Effects of preoperative combined aerobic and resistance exercise training in cancer patients undergoing tumour resection surgery: A systematic review of randomised trials

The Physical Activity and Cancer Control (PACC) framework: update on the evidence, guidelines, and future research priorities

BACKGROUND

We proposed the Physical Activity and Cancer Control (PACC) framework in 2007 to help organise, focus, and stimulate research on physical activity in eight cancer control categories: prevention, detection, treatment preparation/coping, treatment coping/effectiveness, recovery/rehabilitation, disease prevention/health promotion, palliation, and survival.

METHODS

This perspective paper provides a high-level overview of the scientific advances in physical activity research across cancer control categories, summarises current guidelines, updates the PACC framework, identifies remaining and emerging knowledge gaps, and provides future research directions.

RESULTS

Many scientific advances have been made that are reflected in updated physical activity guidelines for six of the cancer control categories apart from detection and palliation. Nevertheless, the minimal and optimal type, dose, and timing of physical activity across cancer control categories remain unknown, especially for the understudied population subgroups defined by cancer type, age, race/ethnicity, and resource level of regions/countries.

CONCLUSION

To achieve the full benefit of physical activity in cancer control, future research should use innovative study designs that include diverse at-risk populations and understudied cancer sites. Additionally, effective behaviour change strategies are needed to increase physical activity levels across populations that use implementation science to accelerate the translation from evidence generation into practical, real-world interventions.

[Preoperative evaluation of adult patients before elective, non-cardiothoracic surgery : A joint recommendation of the German Society for Anesthesiology and Intensive Care Medicine, the German Society for Surgery and the German Society for Internal Medicine]

The 70 recommendations summarize the current status of preoperative risk evaluation of adult patients prior to elective non-cardiothoracic surgery. Based on the joint publications of the German scientific societies for anesthesiology and intensive care medicine (DGAI), surgery (DGCH), and internal medicine (DGIM), which were first published in 2010 and updated in 2017, as well as the European guideline on preoperative cardiac risk evaluation published in 2022, a comprehensive re-evaluation of the recommendation takes place, taking into account new findings, the current literature, and current guidelines of international professional societies. The revised multidisciplinary recommendation is intended to facilitate a structured and common approach to the preoperative evaluation of patients. The aim is to ensure individualized preparation for the patient prior to surgery and thus to increase patient safety. Taking into account intervention- and patient-specific factors, which are indispensable in the preoperative risk evaluation, the perioperative risk for the patient should be minimized and safety increased. The recommendations for action are summarized under "General Principles (A)," "Advanced Diagnostics (B)," and the "Preoperative Management of Continuous Medication (C)." For the first time, a rating of the individual measures with regard to their clinical relevance has been given in the present recommendation. A joint and transparent agreement is intended to ensure a high level of patient orientation while avoiding unnecessary preliminary examinations, to shorten preoperative examination procedures, and ultimately to save costs. The joint recommendation of DGAI, DGCH and DGIM reflects the current state of knowledge as well as the opinion of experts. The recommendation does not replace the individualized decision between patient and physician about the best preoperative strategy and treatment.

Physical activity for cancer prehabilitation: A scoping review

This scoping review aims to synthesize the current landscape of physical activity in cancer prehabilitation and identify knowledge gaps. We searched MEDLINE, EMBASE, SCOPUS and WEB OF SCIENCE for exercise interventions and observational studies that measured exercise or physical activity before cancer treatment from inception to January 20, 2023. Fifty-one articles from 44 unique studies were reviewed, including 32 intervention and 12 observational studies. Surgery is the only treatment modality that has been investigated. Included studies used heterogeneous exercise interventions and measures for physical activity. Colorectal and other gastrointestinal, lung, and urologic cancers are the most studied cancer types. Exercise intervention in cancer prehabilitation is highly feasible. The evidence for improved fitness, functional, psychosocial, and clinical outcomes is promising yet limited. Although research has increased recently, prehabilitation exercise remains a relatively under-investigated area in oncology. We have provided research directions towards an ideal cancer prehabilitation design in the real-world setting.

Health Behavior Change Intervention Preferences Expressed by American Indian Cancer Survivors From a Southwest Tribal Community: Semistructured Interview Study

BACKGROUND

While many factors, including social determinants of health, affect cancer mortality, one modifiable risk factor that may contribute to cancer disparities is obesity. The prevalence of obesity in the American Indian/Alaska Native population is 48.1% per the Centers for Disease Control and Prevention. The overall cancer mortality for the American Indian/Alaska Native population is 18% higher than the White population as reported by the American Cancer Society. Interventions tailored to American Indian/Alaska Native communities that promote healthy lifestyle behaviors after cancer diagnosis and prior to cancer surgery (prehab) might improve cancer outcomes for this population.

OBJECTIVE

The aim of the study is to characterize the lifestyle behaviors of San Carlos Apache cancer survivors and identify preferences for the adaption of a prehab intervention.

METHODS

Semistructured interviews and validated questionnaires were completed with San Carlos Apache cancer survivors (N=4), exploring their viewpoints on healthy lifestyle and cancer risk and preferences for program development. A thematic content analysis was conducted.

RESULTS

Participants had an average BMI of 31 kg/m2 and walked 53 minutes daily. The majority of participants reported a high willingness to change eating habits (n=3, 75%). All 4 reported willingness to participate in a diet and exercise program. Important themes and subthemes were identified: (1) cancer is perceived as a serious health condition in the community (N=4, 100%); (2) environmental exposures are perceived as cancer-causing threats (n=3, 75%); (3) healthy diet, exercise, and avoiding harmful substances are perceived as mitigating cancer risk (n=3, 75%); (4) barriers to healthy habits include distance to affordable groceries (n=3, 75%) and lack of transportation (n=2, 50%); (5) there is high interest in a prehab program geared toward patients with cancer (N=4, 100%); and (6) standard monitoring practiced in published prehab programs showed early acceptability with participants (N=4, 100%).

CONCLUSIONS

Collaboration with tribal partners provided important insight that can help inform the adaptation of a culturally appropriate prehab program for San Carlos Apache patients diagnosed with cancer.

[Exercise-Based Prehabilitation In Orthopaedics, Cardiology And Oncology]

Prehabilitation (prehab) aims to prepare patients for surgery, to reduce perioperative complications and to improve postoperative recovery. Pre-operative interventions depend on the indication and the specific patient characteristics and life circumstances. In orthopaedics, the focus is on preoperative improvement of physical performance, function and muscle strength through specific strength, mobility and sensomotoric training. In cardiology, endurance training and respiratory therapy are used in the preoperative phase, as well as coordination and strengthening exercises and occupational therapy to improve physical fitness and performance and reduce cardiovascular risk factors. In oncology, prehab is used preoperatively and also in addition to chemotherapy or radiotherapy to reduce medical side effects and to increase tolerance to cancer therapies (e. g. surgery, chemotherapy, radiotherapy). Exercise interventions in oncology differ according to the type of cancer (e. g. combined strength and endurance training, respiratory therapy, high-intensity interval training and walking). Study results often show positive effects on health resources using prehab. However, further high-quality clinical intervention studies are needed to confirm the clinical benefits of prehab for implementation in routine care.

Preparing for and Not Waiting for Surgery

Cancer surgery is an essential treatment strategy but can disrupt patients' physical and psychological health. With worldwide demand for surgery expected to increase, this review aims to raise awareness of this global public health concern, present a stepwise framework for preoperative risk evaluation, and propose the adoption of personalised prehabilitation to mitigate risk. Perioperative medicine is a growing speciality that aims to improve clinical outcome by preparing patients for the stress associated with surgery. Preparation should begin at contemplation of surgery, with universal screening for established risk factors, physical fitness, nutritional status, psychological health, and, where applicable, frailty and cognitive function. Patients at risk should undergo a formal assessment with a qualified healthcare professional which informs meaningful shared decision-making discussion and personalised prehabilitation prescription incorporating, where indicated, exercise, nutrition, psychological support, 'surgery schools', and referral to existing local services. The foundational principles of prehabilitation can be adapted to local context, culture, and population. Clinical services should be co-designed with all stakeholders, including patient representatives, and require careful mapping of patient pathways and use of multi-disciplinary professional input. Future research should optimise prehabilitation interventions, adopting standardised outcome measures and robust health economic evaluation.

Exercise and Nutrition Interventions for Prehabilitation in Hepato-Pancreato-Biliary Cancers: A Narrative Review

Gastrointestinal (GI) cancers constitute over 25% of global cancer cases annually, with hepato-pancreato-biliary (HPB) cancers presenting particularly poor prognosis and challenging surgical treatments. While advancements in clinical care have improved post-operative outcomes over time, surgery for HPB cancers remains associated with high morbidity and mortality rates. Patients with HPB cancer are often older, diagnosed at later stages, and have a higher prevalence of co-morbid conditions, leading to reduced life expectancy, suboptimal post-operative recovery, and increased recurrence risk. Exercise and nutrition interventions have emerged as safe non-pharmacological strategies to enhance clinical outcomes among cancer survivors, but their potential in the pre-operative period for patients with HPB cancer remains underexplored. This narrative review evaluates existing evidence on exercise and nutritional interventions during pre-operative prehabilitation for HPB cancer populations, focusing on clinically relevant post-operative outcomes related to frailty and malnutrition. We conducted a literature search in PubMed and Google Scholar databases to identify studies utilizing a prehabilitation intervention in HPB cancer populations with exercise and nutritional components. The currently available evidence suggests that incorporating exercise and nutrition into prehabilitation programs offers a critical opportunity to enhance post-operative outcomes, mitigate the risk of comorbidities, and support overall survivorship among HPB cancer populations. This review underscores the need for further research to optimize the timing, duration, and components of pre-operative prehabilitation programs, emphasizing patient-centered, multidisciplinary approaches in this evolving field.

Prehabilitation programs for individuals with cancer: a systematic review of randomized-controlled trials

BACKGROUND

Prehabilitation programs focusing on exercise training as the main component are known as a promising alternative for improving patients' outcomes before cancer surgery. This systematic review determined the benefits and harms of prehabilitation programs compared with usual care for individuals with cancer.

METHODS

We searched CENTRAL, MEDLINE, and EMBASE from inception to June 2022, and hand searched clinical trial registries. We included randomized-controlled trials (RCTs) in adults, survivors of any type of cancer, that compared prehabilitation programs that had exercise training as the major component with usual care or other active interventions. Outcome measures were health-related quality of life (HRQL), muscular strength, postoperative complications, average length of stay (ALOS), handgrip strength, and physical activity levels. Two reviewers independently screened the studies, extracted data, and assessed the risk of bias and the certainty of the evidence.

RESULTS

Twenty-five RCTs (2682 participants) published between 2010 and 2022 met our inclusion criteria. Colorectal and lung cancers were the most common diagnoses. The studies had methodological concerns regarding outcome measurement, selective reporting, and attrition. Five prehabilitation programs were compared to usual care (rehabilitation): combined training, aerobic training, respiratory muscle training plus aerobic training, respiratory muscle training plus resistance training, and pelvic floor training. The studies provided no clear evidence of an effect between groups. We assessed the overall certainty of the evidence as very low, downgraded due to serious study limitations and imprecision.

CONCLUSION

Prehabilitation programs focusing on exercise training may have an effect on adults with cancer, but the evidence is very uncertain. We have very little confidence in the results and the true effect is likely to be substantially different from these. Further research is needed before we can draw a more certain conclusion.

SYSTEMATIC REVIEW REGISTRATION

CRD42019125658.

Prehabilitation: a narrative review focused on exercise therapy for the prevention of postoperative pulmonary complications following lung resection

Extensive preventive strategies in the perioperative period are popular worldwide. Novel "prehabilitation" approaches are being defined for every individual surgical discipline. With intention to reduce perioperative morbidity, "prehabilitation" was developed to increase "physical wellness" considering exercise capacity, nutritional status, and psychological support. Thus, prehabilitation could be well-suited for patients undergoing lung cancer surgery. Theoretically, improving physical condition may increase the chances of having a better post-operative course, especially among frail patients. In this review, we describe the concept of prehabilitation with possible benefits, its role in the Enhanced Recovery After Surgery protocols, and its potential for the future.

[Exercise therapy in prehabilitation : Current findings in urology]

BACKGROUND

Prehabilitation refers to interventions that take place before starting medical treatment. Prehabilitation exercise therapy aims to increase functional physical capacities to improve recovery and reduce side effects.

OBJECTIVES

To present the evidence and potential of prehabilitation exercise therapy in urological oncology.

METHODS

Compilation and explanation of study results.

RESULTS

Studies are limited and primarily focused on prostate and bladder cancer. Current data show positive effects on physical functioning and cardiorespiratory capacity. The majority of prehabilitation studies in prostate cancer focus on specific goals of physical functioning, particularly maintenance and recovery of urinary continence with inconsistent results.

CONCLUSIONS

There is preliminary evidence to improve cardiorespiratory fitness and overall physical functioning in urinary bladder and prostate cancer. Further in-depth research is needed to map the potential spectrum of prehabilitation exercise therapy in uro-oncology.

Prehabilitation in the lung cancer pathway: a scoping review

BACKGROUND

Lung cancer is the third most common type of cancer in the UK. Treatment outcomes are poor and UK deaths from lung cancer are higher than any other cancer. Prehabilitation has shown to be an important means of preparing patients both physically and psychologically for cancer treatment. However, little is understood about the context and mechanisms of prehabilitation that can impact physiological and psychological wellbeing. Our aim was to review and summarise primary research on prehabilitation in the lung cancer pathway using a realist approach.

METHODS

A scoping review of empirical primary research was conducted. Five online medical databases from 2016 - February 2023 were searched. All articles reporting on prehabilitation in lung cancer were included in the review. For this review, prehabilitation was defined as either a uni-modal or multi-modal intervention including exercise, nutrition and/or psychosocial support within a home, community or hospital based setting. A realist framework of context, mechanism and outcome was used to assist with the interpretation of findings.

RESULTS

In total, 31 studies were included in the review, of which, three were published study protocols. Over 95% of studies featured an exercise component as part of a prehabilitation programme. Twenty-six of the studies had a surgical focus. Only two studies reported using theory to underpin the design of this complex intervention. There was large heterogeneity across all studies as well as a lack of clinical trials to provide definitive evidence on the programme design, setting, type of intervention, patient criteria, delivery, duration and outcome measures used.

CONCLUSION

A standardised prehabilitation programme for lung cancer patients does not yet exist. Future lung cancer prehabilitation programmes should take into account patient led values, needs, goals, support structures and beliefs, as these factors can affect the delivery and engagement of interventions. Future research should consider using a conceptual framework to conceptualise the living with and beyond cancer experience to help shape and inform personalised prehabilitation services.

Prehabilitation versus no prehabilitation to improve functional capacity, reduce postoperative complications and improve quality of life in colorectal cancer surgery

BACKGROUND

Surgery is the cornerstone in curative treatment of colorectal cancer. Unfortunately, surgery itself can adversely affect patient health. 'Enhanced Recovery After Surgery' programmes, which include multimodal interventions, have improved patient outcomes substantially. However, these are mainly applied peri- and postoperatively. Multimodal prehabilitation includes multiple preoperative interventions to prepare patients for surgery with the aim of increasing resilience, thereby improving postoperative outcomes.

OBJECTIVES

To determine the effects of multimodal prehabilitation programmes on functional capacity, postoperative complications, and quality of life in adult patients undergoing surgery for colorectal cancer.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and PsycINFO in January 2021. We also searched trial registries up to March 2021.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) in adult patients with non-metastatic colorectal cancer, scheduled for surgery, comparing multimodal prehabilitation programmes (defined as comprising at least two preoperative interventions) with no prehabilitation. We focused on the following outcomes: functional capacity (i.e. 6-minute walk test, VO2peak, handgrip strength), postoperative outcomes (i.e. complications, mortality, length of hospital stay, emergency department visits, re-admissions), health-related quality of life, compliance, safety of prehabilitation, and return to normal activities.

DATA COLLECTION AND ANALYSIS

Two authors independently selected studies, extracted data, assessed risk of bias and used GRADE to assess the certainty of the evidence. Any disagreements were solved with discussion and consensus. We pooled data to perform meta-analyses, where possible.

MAIN RESULTS

We included three RCTs that enrolled 250 participants with non-metastatic colorectal cancer, scheduled for elective (mainly laparoscopic) surgery. Included trials were conducted in tertiary care centres and recruited patients during periods ranging from 17 months to 45 months. A total of 130 participants enrolled in a preoperative four-week trimodal prehabilitation programme consisting of exercise, nutritional intervention, and anxiety reduction techniques. Outcomes of these participants were compared to those of 120 participants who started an identical but postoperative programme. Postoperatively, prehabilitation may improve functional capacity, determined with the 6-minute walk test at four and eight weeks (mean difference (MD) 26.02, 95% confidence interval (CI) -13.81 to 65.85; 2 studies; n = 131; and MD 26.58, 95% CI -8.88 to 62.04; 2 studies; n = 140); however, the certainty of evidence is low and very low, respectively, due to serious risk of bias, imprecision, and inconsistency. After prehabilitation, the functional capacity before surgery improved, with a clinically relevant mean difference of 24.91 metres (95% CI 11.24 to 38.57; 3 studies; n = 225). The certainty of evidence was moderate due to downgrading for serious risk of bias. The effects of prehabilitation on the number of complications (RR 0.95, 95% CI 0.70 to 1.29; 3 studies; n = 250), emergency department visits (RR 0.72, 95% CI 0.39 to 1.32; 3 studies; n = 250) and re-admissions (RR 1.20, 95% CI 0.54 to 2.65; 3 studies; n = 250) were small or even trivial. The certainty of evidence was low due to downgrading for serious risk of bias and imprecision. The effects on VO2peak, handgrip strength, length of hospital stay, mortality rate, health-related quality of life, return to normal activities, safety of the programme, and compliance rate could not be analysed quantitatively due to missing or insufficient data. The included studies did not report a difference between groups for health-related quality of life and length of hospital stay. Data on remaining outcomes were not reported or were reported inadequately in the included studies.

AUTHORS' CONCLUSIONS

Prehabilitation may result in an improved functional capacity, determined with the 6-minute walk test both preoperatively and postoperatively. A solid effect on the number of omplications, postoperative emergency department visits and re-admissions could not be established. The certainty of evidence ranges from moderate to very low, due to downgrading for serious risk of bias, imprecision and inconsistency. In addition, only three heterogeneous studies were included in this review. Therefore, the findings of this review should be interpreted with caution. Numerous relevant RCTs are ongoing and will be included in a future update of this review.

Novel nutrition strategies to enhance recovery after surgery

Surgery and traumatic injury set off a cascade of metabolic changes that are becoming better understood. Recently, strategies and protocols have been developed for optimizing outcomes, and this has yielded beneficial results. This brief review evaluates three specific nutrition or metabolic interventions in the postoperative setting that attempt to optimize outcomes. We limited this to three subspecialty areas including oncologic surgery, orthopedic surgery, and cardiac surgery. These agents included fish oils, factors to prevent dysbiosis, and resistance exercise and its role in enhancing protein update. Where these novel agents fit into the basic tenets of postoperative nutrition interventions does not change the narrative: deliver graduated early enteral feeding to attenuate the metabolic response to surgical stress, maintain the gastrointestinal mucosal barrier, use immune/metabolic modulation to enhance immune response while attenuating excessive inflammation, and support the microbiome.

The Role and Effect of Multimodal Prehabilitation Before Major Abdominal Surgery: A Systemic Review and Meta-Analysis

BACKGROUND

For patients undergoing abdominal surgery, multimodal prehabilitation, including nutrition and exercise interventions, aims to optimize their preoperative physical and physiological capacity. This meta-analysis aims to explore the impact of multimodal prehabilitation on surgical and functional outcomes of abdominal surgery.

METHODS

Medline, Embase and CENTRAL were searched for articles about multimodal prehabilitation in major abdominal surgery. Primary outcomes were postoperative complications with a Clavien-Dindo score ≥3, and functional outcomes, measured by the 6-Minute Walking Test (6MWT). Secondary outcome measures included the quality-of-life measures. Pooled risk ratio (RR) and 95% confidence interval (CI) were estimated, with DerSimonian and Laird random effects used to account for heterogeneity.

RESULTS

Twenty-five studies were included, analysing 4,210 patients across 13 trials and 12 observational studies. Patients undergoing prehabilitation had significantly fewer overall complications (RR = 0.879, 95% CI 0.781-0.989, p = 0.034). There were no significant differences in the rates of wound infection, anastomotic leak and duration of hospitalization. The 6MWT improved preoperatively in patients undergoing prehabilitation (SMD = 33.174, 95% CI 12.674-53.673, p = 0.005), but there were no significant differences in the 6MWT at 4 weeks (SMD = 30.342, 95% CI - 2.707-63.391, p = 0.066) and 8 weeks (SMD = 24.563, 95% CI - 6.77-55.900, p = 0.104) postoperatively.

CONCLUSIONS

As preoperative patient optimization shifts towards an interdisciplinary approach, evidence from this meta-analysis shows that multimodal prehabilitation improves the preoperative functional capacity and reduces postoperative complication rates, suggesting its potential in effectively optimizing the abdominal surgery patient. However, there is a large degree of heterogenicity between the prehabilitation interventions between included articles; hence results should be interpreted with caution.

Clinical practice guidelines for enhanced recovery after colon and rectal surgery from the American Society of Colon and Rectal Surgeons and the Society of American Gastrointestinal and Endoscopic Surgeons

The American Society of Colon and Rectal Surgeons (ASCRS) and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) are dedicated to ensuring high-quality innovative patient care for surgical patients by advancing the science, prevention, and management of disorders and diseases of the colon, rectum, and anus as well as minimally invasive surgery. The ASCRS and SAGES society members involved in the creation of these guidelines were chosen because they have demonstrated expertise in the specialty of colon and rectal surgery and enhanced recovery. This consensus document was created to lead international efforts in defining quality care for conditions related to the colon, rectum, and anus and develop clinical practice guidelines based on the best available evidence. While not proscriptive, these guidelines provide information on which decisions can be made and do not dictate a specific form of treatment. These guidelines are intended for the use of all practitioners, healthcare workers, and patients who desire information about the management of the conditions addressed by the topics covered in these guidelines. These guidelines should not be deemed inclusive of all proper methods of care nor exclusive of methods of care reasonably directed toward obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all the circumstances presented by the individual patient. This clinical practice guideline represents a collaborative effort between the American Society of Colon and Rectal Surgeons (ASCRS) and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and was approved by both societies.

Preoperative respiratory therapy in patients undergoing surgery for lung cancer: A randomized controlled trial

BACKGROUND

A preoperative respiratory therapy treatment was performed to analyze the effectiveness, with respect to postoperative air leak and pain, in patients undergoing surgery for lung cancer.

OBJECTIVES

To analyze air leakage and postoperative pain.

MATERIAL AND METHODS

Seventy one patients were studied, with a mean age of 62.58 years. Descriptive variables of gender, carcinogenic pathology, type of surgical incision and lung resection, use of glue and endostapler, and presence of adhesions were analyzed. Likewise, analysis of the quantitative variables of age, body mass index and forced expiratory volume in 1 s Two homogeneous groups resulted. Differentiated, experimental group (EG) that performed preoperative respiratory therapy and control group (CG).

RESULTS

There were statistically significant differences in favor of the EG with respect to postoperative air leak on days 1-2 during the performance of physiotherapy techniques, the food and during the performance of the exercises autonomously. Furthermore, differences in air leakage were observed on days 2-4 during gait. The number of patients decreased to a greater extent in the EG. Regarding pain, there were statistically significant differences in the sample on days 1-4, with greater intensity of pain in the CG and after doing physiotherapy every day except the second.

CONCLUSIONS

Preoperative respiratory therapy in patients undergoing surgery for lung cancer was effective in reducing the number of patients who presented postoperative air leak and reducing pain in the EG.

Effects of prehabilitation on postoperative outcomes in frail cancer patients undergoing elective surgery: a systematic review and meta-analysis

PURPOSE

This systematic review and meta-analys is aimed to explore the effects of prehabilitation on postoperative outcomes in frail cancer patients.

METHODS

A comprehensive literature search was conducted using PubMed, Cochrane Library, Embase, Web of Science, CINAHL Complete, and other databases from database inception to 15 March 2022. Studies were included if they consisted of a prehabilitation intervention in frail cancer patients undergoing elective surgery.

RESULTS

A total of 9 studies encompassing 1313 patients were included in the review. Through meta-analysis, prehabilitation has a positive impact on total complications (RR = 0.83, 95% CI = 0.73 to 0.94, P = 0.004), severe complications (RR = 0.62, 95% CI = 0.43 to 0.90, P = 0.01), and the average length of hospital stay (MD =  - 1.36, 95% CI =  - 2.38 to - 0.35, P = 0.008). But it had no differences in 30-day and 3-month mortality and 30-day and 3-month readmission rates. Through qualitative synthesis, two studies found that prehabilitation had a favorable tendency to promote functional recovery compared with the control group.

CONCLUSION

Prehabilitation had a positive effect on postoperative complications and the average length of hospital stay in frail cancer patients. A personalized and supervised multimodal prehabilitation program with exercise at its core may be more beneficial for them. More studies with extensive follow-up are needed to confirm and update the findings of these results.

Timed up and go test and long-term survival in older adults after oncologic surgery

BACKGROUND

Physical performance tests are a reflection of health in older adults. The Timed Up and Go test is an easy-to-administer tool measuring physical performance. In older adults undergoing oncologic surgery, an impaired TUG has been associated with higher rates of postoperative complications and increased short term mortality. The objective of this study is to investigate the association between physical performance and long term outcomes.

METHODS

Patients aged ≥65 years undergoing surgery for solid tumors in three prospective cohort studies, 'PICNIC', 'PICNIC B-HAPPY' and 'PREOP', were included. The TUG was administered 2 weeks before surgery, a score of ≥12 seconds was considered to be impaired. Primary endpoint was 5-year survival, secondary endpoint was 30-day major complications. Survival proportions were estimated using Kaplan-Meier curves. Cox- and logistic regression analysis were used for survival and complications respectively. Hazard ratios (aHRs) and Odds ratios (aOR) were adjusted for literature-based and clinically relevant variables, and 95% confidence intervals (95% CIs) were estimated using multivariable models.

RESULTS

In total, 528 patients were included into analysis. Mean age was 75 years (SD 5.98), in 123 (23.3%) patients, the TUG was impaired. Five-year survival proportions were 0.56 and 0.49 for patients with normal TUG and impaired TUG respectively. An impaired TUG was an independent predictor of increased 5-year mortality (aHR 1.43, 95% CI 1.02-2.02). The TUG was not a significant predictor of 30-day major complications (aOR 1.46, 95% CI 0.70-3.06).

CONCLUSIONS

An impaired TUG is associated with increased 5-year mortality in older adults undergoing surgery for solid tumors. It requires further investigation whether an impaired TUG can be reversed and thus improve long-term outcomes.

TRIAL REGISTRATION

The PICNIC studies are registered in the Dutch Clinical Trial database at www.trialregister.nl: NL4219 (2010-07-22) and NL4441 (2014-06-01). The PREOP study was registered with the Dutch trial registry at www.trialregister.nl: NL1497 (2008-11-28) and in the United Kingdom register (Research Ethics Committee reference 10/H1008/59).  https://www.hra.nhs.uk/planning-and-improving-research/application-summaries/research-summaries/?page=15&query=preop&date_from=&date_to=&research_type=&rec_opinion=&relevance=true .

Prehabilitation. An Interdisciplinary Patient-Centric Conceptual Framework

OBJECTIVES

To review the recent literature around patient-centric prehabilitation in oncology patients and propose a conceptual framework to inform development of interdisciplinary prehabilitation services leading to focused, individualized prehabilitation interventions.

DATA SOURCES

A review of recent peer-reviewed literature, national guidance, and government strategy on prehabilitation in oncology patients.

CONCLUSION

Patient- centric prehabilitation is key to improving patient's experiences of cancer throughout the cancer journey while improving population health and reducing financial costs. Successful personalized prehabilitation interventions are comprised of an interplay between individual interdisciplinary roles, as illustrated in the conceptual framework. The role of the nurse underpins this whole process in patient screening, assessment, implementation of the intervention, and patient reassessment, ensuring care is dynamic and tailored to patient need.

IMPLICATIONS FOR NURSING PRACTICE

The review has discussed the key role that nurses play in the process but warrants more research in the area. The conceptual framework provides a basis to develop interdisciplinary prehabilitation services underpinned by the nurse's role. The review advocates the use of educational interventions to equip all health professionals with prehabilitation knowledge to enable interdisciplinary prehabilitation services to be developed.

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)

Prehabilitation versus no prehabilitation to improve functional capacity, reduce postoperative complications and improve quality of life in colorectal cancer surgery

BACKGROUND

Surgery is the cornerstone in curative treatment of colorectal cancer. Unfortunately, surgery itself can adversely affect patient health. 'Enhanced Recovery After Surgery' programmes, which include multimodal interventions, have improved patient outcomes substantially. However, these are mainly applied peri- and postoperatively. Multimodal prehabilitation includes multiple preoperative interventions to prepare patients for surgery with the aim of increasing resilience, thereby improving postoperative outcomes.

OBJECTIVES

To determine the effects of multimodal prehabilitation programmes on functional capacity, postoperative complications, and quality of life in adult patients undergoing surgery for colorectal cancer.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and PsycINFO in January 2021. We also searched trial registries up to March 2021.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) in adult patients with non-metastatic colorectal cancer, scheduled for surgery, comparing multimodal prehabilitation programmes (defined as comprising at least two preoperative interventions) with no prehabilitation. We focused on the following outcomes: functional capacity (i.e. 6-minute walk test, VO2peak, handgrip strength), postoperative outcomes (i.e. complications, mortality, length of hospital stay, emergency department visits, re-admissions), health-related quality of life, compliance, safety of prehabilitation, and return to normal activities.

DATA COLLECTION AND ANALYSIS

Two authors independently selected studies, extracted data, assessed risk of bias and used GRADE to assess the certainty of the evidence. Any disagreements were solved with discussion and consensus. We pooled data to perform meta-analyses, where possible.

MAIN RESULTS

We included three RCTs that enrolled 250 participants with non-metastatic colorectal cancer, scheduled for elective (mainly laparoscopic) surgery. Included trials were conducted in tertiary care centres and recruited patients during periods ranging from 17 months to 45 months. A total of 130 participants enrolled in a preoperative four-week trimodal prehabilitation programme consisting of exercise, nutritional intervention, and anxiety reduction techniques. Outcomes of these participants were compared to those of 120 participants who started an identical but postoperative programme. Postoperatively, prehabilitation may improve functional capacity, determined with the 6-minute walk test at four and eight weeks (mean difference (MD) 26.02, 95% confidence interval (CI) -13.81 to 65.85; 2 studies; n = 131; and MD 26.58, 95% CI -8.88 to 62.04; 2 studies; n = 140); however, the certainty of evidence is low and very low, respectively, due to serious risk of bias, imprecision, and inconsistency. After prehabilitation, the functional capacity before surgery improved, with a clinically relevant mean difference of 24.91 metres (95% CI 11.24 to 38.57; 3 studies; n = 225). The certainty of evidence was moderate due to downgrading for serious risk of bias. Prehabilitation may also result in fewer complications (RR 0.95, 95% CI 0.70 to 1.29; 3 studies; n = 250) and fewer emergency department visits (RR 0.72, 95% CI 0.39 to 1.32; 3 studies; n = 250). The certainty of evidence was low due to downgrading for serious risk of bias and imprecision. On the other hand, prehabilitation may also result in a higher re-admission rate (RR 1.20, 95% CI 0.54 to 2.65; 3 studies; n = 250). The certainty of evidence was again low due to downgrading for risk of bias and imprecision. The effect on VO2peak, handgrip strength, length of hospital stay, mortality rate, health-related quality of life, return to normal activities, safety of the programme, and compliance rate could not be analysed quantitatively due to missing or insufficient data. The included studies did not report a difference between groups for health-related quality of life and length of hospital stay. Data on remaining outcomes were not reported or were reported inadequately in the included studies.

AUTHORS' CONCLUSIONS

Prehabilitation may result in an improved functional capacity, determined with the 6-minute walk test both preoperatively and postoperatively. Complication rates and the number of emergency department visits postoperatively may also diminish due to a prehabilitation programme, while the number of re-admissions may be higher in the prehabilitation group. The certainty of evidence ranges from moderate to very low, due to downgrading for serious risk of bias, imprecision and inconsistency. In addition, only three heterogeneous studies were included in this review. Therefore, the findings of this review should be interpreted with caution. Numerous relevant RCTs are ongoing and will be included in a future update of this review.

Pre-habilitation before colorectal cancer surgery could improve postoperative gastrointestinal function recovery: a case-matched study

PURPOSE

While its effect is controverted, multimodal pre-habilitation could be used to improve the postoperative course following colorectal cancer surgery. However, by increasing lean body mass, pre-habilitation could reduce the time needed to recover gastrointestinal (GI) functions. The aim was to assess the impact of pre-habilitation before colorectal cancer surgery on postoperative GI motility recovery.

METHODS

This is a matched retrospective study based on a prospective database including patients undergoing colorectal surgery without pre-habilitation (NPH) (2016-2018) and with pre-habilitation (PH group) (2018-2019). The main outcome measure was the time to GI-3 recovery (tolerance to solid food and flatus and/or stools).

RESULTS

One hundred thirteen patients were included, 37 underwent pre-habilitation (32.7%). The patient's age, the surgical procedure, the surgical access, the rate of synchronous metastasis, the rate of preoperative chemoradiotherapy, and the rate of stoma were more important in the PH group. Conversely, the rate of patients with an ASA score of > 2 was higher in the NPH group. By matching patients according to age, gender and surgical procedure, 84 patients were compared (61 in the NPH group and 23 in the PH group). The mean of GI-3 recovery was significantly lower in the PH group. The other endpoints were not significantly different but time to GI function recovery and medical morbidity tended to be higher in the NPH group. Compliance with the enhanced recovery program was significantly higher in the PH group.

CONCLUSION

Pre-habilitation before colorectal cancer surgery reduced time to GI function recovery and may increase compliance with the enhanced recovery program.

Psychological Interventions Prior to Cancer Surgery: a Review of Reviews

Purpose of Review

Patients with cancer who have high levels of psychological distress have poor treatment compliance and worse outcomes. This “review of reviews” provides a narrative synthesis of the impact of psychological prehabilitation interventions on individuals awaiting cancer surgery.

Recent Findings

Twenty reviews of prehabilitation with psychological interventions were identified. There is a trend towards improved psychological outcomes following intervention, particularly when psychologist-led. However, there was considerable heterogeneity within interventions, outcome measures, and timing of assessment precluding numeric synthesis. Methodological limitations including non-blinding, absence of stratification, and underpowered studies were also pervasive.

Summary

Providing psychological support early in the cancer pathway and prior to surgery has the potential to improve psychological health and outcomes. The application of existing knowledge in psycho-oncology, including distress screening, is needed in the prehabilitation setting. Consistent outcome assessments, accurate reporting of intervention components and delivery methods, and a consideration of effective systems and economical implementation strategies would facilitate advancements in this field.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40140-021-00505-x.

Poor treatment tolerance in head and neck cancer patients with low muscle mass

BACKGROUND

We ascertain the role of a low cervical paraspinal skeletal muscle index (CPSMI) as a biomarker for poor treatment tolerance in patients with operable mucosal head and neck squamous cell carcinoma (HNSCC).

METHODS

A prospective cohort of patients with operable HNSCC requiring microvascular reconstruction was evaluated. Low CPSMI was calculated using preoperative CT neck imaging. Poor treatment tolerance, a composite measure of incomplete therapy or severe morbidity/mortality during treatment, was the primary outcome.

RESULTS

One hundred and twenty-seven patients underwent extirpative surgery with a mean age was 60.5. Poor treatment tolerance occurred in 71 (56%) patients with 21 not completing recommended adjuvant therapy and 66 having severe treatment-related morbidity. A low CPSMI was independently associated with poor treatment tolerance (OR 2.49, 95%CI 1.10-5.93) and delay to adjuvant therapy (OR 4.48, 95%CI 1.07-27.6) after adjusting for multiple confounders.

CONCLUSION

Low CPSMI was independently associated with poor treatment tolerance in patients with operable HNSCC.

Cervical paraspinal skeletal muscle index outperforms frailty indices to predict postoperative adverse events in operable head and neck cancer with microvascular reconstruction

OBJECTIVE

Sarcopenia is increasingly being recognized as a negative prognostic factor in patients with head and neck cancer (HNC). We associate a sarcopenia biomarker measured radiographically from computed tomography (CT) of the neck to postoperative adverse events in patients with operable HNC.

PATIENTS AND METHODS

A prospective cohort of treatment-naïve HNC patients undergoing surgery with microvascular reconstruction was performed. Cervical paraspinal skeletal muscle index (CPSMI) was calculated using preoperative CT neck imaging and adjusted for height and sex. Postoperative adverse events, including Clavien-Dindo Grade 3+ complications and fistula, were recorded within 30-days of the index surgery. Multivariate logistic regression was used to evaluate the association between CPSMI and postoperative complications. The modified frailty index (mFI) and Risk Assessment Index (RAI) were compared with CPSMI outcomes.

RESULTS

A total of 127 patients with mucosal HNC were included in the study. The mean age was 60.5 years, and 87 (68.5%) patients were male. Sixty Clavien-Dindo grade 3+ events occurred; 17 patients developed an oro/pharyngocutaneous fistula. Low CPSMI was independently associated with Clavien-Dindo Grade 3+ events (OR 2.80, 95% CI of 1.18-6.99) and fistula (OR of 6.10, 95% CI of 1.53-24.3) when adjusted for multiple factors. CPSMI outperformed the mFI and RAI frailty indices to predict postoperative adverse events (p < .05).

CONCLUSION

Low CPSMI is independently associated with postoperative adverse events and outperforms current frailty indices inoperable HNC with microvascular reconstruction.

Associations between a composite score of hemoglobin, CRP and albumin and physical performance in older patients undergoing gastrointestinal cancer surgery

BACKGROUND & AIMS

Abnormal levels of hemoglobin, C-reactive protein (CRP) and albumin are common in people with gastrointestinal cancer. The hypothesis was that this is of importance for physical performance in older persons in the perioperative context. Thus, the aim was to evaluate the association between hemoglobin, CRP and albumin and physical performance before and after abdominal cancer surgery in older patients.

METHODS

Patients ≥70 years of age scheduled for abdominal cancer surgery were invited to take part in the study. Data on levels of hemoglobin, CRP and albumin and physical performance (Six-Minute Walk Test, functional leg strength [chair-stands completed in 30 s], and maximal inspiratory muscle strength), were collected at baseline (n = 178) and physical performance was reassessed before discharge (n = 120). A composite score of 0-3 points was used, based on the presence or not of anemia, elevated CRP or hypoalbuminemia. Multivariable linear regressions were used for statistical analysis.

RESULTS

Before surgery, walking distance in patients scoring 2-3 (presence of 2 or 3 abnormal values) was shorter in comparison to patients scoring 0 (all values within normal range) in the multivariable model (-39.1 m; 95% CI -74.2, -3.9, p = 0.030). The number of chair stands performed during 30 s was lower in patients scoring 1 (-1.7; 95% CI -3.2, -0.2, p = 0.028) and 2-3 (-1.6; 95% CI -3.0, -0.1, p = 0.037) compared to patients scoring 0. No significant differences were seen between score groups and inspiratory muscle strength. After surgery, no differences were seen in walking distance or chair stands between patients with different scores.

CONCLUSIONS

Older patients with abnormal concentrations of hemoglobin, CRP and albumin before gastrointestinal cancer surgery showed impaired physical performance before surgery. Knowledge about potentially modifiable factors prior to cancer surgery increases the possibility to prepare the individual, which in turn might contribute to reduced morbidity and faster recovery after surgery.

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

BACKGROUND

Neoadjuvant therapy reduces fitness, muscle mass, and quality of life (QOL). For patients undergoing chemotherapy and surgery for esophagogastric cancer, maintenance of fitness is paramount. This study investigated the effect of exercise and psychological prehabilitation on anaerobic threshold (AT) at cardiopulmonary exercise testing (CPET). Secondary endpoints included peak oxygen uptake (peak VO₂), skeletal muscle mass, QOL, and neoadjuvant therapy completion.

METHODS

This parallel-arm randomized controlled trial assigned patients with locally advanced esophagogastric cancer to receive prehabilitation or usual care. The 15-week program comprised twice-weekly supervised exercises, thrice-weekly home exercises, and psychological coaching. CPET was performed at baseline, 2 weeks after neoadjuvant therapy, and 1 week preoperatively. Skeletal muscle cross-sectional area at L3 was analyzed on staging and restaging computed tomography. QOL questionnaires were completed at baseline, mid-neoadjuvant therapy, at restaging laparoscopy, and postoperatively at 2 weeks, 6 weeks and 6 months.

RESULTS

Fifty-four participants were randomized (prehabilitation group, n = 26; control group, n = 28). No difference in AT between groups was observed post-neoadjuvant therapy. Prehabilitation resulted in an attenuated peak VO₂ decline {-0.4 [95% confidence interval (CI) -0.8 to 0.1] vs. -2.5 [95% CI -2.8 to -2.2] mL/kg/min; p = 0.022}, less muscle loss [-11.6 (95% CI -14.2 to -9.0) vs. -15.6 (95% CI -18.7 to -15.4) cm²/m²; p = 0.049], and improved QOL. More prehabilitation patients completed neoadjuvant therapy at full dose [prehabilitation group, 18 (75%) vs. control group, 13 (46%); p = 0.036]. No adverse events were reported.

CONCLUSIONS

This study has demonstrated some retention of cardiopulmonary fitness (peak VO₂), muscle, and QOL in prehabilitation subjects. Further large-scale trials will help determine whether these promising findings translate into improved clinical and oncological outcomes. Trial Registration ClinicalTrials.gov NCT02950324.

SupPoRtive Exercise Programmes for Accelerating REcovery after major ABdominal Cancer surgery trial (PREPARE-ABC): Study protocol for a multicentre randomized controlled trial

BACKGROUND

Exercise programmes can increase cardiopulmonary reserve and functional capacity prior to surgery and can improve clinical, functional and survival outcomes after a colorectal cancer diagnosis. However, the impact of pre- and postoperative exercise on postoperative recovery outcomes and longer-term health-related quality of life are unknown; thus, there is a need for high-quality randomized controlled trials.

METHOD

SupPoRtive Exercise Programmes for Accelerating REcovery after major Abdominal Cancer surgery (PREPARE-ABC) is a three-arm multicentre randomized controlled trial with internal pilot. The primary objective is to assess the effects of pre- and postoperative exercise on surgical outcomes and longer-term health-related quality of life in cancer patients undergoing colorectal resection. The aim of PREPARE-ABC is to randomize 1146 patients at the individual level (1:1:1) to hospital-supervised exercise, home-supported exercise or treatment as usual. The primary outcomes are short-term (30-day) morbidity, assessed using the Clavien-Dindo classification, and longer-term health-related quality of life, assessed using the Medical Outcomes Study Health Questionnaire (36-item Short-Form Survey [SF-36]). Secondary outcomes include cardiopulmonary fitness, physical activity behaviour change, psychological health status and cost-effectiveness. A process evaluation of intervention delivery and usual care also will be undertaken.

DISCUSSION

This is the first UK-based definitive randomized controlled trial to investigate the effects of pre- and postoperative exercise on short-term postoperative health outcomes and longer-term health-related quality of life in colorectal cancer patients. The trial will yield robust clinical and cost-effectiveness data to underpin clinical guidance on how exercise programmes should be implemented in the routine management of patients undergoing major colorectal cancer surgery.

Pre-admission interventions (prehabilitation) to improve outcome after major elective surgery: a systematic review and meta-analysis

OBJECTIVE

To determine the benefits and harms of pre-admission interventions (prehabilitation) on postoperative outcomes in patients undergoing major elective surgery.

DESIGN

Systematic review and meta-analysis of randomised controlled trials (RCTs) (published or unpublished). We searched Medline, Embase, CENTRAL, DARE, HTA and NHS EED, The Cochrane Library, CINAHL, PsychINFO and ISI Web of Science (June 2020).

SETTING

Secondary care.

PARTICIPANTS

Patients (≥18 years) undergoing major elective surgery (curative or palliative).

INTERVENTIONS

Any intervention administered in the preoperative period with the aim of improving postoperative outcomes.

OUTCOMES AND MEASURES

Primary outcomes were 30-day mortality, hospital length of stay (LoS) and postoperative complications. Secondary outcomes included LoS in intensive care unit or high dependency unit, perioperative morbidity, hospital readmission, postoperative pain, heath-related quality of life, outcomes specific to the intervention, intervention-specific adverse events and resource use.

REVIEW METHODS

Two authors independently extracted data from eligible RCTs and assessed risk of bias and the certainty of evidence using Grading of Recommendations, Assessment, Development and Evaluation. Random-effects meta-analyses were used to pool data across trials.

RESULTS

178 RCTs including eight types of intervention were included. Inspiratory muscle training (IMT), immunonutrition and multimodal interventions reduced hospital LoS (mean difference vs usual care: -1.81 days, 95% CI -2.31 to -1.31; -2.11 days, 95% CI -3.07 to -1.15; -1.67 days, 95% CI -2.31 to -1.03, respectively). Immunonutrition reduced infective complications (risk ratio (RR) 0.64 95% CI 0.40 to 1.01) and IMT, and exercise reduced postoperative pulmonary complications (RR 0.55, 95% CI 0.38 to 0.80, and RR 0.54, 95% CI 0.39 to 0.75, respectively). Smoking cessation interventions reduced wound infections (RR 0.28, 95% CI 0.12 to 0.64).

CONCLUSIONS

Some prehabilitation interventions may reduce postoperative LoS and complications but the quality of the evidence was low.

PROSPERO REGISTRATION NUMBER

CRD42015019191.

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).

[Background, Necessity and Methodology of the S3 Guideline "Perioperative Management of Gastrointestinal Tumours (POMGAT)"]

Malignancies are among the most common diseases, especially in old age, and are responsible for 25% of all deaths in Germany. Especially carcinomas of the gastrointestinal tract can be cured in most cases only through extensive surgery with significant morbidity. About 25 years ago, the multimodal, perioperative Fast Track (FT) concept for reducing postoperative complications was introduced and additional elements were added in the following years. Meanwhile, there is growing evidence that adherence to the key elements of more than 70% leads to reduction in postoperative adverse events as well as a shorter hospital stay and could be associated with an improved oncological outcome. Despite the high level of awareness and the proven advantages of the FT concept, the implementation and maintenance of the measures is difficult and results in an adherence of only 20 - 40%. There are many reasons for this: In addition to a lack of interdisciplinary and interprofessional cooperation and the time consuming and extended logistical efforts, limited human resources are often listed as one of the main causes. We took these aspects as an opportunity and started to develop a S3 guideline for perioperative treatment to accelerate the recovery of patients with gastrointestinal malignancies. By creating a consensus- and evidence-based, multidisciplinary guideline, many of the problems listed above could probably be solved by optimising and standardising interdisciplinary care, which is particularly important in a setting with many different disciplines and their competing interests. Furthermore, the standardisation of the perioperative procedures will reduce the time and logistical effort. The presentation of the evidence allows increased transparency and justifies the additional personnel expenditure on hospital medicine and health insurance companies. In addition, the evidence-based quality indicators generated during the development of the guideline make it possible to include perioperative standards in certification systems and thus to measure and check the quality of perioperative care.

Preoperative In-Hospital Rehabilitation Improves Physical Function in Patients with Pancreatic Cancer Scheduled for Surgery

Low preoperative physical function in cancer patients is associated with postoperative complications; however, there have been no reports on the benefits of in-hospital preoperative rehabilitation on preoperative physical function in patients with pancreatic cancer. Therefore, the aim of this study was to quantitatively determine the effects of preoperative in-hospital rehabilitation provided under the supervision of a physiotherapist, on preoperative physical function in patients with pancreatic cancer. The study subjects were 26 patients (15 males, 11 females; age 71.2 ± 8.5 years, range: 51-87 years), including four patients with preoperative chemotherapy, scheduled for surgery for pancreatic cancer. Muscle strengthening exercises and aerobic exercises were conducted 11.9 ± 5.1 days prior to surgery. Cardiopulmonary exercise testing, 6-minute walk distance, and the Functional Independence Measure score were measured before and after the rehabilitation program. We also investigated the relation between the rehabilitation program and incidence of postoperative complications. All 26 study patients completed the preoperative rehabilitation program and no adverse events were noted. Peak oxygen uptake during cardiopulmonary exercise testing and 6-minute walk distance increased significantly after the rehabilitation program. The Functional Independence Measure score remained constant throughout the intervention. No wound infection, delirium, deep vein thrombosis, or respiratory complications were encountered postoperatively. In-hospital preoperative rehabilitation under the supervision of a physiotherapist significantly improved physical function and maintained physical activity in patients with pancreatic cancer. Such improvements may contribute toward preventing serious postoperative complications, resulting in better outcomes.

Harnessing Nutrition and Physical Activity for Breast Cancer Prevention and Control to Reduce Racial/Ethnic Cancer Health Disparities

There are well-known racial/ethnic disparities in the prevalence of obesity and physical inactivity, as well as breast cancer risk and survival. However, most of the current scientific evidence that serves as a foundation for nutrition and physical activity guidelines is based on studies conducted in predominantly non-Hispanic White populations. Similarly, exercise, diet, or lifestyle intervention trials for breast cancer prevention and survivorship are scarce in racial/ethnic minority populations. We review the current evidence for racial/ethnic disparities in obesity and breast cancer risk and survival (we are focusing on obesity, because this is considered an ASCO priority, and studies conducted in the United States), discuss the evolution of nutrition/physical activity guidelines for cancer prevention and control, and provide an overview of lifestyle interventions, including barriers and facilitators in implementation and dissemination science among minority populations underrepresented in research. There is a critical need to include racially/ethnically diverse populations in cancer prevention and control research or to specifically target minority populations in which disparities are known to exist to achieve much needed health equity.

A multimodal prehabilitation program in high-risk patients undergoing elective resection for colorectal cancer: A retrospective cohort study

AIM

Up to 50% of the patients experience complications after colorectal cancer (CRC) surgery. Improved preoperative physical and nutritional status can enhance clinical outcomes and reduce postoperative complications. This retrospective, single-center, observational cohort study assessed the impact of a four-week multimodal prehabilitation program on postoperative complications, unplanned readmissions, length of stay, and mortality in elective high-risk CRC patients.

METHOD

Elective high-risk CRC patients, defined as ASA ≥3 or ≥65yr, who attended the multimodal prehabilitation program (prehabilitation-group) were compared to a historical cohort receiving standard care (control-group). Differences in outcomes between these groups were tested using Fisher's Exact and Mann-Whitney U test. To adjust for confounding, multivariate logistic regression analysis was performed. The main study outcome was the occurrence of postoperative complications. Secondary outcomes included unplanned readmissions, length of hospital stay, and mortality.

RESULTS

351 patients were included (n = 275 control-group, n = 76 prehabilitation-group). The complication rate was lower in the prehabilitation group compared to the control group, 26.3% (n = 20) versus 40% (n = 110) (p = .032). There were fewer unplanned readmissions in the prehabilitation group compared to the control group, 5.3% (n = 4) versus 16.4% (n = 45), p = .014. Median hospital days of stay was 1 day shorter for the prehabilitation-group (p = .004), mortality did not significantly differ between the groups.

CONCLUSION

This study shows that the used multimodal prehabilitation program leads to a reduction of medical postoperative complications, unplanned readmissions, and shortens the median hospital stay compared with standard care in high-risk CRC patients undergoing elective CRC surgery.

Preoperative physical exercise strategies for patients undergoing major abdominal cancer surgery: a scoping review

BACKGROUND

Although preoperative physical exercise has been demonstrated to be associated with clinical improvements among abdominal cancer patients, there remains heterogeneity in exercise strategies and uncertainty of what the optimal strategies should be.

PURPOSE

This scoping review aimed to review and summarize the existing knowledge about preoperative exercise strategies for abdominal cancer patients.

METHODS

The Joanna Briggs Institute (JBI) framework for conducting scoping reviews was adopted to investigate preoperative physical exercise strategies for patients undergoing major abdominal cancer surgery.

RESULTS

A total of 1563 studies were identified and 24 were included in this review. Most of the study populations were colorectal cancer (n = 14). The most common type of exercise was a combination of aerobic and resistance exercises (n = 19). The most common form of aerobic exercise was walking (n = 13) or cycling (n = 12). Most resistance exercises were targeting at major muscle groups (n = 12). Most of the studies were performed at moderate intensity (n = 14) with frequency of 2 ~ 3 times/week (n = 14). The time of a training session was 30 ~ 60 min in half studies (n = 12). The intervention duration for most studies was less than 4 weeks (n = 11). Exercise locations included home (n = 10), facility (n = 7), and a combination of home and facility (n = 5). Phone calls were utilized by nearly half of the home-based exercise studies to supervise the exercise adherence (n = 7).

CONCLUSIONS

This review provides a comprehensive summary of preoperative physical exercise strategies. It has the potential to inform clinical practice and future studies.

Perspectives on functional status in older adults with cancer: An interprofessional report from the International Society of Geriatric Oncology (SIOG) nursing and allied health interest group and young SIOG

Most adults with cancer are over 65 years of age, and this cohort is expected to grow exponentially. Older adults have an increased burden of comorbidities and risk of experiencing adverse events on anticancer treatments, including functional decline. Functional impairment is a predictor of increased risk of chemotherapy toxicity and shorter survival in this population. Healthcare professionals caring for older adults with cancer should be familiar with the concept of functional status and its implications because of the significant interplay between function, cancer, anticancer treatments, and patient-reported outcomes. In this narrative review, we provide an overview of functional status among older patients with cancer including predictors, screening, and assessment tools. We also discuss the impact of functional impairment on patient outcomes, and describe the role of individual members of an interprofessional team in addressing functional impairment in this population, including the use of a collaborative approach aiming to preserve function.

What are the impact and the optimal design of a physical prehabilitation program in patients with esophagogastric cancer awaiting surgery? A systematic review

Background

Substantial postoperative complications occur after tumor resection for esophagogastric cancers. Physical prehabilitation programs aim to prepare patients for surgery by improving their functional status with the aim of reducing postoperative complications. This systematic review aims to summarize the effects of physical prehabilitation programs on exercise capacity, muscle strength, respiratory muscle function, postoperative outcomes, and health-related quality of life and to determine the optimal design of such a program to improve these outcomes in esophagogastric cancer patients undergoing tumor resection.

Methods

A systematic literature review was conducted using PubMed, The Cochrane Library, Scopus, and PEDro databases to identify studies evaluating the effects of physical prehabilitation program on exercise capacity, muscle strength, respiratory muscle function, postoperative complications, length of hospital stay, mortality, and health-related quality of life in patients with esophagogastric cancer awaiting surgery. Data from all studies meeting the inclusion criteria were extracted. The quality of each selected study was determined using the Downs and Black checklist.

Results

Seven studies with 645 participants were included. The preoperative exercise program consisted of respiratory training alone in three studies, a combination of aerobic and resistance training in two studies, and a combination of respiratory, aerobic, and resistance training in two studies. Training frequency ranged from three times a day to twice a week and each session lasted between 20 and 75 min. Four studies were of fair quality and three of good quality. Some studies reported improvements in maximal inspiratory pressure, inspiratory muscle endurance, postoperative (pulmonary) complications, and length of hospital stay in the preoperative exercise group compared to the control group.

Conclusion

This systematic review reports the current evidence for physical prehabilitation programs in patients with esophagogastric cancer awaiting surgery. However, due to the limited number of randomized controlled trials, the significant heterogeneity of exercise programs, and the questionable quality of the studies, higher quality randomized controlled trials are needed.

Trial registration

PROSPERO Registration Number: CRD42020176353.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13102-021-00260-w.

A Pragmatic Non-Randomized Trial of Prehabilitation Prior to Cancer Surgery: Study Protocol and COVID-19-Related Adaptations

Background

Experimental data highlight the potential benefits and health system cost savings related to surgical prehabilitation; however, adequately powered randomized controlled trial (RCT) data remain nascent. Emerging prehabilitation services may be informed by early RCT data but can be limited in informing real-world program development. Pragmatic trials emphasize external validity and generalizability to understand and advise intervention development and implementation in clinical settings. This paper presents the methodology of a pragmatic prehabilitation trial to complement emerging phase III clinical trials and inform implementation strategies.

Methods

This is a pilot pragmatic clinical trial conducted in a large academic hospital in Toronto, Ontario, Canada to assess feasibility of clinical implementation and derive estimates of effectiveness. Feasibility data include program referral rates, enrolment and attrition, intervention adherence and safety, participant satisfaction, and barriers and facilitators to programming. The study aims to receive 150 eligible referrals for adult, English-speaking, preoperative oncology patients with an identified indication for prehabilitation (e.g., frailty, deconditioning, malnutrition, psychological distress). Study participants undergo a baseline assessment and shared-decision making regarding the intervention setting: either facility-based prehabilitation or home-based prehabilitation. In both scenarios, participants receive an individualized exercise prescription, stress-reduction psychological support, nutrition counseling, and protein supplementation, and if appropriate, smoking cessation program referrals. Secondary objectives include estimating intervention effects at the week prior to surgery and 30 and 90 days postoperatively. Outcomes include surgical complications, postoperative length of stay, mortality, hospital readmissions, physical fitness, psychological well-being, and quality of life. Data from participants who decline the intervention but consent for research-related access to health records will serve as comparators. The COVID-19 pandemic required the introduction of a 'virtual program' using only telephone or internet-based communication for screening, assessments, or intervention was introduced.

Conclusion

This pragmatic trial will provide evidence on the feasibility and viability of prehabilitation services delivered under usual clinical conditions. Study amendments due to the COVID-19 pandemic are presented as strategies to maintain prehabilitation research and services to potentially mitigate the consequences of extended surgery wait times.

The effect of short-term exercise prehabilitation on skeletal muscle protein synthesis and atrophy during bed rest in older men

BACKGROUND

Poor recovery from periods of disuse accelerates age-related muscle loss, predisposing individuals to the development of secondary adverse health outcomes. Exercise prior to disuse (prehabilitation) may prevent muscle deterioration during subsequent unloading. The present study aimed to investigate the effect of short-term resistance exercise training (RET) prehabilitation on muscle morphology and regulatory mechanisms during 5 days of bed rest in older men.

METHODS

Ten healthy older men aged 65-80 years underwent four bouts of high-volume unilateral leg RET over 7 days prior to 5 days of inpatient bed rest. Physical activity and step-count were monitored over the course of RET prehabilitation and bed rest, whilst dietary intake was recorded throughout. Prior to and following bed rest, quadriceps cross-sectional area (CSA), and hormone/lipid profiles were determined. Serial muscle biopsies and dual-stable isotope tracers were used to determine integrated myofibrillar protein synthesis (iMyoPS) over RET prehabilitation and bed rest phases, and acute postabsorptive and postprandial myofibrillar protein synthesis (aMyoPS) rates at the end of bed rest.

RESULTS

During bed rest, daily step-count and light and moderate physical activity time decreased, whilst sedentary time increased when compared with habitual levels (P < 0.001 for all). Dietary protein and fibre intake during bed rest were lower than habitual values (P < 0.01 for both). iMyoPS rates were significantly greater in the exercised leg (EX) compared with the non-exercised control leg (CTL) over prehabilitation (1.76 ± 0.37%/day vs. 1.36 ± 0.18%/day, respectively; P = 0.007). iMyoPS rates decreased similarly in EX and CTL during bed rest (CTL, 1.07 ± 0.22%/day; EX, 1.30 ± 0.38%/day; P = 0.037 and 0.002, respectively). Postprandial aMyoPS rates increased above postabsorptive values in EX only (P = 0.018), with no difference in delta postprandial aMyoPS stimulation between legs. Quadriceps CSA at 40%, 60%, and 80% of muscle length decreased significantly in EX and CTL over bed rest (0.69%, 3.5%, and 2.8%, respectively; P < 0.01 for all), with no differences between legs. No differences in fibre-type CSA were observed between legs or with bed rest. Plasma insulin and serum lipids did not change with bed rest.

CONCLUSIONS

Short-term resistance exercise prehabilitation augmented iMyoPS rates in older men but did not offset the relative decline in iMyoPS and muscle mass during bed rest.

Multiphasic Prehabilitation Across the Cancer Continuum: A Narrative Review and Conceptual Framework

The field of cancer survivorship has significantly advanced person-centered care throughout the cancer continuum. Within cancer survivorship, the last decade has seen remarkable growth in the investigation of prehabilitation comprising pre-treatment interventions to prevent or attenuate the burden of oncologic therapies. While the majority of evidence remains in the surgical setting, prehabilitation is being adapted to target modifiable risk factors that predict poor treatment outcomes in patients receiving other systemic and localized anti-tumor treatments. Here, we propose a multiphasic approach for prehabilitation across the cancer continuum, as a conceptual framework, to encompass the variability in cancer treatment experiences while adopting the most inclusive definition of the cancer survivor.

The Impact of Prehabilitation on Post-operative Outcomes in Oesophageal Cancer Surgery: a Propensity Score Matched Comparison

BACKGROUND

Patients undergoing oesophageal cancer surgery are often frail with a high risk of post-operative complications. Prehabilitation has been shown to reduce post-operative complications in specific patient populations but evidence in oesophageal cancer patients is inconclusive.

METHODS

Between January 2016 and April 2019, all patients with resectable oesophageal cancer who underwent curative treatment at a specialist tertiary centre participated in a personalised, home-based, multimodal prehabilitation programme. Post-operative complications and hospital stay in this group were compared to a control sample. Propensity score matching was used to control for differences in baseline characteristics.

RESULTS

Seventy-two patients who completed prehabilitation and 39 control patients were studied; following propensity score matching, there were 38 subjects in each group. In comparison to matched controls, patients in the prehabilitation group had a lower incidence of post-operative pneumonia (prehabilitation = 26%; control = 66%; p = 0.001) and a shorter length of stay (prehabilitation = median 10 days, IQR 8-17 days; control = median 13 days, IQR 11-20 days; p = 0.018). On multivariate regression analysis, participation in prehabilitation was associated with a 77% lower incidence of post-operative pneumonia (OR 0.23, 95% CI 0.09 to 0.55 p = 0.001). There was no significant difference in the incidence of overall complications or severe complications.

CONCLUSION

Prehabilitation was associated with a lower incidence of post-operative pneumonia and shorter hospital length of stay following oesophagectomy. This model of home based, personalised, and supervised prehabilitation is effective and relevant to centralised cancer services.

Feasibility of Prehabilitation Prior to Breast Cancer Surgery: A Mixed-Methods Study

Background

Breast cancer surgery results in numerous acute and long-term adverse outcomes; the degree to which these can be mitigated or prevented through prehabilitation is unknown.

Methods

We conducted a longitudinal, single-arm, mixed-methods study to examine the feasibility of prehabilitation in 22 women undergoing breast cancer surgery. All participants received an individualized exercise prescription including upper quadrant-specific resistance and mobility training and aerobic exercise for the duration of their surgical wait time. Feasibility was assessed by recruitment, adherence, attrition, and intervention-related adverse event rates. An exploratory investigation of intervention efficacy was conducted via a 6-min walk test, upper-quadrant strength and range of motion, volumetric chances associated with lymphedema, and participant-reported quality of life, fatigue, pain, and disability. Outcome assessments were conducted at baseline, prior to surgery, and at six and 12 weeks after surgery. Semi-structured interviews with a subset of participants (n = 5) and health-care providers (H; n = 2) were conducted to provide further insights about intervention feasibility. Qualitative data were analyzed using a hybrid inductive and deductive thematic analysis approach.

Results

Recruitment and attrition rates were 62 and 36%, respectively. Average prehabilitation duration was 31 days (range = 7–69 days). Seventy six percent of participants complied with at least 70% of their prehabilitation prescription. There was a clinically significant increase in the 6-min walk distance from baseline to the preoperative assessment (57 m, 95% CI = −7.52, 121.7). The interviews revealed that the intervention was favorably received by participants and HCPs and included suggestions that prehabilitation (i) should be offered to all surgical candidates, (ii) is an avenue to regain control in the preoperative period, (iii) is a facilitator of postoperative recovery, and (iv) is an opportunity to provide education regarding postoperative rehabilitation protocols. A preference for multimodal prehabilitation (including dietetic and psychological counseling) was also highlighted.

Conclusion

Our findings suggest that surgical prehabilitation in women with breast cancer is feasible. Data are hampered by study sample size and lack of a control group. Thus, randomized controlled trials to examine prehabilitation efficacy in people with breast cancer, especially interventions employing a multimodal strategy, are warranted.

Urinary titin N-terminal fragment concentration is an indicator of preoperative sarcopenia and nutritional status in patients with gastrointestinal tract and hepatobiliary pancreatic malignancies

OBJECTIVES

Recent reports indicate that preoperative patients with gastrointestinal malignancies often have sarcopenia. The diagnosis of sarcopenia is generally done by evaluation of walking speed, grip strength, and skeletal muscle volume of the limbs on computed tomography (CT). However, these parameters are objective indices, and new indicators for diagnosis, such as molecular biomarkers, have been anticipated. The aim of this study was to investigate whether titin, a muscular contractile protein present in sarcomeres, is an indicator of sarcopenia.

METHODS

We analyzed 39 patients with gastrointestinal tract and hepatobiliary pancreatic malignancies who underwent surgery. We compared urinary titin n-terminal fragment concentration (UTF) with clinical factors, subcutaneous fat volume, and skeletal muscle volume index, and also compared UTF levels between patients with and without sarcopenia.

RESULTS

The patients comprised 24 men and 15 women, with a mean age of 72 y (range: 35-85 y). Cancer locations were the pancreas (n = 17), liver (n = 9), stomach (n = 5), colorectum (n = 5), and esophagus (n = 3). UTF was significantly higher in patients with sarcopenia (P = 0.04), and showed statistically significant negative correlations with albumin (r = -2.61, P = 0.001), pre-albumin (r = -2.14, P = 0.02), body mass index (r = -0.49, P = 0.007), cholinesterase (r = -0.02, P = 0.01, skeletal muscle volume index (r = -0.16, P = 0.04), and subcutaneous fat volume (r = -0.03, P = 0.007).

CONCLUSION

UTF may be a new index for preoperative nutritional assessment in patients with gastrointestinal malignancies.

Feasibility and Preliminary Effectiveness of a Tele-Prehabilitation Program in Esophagogastric Cancer Patients

Tele-rehabilitation provides better access to healthcare services and optimizes exercise adherence. However, its feasibility and effectiveness are unknown in the preoperative period in esophagogastric cancer patients. We aimed to assess the feasibility and the preliminary effects of a “tele-prehabilitation” program in esophagogastric cancer patients requiring surgery. Enrolled participants performed an internet-based tele-prehabilitation including aerobic, resistance and inspiratory muscle training over 2–4 weeks. The primary outcome was feasibility, measured in terms of recruitment, retention and attendance rates, adverse events and patient satisfaction. Secondary outcomes (functional exercise capacity, fatigue, quality of life, anxiety and depression) were assessed at baseline, presurgery, and 4 and 12 weeks postsurgery. Among the 24 eligible subjects, 23 were enrolled, 22 performed the intervention and 15 completed the study. Recruitment and retention rates were both 96%. Attendances to aerobic and resistance sessions and inspiratory muscle training were 77% and 68%, respectively. No adverse events occurred, and the satisfaction was excellent. After prehabilitation, participants significantly improved fatigue (p = 0.039), quality of life (p = 0.009), physical well-being (p = 0.034), emotional well-being (p = 0.005) and anxiety (p = 0.044). This study demonstrated the feasibility of a tele-prehabilitation in esophagogastric cancer patients undergoing surgery, with a high recruitment rate, retention rate and satisfaction, a good attendance to exercise sessions and no exercise-related adverse events.

Skeletal muscle index is an independent predictor of early recurrence in non-obese colon cancer patients

Purpose

Progressive loss (sarcopenia) and fatty infiltration of muscle mass (myosteatosis) are well-established risk factors for an adverse clinical outcome in obese patients. Data concerning non-obese sarcopenic patients in oncologic surgery are scarce and heterogeneous. The aim of this study was to determine the impact of sarcopenia and myosteatosis in non-obese patients with cancer of the right colon on clinical outcome.

Methods

This study comprised 85 patients with a BMI < 30 kg/m², who underwent surgery for right colon cancer in a single center. Skeletal muscle area (SMA), visceral fat area (VFA), and myosteatosis were retrospectively assessed using preoperative abdominal CT images. Univariate und multivariate analysis was performed to evaluate the association between body composition, complications, and oncologic follow-up.

Results

Traditional risk factors such as visceral fat (p = 0.8653), BMI (p = 0.8033), myosteatosis (p = 0.7705), and sarcopenia (p = 0.3359) failed to show any impact on postoperative complications or early recurrence. In our cohort, the skeletal muscle index (SMI) was the only significant predictor for early cancer recurrence (p = 0.0467).

Conclusion

SMI is a significant prognostic factor for early cancer recurrence in non-obese colon cancer patients. Our study shows that conventional thresholds for sarcopenia and BMI do not seem to be reliable across various cohorts. Target prehabilitation programs could be useful to improve outcome after colorectal surgery.

Trial Registration

DRKS00014655, www.apps.who.int/trialsearch