Physical activity levels in locally advanced rectal cancer patients following neoadjuvant chemoradiotherapy and an exercise training programme before surgery: a pilot study

What is the role of physical exercise in the era of cancer prehabilitation? A systematic review

PURPOSE

Exercise before surgery, as part of prehabilitation, aiming to enhance patients' functional and physiological capacity, has become widespread, necessitating an in-depth understanding.

METHODS

A systematic search was conducted on Pubmed, Cochrane, and Scopus to examine the effect of exercise as prehabilitation, alone or in combination with other interventions, in patients with cancer. Interventional studies applying a single-arm, randomized controlled, or nonrandomized design were included.

RESULTS

A total of 96 studies were included, and categorized according to cancer types, i.e., gynecological, breast, urological, gastrointestinal and lung cancer. For each cancer site, the effect of exercise, on physical fitness parameters and postoperative outcomes, including length of hospital stay and postoperative complications, was reported.

CONCLUSION

Exercise as prehabilitation may have an important role in improving physical fitness, postoperative outcomes, and accelerating recovery, especially in certain types of malignancies.

The effect of a pre- and post-operative exercise program versus standard care on physical activity and sedentary behavior of patients with esophageal and gastric cancer undergoing neoadjuvant treatment prior to surgery (the PERIOP-OG Trial): a randomized controlled trial†

Neoadjuvant cancer treatment (NCT) reduces both physical fitness and physical activity (PA) levels, which can increase the risk of adverse outcomes in cancer patients. This study aims to determine the effect of exercise prehabilitation on PA and sedentary behavior (SB) in patients undergoing NCT and surgery for esophagogastric malignancies. This study is a randomized pragmatic controlled multi-center trial conducted across three Irish hospitals. Participants were aged ≥18 years scheduled for esophagectomy or gastrectomy and were planned for NCT and surgery. Participants were randomized to an exercise prehabilitation group (EX) that commenced following cancer diagnosis, continued to the point of surgery, and resumed following recovery from surgery for 6 weeks or to usual care (UC) who received routine treatment. The primary outcome measures were PA and SB. Between March 2019 and December 2020, 71 participants were recruited: EX (n = 36) or UC (n = 35). No significant differences were found between the EX group and UC group on levels of PA or SBs across all measured timepoints. Significant decreases in moderate-vigorous physical activity levels (MVPAs) were found between baseline and post-surgery (P = 0.028), pre-surgery and post-surgery (P = 0.001) and pre-surgery and 6-week follow-up (P = 0.022) for all participants. Step count also significantly decreased between pre-surgery and post-surgery (P < 0.001). Baseline aerobic fitness was positively associated to PA levels and negatively associated with SB. Esophagogastric cancer patients have lower than recommended levels of PA at the time of diagnosis and this decreased further following completion of NCT. An optional home- or group-based exercise intervention was not effective in improving PA levels or behaviors across the cancer treatment journey.

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.

Changes in Self-Reported and Device-Measured Physical Activity Before Abdominal Resection Surgery: A Meta-Analysis

OBJECTIVE

To determine the effect of interventions on physical activity levels of patients awaiting abdominal resection surgery using self-reported as well as device-measured outcome measures.

DATA SOURCE

PubMed and EMBASE databases were searched on the 18th of April 2023 up to April 2023 for studies on interventions to promote physical activity during the preoperative phase.

REVIEW METHODS

Studies were included if pre- and post-intervention physical activity was measured between diagnosis and abdominal surgery. Risk of bias was assessed by the Physiotherapy Evidence Database (PEDro) assessment tool for trials. Meta-analyses were performed to assess the effect of the pre-surgery activity promoting interventions on self-reported and device-measured physical activity.

RESULTS

Seventeen studies were included in the analysis with 452 subjects in the intervention groups. The random-effect meta-analysis showed a moderate improvement in intervention groups measures in pre-surgery physical activity levels compared to the baseline (SMD = 0.67, [CI = 0.30;1.03], I2 = 79%). The self-reported subgroup meta-analysis showed the largest increase in performed physical activity, (SMD = 0.78, [CI = 0.4;1.15], I2 = 79%) whilst non-significant increase was shown in the device-measured subgroup (SMD = 0.16, [CI = -0.64;0.97], I2 = 58%).

CONCLUSION

Increasing physical activity in the preoperative phase is feasible. Self-reported physical activity outcome measures show larger effects compared to device-measured outcome measures. More high-quality research should be performed utilizing objective measures.

Effectiveness of Non-pharmacologic Interventions on Device-measured Physical Activity in Adults With Cancer, and Methodology Used for Assessment: A Systematic Review and Meta-analysis

OBJECTIVE

To investigate the effectiveness of different types of interventions aimed at enhancing device-measured physical activity (PA) and summarize the devices and methodologies used to measure PA in adults with cancer.

DATA SOURCES

A systematic review was prospectively registered on PROSPERO (CRD42020199466). The search was conducted in PubMed, The Cochrane Library, EMBASE (via Ovid), and PEDro from 2005 onward.

STUDY SELECTION

Prospective interventional studies (randomized controlled trials [RCTs], non-randomized controlled trials, and single-group trials), that included adults within 12 months from cancer diagnosis, and device-measured PA before and after commencement of an intervention were included. Studies were excluded if PA was measured at a single time point. Two independent reviewers screened 3033 records and 30 articles met the inclusion criteria.

DATA EXTRACTION

Two reviewers independently extracted the data. PEDro scale and GRADE approach were used to assess methodological quality of RCTs and overall quality of evidence, respectively. A meta-analysis of relevant RCTs was conducted.

DATA SYNTHESIS

Thirty studies were identified, mainly including adults with multiple cancer types. Interventions were behavior change interventions (n=15), exercise training (n=13), neuromuscular electrostimulation (n=1), or a nutritional program (n=1). The meta-analysis showed improvements on moderate-to-vigorous intensity PA (MVPA) in the experimental group (8 studies; standardized mean difference (SMD)=0.23; 95% CI 0.06-0.39); with subgroup analysis showing that findings were mainly driven by behavior change interventions (5 studies; SMD=0.23, 95% CI 0.05-0.41). An uncertain effect on sedentary behavior, daily steps, and light intensity PA was found. PA was measured with medical devices and commercial wearables, quality of the methodology was variable.

CONCLUSIONS

Behavior change interventions increased device-derived MVPA in adult cancer patients who underwent the intervention within 12 months of the cancer diagnosis. Various devices and methodologies were used to assess PA, which limits comparisons across the studies.

Effects of exercise training on cancer patients undergoing neoadjuvant treatment: A systematic review

OBJECTIVES

This systematic review aimed to analyze the effects of different exercise protocols on physical fitness (cardiorespiratory fitness, muscle strength, and body composition), quality of life, cancer-related fatigue, and sleep quality in patients with different types of cancer undergoing neoadjuvant treatment.

DESIGN

Systematic review.

METHOD

A comprehensive search of existing literature was carried out using four electronic databases: PubMed, Scopus, Web of Science, and Cochrane Library (published until October 19, 2022). All databases were searched for randomized controlled trials, quasi-experimental investigations, and pre-post investigations assessing the effects of exercise in cancer patients during neoadjuvant treatment. Excluded articles included multicomponent interventions, such as exercise plus diet or behavioral therapy, and investigations performed during adjuvant treatment or survivorship. The methodological quality of each study was assessed using the Physiotherapy Evidence Database (PEDro) scale.

RESULTS

Twenty-seven trials involving 999 cancer patients were included in this review. The interventions were conducted in cancer patients undergoing neoadjuvant treatment for rectal (n = 11), breast (n = 5), pancreatic (n = 4), esophageal (n = 3), gastro-esophageal (n = 2), and prostate (n = 1) cancers, and leukemia (n = 1). Among the investigations included, 14 utilized combined exercise protocols, 11 utilized aerobic exercise, and two utilized both aerobic and resistance training separately. Exercise interventions appeared to improve cardiorespiratory fitness, muscle strength, body composition, and quality of life, although many investigations lacked a between-group analysis.

CONCLUSION

Despite limited evidence, exercise interventions applied during neoadjuvant treatment demonstrate promising potential in enhancing cardiorespiratory fitness, muscle strength, body composition, and overall quality of life. However, a scarcity of evidence remains on the effects of exercise on cancer-related fatigue and sleep quality. Further research with high-quality randomized controlled trials is warranted.

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.

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)

"Optimal recovery" after colon cancer surgery in the elderly, a comparative cohort study: Conventional care vs. enhanced recovery vs. prehabilitation

BACKGROUND

Colon cancer in elderly patients is an increasing problem due to its prevalence and progressive aging population. Prehabilitation has experienced a great grown in this field. Whether it is the best standard of care for these patients has not been elucidated yet.

METHODS

A retrospective comparative cohort study of three different standards of care for elderly colon cancer patients (>65 years) was conducted. A four-weeks trimodal prehabilitation program (PP), enhanced recovery program (ERP) and conventional care (CC) were compared. Global complications, major complications (Clavien-Dindo ≥ 3), reinterventions, mortality, readmission and length of stay were measured. Optimal recovery, defined as postoperative course without major complications, no mortality, hospital discharge before the fifth postoperative day and without readmission, was the primary outcome measure. The influence of standard of care in optimal recovery and postoperative outcomes was assessed with univariate and multivariate logistic regression models.

RESULTS

A total of 153 patients were included, 51 in each group. Mean age was 77.9 years. ASA Score distribution was different between groups (ASA III-IV: CC 56.9%, ERP 25.5%, PP 58.9%; p = 0.014). Optimal recovery rate was 55.6% (PP 54.9%, ERP 66.7%, CC 45.1%; p = 0.09). No differences were found in major complications (p = 0.2) nor reinterventions (p = 0.7). Uneventful recovery favors ERP and PP groups (p = 0.046 and p = 0.049 respectively).

CONCLUSIONS

PP and ERP are safe and effective for older colon cancer patients. Fewer overall complications and readmissions happened in ERP and PP patients. Major complications were independent of the standard of care used.

Effects and duration of exercise-based prehabilitation in surgical therapy of colon and rectal cancer: a systematic review and meta-analysis

Purpose

Functional capacity is an independent indicator of morbidity in colon and rectal cancer surgery. This systematic review describes the evaluated and synthesized effects of exercise prehabilitation depending on the duration of interventions on functional and postoperative outcomes in colon and rectal cancer surgery.

Methods

Three electronic databases (MEDLINE Pubmed, Web of Sciences, and Cochrane Registry) were systematically searched (January 2022) for controlled trials that investigated the effects of prehabilitation prior to colo-rectal cancer resection.

Results

Twenty-three studies were included in this systematic review and 14 in our meta-analyses assessing these outcomes: the 6 min walk distance (6MWD), postoperative overall complications, and length of stay (LOS). We observed a significant improvement in preoperative functional capacity as measured with 6MWD (mean difference: 30.8 m; 95% CI 13.3, 48.3; p = 0.0005) due to prehabilitation. No reductions in LOS (mean difference: – 0.27 days; 95% CI – 0.93, 0.40; p = 0.5) or postoperative overall complications (Odds ratio: 0.84; 95% CI 0.53, 1.31; p = 0.44) were observed. Prehabilitation lasting more than 3 weeks tended to lower overall complications (Odds ratio: 0.66; 95% CI 0.4, 1.1; p = 0.11). However, the prehabilitation time periods differed between colon and rectal carcinoma resections.

Conclusion

Prehabilitation while the patient is preparing to undergo surgery for colorectal carcinoma improves functional capacity; and might reduce postoperative overall complications, but does not shorten the LOS. The studies we reviewed differ in target variables, design, and the intervention’s time period. Multicenter studies with sufficient statistical power and differentiating between colon and rectal carcinoma are needed to develop implementation strategies in the health care system.

Registration

PROSPERO CRD42022310532

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.

Prehabilitation in rectal surgery: a narrative review

AIM

Neoadjuvant chemotherapy (NACRT) can make decompensated patients more vulnerable prior to rectal surgery. Prehabilitation is an intervention which enhances functional capacity to withstand the stress of surgery. The aim of this review was to evaluate the impact of prehabilitation for patients undergoing rectal surgery on physical fitness and clinical outcomes and to establish feasibility of prehabilitation.

METHODS

An analysis of the literature was conducted of PubMed, the Cochrane Library, MEDLINE, EMBASE and ScienceDirect. Articles were initially included based on their title and abstracts reviewed. Full-text copies of those selected were obtained for confirmation of inclusion.

RESULTS

Eight studies were included. Heterogenicity was observed in the structure of exercise programmes. Improvements in physical fitness were observed in six studies. One study demonstrated a statistically significant improvement in quality of life. The prehabilitation programmes were shown to be feasible, with high completion rates. No adverse events were reported. There was limited data regarding the impact of prehabilitation on postoperative outcomes.

CONCLUSION

Current evidence on prehabilitation in rectal surgery has considerable heterogenicity in both structure of programmes and outcome measures. Standardisation is required for future evaluation of the impact on outcomes. A trimodal approach of exercise, nutritional and psychological interventions has been employed in similar programmes, and should be used in rectal surgery. The intervention should be tailored to the patient and environment. This review highlights the benefits, safety and feasibility of prehabilitation and provides a platform for consensus-building for international trials.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Physical Activity: A Systematic Review to Inform Nurse Recommendations During Treatment for Colorectal Cancer

Colorectal cancer (CRC) is the third most common cancer in the world (American Cancer Society [ACS], 2021). Because of increasing survival rates, there is a need improve survivors' quality of life (QOL), physical functioning, recurrence risk, and comorbidity prevalence (ACS, 2020). Many patients with CRC have poor QOL during and after treatment; other common side effects include fatigue, depression, anxiety, and decreased sleep quality (Bourke et al., 2014; Cramer et al., 2014; Gao et al., 2020). Focusing on the treatment period is important because physical activity (PA) may decrease side effects and prevent PA decline and functional decline, both of which can become significant barriers to PA following treatment. In addition, patients with CRC have a higher rate of comorbidities than patients without cancer, making lifestyle changes pre- and post-treatment particularly important for their continued survival and QOL (ACS, 2020).

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).

Impact of prehabilitation on objectively measured physical activity levels in elective surgery patients: a systematic review

OBJECTIVE

To systematically review the impact of prehabilitation on objectively measured physical activity (PA) levels in elective surgery patients.

DATA SOURCES

Articles published in Web of Science Core Collections, PubMed, Embase (Ovid), CINAHL (EBSCOHost), PsycInfo (EBSCOHost) and CENTRAL through August 2020.

STUDY SELECTION

Studies that met the following criteria: (1) written in English, (2) quantitatively described the effect(s) of a PA intervention among elective surgery patients prior to surgery and (3) used and reported objective measures of PA in the study.

DATA EXTRACTION AND SYNTHESIS

Participant characteristics, intervention details, PA measurement, and clinical and health-related outcomes were extracted. Risk of bias was assessed following the revised Cochrane risk of bias tool. Meta-analysis was not possible due to heterogeneity, therefore narrative synthesis was used.

RESULTS

6533 unique articles were identified in the search; 21 articles (based on 15 trials) were included in the review. There was little evidence to suggest that prehabilitation is associated with increases in objectively measured PA, but this may be due to insufficient statistical power as most (n=8) trials included in the review were small feasibility/pilot studies. Where studies tested associations between objectively measured PA during the intervention period and health-related outcomes, significant beneficial associations were reported. Limitations in the evidence base precluded any assessment via meta-regression of the association between objectively measured PA and clinical or health-related outcomes.

CONCLUSIONS

Additional large-scale studies are needed, with clear and consistent reporting of objective measures including accelerometry variables and outcome variables, to improve our understanding of the impact of changes in PA prior to surgery on surgical and health-related outcomes.

PROSPERO REGISTRATION NUMBER

CRD42019151475.

Exercise intervention in cancer patients with sleep disturbances scheduled for elective surgery: Systematic review

BACKGROUND & OBJECTIVES

Sleep disturbance is one of the patients' major complaints after major surgery and can impair postoperative recovery. Pre-operative exercise has been shown to increase functional capacity and resilience in cancer patients; scarce knowledge is available on the effects of pre-operative exercise on sleep disturbances. This systematic review aims to determine the impact of pre-operative exercise training alone or as part of multimodal prehabilitation on sleep disturbances and sleep quality in cancer patients.

METHODS

A systematic search including Biosis, Cochrane Library and CENTRAL, EMBASE, MEDLINE, and clinical trial registries (clinicaltrials.gov, International Clinical Trials Registry Platform) was performed to identify studies involving a pre-operative exercise intervention in cancer patients awaiting surgery. Trials had to contain at least one sleep measure, assessed subjectively and objectively were included in the systematic review. The quality of the included trials was assessed using the Cochrane Risk of Bias Tool for assessing the risk of bias in randomized trials tool and the ROBINS-I tool for evaluating the risk of bias in non-randomized studies.

RESULTS

Seven studies were included (1 RCT, 2 non-RCTs and 4 single-arm design). Due to substantial heterogeneity in the interventions across studies, a meta-analysis was not conducted. The available empirical evidence on the presurgical effect of exercise on sleep outcomes is scarce and, overall, suggests that it has a limited effect. Besides, non-significant improvement of the pre-operative exercise on sleep was unique to the studies that used subjective measures to assess sleep disturbances changes during cancer treatment.

CONCLUSION

There are conflicting results and a lack of quality data proving the pre-operative exercise on sleep quality and disturbances. More research is needed in the pre-operative period using clinical sleep disturbances such as insomnia as an inclusion criterion, subjectively and objectively assessed.

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

Background

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

Methods

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

Results

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

Conclusion

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

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.

Internet of Things in active cancer Treatment: A systematic review

The Internet of Things (IoT) applied to the treatment of cancer patients has been explored and the results are promising. This review aims to identify the applications and benefits of using IoT techniques, especially wearable devices, on the management of the adverse effects and symptoms, quality of life, and survival in cancer patients undergoing active treatment. The work also presents the architecture and taxonomy of the use of IoT, the challenges and the relevant results, as well as the association of the collected information with the type of treatment and the type of cancer. This study was based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and considered articles from the last 10 years. Specific and general research questions and the PICOS approach were used to define the search string and to guide the selection of articles. The search retrieved 1678 publications, of which 121 were included for a full review. 67% of selected studies addressed the monitoring and follow-up of physical activities and their associations with the adverse effects and symptoms related to cancer treatment. Besides, 53% evaluated sleep patterns, heart rate, and oxygen saturation levels. One-third of the studies assessed patients with the indication for surgery and about one-half evaluated patients undergoing chemotherapy. Furthermore, the IoT allowed verifying associations of human behaviors with adverse effects and quality of life. IoT was observed to contribute to monitoring cancer patients, improve their quality of life and manage adverse effects related to cancer treatment. 53% were pilot studies and 93% were published in the last 5 years, which demonstrates to be a recent issue and therefore still has a lot to be explored.

Supervised Physical Rehabilitation in the Treatment of Patients with Advanced Cancer: a Systematic Review and Meta-analysis

BACKGROUND

As the survival rate of cancer patients increases, the clinical importance of rehabilitation provided by healthcare professionals also increases. However, the evidence supporting the relevance of rehabilitation programs is insufficient. This study aimed to review the literature on effectiveness in physical function, quality of life (QOL) or fatigue of supervised physical rehabilitation in patients with advanced cancer.

METHODS

A systematic review and meta-analysis was conducted following the Cochrane guidelines. We narratively described the results when meta-analysis was not applicable or appropriate. Literature databases including Ovid-MEDLINE, Ovid-EMBASE, and the Cochrane Library, as well as several Korean domestic databases, were searched up to June 2017 for studies that investigated the effectiveness of supervised physical rehabilitation programs on physical function, QOL or fatigue in patients with advanced cancer. The quality of the selected studies was evaluated independently by paired reviewers.

RESULTS

Eleven studies with 922 participants were finally selected among 2,459 articles. The meta-analysis revealed that after physical exercise, the physical activity level and strength of patients with advanced cancer increased significantly. The QOL showed a statistically significant improvement after physical rehabilitation according to the European Organization for Research and Treatment of Cancer version C30. Though some of measurements about cardiovascular endurance or strength in several studies were not able to be synthesized, each study reported that they were significantly improved after receiving rehabilitation.

CONCLUSION

Supervised physical rehabilitation for patients with advanced cancer is effective in improving physical activity, strength, and QOL. However, more trials are needed to prove the effectiveness of supervised exercise and to strengthen the evidence.

Timed Stair-Climbing as a Surrogate Marker for Sarcopenia Measurements in Predicting Surgical Outcomes

BACKGROUND

Estimating sarcopenia by measuring psoas muscle density (PMD) has been advocated as a method to accurately predict post-operative morbidity. The aim of the present study was to determine whether the Timed Stair Climb (TSC) could be used to replace PMD measurements in predicting morbidity.

METHODS

Patients were prospectively enrolled from March 2014-2015 and were eligible if they were undergoing an abdominal operation. PMD was measured using pre-operative CT scans obtained within 90 days of surgery. Ninety-day complications were assessed using the Accordion Severity Grading System. Multivariable analysis was performed to identify risk factors associated with operative morbidity.

RESULTS

Of the patients, 298 were enrolled and completed TSC prior to undergoing an operation. Using the According Grading System, a grade 2 or higher complication occurred in 72 (24. 2%) patients with 8 (2.7%) deaths. There was an indirect relationship between PMD and TSC (P < 0.0001) and a direct relationship between TSC and complications (P = 0.04). On multivariable analysis decreasing PMD (P = 0.018) and increasing TSC (P = 0.026) were predictive of post-operative morbidity. Receiver operating characteristic curves demonstrated that the TSC was superior to both the ACS NSQIP Risk Calculator and PMD in predicting outcomes (TSC vs. PMD, P = 0.012; PMD vs. ACS NSQIP, P = 0.013; TSC vs. ACS NSQIP, P < 0.0001).

CONCLUSION

TSC, PMD, and the ACS NSQIP calculator are all useful tools; however, the TSC is superior in predicting post-operative morbidity.

A Review of Accelerometer-based Activity Monitoring in Cancer Survivorship Research

BACKGROUND

In the cancer survivorship context, physical activity and sedentary behavior have been measured using different methods.

PURPOSE

To conduct a narrative review of published research in cancer survivor populations to summarize the quality and identify gaps in reporting on accelerometer data collection, data processing, and outcome measures in cancer survivors.

METHODS

An initial PubMed® search of articles published in English was conducted in January 2017, and a final search was conducted in May 2017. Variables extracted included study characteristics, methods for accelerometry data collection (e.g., device used), data processing (e.g., cut points used), and data reporting (e.g., time spent in different activity intensities).

RESULTS

A total of 46 articles were eligible for inclusion in the review. The majority of studies (34 of 46) targeted a single cancer group and 18 of these 34 studies were in survivors of breast cancer. Half (54%) of the studies used an ActiGraph® accelerometer. Methods of accelerometer data processing varied across studies. Definitions of non-wear time, vectors used during processing, and filters applied during processing were reported by 51%, 60%, and 8% of studies, respectively. Most studies reported moderate and vigorous physical activity (78%), 50% reported sedentary time, and 43% reported light-intensity activity. Cut points to categorize these activities varied between studies.

CONCLUSIONS

This narrative review highlights inconsistency in the methods used to collect, process, and report accelerometry data across cancer survivor studies. Accelerometry has potential to add detailed knowledge of the levels and patterns of physical activities and sedentary behaviors across the cancer spectrum. Recommendations are made to improve data processing and reporting methods to maximize the scientific validity of future accelerometer research in this field.

Exercise interventions for people undergoing multimodal cancer treatment that includes surgery

BACKGROUND

People undergoing multimodal cancer treatment are at an increased risk of adverse events. Physical fitness significantly reduces following cancer treatment, which is related to poor postoperative outcome. Exercise training can stimulate skeletal muscle adaptations, such as increased mitochondrial content and improved oxygen uptake capacity may contribute to improved physical fitness.

OBJECTIVES

To determine the effects of exercise interventions for people undergoing multimodal treatment for cancer, including surgery, on physical fitness, safety, health-related quality of life (HRQoL), fatigue, and postoperative outcomes.

SEARCH METHODS

We searched electronic databases of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, SPORTDiscus, and trial registries up to October 2018.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that compared the effects of exercise training with usual care, on physical fitness, safety, HRQoL, fatigue, and postoperative outcomes in people undergoing multimodal cancer treatment, including surgery.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, performed the data extraction, assessed the risk of bias, and rated the quality of the studies using Grading of Recommendation Assessment, Development, and Evaluation (GRADE) criteria. We pooled data for meta-analyses, where possible, and reported these as mean differences using the random-effects model.

MAIN RESULTS

Eleven RCTs were identified involving 1067 participants; 568 were randomly allocated to an exercise intervention and 499 to a usual care control group. The majority of participants received treatment for breast cancer (73%). Due to the nature of the intervention, it was not possible to blind the participants or personnel delivering the intervention. The risk of detection bias was either high or unclear in some cases, whilst most other domains were rated as low risk. The included studies were of moderate to very low-certainty evidence. Pooled data demonstrated that exercise training may have little or no difference on physical fitness (VO₂ max) compared to usual care (mean difference (MD) 0.05 L/min^-1, 95% confidence interval (CI) -0.03 to 0.13; I² = 0%; 2 studies, 381 participants; low-certainty evidence). Included studies also showed in terms of adverse effects (safety), that it may be of benefit to exercise (8 studies, 507 participants; low-certainty evidence). Furthermore, exercise training probably made little or no difference on HRQoL (EORTC global health status subscale) compared to usual care (MD 2.29, 95% CI -1.06 to 5.65; I² = 0%; 3 studies, 472 participants; moderate-certainty evidence). However, exercise training probably reduces fatigue (multidimensional fatigue inventory) compared to usual care (MD -1.05, 95% CI -1.83 to -0.28; I² = 0%; 3 studies, 449 participants moderate-certainty evidence). No studies reported postoperative outcomes.

AUTHORS' CONCLUSIONS

The findings should be interpreted with caution in view of the low number of studies, the overall low-certainty of the combined evidence, and the variation in included cancer types (mainly people with breast cancer), treatments, exercise interventions, and outcomes. Exercise training may, or may not, confer modest benefit on physical fitness and HRQoL. Limited evidence suggests that exercise training is probably not harmful and probably reduces fatigue. These findings highlight the need for more RCTs, particularly in the neoadjuvant setting.

Risk Assessment

Purpose of Review

The central question of preoperative assessment is not “What can be done?” but “What should be done and how?” Predicting a patient’s risk of unwanted outcomes is vital to answering this question. This review discusses risk prediction tools currently available and anticipates future developments.

Recent Findings

Simple, parsimonious risk scales and scores are being replaced by complex risk prediction models as high-capacity information systems become ubiquitous. The accuracy of risk estimation will be further increased by improved assessment of physical fitness, frailty, and incorporation of existing and novel biomarkers. However, the limitations of risk prediction for individual patient care must be recognized.

Summary

Risk prediction is transforming from clinical estimation to statistical science. Predictions should be used within the context of a patient’s baseline risk (life expectancy independent of surgery), personal circumstances, quality of life, their expectations and values, and consideration of outcomes that are meaningful for the patient.