Prehabilitation evidence and insight review

Question 1

What is the cancer definition of prehabilitation?

Answer 1

“A process on the cancer continuum of care that occurs between the time of cancer diagnosis and the beginning of acute treatment and includes physical and psychological assessment that establish a baseline level, identify impairments, and provide interventions that promote physical and psychological health to reduce the incidence and/or severity of future impairments”

Question 2

What are the the 3 key points for prehabilitation and how should you implement these points?

Answer 2

For all:
- Prehabilitation is for anyone with cancer
a) Anyone undergoing treatment including pallitative and those suspected of cancer

Personal:
- Person-centred (tailored to individual) - aids in building resilience and empowers them

a) Words optimised or maximised - aim to improve or maintain mental/physical wellbeing
b) Partnership with patient - shared decision making

Process:
- Process in continuum of care with no start of end date

a) Clearly state fitness can increase in 2 weeks
b) Possible need to prescribe prehabilitation - this could make it more powerful

Question 3

What is the difference between standard care and prehabilitation?

Answer 3

Standard care: Essential medical preparation including blood tests, blood pressure, appropriate scans and preparations they must make.

Prehabilitation includes multimodal approach looking at wide physical, psychosocial, and psychological wellbeing.

Question 4

Why is prehabilitation beneficial over standard care?

Answer 4

Greater supervision with more professional involvement — Greater motivation and engagement with more control — Better compliance — Improved outcomes and improved patient experience

Question 5

Outline the four main stages of cancer rehabilitation?

Answer 5

1) Preventative (Prehab): Aiming to reduce impact of expected disabilities and provide assistance in learning to cope with disasbilities
2) Restorative (Conventional rehab): Aiming to return patient to pre-illness level of function without disability
3) Supportive: Aiming to limit functional loss and support in presence of persistent disease and continual need for treatment
4) Pallitative: Aim to reduce complications and provide support with symptom management

Question 6

Can you outline the first 3 things done with cancer patients in prehabilitation?

Answer 6

Pre-assessment:
1) Measure baseline: Enable individual to understand effect of prehabilitation regime.
2) Identify risk factors: Develop personalised goals for peri- and post-treatment outcomes
3) Inform and make joint decisions: Important patient is aware of process they are about to undertake and how they will be affected at each stage.

Question 7

What did the Southampton study titled Patients experience of exercise and cancer. Informing WESFIT Pilot Patient Involvement Report Feedback to participants (2017) show

Answer 7

• Joint decision-making was identified as particularly important as it means patients are actively involved in their own wellbeing and recovery
• Patients like to receive their fitness monitoring e.g (Cardiopulmonary exercise testing score) as they are proud to see improvements
• Important patients receive support to return safely to exercise - one conversation at least to get back on track with exercise

Question 8

What are the 4 factors that should be considered when delivering a prehabilitation intervention?

Answer 8

Personalised regime: Regime should be personalised

Length of regime: Varies from 1 weeks to 2 months with most typically being 4-6 weeks

Setting: Each area must be treated differently depending on transport

Opt-in vs. Opt-out: Opt-in approach likely best as becomes prescribed and considered a treatment - more powerful with greater adherence

Question 9

What is the final stage of Prehabilitation and what does this help with?

Answer 9

Follow-up post-intervention:
1) Determine progress: Helps us further understand and develop prehabilitation models. Share successes with the patient
2) Ensure appropriate follow up: Exercise continuation with link to local services or rehabilitation so important to establish strong connection

Question 10

What are the benefits of post-treatment follow up?

Answer 10

Engages patient’s in their own progress and adds to the prehabilitation evidence base, in particular understanding the efficacy of each intervention

Question 11

What elements are always, often, and sometimes seen in the current prehabilitation services?

Answer 11

Always: Physical activity
Often: Dietary support
Some-times: Anaemia management, Smoking cessation/Alcohol reduction, Respiratory exercises, Lymphoedema management, Medication and comorbidities review

Question 12

Outline the Belfast physio study and what they found?

Answer 12

• 18-month pilot study starting in 2015 funded by Prostate Cancer UK who treated 131 men.
• 81% consented to digital rectal examination
• 50% were performing the pelvic floor exercises incorrectly which negatively impact their continence

Question 13

What did the Macmillan cancer report titled: “What motivates people with cancer to get active? Understanding the motivations and barrier to physical activity in people living with cancer (2015)” show

Answer 13

Identified factors effecting participation for activity:
1) Individual drivers: Regaining control, Confidence, Self-identity, Motivation, Mental-wellbeing, Positive achievements
2) Social network (Friends/Family): Sense of duty, Support from close friends and family, Social stigma, Someone to do it with
3) Physical symptoms: Physical symptoms and side effects of cancer treatment identified as barriers
4) Physical environment: Proximity of facilities, Appropriateness of facilities and staff, Spending time outdoors

Question 14

What is nutrition important in prehabilitation and what can poor nutrition lead to?

Answer 14

1) Cachexia (significant weight loss, muscle protein depletion, fatigue, weakness)
2) Poor physical function
3) Treatment tolerance reduced (Systemic inflammatory syndrome)
4) Quality of life

• Unfavourable prognosis
• Increased treatment toxicity - can’t metabolise drugs effectively - less access to treatments
• Continuous deterioration - physical and mental

Question 15

What are the 4 interventions outlined by the European Journal of Nutrition Metabolism for cancer patients?

Answer 15

1) Nutrition counselling: Aim to maintain or increase energy and protein intake
2) Oral nutritional supplements: Most often recommended to supplement food intake
3) Artificial nutrition: Application of nutrients via enteral tubes (enteral or parental)
4) Drug therapy: Pharmacological agents to stimulate appetite, decrease systemic inflammation and/or hyper catabolism or increase muscle mass

Question 16

What is the aim of nutritional interventions for cancer patients?

Answer 16

1) Treat malnutrition
2) Maintain or improve food intake
3) Mitigate metabolic derangements
4) Maintain skeletal muscle mass and physical performance
5) Reduce risk of reduction or interruption of anticancer treatment and reduced quality of life

Question 17

What are some negative things with cancer nutrition when speaking and treating patients?

Answer 17

1) Artificial nutrition is associated with risks/cost
2) Theoretical arguments that nutrients “feed the tumour” are not supported by evidence: PATIENTS SHOULD NOT DIET

Question 18

How many stages are there in the MacMillan NICE psychological guidelines are outlined for psychological wellbeing and what groups are they delivered by

Answer 18

1: All health and social care professionals
2: Health and social care professionals with additional expertise
3: Trained and accredited professionals
4: Mental health specialists

Question 19

On the NICE 4 stage model - how are each of the four stages recognised and provide some examples of psychopathology

Answer 19

1: Recognition of psychological needs
2: Recognition of psychological distress
3: Recognition of psychological distress and diagnosis of some psychopathology
4: Diagnosis of psychopathology

Psychopathology: Significant impairment in Eating, Social withdrawal, Substance abuse, Self-harm, Withdrawal

Question 20

What are the intervention used across each level of risk for psychological interventions?

Answer 20

1: Effective information giving, compassionate communication and general psychological support
2: Psychological techniques such as problem solving
3: Counselling and specific psychological interventions such as anxiety management and solution-focused therapy delivered according to an explicit framework.
4: Specialist psychological and psychiatric interventions such as psychotherapy, including cognitive behavioural therapy.

Question 21

What was found in the annals of surgical oncology and by who?

Answer 21

Tsimopoulou and colleagues conducted a systematic review of seven studies in 605 cancer patients (breast, gynecologic, colorectal and prostate). No improvement in surgical outcomes (length or hospital stay, complications, analgesia use, or mortality) but positively impacted immunologic function. Positively impact psychological outcomes, quality of life, and somatic symptoms

Question 22

What are some examples of psychological interventions used in cancer patients?

Answer 22

1) Peers and buddies: Provide low level support and an invaluable insight into cancer experience
2) Information centre: Visiting a Macmillan information centre
3) Stress management training - relaxation techniques such as breathing, progressive muscle relaxation and meditation
4) Professional support from a clinical psychologist

Question 23

Who should psychological interventions be delivered by?

Answer 23

Level 1-2: Distress experienced by patients can be managed and resolved with minimal training by non-specialist workforce.
Level 3-4: Distress experienced by cancer patients is severe and persistent enough to require specialist support by mental health professionals such as psychologists and psychiatrists

Question 24

What do the PREPARE programme from London suggest

Answer 24

• Stopping smoking prior to surgery can reduce risk of post-operative heart and lung complications, decrease wound healing time and reduce hospital length of stay.
• Stopping alcohol prior to surgery can reduce heart function and cause mild dehydration - requires time as stopping alcohol suddenly can increase risk of health problems

Question 25

What is the issue with anaemia, how is it caused and how is it assessed

Answer 25

• Side effects of cancer and its treatment such as chemotherapy and radiotherapy.
• Occurs due to internal bleeds
• High pre-operative haemoglobin reduce need to peri-operative transfusion
• Pre-operative teams can investigate and treat anaemia helping to reduce costs
• Patient assessment should aim to determine whether there is a underlying cause of the iron deficiency in anaemia and whether the person has complications through history, examination and appropriate investigations (NICE guidelines)

Question 26

How should Iron deficiency be managed?

Answer 26

• Refer for appropriate investigation to appropriate speciality (gastroenterology, surgery, or gynaecology)
• Treat for underlying cause if appropriate in primary care
• Treat iron deficiency anaemia with ferrous sulphate first-line and advise about diet

Question 27

Why are respiratory exercises important in peri-operative care?

Answer 27

• Reduce risk of lung problems by opening up the airways and moving phlegm
• Perform both pre- and post operatively with practising pre-op making them easier to perform afterwards

Question 28

What are some breathing exercise examples and recommendations?

Answer 28

1) Focused breathing: In through the nose and out for the mouth - 5 seconds in and 5 seconds out if tolerated
2) Diaphragmatic breathing: Hands on belly and chest - belly should move - breath in through nose - exhale with pursed lips as you breath out and tighten your stomach muscles. 5 to 10 minutes 3 to 4 times per day.
3) Pursed lip breathing: Inhale slowly through nose (2-3 seconds) and breath out through pursed lips (as if blowing out a candle). Repeat cycle for up to 10 minutes

Question 29

What are the five main approaches to the management of lymphoedema

Answer 29

1) Skin care and cellulitis prevention:
- Clean skin, Moisturising daily, Carefully drying
- Protect skin (Infection risk)
- Electric shaver
- Good fitting clothes
- Insect bits and sunburn
2) Exercise
- Stimulate lymphatic flow
3) Lymphatic drainage
4) Compression therapy
5) Massage

Question 30

What is the importance of medication and comorbidities review

Answer 30

1) Medication is critical in determining suitability for individual interventions of a prehabilitation regime
2) Optimising co-morbid conditions such as hypertension and diabetes are important parts of prehabilitation

Question 31

What are the issues with hypertension and diabetes in cancer patients?

Answer 31

1) Delayed wound healing
2) Increased risk of kidney dysfunction, respiratory events, and cardiovascular events
3) Impaired immune function
4) Can increase risk of hemodynamic instability, respiratory depression, and delayed emergence from anesthesia post-op.

Question 32

What was found in the PREPARE programme at Imperial hospital?

Answer 32

1) Reduced median hospital length stay from 12 to 8 days
2) Prevented anticipated deterioration in physical function and QOL in patients receiving neo-adjuvant treatment
3) Reduced post-operative complication rates from 80% to 29% (Clavien-Dindo system)
4) Improvement in physical function (4.6-5.1 METs)
5) Reduced rates incidence of post-operative pneumonia from 60% to 29%
6) Improvement in self-confidence

Question 33

What are the core roles in physical activity prehabilitation?

Answer 33

Core:
1) Physiotherapist (Increased risk patient/patient with fatigue)
2) Occupational therapist
3) Exercise physiologist
4) CNS with appropriate training

Question 34

What are 8 core soft-skills a exercise professional needs when working with patients?

Answer 34

1) Be encouraging
2) Friendly
3) Knowledgeable
4) Good communication skills
5) Be genuinely proud of patients
6) Supportive of progressive (new ideas)
7) Show empathy
8) Don’t push patients too hard can lead to disengagement

Question 35

What are the core registered professionals in Psychological wellbeing?

Answer 35

1) Psychologist
2) Psychiatrist
3) Occupational therapist
4) Counsellor
5) Physiotherapist
6) CNS (Level 2)

Question 36

How are patients stratified for psycho-social wellbeing?

Answer 36

High complexity: Directed towards psychologist and psychiatrists
Medium complexity: Occupational therapists, Counsellors and CNSs

Question 37

What is the core clinical team for dietary support?

Answer 37

1) Dietician
2) CNS/Nurse
3) Speech and language therapist

Question 38

How is care delivered in dietary patients?

Answer 38

80% advised just to ‘eat well’ could have care delivered by CNS, Nurse, and other allied health professionals

Question 39

What are 3 cases the multi-disciplinary team should make for prehabiltiation?

Answer 39

1) Ability to talk about prehabilitation: Many health professionals think they are delivering prehab when just delivering standard care
2) Timing: Avoid delay or accept delay if benefits outway risk (Delays due to diagnostic testing or second/third opinion)
3) Expenses: Justified by greater need for rehabilitation visits, lost time from work, and sometimes permanent disability

Question 40

What are the benefits of prehabilitation pre, peri, post, and long term?

Answer 40

Pre: Improved fitness, Improved Patient experience, Improved fatigue, Improved frailty, Active involvement, Set expectations

Peri: Tolerance of treatment, Increased options, Reduced complications (wound healing, infections, mobility), Reduced length of stay in high dependency care units, Communication and coordination of care, Joins up service

Post: Reduced burden on carers, Reduced recovery period, Prevent family breakdown, Fewer readmission, Reduced contact with primary care

Long-term: Increased survival, Reduced risk of further conditions, Reduced cost of healthcare (aspirational), Primed for future rehab, Return to life roles (family, work, community), Reduced impact of some late effects (fatigue, incontinence), Increased confidence in prehab, Sustained lifestyle changes, Reduced contact with mental health, Stave of frailty and disability

Question 41

Where is the evidence for prehabilitation in cancer care?

Answer 41

1) Cancer prehabilitation studies
2) Cancer prehabilitation services and pilots
3) Draw upon wider cancer rehabilitation and recovery evidence (ERAS+)

Question 42

What did Silver and Baima (2014) find in the American Journal of Physical medicine and Rehabilitation

Answer 42

Review looking at evidence for cancer prehabilitation in non cancer conditions and found Prehab:
1) Increases functional capacity
2) Improves quality of life
3) Decreases depression
4) Reduces hospital length of stay
5) Increases physical fitness
6) Reduce complications
7) Less costly per patients then standard care

Question 43

List the two systematic reviews outlining evidence in prehabilitation

Answer 43

1) Preoperative exercise therapy for elective major abdominal surgery: a systematic review - Pouvels (2014) International Journal of surgery
- Total of 6 studies - Pre-operative exercise and chest physiotherapy in abdominal cancer.
- Improvement in physical fitness across most and chest physio reduces pulmonary complications

2) Psychological Prehabilitation Before Cancer Surgery: A Systematic Review
- Seven studies - Psychological interventions in prehab. Tsimopoulou (2014) Annals of surgical oncology
- Interventions did not affect traditional surgical outcomes (e.g., length of hospital stay, complications, analgesia use, or mortality) but positively affected patients’ immunologic function. Psychological interventions positively impacted patients’ reported outcome measures including psychological outcomes, quality of life, and somatic symptoms.

Question 44

What large study has shown evidence in prehabilitation for cancer and outline it

Answer 44

Is preoperative physical activity related to post-surgery recovery? A cohort study of patients with breast cancer Nilsson and colleagues (2016) BMJ
- Patients planned for breast cancer surgery filled out a questionnaire before, as well as at 3 and 6 weeks after the operation.
- Categorised into 4 levels - 220 participants
- More active participants (level 3 or 4) had an 85% increased chance of feeling physically recovered at 3 weeks after the operation. No difference was seen after 6 weeks.

Question 45

What two medium studies have shown evidence in prehabilitation and outline them

Answer 45

Efficacy of a multiprofessional rehabilitation programme in radical cystectomy pathways: a prospective randomized controlled trial. Jensen (2014) Scandinavian journal or urology
- 107 patients were included in a prospective randomized controlled design. The intervention included standardized preoperative and postoperative strength and endurance exercises and progressive postoperative mobilization. The programme was initiated 2 weeks before surgery.
- Patients adhering to prehabilitation prior to radical cystectomy showed
improved mobilization and ability to perform daily activities. No difference
was seen in likelihood of post-operative complications and no reductive in
length of stay

Multimodal prehabilitation improves functional capacity before and after colorectal surgery for cancer: a five-year research experience Minella and colleagues (2017) Sweden.
- 185 participants performing trimodal prehabilitation (exercise, nutrition, and coping strategies for anxiety) were compared to the patients who underwent the trimodal program only after surgery (rehabilitation/control group).
- Changes in 6MWD before surgery, at four and eight weeks were compared between groups.
- 6MWD higher for prehabilitation group were higher compared to the rehabilitation/control group during the preoperative period 46.7 m vs. -5.8 at four weeks [-11.2 vs. -72.5 and at eight weeks [17.0 vs. -8.8 The proportion of subjects experiencing a significant preoperative improvement in physical fitness was higher in prehabilitation [68 (60%) vs. 15 (21%), +19m 6MWT

Question 46

Outline the two small papers in the Macmillan evidence review and their results

Answer 46

Impact of preoperative pulmonary rehabilitation on the Thoracoscore of patients undergoing lung resection Thomas and Goldsmith (2016) Interact cardiovascular thoracic surgery

Question 47

What is the issue with dyspnea in cancer patients pre-surgery?

Answer 47

Patients with dyspnoea who are suitable for lung resection have a higher in-hospital mortality following surgery as predicted by the Thoracoscore Thomas and Goldsmith (2016) Cardiovascular Thoracic Journal
- Multimodal prehabilitation (respiratory exercises, cardiovascular exercises,
smoking education and pharmacology agents)
- 42 patients dyspnoea grade ≥2 and performance status ≥1 for lung resection and recruited them for PPR. Hospital mortality, complication rates and the length of hospital stay following surgery were compared between those who received PPR vs. straight to surgery.
- 33 patients received PPR for a mean duration of 7.1 [SD 6.5] days. Their mean Thoracoscores before and after PPR were 6.4 and 1.7% dyspnoea grade 3.8 and 2.2 and performance status 2.7 and 1.7 respectively. Mortality 0 vs 11.1% (P = 0.05), postoperative complication rate 5.3% vs 37.5% and mean length of hospital stay 8.7 days vs 10.3 (P = 0.26).

Randomized clinical trial of prehabilitation before planned liver resection. Dunne and colleagues (2016) British Journal of Surgery.
- 4-week (12 sessions) high-intensity cycle, interval training programme in patients undergoing elective liver resection for colorectal liver metastases.
- Prehabilitation led to improvements in preoperative oxygen uptake at anaerobic threshold (+1·5 ml per kg per min) and peak exercise (+2·0 ml per kg per min). The oxygen pulse (oxygen uptake per heart beat) at the anaerobic threshold improved (+0·9 (0·0 to 1·8) ml/beat), and a higher peak work rate (+13 (4 to 22) W) was achieved. This was associated with improved preoperative QoL, with the overall SF-36® score increasing by 11 (95 per cent c.i. 1 to 21) (P = 0·028) and the overall SF-36® mental health score by 11 (1 to 22) (P = 0·037).

Question 48

Where are the current gaps in the evidence?

Answer 48

1) What is the best practice in prehabilitation
2) What is the Macmillan model for prehab
3) Who and who should fund prehab
4) Evidence of outcomes for each intervention not just PA
5) Who is best placed to provide prehab, who can realistically provide prehab
6) What are the potential cost saving that can be made

Question 49

What are some ‘other’ psychological interventions suggested by subject-matter experts?

Answer 49

• Hydrotherapy
• Body image
• Mindfulness
• Tai Chi
• Motivation interviewing
• Art and music therapy
• Social coping
• Behaviour change development
• Sleep hygiene
• Healthy conversation

Question 50

What are the scales for measuring progress in cancer patients?

Answer 50

• Cardio Pulmonary Exercise Testing (CPET)
• 6 Minute Walking Distance (6MWD)
• EQ-5D (generic health measurements)
• Patient Activation Measurement (PAM)
• Canadian Occupational Performance Measure (COPM)
• Functional Assessment of Chronic Illness Therapy (FACIT)
• Hand grip
• Incremental shuffle test
• Hospital Anxiety and Depression Scale (HADS)
• Warwick-Edinburgh Mental Well-being Scale
• Patient experience
• Blood tests
• Heart monitors
• SF-36® mental health score
• Internal Consultation on Incontinence Questionnaire (ICIQ)
• Patient diaries
• Scans
• PSS: International Prostate Symptom Score and Quality of Life (I-PSS)