A feasibility study of an unsupervised, pre-operative exercise program for adults with lung cancer

The use of technology in cancer prehabilitation: a systematic review

Aim

This review aimed to evaluate the effectiveness and feasibility of cancer prehabilitation programs delivered through technological enablers compared to conventional face-to-face interventions.

Methods

A systematic review was conducted, searching PubMed, Embase, and CINAHL for studies published from inception to February 6, 2024. Studies were included if they involved adult cancer patients in primary research, utilized technology for prehabilitation, and assessed functional, psychological, and quality of life outcomes.

Results

Sixteen studies were included, encompassing wearables, apps, teleprehabilitation, and virtual reality. All studies reported feasibility, but challenges included technical issues, lack of supervision, and non-compliance. Effectiveness depended on intervention rigor and technology type. Wearables offered objective monitoring but faced compliance issues. Videoconferencing provided supervision and could mitigate compliance concerns. Multimodal programs and intervention-specific outcome measures were recommended.

Conclusion

Technology-based prehabilitation programs seem feasible, but effectiveness depends on intervention design and technology employed. Future research should focus on developing robust evidence to guide clinical practice and explore the potential of integrated technological solutions.

Systematic review registration

PROSPERO, identifier CRD42022376028.

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.

Barriers and facilitators to smartwatch-based prehabilitation participation among frail surgery patients: a qualitative study

BACKGROUND

For older, frail adults, exercise before surgery through prehabilitation (prehab) may hasten return recovery and reduce postoperative complications. We developed a smartwatch-based prehab program (BeFitMe) for older adults that encourages and tracks at-home exercise. The objective of this study was to assess patient perceptions about facilitators and barriers to prehab generally and to using a smartwatch prehab program among older adult thoracic surgery patients to optimize future program implementation.

METHODS

We recruited patients, aged ≥50 years who had or were having surgery and were screened for frailty (Fried's Frailty Phenotype) at a thoracic surgery clinic at a single academic institution. Semi-structured interviews were conducted by telephone after obtaining informed consent. Participants were given a description of the BeFitMe program. The interview questions were informed by The Five "Rights" of Clinical Decision-Making framework (Information, Person, Time, Channel, and Format) and sought to identify the factors perceived to influence smartwatch prehab program participation. Interview transcripts were transcribed and independently coded to identify themes in for each of the Five "Rights" domains.

RESULTS

A total of 29 interviews were conducted. Participants were 52% men (n = 15), 48% Black (n = 14), and 59% pre-frail (n = 11) or frail (n = 6) with a mean age of 68 ± 9 years. Eleven total themes emerged. Facilitator themes included the importance of providers (right person) clearly explaining the significance of prehab (right information) during the preoperative visit (right time); providing written instructions and exercise prescriptions; and providing a preprogrammed and set-up (right format) Apple Watch (right channel). Barrier themes included pre-existing conditions and disinterest in exercise and/or technology. Participants provided suggestions to overcome the technology barrier, which included individualized training and support on usage and responsibilities.

CONCLUSIONS

This study reports the perceived facilitators and barriers to a smartwatch-based prehab program for pre-frail and frail thoracic surgery patients. The future BeFitMe implementation protocol must ensure surgical providers emphasize the beneficial impact of participating in prehab before surgery and provide a written prehab prescription; must include a thorough guide on smartwatch use along with the preprogrammed device to be successful. The findings are relevant to other smartwatch-based interventions for older adults.

The use of digital technologies to support home-based prehabilitation prior to major surgery: A systematic review

BACKGROUND

Prehabilitation is a multidimensional and multidisciplinary approach, to prepare patients for surgery, with the aim of improving postoperative outcomes. Worldwide, healthcare systems are facing challenges with a gap between demand and supply of healthcare services. Telehealth is seen as a solution for delivering sustainable and efficient treatments. The effect of providing prehabilitation using telehealth solutions is unclear.

OBJECTIVE

This systematic review investigated the existing literature regarding the effects and feasibility of technologies for remotely supporting home-based prehabilitation compared to standard care on pre- and postoperative outcomes in adults undergoing elective major surgery.

METHODS

A literature search identified relevant studies published between 1 January 2012 and December 2022 in PubMed, PsychInfo, Cinahl and the Cochrane Library. We included RCTs, feasibility and pilot studies. The quality of studies was evaluated using Cochrane's Risk of bias assessment and by narratively rating the certainty of evidence.

RESULTS

Six randomized controlled trials and 20 pilot/feasibility studies were included. The number and content of the interventions varied, depending on context and resources. Multiple approaches in the use of digital healthcare solutions were applied and the results highlight the potential of providing health services remotely.

CONCLUSION

The use of technologies to support remote home-based prehabilitation in patients undergoing elective major surgery is feasible and has high acceptability, though telehealth is a broad term and wide-ranging strategies are used. Digital technologies for supporting home-based prehabilitation are likely to play an essential role in future health care as resources are scarce and innovative solutions are needed.

Features of teleoncology in lung cancer: A scoping review

OBJECTIVES

There are several challenges in providing healthcare services for lung cancer patients. Using teleoncology is an effective solution to meet such challenges. Given this, we in this study aimed to identify the features of teleoncology in lung cancer.

METHODS

We conducted this scoping review in 2023. We first searched scientific databases including PubMed, Scopus, ISI Web of Sciences, and Science Direct by combining related keywords for the past 12 years (2012-2023).

RESULTS

After reviewing 860 articles, we selected 39 studies for the purpose of this study. The interventions of teleoncology for lung cancer patients have four main categories, namely: monitoring of symptoms, monitoring the process of treatment and rehabilitation of patients, self-management and patient empowerment, and providing consultation for patients.

CONCLUSION

The appropriate implementation of teleoncology systems improves the patient's condition and reduces lung cancer complications by improving the availability of different health services.

PRACTICE IMPLICATIONS

More attention should be paid to the evaluation of telemedicine systems from the perspective of patients and health service providers. Also, the latest platforms, including mobile phone-based software, should be used to implement such systems.

Data-Driven Personalized Care in Lung Cancer: Scoping Review and Clinical Recommendations on Performance Status and Activity Level of Patients With Lung Cancer Using Wearable Devices

PURPOSE

Performance status (PS) is a crucial assessment for research and clinical practice in lung cancer (LC), including its usage for the assessment of the suitability and toxicity of treatment or eligibility for clinical trials of patients with LC. These PS assessments are subjective and lead to substantial discrepancies between observers. To improve the objectivity of PS assessments, Electronic Activity Monitoring devices (EAMs) are increasingly used in oncology, but how these devices are used for PS assessments in LC is an issue that remains unclear. The goal of this study is to address the challenges and opportunities of the use of digital tools to support PS assessments in patients with LC.

METHODS

The literature review followed PRISMA-ScR methodology. Searches were performed in the ScienceDirect, PsycInfo, ACM, IEEE Xplore, and PubMed databases. Furthermore, a panel discussion was performed to address the clinical use cases.

RESULTS

Thirty-two publications were found. Most of the studies used wrist accelerometry-based wearables (59%) and monitored sleep activity (SA; 28%) or physical activity (PA; 72%). Critical findings include positive usefulness of the use of wearables to categorize moderate-to-vigorous/light PA, which was associated with better sleep and health. In addition, steps and time awake immobile were found to be associated with risk of hospitalization and survival. Use cases identified included the health assessment of patients and clinical research.

CONCLUSION

There are positive experiences in the use of EAM to complement PS assessment in LC. However, there is a need for adapting thresholds to the particularities of patients with LC, for example, differentiating moderate-to-vigorous and light. Moreover, developing methodologies combining PS assessments and the use of EAM adapted to clinical and research practice is needed.

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.

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.

Use of Wearable Activity-Monitoring Technologies to Promote Physical Activity in Cancer Survivors: Challenges and Opportunities for Improved Cancer Care

The aim of this review was to explore the acceptability, opportunities, and challenges associated with wearable activity-monitoring technology to increase physical activity (PA) behavior in cancer survivors. A search of Medline, Embase, CINAHL, and SportDiscus was conducted from 1 January 2011 through 3 October 2022. The search was limited to English language, and peer-reviewed original research. Studies were included if they reported the use of an activity monitor in adults (+18 years) with a history of cancer with the intent to motivate PA behavior. Our search identified 1832 published articles, of which 28 met inclusion/exclusion criteria. Eighteen of these studies included post-treatment cancer survivors, eight were on active cancer treatment, and two were long-term cancer survivor studies. ActiGraph accelerometers were the primary technology used to monitor PA behaviors, with Fitbit as the most commonly utilized self-monitoring wearable technology. Overall, wearable activity monitors were found to be an acceptable and useful tool in improving self-awareness, motivating behavioral change, and increasing PA levels. Self-monitoring wearable activity devices have a positive impact on short-term PA behaviors in cancer survivors, but the increase in PA gradually attenuated through the maintenance phase. Further study is needed to evaluate and increase the sustainability of the use of wearable technologies to support PA in cancer survivors.

Technology-assisted behavioral intervention to encourage prehabilitation in frail older adults undergoing surgery: Development and design of the BeFitMe™ Apple Watch app

Objective

Increasing the physical activity of frail, older patients before surgery through prehabilitation (prehab) can hasten return to autonomy and reduce complications postoperatively. However, prehab participation is low in the clinical setting. In this study, we re-design an existing prehab smartphone application (BeFitMe™) using a novel standalone Apple Watch platform to increase accessibility and usability for vulnerable patients.

Methods

Design Science Research Methodology was used to (1) develop an approach to clinical research using standalone Apple Watches, (2) re-design BeFitMe™ for the Apple Watch platform, and (3) incorporate user feedback into app design. In phase 3, beta and user testers gave feedback via a follow-up phone call. Exercise data was extracted from the watch after testing. Descriptive statistics were used to summarize accessibility and usability.

Results

BeFitMe™ was redesigned for the Apple Watch with full functionality without requiring patients to have an iPhone or internet connectivity and the ability to passively collect exercise data without patient interaction. Three study staff participated in beta testing over 3 weeks. Six randomly chosen thoracic surgery patients participated in user testing over 12 weeks. Feedback from beta and user testers was addressed with updated software (versions 1.0-1.10), improved interface and notification schemes, and the development of educational materials used during enrollment. The majority of users (5/6, 83%) participated by responding to at least one notification and data was able to be collected for 54/82 (68%) of the days users had the watches. The amount of data collected in BeFitMe™ Watch app increased from 2/11 (16%) days with the first patient tester to 13/13 (100%) days with the final patient tester.

Conclusions

The BeFitMe™ Watch app is accessible and usable. The BeFitMe™ Watch app may help older patients, particularly those from vulnerable backgrounds with fewer resources, participate in prehab prior to surgery.

Consumer Wearables for Patient Monitoring in Otolaryngology: A State of the Art Review

OBJECTIVE

Consumer wearables, such as the Apple Watch or Fitbit devices, have become increasingly commonplace over the past decade. The application of these devices to health care remains an area of significant yet ill-defined promise. This review aims to identify the potential role of consumer wearables for the monitoring of otolaryngology patients.

DATA SOURCES

PubMed.

REVIEW METHODS

A PubMed search was conducted to identify the use of consumer wearables for the assessment of clinical outcomes relevant to otolaryngology. Articles were included if they described the use of wearables that were designed for continuous wear and were available for consumer purchase in the United States. Articles meeting inclusion criteria were synthesized into a final narrative review.

CONCLUSIONS

In the perioperative setting, consumer wearables could facilitate prehabilitation before major surgery and prediction of clinical outcomes. The use of consumer wearables in the inpatient setting could allow for early recognition of parameters suggestive of poor or declining health. The real-time feedback provided by these devices in the remote setting could be incorporated into behavioral interventions to promote patients' engagement with healthy behaviors. Various concerns surrounding the privacy, ownership, and validity of wearable-derived data must be addressed before their widespread adoption in health care.

IMPLICATIONS FOR PRACTICE

Understanding how to leverage the wealth of biometric data collected by consumer wearables to improve health outcomes will become a high-impact area of research and clinical care. Well-designed comparative studies that elucidate the value and clinical applicability of these data are needed.

Monitoring Patients Reported Outcomes after Valve Replacement Using Wearable Devices: Insights on Feasibility and Capability Study: Feasibility Results

Wearable devices (WDs) can objectively assess patient-reported outcomes (PROMs) in clinical trials. In this study, the feasibility and acceptability of using commercial WDs in elderly patients undergoing transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR) will be explored. This is a prospective observational study. Participants were trained to use a WD and a smartphone to collect data on their physical activity, rest heart rate and number of hours of sleep. Validated questionnaires were also used to evaluate these outcomes. A technology acceptance questionnaire was used at the end of the follow up. In our participants an overall good compliance in wearing the device (75.1% vs. 79.8%, SAVR vs. TAVR) was assessed. Half of the patients were willing to continue using the device. Perceived ease of use is one of the domains that scored higher in the technology acceptance questionnaire. In this study we observed that the use of a WD is accepted in our frail population for an extended period. Even though commercial WDs are not tailored for clinical research, they can produce useful information on patient behavior, especially when coordinated with intervention tailored to the single patient.

The role of technology in the perioperative management of bladder cancer patients

Consumer technology in the form of personal computers, mobile devices, and wearable technology, despite current underutilization, has the potential to greatly enhance the practice of urologic oncology and the surgical care of bladder cancer patients, particularly through the dissemination of educational videos, telemedicine, and the use of wearable technology for patient monitoring. A comprehensive healthcare application can unite all of these features, providing curated educational videos at different timepoints in surgical care, facilitating communication between the patient and the care team, and interfacing with wearable technology and other peripherals to allow for nonintrusive patient monitoring to help facilitate early identification of complications and to follow post-operative patient progress. Here we seek to review the available literature on this topic, discuss our institutional experience, and provide future perspectives in the perioperative management of bladder cancer patients.

Potential effectiveness of a surgeon-delivered exercise prescription and an activity tracker on pre-operative exercise adherence and aerobic capacity of lung cancer patients

OBJECTIVES

Pre-operative exercise may improve functional outcomes for lung cancer patients, but barriers associated with cost, resources, and burden make it challenging to deliver pre-operative exercise programs. The goal of this proof-of-concept study was to determine level of moderate-vigorous physical activity (MVPA) and change in aerobic capacity after participation in a home-based pre-operative exercise intervention.

MATERIALS AND METHODS

Eighteen patients scheduled for surgery for suspected stage I-III lung cancer received an exercise prescription from their surgeon and wore a commercially-available device that tracked their daily MVPA throughout the pre-operative period. Descriptive statistics were used to calculate adherence to the exercise prescription. A one-sample t-test was used to explore change in aerobic capacity from baseline to the day of surgery.

RESULTS

Participants exhibited a mean of 20.4 (sd = 46.2) minutes of MVPA per day during the pre-operative period. On average, the sample met the goal of 30 min of MVPA on 16.4% of the days during the pre-operative period. The mean distance achieved at baseline for the 6-min walk test was 456.7 m (sd = 72.9), which increased to 471.1 m (sd = 88.4) on the day of surgery. This equates to a mean improvement of 13.8 m (sd = 37.0), but this difference was not statistically different from zero (p = 0.14). Eight of the 17 participants (47%) demonstrated a clinically significant improvement of 14 m or more.

CONCLUSION

A surgeon-delivered exercise prescription plus an activity tracker may promote clinically significant improvement in aerobic capacity and MVPA engagement among patients with lung cancer during the pre-operative period, but may need to be augmented with more contact with and support from practitioners over time to maximize benefits.

TRIAL REGISTRATION

The study protocol was registered with ClinicalTrials.gov prior to initiating participant recruitment (NCT03162718).

Bridging the gap: a pre-post feasibility study of embedding exercise therapy into a co-located cancer unit

PURPOSE

To establish the feasibility of embedding a flexible, exercise-based rehabilitation program into a cancer treatment unit to allow cancer survivors early exercise support.

METHOD

A pre-post study was conducted using Bowen's Framework to describe key domains of feasibility: demand (referrals), acceptability (uptake, attendance, satisfaction), implementation (resources), practicality (adverse events, costs) and limited-efficacy (function, quality of life, self-efficacy). Participants were medically stable, adult cancer survivors receiving curative or palliative treatment for cancer at the health service. Participants completed an 8-week home or hospital-based exercise program. Data were analysed descriptively. Standardised mean differences (Hedge's g) and mean differences were calculated to determine effect size and clinical significance.

RESULTS

The exercise-based rehabilitation service received 155 referrals over 6 months. Of those eligible, 73/119 (61%) commenced. Participants opting for twice-weekly, hospital-based exercise attended 9/16 (56%) sessions. Participants reported high satisfaction and there were no major adverse events. The program utilised existing resources, with the predominant cost being staff. The average health service cost per participant was AUD $1,104. Participants made clinically significant gains in function (6-min walk distance; + 73 m, 95% confidence interval 49 to 96) and quality of life (EORTC QLQ-C30 Global quality of life; + 8 units, 95% confidence interval 3 to 13).

CONCLUSION

Implementation of exercise-based rehabilitation in a co-located cancer unit was safe and feasible. Access, patient and staff education and establishing funding streams are important implementation considerations. Implications for cancer survivors Access to exercise in a cancer unit provides opportunity for early intervention to optimise function during treatment.

Patient generated health data and electronic health record integration in oncologic surgery: A call for artificial intelligence and machine learning

In this review, we aim to assess the current state of science in relation to the integration of patient-generated health data (PGHD) and patient-reported outcomes (PROs) into routine clinical care with a focus on surgical oncology populations. We will also describe the critical role of artificial intelligence and machine-learning methodology in the efficient translation of PGHD, PROs, and traditional outcome measures into meaningful patient care models.