Prehabilitation Before Cancer Treatment May Be Unrealistic

Helen Leask

August 23, 2019

"You wouldn't run a marathon without undertaking any training," comment the authors in the introduction to a new landmark document on guidance for cancer "prehabilitation."

Prehabilitation after a cancer diagnosis "aims to optimise a person's health and wellbeing to help maximise their resilience to treatment throughout their journey," explain Fran Woodard, executive director of the UK's Macmillan Cancer Support, and colleagues.

The Macmillan charity produced the new report in collaboration with the Royal College of Anaesthetists and the National Institute for Health Research.

Released in the United Kingdom last month, the 86-page document explores physical activity, exercise, nutrition, and psychological support for cancer patients who are facing treatment with surgery, chemotherapy, and/or radiotherapy.

But is this approach realistic?

A recent editorial in the BMJ raises doubts about the approach.

Health service leaders "need to think seriously...about several barriers to implementation, as well as the overall merits of the approach," say Ceinwen Giles of Shine Cancer Support and Prof Steven Cummins of the London School of Hygiene and Tropical Medicine in their editorial.

In an email interview with Medscape Medical News, Giles acknowledged the rationale for cancer prehabilitation: "[There's] increasing recognition that many people can't finish treatment because they aren't fit enough or don't recover as well as they could."

However, she also said that there is concern among her colleagues at the Shine Cancer Support regarding the approach. Some of those colleagues are rehab/prehab practitioners, "so they were able to talk about prehab both as a patient and as someone delivering the service."

A major concern was information overload.

A patient who has just received a diagnosis of cancer is likely to be upset and worried, even traumatized, the editorialists point out, and so may not be able to take in information about prehabilitation in addition to all the information about the cancer and potential treatments.

"Patients are given so much information when they're first well as decisions to make," said Giles. She said that her colleagues who have been cancer patients said that "they felt like being told to start exercising and making big lifestyle changes at that point might have been difficult."

In addition, if it is "delivered poorly, the approach also risks appearing to blame patients for developing cancer — something which would undermine relationships with healthcare teams," the editorialists write.

For example, a cancer patient may interpret advice on nutrition and the maintenance of a healthy body weight along the lines of, "you're overweight, which is why you got cancer,' " Giles said.

Giles also said that the core components of the approach — which focuses on diet, exercise, glycemic control, and smoking — are known to be less effective in disadvantaged populations, potentially creating inequalities in cancer prehab.

"To make the biggest difference, you'll need to make sure you're reaching more marginalised communities and those for whom the concept of prehab and components such as behavioural change and exercise may be more difficult to take up," Giles said.

Underpinning the whole approach is "the critical matter of workforce," Giles and Communigs write in their editorial.

The Macmillan report "argues that rehabilitation should be delivered by a multiprofessional team that could include GPs [general practitioners], allied health professionals, nurses, physiologists, fitness instructors, pharmacists, psychologists, and rehabilitation and social workers. These staff are to be drawn from across the NHS [National Health Service], local authorities, public health teams, and the independent and third sectors, with primary care playing a key role," the editorialists write.

They point out that the NHS workforce is "facing substantial difficulties." The number of GPs relative to the population is falling, and there are almost 40,000 nursing vacancies across the country.

They also cite a Cancer Research UK report that predicts that staffing in "key workforce groups will have to double by 2020 just to meet forecasted needs of patients with cancer."

Efforts in the United States

Across the Atlantic, the National Institutes of Health spearheaded the publication of the first US national cancer rehabilitation recommendations in 2016. The recommendations touch on the idea of cancer prehabilitation for all patients, not just presurgical patients.

"We came up with 10 recommendations, and one of them had to do with offering prehab before treatment in some cases," said expert group member Julie Silver, MD, who is director of cancer rehabilitation at Harvard Medical School, Boston, Massachusetts.

Silver said that so far, the aspect of cancer prehabilitation that has been easiest to implement in the United States has been exercise, and that sometimes, enthusiasm outstrips the science.

Silver gave the example of centers that offer "exercise only" programs. "But this may not be the safest type of care for patients, especially elderly or frail patients," she said.

Silver said that "multimodal prehabilitation is ideal" and that any intervention should be back-engineered from the likely outcomes of that particular cancer treatment. She gave the example of breast cancer patients who are at high risk for post-mastectomy pain and upper-quadrant mobility problems. "This is very different to the situation in, for example, prostate cancer," Silver said.

Silver has just enrolled her first patient in a 5-year study of prehab for patients slated to undergo resection for pancreatic cancer — a surgery that carries 8% mortality. The research is led by Motaz Qadan, MD, PhD, and Naomi Sell, MD, who are surgeons at Massachusetts General Hospital in Boston.

Silver cautions against overselling prehabilitation and having "everyone run and get it.

"It doesn't work like that," Silver said. "It's not available everywhere, and it really should be carefully delivered, just like any medical care."

Giles also argued against a one-size-fits-all approach. "I...want to make sure, though, that, given the severe financial strains facing health and social care, the money goes where it will make the most difference and that we know more about how we can make the biggest impact for everyone."

Giles is interim chair of the Patient and Public Voices Forum for the NHS England Cancer Programme and is a director at Shine Cancer Support. Cummings has disclosed no relevant financial relationships. Silver has received grant funding from the Arnold P. Gold Foundation, the Binational Scientific Foundation, the Warshaw Institute, and Massachusetts General Hospital's Department of Medical Oncology. Silver has personally funded the Be Ethical Campaign.

Macmillan Cancer Support. Prehabilitation for People With Cancer. Full text

BMJ. Published August 14, 2019. Editorial

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