PREHABILITATION FOR PATIENTS WITH ESOPHAGEAL CANCER: DO ALL PATIENTS RESPOND TO TRAINING?

E. Reijneveld¹, J. Dronkers¹, E. van Adrichem², M. Velthuis³, S. Beijer³, J. Ruurda⁴, C. Veenhof^5,1

¹Utrecht University of Applied Sciences, Research Group Innovation of Human Movement Care, Utrecht, Netherlands, ²Hanze University of Applied Sciences, School of Nursing, Groningen, Netherlands, ³Netherlands Comprehensive Cancer Organisation, Utrecht, Netherlands, ⁴University Medical Center Utrecht, Utrecht University, Department of Surgery, Utrecht, Netherlands, ⁵University Medical Center Utrecht, Department of Rehabilitation, Physiotherapy Science and Sport, Utrecht, Netherlands

Background: Prehabilitation programs are increasingly implemented in usual care pathways to recover from chemoradiotherapy and to optimize physical fitness before major surgery. Improvement of the exercise capacity is an important element during prehabilitation and associated with better postoperative outcomes. However, the effectiveness of prehabilitation programs varies between patients. From clinical practice, the question raises to what extent patients with a low exercise capacity respond to a prehabilitation program. To optimize and personalize preoperative interventions, it is important to have insight into the effectiveness and feasibility of prehabilitation in patients with different degrees of exercise capacity.

Purpose: To investigate whether the effectiveness and feasibility of a prehabilitation program varies between patients with a low, moderate and high exercise capacity.

Methods: This multicenter prospective cohort study included patients in a curative trajectory for esophageal cancer. In the six-week period between chemoradiotherapy and esophagectomy, patients received nutritional support and supervised exercise training, as part of the usual care pathway. Recommended training frequency was three times a week. Exercise capacity was measured by the Steep Ramp Test before (T0) and after (T1) chemoradiotherapy, and after finishing the exercise program (T2). Linear mixed model analyses were performed to analyze changes in exercise capacity in patients with a low (<175 Watt), moderate (175-300 Watt) and high (>300 Watt) exercise capacity at baseline. Feasibility of the prehabilitation program was investigated using a questionnaire about the performed training frequency and experiences with the program.

Results: 236 patients (182 men) were included, mean age 66.0±9.4 years. Mean exercise capacity decreased from 232.1±70.4 Watt to 207.9±65.2 during chemoradiotherapy (p<.01) and improved to 240.6±58.6 during prehabilitation (p<.01). Patients with a low exercise capacity (n=36) showed a smaller decrease from T0 to T1 (-10.5±30.1; n=36) compared to patients with a moderate (-24.8±38.4; n=173) and high (-36.2±33.9; n=27) exercise capacity, p=.04. Improvement during prehabilitation was not significantly different between patients with a low (+34.6±30.6), moderate (+34.0±37.8) and high (+27.9±32.4) exercise capacity, p=.93. Training frequency per week in patients with a low exercise capacity was ≤1 time in 18%, 2 times in 53% and ≥3 times in 29% of patients. Percentages for patients with a moderate exercise capacity were 7%, 39% and 55% respectively, and 5%, 47% and 47% respectively for patients with a high exercise capacity. 96% of all patients felt better prepared for surgery because of the exercise program. This percentage was similar in all groups.

Conclusions: The effectiveness of prehabilitation in patients with esophageal cancer is similar for patients with different degrees of exercise capacity. Patients respond well to prehabilitation and are able to recover from the impact of chemoradiotherapy.

Implications: Patients with a low exercise capacity respond well to prehabilitation, which implies that a major surgery is also possible for frail patients after following a prehabilitation program. For patients with a low exercise capacity, meeting the recommended exercise frequency seems more difficult and they may benefit from more guidance during the program. Therefore, personalization of programs based on the degree of exercise capacity is recommended.

Funding acknowledgements: This study was funded by the foundation ‘Vrienden Integrale Oncologische Zorg’.

Keywords:
Prehabilitation
Cancer
Exercise

Topics:
Oncology, HIV & palliative care
Disability & rehabilitation

Did this work require ethics approval? No

Reason: The prehabilitation program was designed as a quality improvement program for patients with esophageal cancer and the intervention (including measurements of physical fitness and nutritional status) was offered to patients as part of the standard of care in the participating hospitals. For this study, data collected from usual care measurements were used. Patients were informed about the study and signed informed consent for the use of data for scientific research. The medical ethics committee advised that formal ethics approval was not required.