The Role and Scope of Prehabilitation in Cancer Care
Introduction
Cancer treatment has long focused on patient outcomes related to overall survival, relapse rates, and treatment response rate (ie, partial response, complete response). Traditional cancer treatment includes surgery, radiation, and/or chemotherapy. Over time, as these treatments have improved, quality of life after cancer treatment has received increased attention. Cancer survivors may struggle with persistent impairments even when the cancer is treated: nearly one in four cancer survivors experience poor health, compared with one in 10 in a cancer-free population cohort.1 A large study of Australian cancer survivors demonstrated that psychological distress among survivors is related more to physical disability than to the diagnosis of the cancer itself.2 Prehabilitation protocols are designed to improve patient functional and psychological well-being, and may offer a solution to the widespread issue of decreased functional health after cancer treatment.
The principal tenet of prehabilitation holds that patients who are stronger with more endurance before cancer treatment will fare better after surgery, radiation, or chemotherapy than those with poor functional status. Cancer prehabilitation is defined as “identifying impairments and offering exercises aimed at strengthening and stabilizing potential at-risk organ systems prior to this treatment.” 3 Prehabilitation may prevent or decrease complications. Prehabilitation can also improve patients’ functional status to an acceptable level to allow for treatment or surgery. For example, lung cancer surgery can often only be tolerated by patients who can achieve a certain level of performance on pulmonary function tests. Aerobic training can improve pulmonary function tests, and thus broaden treatment options to include surgery.
Prehabilitation affects clinical practice by improving patient outcomes such as functional status and quality of life. Furthermore, patients diagnosed with cancer experience distress in both the physical and psychological dimension. Male cancer patients cited “limitations in everyday activities” and female patients cited “anxiety/worries” regarding areas of greatest concern.4 Often, a waiting period is required for testing or treatment after diagnosis. Offering an action plan, including a treatment plan with lifestyle modifications (exercise implementation, dietary modification), affords an opportunity for the patient to improve functional status while waiting to begin cancer treatment. Cancer prehabilitation can provide an actionable regimen for patients experiencing distress and who wish to preserve their ability to engage in premorbid activities after cancer treatment.
Prehabilitation research is increasing at an exciting pace. On the NCBI PubMed database, a search query for “cancer prehab” produced two results in March 20133 and produced 17 results in June 2019. Likewise, “cancer prehabilitation” resulted in six items in March 20133 and 169 items in June 2019. The goal of this article is to present the current best evidence about the role and scope of prehabilitation in the cancer treatment trajectory. We provide an overview of the efficacy and benefits of prehabilitation in different cancer survivor populations and of the two major prehabilitation approaches, unimodal and multimodal regimens.
A unimodal regimen consists of exercise only and multimodal regimens include a combination of targeted and conditioning exercise programs, nutritional and psychological interventions, and health behaviors (such as smoking cessation). Of the two approaches, experts endorse the multimodal approach, while acknowledging that barriers to access exist. One such barrier is timeliness in cancer diagnosis and treatment. A 2015 systematic review validated the association of superior outcomes afforded specific cancers (breast, colorectal, head and neck (H+N), testicular, and melanoma) treated in a prompt manner.5 Table 1 depicts the various benefits (eg, quality of life) associated with specific prehabilitation regimens.6, 7, 8 Importantly, prehabilitation has the potential to improve function and quality of life in cancer survivors.
Section snippets
Unimodal Prehabilitation Regimens in Cancer Survivor Populations
The unimodal regimen consists of one intervention only and predates most multimodal regimens. Studies exist for a variety of sites of malignancy, including gastrointestinal, lung, prostate, breast, gynecologic, and H+N cancers. Potential benefits of prehabilitation are summarized in Table 2.9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21
Multimodal Prehabilitation Regimens in Cancer Survivor Populations
Multimodal prehabilitation can include targeted or whole-body exercise, nutrition, psychologic support, education, and smoking cessation, or any combination of these components. Many experts endorse this as the preferred form of prehabilitation when available.42 Targeted or focused exercise generally involves the use of stretching and strengthening to treat or prevent muscle/joint impairment, such as shoulder range of motion exercises before axillary node dissection in breast cancer.43
Barriers to implementation
A cohort of lung and CRC patients preferred home-based prehabilitation in the form of one supervised session a week.4 They did enjoy the supervised sessions, but the biggest barrier to their consistent participation was transportation.4 Transportation and cost are consistent barriers to exercise participation in patients with breast cancer.78 Home-based prehabilitation has been successfully executed in patients with pancreatic cancer, and this may serve as a model for other cancers.79
The
Role of the Oncology Nurse
The role of the oncology nurse is broad and multidisciplinary collaboration is a key component. Nurses participate in cancer prehabilitation by performing functional assessments, documenting status changes, providing education to patients and other providers, and performing or connecting patients to available unimodal or multimodal prehabilitation.85 Nurse navigators in particular may be the only consistent provider the patient sees throughout surgery, chemotherapy, and/or radiation treatments.
Conclusion
Cancer prehabilitation presents an opportunity to improve patient quality of life in preparation for intensive treatments involving surgery, chemotherapy, and radiation. Exercise may be offered in both unimodal and multimodal regimens, with multimodal regimens including nutrition, psychological intervention, education, and smoking cessation. Benefits include improved functional status, better quality of life, reduced morbidity, improved mental well-being, and reduced health care expenditures.
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