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A Conversation with Dr Franco Carli, a Leader in Cancer Prehabilitation Research

VBCC - December 2014, Vol 5, No 10 - Cancer Prehabilitation
Julie K. Silver, MD
Associate Professor and Associate Chair for Strategic Initiatives
Department of Physical Medicine and Rehabilitation
Harvard Medical School
Boston, MA

In 2013, I coauthored the first review on cancer prehabilitation.1 Since its publication, I have been inundated with requests from various healthcare professionals to learn more about prehabilitation. This is the first of 3 perspectives by a researcher, a physician, and a patient regarding prehabilitation.

Let us begin by defining cancer prehabilitation, which is not as simple as “whatever is done before surgery or other cancer treatments begin.” In a previous review, my colleagues and I defined it as “a process on the cancer continuum of care that occurs between the time of cancer diagnosis and the beginning of acute treatment and includes physical and psychological assessments that establish a baseline functional level, identify impairments, and provide interventions that promote physical and psychological health to reduce the incidence and/or severity of future impairments.”2

Prehabilitation is time-based and outcomes-focused, with document­able data that compare a patient’s baseline status to the status at discrete points along the care continuum; ideally there are at least 4 times when patients are assessed, including (1) baseline, (2) after prehabilitation but before the start of cancer treatment, (3) after cancer treatment (eg, surgery) at the rehabilitation evaluation, and (4) at discharge from rehabilitation. This means that handing someone an educational booklet or a printed sheet of exercises or encouraging a better diet before surgery would not be considered prehabilitation.

Franco Carli, MD, MPhil, Professor of Anesthesia, McGill University, Montréal, Québec, Canada, has been studying surgical prehabilitation in patients with colorectal cancer. Recently, Dr Carli and his colleagues published the results of a randomized controlled trial (RCT) with a trimodal prehabilitation approach that included nutritional supplementation, stress reduction, and exercise components; one group had prehabilitation and postoperative rehabilitation and the other group only had postoperative rehabilitation.3

Dr Silver: Briefly describe your new study and why it is important.
Dr Carli: This RCT was set up to determine whether multimodal prehab (exercise + nutritional supplement + relaxation), starting 4 weeks before colorectal resection for cancer and continued for 8 weeks after surgery, would help patients recover faster than a rehab group receiving the same multimodal regimen after surgery. The results demonstrated that >80% of the prehab patients returned to baseline by 8 weeks compared with 60% of the rehab-only group. This is the first time multimodal prehab and/or rehab was administered in this population. Although it is clear that the patients who are in the prehab have more chance to return to baseline faster, 60% of the rehab patients can catch up by 8 weeks. Only 30% of patients in the historical control group, where no intervention was done, returned to preoperative baseline by 8 weeks. This could suggest that prehabilitation is the optimal way, but if limited time for prehab is allowed, at least the program can be initiated after surgery.

Dr Silver: How did your earlier studies utilizing a single modality (exercise) influence your multimodal approach?
Dr Carli: In our first RCT, using intense exercise, we found that many of the patients were unable to sustain such efforts. Also, we found almost 20% of patients with high anxiety and depression. Finally, we did not account for nutrition, and we believe this was an important component to control for together with the other 2 components.

Dr Silver: How important is the nutritional component, and why?
Dr Carli: In our recent study on preoperative nutritional assessment in this population, 62% of patients were considered well-nourished, 26% suspected or nutritionally at risk, and 8% severely undernourished. According to the PG-SGA (nutritional assessment questionnaire), 52% of patients scored 4 to 8 or >9, indicating requirement for dietary intervention or symptom management. Undernutrition, before or after surgery, is associated with higher mortality, morbidity, costs, and delayed recovery after abdominal surgery. This implies that appropriate nutrition ought to be considered in the perioperative period.

Dr Silver: How important is the psychosocial component, and why?
Dr Carli: These patients are under intense psychological stress once they receive the diagnosis of cancer and the need for surgical treatment. They feel lost and with lowered self-esteem. The majority of patients (>75%) wanted to participate in the prehabilitation study. It is clear that 4 weeks are not sufficient to intervene with modification of their behavior; however, the counseling helps them to meditate and improve their breathing. This component of the prehabilitation could help them to allay their anxiety, and make them more willing to be engaged in the prehab program, and be more empowered. We have included the psychosocial component, because there is sufficient evidence in the literature that stress reduction improves wound healing.

Dr Silver: What are the key take-home points for researchers regarding prehabilitation?
Dr Carli: There is a need to determine whether prehab impacts other outcomes besides functional capacity; for example, postoperative complications or hospital readmissions. These represent important outcomes for the institution and society. And, of course, impact on health costs of this program. In addition, there is a need to determine how and what type of exercise influences outcomes (aerobic vs resistance), and what type of nutrition (immune nutrition or regular) should be used.

Dr Silver: What are the key take-home points for oncologists regarding prehabilitation?
Dr Carli: Oncologists should be interested in joining the team [in addition to surgeons], because at least 30% to 40% of the patients will need some type of adjuvant therapy, and the stress associated with this intervention is not less than that caused by surgery. I could see a concept of tumor board where all care is reviewed, including whether the patient should begin prehabilitation.

Dr Silver: With limited time and/or resources, what are the most impor­tant tests, and what are the most important interventions?
Dr Carli: I believe that patients want to recover as soon as possible after hospital intervention. Recovery for our patients means the ability to function in society and to be independent. Walking is a measure of functional capacity. We use the 6-minute walk test, which is easy to be administered and monitored and has been validated in surgical patients. We have reported that with <60% of predicted value (approximately <390 meters), patients with colorectal cancer are at risk for postoperative cardiorespiratory complications. Nutritional questionnaires, such as the PG-SGA or RS-2002, can be used as screening tools in the surgeon’s office or in the preoperative clinic.

Clearly, each patient needs to be assessed for nutritional risk and for physical fitness before starting prehabilitation. Those that we need to pay more attention to are the elderly (age >70 years), malnourished or poorly nourished, those living alone in nursing homes, and those with comorbidities, such as diabetes, cardiorespiratory disease, or body mass index >40 kg/m2.

Dr Silver: What will you be studying next, and why?
Dr Carli: We want to better understand the impact of physical activity and/or nutrition on muscle function and mental behavior, and how to minimize the time for patients to recover from surgery. Of course, the sooner the patient recovers, the better the quality of life and the less cost to society.

Dr Silver: What is the role of nursing in prehabilitation?
Dr Carli: Essential. Nurses are part of the team and can lead in this program by coordinating the various steps patients go through. They are professionals with knowledge and adequate health education to explain the various components of prehabilitation and provide support.

Dr Silver: Is prehabilitation undervalued and underutilized in oncology? Why, or why not?
Dr Carli: In my view, it is underutilized, but I am not sure whether it is undervalued. This depends on whether the underutilization is because this intervention is not well-known in many circles or is not considered an option because it does not “cure” cancer. To any patient, this program makes sense. Most of the patients ask, “Why, then, is it not made available?”

Dr Silver: What else do you want to share with oncologists about prehabilitation or your work?
Dr Carli: We need to have more institutions that are engaged in this type of work, so that we could exchange information and learn from each other’s experience. We also need government grants and other research and education funding to understand better what we are trying to achieve. The majority of patients involved in prehabilitation are unanimously excited by the program. They feel engaged and not abandoned; they believe they can control their health, and this is a positive objective of prehabilitation.




References
  1. Silver JK, Baima J. 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. 2013;92:715-727.
  2. Silver JK, Baima J, Mayer RS. Impairment-driven cancer rehabilitation: an essential component of quality care and survivorship. CA Cancer J Clin. 2013;63:295-317.
  3. Gillis C, Li C, Lee L, et al. Prehabilitation versus rehabilitation: a randomized control trial in patients undergoing colorectal resection for cancer. Anesthesiology. 2014;121:937-947.
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Last modified: December 23, 2014
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