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

Intervention combinations within multimodal prehabilitation and their effect on health-related quality of life, fatigue, and adherence in the adult cancer population: an umbrella review protocol

OBJECTIVE

This umbrella review will investigate intervention combinations that are provided as multimodal prehabilitation and their effect on health-related quality of life, fatigue, and adherence in the adult cancer population.

INTRODUCTION

Cancer and treatment-related long-term and late effects are a significant source of impairment worldwide. Multimodal prehabilitation has been the subject of intense research in recent years due to its potential to improve cancer treatment and surgical outcomes. Prehabilitation has been provided in different combinations of exercise, nutrition, and psychological support, although evidence of effectiveness varies in the literature.

INCLUSION CRITERIA

The review will consider quantitative and mixed methods (segregated approach) systematic reviews investigating the effectiveness of multimodal prehabilitation compared with any other or no intervention for adults with cancer (≥18 years). Systematic reviews focusing solely on unimodal prehabilitation or rehabilitation during or after cancer treatment will be excluded.

METHODS

This review will follow the JBI methodology for umbrella reviews. The following databases will be searched from 2001 onwards: MEDLINE, Emcare, PsycINFO, and AMED (Ovid); CINAHL (EBSCOhost); PEDro; Cochrane Database of Systematic Reviews; and Epistemonikos. Backchaining and forward citation tracking will also be performed. Organizational websites will be searched for relevant gray literature. Two reviewers will perform title/abstract and full-text screening against the inclusion criteria, and disagreements will be resolved via discussion or a third reviewer. Relevant population, intervention, and outcome data will be extracted from included full-text documents, and the quality of reports will be determined using the JBI checklist for systematic reviews. The results will be presented in tabular and narrative format.

REVIEW REGISTRATION

PROSPERO CRD42024511601.

Enhancing Mobility in Oncology: Evidence-Based Practices Across the Care Continuum

OBJECTIVES

Provide an overview of research-derived insights aimed at elucidating best practices for enhancing mobility in patients with cancer throughout the entirety of the care continuum. Highlighting the value of a multidisciplinary approach involving various healthcare professionals to optimize mobility outcomes for patients with cancer and the benefits of different approaches.

METHODS

A literature search was conducted in PubMed/Medline, CINAHL, Scopus, Embase, and on Google Scholar using search terms, mobility, exercise, cancer, nurs*, physical activity, pre-habilitation, rehabilitation, best practices. Systematic reviews, meta-analyses, peer reviewed research studies, exercise, and physical activity recommendations were reviewed to provide a comprehensive overview of strategies aimed at enhancing mobility in patients with cancer.

RESULTS

Twenty-nine references were included in this overview of enhancing mobility in patients with cancer across the care continuum.

CONCLUSIONS

Evidence-based strategies prioritize enhancing mobility for patients with cancer, aiming to boost physical functioning and overall quality of life. Healthcare providers should consider each patient's unique needs and limitations when implementing these evidence-based approaches, emphasizing a multidisciplinary approach involving oncologists, surgeons, nurses, physical therapists, occupational therapists, and other professionals to ensure comprehensive and personalized care focused on improving mobility.

IMPLICATIONS FOR NURSING PRACTICE

Nurses advocate for incorporating exercise into cancer care plans throughout the entire treatment journey, collaborating with healthcare team members to tailor programs to individual patient needs. Working together as an interdisciplinary team, nurses help develop an overall care plan that emphasizes exercise as an important aspect of cancer care, using their expertise to create customized exercise routines to encourage and motivate patients to participate in physical activity.

Impact of exercise on chemotherapy-induced peripheral neuropathy in survivors with post-treatment primary breast cancer

PURPOSE

Chemotherapy-induced peripheral neuropathy (CIPN) is a debilitating side effect of neurotoxic chemotherapy. Exercise activates neuromuscular function and may improve CIPN. We examined the association between exercise and CIPN symptoms in breast cancer survivors.

METHODS

In a retrospective cross-sectional study, we included patients completing a survey assessing exercise exposure and neuropathy symptoms in a tertiary cancer center survivorship clinic. We evaluated exercise duration and intensity using a standardized questionnaire quantified in metabolic equivalent tasks (MET-h/wk). We defined exercisers as patients meeting the National Physical Activity Guidelines' criteria. We used multivariable logistic regressions to examine the relationship between exercise and CIPN and if this differed as a function of chemotherapy regimen adjusting for age, gender, and race.

RESULTS

We identified 5444 breast cancer survivors post-chemotherapy (median age 62 years (interquartile range [IQR]: 55, 71); median 4.7 years post-chemotherapy (IQR: 3.3, 7.6)) from 2017 to 2022. CIPN overall prevalence was 34% (95% confidence interval [CI]: 33%, 36%), 33% for non-taxane, and 37% for taxane-based chemotherapy. CIPN prevalence was 28% (95% CI: 26%, 30%) among exercisers and 38% (95% CI: 37%, 40%) among non-exercisers (difference 11%; 95% CI: 8%, 13%; p < 0.001). Compared to patients with low (<6 MET-h/wk) levels of exercise (42%), 11% fewer patients with moderate (6-20.24 MET-h/wk) to high (>20.25 MET-h/wk) levels of exercise reported CIPN. Exercise was associated with reduced prevalence of all CIPN symptoms regardless of chemotherapy type.

CONCLUSION

CIPN may persist several years following chemotherapy among patients with breast cancer but is significantly reduced by exercise in a dose-dependent manner.

Health professional attitudes and perceptions of prehabilitation and nutrition before haematopoietic cell transplantation

BACKGROUND

Nutritional prehabilitation may improve haematopoietic cell transplantation (HCT) outcomes, although little evidence exists. The present study aimed to understand healthcare professional (HCP) perceptions of prehabilitation and nutritional care pre-HCT in UK centres.

METHODS

An anonymous online survey (developed and refined via content experts and piloting) was administered via email to multidisciplinary HCPs in 39 UK adult centres, between July 2021 and June 2022. Data are presented as proportions of responses. Routine provision denotes that care was provided >70% of time.

RESULTS

Seventy-seven percent (n = 66) of HCPs, representing 61.5% (n = 24) of UK adult HCT centres, responded. All HCPs supported prehabilitation, proposing feasible implementation between induction chemotherapy (60.4%; n = 40) and first HCT clinic (83.3%; n = 55). Only 12.5% (n = 3) of centres had a dedicated prehabilitation service. Nutrition (87.9%; n = 58), emotional wellbeing (92.4%; n = 61) and exercise (81.8%; n = 54) were considered very important constituents. HCPs within half of the HCT centres (n = 12 centres) reported routine use of nutrition screening pre-HCT with a validated tool; 66.7% of HCPs (n = 36) reported using the malnutrition universal screening tool (MUST). Sixty-two percent (n = 41) of HCPs reported those at risk, received nutritional assessments, predominantly by dietitians (91.6%; n = 22) using the dietetic care process (58.3%; n = 14). Body mass index (BMI) was the most frequently reported body composition measure used by HCPs (70.2%, n = 33). Of 59 respondents, non-dietitians most routinely provided dietary advice pre-HCT (82.4%; n = 28 vs. 68%; n = 17, p = 0.2); including high-energy/protein/fat and neutropenic diet advice. Prophylactic enteral feeding pre-HCT was rare, indicated by low BMI and significant unintentional weight loss. Just under half (n = 25 of 59, 42.4%) HCPs reported exercise advice was given routinely pre-HCT.

CONCLUSIONS

Nutrition and prehabilitation pre-HCT are considered important and deliverable by HCPs, but current provision in UK centres is limited and inconsistent.

Summary of the best evidence for prehabilitation management of patients with non-small cell lung cancer

Objective

This study adopts an evidence-based methodology to establish a comprehensive theory foundation for preoperative prehabilitation management in non-small cell lung cancer (NSCLC) patients.

Methods

A systematic literature review linked to prehabilitation management for NSCLC patients was conducted, utilizing reputable databases such as UpToDate, BMJ Best Practice, UK NICE, SIGN, GIN, Joanna Briggs Institute Library, Cochrane Library, Web of Science, Embase, OVID evidence-based database, PubMed, Chinese Wanfang database, CNKI, CBM, ATS, BTS, AACVPR, and EACTS. The search encompassed articles, including clinical decision-making, guidelines, evidence summaries, expert consensuses, and systematic reviews, from the inception of databases up to March 31st, 2023. Two researchers performed quality assessment of the literature and subsequent evidence extraction.

Results

Nineteen articles were included, comprising five guidelines, three expert consensuses, seven systematic reviews, and four randomized controlled trials. A total of 41 pieces of evidence were summarized, addressing key aspects such as the multidisciplinary team, appropriate patient population, prehabilitation modes, timing of prehabilitation, prehabilitation assessment, prehabilitation content, quality control, and effectiveness evaluation.

Conclusions

The synthesis of the best evidence for prehabilitation management in NSCLC patients provides a solid evidence-based foundation for its implementation. It is recommended that healthcare professionals conduct thorough patient evaluations, optimize and integrate medical resources, and collaboratively engage in interdisciplinarity efforts to develop and implement personalized and multimodal prehabilitation plans.

Exercise in cancer patients: assistance levels and referral pathways-a position statement from the Spanish Society of Medical Oncology

There is growing evidence about how physical activity can improve cancer care. Unfortunately, exercise is still not widely prescribed to oncology patients, despite the benefit it brings. For this to occur, it is necessary for a multidisciplinary approach involving different types of healthcare professionals, given that each treatment be tailored for each single case. Besides incorporating appropriate infrastructures and referral pathways, we need to integrate exercise into healthcare practice, which ameliorates patients' quality of life and treatment side effects. From the Spanish Society of Medical Oncology (SEOM), and through the Exercise and Cancer Working Group, we indicate considerations, analyze patient care scenarios, and propose a referral pathway algorithm for exercise prescription, taking in account the patient's needs. In later sections of this paper, we describe how this algorithm could be implemented, and how the exercise programs should be built, including the physical activity contents, the settings, and the delivery mode. We conclude that professionals, infrastructures, and organizations should be available at every assistance level to create programs providing adequate exercise training for cancer patients.

The impact of a physical exercise program on quality of life, fatigue, physical performance, and level of physical activity in patients with cancer

OBJECTIVE

Increasing evidence suggests that exercise programs are of great value in the rehabilitation and survivorship of patients with cancer. However, challenges remain regarding maintaining patients more physically active. This study aimed to evaluate the impact of a supervised exercise program on quality of life, fatigue, physical performance, and levels of physical activity of patients with cancer.

METHODS

An observational longitudinal study, with a 1-year prospective follow-up, was developed.

SETTING

This is a university-based outpatient rehabilitation program in a high-complexity cancer care center in Sao Paulo.

RESULTS

After the program, patients showed a significant gain in quality of life (p<0.0001), physical performance (p<0.0001), and improvement in fatigue (p<0.0001). After 12 months, 81.1% of the patients remained active, and only 4.5% declared themselves to be sedentary.

CONCLUSION

The results of this study confirm that exercise programs are an important tool in the rehabilitation of patients with cancer and that an initial supervised exercise program, in combination with follow-ups, can help increase the levels of physical activity of this population.

CLINICAL REHABILITATION IMPACT

This study provides additional information on the outcomes that are expected with the provision of a supervised physical exercise program in the rehabilitation care of patients with cancer and that additional follow-ups could further benefit this population.

Current landscape and support for practical initiation of oncological prehabilitation translatable to thyroid cancer: A position paper

Despite a growing body of evidence for the effectiveness of prehabilitation, the uptake of prehabilitation in Europe remains low. Contributing factors range from limited awareness and understanding of prehabilitation to a lack of supporting infrastructure and reimbursement challenges. In this position paper, the authors propose a new comprehensive definition of prehabilitation and identify differentiated thyroid cancer as a type of cancer particularly well-suited for prehabilitation. To support clinicians with the implementation of prehabilitation programs in their clinics, the authors discuss the following practical solutions: a) find the most appropriate prehabilitation program for each patient; b) raise awareness among peers; c) develop evidence to demonstrate the effectiveness of prehabilitation; d) expand the interdisciplinary team; e) expand your network and make use of existing assets; f) utilize learnings from the COVID-19 pandemic.

Variation in Hospital Mortality After Complex Cancer Surgery: Patient, Volume, Hospital or Social Determinants?

INTRODUCTION

We sought to define the individual contributions of patient characteristics (PCs), hospital characteristics (HCs), case volume (CV), and social determinants of health (SDoH) on in-hospital mortality (IHM) after complex cancer surgery.

METHODS

The California Department of Health Care Access and Information database identified patients who underwent esophagectomy (ES), pneumonectomy (PN), pancreatectomy (PD), or proctectomy (PR) for a malignant diagnosis between 2010 and 2020. Multi-level multivariable regression was performed to assess the proportion of variance explained by PCs, HCs, CV and SDoH on IHM.

RESULTS

A total of 52,838 patients underwent cancer surgery (ES: n = 2,700, 5.1%; PN: n = 30,822, 58.3%; PD: n = 7530, 14.3%; PR: n = 11,786, 22.3%) across 294 hospitals. The IHM for the overall cohort was 1.7% and varied from 4.4% for ES to 0.8% for PR. On multivariable regression, PCs contributed the most to the variance in IHM (overall: 32.0%; ES: 21.6%; PN: 28.0%; PD: 20.3%; PR: 39.9%). Among the overall cohort, CV contributed 2.4%, HCs contributed 1.3%, and SDoH contributed 1.2% to the variation in IHM. CV was the second highest contributor to IHM among ES (5.3%), PN (5.3%), and PD (5.9%); however, HCs were a more important contributor among patients who underwent PR (8.0%). The unexplained variance in IHM was highest among ES (72.4%), followed by the PD (67.5%) and PN (64.6%) patient groups.

CONCLUSIONS

PCs are the greatest underlying contributor to variations in IHM following cancer surgery. These data highlight the need to focus on optimizing patients and exploring unexplained sources of IHM to improve quality of surgical care.

An Integrated Care Approach to Improve Well-Being in Breast Cancer Patients

BACKGROUND

Breast cancer (BC) treatment has recently been revolutionized by the introduction of newer targeted agents, that helped tailoring therapies around the single patient. Along with increased survival rates, a careful evaluation of diet, lifestyle habits, physical activity, emotional and psychological experiences linked to the treatment journey, is now mandatory. However, a true proposal for an omnicomprehensive and "integrative" approach is still lacking in literature.

METHODS

A scientific board of internationally recognized specialists throughout different disciplines designed a shared proposal of holistic approach for BC patients.

RESULTS

A narrative review, containing information on BC treatment, endocrinological and diet aspects, physical activity, rehabilitation, integrative medicine, and digital narrative medicine, was developed.

CONCLUSIONS

In the context of a patient-centered care, BC treatment cannot be separated from a patient's long-term follow-up and care, and an organized interdisciplinary collaboration is the future in this disease's cure, to make sure that our patients will live longer and better.

TRIAL REGISTRATION

NCT05893368: New Model for Integrating Person-based Care (PbC) in the Treatment of Advanced HER2-negative Breast Cancer (PERGIQUAL). Registration date: 29th May 2023.

Prehabilitation for Patients with Cancer Undergoing Radiation Therapy: a Scoping Review

AIMS

Prehabilitation is a process of identifying and assessing factors that could compromise the physical and psychological health of patients undergoing cancer treatment and implementing an intervention to combat such concerns. The use of prehabilitation in cancer surgery has yielded positive outcomes in rectal, lung and abdominal cancers. Prehabilitation strategies have potential to improve the management of patients receiving radiation therapy or chemoradiation. The aim of the present study was to map the evidence of the assessment and evaluation of prehabilitation for radiation therapy patients.

MATERIALS AND METHODS

A database search using EMBASE and PubMed was conducted. The PRISMA guidelines were adhered to. Keywords included prehabilitation, radiation therapy/radiotherapy, chemoradiotherapy/chemoradiation, intervention and exercise. Types of prehabilitation strategy, their purposes and impact, according to cancer site, were analysed.

RESULTS

Prehabilitation is most commonly evaluated in head and neck cancer, whereby unimodal, physical interventions manage dysphagia. Prehabilitation for lung cancer demonstrated its ability to widen treatment options for patients. Physical prehabilitation is administered to combat adverse effects of neoadjuvant chemoradiation therapy in patients with rectal cancer.

CONCLUSION

Prehabilitation is adaptive and tailored to specific patient and site needs; thus it is applied across a wide range of cancer sites. More interventions by which radiation therapy is the definitive treatment modality and larger sample sizes within these studies are warranted to increase prehabilitation utilisation for patients undergoing radiation therapy.

Perioperative Considerations for the Surgical Treatment of Crohn's Disease with Discussion on Surgical Antibiotics Practices and Impact on the Gut Microbiome

Crohn's disease, a chronic inflammatory process of the gastrointestinal tract defined by flares and periods of remission, is increasing in incidence. Despite advances in multimodal medical therapy, disease progression often necessitates multiple operations with high morbidity. The inability to treat Crohn's disease successfully is likely in part because the etiopathogenesis is not completely understood; however, recent research suggests the gut microbiome plays a critical role. How traditional perioperative management, including bowel preparation and preoperative antibiotics, further changes the microbiome and affects outcomes is not well described, especially in Crohn's patients, who are unique given their immunosuppression and baseline dysbiosis. This paper aims to outline current knowledge regarding perioperative management of Crohn's disease, the evolving role of gut dysbiosis, and how the microbiome can guide perioperative considerations with special attention to perioperative antibiotics as well as treatment of Mycobacterium avium subspecies paratuberculosis. In conclusion, dysbiosis is common in Crohn's patients and may be exacerbated by malnutrition, steroids, narcotic use, diarrhea, and perioperative antibiotics. Dysbiosis is also a major risk factor for anastomotic leak, and special consideration should be given to limiting factors that further perturb the gut microbiota in the perioperative period.

Feasibility study of a multimodal prehabilitation programme in women receiving neoadjuvant therapy for breast cancer in a major cancer hospital: a protocol

INTRODUCTION

Neoadjuvant therapy has become a standard treatment for patients with stage II/III HER2 positive and triple negative breast cancer, and in well-selected patients with locally advanced and borderline resectable high risk, luminal B breast cancer. Side effects of neoadjuvant therapy, such as fatigue, cardiotoxicity, neurotoxicity, anxiety, insomnia, vasomotor symptoms, gastrointestinal disturbance as well as a raft of immune-related adverse events, may impact treatment tolerance, long-term outcomes, and quality of life. Providing early supportive care prior to surgery (typically termed 'prehabilitation') may mitigate these side effects and improve quality of life.During our codesign of the intervention, consumers and healthcare professionals expressed desire for a programme that 'packaged' care, was easy to access, and was embedded in their care pathway. We hypothesise that a multimodal supportive care programme including exercise and complementary therapies, underpinned by behavioural change theory will improve self-efficacy, quality of life, readiness for surgery and any additional treatment for women with breast cancer. We seek to explore cardiometabolic, residual cancer burden and surgical outcomes, along with chemotherapy completion (relative dose intensity). This article describes the protocol for a feasibility study of a multimodal prehabilitation programme.

METHODS AND ANALYSIS

This is a prospective, mixed-method, feasibility study of a multi-modal programme in a hospital setting for 20-30 women with breast cancer receiving neoadjuvant therapy. Primary outcomes are recruitment rate, retention rate, adherence and acceptability. Secondary outcomes include patient reported outcome measures (PROMs), surgical outcomes, length of stay, satisfaction with surgery, chemotherapy completion rates, changes in metabolic markers and adverse events. Interviews and focus groups to understand the experience with prehabilitation and different factors that may affect feasibility of the intervention . The output of this study will be a codesigned, evidence-informed intervention assessed for feasibility and acceptability by women with breast cancer and the healthcare professionals that care for them.

ETHICS AND DISSEMINATION

The study received ethics approval from the St Vincents Hospital HREC (HREC/2021/ETH12198). Trial results will be communicated to participants, healthcare professionals, and the public via publication and conferences.

TRIAL REGISTRATION NUMBER

ACTRN12622000584730.

Prehabilitation in radiation therapy: a scoping review

PURPOSE/OBJECTIVES

Radiation therapy (RT) is a central component of cancer treatment with survival and long-term quality-of-life benefits across a spectrum of oncologic diagnoses. However, RT has been associated with varying levels of fatigue, pain, weight loss, and changes in mental health both during and post-treatment. Prehabilitation aims to optimize health prior to anti-neoplastic therapy in order to reduce side effects, increase adherence to treatment, expedite post-treatment recovery, and improve long-term outcomes. Though prehabilitation has been studied in those undergoing cancer-related surgery, literature on prehabilitation in individuals undergoing RT has not been comprehensively explored. Thus, this scoping review aims to summarize the existing literature focused on prehabilitation interventions for patients receiving RT.

MATERIALS/METHODS

The PRISMA-ScR checklist for conducting scoping reviews was adopted to identify and evaluate studies investigating the efficacy of prehabilitation before and during RT for cancer over the past 21 years (10/2002-10/2022). A search of prehabilitation and RT was performed to identify studies investigating prehabilitation interventions in adult cancer patients undergoing RT.

RESULTS

A total of 30 articles met inclusion criteria, yielding 3657 total participants. Eighteen (60%) studies were randomized controlled trials (RCTs) with sample sizes ranging from 21 to 221. The most commonly studied populations were patients with head and neck cancer, followed by rectal, breast, and lung cancer. A majority (80%) of studies evaluated one prehabilitation intervention (i.e., unimodal). Targeted physical exercises were the most common intervention, followed by general physical exercises and technology/apps. Adherence/feasibility was the most common primary outcome, representing 30% of studies. All studies reported data on sex, and 5 (17%) reported data on race and/or ethnicity.

CONCLUSIONS

Prehabilitation interventions have been successfully implemented in patients with cancer undergoing surgical treatment. Based on limited current literature, prehabilitation appears to have a promising effect in reducing morbidity in adult cancer patients requiring RT. Though our review identified many RCTs, they were frequently small sample trials with primary outcomes focused on feasibility, rather than functional status or quality of life. Thus, there is a need for adequately powered, randomized controlled intervention trials to investigate the efficacy of prehabilitation and maximize the treatment outcomes for patients undergoing RT.

Update on the management of elderly patients with colorectal cancer

Colorectal cancer (CRC) is one of the most common tumours worldwide, and 70% of CRC patients are over 65 years of age. However, the scientific evidence available for these patients is poor, as they are underrepresented in clinical trials. Therefore, a group of experts from the Oncogeriatrics Section of the Spanish Society of Medical Oncology (SEOM), the Spanish Cooperative Group for the Treatment of Digestive Tumours, (TTD) and the Multidisciplinary Spanish Group of Digestive Cancer (GEMCAD) have reviewed the scientific evidence available in older patients with CRC. This group of experts recommends a multidisciplinary approach and geriatric assessment (GA) before making a therapeutic decision because GA predicts the risk of toxicity and survival and helps to individualize treatment. In addition, elderly patients with localized CRC should undergo standard cancer resection, preferably laparoscopically. The indication for adjuvant chemotherapy (CT) should be considered based on the potential benefit, the risk of recurrence, the life expectancy and patient comorbidities. When the disease is metastatic, the possibility of radical treatment with surgery, radiofrequency (RF) or stereotactic body radiation therapy (SBRT) should be considered. The efficacy of palliative CT is similar to that seen in younger patients, but elderly patients are at increased risk of toxicity. Clinical trials should be conducted with the elderly population and include GAs and specific treatment plans.

[Pre-rehabilitation of oncological patients before extensive abdominal and thoracic surgery: a literature review]

Surgery is one of the leading treatment methods of patients with primary or recurrent malignant neoplasms in the thoracic or abdominal cavity. Extensive abdominal interventions are accompanied by such adverse outcomes as blood loss, hypoxia, inflammation, blood clotting abnormality, emotional and cognitive disorders, that increases the incidence of serious complications and worsens the treatment outcome and life quality in weakened oncological patients. Multimodal pre-rehabilitation before surgery can significantly decrease the incidence and severity of postoperative complications. The rehabilitation complex includes exercise therapy, nutritional and psychological support, smoking cessation and pharmacotherapy. Currently, there are a number of questions facing rehabilitation specialists and oncologists, that are related to the determination of pre-rehabilitation optimal timing and process duration, the choice of specific physical exercises, determining the load intensity. This review presents a current view on understanding of surgical stress in extensive abdominal interventions, its effect on the oncological process course, summarizes the experience of last years in choosing pre-rehabilitation program taking into account pathogenetic mechanisms of surgical stress and individual patient's characteristics. Special attention is paid to the comparison of physical exercises' various types, their action mechanisms at different stages of pathological process, the issues of load dosing during pre-rehabilitation activities.

Frailty in end-stage liver disease: Understanding pathophysiology, tools for assessment, and strategies for management

Frailty and sarcopenia are frequently observed in patients with end-stage liver disease. Frailty is a complex condition that arises from deteriorations across various physiological systems, including the musculoskeletal, cardiovascular, and immune systems, resulting in a reduced ability of the body to withstand stressors. This condition is associated with declined resilience and increased vulnerability to negative outcomes, including disability, hospitalization, and mortality. In cirrhotic patients, frailty is influenced by multiple factors, such as hyperammonemia, hormonal imbalance, malnutrition, ascites, hepatic encephalopathy, and alcohol intake. Assessing frailty is crucial in predicting morbidity and mortality in cirrhotic patients. It can aid in making critical decisions regarding patients' eligibility for critical care and transplantation. This, in turn, can guide the development of an individualized treatment plan for each patient with cirrhosis, with a focus on prioritizing exercise, proper nutrition, and appropriate treatment of hepatic complications as the primary lines of treatment. In this review, we aim to explore the topic of frailty in liver diseases, with a particular emphasis on pathophysiology, clinical assessment, and discuss strategies for preventing frailty through effective treatment of hepatic complications. Furthermore, we explore novel assessment and management strategies that have emerged in recent years, including the use of wearable technology and telemedicine.

Understanding Variation in In-hospital Mortality After Major Surgery in the United States

OBJECTIVES

We aimed to quantify the contributions of patient characteristics (PC), hospital structural characteristics (HC), and hospital operative volumes (HOV) to in-hospital mortality (IHM) after major surgery in the United States (US).

BACKGROUND

The volume-outcome relationship correlates higher HOV with decreased IHM. However, IHM after major surgery is multifactorial, and the relative contribution of PC, HC, and HOV to IHM after major surgery is unknown.

STUDY DESIGN

Patients undergoing major pancreatic, esophageal, lung, bladder, and rectal operations between 2006 and 2011 were identified from the Nationwide Inpatient Sample linked to the American Hospital Association survey. Multilevel logistic regression models were constructed using PC, HC, and HOV to calculate attributable variability in IHM for each.

RESULTS

Eighty thousand nine hundred sixty-nine patients across 1025 hospitals were included. Postoperative IHM ranged from 0.9% for rectal to 3.9% for esophageal surgery. Patient characteristics contributed most of the variability in IHM for esophageal (63%), pancreatic (62.9%), rectal (41.2%), and lung (44.4%) operations. HOV explained < 25% of variability for pancreatic, esophageal, lung, and rectal surgery. HC accounted for 16.9% and 17.4% of the variability in IHM for esophageal and rectal surgery. Unexplained variability in IHM was high in the lung (44.3%), bladder (39.3%), and rectal (33.7%) surgery subgroups.

CONCLUSIONS

Despite recent policy focus on the volume-outcome relationship, HOV was not the most important contributor to IHM for the major organ surgeries studied. PC remains the largest identifiable contributor to hospital mortality. Quality improvement initiatives should emphasize patient optimization and structural improvements, in addition to investigating the yet unexplained sources contributing to IHM.

Personalized multimodal prehabilitation reduces cardiopulmonary complications after pancreatoduodenectomy: results of a propensity score matching analysis

BACKGROUND

The purpose of prehabilitation is to improve postoperative outcomes by increasing patients' resilience against the stress of surgery. This study investigates the effect of personalized multimodal prehabilitation on patients undergoing pancreatoduodenectomy.

METHODS

Included patients were screened for six modifiable risk factors: (1) low physical fitness, (2) malnutrition, (3) low mental resilience, (4) anemia and hyperglycemia, (5) frailty, and (6) substance abuse. Interventions were performed as needed. Using 1:1 propensity score matching (PSM), patients were compared to a historical cohort.

RESULTS

From 120 patients, 77 (64.2%) performed a cardiopulmonary exercise test to assess their physical fitness and provide them with a preoperative training advice. Furthermore, 88 (73.3%) patients received nutritional support, 15 (12.5%) mental support, 17 (14.2%) iron supplementation to correct for iron deficiency, 18 (15%) regulation support for hyperglycemia, 14 (11.7%) a comprehensive geriatric assessment, and 19 (15.8%) substance abuse support. Of all patients, 63% required ≥2 prehabilitation interventions. Fewer cardiopulmonary complications were observed in the prehabilitation cohort (9.2% versus 23.3%; p = 0.002). In surgical outcomes and length of stay no differences were observed.

CONCLUSION

Our prehabilitation program is effective in detecting risk factors in patients; most patients required multiple interventions. Consequently, a reduction in cardiopulmonary complications was observed.

Post-Cancer Treatment Reflections by Patients Concerning the Provisions and Support Required for a Prehabilitation Programme

BACKGROUND

Evidence suggests that physical fitness interventions, mental health support and nutritional advice before surgery (prehabilitation) could reduce hospital stay and improve quality of life of patients with cancer. In this study we captured the opinions of a group of patients with cancer undergoing these interventions after treatment to discover what a prehabilitation programme should encompass.

METHODS

Patients from the Cancer and Rehabilitation Exercise (CARE) programme based in Nottingham took part in a 26-point online questionnaire about the design of prehabilitation programmes.

RESULTS

The questionnaire was completed over a 2-week period in December 2021 by 54 patients from the CARE programme. Their responses were as follows: 44 (81.5%) participants would have participated in prehabilitation had it been available to them and 28 (51.9%) ranked physical exercise as the most important component. Forty (74.1%) participants believed the counselling aspect of prehabilitation would have contributed to a successful outcome and 35 (64.8%) thought dietary advice would have benefitted them before surgery. Thirty-one (57.4%) participants preferred the programme to take place in a fitness centre, rather than at home or hospital and 43 (79.6%) would have liked to have known about prehabilitation from their doctor at the time of diagnosis.

CONCLUSIONS

Patients are interested in prehabilitation to become more physically fit and mentally prepared for surgery. They expressed the need for a focus on physical exercise, counselling to improve mental health and personalised nutritional advice. Tailoring a prehabilitation programme, with input from patients, could contribute to improving patient outcomes following cancer treatments.

Assessing real-world implementability of a multimodal group-based tele-prehabilitation program in cancer care: a pragmatic feasibility study

Introduction

Multimodal prehabilitation is intended to optimize a patient's mental and physical health prior to surgery. Most multimodal prehabilitation interventions are delivered on a one-on-one format, which may limit benefits associated with social interactions that can be achieved in a group context, and are delivered in-person, which may limit the accessibility. The purpose of this study was to develop a group-based, multimodal, tele-prehabilitation intervention for individuals diagnosed with cancer (iACTIF) and assess its implementability in a "real-world" clinical setting by measuring feasibility, acceptability, fidelity, and preliminary effects.

Methods

A prospective, single-group, pragmatic feasibility study was conducted with assessments at baseline, pre-surgery, and 12-weeks post-surgery. iACTIF consisted of three 90-min live videoconference sessions per week, including exercise and educational components. Descriptive statistics were used to document feasibility, acceptability, and fidelity indicators. Paired t-test, Wilcoxon test, and Cohen's D-test were conducted to assess changes in health-related outcomes.

Results

A total of 25 participants (mean age ± SD= 60.2 ± 14.0) were recruited. The feasibility assessment revealed a low referral rate (31.4%) and a high study retention (98%) and program attendance [session attended/possible session] (70.2%), with a prehabilitation window of 32.7 days (SD= 20.9, median= 28). Acceptability was high (84%-100%) according to satisfaction, utility and safety, delivery modality, and intention to continue physical activity and to recommend iACTIF to a relative. Pre-post-intervention assessments suggest positive changes on physical functional capacity based on the 2-min step test (mean difference= +18.9 steps, p=0.005), the 30-s sit-to-stand (mean difference= +1.1 repetition, p=0.011), and volume of moderate intensity physical activity per week (mean difference= +104.8 min, p<0.001). Fidelity was supported by conformity and coherence, with only minimal adjustments required to meet participants' needs.

Discussion

iACTIF implementability in a "real-world" clinical setting is promising, and preliminary outcomes suggest moderate benefits on physical health and small increase in mental health indicators.

Current status of and future perspectives on care for cancer survivors in China

Cancer is currently a major public health issue faced by countries around the world. With the progress of medical science and technology, the survival rate of cancer patients has increased significantly and the survival time has been effectively prolonged. How to provide quality and efficient care for the increasingly large group of cancer survivors with limited medical resources will be a key concern in the field of global public health in the future. Compared to developed countries, China's theoretical research and practical experience in care for cancer survivors are relatively limited and cannot meet the multi-faceted and diverse care needs of cancer patients. Based on the existing models of care worldwide, the current work reviews care for cancer survivors in China, it proposes considerations and suggestions for the creation of models of cancer care with Chinese characteristics in terms of optimizing top-level system design, enhancing institutional mechanisms, accelerating human resource development, and enhancing self-management and social support for patients.

Rehabilitation Interventions for Head and Neck Cancer-Associated Lymphedema: A Systematic Review

Importance

Head and neck cancer-associated lymphedema (HNCaL) affects up to 90% of survivors of head and neck cancer and is a substantial contributor to disability following head and neck cancer treatment. Despite the prevalence and morbidity associated with HNCaL, rehabilitation interventions are not well studied.

Objective

To identify and appraise the current evidence for rehabilitation interventions in HNCaL.

Evidence Review

Five electronic databases were searched systematically from inception to January 3, 2023, for studies on HNCaL rehabilitation interventions. Study screening, data extraction, quality rating, and risk of bias assessment were performed by 2 independent reviewers.

Findings

Of 1642 citations identified, 23 studies (1.4%; n = 2147 patients) were eligible for inclusion. Six studies (26.1%) were randomized clinical trials (RCTs) and 17 (73.9%) were observational studies. Five of the 6 RCTs were published during 2020 to 2022. Most studies had fewer than 50 participants (5 of 6 RCTs; 13 of 17 observational studies). Studies were categorized by intervention type, including standard lymphedema therapy (11 studies [47.8%]) and adjunct therapy (12 studies [52.2%]). Lymphedema therapy interventions included standard complete decongestive therapy (CDT) (2 RCTs, 5 observational studies), modified CDT (3 observational studies), therapy setting (1 RCT, 2 observational studies), adherence (2 observational studies), early manual lymphatic drainage (1 RCT), and inclusion of focused exercise (1 RCT). Adjunct therapy interventions included advanced pneumatic compression devices (APCDs) (1 RCT, 5 observational studies), kinesio taping (1 RCT), photobiomodulation (1 observational study), acupuncture/moxibustion (1 observational study), and sodium selenite (1 RCT, 2 observational studies). Serious adverse events were either not found (9 [39.1%]) or not reported (14 [60.9%]). Low-quality evidence suggested the benefit of standard lymphedema therapy, particularly in the outpatient setting and with at least partial adherence. High-quality evidence was found for adjunct therapy with kinesio taping. Low-quality evidence also suggested that APCDs may be beneficial.

Conclusions and Relevance

The results of this systematic review suggest that rehabilitation interventions for HNCaL, including standard lymphedema therapy with kinesio taping and APCDs, appear to be safe and beneficial. However, more prospective, controlled, and adequately powered studies are needed to clarify the ideal type, timing, duration, and intensity of lymphedema therapy components before treatment guidelines can be established.

Myths and truths on biophysics-based approach in rehabilitation of musculoskeletal disorders

Musculoskeletal disorders (MSD) are a crucial issue in current literature due to their impact on physical function, social, and economic costs. Rehabilitation plays a pivotal role in the therapeutic management of these disabling conditions with growing evidence underlining positive effects in improving functional outcomes. However, to date, several questions are still open about the mechanisms underpinning functional improvements while recent research is now focusing on a deeper understanding of the biophysical processes underpinning the macroscopical effects of these treatments. Thus, this narrative review aims at providing a comprehensive overview about the state of the art of biophysical dimensions of currently available treatments for MSD. PubMed, Scopus, CENTRAL, PEDro, and Web of Science were searched between March 2022 and October 2022 for in vitro and in vivo studies, clinical trials, systematic reviews, and meta-analysis addressing the issue of biophysics-based approach in rehabilitation of MSD. Our findings showed that a biophysical approach might be integrated into regenerative rehabilitation, aiming at enhancing regenerative processes by mechanical and biophysical stimuli. In addition, a biophysical-based approach has been proposed to improve knowledge about several instrumental physical therapies, including shock wave therapies, low-level laser therapy, ultrasound, short-wave diathermy, electrical stimulation, pulsed electromagnetic field, and vibration therapy. In accordance, emerging research is now focusing on the biophysical properties of several medical procedures to improve pain management in patients with MSD. Taken together, our results showed promising results of the integration of a biophysical-based approach in rehabilitation, albeit several limitations currently limit its implementation in routine clinical setting. Unfortunately, the state of the art is still inconclusive, and the low quality of clinical studies based on the biophysical approach did not provide clear treatment protocols. Further studies are needed to promote a precise rehabilitation approach targeting biological modification and enhancing the functional improvement of patients with MSDs.

[Nutritional supportive care in the course of patients with esophagogastric cancers]

Supportive care plays a central role in the management of patients with esophagogastric cancers, at all disease stages. Malnutrition has a high prevalence in this population, reaching up to 60 % of the patients. Sarcopenia and cachexia are also common. These complications have negative impact on functional abilities, quality of life and overall survival. They impair anti-tumor treatments effectiveness and increase their toxicity. Early detection and management are needed, before reaching advanced stages, which are refractory to therapeutic interventions. Specific nutritional support is recommended, relying on different nutritional support tools (dietetic counseling, oral supplements, artificial nutrition), depending on the clinical situation. When artificial nutrition is recommended, enteral nutrition (nasogastric tube, gastrostomy or jejunostomy) should be preferred. When enteral nutrition is impossible or insufficient, parenteral nutrition could be necessary. For patients with advanced esophagogastric cancers, digestive prostheses and decompressive radiation therapy may have a symptomatic benefit on dysphagia. Adapted physical activity is also recommended at all stages of cancer care and ongoing clinical trials will help to specify its modalities and to optimize its place in the therapeutic strategy. Finally, psychosocial support could be useful. A combined approach of these different interventions on the nutritional, physical and psychological aspects is beneficial for patients with esophagogastric cancers. This multimodal and multidisciplinary approach applies to both the early stages of the disease, with prehabilitation and/or rehabilitation to reduce perioperative morbidity and mortality and the advanced stages, with a benefit on survival and quality of life, in parallel with anti-tumor treatments.

Exercise Training in Elderly Cancer Patients: A Systematic Review

Due to the aging of the population, in 70% of cases, a new cancer diagnosis equals a cancer diagnosis in a geriatric patient. In this population, beyond the concept of mortality and morbidity, functional capacity, disability, and quality of life remain crucial. In fact, when the functional status is preserved, the pathogenetic curve towards disability will stop or even regress. The present systematic review investigated the effectiveness of physical exercise, as part of a holistic assessment of the patient, for preventing disability and improving the patient’s quality of life, and partially reducing all-cause mortality. This evidence must point towards decentralization of care by implementing the development of rehabilitation programs for elderly cancer patients either before or after anti-cancer therapy.

Improved Postoperative Outcomes after Prehabilitation for Colorectal Cancer Surgery in Older Patients: An Emulated Target Trial

BACKGROUND

The aim of this study was to assess the effect of a multimodal prehabilitation program on perioperative outcomes in colorectal cancer patients with a higher postoperative complication risk, using an emulated target trial (ETT) design.

PATIENTS AND METHODS

An ETT design including overlap weighting based on propensity score was performed. The study consisted of all patients with newly diagnosed colorectal cancer (2016-2021), in a large nonacademic training hospital, who were candidate to elective colorectal cancer surgery and had a higher risk for postoperative complications defined by: age ≥ 65 years and or American Society of Anesthesiologists score III/IV. Intention-to-treat (ITT) and per-protocol analyses were performed to evaluate the effect of prehabilitation compared with usual care on perioperative complications and length of stay (LOS).

RESULTS

Two hundred fifty-one patients were included: 128 in the usual care group and 123 patients in the prehabilitation group. In the ITT analysis, the number needed to treat to reduce one or more complications in one person was 4.2 (95% CI 2.6-10). Compared with patients in the usual care group, patients undergoing prehabilitation had a 55% lower comprehensive complication score (95% CI -71 to -32%). There was a 33% reduction (95% CI -44 to -18%) in LOS from 7 to 5 days.

CONCLUSIONS

This study showed a clinically relevant reduction of complications and LOS after multimodal prehabilitation in patients undergoing colorectal cancer surgery with a higher postoperative complication risk. The study methodology used may serve as an example for further larger multicenter comparative effectiveness research on prehabilitation.

A systematic review of multimodal prehabilitation in breast cancer

PURPOSE

Breast cancer is the most prevalent malignancy in women. Prehabilitation may offer improvements in physical and psychological wellbeing among participants prior to treatment. This systematic review aimed to determine the efficacy of prehabilitation in participants diagnosed with breast cancer.

METHODS

A systematic review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Guidelines. Studies exploring the impact of prehabilitation in participants with breast cancer were included. Studies were assessed independently according to pre-eligibility criteria, with data extraction and methodological quality assessed in parallel.

RESULTS

3184 records were identified according to our search criteria, and 14 articles were included. Articles comprised of quantitative randomised controlled trials (n = 7), quantitative non-randomised studies (n = 5), a qualitative study (n = 1), and a mixed-method study (n = 1). The majority of selected studies completed exercise programs (n = 4) or had exercise components (n = 2), with two focusing on upper-limb exercise. Five articles reported complementary and alternative therapies (n = 5). Two articles reported smoking cessation (n = 2), with a single study reporting multi-modal prehabilitation (n = 1). Mostly, prehabilitation improved outcomes including physical function, quality of life, and psychosocial variables (P < 0.05). The qualitative data identified preferences for multimodal prehabilitation, compared to unimodal with  an interest in receiving support for longer.

CONCLUSIONS

Prehabilitation for patients with breast cancer is an emerging research area that appears to improve outcomes, however, ensuring that adequate intervention timeframes, follow-up, and population groups should be considered for future investigations.

IMPLICATIONS FOR CANCER SURVIVORS

The implementation of prehabilitation interventions for individuals diagnosed with breast cancer should be utilised by multidisciplinary teams to provide holistic care to patients as it has the potential to improve outcomes across the cancer care trajectory.

Understanding Patients’ Experiences and Perspectives of Tele-Prehabilitation: A Qualitative Study to Inform Service Design and Delivery

Background: Tele-prehabilitation is a behaviour change intervention that facilities the modification of unhealthy lifestyle behaviours. Understanding patients’ experiences of tele-prehabilitation provides important insights into service improvement. In this study, we aimed to describe our patients’ perceptions of tele-prehabilitation and capture their capabilities, opportunities, and motivations to participate. This was a qualitative study to inform our service design and delivery. Methods: Following purposive sampling, 22 qualitative semistructured interviews were conducted with patients in the community that had completed tele-prehabilitation. Interviews were recorded and transcribed. Deductive content analysis was used to map the identified themes against theoretical determinants of health behaviour change. Results: We conducted 22 interviews. Our patients described their overall experience of tele-prehabilitation as positive and provided important insights that impacted their capabilities, opportunities, and motivations to engage with our service. Our team provided them the capabilities and self-efficacy to engage by personalising multimodal plans and setting goals. The remote delivery of our service was a recurring positive theme in providing flexibility and widening accessibility to participation. A missed opportunity was the potential for peer support through shared experiences with other patients. Patients showed greater motivation to participate for immediate perioperative benefit compared to long-term health gains. Conclusion: Patients’ experiences and perspectives of tele-prehabilitation can be enhanced by incorporating the findings from this qualitative study into service redesign and delivery. We recommend: (1) applying holistic principles in care and goal-setting, (2) delivering a combination of home-based and in-centre programmes, and (3) engaging with patients at the start of their cancer journey when they are most motivated. In turn, this can result in more effective uptake, improve adherence to interventions, and greater satisfaction.

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.

Considerations for multimodal prehabilitation in women with gynaecological cancers: a scoping review using realist principles

BACKGROUND

There is increasing recognition that prehabilitation is important as a means of preparing patients physically and psychologically for cancer treatment. However, little is understood about the role and optimal nature of prehabilitation for gynaecological cancer patients, who usually face extensive and life-changing surgery in addition to other treatments that impact significantly on physiological and psychosexual wellbeing.

REVIEW QUESTION

This scoping review was conducted to collate the research evidence on multimodal prehabilitation in gynaecological cancers and the related barriers and facilitators to engagement and delivery that should be considered when designing a prehabilitation intervention for this group of women.

METHODS

Seven medical databases and four grey literature repositories were searched from database inception to September 2021. All articles, reporting on multimodal prehabilitation in gynaecological cancers were included in the final review, whether qualitative, quantitative or mixed-methods. Qualitative studies on unimodal interventions were also included, as these were thought to be more likely to include information about barriers and facilitators which could also be relevant to multimodal interventions. A realist framework of context, mechanism and outcome was used to assist interpretation of findings.

RESULTS

In total, 24 studies were included in the final review. The studies included the following tumour groups: ovarian only (n = 12), endometrial only (n = 1), mixed ovarian, endometrial, vulvar (n = 5) and non-specific gynaecological tumours (n = 6). There was considerable variation across studies in terms of screening for prehabilitation, delivery of prehabilitation and outcome measures. Key mechanisms and contexts influencing engagement with prehabilitation can be summarised as: (1) The role of healthcare professionals and organisations (2) Patients' perceptions of acceptability (3) Factors influencing patient motivation (4) Prehabilitation as a priority (5) Access to prehabilitation.

IMPLICATIONS FOR PRACTICE

A standardised and well evidenced prehabilitation programme for women with gynaecological cancer does not yet exist. Healthcare organisations and researchers should take into account the enablers and barriers to effective engagement by healthcare professionals and by patients, when designing and evaluating prehabilitation for gynaecological cancer patients.

Patient experience of the acute post-surgical period following total laryngectomy during the COVID-19 era

BACKGROUND

Total laryngectomy (TL) results in permanent functional changes requiring rapid development of complex new skills. A significant portion of this learning happens in the acute post-surgical stage. There is increasing interest in enhanced recovery after surgery (ERAS) protocols in TL; however, implementation has been difficult. COVID-19 has placed significant pressures on acute services, requiring rapid service changes for TL patients.

AIMS

To understand the acute patient experience of having a TL both before and during COVID-19.

METHODS & PROCEDURES

Semi-structured interviews using a pre-designed topic guide were conducted with 10 people who had undergone a TL within the last 2 years. Participants were recruited by their speech and language therapists using purposive sampling. Braun and Clarke's iterative approach to data collection and thematic analysis was used to generate key themes from the data.

OUTCOMES & RESULTS

Thematic analysis identified four main themes: (1) pre-operative information-giving: 'it was just words'; (2) decision-making influences: 'I just wanted them to get it all out and get it over with'; (3) coping with adjustment to the new normal: 'this is part of me now'; and (4) the importance of relationship-building: 'when you've had something like this, you need some care and understanding'.

CONCLUSIONS & IMPLICATIONS

The need for an individualized approach to TL intervention which incorporates medical and psycho-social approaches from pre-treatment to acute discharge is vital. ERAS models should be reviewed to shift beyond the medical model alone. Rapid service changes due to COVID-19 did not contribute any major changes to the acute patient-reported experience.

WHAT THIS PAPER ADDS

What is already known on the subject We know that ERAS protocols have the potential to improve patient outcomes following TL. However, the research does not consider anything other than the early oral feeding debate and it has therefore been difficult to implement ERAS protocols in current service models. COVID19 required head and neck cancer services to make quick changes to surgical pathways, with the potential that some ERAS protocols had been adopted inadvertently. In order to understand the impact of this, we need to understand the patient experience following TL both before and during COVID19. What this paper adds to existing knowledge This paper used qualitative interviews to understand the acute patient experience following TL both during and before COVID19. Findings from these interviews highlighted that people were on the most part, well prepared for the functional changes they would experience after surgery. However, people felt there were gaps in service delivery at the pre-treatment and early discharge home period. Overall, the gaps identified were from a more psycho-social need suggesting that future ERAS models of care should consider both medical and psycho-social principles to enhance patient experience and outcome. What are the potential or actual clinical implications of this work? Pre-treatment services provided to people who have a TL could be reviewed to help maximize long-term adjustment to life. Areas which could be reviewed include the method and mode of information delivery. Further work needs to be done in partnership with community services to improve the immediate discharge home experience.

Biopsychosocial Markers of Body Image Concerns in Patients with Head and Neck Cancer: A Prospective Longitudinal Study

(1) Background: Patients and survivors of head and neck cancer (HNC) are at a high risk of developing body image concerns. Despite the prevalence of body image concerns in patients with HNC, there is a lack of longitudinal research exploring the wide array of its associated determinants. The current longitudinal study examined the determinants and longitudinal course of body image dissatisfaction in patients with HNC. (2) Methods: Patients participated in Structured Clinical Interviews and self-administered questionnaires at four time-points: (T1) upon cancer diagnosis, (T2) at 3 months post-diagnosis, (T3) at 6 months post-diagnosis, and (T4) at 12 months post-diagnosis. They also underwent a disfigurement rating on an objective scale. (3) Results: Two hundred and twenty-four patients participated in our study. Fourteen percent to twenty-eight percent of patients reported at least moderate body image concerns across time points, with the lowest rates at baseline and the highest at 3 months (T1). It was found that patients more predisposed to developing higher levels of body image concerns presented physical markers (i.e., advanced cancer stage, lower physical functioning, higher disfigurement), psychosocial markers (i.e., higher depression, higher anxiety, and higher levels of coping with denial), and health disparities (i.e., younger age, female sex, French language, and marital status, with divorced and widowers most affected). (4) Conclusions: The findings of this study highlight the multifaceted nature of body image concerns in patients with HNC and its biopsychosocial determinants. Clinicians should pay specific attention to these biopsychosocial markers in their clinics to predict high levels of body image concerns and tailor communication/refer for support accordingly.

Tailoring prehabilitation to address the multifactorial nature of functional capacity for surgery

Mounting evidence suggests that recovery begins before the surgical incision. The pre-surgery phase of recovery - the preparation for optimal surgical recovery - can be reinforced with prehabilitation. Prehabilitation is the approach of enhancing the functional capacity of the individual to enable them to withstand a stressful event. With this narrative review, we apply the Wilson & Cleary conceptual model of patient outcomes to specify the complex and integrative relationship of health factors that limit functional capacity before surgery. To have the greatest impact on patient outcomes, prehabilitation programs require individualized and coordinated care from medical, nutritional, psychosocial, and exercise services. This article is protected by copyright. All rights reserved.

The Role of Prehabilitation in Modern Esophagogastric Cancer Surgery: A Comprehensive Review

Simple Summary

Surgery is the only potentially curative treatment option for esophagogastric cancer. Although esophagectomy/gastrectomy remains associated with major surgical trauma and significant morbidity. Prehabilitation has emerged as a novel strategy to improve postoperative outcomes by preparing patients for a surgery-associated physiological challenge. We discuss current knowledge and the results of studies on the role of prehabilitation in esophagogastric cancer surgery.

Abstract

Esophagogastric cancer is among the most common malignancies worldwide. Surgery with or without neoadjuvant therapy is the only potentially curative treatment option. Although esophagogastric resections remain associated with major surgical trauma and significant postoperative morbidity. Prehabilitation has emerged as a novel strategy to improve clinical outcomes by optimizing physical and psychological status before major surgery through exercise and nutritional and psychological interventions. Current prehabilitation programs may be unimodal, including only one intervention, or multimodal, combining the benefits of different types of interventions. However, it still is an investigational treatment option mostly limited to clinical trials. In this comprehensive review, we summarize the current evidence for the role of prehabilitation in modern esophagogastric cancer surgery. The available studies are very heterogeneous in design, type of interventions, and measured outcomes. Yet, all of them confirm at least some positive effects of prehabilitation in terms of improved physical performance, nutritional status, quality of life, or even reduced postoperative morbidity. However, the optimal interventions for prehabilitation remain unclear; thus, they cannot be standardized and widely adopted. Future studies on multimodal prehabilitation are necessary to develop optimal programs for patients with esophagogastric cancer.

Brain Prehabilitation for Oncologic Surgery

PURPOSE OF REVIEW

This review aims to summarize the current research on postoperative cognitive complications, such as delirium and cognitive dysfunction. This includes discussion on preoperative preventive strategies, such as physical and nutritional prehabilitation as well as up-to-date information on neuroprehabilitation.

RECENT FINDINGS

Current recommendations for prevention of postoperative delirium have focused on multicomponent interventions. The optimal composition of surgical prehabilitation programs targeting exercise and nutrition has not yet been established. The Neurobics Trial shows that cognitive prehabilitation improves cognitive reserve and may be a useful addition to multimodal surgical prehabilitation. Perioperative management of oncologic patients is often associated with a myriad of challenges, such as the management of tumor-related pathologies, adverse events from neoadjuvant therapy, and chronic metabolic and immunological changes associated with malignancy. In addition, oncologic patients are at increased risk of developing frailty, which adversely affects postoperative recovery and further cancer treatment. As a result, oncologic patients are at considerable risk of developing postoperative cognitive complications, such as delirium and cognitive dysfunction. In this review, we discuss the effect of prehabilitation on postoperative cognitive outcomes.

Digital Support to Multimodal Community-Based Prehabilitation: Looking for Optimization of Health Value Generation

Prehabilitation has shown its potential for most intra-cavity surgery patients on enhancing preoperative functional capacity and postoperative outcomes. However, its large-scale implementation is limited by several constrictions, such as: i) unsolved practicalities of the service workflow, ii) challenges associated to change management in collaborative care; iii) insufficient access to prehabilitation; iv) relevant percentage of program drop-outs; v) need for program personalization; and, vi) economical sustainability. Transferability of prehabilitation programs from the hospital setting to the community would potentially provide a new scenario with greater accessibility, as well as offer an opportunity to effectively address the aforementioned issues and, thus, optimize healthcare value generation. A core aspect to take into account for an optimal management of prehabilitation programs is to use proper technological tools enabling: i) customizable and interoperable integrated care pathways facilitating personalization of the service and effective engagement among stakeholders; ii) remote monitoring (i.e. physical activity, physiological signs and patient-reported outcomes and experience measures) to support patient adherence to the program and empowerment for self-management; and, iii) use of health risk assessment supporting decision making for personalized service selection. The current manuscript details a proposal to bring digital innovation to community-based prehabilitation programs. Moreover, this approach has the potential to be adopted by programs supporting long-term management of cancer patients, chronic patients and prevention of multimorbidity in subjects at risk.

The impact of body composition on treatment in ovarian cancer: a current insight

INTRODUCTION

Epithelial ovarian cancer (EOC) remains the most lethal of gynecological cancers. Sarcopenia and low Skeletal Muscle Radiodensity (SMD) are highly prevalent in EOC. Cross sectional imaging via MRI and CT are considered the gold standard for quantification of muscle mass and muscle density. Skeletal Muscle Index (SMI) and SMD-based thresholds for sarcopenia in EOC vary significantly and specific EOC thresholds for sarcopenia have not been defined.

AREAS COVERED

Sarcopenia and low SMD are highly prevalent in EOC affecting between 11-68% and 21-35% of women, respectively. SMD may be a better prognostic biomarker in ovarian cancer than SMI. Reduced SMI and SMD may also influence the risk of postoperative complications but further studies are required. There is increasing evidence that sarcopenia increases during neoadjuvant chemotherapy.

EXPERT COMMENTARY

Prehabilitation studies in surgical oncology indicate encouraging results, such as, maintenance of SMI, reduced length of stay and surgical complication rates, improved health-related quality of life and functional capacity. Early identification of body composition abnormalities would permit targeted intervention prior to, and after surgery. Cross-sectional imaging is routinely used for staging and surveillance of EOC patients and hence assessment of body composition abnormalities is possible and an underutilized resource.

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.

Prehabilitation is the Gateway to Better Functional Outcomes for Individuals with Cancer

Prehabilitation is a clinical model that introduces components of rehabilitation to patients prior to undergoing intensive medical interventions, such as surgery, in order to optimize function and improve tolerability to the intervention. Cancer care introduces a continuum of sequential or concurrent intensive anti-neoplastic medical interventions that are known to be detrimental to a patient's function. Prehabilitation evidence has grown across several areas of oncology care delivery demonstrating that a multi-modal rehabilitative intervention, delivered prior to oncology-direct therapies, leads to better functional outcomes and improves important endpoints associated with surgery and cancer treatment. This commentary article provides a brief history of the emergence of prehabilitation in cancer care delivery, reviews the current evidence base and guidelines for prehabilitation, and offers insights for future implementation of this model as a standard in oncology care. A prehabilitation program is an optimal starting point for most patients undergoing anti-neoplastic therapy as it serves as a gateway to improving functional outcomes throughout the cancer continuum. Future research in prehabilitation should aim to reach beyond measuring functional outcomes and to explore the impact of this model on important disease treatment endpoints such as tumor response to oncology-directed treatment, impact on treatment-related toxicities, and disease progression.