Prehabilitation to Improve Outcomes of Patients with Gynaecological Cancer: A New Window of Opportunity?

Exercise Across the Phases of Cancer Survivorship: A Narrative Review

Exercise has long been recognized as an important component of treatment for various diseases. However, the benefits and risks of exercise interventions must be carefully evaluated to ensure the former outweighs the latter. As cancer patients undergo diverse treatment modalities with distinct objectives, a systematic approach partitioning the cancer journey into distinct phases is necessary to inform tailored exercise prescriptions. This narrative review summarizes exercise benefits and mechanisms for cancer patients and survivors across four distinct survivorship periods-before surgery, after surgery and before adjuvant treatment, during nonsurgical treatment (adjuvant and neoadjuvant), and during extended survival. In summary, exercise reduces the risks of complications and declines in physical functioning while improving fatigue, quality of life, and the ability to manage treatment effects. Although additional research is warranted, existing evidence is sufficient to integrate exercise into clinical oncology practice and cancer survivorship programs.

Impact of FRAilty screening and Geriatric assessment and INtervention in older patients with epithelial Ovarian Cancer: A multicenter randomized clinical trial protocol (FRAGINOC)

INTRODUCTION

Radical surgery combined with chemotherapy is the only potential curative treatment of patients with advanced epithelial ovarian cancer (EOC). However, 43% of older Danish patients with EOC are not referred to surgery due to frailty, age, or fear of complications. Comprehensive geriatric assessment (CGA) has demonstrated ability to reduce frailty in older patients, but there is a knowledge gap regarding its effect before or during treatment in older adults with EOC. This protocol presents a randomized controlled trial (RCT), which evaluates the effect of CGA-based interventions including individualized physical exercise therapy in older adults with EOC during neoadjuvant chemotherapy (NACT).

MATERIALS AND METHODS

This RCT will include patients aged ≥70 years with primary EOC referred to NACT. Patients will be randomized 1:1 to intervention or standard of care, along with neoadjuvant antineoplastic treatment. Stratification for performance status and center of inclusion will be performed. In the intervention arm, a geriatrician will perform CGA and corresponding geriatric interventions and patients will undergo an individualized home-based exercise program managed by a physiotherapist. All patients will be evaluated with Geriatric-8, modified Geriatric-8, clinical frailty scale, and physical tests at randomization. Predictive values (positive/negative) will be evaluated for CGA detected impairments. The primary endpoint is the proportion of patients referred to interval debulking surgery (IDS). Secondary endpoints include the proportion who complete oncological treatment, improvements in physical tests, quality of life measured by European Organization for Research and Treatment of Cancer-Quality of Life questionnaires at inclusion, after three cycles of chemotherapy, and at end of chemotherapy treatment. Furthermore, the association between results of geriatric screening tests, CGA, and physical tests with complication rate and progression free survival will be examined. The primary outcome will be analyzed with logistic regression in the intention-to-treat population. Power calculations reveal the need to enroll 216 patients.

DISCUSSION

The present study examines whether CGA-based interventions including individualized physical exercise can increase the referral rate for potential curative IDS in older patients with EOC. If successful, this will result in more patients undergoing surgery and completing chemotherapy, preventing complications, and ultimately improving quality of life and survival. The study setup may establish the basis for direct clinical implementation if proven effective.

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.

Feasibility of Introducing a Prehabilitation Program into the Care of Gynecological Oncology Patients-A Single Institution Experience

Prehabilitation is an upcoming strategy to optimize patient's functional capacity, nutritional status, and psychosocial well-being in order to reduce surgical complications and enhance recovery. This study aims to assess the feasibility of implementing a multimodal prehabilitation program into the standard care of gynecological oncology patients at an academic hospital in terms of recruitment, adherence, and safety, which were assessed by the number of patients eligible, recruitment rate, participation rate, and adherence to individual modalities. Data were derived from the F4S PREHAB trial, a single-center stepped-wedge trial implementing a multimodal prehabilitation program among various surgical specialties. All patients undergoing elective surgery as part of treatment for ovarian, uterine, and vulvar cancer at the Radboudumc, an academic hospital in The Netherlands, between May 2022 and September 2023 were considered eligible for the F4S PREHAB trial and, consequently, were included in this cohort study. The multimodal prehabilitation program comprised a physical exercise intervention, nutritional intervention, psychological intervention, and an intoxication cessation program. A total of 152 patients were eligible and approached for participation of which 111 consented to participate, resulting in a recruitment rate of 73%. Participants attended an average of six exercise sessions and adhered to 85% of possible training sessions. Respectively, 93% and 98% of participants adhered to the prescribed daily protein and vitamin suppletion. Ten participants were referred to a psychologist and completed consultations. Out of nine active smokers, two managed to quit smoking. A total of 59% adhered to alcohol cessation advice. No adverse events were reported. This study demonstrates that introducing a multimodal prehabilitation program into the standard care of gynecological oncology patients is feasible in terms of recruitment and adherence, with no serious adverse events.

Barriers to and facilitators of a healthy lifestyle for patients with gynecological cancer: a systematic review of qualitative and quantitative research with healthcare providers and patients

The prevalence of an unhealthy lifestyle among patients with gynecological cancer is high and associated with increased risk of all-cause mortality. Although lifestyle changes have the potential to improve outcomes, lifestyle counseling is not routinely integrated into standard care. This review explores research on the barriers to and facilitators of both the promotion of healthy lifestyles by healthcare providers (HCPs) and healthy lifestyle changes by patients with gynecological cancer. The Theoretical Domains Framework (TDF) was used to deductively code the identified factors for a comprehensive understanding of the barriers and facilitators. A search across five databases yielded a total of 12,687 unique studies, of which 43 were included in the review. Of these 43, 39 included gynecological cancer patients and only 6 included HCPs. Among the barriers identified for HCPs, most studies evaluated barriers regarding weight loss counseling. Limited knowledge, reluctance to address weight loss, skepticism about the benefits, and workload concerns were commonly reported barriers for HCPs. HCPs will benefit from education and training in lifestyle counseling, including effective communication skills like motivational interviewing. Gynecological cancer patients lacked tools, support, knowledge, and faced mental health issues, environmental constraints, and physical limitations. The review emphasizes the importance of addressing these barriers and utilizing identified facilitators, such as social support, to promote and support healthy lifestyle behaviors on the part of patients and their promotion by HCPs. Future research should focus not only on patients but also on supporting HCPs and implementing necessary changes in current practices.

Is Cardiopulmonary Exercise Testing Predictive of Surgical Complications in Patients Undergoing Surgery for Ovarian Cancer?

Preoperative cardiopulmonary exercise testing (CPET) provides an objective assessment of functional capability. In other intra-abdominal surgical specialties, CPET outcomes are predictive of operative morbidity. However, in ovarian cancer surgery, its predictive value remains unknown. In this study, we evaluated the association between CPET performance and surgical morbidity in ovarian cancer patients. Secondly, we assessed the association between CPET performance and other surgical outcomes (i.e., hospital stay, readmission and residual disease). This was a retrospective cohort study of patients undergoing primary surgery for ovarian cancer between 2020 and 2023. CPET performance included peak oxygen uptake (VO2 max), ventilatory efficiency (VE/VO2) and anaerobic threshold. Outcomes were operative morbidity and included intra- and postoperative complications (Clavien-Dindo), hospital stay, readmission within 30 days and residual disease. A total of 142 patients were included. A lower VO2 peak and a higher VE/VCO2 were both associated with the occurrence of postoperative complications, and a poorer anaerobic threshold was associated with more transfusions. VE/VCO2 remained significantly associated after multivariate analysis (p = 0.035). None of the CPET outcomes were associated with length of stay, readmission or residual disease. In conclusion, VE/VCO2 was significantly associated with an increased risk of all-cause postoperative complications in ovarian cancer patients undergoing primary surgery.

Upper-Abdominal Cytoreduction for Advanced Ovarian Cancer—Therapeutic Rationale, Surgical Anatomy and Techniques of Cytoreduction

Cytoreductive surgery (CRS) is the cornerstone of treating advanced ovarian cancer. Approximately 60–70% of patients with advanced ovarian cancer will have involvement in the upper abdomen or the supracolic compartment of the abdominal cavity. Though the involvement of this region results in poorer survival compared, complete cytoreduction benefits overall survival, making upper-abdominal cytoreduction an essential component of CRS for advanced ovarian cancer. The upper abdomen constitutes several vital organs and large blood vessels draped with the parietal or visceral peritoneum, common sites of disease in ovarian cancer. A surgeon treating advanced ovarian cancer should be well versed in upper-abdominal cytoreduction techniques, including diaphragmatic peritonectomy and diaphragm resection, lesser omentectomy, splenectomy with or without distal pancreatectomy, liver resection, cholecystectomy, and suprarenal retroperitoneal lymphadenectomy. Other procedures such as clearance of the periportal region, Glisson’s capsulectomy, clearance of the superior recess of the lesser sac, and Morrison’s pouch are essential as these regions are often involved in ovarian cancer. This manuscript covers the surgical anatomy of the upper abdomen, the techniques and therapeutic rationale of upper-abdominal cytoreduction, and specific measures for perioperative management of these patients. The main focus is the description of various peritonectomies and regional lymphadenectomies.