Expert insight

By Miss Susan Moug, Consultant Surgeon, RAH | Honorary Clinical Associate Professor, University of Glasgow

Note from the Editor: Miss Moug presented at the 2019 SCPN conference on this topic. Her slides can be found here.

1. What is the difference between prehabilitation and rehabilitation in cancer care?

Basically it is a timing definition. Both prehab and rehab contain the same key components (nutrition, physical activity, psychological aspects) but one is started before the first treatment for cancer (prehab) and one after (rehab). First treatment includes any type of treatment as research has shown that prehab can be started prior to chemotherapy, radiotherapy and surgery allowing all patients with cancer to be considered for prehab (1). Rehab can start at any point after any cancer treatment. There is a small amount of evidence (2) that prehab may be better than rehab as you are anticipating the change or deterioration that a patient may undergo with their treatment and trying to offset that. A similar comparison is to running a marathon – you need to train to do it and get the best from it, exactly the same thought process as for any kind of cancer treatment.

2. What evidence is there that patients are able to undertake prehab activities just after a cancer diagnosis?

Lots and lots and lots. In addition to being safe and feasible, there is some discussion that you are empowering the patient to make their own  decisions about their care at a time when they feel, not only vulnerable, but out of control (3). Patients should certainly be given the option or
prehab.

3. Isn’t is unkind to  add more demands to what a patient must do when they are already coping with a diagnosis? Doesn’t this make them feel guilty?

You would not withhold treatment from a patient because you thought it was too much for them. You would discuss the options with them and explain the pros and cons. It is the same with prehab. If the patient is aware of the evidence that a prehab programme followed by rehab may improve their health in the short and long-term, then you are responsible as a health professional to discuss that with them. If the patient chooses not to go ahead with prehab then that is their choice. But we should ask them again about rehab as we go through their treatment pathway. I see it as similar to smoking advice.

4. Is there any evidence that prehab makes a difference to surgical outcomes in colorectal cancer?

Yes. A trial was published earlier this year from Spain (4) where patients undergoing major abdominal surgery (including for colorectal  cancer) who had prehab had 50% less complications after their surgery than those that didn’t. These patients were older (70+) and had  comorbidities which again, supports the evidence that prehab can benefit  previously overlooked patient groups.

5. Is there a good website that provides guidance on prehab?

You can look up the ACSM guidelines. However, Macmillan in conjunction with Royal College of  Anaesthetists have just got together to  develop guidelines for prehab that should be completed by July 2019. This group brings many different experts together and you can follow them on twitter #prehab4cancer.

References
1. Bott RK et al. (2017) Exercise Prehabilitation during Neoadjuvant Cancer Treatment in Patients with Gastrointestinal and Thoracic Cancer: A Systematic Review. Gastrointest Cancer Res Ther; 2(1):id1014
2. Gillis C et al. (2014). Prehabilitation versus rehabilitation: A randomized control trial in patients undergoing colorectal resection for cancer. Anesthesiology; 121:937-47
3. Silv er JK, et al. (2013) Cancer Prehabilitation. An Opportunity to Decrease Treatment-Related Morbidity , Increase Cancer Treatment Options, and Improve Physical and Psychological Health Outcomes. Am J Phys Med Rehabil; 92(8):715-727
4. Barberan-Garcia et al. (2018) Personalised prehabilitation in high-risk patients undergoing elective major abdominal surgery: a randomised controlled trial. Annals of Surgery Jan;267(1):50-56. doi: 10.1097/SLA.0000000000002293