available-case analysis based on completed assessments) was conducted at McGill University Health Centre (Montreal, Quebec, Canada) comparing prehabilitation with a control group. Intervention consisted of preoperative exercise and nutrition optimization. Participants were adults awaiting elective esophagogastric resection for cancer. The study dates were February 13, 2013, to February 10, 2017.

Main Outcomes and Measures

The primary outcome was change in functional capacity, measured with absolute change in 6-minute walk distance (6MWD). Preoperative (end of the prehabilitation period) and postoperative (from 4 to 8 weeks after surgery) data were compared between groups.

Results

Sixty-eight patients were randomized, and 51 were included in the primary analysis. The control group were a mean (SD) age, 68.0 (11.6) years and 20 (80%) men. Patients in the prehabilitation group were a mean (SD) age, 67.3 (7.4) years and 18 (69%) men. Compared with the control group, the prehabilitation group had improved functional capacity both before surgery (mean [SD] 6MWD change, 36.9 [51.4] vs -22.8 [52.5] m; P < .001) and after surgery (mean [SD] 6MWD change, 15.4 [65.6] vs -81.8 [87.0] m; P < .001).

Conclusions and Relevance

Prehabilitation improves perioperative functional capacity in esophagogastric surgery. Keeping patients from physical and nutritional status decline could have a significant effect on the cancer care continuum.

Trial Registration

ClinicalTrials.gov Identifier: NCT01666158.