Importance Research supports use of prehabilitation to optimize physical status before and after colorectal cancer resection, but its effect on postoperative complications remains unclear. Frail patients are a target for prehabilitation interventions owing to increased risk for poor postoperative outcomes. Objective To assess the extent to which a prehabilitation program affects 30-day postoperative complications in frail patients undergoing colorectal cancer resection compared with postoperative rehabilitation. Design, Setting, and Participants This single-blind, parallel-arm, superiority randomized clinical trial recruited patients undergoing colorectal cancer resection from September 7, 2015, through June 19, 2019. Patients were followed up for 4 weeks before surgery and 4 weeks after surgery at 2 university-affiliated tertiary hospitals. A total of 418 patients 65 years or older were assessed for eligibility. Of these, 298 patients were excluded (not frail [n = 290], unable to exercise [n = 3], and planned neoadjuvant treatment [n = 5]), and 120 frail patients (Fried Frailty Index,≥2) were randomized. Ten patients were excluded after randomization because they refused surgery (n = 3), died before surgery (n = 3), had no cancer (n = 1), had surgery without bowel resection (n = 1), or were switched to palliative care (n = 2). Hence, 110 patients were included in the intention-to-treat analysis (55 in the prehabilitation [Prehab] and 55 in the rehabilitation [Rehab] groups). Data were analyzed from July 25 through August 21, 2019. Interventions Multimodal program involving exercise, nutritional, and psychological interventions initiated before (Prehab group) or after (Rehab group) surgery. All patients were treated within a standardized enhanced recovery pathway. Main Outcomes and Measures The primary outcome included the Comprehensive Complications Index measured at 30 days after surgery. Secondary outcomes were 30-day overall and severe complications, primary and total length of hospital stay, 30-day emergency department visits and hospital readmissions, recovery of walking capacity, and patient-reported outcome measures. Results Of 110 patients randomized, mean (SD) age was 78 (7) years; 52 (47.3%) were men and 58 (52.7%) were women; 31 (28.2%) had rectal cancer; and 87 (79.1%) underwent minimally invasive surgery. There was no between-group difference in the primary outcome measure, 30-day Comprehensive Complications Index (adjusted mean difference, –3.2; 95% CI, –11.8 to 5.3;P = .45). Secondary outcome measures were also not different between groups. Conclusions and Relevance In frail patients undergoing colorectal cancer resection (predominantly minimally invasive) within an enhanced recovery pathway, a multimodal prehabilitation program did not affect postoperative outcomes. Alternative strategies should be considered to optimize treatment of frail patients preoperatively. Trial Registration ClinicalTrials.gov identifier:NCT02502760

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Effect of Multimodal Prehabilitation vs Postoperative Rehabilitation on 30-Day Postoperative Complications for Frail Patients Undergoing Resection of Colorectal Cancer: A Randomized Clinical Trial.

Withdrawal of treatment is a common activity in intensive care, involving 82% of deaths in our unit During this process, a comprehensive plan addressing all aspects of the patient's care is required [1] Personalisation of the treatment withdrawal process enables a higher quality of care to be delivered but relies on effective communication between doctors and nursing staff A well-structured treatment withdrawal form can help to promote both of these Methods The original form consisted of a checklist, with statements grouped under the following headings: 'reason for withdrawal, management and method' Initial semi-structured interviews identified a need for a clearer form with more detailed instructions, such as the timing of when interventions should be stopped Therefore, the form was re-formatted to follow a 'traffic light' system, to ensure all aspects, from physical interventions to communication have been addressed A box was added to prompt clinicians to specify when an intervention should be stopped Points prompting consideration of geographical location of the patient and palliative care referral were also added, following further suggestions from the interviews The revised form was implemented for 2 months during the COVID-19 pandemic Results Repeat interviews were conducted with 20 members of staff to assess efficacy and minor revisions were made to produce a final form (Fig 1) The revised stucture was well received, and the form was described as 'clear' (n = 8) and 'easy to follow' (n = 6) Suggestions to add a medication review prompt (n = 4) were addressed Discussion Good-quality end-of-life care needs to be individualised to the patient and their family's needs and circumstances Its effective delivery relies on multiple members of the team working together to ensure that the patient's physical, holistic and spiritual needs are met This is only possible through clear communication between different members of the team By taking a multidisciplinary approach, we have recognised that we can improve the process by encouraging individualised care plans and promoting clear communication between members of staff The revised form aims to do this through a comprehensive yet clear and structured format and has received positive feedback

The effect of trimodal prehabilitation on the physical and psychological health of patients undergoing colorectal surgery: a randomised clinical trial

This narrative review presents a biological rationale and evidence to describe how the preoperative condition of the patient contributes to postoperative morbidity. Any preoperative condition that prevents a patient from tolerating the physiological stress of surgery (e.g. poor cardiopulmonary reserve, sarcopaenia), impairs the stress response (e.g. malnutrition, frailty), and/or augments the catabolic response to stress (e.g. insulin resistance) is a risk factor for poor surgical outcomes. Prehabilitation interventions that include exercise, nutrition, and psychosocial components can be applied before surgery to strengthen physiological reserve and enhance functional capacity, which, in turn, supports recovery through attaining surgical resilience. Prehabilitation complements Enhanced Recovery After Surgery (ERAS) care to achieve optimal patient outcomes because recovery is not a passive process and it begins preoperatively. 

Prehabilitation, enhanced recovery after surgery, or both? A narrative review

Multimodal Prehabilitation for Lung Cancer Surgery: A Randomized Controlled Trial.

Multimodal prehabilitation is increasingly recognized as an important component of the pre-operative pathway in oncology. It aims to optimize physical and psychological health through delivery of a series of tailored interventions including exercise, nutrition, and psychological support. At the core of this prescription is a need for considerable health behavior change, to ensure that patients are engaged with and adhere to these interventions and experience the associated benefits. To date the prehabilitation literature has focused on testing the efficacy of devised exercise and nutritional interventions with a primary focus on physiological and mechanistic outcomes with little consideration for the role of behavioral science, supporting individual behavior change or optimizing patient engagement. Changing health behavior is complex and to maximize success, prehabilitation programs should draw on latest insights from the field of behavioral science. Behavioral science offers extensive knowledge on theories and models of health behavior change to further advance intervention effectiveness. Similarly, interventions developed with a person-centered approach, taking into consideration individual needs and preferences will increase engagement. In this article, we will provide an overview of the extent to which the existing prehabilitation literature incorporates behavioral science, as well as studies that have explored patient's attitudes toward prehabilitation. We will go on to describe and critique ongoing trials in a variety of contexts within oncology prehabilitation and discuss how current scientific knowledge may be enhanced from a behavioral science perspective. We will also consider the role of "surgery schools" and detail practical recommendations that can be embedded in existing or emerging clinical settings.

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The Role of Behavioral Science in Personalized Multimodal Prehabilitation in Cancer.

BACKGROUND Exercise training is a component of the pre-habilitation program. While in one previous study the training was home-based, in a subsequent investigation it was supervised in hospital. The hypothesis of this secondary analysis of the two studies was to determine whether supervised exercise further accelerates the return to baseline walking ability. METHODS Data from two consecutive randomized control trials (RCT) comparing pre-habilitation to the rehabilitation of cancer patients scheduled for colorectal surgery were pooled for analysis. The interventions were similar and included home-based exercise training, nutritional counseling and protein supplementation, and relaxation techniques administered either before surgery (pre-habilitation) or after surgery (rehabilitation). Patients in the second RCT received additional supervised exercise sessions. Functional capacity was assessed with the 6-minute walk test (6 MWT) at baseline, before surgery, and at 4 and 8 weeks after surgery. Adjusted logistic regression was used to determine the improvement of the 6-minute walk distance (6MWD). RESULTS Baseline mean 6MWD of 63 patients in the supervised group was 465.1 m (SD, 115), and that of 77 patients in the nonsupervised group was 407.8 m (SD, 109) (P < 0.01). Perioperative supervised exercise training enhanced further functional capacity and muscle strength when compared with the nonsupervised group (P < 0.01). Those receiving exercise supervision had over two times higher chances to return to baseline after surgery. Supervised pre-habilitation was the best combination (4 weeks OR = 7.71, and at 8 weeks OR = 8.62). CONCLUSION Supervised exercise training leads to meaningful changes in functional capacity thus accelerating the postoperative return to baseline activities.

Supervised exercise training with multimodal pre-habilitation leads to earlier functional recovery following colorectal cancer resection.

Objective Depression and poor functional status (FS) frequently co-occur. Though both predict adverse surgical outcomes, research examining preoperative functional performance (FP; self-reported) and functional capacity (FC; performance-based) measures in depressed cancer patients is lacking. Prehabilitation, a preoperative intervention including exercise, nutrition, and stress-reduction, may improve FC; however, whether depressed patients benefit from this intervention remains unknown. The primary objectives were to (a) assess differences in FP and FC and (b) explore the impact of prehabilitation on FC in individuals with depressive symptoms versus those without. Method A secondary analysis was conducted on 172 colorectal cancer patients enrolled in three studies comparing prehabilitation with a control group (rehabilitation). Measures were collected at 4 weeks pre- and 8 weeks postoperatively. FP, FC, and psychological symptoms were assessed using the 36-Item Short Form Health Survey, Six-Minute Walk Distance (6MWD), and Hospital Anxiety and Depression Scale (HADS), respectively. Subjects were divided into three groups according to baseline psychological symptoms: no psychological-symptoms (HADS-N), anxiety-symptoms (HADS-A), or depressive-symptoms (HADS-D). Main objectives were tested using analyses of variance, chi-square tests, and multivariate logistic regression. Results At baseline, HADS-D reported lower FP, had shorter 6MWD, and a greater proportion walked ≤ 400 m. Prehabilitation was associated with significant improvements in 6MWD in HADS-D group but not in HADS-N or HADS-A groups. Conclusion Poorer FS was observed in subjects with depressive symptoms, and these subjects benefited most from prehabilitation intervention. Future research could examine whether severity of depression and co-occurrence of anxiety differentially impact FS and whether prehabilitation can improve psychological symptoms and quality of life. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

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Agnihotram V. Ramanakumar

Papers

Supervised exercise training with multimodal pre-habilitation leads to earlier functional recovery following colorectal cancer resection.

Depression and functional status in colorectal cancer patients awaiting surgery: Impact of a multimodal prehabilitation program.

Depression and Functional Status in Colorectal Cancer Patients Awaiting Surgery; Impact of a Multimodal Prehabilitation Program