Patients' perceptions of quality of life during active treatment for locally advanced rectal cancer: the importance of preoperative exercise

What moves patients to participate in prehabilitation before major surgery? A mixed methods systematic review

BACKGROUND

Prehabilitation offers patients the opportunity to actively participate in their perioperative care by preparing themselves for their upcoming surgery. Experiencing barriers may lead to non-participation, which can result in a reduced functional capacity, delayed post-operative recovery and higher healthcare costs. Insight in the barriers and facilitators to participation in prehabilitation can inform further development and implementation of prehabilitation. The aim of this review was to identify patient-experienced barriers and facilitators for participation in prehabilitation.

METHODS

For this mixed methods systematic review, articles were searched in PubMed, EMBASE and CINAHL. Articles were eligible for inclusion if they contained data on patient-reported barriers and facilitators to participation in prehabilitation in adults undergoing major surgery. Following database search, and title and abstract screening, full text articles were screened for eligibility and quality was assessed using the Mixed Method Appraisal Tool. Relevant data from the included studies were extracted, coded and categorized into themes, using an inductive approach. Based on these themes, the Capability, Opportunity, Motivation, Behaviour (COM-B) model was chosen to classify the identified themes.

RESULTS

Three quantitative, 14 qualitative and 6 mixed methods studies, published between 2007 and 2022, were included in this review. A multitude of factors were identified across the different COM-B components. Barriers included lack of knowledge of the benefits of prehabilitation and not prioritizing prehabilitation over other commitments (psychological capability), physical symptoms and comorbidities (physical capability), lack of time and limited financial capacity (physical opportunity), lack of social support (social opportunity), anxiety and stress (automatic motivation) and previous experiences and feeling too fit for prehabilitation (reflective motivation). Facilitators included knowledge of the benefits of prehabilitation (psychological capability), having access to resources (physical opportunity), social support and encouragement by a health care professional (social support), feeling a sense of control (automatic motivation) and beliefs in own abilities (reflective motivation).

CONCLUSIONS

A large number of barriers and facilitators, influencing participation in prehabilitation, were found across all six COM-B components. To reach all patients and to tailor prehabilitation to the patient's needs and preferences, it is important to take into account patients' capability, opportunity and motivation.

TRIAL REGISTRATION

Registered in PROSPERO (CRD42021250273) on May 18th, 2021.

The Effects of Multimodal Prehabilitation Interventions in Men Affected by Prostate Cancer on Physical, Clinical and Patient Reported Outcome Measures: A Systematic Review

OBJECTIVES

To synthesize existing evidence on the effects of multimodal prehabilitation interventions in men affected by prostate cancer on physical, clinical, and patient-reported outcome measures.

DATA SOURCES

A systematic review was conducted according to the PRISMA 2020 Statement Guidelines. Electronic databases (ie, Medline, Embase, CINAHL and Cochrane CENTRAL, and clinicaltrials.gov) were searched using key search terms. Articles were assessed according to prespecified eligibility criteria. Data extraction and quality appraisal was conducted. The findings were integrated in a narrative synthesis.

CONCLUSION

Of the 5863 publications screened, 118 articles were assessed in full text and 17 studies met the prescreening eligibility criteria. There were a range of study designs that included randomized controlled clinical trials (n = 11), quasi experimental (n = 4), cohort (n = 1), and case series (n = 1), covering a total of 1739 participants. The prehabilitation interventions included physical activity, peer support, pelvic floor muscle training, diet, nurse-led prehabilitation, psychological, and prehabilitation administration of phosphodiesterase-5 inhibitors.

IMPLICATIONS FOR NURSING PRACTICE

Significant heterogeneity existed in the prehabilitation intervention programs for men affected by prostate cancer in terms of the composition, duration, method of administration, and the outcomes measured to quantify their impact. This systematic review has identified that multimodal prehabilitation interventions are an emerging area for practice and research among men affected by prostate cancer. Importantly, there has been a lack of focus on the inclusion of partners as critical companions during this distressing phase of the cancer care continuum. For the moment, all members of the multidisciplinary team caring for people affected by prostate cancer are encouraged to use the findings in this review to inform holistic models of care.

The Wessex Fit-4-Cancer Surgery Trial (WesFit): a protocol for a factorial-design, pragmatic randomised-controlled trial investigating the effects of a multi-modal prehabilitation programme in patients undergoing elective major intra–cavity cancer surgery

Background: Surgical resection remains the primary curative treatment for intra-cavity cancer. Low physical fitness and psychological factors such as depression are predictive of post–operative morbidity, mortality and length of hospital stay. Prolonged post-operative morbidity is associated with persistently elevated risk of premature death. We aim to investigate whether a structured, responsive exercise training programme, a psychological support programme or combined exercise and psychological support, delivered between treatment decision and major intra-cavity surgery for cancer, can reduce length of hospital stay, compared with standard care.

Methods: WesFit is a pragmatic , 2x2 factorial-design, multi-centre, randomised-controlled trial, with planned recruitment of N=1560. Participants will be randomised to one of four groups. Group 1 (control) will receive usual pre-operative care, Group 2 (exercise) patients will undergo 2/3 aerobic, high-intensity interval training sessions per week supervised by personal trainers. Group 3 (psychological support) patients are offered 1 session per week at a local cancer support centre. Group 4 will receive both exercise and psychological support. All patients undergo baseline and pre-operative cardiopulmonary exercise testing, complete self-report questionnaires and will be followed up at 30 days, 12 weeks and 12 months post-operatively. Primary outcome is post-operative length-of-stay. Secondary outcomes include disability-adjusted survival at 1-year postoperatively, post-operative morbidity, and health-related quality of life. Exploratory investigations include objectively measured changes in physical fitness assessed by cardiopulmonary exercise test, disease-free and overall mortality at 1-year postoperatively, longer-term physical activity behaviour change, pre-operative radiological tumour regression, pathological tumour regression, pre and post-operative body composition analysis, health economics analysis and nutritional characterisation and its relationship to post-operative outcome.

Conclusions: The WesFit trial will be a randomised controlled study investigating whether a high-intensity exercise training programme +/- psychological intervention results in improvements in clinical and patient reported outcomes in patients undergoing major inter-cavity resection of cancer.

ClinicalTrials.gov registration: NCT03509428 (26/04/2018)

Preparing for colorectal surgery: a qualitative study of experiences and preferences of patients in Western Canada

Objectives

The burden and costs of abdominal surgery for chronic conditions are on the rise, but could be reduced through self-management support. However, structured support to prepare for colorectal surgery is not routinely offered to patients in Canada. This study aimed to describe experiences and explore preferences for multimodal prehabilitation among colorectal surgery patients.

Methods

A qualitative descriptive study using three focus groups (FG) was held with 19 patients who had a surgical date for abdominal surgery (April 2017-April 2018) and lived close (≤ 50 km radius) to a tertiary hospital in Western Canada (including a Surgical Lead for the British Columbia Enhanced Recovery After Surgery (ERAS) Collaborative). FGs were audio-taped and verbatim transcribed with coding and pile-and-sort methods performed by two independent reviewers, confirmed by a third reviewer, in NVivo v9 software; followed by thematic analysis and narrative synthesis.

Results

Four themes emerged: support, informed decision-making, personalization of care, and mental/emotional health, which patients felt was particularly important but rarely addressed. Patient preferences for prehabilitation programming emphasised regular support from a single professional source, simple health messages, convenient access, and flexibility.

Conclusions

There is an unmet need for structured preoperative support to better prepare patients for colorectal surgery. Future multimodal prehabilitation should be flexible and presented with non-medical information so patients can make informed decisions about their preoperative care and surgical outcomes. Healthcare providers have an important role in encouraging healthy lifestyle changes before colorectal surgery, though clearer communication and accurate advice on self-care, particularly mental health, are needed for improving patient outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08130-y.

• Optimising preoperative care for abdominal surgery patients could improve outcomes.

• Patient experiences of preparing for colorectal surgery could inform future interventions, but patient-oriented research to improve quality of care is scarce.

• There is an unmet need for preoperative support in colorectal surgery.

• Future multimodal prehabilitation should incorporate patient preferences.

Attitudes to and Experiences of Physical Activity After Colon Cancer Diagnosis Amongst Physically Active Individuals - A Qualitative Study

BACKGROUND

Physical activity improves survival, reduces postoperative complications, and reduces the risk of developing colon cancer. It is important to maintain physical activity after receiving a diagnosis of colon cancer to improve postoperative recovery. Individuals who are physically active and diagnosed with colon cancer presumably have different motivations to maintain physical activity compared to their sedentary counterparts.

OBJECTIVE

Enlighten how the diagnosis of colon cancer might affect physically active individuals in their attitude and experiences towards physical activity.

METHODS

A qualitative study using content analysis was conducted in northern Sweden based on semi-structured telephone interviews of twenty patients diagnosed with colon cancer. All participants met the recommendations for physical activity issued by the World Health Organization.

RESULTS

Participants were between 50 and 88 years and 50% were male. Three main categories were identified: I'll fight the cancer and come out stronger; The diagnosis makes no difference; and The diagnosis is an obstacle for physical activity. These main categories represent the ways the individuals reacted to the diagnosis of colon cancer regarding their physical activity.

CONCLUSION

Attitudes to and experience of physical activity after colon cancer diagnosis varied from a will to increase physical activity and fight the cancer, to the diagnosis putting a stop to physical activity. It is important that healthcare professionals recommend physical activity even in already physically active individuals, to encourage continued physical activity after diagnosis of colon cancer.

Physical activity programmes for patients undergoing neo-adjuvant chemoradiotherapy for rectal cancer: A systematic review and meta-analysis

BACKGROUND

Patients diagnosed with localized rectal cancer should undergo Neoadjuvant Radio-Chemotherapy (NACRT) followed, a few weeks later, by surgical resection. NACRT is known to cause significant decline in the physical and psychological health of patients. This literature review aims to summarize the effects of a prehabilitation programme during and/or after NACRT but before surgery.

METHODS

Articles included in this review have been selected by two independent researchers on Pubmed, Google Scholar, and Cochrane databases with the following terms: "Rectal Cancer AND Physical Activity" and "Exercise AND Rectal Cancer."

RESULTS

We obtained 560 articles. We selected 12 of these, representing 7 series but only one randomized study, constituting 153 patients in total. Most studies included have considerable variation in their prehabilitation programmes, in terms of supervision, training content, frequency, intensity, duration, and temporality, in regard to NACRT and surgery. Implementing a prehabilitation programme during NACRT seems feasible and safe, with adherence ranging from 58% to 100%. VO2max (maximal oxygen consumption during incremental exercise) was improved in three of the studies during the prehabilitation programme. No significant difference in the step count, 6-minute-walk test, or quality of life was seen.

CONCLUSIONS

Prehabilitation programmes during NACRT for localized rectal cancer patients are safe and feasible; however, due to considerable variation in the prehabilitation programmes and their small size, impact on fitness, quality of life, and surgical outcome are unknown. Larger randomized studies are needed.

The Wessex Fit-4-Cancer Surgery Trial (WesFit): a protocol for a factorial-design, pragmatic randomised-controlled trial investigating the effects of a multi-modal prehabilitation programme in patients undergoing elective major intra-cavity cancer surgery

Background: Surgical resection remains the primary curative treatment for intra-cavity cancer. Low physical fitness and psychological factors such as depression are predictive of post-operative morbidity, mortality and length of hospital stay. Prolonged post-operative morbidity is associated with persistently elevated risk of premature death. We aim to investigate whether a structured, responsive exercise training programme, a psychological support programme or combined exercise and psychological support, delivered between treatment decision and major intra-cavity surgery for cancer, can reduce length of hospital stay, compared with standard care. Methods: WesFit is a pragmatic , 2x2 factorial-design, multi-centre, randomised-controlled trial, with planned recruitment of N=1560. Participants will be randomised to one of four groups. Group 1 (control) will receive usual pre-operative care, Group 2 (exercise) patients will undergo 2/3 aerobic, high-intensity interval training sessions per week supervised by personal trainers. Group 3 (psychological support) patients are offered 1 session per week at a local cancer support centre. Group 4 will receive both exercise and psychological support. All patients undergo baseline and pre-operative cardiopulmonary exercise testing, complete self-report questionnaires and will be followed up at 30 days, 12 weeks and 12 months post-operatively. Primary outcome is post-operative length-of-stay. Secondary outcomes include disability-adjusted survival at 1-year postoperatively, post-operative morbidity, and health-related quality of life. Exploratory investigations include objectively measured changes in physical fitness assessed by cardiopulmonary exercise test, disease-free and overall mortality at 1-year postoperatively, longer-term physical activity behaviour change, pre-operative radiological tumour regression, pathological tumour regression, pre and post-operative body composition analysis, health economics analysis and nutritional characterisation and its relationship to post-operative outcome. Conclusions: The WesFit trial will be a randomised controlled study investigating whether a high-intensity exercise training programme +/- psychological intervention results in improvements in clinical and patient reported outcomes in patients undergoing major inter-cavity resection of cancer. ClinicalTrials.gov registration: NCT03509428 (26/04/2018).

The effects of neoadjuvant chemoradiotherapy and an in-hospital exercise training programme on physical fitness and quality of life in locally advanced rectal cancer patients: a randomised controlled trial (The EMPOWER Trial)

BACKGROUND

The EMPOWER trial aimed to assess the effects of a 9-week exercise prehabilitation programme on physical fitness compared with a usual care control group. Secondary aims were to investigate the effect of (1) the exercise prehabilitation programme on psychological health; and (2) neoadjuvant chemoradiotherapy (NCRT) on physical fitness and psychological health.

METHODS

Between October 2013 and December 2016, adults with locally advanced rectal cancer undergoing standardised NCRT and surgery were recruited to a multi-centre trial. Patients underwent cardiopulmonary exercise testing (CPET) and completed HRQoL questionnaires (EORTC-QLQ-C30 and EQ-5D-5L) pre-NCRT and post-NCRT (week 0/baseline). At week 0, patients were randomised to exercise prehabilitation or usual care (no intervention). CPET and HRQoL questionnaires were assessed at week 0, 3, 6 and 9, whilst semi-structured interviews were assessed at week 0 and week 9. Changes in oxygen uptake at anaerobic threshold (VO2 at AT (ml kg-1 min-1)) between groups were compared using linear mixed modelling.

RESULTS

Thirty-eight patients were recruited, mean age 64 (10.4) years. Of the 38 patients, 33 were randomised: 16 to usual care and 17 to exercise prehabilitation (26 males and 7 females). Exercise prehabilitation significantly improved VO2 at AT at week 9 compared to the usual care. The change from baseline to week 9, when adjusted for baseline, between the randomised groups was + 2.9 ml kg -1 min -1; (95% CI 0.8 to 5.1), p = 0.011.

CONCLUSION

A 9-week exercise prehabilitation programme significantly improved fitness following NCRT. These findings have informed the WesFit trial (NCT03509428) which is investigating the effects of community-based multimodal prehabilitation before cancer surgery.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01914068 . Registered 1 August 2013.

Perceptions of wellbeing and quality of life following participation in a community-based pre-operative exercise programme in men with newly diagnosed prostate cancer: A qualitative pilot study

Background

Men with a newly diagnosed prostate cancer are often treated by surgery. The time window between cancer diagnosis and surgery causes high levels of uncertainty and stress, which negatively impact quality of life (QoL). We previously reported a larger intervention pilot study which demonstrated that participation in a community-based pre-operative exercise programme significantly improved physical fitness and health-related quality of life in men with prostate cancer prior to surgery. The aim of the current pilot study was to get an insight into men’s perceptions of wellbeing and QoL following completion of the pre-operative exercise programme.

Methods

From November 2017 to June 2018, men scheduled for prostate cancer surgery were recruited and took part in a prescribed community-based pre-operative exercise programme in the time available between referral and surgery. Following completion of the pre-operative exercise programme (within 1 week before surgery), participants took part in one semi-structured interview which explored four broad QoL domains: physical, psychological, social, and spiritual wellbeing. Data were analysed using thematic analysis (a bottom up/inductive analysis).

Results

Eleven men were recruited: mean standard deviation (SD) age was 60 ± 7 years. Data supported four main themes. Participation in the community-based pre-operative exercise training programme (over a mean (SD) of 4 ± 2 weeks) provided participants with: 1) a teachable moment; 2) a journey of preparation; 3) a sense of optimism; and 4) social connectedness prior to surgery.

Conclusion

This study provides an insight into how the exercise programme impacted wellbeing and QoL in men preparing for prostate cancer surgery. These findings highlight the important role that exercise prehabilitation plays for men preparing for prostate cancer surgery. Such exercise programmes can be easily implemented into standard cancer pathways by establishing relationships between hospital teams and community exercise programmes.

What matters to you? An investigation of patients' perspectives on and acceptability of prehabilitation in major cancer surgery

OBJECTIVE

To understand perspectives on and acceptability of prehabilitation among patients undergoing complex abdominal cancer surgery (cytoreductive surgery with or without hyperthermic intraperitoneal chemotherapy).

METHODS

Seventy-nine patients admitted to a Danish colorectal or ovarian cancer centre participated in qualitative semi-structured interviews and/or registered their prehabilitation activities based on preoperative recommendations presented in a leaflet. Malterud's principles of systematic text condensation were used to analyse the interview data, and descriptive statistics were used to describe the activity registrations.

RESULTS

Five domains clarify central aspects of the patients' perspectives on and acceptability of prehabilitation: the preoperative period, attitudes towards prehabilitation, the actual prehabilitation performed, motivation to take action and the need for support.

CONCLUSION

Patients undergoing major abdominal cancer surgery are interested in and positive towards prehabilitation, but it has to be on their terms. The patients need support and supervision, but it has to be provided in a setting and in a way that are in line with the patient's preferences, resources and values. Thus, patient involvement is necessary to create prehabilitation programmes that are feasible and fit into patients' everyday lives.

Feasibility, tolerability, and effects of exercise-based prehabilitation after neoadjuvant therapy in esophagogastric cancer patients undergoing surgery: an interventional pilot study

Patients requiring surgery for locally advanced esophagogastric cancer often require neoadjuvant therapy (NAT), which may have a detrimental impact on cardiorespiratory reserve. The aims of this study were to investigate the feasibility and tolerability of a 5-week preoperative high-intensity interval training program after NAT, and to assess the potential effects of the training protocol on exercise capacity, muscle function, and health-related quality of life (HRQL). We prospectively studied consecutive patients with resectable locally advanced esophageal and gastric cancer in whom NAT was planned (chemo- or chemoradiotherapy). Feasibility was assessed with the TELOS (Technological, Economics, Legal, Operational, and Scheduling) components, and data on exercise tolerability (attendance and occurrence of adverse or unexpected events). Exercise capacity was assessed with peak oxygen uptake (VO2peak) in a cardiopulmonary exercise test at baseline, post-NAT, and following completion of a high-intensity interval exercise training (25 sessions). Changes in muscle strength and HRQL were also assessed. Of 33 recruited subjects (mean age 65 years), 17 received chemoradiotherapy and 16 chemotherapy. All the TELOS components were addressed before starting the intervention; from a total of 17 questions considered as relevant for a successful implementation, seven required specific actions to prevent potential concerns. Patients attended a mean of 19.4 (6.4) exercise sessions. The predefined level of attendance (≥15 sessions of scheduled sessions) was achieved in 27 out of 33 (81.8%) patients. Workload progression was adequate in 24 patients (72.7%). No major adverse events occurred. VO2peak decreased significantly between baseline and post-NAT (19.3 vs. 15.5 mL/Kg/min, P < 0.05). Exercise led to a significant improvement of VO2peak (15.5 vs. 19.6 mL/kg/min, P < 0.05). Exercise training was associated with clinically relevant improvements in some domains of HRQL, with the social and role function increasing by 10.5 and 11.6 points, respectively, and appetite loss and fatigue declining by 16 and 10.5, respectively. We conclude that a structured exercise training intervention is feasible and safe following NAT in patients with esophagogastric cancer, and it has positive effects to restore exercise capacity to baseline levels within 5 weeks with some improvements in HRQL.

The Role of Behavioral Science in Personalized Multimodal Prehabilitation in Cancer

Multimodal prehabilitation is increasingly recognized as an important component of the pre-operative pathway in oncology. It aims to optimize physical and psychological health through delivery of a series of tailored interventions including exercise, nutrition, and psychological support. At the core of this prescription is a need for considerable health behavior change, to ensure that patients are engaged with and adhere to these interventions and experience the associated benefits. To date the prehabilitation literature has focused on testing the efficacy of devised exercise and nutritional interventions with a primary focus on physiological and mechanistic outcomes with little consideration for the role of behavioral science, supporting individual behavior change or optimizing patient engagement. Changing health behavior is complex and to maximize success, prehabilitation programs should draw on latest insights from the field of behavioral science. Behavioral science offers extensive knowledge on theories and models of health behavior change to further advance intervention effectiveness. Similarly, interventions developed with a person-centered approach, taking into consideration individual needs and preferences will increase engagement. In this article, we will provide an overview of the extent to which the existing prehabilitation literature incorporates behavioral science, as well as studies that have explored patient's attitudes toward prehabilitation. We will go on to describe and critique ongoing trials in a variety of contexts within oncology prehabilitation and discuss how current scientific knowledge may be enhanced from a behavioral science perspective. We will also consider the role of “surgery schools” and detail practical recommendations that can be embedded in existing or emerging clinical settings.

Older patients' attitudes towards, and perceptions of, preoperative physical activity and exercise prior to colorectal cancer surgery-a gap between awareness and action

Purpose

Time for preoperative optimisation prior to colorectal cancer surgery is limited and older people tend to decline exercise interventions. This study sought to describe attitudes towards, and perceptions of, preoperative physical activity and exercise in older people prior to colorectal cancer surgery.

Methods

This is a qualitative interview study, analysed with inductive content analysis. Seventeen participants scheduled for colorectal surgery were recruited as a purposeful sample from two hospitals in Stockholm, Sweden. Individual semi-structured interviews were conducted, face-to-face (n = 8) or by telephone (n = 9).

Results

Nine participants were male, median age was 75 years (range 70–91). The theme, ‘a gap between awareness and action’, was identified based on two main categories: ‘Attitudes towards preoperative physical exercise have a multifactorial base’ and ‘Preoperative physical exercise is possible with a push in the right direction’. The material described a gap between awareness of the benefits of physical activity and reports of performing physical activity. The reasons for the gap between thoughts and action in this respect seem to be multifactorial. Support from others emerged as an important possibility for overcoming the gap.

Conclusions

A gap between the patients’ awareness and action appeared in our material. Understanding this can guide healthcare professionals (HCPs) as to the support needed preoperatively. Advice on physical exercise before surgery should be specific, and individually tailored support for action should be offered. This support should also consider the individual’s current physical activity and preoperative attitude towards physical exercise.

Investigating How Bowel Cancer Survivors Discuss Exercise and Physical Activity Within Web-Based Discussion Forums: Qualitative Analysis

Background

Online cancer support group discussions enable patients to share their illness experience with others. The sharing of technical and emotional support information and the ability to ask for advice are some of the primary discussions shared online. People with bowel cancer can also use these forums to support each other by sharing information based on personal experiences. This type of support provides newly diagnosed patients with advice about several topics, including exercise from those who have been there. Information gathered from online discussion boards may complement the advice received by health professionals.

Objective

This study aimed to explore the nature of information related to exercise and physical activity exchanged online for cancer survivors.

Methods

A public open access bowel cancer discussion board was searched for threads containing information related to physical activity or exercise. Keywords such as exercise, physical activity, moving, walking, lifting, weights training, and resistance were used to search for threads (online conversations) related to exercise or physical activity. Only threads initiated by bowel cancer patients or survivors were included. From more than 6000 posts, the inclusion criteria yielded 75 threads for analysis. Inductive thematic analysis was conducted across all included threads.

Results

Analysis yielded 3 main themes: level of exercise competence, beneficial dimensions of exercise, and faith in the knowledge. Level of exercise competence illustrated the varying definitions of exercise that members of the forum discussed in the forum. Beneficial dimensions of exercise revealed that forum members shared both the spiritual benefits associated with exercise as well as the physical benefits or goodness that they feel exercise or physical activity provides them. Faith in the knowledge of exercise demonstrated that forum members were aware of the general benefits of exercise but felt disappointed that it did not keep the cancer at bay. However, members also had faith that exercise would keep them healthy after diagnosis and treatment.

Conclusions

The analysis revealed that people with bowel cancer discuss exercise and physical activity online and that they view exercise as having a mostly positive influence on their cancer journey. However, personal definitions of exercise became a source of conflict within the group. People with bowel cancer seeking information about exercise may benefit from participating in online support groups as it appears that there are many similar others willing to share their personal experiences with exercise. In addition, health care professionals responsible for caring for people with bowel cancer may use these findings to discuss exercise with their patients while being mindful of how they may view exercise.

Feasibility of a novel exercise prehabilitation programme in patients scheduled for elective colorectal surgery: a feasibility randomised controlled trial

Background and objectives

To investigate the feasibility of delivering a functional exercise-based prehabilitation intervention and its effects on postoperative length of hospital stay, preoperative physical functioning and health-related quality of life in elective colorectal surgery.

Materials and methods

In this randomised controlled feasibility trial, 22 elective colorectal surgery patients were randomly assigned to exercise prehabilitation (n = 11) or standard care (n = 11). Feasibility of delivering the intervention was assessed based on recruitment and compliance to the intervention. Impact on postoperative length of hospital stay and complications, preoperative physical functioning (timed up and go test, five times sit to stand, stair climb test, handgrip dynamometry and 6-min walk test) and health-related quality of life were also assessed.

Results

Over 42% of patients (84/198) screened were deemed ineligible for prehabilitation due to insufficient time existing prior to scheduled surgery. Of those who were eligible, approximately 18% consented to the trial. Median length of hospital stay was 8 [range 6–27] and 10 [range 5–12] days respectively for the standard care and prehabilitation groups. Patterns towards preoperative improvements for the timed up and go test, stair climb test and 6-min walk test were observed for all participants receiving prehabilitation but not standard care.

Conclusions

Despite prehabilitation appearing to convey positive benefits on physical functioning, short surgical wait times and patient engagement represent major obstacles to implementing exercise prehabilitation programmes in colorectal cancer patients.

Electronic supplementary material

The online version of this article (10.1007/s00520-019-05098-0) contains supplementary material, which is available to authorized users.

[Preconditioning prior to visceral oncological surgery : A paradigm shift in visceral surgery?]

BACKGROUND

Postoperative complications after complex visceral oncological surgery can lead to substantial impairment of patients. In addition, preoperative physical performance and the severity of postoperative complications determine the long-term recovery process of physical function. Therefore, preconditioning in the preoperative period should be an important part of the preoperative/neoadjuvant treatment.

OBJECTIVE

The aim of this article is a critical appraisal of current concepts of prehabilitation as well as their development potential and applicability in visceral surgery.

MATERIAL AND METHODS

Based on a selective literature review, current studies and implemented concepts are presented and therapy algorithms are provided.

RESULTS

This study differs in primary outcome, design and temporal framework of the intervention. The study results showed positive effects of an active increase in physical fitness in the preoperative period with respect to the quality of life, convalescence and postoperative pulmonary complication rate.

DISCUSSION

In addition to the assessment of the individual risk of complications by means of spiroergometry, a targeted nutrition and exercise program can increase the individual performance level prior to visceral surgery and, thus, influence the postoperative risk of complications. The performance should be understood as a modifiable risk factor, which can also be positively influenced in the preoperative phase, even in a short time period. Individual preoperative care optimizes the physical and psychological situation of patients. To ensure the required individual care, approaches must be created and pursued, which can be implemented in a decentralized way.

How Does a Supervised Exercise Program Improve Quality of Life in Patients with Cancer? A Concept Mapping Study Examining Patients' Perspectives

BACKGROUND

Previous systematic reviews and meta-analyses demonstrated beneficial effects of exercise during or following cancer treatment on quality of life (QoL). Aiming to understand how exercise contributes to a patient's QoL, we examined patients' perspectives via a process called concept mapping. This unique method provides structure and objectivity to rich qualitative data.

METHODS

Patients with cancer who were participating in an exercise program were invited to enroll. Eleven meetings with 3-10 patients were organized in which patients generated ideas in response to the question "How has participating in a supervised exercise program contributed positively to your QoL?" Next, patients individually clustered (based on similarity) and rated (based on importance) the ideas online. The online assessments were combined, and one concept map was created, visualizing clusters of ideas of how patients perceive that participating in a supervised exercise program improved their QoL. The research team labelled the clusters of ideas, and physiotherapists reflected on the clusters during semistructured interviews.

RESULTS

Sixty patients attended the meetings; of these, one patient was not able to generate an idea in response to the statement. Forty-four patients completed the online clustering and rating of ideas. The resulting concept map yielded six clusters: personalized care, coaching by a physiotherapist, social environment, self-concept, coping, and physical fitness and health. Personalized care was rated as most important. Overall, physiotherapists recognized these clusters in practice.

CONCLUSION

Patients with cancer reported that participating in a supervised exercise program improved their physical fitness and influenced social, mental, and cognitive factors, resulting in improvements in QoL. These results can be used to increase the awareness of the importance of supervised exercise programs for the QoL of patients with cancer.

IMPLICATIONS FOR PRACTICE

According to patients, a supervised exercise program contributes positively to their quality of life by improving physical fitness and health and providing personalized care, coaching by a physiotherapist, and improved social environment, self-concept, and coping. This knowledge could help to increase physicians' and patients' awareness of the importance of an exercise program during or following cancer treatment, possibly improving referral, participation, and adherence rates to these programs. Furthermore, patients' perspectives may be used to improve supervised exercise programs, taking into account the importance of personalized care, the supervision of a physiotherapist, the social environment, self-concept, and coping.

Evaluation of a physiatrist-directed prehabilitation intervention in frail patients with colorectal cancer: a randomised pilot study protocol

INTRODUCTION

Prehabilitation interventions have shown efficacy in the orthopaedic and cardiothoracic surgical populations, but there has been limited evidence for general surgical patients. We present the protocol for a pilot trial of a novel prehabilitation intervention, consisting of a physiatrist-directed preoperative assessment and treatment programme.

METHODS AND ANALYSIS

This is a single-centre pilot randomised controlled trial investigating physiatrist-directed prehabilitation for a 4 to 6-week preoperative period. We will block randomise 40-50 participants awaiting surgery for colorectal cancer to prehabilitation versus control. Participants in the prehabilitation arm will undergo assessment by a physiatrist and enrol in a supervised exercise programme. The control group will not undergo any prehabilitation interventions in the preoperative period. Our primary outcome is feasibility, measured by examining recruitment, refusal, retention and adherence rates as well as participant satisfaction and feedback. Secondary outcomes include physical fitness, functional ability, health-related quality of life, postoperative complications, mortality, readmissions, length of stay, prehabilitation interventions performed and exercise complications.

ETHICS AND DISSEMINATION

This study has been approved by the Hamilton Integrated Research Ethics Board (HIREB reference number 2015-0090-GRA). The results of this pilot study will be used to design a full-scale study and published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT02531620; Pre-results.

Physical Activity and Quality of Life in Cancer Survivors: A Meta-Synthesis of Qualitative Research

Qualitative research on the impact of physical activity on quality of life (QoL) in adults diagnosed with cancer is accumulating. However, the field of physical activity and cancer survivorship lack a synthesis of this research to reliably understand the implications for future research and practice. The aim of this meta-synthesis was to identify, appraise, and synthesize qualitative research on cancer survivors’ perspectives of the impact of physical activity on their QoL. Seven electronic databases were searched for original studies published in English, and reference lists of relevant studies were hand-searched to identify additional studies. Forty studies met eligibility criteria and were included in this meta-synthesis. Study characteristics and major findings were extracted, and findings were summarized, compared, and synthesized. Themes identified in this review revealed that physical activity positively impacted four dimensions of cancer survivors’ QoL: physical (e.g., managing the physical consequences of cancer and its treatment), psychological (e.g., evoking positive self-perceptions), social (e.g., feeling understood by others), and spiritual (e.g., redefining life purpose). This meta-synthesis corroborates conclusions from reviews of quantitative research and illustrates that physical activity can be used to improve QoL in adult cancer survivors, regardless of diagnosis (i.e., stage, cancer type) and treatment status. It also provides detailed insight into specific aspects within each dimension of QoL impacted by physical activity from cancer survivors’ perspectives, which is important for understanding the meaning and utility of physical activity for them. However, more research is needed to further develop the qualitative evidence base in order to better understand how physical activity impacts on QoL experiences in men, young adults, and adults diagnosed with less common types of cancer at different points along cancer trajectory (i.e., diagnosis, treatment, post-treatment, palliation).

The effects of neoadjuvant chemoradiotherapy and an in-hospital exercise training programme on physical fitness and quality of life in locally advanced rectal cancer patients (The EMPOWER Trial): study protocol for a randomised controlled trial

BACKGROUND

The standard treatment pathway for locally advanced rectal cancer is neoadjuvant chemoradiotherapy (CRT) followed by surgery. Neoadjuvant CRT has been shown to decrease physical fitness, and this decrease is associated with increased post-operative morbidity. Exercise training can stimulate skeletal muscle adaptations such as increased mitochondrial content and improved oxygen uptake capacity, both of which are contributors to physical fitness. The aims of the EMPOWER trial are to assess the effects of neoadjuvant CRT and an in-hospital exercise training programme on physical fitness, health-related quality of life (HRQoL), and physical activity levels, as well as post-operative morbidity and cancer staging.

METHODS/DESIGN

The EMPOWER Trial is a randomised controlled trial with a planned recruitment of 46 patients with locally advanced rectal cancer and who are undergoing neoadjuvant CRT and surgery. Following completion of the neoadjuvant CRT (week 0) prior to surgery, patients are randomised to an in-hospital exercise training programme (aerobic interval training for 6 to 9 weeks) or a usual care control group (usual care and no formal exercise training). The primary endpoint is oxygen uptake at lactate threshold ([Formula: see text] at [Formula: see text]) measured using cardiopulmonary exercise testing assessed over several time points throughout the study. Secondary endpoints include HRQoL, assessed using semi-structured interviews and questionnaires, and physical activity levels assessed using activity monitors. Exploratory endpoints include post-operative morbidity, assessed using the Post-Operative Morbidity Survey (POMS), and cancer staging, assessed by using magnetic resonance tumour regression grading.

DISCUSSION

The EMPOWER trial is the first randomised controlled trial comparing an in-hospital exercise training group with a usual care control group in patients with locally advanced rectal cancer. This trial will allow us to determine whether exercise training following neoadjuvant CRT can improve physical fitness and activity levels, as well as other important clinical outcome measures such as HRQoL and post-operative morbidity. These results will aid the design of a large, multi-centre trial to determine whether an increase in physical fitness improves clinically relevant post-operative outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01914068 (received: 7 June 2013).

SPONSOR

University Hospital Southampton NHS Foundation Trust.

Systematic review of pre-operative exercise in colorectal cancer patients

The aim of this systematic review was to evaluate the evidence for exercise interventions prior to surgery for colorectal cancer resection. The evidence for use of exercise to improve physical fitness and surgical outcomes is as yet unknown. A systematic search was performed of MEDLINE, EMBASE, CINAHL, AMED and BNI databases for studies involving pre-operative exercise in colorectal cancer patients. Eight studies were included in the review. There is evidence that pre-operative exercise improves functional fitness, and to a lesser extent objectively measurable cardio-respiratory fitness prior to colorectal cancer resection. There is no clear evidence at present that this improvement in fitness translates into reduced peri-operative risk or improved post-operative outcomes. Current studies are limited by risk of bias. This review highlights the common difficulty in transferring promising results in a research setting, into significant improvements in the clinical arena. Future research should focus on which type of exercise is most likely to maximise patient adherence and improvements in cardio-respiratory fitness. Ultimately, adequately powered, randomised controlled trials are needed to investigate whether pre-operative exercise improves post-operative morbidity and mortality.

Exercise intervention in people with cancer undergoing neoadjuvant cancer treatment and surgery: A systematic review

BACKGROUND

Neoadjuvant cancer treatment decreases physical fitness. Low levels of physical fitness are associated with poor surgical outcome. Exercise training can stimulate skeletal muscle adaptations, such as increased mitochondrial content and improved oxygen uptake capacity that may contribute to improving physical fitness. This systematic review evaluates the evidence in support of exercise training in people with cancer undergoing the "dual hit" of neoadjuvant cancer treatment and surgery.

METHODS

We conducted a systematic database search of Embase Ovid, Ovid Medline without Revisions, SPORTDiscus, Web of Science, Cochrane Central Register of Controlled Trials Library and ClinicalTrials.gov to identify trials addressing the effect of exercise training in people scheduled for neoadjuvant cancer treatment and surgery. Data extraction and analysis were based on a pre-defined plan.

RESULTS

The database search yielded 6489 candidate abstracts. Ninety-four references included the required terms. Four studies were eligible for inclusion (breast cancer, locally advanced rectal cancer). All studies reported that exercise training was safe and feasible and that adherence rates were acceptable (66-96%). In-hospital exercise training improves physical fitness however the impact on HRQoL and other clinical important outcomes was uncertain.

CONCLUSION

This is the first systematic review of the effects of exercise training in people scheduled for "dual-hit" treatment. This evidence synthesis indicates that this approach is safe and feasible but that there are insufficient controlled trials in this area to draw reliable conclusions about the efficacy of such an intervention, the optimal characteristics of the intervention, or the impact on clinical or patient reported outcomes.

Improving Spiritual Well-Being in Patients with Lung Cancers

Patients with lung cancer report more disease burden and lower spiritual well-being (SWB) compared with other cancer patients. Understanding variables that lessen disease burden and improve SWB is essential. The aim of this study was to explore the relationship between motivational level for physical activity and SWB in patients with lung cancer. Linear regression showed increased SWB as stage of change for physical activity increased (p < 0.0001), even after adjusting for multiple demographic variables.

Cancer survivors' experience of exercise-based cancer rehabilitation - a meta-synthesis of qualitative research

BACKGROUND

Evidence for the safety and benefits of exercise training as a therapeutic and rehabilitative intervention for cancer survivors is accumulating. However, whereas the evidence for the efficacy of exercise training has been established in several meta-analyses, synthesis of qualitative research is lacking. In order to extend healthcare professionals' understanding of the meaningfulness of exercise in cancer survivorship care, this paper aims to identify, appraise and synthesize qualitative studies on cancer survivors' experience of participation in exercise-based rehabilitation.

MATERIAL AND METHODS

Five electronic databases (PubMed, PsychINFO, EMBASE, Cinahl and Scopus) were searched systematically for articles published up to May 2014 using keywords and MeSH terms. To be included, studies had to contain primary data pertaining to patient experiences from participation in supervised, structured moderate to vigorous-intensity exercise.

RESULTS

In total 2447 abstracts were screened and 37 papers were read in full. Of these, 19 studies (n = 390) were selected for inclusion and critically appraised. Synthesis of data extracted from eight studies including in total 174 patients (77% women, age 28-76 years) exclusively reporting experiences of participation in structured, supervised exercise training resulted in nine themes condensed into three categories: 1) emergence of continuity; 2) preservation of health; and 3) reclaiming the body reflecting the benefits of exercise-based rehabilitation according to cancer survivors. Accordingly, the potential of rebuilding structure in everyday life, creating a normal context and enabling the individual to re-establish confidentiality and trust in their own body and physical potential constitute substantial qualities fundamental to the understanding of the meaningfulness of exercise-based rehabilitation from the perspective of patients.

CONCLUSIONS

In addition to the accumulating evidence for the efficacy of exercise training in cancer rehabilitation, it is incumbent upon clinicians and policy-makers to acknowledge and promote the meaningfulness of exercise for the individual, and to use this knowledge to provide new solutions to current problems related to recruitment of underserved populations, long-term adherence and implementation.