Prehabilitation in cancer care

This page forms part of the MSc two-year accelerated physiotherapy programme at Northumbria University in the UK. The project developed aimed to investigate a contemporary area of physiotherapy practice within a general theme of innovation and service development.

Introduction

Over 330,000 patients in the UK are diagnosed with cancer each year, this is forecast to rise by 40% by 2030 (Cancer Research UK, 2014). Globally, the World Health Organisation (WHO) reports in 2018, cancer is the second leading cause of death and is estimated to account for 9.6 million death (WHO, 2019). Lung, prostate, colorectal, stomach and liver cancer are the most common types of cancer in men, while breast, colorectal, lung, cervix and thyroid cancer are the most common among women. (WHO, 2019). Outcomes remain particularly poor for those with pancreatic, oesophageal, lung cancers and brain tumours, and many rarer cancers (Cancer Research UK, 2014). In 1970 (24%), approximately one quarter of patients would survive cancer, today approximately 50% survive. The goal for the next 25 years is for 75% of people to survive (Cancer Research UK, 2014). The WHO estimates that between 30-50% of cancers could be prevented by healthy lifestyle choices such as avoidance of tobacco (responsible for 22% of all cancer related deaths) and immunisation against cancer causing infections (WHO, 2019). In low income countries, less than 30% reported treatment services were generally available in 2015, compared to 90% in high income countries (WHO, 2019). Only 14% of people who need palliative care receive it worldwide (WHO, 2019). 70% of all cancer deaths occur in low and middle income countries (WHO, 2019). People worldwide are living longer; by 2050 it is anticipated that the world’s population aged 60 years and older is expected to total 2 billion, up from 900 million in 2015. The rising prevalence of cancers worldwide combined with an ageing population signify the need for effective management strategies which support individuals to maintain healthy behaviours throughout life. If these added years are dominated by declines in physical and mental capacity, the implications for older people and for society are more negative (WHO, 2018).

How is cancer treated and/or managed?

Treatment options may include

• Surgery

• Medicines and/or radiotherapy;

Treatment planning is guided by tumour type, stage and available resources and informed by the preference of the patient.

Palliative care focusing on improving the quality of life of patients and their families is an essential component of cancer care. Accelerated action is needed to improve cancer care, achieve global targets to reduce deaths from cancer and provide health care for all consistent with universal health coverage (WHO, 2019).

How can physiotherapy help?

There are a wide range of physical and psychological symptoms associated with cancer, which can affect patients for many years following the end of treatment. Regardless of the type or stage of cancer, exercise has been found to improve quality of life for cancer patients including reducing and prevent future health complications and disability which can positively improve an individual’s body image and ability to return to work. Physiotherapists are experts in finding the best ways for cancer patients to be active; this may involve exercise programmes or advice on everyday activities.

Effects of cancer and associated treatments

• Lymphoedema and fatigue is estimated to debilitate 75-95% of all cancer patients; specialist physiotherapy can help to alleviate these symptoms.

• Reduced bone quality can lead to osteoporosis, increased risk of fragility fractures, pain and disability. Physiotherapy exercise can reduce bone loss and the likelihood of falls in patients with poor bone density.

• Pain can lead to a vicious cycle of fear, inactivity and further disability leading to increased length of hospital stay. Physiotherapy has been shown to reduce the length of inpatient stays; representing better quality of life and reduced cost to the National Health Service (NHS).

• Excessive weight gain and loss can be an effect of treatment, stage and type of cancer. Physiotherapy can be beneficial for maintaining a healthy weight and preventing muscle wastage (CSP, 2012). Evidence shows that exercise reduces the risk of cancer recurrence and mortality.

• Mortality can be reduced by 50%, 40% and 30% in bowel, breast and prostate cancer respectively.

• Disease progression was reduced by 57% in men with prostate cancer who engaged in three hours a week of moderate intensity exercise (CSP, 2012)

Cancer Prehabilitation - What does it involve?

The Association of Chartered Physiotherapists in Oncology and Palliative Care (ACPOPC) are a professional network of physiotherapists developing and promoting high standards of physiotherapy practice for patients with cancer. They acknowledge the evolving evidence base for prehabilitation and its positive impact on treatment outcomes, recognising the need to front load rehabilitation as a priority for improving cancer outcomes over the next 5 years.

Cancer prehabilitation involves physical and psychological assessments to identify patient’s baseline functional level and possible pre-existing comorbidities. This allows the implementation of appropriate interventions aiming to optimise patient’s health before starting acute treatments (Silver & Baimas, 2013). Interventions may include exercise, respiratory physiotherapy, nutritional support and psychological counselling encompassing a multi-modal approach. Tailoring prehabilitation can better prepare cancer patients for the physical and psychological challenges ahead and potentially improve cancer treatment survival outcomes.

Prehabilitation also provides an opportunity for patients to become immediately involved in their own care beyond decision making about future treatments. Cancer prehabilitation offers an opportunity for patients to proactively engage in their rehabilitation process simultaneously improving physical and psychological health outcomes and develop therapeutic relations between patients and therapists (Silver & Baimas, 2013).

Prehabilitation can improve patient’s emotional and physical health in the run up to treatment, reduce treatment related morbidity, reduce the length of hospital stays and readmissions and facilitate patient’s return to their highest level of function possible (Silver & Baimas, 2013).

Lung cancer patients who initially had insufficient lung function to be candidates for a lobectomy, were able to undergo surgery after intensive prehabilitation including aerobic exercises, breathing exercises, education and smoking cessation, demonstrating the potential of prehabilitation to improve treatment options (Cecsario et al., 2007).

Allowing the patient to actively engage in an exercise prehabilitation program can help alleviate some of the emotional distress associated with cancer treatment (Carli et al., 2010). Psychosocial factors such a self-efficacy and mental health prior to surgery can be predictive of future treatment outcomes (Macmillan Cancer Support, 2017). When compared to psychological counselling alone, a combined prehabilitation program was more effective in significantly reducing depression and improved physical functioning prior to surgery (Furze et al., 2009). Group prehabilitation can also offer social support as well as functional and psychological benefits (Ferreira et al., 2018).

The below diagram summarises some of the main positive effects of prehabilitation in cancer patients (Macmillan, 2019).

Why are physiotherapists key to prehabilitation?

The types of professionals who assist patients at different levels can potentially vary according to type of prehabilitation need.

The physiotherapist role is important to prehabilitation, particularly in more complex patients. Physiotherapists are identified as the registered professionals most critical to Physical Activity, particularly for complex cases, but all registered professionals can give advice to a degree. Volunteers, support workers, fitness instructors/ personal trainers and rehabilitation/therapy assistants, are identified as key unregistered professionals and can be involved in the prehabilitation of less complex individuals.

Overview of interventions in prehabilitation
There are consistent elements across prehabilitation services. Physical activity is always present, whilst other elements vary in frequency. This is important to be aware of when considering the role of physiotherapists and others in the MDT.
Prehabilitation interventions	Always	Often	Some-times
Physical activity*	X
Dietary support*		X
Psychological wellbeing*		X
Anaemia management			X
Smoking cessation and alcohol reduction			X
Respiratory exercises			X
Medication and comorbidities review			X
Other			X

*Based on current evidence, it is suggested that patients should have access to physical activity, dietary and psychological support as a minimum. 

Cancer care MDT

Different professionals can prescribe physical activity but registered physiotherapists have the tools to provide a multi-faceted approach to prehabilitation e.g. combining physical activity, respiratory exercises and aid in lymphoedema management. This also emphasises the importance of MDT working in prehabilitation and the importance of other professionals who can also play a part in informing patients and emphasising the importance of physical activity. Delivery is naturally driven by involvement of a range of professionals. A multidisciplinary team has been highlighted as an integral part of promoting the best care for cancer patients (Bancroft, 2003).

Well-being and person-centred care – looking beyond the physical impact

Physiotherapists are identified as having a core role in psychological well-being by providing a patient-centred approach to care, Physiotherapists are involved in exploring expectations and goals that are specific to each individual in order to find out what is most valuable to them. Facilitating this dialogue with patients is key to supporting long-term conditions and provides psychological support. Optimising communication between patients and health professionals is a vital component of patient centred care, which has been shown to correlate with improved patient outcomes when effective (Epstein and Street, 2007). Requirements often cited as necessary for effective working with cancer patients include high levels of compassion, sensitivity and empathy within excellent communication skills. Emotional resilience is also required in helping patients during this very difficult time, hence it is important to consider these ‘soft skills’ when working with cancer patients (Mazor et al., 2013).

Standard pre-treatment care is part of the wider offering of prehabilitation. Standard care involves medical preparations, whereas prehabilitation looks at the wider wellbeing of the patient and often has greater professional involvement. With prehabilitation, patients have greater professional involvement and a personalised regime. This may allow them to feel more motivated than with standard care, as they are more actively involved in their own their own wellbeing and recovery. Combined with the effect of looking at a patient’s wider wellbeing, this could lead to better outcomes for the individual:

(Macmillan, 2017)

Physical activity is a key intervention of prehabilitation, but what differentiates it from standard care is increased involvement of professionals and an organised plan of exercise. This can lead to greater engagement of patients as they are actively involved in their own wellbeing, which can lead to improved outcomes as a result. Physiotherapists play a key role in the holistic approach to prehabilitation, providing mental and physical support to improve quality of life, function and overall experience in preparation for cancer treatment.

Evidence for Cancer Prehabilitation

Prehabilitation exercise interventions tend to focus on cardiovascular health and/or muscle strengthening before and during treatment or surgery. Internventions have been found to demonstrate a range of benefits for patients living with a range of cancer types. Pre-surgery interventions have more commonly been investigated than other cancer treatments. Optimal prescription and implementation of such programmes are yet to be determined and may vary for cancer treatment and type, with a range of location, length and modalities included in current prehabilitation interventions.

Examples of prehabilitation in reducing secondary complications:

• Reduced pulmonary complications patients with abdominal cancer through improving physical fitness (Minnella et al., 2017).

• Lower post-operative length of stay and intercostal catheter use with preoperative exercise training in lung cancer (Cavalheri and Granger, 2017).

• Improved postoperative continence following prostatectomy at 3 months with pre-operative pelvic floor muscle training (Chang, Lam, and Patel, 2016)

• Lower incidence of respiratory complications and reduced length of stay in lung cancer patients post re-section with strength and aerobic training (Rodriguez-Larrad, Lascurain-Aguirrenben and Abecia-Inchaurregi, 2014).

Examples of prehabilitation in Improving physical and non-physical outcomes:

• Prehabilitation involving strength and endurance exercises was found to improve mobilility and activities of daily living in patients with bladder cancer (Bloom, 2017).

• Tailored walking and cycling programmes improved cardiorespiratory fitness prior to abdominal surgery including abdominal cancers (Jijazi, Gondal & Aziz, 2017).

• Exercise prehabilitation prior to lung cancer surgery has been found to improve post-surgical 6MW distances as well as functional capacity (Cavalheri and Granger, 2017; Rodriguez-Larrad, Lascurain-Aguirrenben & Abecia-Inchaurregi, 2014).

• Prehabilitation involving a yoga intervention reduced patient anxiety and reduced distress and symptom severity in breast cancer patients (Rao et al., 2009)

Examples of prehabilitation in broadening treatment possibilities:

• Prehabilitation involving resistance and aerobic training improved tolerance of chemotherapy dose and chemotherapy completion (correlated with patient survival) in breast cancer patients (Cortneya et al., 2007).

• Prehabilitation to increase range of motion at the shoulder joint, where maintenance of abduction and external rotation are necessary for chemotherapy, increased tolerance of radiation treatment in breast cancer patients.

Working examples of prehabilitation in practice:

Surrey:

The Royal County Hospital Guilford, a specialist hospital for cancer treatment, have developed a multimodal prehabilitation service in a two year prehabilitation pilot service. This provides cancer patients preparing for surgery with physiotherapy, occupational therapy and dietetic support aiming to improve post-operative recovery. Patients having treatment and awaiting surgery for urological, gynaecological, hepato-pancreatic-biliary cancers, cervical, pancreatic, and bladder cancers were included in the programme. Physiotherapy input consisted of 5 weeks of physiotherapy exercise classes and home exercise programmes focusing on strength training and cardiovascular fitness. Outcome measure including six minute walk test, sit-to-stand in 60 seconds, and hand-grip strength were assessed before and after the programme.

Exercises included walking swimming and cycling as well and upper and lower body strength exercises. Physiotherapists aimed to empower patients to confidently complete the exercises at home. Final assessments found improvements in 6 minute walk test, sit to stand and reduced length of hospital stay following surgery (Chartered Society of Physiotherapy, 2018).

Across the NHS there are multiple pilot services for prehabilitation for cancer treatment:

• Men with prostate cancer are being offered prehabilitation for continence related problems following surgery in Belfast.

• PREPARE is a programme dedicated to oesophago-gastric surgery prehabilitation. The programme includes multiple interventions -Physical fitness, Respiratory exercises, Eat well, Psychological well-being, Ask about medications, Remove bad habits, and Enhanced recovery after treatment.

The below table gives examples of how prehabilitation could be implemented into the current cancer pathway (Macmillan, 2019).

Contraindications to exercise and prehabilitation in people with cancer

There should be caution taken where individuals have certain types of cancer or are having certain types of treatment. For example, if cancer has spread to bone, or during treatments associated with reduced immunity or reduction in normal blood counts. In these situations, the advice of the oncology team should be sought.

Potential adverse effect	Safety principles
Exacerbation of symptoms (e.g. pain, fatigue, nausea, dyspnoea)	• Monitor symptoms and modify activity type based on site of treatment (e.g. avoid exercise bike after prostate/rectal surgery • Avoid high-intensity activities during symptomatic episodes
Anaemia	• Delay moderate to vigorous intensity activities until resolved
Infection	• Avoid high intensity/volume of activities if immunosuppressed • Minimise use of public exercise venues if immunosuppressed, using catheters, or during wound recovery
Falls	• Avoid activities needing considerable balance/coordination (e.g. treadmill, bicycle), if patient has dizziness, frailty, peripheral sensory neuropathy • Incorporate muscle strength, balance and co-ordination exercises
Bone fracture	• Avoid high impact or contact activities if patient has bone metastases, or is at osteoporosis risk
Hernia	• Anyone with a stoma should start with low resistance exercise and progress slowly to avoid herniation
Lymphoedema	• To prevent lymphoedema, progress resistance exercises in small and gradual increments • To avoid exacerbation of lymphoedema, avoid strenuous repetitive exercise with affected limb, and wear compression garment
Peripheral Neuropathy	• Some people have loss of sensation, or feelings of pins and needles, in their hands and feet due to cancer treatments. • The type of exercise should be modified if these symptoms are affecting ability to participate safely.

References

Bancroft, M.I. (2003) 'Physiotherapy in cancer rehabilitation: a theoretical approach' Physiotherapy 89(12), pp.729-733.

Bloom, E. (2017) 'Prehabilitation evidence and insight review'

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Cavalheri, V. and Granger, C. (2017) ‘Preoperative exercise training for patients with non‐small cell lung cancer’, Cochrane Database of Systematic Reviews, (6).

Chang, J., Lam, V. and Patel, M. (2015) ‘Preoperative pelvic floor muscle exercise and post prostatectomy incontinence. A systematic review and meta-analysis’, European Urology Supplements, 14(2), p.364.

Chartered Society of Physiotherapists (CSP) (2012) ‘Physiotherapy works: cancer survivorship’. Available at: https://www.csp.org.uk/publications/physiotherapy-works-cancer-survivorship (Accessed 24th November 2019)

Chartered Society of Physiotherapy (2016) Belfast physios use prehab to improve quality of life for men with prostate cancer. Available at: https://www.csp.org.uk/news/2016-09-29-belfast-physios-use-prehab-improve-quality-life-men-prostate-cancer

Chartered Society of Physiotherapy (2018) Cancer Prehab: fit for surgery. Available at: https://www.csp.org.uk/frontline/article/cancer-prehab-fit-surgery

Corrigan, J.M., Swift, E.K. and Hurtado, M.P. eds. (2001) 'Envisioning the national health care quality report. National Academies Press'

Courneya, K.S., Segal, R.J., Mackey, J.R., Gelmon, K., Reid, R.D., Friedenreich, C.M., Ladha, A.B., Proulx, C., Vallance, J.K., Lane, K. and Yasui, Y. (2007) 'Effects of aerobic and resistance exercise in breast cancer patients receiving adjuvant chemotherapy: a multicenter randomized controlled trial. Journal of clinical oncology' 25(28), pp.4396-4404.

Epstein, R.M. and Street Jr, R.L. (2007) 'Patient-centered communication in cancer care: promoting healing and reducing suffering'

Hijazi, Y., Gondal, U. and Aziz, O. (2017) ‘A systematic review of prehabilitation programs in abdominal cancer surgery’, International Journal of Surgery, 39, pp.156-162.

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Macmillan (2017). Physical activity and cancer: a concise evidence review. Available: https://www.macmillan.org.uk/_images/the-importance-physical-activity-for-people-living-with-and-beyond-cancer_tcm9-290123.pdf

Mazor, K.M., Gaglio, B., Nekhlyudov, L., Alexander, G.L., Stark, A., Hornbrook, M.C., Walsh, K., Boggs, J., Lemay, C.A., Firneno, C. and Biggins, C. (2013) 'Assessing patient-centered communication in cancer care: stakeholder perspectives', Journal of Oncology Practice, 9(5), pp.e186-e193.

Minnella, E.M., Bousquet-Dion, G., Awasthi, R., Scheede-Bergdahl, C. and Carli, F. (2017) 'Multimodal prehabilitation improves functional capacity before and after colorectal surgery for cancer: a five-year research experience', Acta Oncologica, 56(2), pp.295-300

Nilsson, H., Angerås, U., Bock, D., Börjesson, M., Onerup, A., Olsen, M.F., Gellerstedt, M., Haglind, E. and Angenete, E. (2016) 'Is preoperative physical activity related to post-surgery recovery? A cohort study of patients with breast cancer' British Medical Journal 6(1)

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Rodriguez-Larrad, A., Lascurain-Aguirrebena, I., Abecia-Inchaurregui, L.C. and Seco, J. (2014) ‘Perioperative physiotherapy in patients undergoing lung cancer resection’, Interactive Cardiovascular and Thoracic Surgery, 19(2), pp.269-281.

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