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Cancer

REVIEW & ANALYSIS

Cancer PrehabilitationAn Opportunity to Decrease Treatment-Related Morbidity,Increase Cancer Treatment Options, and Improve Physicaland Psychological Health Outcomes

ABSTRACTSilver JK, Baima J: Cancer prehabilitation: an opportunity to decrease treatment-related morbidity, increase cancer treatment options, and improve physical andpsychological health outcomes. Am J Phys Med Rehabil 2013;92:715Y727.

Cancer prehabilitation, a process on the continuum of care that occurs between thetime of cancer diagnosis and the beginning of acute treatment, includes physicaland psychological assessments that establish a baseline functional level, identifiesimpairments, and provides targeted interventions that improve a patient’s health toreduce the incidence and the severity of current and future impairments. There isa growing body of scientific evidence that supports preparing newly diagnosedcancer patients for and optimizing their health before starting acute treatments.This is the first review of cancer prehabilitation, and the purpose was to describeearly studies in the noncancer population and then the historical focus in cancerpatients on aerobic conditioning and building strength and stamina through anappropriate exercise regimen. More recent research shows that opportunitiesexist to use other unimodal or multimodal prehabilitation interventions to decreasemorbidity, improve physical and psychological health outcomes, increase the num-ber of potential treatment options, decrease hospital readmissions, and reduceboth direct and indirect healthcare costs attributed to cancer. Future research maydemonstrate increased compliance with acute cancer treatment protocols and,therefore, improved survival outcomes. New studies suggest that a multimodalapproach that incorporates both physical and psychological prehabilitation in-terventions may be more effective than a unimodal approach that addresses justone or the other. In an impairment-driven cancer rehabilitation model, identifyingcurrent and anticipating future impairments are the critical first steps in improvinghealthcare outcomes and decreasing costs. More research is urgently needed toevaluate the most effective prehabilitation interventions, and combinations thereof,for survivors of all types of cancer.

Key Words: Prehabilitation, Rehabilitation, Cancer, Function, Survivors, Disability,Survivorship

Authors:Julie K. Silver, MDJennifer Baima, MD

Affiliations:From the Department of PhysicalMedicine and Rehabilitation, HarvardMedical School, Boston, Massachusetts.

Correspondence:All correspondence and requests forreprints should be addressed to Julie K.Silver, MD, Department of PhysicalMedicine and Rehabilitation, HarvardMedical School, Countway Library, 2ndFloor, 10 Shattuck St, Boston, MA02115.

Disclosures:Dr Silver is the cofounder of OncologyRehab Partners, LLC, which developedthe STAR Program (SurvivorshipTraining and Rehabilitation). Dr Baimahas no disclosures. Financial disclosurestatements have been obtained, and noconflicts of interest have been reportedby the authors or by any individuals incontrol of the content of this article.

0894-9115/13/9208-0715/0American Journal of PhysicalMedicine & RehabilitationCopyright * 2013 by LippincottWilliams & Wilkins

DOI: 10.1097/PHM.0b013e31829b4afe

www.ajpmr.com Cancer Prehabilitation 715

Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

Increasing the quantity and quality of life in cancerpatients is challenging. There is significant literaturedocumenting cancer-related and cancer treatmentYrelated impairments, disability, and evidence-basedrehabilitation interventions.1Y6 In fact, the prospec-tive surveillance model has recently been suggestedas an improved model for rehabilitation care in thebreast cancer population.7Y10 In an impairment-drivencancer rehabilitation model, identifying current andanticipating future impairments are the critical firststeps in improving healthcare outcomes and de-creasing costs. This is the first review on cancerprehabilitation, and the purpose was to describe theavailable research in this important area of oncologycare. A review of the current literature was conductedinMarch 2013 on prehabilitation in general and then,more specifically, as it applies to an oncology popu-lation with PubMed and then repeated with Scopus(Table 1). Identical search terms were used andsimilar results were found, with Scopus yielding twoadditional studies that were incorporated into thisreview. Using prehabilitation as a search term didnot identify most of the articles used in this reviewbecause many pretreatment interventions were notidentified in the literature as prehabilitation. Generalprehabilitation studies were selected to highlightspecific issues as these apply to noncancer patientpopulations, whereas a comprehensive literature re-view was performed to describe the current evidencefor cancer prehabilitation. This review is designedto describe the current literature and acknowledgesthat the research to date, although promising inconcept and early small studies, reveals an urgentneed for larger randomized controlled trials of bothunimodal and multimodal interventions in the on-cology population.

Prehabilitation typically occurs at the begin-ning of the rehabilitation care continuum and is usedin anticipation of an upcoming stressor, such as sur-gery. Cancer prehabilitation may be defined as aprocess on the continuum of care that occurs be-tween the time of cancer diagnosis and the beginningof acute treatment, includes physical and psycho-logical assessments that establish a baseline func-tional level, identifies impairments, and providestargeted interventions that improve a patient’s healthto reduce the incidence and the severity of currentand future impairments. Prehabilitation is the be-ginning of the rehabilitation care continuum duringwhich there may be an opportunity to obtain abaseline status, identify pretreatment impairments,improve physical and emotional health before treat-ment, reduce treatment-related morbidity and/ormortality, decrease length of hospital stay and/orreadmissions, increase available treatment optionsfor patients who would not otherwise be candidates,and quickly facilitate return of patients to the highestlevel of function possible. The primary goal ofprehabilitation is to prevent or reduce the severity ofanticipated treatment-related impairments that maycause significant disability.

Prehabilitation from a HistoricalPerspective

Although prehabilitation is not a new conceptand its use is not specific to individuals diagnosedwith cancer, evidence-based prehabilitation interven-tions appropriate for use within this specific popula-tion are emerging. Historically, prehabilitation usingunimodal or multimodal approaches has been usedin diverse noncancer patient populations and dem-onstrated improved patient outcomes by means of avariety of methods. Before considering how prehabili-tation can improve care in newly diagnosed cancerpatients, it is important to briefly consider the his-torical evidence supporting the use of prehabilitationin other diverse patient populations.

One of the earliest articles on prehabilitationwas published in the British Medical Journal in 1946and was focused on improving the health of men,such that substandard military recruits could befashioned into standard recruits.11 Before prehabili-tation, many recruits were simply rejected for poorgeneral development caused by malnutrition, inade-quate education, insanitation, poverty, and lack ofopportunity. The prehabilitation program offeredseveral interventions including nutritious food,lodging, hygiene, recreation, controlled physical train-ing, and general education. Of the approximately

TABLE 1 Prehabilitation literature search results

Search Term

No. ArticlesIdentifiedin PubMeda

Cancer prehab 2Cancer prehabilitation 6Prehabilitation 57Fast track cancer rehabilitation 64Prophylactic cancer rehabilitation 68Pretreatment cancer rehabilitation 84Perioperative cancer rehabilitation 186Preoperative cancer exercise 257Preoperative cancer rehabilitation 570Prophylactic rehabilitation 660Preoperative rehabilitation 4502

aSearches were conducted in March 2013.

716 Silver and Baima Am. J. Phys. Med. Rehabil. & Vol. 92, No. 8, August 2013


12,000 men who reportedly underwent prehabilita-tion, 85% successfully completed the program, andboth physical training and intelligence testing im-proved within 2 mos.

More recently, in 2002, Topp et al.12 focused onimproving physical function before an upcomingelective intensive care unit hospitalization and de-fined the goal of their prehabilitation program asBI enhancing functional capacity of the individualto better withstand the stressor of inactivity.[ Theprehabilitation program proposed included slowwalking to warm up, aerobic conditioning, strengthtraining, flexibility, and functional tasks and wasscheduled for two to three sessions per week. Theyconcluded, BDeclines in physical activity among ICUpatients represents a significant health risk thatmay be reduced through introducing prehabilitationinterventions.[12

Numerous recent prehabilitation studies havefocused on outcomes after elective orthopedic sur-gery.13Y21 For example, although case studies maybe difficult to extrapolate to larger populations, oneinteresting study compared a patient who had 4 wksof prehabilitation with another patient getting usualcare before knee replacement.22 The patient who re-ceived prehabilitation had less pain and better func-tion in the postoperative period than did the patientreceiving usual care. A second case study of physicalfunction outcomes involved a patient who had kneereplacement surgery on the right with usual carethat was later followed by knee replacement on theleft with prehabilitation.23 This patient demonstrateda 30% improvement in function, a 50% increasein knee strength, and decreased preoperative kneepain in the left knee. In a larger study by Swanket al.,16 researchers hypothesized that exercise be-fore having surgery would improve outcomes andpostoperative recovery. At the end of this study of71 participants (35 in the prehabilitation group and36 in the usual care group), the researchers con-cluded that short-term prehabilitation was more ef-fective in increasing leg strength and the ability toperform functional tasks before total knee replace-ment than was usual care.

Jack et al.24 reported on the benefits of periop-erative exercise training in elderly subjects, notingthat, in patients who are deconditioned (Bless fit[),there is a higher incidence of morbidity and mortal-ity. In this review, the authors also noted that thereis a paucity of high-quality clinical trials of preoper-ative exercise training, particularly in the elderly.Although their review indicated that prehabilitationcan improve objectively measured fitness in theshort periods before major surgery, it was not clear

how it impacted surgical outcomes in older people.However, they went on to explain that inspiratorymuscle training before surgery may prevent specificcomplications such as atelectasis. These authorsconcluded, BTaken together, these findings are en-couraging and support the notion that pre- andpostoperative exercise training may be of benefit topatients. There is an urgent need for adequatelypowered randomized control studies addressing ap-propriate clinical outcomes in this field.[24

The relationship between physical and psycho-logical outcomes is well known, and, as such, bothhave been considered when examining the efficacy ofprehabilitation interventions. For example, a studyconducted by Furze et al.25 evaluated both physicaland psychological outcomes in participants who werebeing scheduled for coronary artery bypass graft sur-gery. In this study, the researchers found that nursecounseling combined with a prehabilitation program(vs. nurse counseling alone) significantly reduceddepression and cardiacmisconceptions and improvedphysical functioning before surgery.

Because prehabilitation had been shown to im-prove physical outcomes, it seemed to follow that itsuse might also provide an opportunity to decreasehospital lengths of stay and/or decrease healthcarecosts in other ways. Arthur et al.26 found that, inpatients who were planning to undergo an electivecoronary bypass graft surgery, those who partici-pated in a prehabilitation exercise intervention twiceper week concomitant with education and nursingfollow-up by telephone spent 1 day less in the hospitaloverall and less time in the intensive care unit thandid controls. Further, prehabilitation patients reportedimproved quality-of-life for up to 6 mos after surgery.Another study from the Netherlands that focused onexercise of the respiratory muscles only had a similaroutcome, additionally reporting fewer pulmonarycomplications after surgery.27 The orthopedic litera-ture, too, demonstrated success using prehabilitationto decrease lengths of hospital stay and postsurgicaloutcomes in the spinal surgery population. In onestudy of 60 patients who underwent primary lumbardecompression and fusion in Denmark, patients inthe prehabilitation group reached recovery mile-stones faster and left the hospital earlier than thosein the control group.18 This study also found thatthe prehabilitation and early rehabilitation programwas less costly per patient than was standard care.20

Although the direct costs before surgery in the in-tervention group were higher because of the cost ofthe prehabilitation, the overall costs were lower andimproved in both the direct and the indirect costanalysis of the perioperative period.



In addition to improving outcomes, decreasinglengths of stay, and improving surgical cost-effectiveness, prehabilitation has also been shownto increase available treatment options for lungcancer patients, ultimately enabling patients previ-ously considered poor candidates for pulmonary re-section to have surgery.28 Moreover, the benefits ofprehabilitation are not limited to patients undergo-ing a hospitalization or disease-related interventionand have been targeted at vulnerable populationsthat are likely to be high users of healthcare re-sources. For example, Gill et al.29 studied prehabi-litation in community-dwelling frail older adultsand demonstrated gains in physical performance,mobility, and ability to perform activities of dailyliving. Finally, by providing an opportunity to obtainpretreatment baselines, prehabilitation can facilitatebetter understanding of both the effects of treatmentand factors that promote better outcomes as well asprevent an anticipated medical condition or lessenthe severity of an existing one.14,15

Lung Cancer Prehabilitation: A Model forImproving Outcomes in a VulnerablePopulation

In a 2013 study, Billmeier et al.30 assessed pre-dictors of nursing home admission, severe functionalimpairment, or death 1 yr after surgery for nonYsmallcell lung cancer and wrote, BPatients perceive long-term disability to be one of the most undesirablecomplications of lung cancer treatments.[ Preoper-ative exercise testing in this population has beencorrelated with prognosis, and short-term intensephysical therapy has been demonstrated to increaseoxygen saturation, improve exercise capacity, andreduce hospital stays.31,32

A closer study of pulmonary cancer prehabili-tation is warranted because it may be a model of carefor other cancers in which prehabilitation has notbeen as well studied. Looking back at the literature,the issue of whether pulmonary prehabilitation mightchange a cancer patient’s outcome or a physician’streatment options was initially examined by Weineret al.28 in 1997. In addition, it was of interest to de-termine whether it was possible to predict whichlung cancer patients would tolerate lung resection,a potentially lifesaving treatment. This prospectiveand randomized study examined the effects of in-centive spirometry and inspiratory muscle trainingon predicted postoperative pulmonary function (forcedexpiratory volume) after lung resection in patientswith both chronic obstructive pulmonary disease(COPD) and lung cancer. Exercise interventions,

used 2 wks before and for 3 mos after lung resec-tion, were effective in significantly improving lungfunction. The authors went on to hypothesize thatthis beneficial effect could possibly hold true forpatients with more severe lung disease who werenot previously thought to be candidates for resectionbecause of their poor lung function at baseline. Thestudy demonstrated that prehabilitation not onlycould improve lung function but also may altercancer treatment options for patients with comorbidlung disease.

In 1980, Dietz33 described Bpreventive rehabili-tation[ as an opportunity for patients who are highrisk for surgery to decrease potential morbidity andmortality. Dietz recommended counseling and theteaching of techniques to overcome anxiety and fearof the unknown to all cancer patients. Preoperativebreathing training was suggested for all patients but,in particular, for lung cancer surgical candidates,including breathing control and proper coughingtechnique to mobilize secretions.

Despite these early successes with prehabili-tation interventions, in a 2001 article describing thePhysical Exercise Across the Cancer ExperienceFramework, Courneya and Friedenreich noted,34 BAnoverview of the physical exercise literature indicatesthat only 1 [one] time period (i.e., prescreening) andcancer control outcome (i.e., prevention) has receivedsignificant research attention. Some time periods(i.e., treatment and resumption) and cancer controloutcomes (i.e., coping and health promotion) havereceived modest research attention, whereas othertime periods (i.e., screening/diagnosis, pretreatment,and posttreatment) and cancer control outcomes(i.e., detection, buffering, rehabilitation, palliation,and survival) have received only minimal attention.[

More recently, Sekine et al.35 compared 22 lungcancer patients with comorbid COPD who had un-dergone rehabilitation before surgery with 60 histor-ical controls. Patients with clinically and radiologicallydefined COPD underwent a prehabilitation exerciseprogram for 2 wks comprising inspiratory spirometry,breathing and coughing exercises with bronchodilatornebulizers (five times per day), and exercise (walking95000 steps per day). This program was continueduntil hospital admission and postoperatively untildischarge. The control group received chest physio-therapy only during the postoperative period. Despitea lower forced expiratory volume in 1 sec/forcedvolume capacity ratio in the rehabilitation group, thelength of stay was significantly shortened (28% de-crease). The authors also observed a decreased needfor tracheostomy and prolonged oxygen inhalationin the prehabilitation group. Interestingly, although



this study included aerobic exercise (walking), it didnot include any peripheral muscle strengthening;both aerobic exercise and strength training have beenshown to be important elements of fitness programs.

Bobbio et al.36 addressed exercise studies thatincorporated both strength and aerobic componentsin a study in 2007. The prehabilitation program in-cluded cycle ergometry as well as trunk and upperlimb free weight exercises for strength training thattook place as 90-min outpatient appointments,5 days per week for 4 wks. Twelve patients with COPDand nonYsmall cell lung cancer were studied, 11 ofwhom went on to lobectomy. This prospective ob-servational study demonstrated a significant im-provement in maximal aerobic capacity, as measuredby an improvement in peak oxygen consumption(maximum oxygen consumption) despite an absenceof changes in the resting forced expiratory volumein 1 sec/forced volume capacity ratio.

An Italian study recently confirmed the rele-vance of prehabilitation concepts in eight lung cancerpatients with comorbid lung disease.37 Patients whowere not candidates for lobectomy because of mark-edly impaired pulmonary function were evaluated.Prehabilitation consisted of a structured, intense1-mo session of 3 hrs of daily (5 days per week) aer-obic exercises, breathing exercises, education, andcigarette smoking cessation. Pulmonary functionstatus (forced vital capacity) was improved signifi-cantly, as was PaO2 and walking tolerance (6-minwalking distance), allowing these patients to success-fully undergo lobectomy. Remarkably, this study notonly demonstrated the physiologic benefit of a struc-tured preoperative exercise program in lung cancerpatients but also favorably changed treatment optionsfor lung cancer patients with pulmonary disease.

Finally, Nagarajan et al.,38 in a review of tenstudies of preoperative physical therapy and/or pul-monary rehabilitation, concluded that improvementsin peak oxygen consumption support the hypothesisthat prehabilitation programs improve exercise ca-pacity and preserve postsurgical pulmonary function.

Cancer Prehabilitation: An EmergingOpportunity to Improve Outcomes inOncology Care

As cancer prehabilitation research began to evolvebeyond preserving pulmonary function in lung can-cer patients, researchers started to examine otherareas where prehabilitationmight be applied. Urinarycontinence and erectile dysfunction are known com-plications in prostate cancer survivors, and, in onestudy, prehabilitation improved continence outcomes

in patients who received pelvic floor exercise trainingbefore retropubic radical prostatectomy. The prehabi-litation group achieved urinary continence earlierthan did controls, although no long-term benefitaccrued.39 In a 2007 review that included 11 trials(N = 1028), it was confirmed that preoperative pelvicfloor muscle training hastened the return of urinarycontinence after prostatectomy.40

In 1980, Dietz recommended that rehabilita-tion programs involve patients undergoing a mas-tectomy from the time of their initial diagnosis;however, until recently, only anecdotal informationabout involving prehabilitation in breast and othercancer diagnoses and treatments had been ob-tained.33 For example, a case study published in 2007focused on prehabilitation of a patient for chemo-therapy. A 42-yr-old breast cancer survivor wasprescribed a walking program for 1 wk before and8 wks during chemotherapy.41 The patient demon-strated decreased fatigue and improvement in five ofseven functional measures.

Mayo et al.42 recently reexamined data from arandomized trial of two different prehabilitationprograms before colorectal surgery in patients withbenign ormalignant colorectal neoplasms. One groupused stationary cycling plus weight training duringtheir prehabilitation, whereas the other group re-ceived recommendations to increase their dailywalking and practice breathing exercises. Remark-ably, the initial trial showed no significant benefitof the prehabilitation program, and the walking/breathing group had greater functional walking ca-pacity than did the cycling/strengthening groupafter prehabilitation.42 These results were not pre-dicted because the benefits of strength training inaddition to aerobic conditioning are well known.Because of the unexpected outcomes, these data werelater used to examine other factors that may predictthe success of prehabilitation in preserving patientfunctional outcomes. A higher rate of postoperativecomplications was observed in those who deterio-rated during prehabilitation training. Of those whocompleted the prehabilitation program, 33% im-proved their functional status, 38% stayed the same,and 29% deteriorated.

Moreover, Cheema and colleagues43 noted that,as cancer survival rates continue to improve, theemphasis on decreasing morbidity has increasinglybecome an issue. The researchers wrote, BDecreasedmortality among older complex patients has raisedpatients’ expectations for [colorectal cancer] treat-ment and engendered additional concerns amongpatients including quality of life, community reinte-gration, physical performance after cancer resection



and avoidance of treatment-related complications(i.e., patient-centered outcomes).[43 They concludedthat more cancer patients are surviving longer anddemanding more comprehensive care, highlightingthe need for more research in all aspects of cancerprehabilitation.

Although prehabilitation has been shown to im-prove physical outcomes such as pulmonary functionand urinary continence, its application and the needfor its application often reach beyond physical andinto psychosocial domains. In the study by Mayoet al.42 described previously, it was also noted thatthose patients who did improve in functional capacityalso demonstrated improvements in mental healthand vitality. Men improved more than women did,and participants who had a lower functional statusat baseline improved more than those who startedat a higher functional status. Further, participantswith higher pretreatment anxiety levels showedgreater improvement as well. Predictably, patientswho believed that their fitness level aided recoveryshowed more improvement than those who did nothold this same belief.

The relationship between the physical and theemotional burden of cancer continues to becomemore clearly linked. Banks et al.44 published a recentstudy examining whether the elevated levels of psy-chological distress seen in cancer survivors wereprimarily related to aspects of the cancer diagnosis, totreatment, or to a related disability. In a review of self-reported questionnaire-based data from a Medicaredatabase of nearly 90,000 Australianmen and women45 yrs or older, Banks and colleagues44 found thatthe major cause of emotional distress was disability.The researchers wrote, BThe risk of psychologicaldistress in individuals with cancer relates muchmore strongly to their level of disability than it does tothe cancer diagnosis itself.[ Other studies have con-firmed this link aswell. For example, a study by Pontoet al.45 of women living with ovarian cancer foundthat one predictor of distress was poor performancestatus. In yet another study of 112 Jordanian patientsactively being treated with chemotherapy, the re-searchers found that lower scores in emotional andphysical functioning were associated with higherreports of distress.46

For the first time, a new study examined health-related quality-of-life among adult cancer survivorsof all ages across the trajectory of survivorship com-pared with population norms.47 The data from 1,822cancer survivors and 24,804 individuals without acancer history revealed that 24.5% of the cancersurvivors reported poor physical health comparedwith 10.2% of those without cancer. Mental health

reports showed a similar imbalance, with 10.1%of the cancer survivors reporting poor mental healthcompared with 5.9% of those without cancer. Ex-trapolated according to current population data, theseresults represent 3.3 million United States cancersurvivors living with poor physical health and1.4 million living with poor mental health.

Cancer Prehabilitation in the ElderlyPrehabilitation may also have positive effects on

specific populations, such as elderly cancer survivors.Researchers examined the prevalence of exerciseparticipation during and after primary cancer treat-ment in older (Q65 yrs) and the oldest (Q80 yrs)cancer patients who were newly diagnosed.48 In thisstudy, 408 participants with a mean age of 73 yrswere surveyed, and symptoms before chemotherapyand/or radiation therapy, symptoms during treat-ment, and symptoms 6 mos after therapy ended wererecorded. Forty-six percent of the older and 41% ofthe oldest patients reported exercising during treat-ment. Six months after treatment ended, 60% ofthe older and 68% of the oldest patients reportedexercising. Patients who exercised during and aftertreatment reported less shortness of breath, betterself-reported health, less fatigue, and even less totalsymptom burden. These results suggest that ifexercising during and after treatment improves self-reported health, more extensive research on thebenefits of prehabilitation exercise in this populationis needed. In fact, in 2012, a case report did illustratethe effect of prehabilitation in an elderly cancer pa-tient.49 An 88-yr-old woman underwent 3 wks ofprehabilitation before hysterectomy for endometrialcancer. She sustained improvements in exercise tol-erance for 8 wks postoperatively. There was no evi-dence of postoperative delirium despite multiplemedical comorbidities (hypertension, coronary ar-tery disease, and congestive heart failure). Two ad-ditional cases published in 2012 involving high-riskelderly patients with severe COPD and abdominalcancer reported effective prehabilitation and periop-erative rehabilitation.50

Cancer Prehabilitation UsingPsychosocial Interventions

In addition to physical interventions, prehabil-itation provides an opportunity for psychosocialstrategies that may be implemented immediatelyafter a cancer diagnosis. Depression has been shownto increase the length of hospitalization in lungcancer patients undergoing thoracic surgery.51 Fur-ther, there is evidence to suggest that psychosocial



support immediately after diagnosis and before can-cer treatments begin may improve outcomes. Forexample, Cohen et al.52 studied 159 men scheduledto undergo radical prostatectomy who were ran-domly assigned to presurgical stress management,Bsupportive attention,[ or standard care groups.Researchers found that patients who received stressmanagement had significantly lessmood disturbanceduring the preoperative waiting time and signifi-cantly increased immune parameters after surgery.Dietz suggested that a patient undergoing a mastec-tomy should receive support from the time of initialexamination to satisfactory return to society by of-fering psychological support to confront anxiety andfear of the unknown initially and promote adapta-tion at discharge.33 Women with recurrent ovariancancer described the state of living in limbo duringthe transition from health to illness as Bcharacte-rized by loneliness[ and a Bvulnerable position andexistential struggle.[53 It has also been observedthat newly diagnosed lung cancer patients expressedtheir greatest concerns about their illness duringpretreatment planning and later after surgery.53a Inpatients with colorectal cancer, preoperative stomasiting and education, which is usually performedpostoperatively, may reduce anxiety, complications,and healthcare costs.54,55

Judicious Timing of Cancer PrehabilitationInterventions

Delays in cancer treatment may negatively affectprognosis.56Y58 Therefore, the use and the timing ofprehabilitation in relationship to the onset of acutecancer treatment must be seriously considered. Forexample, a 2011meta-analysis study of 15,410 patientswith colorectal cancer found that a 4-wk increasein the time between colon resection and chemo-therapy was associated with a significant decrease inboth overall survival and disease-free survival.59 Afeasibility study in 13 patients by Jones et al.60

examined both the timing and the effect of struc-tured endurance exercise interventions that composea 4- to 6-wk structured exercise program that wasused to increase maximal aerobic capacity on surgicaloutcomes in lung cancer patients. Patients achievedsignificant benefit in improved exercise capacity whileawaiting lobectomy for lung cancer. The gain inmaximal aerobic capacity of prehabilitation patientswas determined and compared with previous studiesof postsurgical pulmonary rehabilitation benefit. Theimprovements seen after this short program weresimilar to those seen in longer traditional exerciseprograms of 12Y15 wks. In a follow-up literature

review including nine additional studies, Nagarajanet al.38 concluded that, BThis proves that PRP [preop-erative rehabilitation program] can improve exercisecapacity in patients prior to major thoracic surgery.[

DISCUSSIONCancer prehabilitation is an emerging medical

disciplineVone that may include unimodal or mul-timodal approachesVthat should be tailored to theneeds of the individual patient (Table 2). Certainly,the current literature seems promising and is con-sistent with optimizing health at every opportunityalong the care continuum. However, more researchis urgently needed in cancer prehabilitation to iden-tify the best interventions to use in various patientpopulations. For example, answering the question ofwhether prehabilitation protocol A might improvecompliance with acute cancer treatment protocol Bis an important one. It seems reasonable to hypothe-size that tailored prehabilitation protocols that betterprepare patients for upcoming physical and psycho-logical challenges would increase their compliancewith acute cancer treatment protocols and, therefore,

TABLE 2 Examples of cancer prehabilitationareas of focus

MusculoskeletalBalance/gaitJoint range of motionTherapeutic exercise (for specific issues)General exercise (to increase physical activity)Stress/distress/copingPainSwallowingSpeechSleepFatigueCognitive functionCardiovascular functionPulmonary functionSmoking cessationAlcohol reduction/cessationSkin protectionDiet/nutritionUrinary continenceBowel/ostomy careActivities of daily living (ADLs)Instrumental activities of daily living (IADLs)Assistive devicesDurable medical equipmentHome safetyWorkplace accommodationsPsychosocial supportSupportive oncology symptom managementIntegrative oncology interventionsOther services



improve cancer treatment survival outcomes. Thisis an important area for future research.

Newly diagnosed cancer patients are often seekingways to become immediately involved in their carethat may go beyond decision making about upcom-ing treatments. A common question that oncologyhealthcare professionals hear from patients is, BWhatcan I do right now to help myself?[ Cancer prehabi-litation affords the oncology health professional anexcellent opportunity to provide expert guidance re-garding targeted prehabilitation interventions thatsimultaneously improve physical and psychologicalhealth outcomes and create a partnership with thepatient.

During cancer prehabilitation, patients receiveassessments and interventions that address not onlytheir current physical and psychological function,including preexisting impairments and comorbidconditions, but also avoidance or attenuation of futurecancer treatmentYinduced impairments and disabil-ities that may negatively impact their health andhealth-related quality-of-life (Table 3). Approachesmay include exercise, medical management, nutri-tional counseling, psychosocial strategies, and other

interventions designed to better prepare patients forthe challenges of forthcoming cancer treatments.

Before planning any prehabilitation course orimplementing any intervention, it is important tofirst establish the current functional status of thepatient and identify any comorbidities. A recent studyapproached prehabilitation and the importance ofobtaining baseline functional status before chemo-therapy from a survey standpoint. Faul et al.61 ques-tioned 192 patients with cancer of various diagnosesand stages about their level of independent exerciseand their quality-of-life 1 wk before their first che-motherapy infusion. Two-thirds of the patients, all ofwhomwere exercising theweek before chemotherapybegan (43% at a mild level and 57% at a moderate tostrenuous level), had lower levels of anxiety and de-pression and better overall mental and physicalquality-of-life than those who did not exercise. Theseresults consequently emphasize the need to docu-ment baseline exercise levels and understand howthese may affect quality-of-life outcomes when de-signing a patient-centered prehabilitation program.

After baseline assessment, it is necessary tothen examine the many potential interventions that

TABLE 3 Goals and benefits of cancer prehabilitationa

Pretreatment baseline Assess and documentPretreatment impairments Identify and reducePretreatment physical functioning ImprovePretreatment psychological functioning ImproveTreatment options IncreaseCancer treatment compliance IncreaseTreatment-related impairments Prevent or reduceUnnecessary testingb ReduceTime to recovery milestones ReduceHospital lengths of stay ReduceHome care therapy visits ReduceRehabilitation outpatient visits ReduceHospital readmissions ReduceRisk for future comorbiditiesc ReduceRisk for cancer recurrence ReduceRisk for second primary cancer ReduceDisability DecreaseMortality DecreasePhysical health outcomes ImprovePsychosocial health outcomes ImproveTime to return to work status ReduceOccupational function ImproveHealth-related quality-of-life ImproveDirect healthcare costs DecreaseIndirect healthcare costs Decrease

After meeting the first goal of cancer prehabilitationVestablishing a pretreatment baselineVand implementing appropriateinterventions thereafter, the physical, psychological, and/or financial benefits of prehabilitation can be seen along the entirecontinuum of cancer care.

aThis is not meant to be a complete list.bFor example, metastatic work-ups for musculoskeletal pain.cFor example, osteoporosis or heart disease.



might be efficacious within each approach, notingthat implementation of each intervention is depen-dent on the location and the extent of the canceras well as the premorbid status of the patient. Forexample, in a lung cancer patient who has an activenicotine addiction, applicable prehabilitation inter-ventions may include breathing exercises and otherelements of pulmonary rehabilitation, smoking ces-sation, and coping skills (Fig. 1). The interventionschosen will ideally complement each other to im-prove the physical and the psychological health of anewly diagnosed cancer patient (e.g., a lung cancerpatient) before beginning acute cancer treatments.

Prehabilitation interventions should be focusedon improving health outcomes. For example, smokingcessation and alcohol cessation or reduction are wellknown prehabilitation interventions that may im-prove cancer treatment outcomes.62 Smoking ces-sation in lung cancer patients before undergoingsurgical resection is, then, an obvious interven-tion. However, there are many other types of cancerdiagnoses in which smoking has been shown to bedeleterious to the perioperative and postoperativerecovery.63,64 One study in patients with brain tumorsand another study in patients with gastrointestinal andthoracic cancers demonstrated both increased mor-bidity and mortality in current smokers.65,66 Both

studies concluded that cigarette smoking is associ-atedwith poor surgical outcomes, increasedmorbidityand mortality, and more complications postopera-tively. The authors recommended smoking cessationto mitigate these risks, and one set went on to state,Bsmoking cessation should be encouraged prior to allmajor cancer surgery in the VA [Veterans Affairs]population to decrease postoperative complicationsand length of stay.[66

Another area where prehabilitation might pro-mote better health outcome is in radiation therapy.PardoMasferrer et al.67 investigated the use of a urea-based cream before radiation therapy. Ninety-eight patients used the lotion three times per day for2Y3 wks before therapy. Compared with historicalcontrols who began cream application concurrentwith radiation therapy, these patients demonstratedthat consistent application of urea-based creambefore radiation therapy made the development of ra-diation dermatitis less likely and reduced skin toxicity.

Prophylactic swallowing exercises in patientswith head and neck cancer have also been studied.68 In2012, Kotz et al.69 published a randomized controlledtrial that found that patients who completed prophy-lactic swallowing exercises had improved swallowingfunction at 3 and 6 mos after chemoradiation ther-apy, although not immediately after chemoradiation

FIGURE 1 Examples of unimodal and multimodal prehabilitation interventions. Each puzzle piece represents aunimodal intervention approach that, when combined with other puzzle pieces into a group, offers amultimodal approach to prehabilitation. The three-part multimodal approach shown in this exampleis designed for a lung cancer patient population. However, as needed, the group could be expanded toinclude other interventions too (e.g., pain management). This puzzle model is an example and is notintended to include all prehabilitation interventions. Reproduced with permission from OncologyRehab Partners, LLC.



therapy, or at 9 and 12 mos after chemoradiationtherapy. Carroll et al.70 reported that prehabilitationswallowing exercises produced measurable improve-ments in posttreatment swallowing function in pa-tients with head and neck cancer who underwentorgan-preservation chemoradiation therapy. Roe andcolleagues71 recently surveyed speech and languagetherapy teams via a national network in the UnitedKingdom and found that, of the 42 participants whocompletely filled out the survey, 71.4% (n = 30) ad-vised patients on prophylactic swallowing exercises.Roe et al.71 noted that this was Bin keeping with ex-pert opinion and emerging evidence.[

It is important to consider not only physicalbut also psychological interventions that may pro-mote better health outcomes. The need for psycho-social support in some patients may be greatest atthe time of diagnosis, as they work to acclimate tothe changes that this will mean in their lives andrally for the challenges ahead. Providing support andinstruction in coping skills during this waiting peri-od, when survivors are in limbo, may be beneficialin alleviating some of their stress and anxiety.72,73 Itis also possible that prehabilitation psychosocial in-terventions, including coping skills, may help pa-tients move ahead with treatment decisions, furtheravoiding treatment delays.

In addition, it is also important to understandand acknowledge the concerns that patients mayhave regarding the initiation of their acute cancertreatments. The reduced survival outcomes in pa-tients who delay therapy support what some cancersurvivors fear: that any delay in starting treatmentmay contribute to a worse outcome. However, it isthe exception rather than the rule that someone whois diagnosed with cancer immediately begins treat-ment. The duration of the waiting period betweendiagnosis and the start of treatment may depend onmany factors, including second opinions; surgicalschedules; further testing; and, sometimes, a patient’spsychological stateVthe patient may simply feeloverwhelmed and unable to readily deal with a newcancer diagnosis and the anticipated treatment.Therefore, the period between diagnosis and thestart of acute cancer treatments may provide anopportunity for prehabilitation interventions thataddress both physical and psychological issues.

With every newcancer diagnosis, physiciansweighthe benefits of treatment vs. the risks. Included inthat analysis is always a consideration of (1) whichtherapiesmay slow the progression of the disease, putthe disease in remission, or even cure themalignancyand (2) how short- and long-term effects of thosetherapies, often used concurrently or sequentially,

might increase the risk for significant treatment-relatedmorbidity. Preventingorminimizing treatment-related morbidityVespecially chronic impairmentsthat may result in significant disabilityVshould be aprimary goal for all oncology clinicians.3

SUMMARYCancer prehabilitation, defined as a process on

the continuum of care that occurs between the timeof diagnosis and the beginning of acute treatment,includes physical and psychological assessments thatestablish a baseline functional level, identifies im-pairments, and provides targeted interventions thatimprove a patient’s health to reduce the incidenceand the severity of current and future impairments.In an impairment-driven cancer rehabilitation model,identifying current and anticipating future impair-ments are a critical first step in improving health-care outcomes and decreasing costs. The opportunityto assess baseline status and intervene to treat orprevent impairments begins almost immediatelyafter diagnosis and continues throughout the carecontinuum.

Perhaps, with most new cancer diagnoses, thereis an opening, whether a few days or a few weeks, toprovide prehabilitation interventions. Pairing tar-geted psychological and physical prehabilitation in-terventions in amultimodal approach is likely to offerthe best overall outcomes. Although the current ev-idence is limited, determining and taking advantageof this Bwindow of opportunity[ for each cancer pa-tient/population are an important area of future re-search that should focus on identifying the mosteffective prehabilitation interventionsVthose thatimprove patient outcomes and reduce direct and in-direct healthcare costs.

ACKNOWLEDGMENT

We thank Julie A. Poorman, PhD, for assis-tance with manuscript preparation.

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Handbook of Sport Neuropsychology

FrankM.Webbe, PhD (ed). New York, NY: SpringerPublishing Company LLC, 2011. 406p. $100.00.ISBN: 978-0-8261-1571-3.

Although the intended audience of this book wasprimarily neuropsychologists, increasing publicawareness and media attention about head inju-ries and sports give it much broader relevance,particularly for those who take care of athletes.The primary focus of the book is concussion insport, and it presents a summary of the currentscience available on the cognitive, neuromotor,vestibular, emotional, and anatomic effects ofsingle and multiple concussions in all levels ofathletes. The appropriateness and the limitationsof various types of imaging in diagnosis andmanagement are reviewed. It also presents stan-dardized recommendations and the existing sci-ence advising return-to-play decisions. It providesa thorough discussion of concussion manage-ment programs including the advantages andthe disadvantages of various types of preseason

screening and the assistance the neuropsychol-ogist can provide in that process. It also ad-dresses some of the controversies surroundinghead injury in sport, including Bheading[ insoccer in children and the possible long-termeffects of multiple concussions over time, in abalanced way. The book also devotes severalchapters to emerging areas in sport neuropsy-chology including attention-deficit/hyperactivitydisorder and learning disabilities in athletes andthe developmental effects of sports participation.

Overall, this is a well referenced, thoroughsummary of the research available on concussionin sportsVits diagnosis, management from a neu-ropsychological perspective, and return-to-playdecision making. It is a worthwhile read for any-one who manages patients at risk for concussionand a good reference with practical advice for thosewho may be called upon to do so.

Overall rating:||||Bonnie J. Weigert, MDUniversity of Wisconsin

Madison, Wisconsin

BOOK REVIEW

DOI: 10.1097/PHM.0b013e31829b4df0



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