Cancer Prehabilitation An Opportunity to Decrease Treatment-Related Morbidity, Increase Cancer Treatment Options, and Improve Physical and Psychological Health Outcomes
01 Aug 2013-American Journal of Physical Medicine & Rehabilitation (Am J Phys Med Rehabil)-Vol. 92, Iss: 8, pp 715-727
TL;DR: This is the first review of cancer prehabilitation, and the purpose was to describe early studies in the noncancer population and then the historical focus in cancer patients on aerobic conditioning and building strength and stamina through an appropriate exercise regimen.
Abstract: Silver JK, Baima J: Cancer prehabilitation: an opportunity to decrease treatmentrelated morbidity, increase cancer treatment options, and improve physical and psychological health outcomes. Am J Phys Med Rehabil 2013;92:715Y727. Cancer prehabilitation, a process on the continuum of care that occurs between the time of cancer diagnosis and the beginning of acute treatment, includes physical and psychological assessments that establish a baseline functional level, identifies impairments, and provides targeted interventions that improve a patient’s health to reduce the incidence and the severity of current and future impairments. There is a growing body of scientific evidence that supports preparing newly diagnosed cancer patients for and optimizing their health before starting acute treatments. This is the first review of cancer prehabilitation, and the purpose was to describe early studies in the noncancer population and then the historical focus in cancer patients on aerobic conditioning and building strength and stamina through an appropriate exercise regimen. More recent research shows that opportunities exist to use other unimodal or multimodal prehabilitation interventions to decrease morbidity, improve physical and psychological health outcomes, increase the number of potential treatment options, decrease hospital readmissions, and reduce both direct and indirect healthcare costs attributed to cancer. Future research may demonstrate increased compliance with acute cancer treatment protocols and, therefore, improved survival outcomes. New studies suggest that a multimodal approach that incorporates both physical and psychological prehabilitation interventions may be more effective than a unimodal approach that addresses just one or the other. In an impairment-driven cancer rehabilitation model, identifying current and anticipating future impairments are the critical first steps in improving healthcare outcomes and decreasing costs. More research is urgently needed to evaluate the most effective prehabilitation interventions, and combinations thereof, for survivors of all types of cancer.
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TL;DR: Based on the evidence available for each item of the multimodal perioperative care pathway, the Enhanced Recovery After Surgery (ERAS) Society, International Association for Surgical Metabolism and Nutrition (IASMEN) and European Society for Clinical Nutrition and Metabolicism (ESPEN) present a comprehensive evidence-based consensus review of peri operative care for colonic surgery.
Abstract: This is the fourth updated Enhanced Recovery After Surgery (ERAS®) Society guideline presenting a consensus for optimal perioperative care in colorectal surgery and providing graded recommendations for each ERAS item within the ERAS® protocol. A wide database search on English literature publications was performed. Studies on each item within the protocol were selected with particular attention paid to meta-analyses, randomised controlled trials and large prospective cohorts and examined, reviewed and graded according to Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. All recommendations on ERAS® protocol items are based on best available evidence; good-quality trials; meta-analyses of good-quality trials; or large cohort studies. The level of evidence for the use of each item is presented accordingly. The evidence base and recommendation for items within the multimodal perioperative care pathway are presented by the ERAS® Society in this comprehensive consensus review.
1,918 citations
Klinikum St. Georg1, Vita-Salute San Raffaele University2, Montreal General Hospital3, Fujita Health University4, University Hospital of Lausanne5, Memorial Hospital of South Bend6, Sapienza University of Rome7, Örebro University8, National Institute for Health Research9, Oregon Health & Science University10, University of São Paulo11, University of Hohenheim12, Rabin Medical Center13
TL;DR: The focus of this guideline is to cover nutritional aspects of the Enhanced Recovery After Surgery (ERAS) concept and the special nutritional needs of patients undergoing major surgery, e.g. for cancer, and of those developing severe complications despite best perioperative care.
1,096 citations
Cites background from "Cancer Prehabilitation An Opportuni..."
...There is strong evidence supporting prehabilitation to mitigate the side effects of therapy in patients with cancer [55]....
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TL;DR: Meaningful changes in postoperative functional exercise capacity can be achieved with a prehabilitation program, as measured using the validated 6-min walk test.
Abstract: Background The preoperative period (prehabilitation) may represent a more appropriate time than the postoperative period to implement an intervention. The impact of prehabilitation on recovery of function al exercise capacity was thus studied in patients undergoing colorectal resection for cancer. Methods A parallel-arm single-blind superiority randomized controlled trial was conducted. Seventy-seven patients were randomized to receive either prehabilitation (n = 38) or rehabilitation (n = 39). Both groups received a home-based intervention of moderate aerobic and resistance exercises, nutritional counseling with protein supplementation, and relaxation exercises initiated either 4 weeks before surgery (prehabilitation) or immediately after surgery (rehabilitation), and continued for 8 weeks after surgery. Patients were managed with an enhanced recovery pathway. Primary outcome was functional exercise capacity measured using the validated 6-min walk test. Results Median duration of prehabilitation was 24.5 days. While awaiting surgery, functional walking capacity increased (≥ 20 m) in a higher proportion of the prehabilitation group compared with the rehabilitation group (53 vs. 15%, adjusted P = 0.006). Complication rates and duration of hospital stay were similar. The difference between baseline and 8-week 6-min walking test was significantly higher in the prehabilitation compared with the rehabilitation group (+23.7 m [SD, 54.8] vs. -21.8 m [SD, 80.7]; mean difference 45.4 m [95% CI, 13.9 to 77.0]). A higher proportion of the prehabilitation group were also recovered to or above baseline exercise capacity at 8 weeks compared with the rehabilitation group (84 vs. 62%, adjusted P = 0.049). Conclusion Meaningful changes in postoperative functional exercise capacity can be achieved with a prehabilitation program.
608 citations
Additional excerpts
...Lean body mass, kg (SD) 52 (11) 56 (10) Fat body mass, kg (SD) 31 (9) 31 (10) Fat percentage, % of weight (SD) 37....
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...Physical activity, kcal/kg per week [IQR] 25 [9–67] 34 [18–63] Grip strength left hand, kg (SD) 29 (11) 32 (9) Grip strength right hand, kg (SD) 30 (11) 34 (10)...
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TL;DR: This is the first updated Enhanced Recovery After Surgery (ERAS) Society guideline presenting a consensus for optimal perioperative care in gynecologic/oncology surgery, and the updated evidence base and recommendation are presented.
Abstract: BACKGROUND: This is the first updated Enhanced Recovery After Surgery (ERAS) Society guideline presenting a consensus for optimal perioperative care in gynecologic/oncology surgery.METHODS: A datab ...
390 citations
TL;DR: In this paper, an impairment-driven cancer rehabilitation model that includes screening and treating impairments all along the care continuum in order to minimize disability and maximize quality of life is presented.
Abstract: Adult cancer survivors suffer an extremely diverse and complex set of impairments, affecting virtually every organ system. Both physical and psychological impairments may contribute to a decreased health-related quality of life and should be identified throughout the care continuum. Recent evidence suggests that more cancer survivors have a reduced health-related quality of life as a result of physical impairments than due to psychological ones. Research has also demonstrated that the majority of cancer survivors will have significant impairments and that these often go undetected and/or untreated, and consequently may result in disability. Furthermore, physical disability is a leading cause of distress in this population. The scientific literature has shown that rehabilitation improves pain, function, and quality of life in cancer survivors. In fact, rehabilitation efforts can ameliorate physical (including cognitive) impairments at every stage along the course of treatment. This includes prehabilitation before cancer treatment commences and multimodal interdisciplinary rehabilitation during and after acute cancer treatment. Rehabilitation appears to be cost-effective and may reduce both direct and indirect health care costs, thereby reducing the enormous financial burden of cancer. Therefore, it is critical that survivors are screened for both psychological and physical impairments and then referred appropriately to trained rehabilitation health care professionals. This review suggests an impairment-driven cancer rehabilitation model that includes screening and treating impairments all along the care continuum in order to minimize disability and maximize quality of life.
315 citations
References
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TL;DR: In a meta-analysis of the available literature on time to AC, longer time toAC was associated with worse survival among patients with resected colorectal cancer.
Abstract: Context Adjuvant chemotherapy (AC) improves survival among patients with resected colorectal cancer. However, the optimal timing from surgery to initiation of AC is unknown. Objective To determine the relationship between time to AC and survival outcomes via a systematic review and meta-analysis. Data Sources MEDLINE (1975 through January 2011), EMBASE, the Cochrane Database of Systematic Reviews, and the Cochrane Central Register of Controlled Trials were searched to identify studies that described the relationship between time to AC and survival. Study Selection Studies were only included if the relevant prognostic factors were adequately described and either comparative groups were balanced or results adjusted for these prognostic factors. Data Extraction Hazard ratios (HRs) for overall survival and disease-free survival from each study were converted to a regression coefficient (β) and standard error corresponding to a continuous representation per 4 weeks of time to AC. The adjusted β from individual studies were combined using a fixed-effects model. Inverse variance (1/SE 2 ) was used to weight individual studies. Publication bias was investigated using the trim and fill approach.
Results We identified 10 eligible studies involving 15 410 patients (7 published articles, 3 abstracts). Nine of the studies were cohort or population based and 1 was a secondary analysis from a randomized trial of chemotherapy. Six studies reported time to AC as a binary variable and 4 as 3 or more categories. Meta-analysis demonstrated that a 4-week increase in time to AC was associated with a significant decrease in both overall survival (HR, 1.14; 95% confidence interval [CI], 1.10-1.17) and disease-free survival (HR, 1.14; 95% CI, 1.10-1.18). There was no significant heterogeneity among included studies. Results remained significant after adjustment for potential publication bias and when the analysis was repeated to exclude studies of largest weight. Conclusion In a meta-analysis of the available literature on time to AC, longer time to AC was associated with worse survival among patients with resected colorectal cancer.
533 citations
"Cancer Prehabilitation An Opportuni..." refers background in this paper
...For example, a 2011meta-analysis study of 15,410 patients with colorectal cancer found that a 4-wk increase in the time between colon resection and chemotherapy was associated with a significant decrease in both overall survival and disease-free survival.(59) A feasibility study in 13 patients by Jones et al....
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TL;DR: Preoperative IMT reduced the incidence of PPCs and duration of postoperative hospitalization in patients at high risk of developing a pulmonary complication undergoing CABG surgery.
Abstract: ContextPostoperative pulmonary complications (PPCs) after coronary artery bypass graft (CABG) surgery are a major source of morbidity and mortality, and increase length of hospital stay and resource utilization. The prehospitalization period before CABG surgery may be used to improve a patient's pulmonary condition. The efficacy of preoperative inspiratory muscle training (IMT) in reducing the incidence of PPCs in high-risk patients undergoing CABG surgery has not yet been determined.ObjectiveTo evaluate the prophylactic efficacy of preoperative IMT on the incidence of PPCs in high-risk patients scheduled for elective CABG surgery.Design, Setting, and PatientsA single-blind, randomized clinical trial conducted at the University Medical Center Utrecht, Utrecht, the Netherlands, with enrollment between July 2002 and August 2005. Of 655 patients referred for elective CABG surgery, 299 (45.6%) met criteria for high risk of developing PPCs, of whom 279 were enrolled and followed up until discharge from hospital.InterventionPatients were randomly assigned to receive either preoperative IMT (n = 140) or usual care (n = 139). Both groups received the same postoperative physical therapy.Main Outcome MeasuresIncidence of PPCs, especially pneumonia, and duration of postoperative hospitalization.ResultsBoth groups were comparable at baseline. After CABG surgery, PPCs were present in 25 (18.0%) of 139 patients in the IMT group and 48 (35.0%) of 137 patients in the usual care group (odds ratio [OR], 0.52; 95% confidence interval [CI], 0.30-0.92). Pneumonia occurred in 9 (6.5%) of 139 patients in the IMT group and in 22 (16.1%) of 137 patients in the usual care group (OR, 0.40; 95% CI, 0.19-0.84). Median duration of postoperative hospitalization was 7 days (range, 5-41 days) in the IMT group vs 8 days (range, 6-70 days) in the usual care group by Mann-Whitney U statistic (z = –2.42; P = .02).ConclusionPreoperative IMT reduced the incidence of PPCs and duration of postoperative hospitalization in patients at high risk of developing a pulmonary complication undergoing CABG surgery.Trial Registrationisrctn.org Identifier: ISRCTN17691887
526 citations
"Cancer Prehabilitation An Opportuni..." refers result in this paper
...Another study from the Netherlands that focused on exercise of the respiratory muscles only had a similar outcome, additionally reporting fewer pulmonary complications after surgery.(27) The orthopedic literature, too, demonstrated success using prehabilitation to decrease lengths of hospital stay and postsurgical outcomes in the spinal surgery population....
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TL;DR: Delays in the initiation of RT is associated with an increase [corrected] in LRR in breast cancer and head and neck cancer, and this should be as short as reasonably achievable.
Abstract: Purpose: The objective of this study was to synthesize what is known about the relationship between delay in radiotherapy (RT) and the outcomes of RT. Methods: A systematic review of the world literature was conducted to identify studies that described the association between delay in RT and the probability of local control, metastasis, and/or survival. Studies were classified by clinical and methodologic criteria and their results were combined using a random-effects model. Results: A total of 46 relevant studies involving 15,782 patients met our minimum methodologic criteria of validity; most (42) were retrospective observational studies. Thirty-nine studies described rates of local recurrence, 21 studies described rates of distant metastasis, and 19 studies described survival. The relationship between delay and the outcomes of RT had been studied in diverse situations, but most frequently in breast cancer (21 studies) and head and neck cancer (12 studies). Combined analysis showed that the 5-year local...
507 citations
TL;DR: Chemotherapy-induced neurotoxicity is frequently delayed in onset and may progress over time in the peripheral nervous system, resulting in chemotherapy-induced peripheral neuropathy.
Abstract: Recent advances in the development and administration of chemotherapy for malignant diseases have led to prolonged survival of patients and the promise of a return to normal lives. The cost of progress comes with a price, however, and the nervous system is frequently the target of therapy-induced toxicity. Unlike more immediate toxicities that affect the gastrointestinal tract and bone marrow, chemotherapy-induced neurotoxicity is frequently delayed in onset and may progress over time. In the peripheral nervous system, the major brunt of the toxic attack is directed against the peripheral nerve, targeting the neuronal cell body, the axonal transport system, the myelin sheath, and glial support structures, resulting in chemotherapy-induced peripheral neuropathy.
381 citations
TL;DR: The effect of a minimum 8-week, multidimensional, preoperative intervention on the presurgery and postsurgery outcomes of patients awaiting elective CABG and a combination of exercise training, education, and social support would affect patients' physical and psychological readiness for surgery and thereby reduce postoperative length of hospital stay.
Abstract: Background In publicly funded health care systems, a waiting period for such services as coronary artery bypass graft surgery (CABG) is common. The possibility of using the waiting period to improve patient outcomes should be investigated. Objective To examine the effect of a multidimensional preoperative intervention on presurgery and postsurgery outcomes in low-risk patients awaiting elective CABG. Design Randomized, controlled trial. Setting A regional cardiovascular surgery center in a tertiary care hospital, southwestern Ontario, Canada. Patients 249 patients on a waiting list for elective CABG whose surgeries were scheduled for a minimum of 10 weeks from the time of study recruitment. Intervention During the waiting period, the treatment group received exercise training twice per week, education and reinforcement, and monthly nurse-initiated telephone calls. After surgery, participation in a cardiac rehabilitation program was offered to all patients. Measurements Postoperative length of stay was the primary outcome. Secondary outcomes were exercise performance, general health-related quality of life, social support, anxiety, and utilization of health care services. Results Length of stay differed significantly between groups. Patients who received the preoperative intervention spent 1 less day [95% CI, 0.0 to 1.0 day] in the hospital overall (P = 0.002) and less time in the intensive care unit (median, 2.1 hours [CI, -1.2 to 16 hours]; P = 0.001). During the waiting period, patients in the intervention group had a better quality of life than controls. Improved quality of life continued up to 6 months after surgery. Mortality rates did not differ. Conclusion The waiting period for elective procedures, such as CABG, may be used to enhance in-hospital and early-phase recovery, improving patients' functional abilities and quality of life while reducing their hospital stay.
372 citations
"Cancer Prehabilitation An Opportuni..." refers background in this paper
...Arthur et al.26 found that, in patients who were planning to undergo an elective coronary bypass graft surgery, those who participated in a prehabilitation exercise intervention twice per week concomitant with education and nursing follow-up by telephone spent 1 day less in the hospital overall and less time in the intensive care unit than did controls....
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...Arthur et al.(26) found that, in patients who were planning to undergo an elective coronary bypass graft surgery, those who participated in a prehabilitation exercise intervention twice per week concomitant with education and nursing follow-up by telephone spent 1 day less in the hospital overall and less time in the intensive care unit than did controls....
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