Surgical Prehabilitation in Patients with Cancer

Prehabilitation, making patients fit for surgery - a new frontier in perioperative care

Optimizing a patients’ condition before surgery to improve the postoperative outcome can be achieved by using prehabilitation; preoperative interventions focusing on modifiable risk factors to improve the physical, nutritional, and mental status of the patient. A multimodal, multidisciplinary approach induces a synergistic effect between the various interventions and affects the outcome postoperatively. While awaiting higher-quality evidence, the worldwide implementation of prehabilitation programs has started, resulting in a true revolution in perioperative care.

What are the attitudes and beliefs of oncologists regarding potential cancer rehabilitation in a tertiary cancer center?

Cancer Rehabilitation (CR) is an emerging field in Physical Medicine & Rehabilitation. Current literature highlights the effectiveness of cancer rehabilitation in improving functional outcomes, shorter length of hospital stay, and improved quality of life. Despite this, there are very few formalized CR programs across all of North America. We conducted a survey at a tertiary cancer center without a formalized CR program to assess the perceived need of such a program and its potential development. This survey of medical, surgical, radiation and pediatric oncologists demonstrated that 92.3% of 39 respondents felt CR was somewhat to very important, particularly for their patients' issues of fatigue, deconditioning, pain management and disposition planning. These findings highlight the value seen by oncologists in the need for further cancer rehabilitation access and formalized program development in order to meet patient needs for improving functional deficits, activities of daily living and quality of life.

Training and Practice Patterns in Cancer Rehabilitation: A Survey of Physiatrists Specializing in Oncology Care

BACKGROUND

Cancer rehabilitation is an integral part of the continuum of care for survivors. Due to the increasing number of survivors, physiatrists commonly see cancer patients in their general practices. Essential to guiding the field is to understand the current training and practice patterns of cancer rehabilitation physicians.

OBJECTIVES

To assess current trends in training and practice for cancer rehabilitation physicians, including the level of burnout among providers in this field.

DESIGN

Cross-sectional descriptive survey study.

SETTING

Online survey.

PARTICIPANTS

American physicians who are affiliated with the Cancer Rehabilitation Physician Consortium (CRPC) of the American Academy of Physical Medicine and Rehabilitation (AAPM&R). The CRPC is a group of cancer rehabilitation providers (both fellowship-trained and not fellowship-trained) with the mission of furthering cancer rehabilitation medicine through education, research, and networking.

METHODS

All CRPC physicians were invited to complete a voluntary and anonymous 43-question online survey. The survey was conceived by a group of eight experts interested in providing additional information to the current literature regarding the training and practice in the cancer rehabilitation field.

MAIN OUTCOME MEASUREMENTS

Training, practice, opioid prescribing, and professional support.

RESULTS

Thirty-seven of 50 physicians participated (response rate = 74%). Respondents were from various states, the three most common being New York (16%, n = 6), Texas (16%, n = 6), and Massachusetts (11%, n = 4). About 57% (n = 21) of the respondents were employed in an academic medical center and 73% (n = 27) reported their primary departmental affiliation was Physical Medicine and Rehabilitation (PM&R). Approximately 78% (n = 29) credited mentorship early in training for their interest in the field. More than half (54%, n = 20) either strongly agreed or agreed that cancer rehabilitation fellowship training is necessary for graduating physiatrists who plan to treat oncology patients/survivors. National PM&R meetings were the primary source of continuing education for 86% (n = 31). Sixty-five percent (n = 24), strongly agreed or agreed that cancer rehabilitation physiatrists should know how to prescribe opioids, and 35% (n = 13) reported prescribing them when appropriate. About 54% (n = 20) rated their level of burnout as low or very low, and more than half (51%, n = 19) believed their burnout level was lower than physiatrists treating other rehabilitation populations.

CONCLUSIONS

Cancer rehabilitation is a growing subspecialty in PM&R, and most physiatrists in general practice will treat many survivors-often for neurologic or musculoskeletal impairments related to cancer or its treatment. Cancer rehabilitation physicians perceive that they have relatively low levels of burnout, and early mentorship and fellowship training is beneficial. Professional conferences and mentorship are a primary source for continuing education.

LEVEL OF EVIDENCE

IV.

Prehabilitation for major abdominal urologic oncology surgery

PURPOSE OF REVIEW

Whether prehabilitation in radical cystectomy adds to the effort of reducing postoperative morbidity and impairments in the survivorship phase has until recently received limited attention. This narrative review aims to summarize the current evidence base on prehabilitaion interventions focusing on the efficacy of procedure-specific interventions and the influence on postoperative outcomes.

RECENT FINDINGS

Given the oncological risk, there is a relative short window to intervene and proactively optimize the patient before radical cystectomy. Preliminary results are however promising and a single-center randomized controlled trial (RCT) has shown that home-based short-term physical prehabilitation is feasible and effective and significantly improves early mobilization, time to perform activities of daily living and health-related quality of life (HRQoL). No significant impact on length of stay or complications was found. Limited evidence support preoperative nutritional interventions in cancer surgery, although evidence suggests improved outcome if malnourished individuals are adequately fed 7-10 days before surgery. No RCTs have evaluated the effect of smoking or alcohol cessation interventions on complications or HRQoL in radical cystectomy. Patient education interventions focusing on stoma care improve significantly self-efficacy in regards to independently change of stoma-appliance up to 1 year postoperatively. Currently, there is no evidence of early intervention considering psychological well being, sexual health or shared decision-making.

SUMMARY

Published data indicate that a group of preoperative multiprofessional interventions including physical exercises, supportive nutritional care and stoma education can postoperatively improve early mobilization, self-efficacy and HRQoL. No evidence for further reduction of length of stay or complications was found.

Prevalence and Consequences of Preoperative Weight Loss in Gynecologic Surgery

Preoperative malnutrition and weight loss negatively impact postoperative outcomes in various surgical fields. However, for gynecologic surgery, evidence is still scarce, especially if surgery is performed within enhanced recovery after surgery (ERAS) pathways. This study aimed to assess the prevalence and impact of preoperative weight loss in patients undergoing major gynecologic procedures within a standardized ERAS pathway between October 2013 and January 2017. Out of 339 consecutive patients, 33 (10%) presented significant unintentional preoperative weight loss of more than 5% during the 6 months preceding surgery. These patients were less compliant to the ERAS protocol (>70% of all items: 70% vs. 94%, p < 0.001) presented more postoperative overall complications (15/33 (45%) vs. 69/306 (22.5%), p = 0.009), and had an increased length of hospital stay (5 ± 4 days vs. 3 ± 2 days, p = 0.011). While patients experiencing weight loss underwent more extensive surgical procedures, after multivariate analysis, weight loss ≥5% was retained as an independent risk factor for postoperative complications (OR 2.44; 95% CI 1.00-5.95), and after considering several surrogates for extensive surgery including significant blood loss (OR 2.23; 95% CI 1.15-4.31) as confounders. The results of this study suggest that systematic nutritional screening in ERAS pathways should be implemented.

Prehabilitation is better than cure

PURPOSE OF REVIEW

With a continuously growing number of older patients undergoing major surgical procedures, reliable parameters practicable in perioperative routine revealing those patients at risk are urgently needed. Recently, the concept of 'prehabilitation' with its key elements exercise, nutrition and psychological stress reduction especially in frail patients is attracting increasing attention.

RECENT FINDINGS

Literature search revealed a huge amount of publications in particular within the last 12 months. Although a single definition of both frailty and prehabilitation is still to be made, various players in the perioperative setting obviously are becoming increasingly convinced about a possible benefit of the program - referring to different components and measures performed. Although physiologically advantages seem obvious, there is hardly any reliable data on clinical outcomes resulting from properly performed studies. This applies especially to octogenarians; thus those at risk for adverse events the concept originally addresses.

SUMMARY

Identifying high-risk patients at the earliest possible stage and increasing their physiological reserve prior to surgery is a promising approach that seems to result in remarkable improvements for older patients. However, further studies on effectiveness in a highly heterogeneous population and agreement on a common concept are mandatory before a final judgement can be given.

Guidelines for perioperative care in gynecologic/oncology: Enhanced Recovery After Surgery (ERAS) Society recommendations-2019 update

BACKGROUND

This is the first updated Enhanced Recovery After Surgery (ERAS) Society guideline presenting a consensus for optimal perioperative care in gynecologic/oncology surgery.

METHODS

A database search of publications using Embase and PubMed was performed. Studies on each item within the ERAS gynecologic/oncology protocol were selected with emphasis on meta-analyses, randomized controlled trials, and large prospective cohort studies. These studies were then reviewed and graded according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system.

RESULTS

All recommendations on ERAS protocol items are based on best available evidence. The level of evidence for each item is presented accordingly.

CONCLUSIONS

The updated evidence base and recommendation for items within the ERAS gynecologic/oncology perioperative care pathway are presented by the ERAS® Society in this consensus review.

Prehabilitation for adults diagnosed with cancer: A systematic review of long-term physical function, nutrition and patient-reported outcomes

OBJECTIVE

Prehabilitation is increasingly being used to mitigate treatment-related complications and enhance recovery. An individual's state of health at diagnosis, including obesity, physical fitness and comorbidities, are influencing factors for the occurrence of adverse effects. This review explores whether prehabilitation works in improving health outcomes at or beyond the initial 30 days post-treatment and considers the utility of prehabilitation before cancer treatment.

METHODS

A database search was conducted for articles published with prehabilitation as a pre-cancer treatment intervention between 2009 and 2017. Studies with no 30 days post-treatment data were excluded. Outcomes post-prehabilitation were extracted for physical function, nutrition and patient-reported outcomes.

RESULTS

Sixteen randomised controlled trials with a combined 2017 participants and six observational studies with 289 participants were included. Prehabilitation interventions provided multi-modality components including exercise, nutrition and psychoeducational aspects. Prehabilitation improved gait, cardiopulmonary function, urinary continence, lung function and mood 30 days post-treatment but was not consistent across studies.

CONCLUSION

When combined with rehabilitation, greater benefits were seen in 30-day gait and physical functioning compared to prehabilitation alone. Large-scale randomised studies are required to translate what is already known from feasibility studies to improve overall health and increase long-term cancer patient outcomes.

Follow the trail: Using insights from the growth of palliative care to propose a roadmap for cancer rehabilitation

Despite research explicating the benefits of cancer rehabilitation interventions to optimize physical, social, emotional, and vocational functioning, many reports document low rates of referral to and uptake of rehabilitation in oncology. Cancer rehabilitation clinicians, researchers, and policy makers could learn from the multidisciplinary specialty of palliative care, which has benefited from a growth strategy and has garnered national recognition as an important and necessary aspect of oncology care. The purpose of this article is to explore the actions that have increased the uptake and integration of palliative care to yield insights and multimodal strategies for the development and growth of cancer rehabilitation. After examining the history of palliative care and its growth, the authors highlight 5 key strategies that may benefit the field of cancer rehabilitation: 1) stimulating the science in specific gap areas; 2) creating clinical practice guidelines; 3) building clinical capacity; 4) ascertaining and responding to public opinion; and 5) advocating for public policy change. Coordinated and simultaneous advances on these 5 strategies may catalyze the growth, utilization, and effectiveness of patient screening, timely referrals, and delivery of appropriate cancer rehabilitation care that reduces disability and improves quality of life for cancer survivors who need these services.

The role of rehabilitation in patients undergoing oesophagectomy for cancer and pre-malignant disease: A qualitative exploration of the views of patients, carers and healthcare providers

OBJECTIVE

Oesophagectomy for cancer is associated with significant morbidity and mortality, and reduced quality of life. Structured rehabilitation potentially offers improved physical and psychological outcomes. We aimed to explore patient, carer and healthcare provider attitudes and preferences towards the role of rehabilitation.

METHODS

We interviewed 15 patients who had undergone an oesophagectomy, 10 carers and 13 healthcare providers about perceived impacts of treatment; preferred components of a rehabilitation program; barriers/enablers of support provision; and participation in rehabilitation programs. Data were analysed using framework analysis.

RESULTS

The overarching theme was "Getting back to normal." Diagnosis of disease signified a disruption to the normal trajectory of patients' lives and the post-treatment period was characterised as striving to return to normal. Patients and carers focused on rehabilitation needs post-treatment including dietary support, physiotherapy and healthcare provider support. Healthcare providers described rehabilitation as potentially beneficial from the pre-treatment phase and, along with carers, highlighted the importance of psychological support. Barriers included access to services, cost of service provision and appointment burden.

CONCLUSION

A need for rehabilitation services was identified by healthcare providers from the point of diagnosis, rather than only after surgery. Implications include improved service provision by healthcare institutions for patients undergoing oesophagectomy.

Next-Generation Cancer Rehabilitation: A Giant Step Forward for Patient Care

PURPOSE

The aim of the study was to review the current state of cancer rehabilitation evidence and practice and delineate an agenda for building the future of cancer rehabilitation care.

FINDINGS

Despite the benefits of cancer rehabilitation interventions and the unmet needs among patients with cancer, very few patients receive these services.

CONCLUSIONS

Interdisciplinary cancer rehabilitation should be implemented from diagnosis forward. Building this care involves coordinating efforts in four critical areas: innovating cancer rehabilitation care delivery, expanding the team of providers, creating precision medicine cancer rehabilitation, and demonstrating the value of cancer rehabilitation to drive referrals and reimbursement.

CLINICAL RELEVANCE

Creating next-generation cancer rehabilitation care has the potential to improve the lives of the growing population of cancer survivors.

Long-Term Survivorship Care After Cancer Treatment: A New Emphasis on the Role of Rehabilitation Services

In May 2018, the National Cancer Policy Forum (NCPF) of the National Academies of Sciences, Engineering, and Medicine (formerly the Institute of Medicine) released a report, Long-Term Survivorship Care After Cancer Treatment: Proceedings of Workshop. NCPF-published reports have historically played a significant role in driving policy and payment model changes in oncology care, in addition to raising awareness about the needs of individuals with cancer. This 2018 report provides a specific set of recommendations for improving symptom management and rehabilitation that suggest the integration of rehabilitation services at the point of cancer diagnosis and throughout the continuum of cancer care to effectively screen for and manage the anticipated functional morbidity associated with cancer treatment. The specificity of these recommendations is of significant relevance to the physical therapy profession and should encourage bold steps to effectively increase the presence of physical therapists as members of interdisciplinary cancer care teams. The profession must act to implement models of prospective care, develop targeted education and training initiatives to assure the knowledge and skills of our workforce for this complex population, and augment the current evidence base with greater attention to health services research aiming to understand the effectiveness of rehabilitation services in improving costs, utilization, and meaningful functional outcomes.

Symptom-based interventions to promote quality survivorship

Survival alone is no longer an adequate outcome for persons with brain tumors; the quality of the survivorship experience should be viewed with equal importance. Symptom management is a significant component of quality survivorship care. Regardless of their histology, brain tumors and therapies used to treat them produce symptoms that affect an individual's ability to function in everyday life. Common symptoms include fatigue, cognitive impairment, distress, and sleep disturbance. Symptom-based interventions for persons with brain tumors focus on prevention, self-management, and prescriptive interventions targeted to these problems. Unfortunately, little evidence exists to support many interventions, making it challenging for clinicians to provide concrete recommendations. Research is needed to provide evidence in support of symptom-based interventions while novel approaches to these challenging problems are developed.

Organization of Multidisciplinary Cancer Care for the Surgical Patient: Role of Anesthesiologists

Purpose of review

The purpose of this review is to describe significant recent trends or developments regarding the role of anesthesiologists in a multidisciplinary team approach to cancer care for the surgical patient. We also discuss our own institutional multidisciplinary approach as a comprehensive cancer center with high surgical volume.

Recent findings

Beyond the multidisciplinary team meeting concept, and local, institution-specific, or national programs, more formalized concepts and models of perioperative care have evolved. These provide a framework for robust involvement of anesthesiologists in cancer care for the surgical patient, with the goal of allowing for optimal individualized cancer outcomes.

Summary

Because of the wide-ranging nature of their perioperative expertise, anesthesiologists play an important role in multidisciplinary team cancer care for surgical patients. This role has been seen in the recent trends toward clinical models, such as the perioperative surgical home and enhanced recovery programs. Areas for future research include multidisciplinary assessment of the impact of such models on perioperative cancer outcomes through integration of data from national outcomes groups.

A Bibliometric Analysis of the Landscape of Cancer Rehabilitation Research (1992-2016)

Cancer rehabilitation research has accelerated as great attention has focused on improving survivorship care. Recent expert consensus has attempted to prioritize research needs and suggests greater focus on studying physical functioning of survivors. However, no analysis of the publication landscape has substantiated these proposed needs. This manuscript provides an analysis of PubMed indexed articles related to cancer rehabilitation published between 1992 and 2017. A total of 22 171 publications were analyzed using machine learning and text analysis to assess publication metrics, topic areas of emphasis, and their interrelationships through topic similarity networks. Publications have increased at a rate of 136 articles per year. Approximately 10% of publications were funded by the National Institutes of Health institutes and centers, with the National Cancer Institute being the most prominent funder. The greatest volume and rate of publication increase were in the topics of Cognitive and Behavioral Therapies and Psychological Interventions, followed by Depression and Exercise Therapy. Four research topic similarity networks were identified and provide insight on areas of robust publication and notable deficits. Findings suggest that publication emphasis has strongly supported cognitive, behavioral, and psychological therapies; however, studies of functional morbidity and physical rehabilitation research are lacking. Three areas of publication deficits are noted: research on populations outside of breast, prostate, and lung cancers; methods for integrating physical rehabilitation services with cancer care, specifically regarding functional screening and assessment; and physical rehabilitation interventions. These deficits align with the needs identified by expert consensus and support the supposition that future research should emphasize a focus on physical rehabilitation.

[Physical Activity and Cancer]

Physical Activity and Cancer Abstract. This article aims to summarize the literature on the role of physical activity in cancer patients and to propose exercise programs based on studies and recommendations. Medical advances with improved early diagnosis and treatment have increased the number of cancer survivors. At the same time, the quality of life of these patients must also be improved. In the different stages of the disease physical activity has an important role to play with its beneficial effects on fatigue, physical condition, mood etc. Collaboration between health system actors and patient education are the key to success in this multi-disciplinary care.

The Malnourished Patient With Obesity: A Unique Paradox in Bariatric Surgery

BACKGROUND

Hypoalbuminemia is a known risk factor for poor outcomes following surgery. Obesity can be associated with modest to severe malnutrition. We evaluated the impact of hypoalbuminemia on surgical outcomes in patients with obesity undergoing elective bariatric surgical procedures.

MATERIALS AND METHODS

The 2015 metabolic and bariatric surgery accreditation and quality improvement program database was queried. Patients ≥ 18 y with body mass index ≥35 undergoing bariatric surgery were included. Revision procedures were excluded. Patients were classified by albumin level (albumin ≥3.5 g/dL [normal], 3.49-3.0 g/dL [mild], 2.99-2.5 g/dL [moderate], and <2.5 g/dL [severe]). Independent logistic regression models were developed to estimate the adjusted odds of (1) death or serious morbidity (DSM); (2) mild to moderate complications; (3) severe complications; and (4) 30-d readmissions by albumin level. In addition, effect modification by >10% weight loss was examined.

RESULTS

A total of 106,577 patients were included in the study. Over 6% of patients had hypoalbuminemia. Fifty-five percent of complications were severe as categorized by the Clavien-Dindo classification. Patients with mild hypoalbuminemia had 20% increased odds of DSM (95% confidence interval: 1.1-1.4). There was increasing likelihood of DSM with severe hypoalbuminemia. Patients with mild hypoalbuminemia had 20% increased odds of 30-d readmission (confidence interval: 1.1-1.3). A >10% weight loss modified the effect of moderate to severe hypoalbuminemia on DSM.

CONCLUSIONS

More than 6% of patients with obesity undergoing bariatric surgery are malnourished. Hypoalbuminemia is an important and modifiable risk factor for postoperative adverse outcomes following bariatric surgery. Preoperative weight loss >10% combined with moderate to severe hypoalbuminemia is synergistic for high rates of DSM and should be addressed before proceeding with bariatric surgery.

The Case for Prehabilitation Prior to Breast Cancer Treatment

Cancer rehabilitation in breast cancer survivors is well established, and there are many studies that focus on interventions to treat impairments as well as therapeutic exercise. However, very little is known about the role of prehabilitation for people with breast cancer. In this narrative review, we describe contemporary clinical management of breast cancer and associated treatment-related morbidity and mortality considerations. Knowing the common short- and long-term sequelae, as well as less frequent but serious sequelae, informs our rationale for multimodal breast cancer prehabilitation. We suggest 5 core components that may help to mitigate short- and long-term sequelae that align with consensus opinion of prehabilitation experts: total body exercise; locoregional exercise pertinent to treatment-related deficits; nutritional optimization; stress reduction/psychosocial support; and smoking cessation. In each of these categories, we review the literature and discuss how they may affect outcomes for women with breast cancer.

Feasibility and Preliminary Efficacy of a 10-Week Resistance and Aerobic Exercise Intervention During Neoadjuvant Chemoradiation Treatment in Rectal Cancer Patients

Background: Neoadjuvant chemoradiation treatment (CRT) in rectal cancer patients is associated with a reduction in physical capacity, lean mass and increased fatigue. As a countermeasure to these treatment-related adverse effects, we examined the feasibility and preliminary efficacy of a 10-week exercise program during CRT. Methods: Ten rectal cancer patients (7 men, aged 27-70 years, body mass index = 26.4 ± 3.8 kg/m²) receiving CRT undertook supervised resistance and aerobic exercise twice weekly. Assessments were undertaken pre- and post-intervention for upper and lower body muscle strength by 1-RM, muscle endurance, physical performance tests, body composition by dual X-ray absorptiometry, quality of life, and fatigue. Results: There was a significant loss in appendicular skeletal muscle (−1.1 kg, P = .012), and fat mass (−0.8 kg, P = .029) following CRT. Despite the loss in skeletal muscle, leg press (P = .030) and leg extension (P = .046) strength improved by 27.2% and 22.7%, respectively, and leg press endurance by 76.7% (P = .007). Changes in strength were accompanied by improved performance (P < .05) in 6-m fast walking speed (6.9%) and dynamic balance as determined by the 6-m backwards walk (15.5%). There was minimal change in quality of life and fatigue, and no adverse events related to training. Conclusions: Exercise during neoadjuvant CRT appears to be feasible and well tolerated in rectal cancer patients and may enhance physical function while minimizing adverse changes in body composition and cancer-related fatigue. These initial findings need to be confirmed in randomized controlled trials.

A Focused Review of Safety Considerations in Cancer Rehabilitation

Cancer and its treatments introduce various adverse effects that may affect survivors' physical, cognitive and psychological functioning. Frequently both tolerance to activity and exercise are affected as well. Rehabilitation providers should have substantive knowledge about the effect of cancer progression and common side effects associated with antineoplastic treatment to safely integrate rehabilitation interventions. Rehabilitation may mitigate loss of function and disability; however, these patients are among the most medically complex that providers treat. This report provides a focused review that synthesizes the current evidence regarding disease progression and oncology-directed treatment side effects within the context of safety considerations for rehabilitation interventions throughout the continuum of cancer care. Descriptive information regarding the evidence for precautions and contraindications is provided so that rehabilitation providers can promote a safe plan of rehabilitation care. It is incumbent upon but also challenging for rehabilitation providers to stay up to date on the many advances in cancer treatment, and there are many gaps in the literature regarding safety issues. Although further research is needed to inform care, this review provides clinicians with a framework to assess patients with the goal of safely initiating rehabilitation interventions.