Principles and guidance for prehabilitation within the management and support of people with cancer

Question 1

What are the governing bodies involved in principles and guidance for prehabilitation in people with cancer?

Answer 1

1) National institute of health research: Nutrition and cancer collaboration
2) Royal college of anaesthetists
3) Macmillan

Question 2

What are the three main benefits of cancer prehabilitation?

Answer 2

Personal empowerment:
1) Fostering a sense of control and purpose in people, facilitating preparation for treatment and improving of quality of life
2) Physical and psychological resilience: An opportunity to improve physical function and psychological wellbeing thus improving resilience to the effects of cancer treatments, enhancing quality of recovery and enabling the living of life as fully as possible
3) Long-term health: An opportunity to reflect on the role of healthy lifestyle practices following a cancer diagnosis, promote positive health behaviour change and improve long-term health.

Question 3

What are the benefits of prehabilitation?

Answer 3

1) Reduce length of stay
2) Improve cardiorespiratory fitness
3) Enhance recovery following treatment
4) Improve nutritional status
5) Reduce post treatment complications
6) Improve aspects of neuro-cognitive function
7) Provide a teachable moment to enable smoking and alcohol cessation
8) Enhance quality of life

Question 4

What are the principles of prehabilitation?

Answer 4

1) Promotes healthy behaviour to maximise resilience to treatment and improve long-term health. Supports them to live life as fully as possible
2) People are less vulnerable to side effects of cancer treatment if they are as healthy as possible - people who are more healthy have more treatment options
3) Intervention are safe, effective and welcomed by individuals with cancer
4) Prehabilitation sits within broader context of health improvement including smoking/alcohol cessation, medication review and management of long-term conditions

Question 5

Outline the four points related to Prehabilitation in the cancer pathway

Answer 5

1) Should underpin the whole cancer pathway with a co-developed personalised prehabilitation plan developed for all patients
2) All cancer multi-disciplinary teams should have representation from those delivering prehabilitation to provide oversight of needs. Community hub MDTs also have important role
3) Personalised prehabilitation care plans should be a document that encompass nutrition, physical and psychological screening to identify need for more detailed assessment according to need and individualised intervention based on screening and assessment along with on-going support and evaluation to aid uptake and adherence
4) Interventions should start as early as possible and in advance of any cancer treatment

Question 6

What 3 things does the document say about screening?

Answer 6

1) Identification of people with cancer requiring prehabilitation should occur as early as possible (screening)
2) Screening should use validated tools to identify the need for more detailed assessment to inform the prescription of targeted or specialist interventions
3) Screening should be aligned to holistic needs assessment and should include psychological risk factors, physical fitness, and nutrition including evaluation of weight loss, poor intake, BMI and nutrition impact symptoms

Question 7

What is screening in the context of cancer patients and what is it’s aim?

Answer 7

• Screening aims to detect cancer at an early stage when it is more treatable, identify individuals at higher risk for cancer or cancer-related complications, and guide appropriate management and referral pathways.
• Screening refers to the systematic process of identifying individuals who may have an increased risk of developing cancer or who may benefit from specific interventions, such as early detection, risk reduction strategies, or supportive care services.

Question 8

What role does screening play in prehabilitation?

Answer 8

Screening plays a crucial role in identifying cancer patients who may benefit from prehabilitation interventions by assessing functional status, identifying risk factors, and determining eligibility for pre-operative rehabilitation programs.

Question 9

What is the importance of assessment interventions in patients with cancer?

Answer 9

1) Encompass comprehensive evaluation of needs identified during screening using validated clinical measurement techniques
2) Should inform the individualised prescription of exercise, nutrition, and psychological interventions

Question 10

What is the purpose, method, and outcomes of screening in prehabilitation patients?

Answer 10

Screening:

Purpose: Screening is a preliminary process used to identify individuals who may be at increased risk for peri-operative complications, functional decline, or poor outcomes and who may benefit from prehabilitation interventions. Screening helps determine eligibility for prehabilitation programs and guides the selection of appropriate assessment tools.

Methods: Typically involves the use of standardized screening tools, questionnaires, or checklists to assess patients’ risk factors, functional capacity, health history, and psychosocial well-being. Screening tools are often brief, simple, and easy to administer and may include measures of physical fitness, performance status, comorbidities, and psychosocial factors.

Outcome: The primary outcome of screening is to identify patients who may benefit from further assessment or referral to prehabilitation programs based on their risk profile and eligibility criteria. Screening helps triage patients and prioritize those who are most likely to benefit from prehabilitation interventions.

Question 11

What is the purpose, methods, and outcomes of assessment in cancer prehabilitation patients?

Answer 11

Purpose: Assessment is a comprehensive process used to evaluate patients’ physical fitness, functional capacity, health status, and treatment needs in greater detail. Assessment provides more detailed information about patients’ individual strengths, weaknesses, goals, and preferences and serves as the foundation for developing personalized exercise prescriptions and care plans.

Methods: Assessment involves a thorough evaluation of patients’ physical fitness, functional status, health history, psychosocial well-being, and treatment goals using validated assessment tools, tests, and measurements. Assessment methods may include cardiopulmonary exercise testing (CPET), strength testing, flexibility assessments, functional mobility tests, health history interviews, and psychosocial screenings.

Outcome: The primary outcome of assessment is to gather detailed information about patients’ baseline physical fitness, functional capacity, health status, and treatment needs to inform the development of personalized exercise prescriptions and care plans. Assessment helps identify areas of strength and areas for improvement, set realistic goals, and monitor progress over time.

Question 12

Outline the features of Universal, Targeted, and Specialist Interventions

Answer 12

Universal: Universal interventions are applicable to anyone with cancer. People with cancer and their families, should receive dietary, exercise and psychological advice and behaviour change support, be sign-posted to appropriate resources, and be advised on how to self-manage, recognise and respond to any change in physical and/or psychological state.

Targeted: Targeted interventions are applicable to those people with cancer with and at risk of late effects of disease or treatment and those with other long-term conditions. Specific needs identified during screening should be addressed with prescribed exercise, nutrition and psychological interventions and
behaviour change support by a registered
health and care professional according to
need. Adherence and effectiveness should
be monitored.

Specialist: Specialist interventions are applicable to people with cancer who have complex needs, complex treatment eg major surgery, severe impairment and/or disability and will need referral to registered professionals to prescribe exercise, nutrition and psychological interventions and behaviour change support according to need. Adherence and effectiveness should
be monitored.

Question 13

What are the three things the document says about service development?

Answer 13

1) Pathways need to be efficient and timely from moment treatment is considered onwards
2) People with cancer as a well as carers, relatives, and a person’s wider network should be support to engage with Prehab services
3) Services delivering Prehab should be co-designed with patients and carers

Question 14

What should be considered about the level of supervision?

Answer 14

1) Monitoring of intervention should be proportionate to need

Question 15

What is the HNA?

Answer 15

• HNA is a simple questionnaire that is completed by a person affected by cancer. It allows them to highlight the most important issues to them at that time, and this can inform the development of a care and support plan with their nurse or key worker.
• Includes physical concerns, Practical concerns, Emotional concerns, Family or relationship concerns, Spiritual concerns, Information or support

Question 16

What does the document say about quality assurance and improvement?

Answer 16

1) Implementation and effectiveness should be audited as part of quality assurance and improvement framework delivered according to recognised standards

2) A set of standard screening, assessment, adherence, efficacy, experience and outcome measures should be defined and used consistently within this framework.

Question 17

What does the document say about leadership?

Answer 17

• Health and care professionals should
  understand and communicate the
  importance of prehabilitation through
  leadership and advocacy.
• Service transformation through effective clinical leadership underpins the development of effective prehabilitation for people with cancer.
• Prehabilitation education related to supporting those with cancer in nutrition, exercise, psychology and behavioural change, should be integrated throughout the undergraduate and postgraduate training of health and care professionals working with those with cancer and other relevant training programmes

Question 18

What two things does the document state about developing the evidence based?

Answer 18

1) Prehab should be underpinned by theory and evidence including discovery science (observational data), experimental data, population science as well as from quality assurance and improvement data.
2) Evidence should be carefully, critically and systematically appraised in the context of current experience so safe and effective guidance that minimises risk and harm.

Question 19

What are the 11 action plan points made in the prehabilitation document?

Answer 19

1) Integrate prehabilitation into established clinical pathway including intergration of screening questions
2) Gather examples of local areas that have had prehab commissioned
3) Gather examples of personalised prehabilitation care plans
4) Develop a ‘community of practice’ resource to provide contacts of local/regional sites and share expertise and learning from established programmes
5) Work with registered and unregistered professional groups to define a competence and training framework
6) Work with PSA, CIMPS, and BASES to develop accreditation programme for exercise professionals in Prehab
7) Develop a standardised set of screening, assessment, adherence, efficacy and outcome measures
8) Develop a quality assurance and quality improvement framework and advocate for inclusion of relevant data in established national audits
9) Conduct gap analysis of current evidence
10) Pursue prehab research agenda in partnership with NIHR, Cancer research UK and National Cancer Research Institute
11) Pursue health economic evaluation of prehab programmes to inform development of viable business cases

Question 20

How does Prehabilitation care differ from typical care

Answer 20

• Screening, assessment, care plan focused on personalised prehabilitation care plan
• Prehab begins at point of diagnosis
• Prescribed activity not just general health and wellbeing support sessions

Question 21

What does Macmillan estimate about late effects of treatment?

Answer 21

• Roughly 1 in 4 individuals have a psychosocial or physical consequence of their treatment
• The number of people living with cancer each year is increasing by 3%

Question 22

What features of the NHS England Long-Term Plan does Prehab align with?

Answer 22

1) Personalised care
2) Screening and early diagnosis,
3) Tackling health inequalities
4) Maximising value

Question 23

What enablers are there to support delivery of Prehab?

Answer 23

1) Supporting the health and care workforce.
2) Making effective use of data and digital technology