Prehabilitation Aims to Prepare Patients for What Lies Ahead

Linda Rodrigue carries around a note card so she can recite accurately the various events in her recent cancer experience. March 7: Needle biopsy. March 11: Breast center visit for biopsy results (not good). March 15: Imaging scan. March 18: Meet surgeon. March 21: Ultrasound on the other breast. March 25: Oncologist appointment. March 27: Surgeon appointment. April 12: Lumpectomy. April 23: Post-surgery visit. April 26: Oncologist visit (recommends chemo and radiation). May 24: Chemo port inserted. May 29: First chemotherapy.

The nearly three-month time frame between biopsy and treatment seems like a reasonable pace. In reality, however, it felt like “wham-bam,” says the 55-yearold South Carolina woman, leaving little time for much else, such as getting into peak shape for treatment.

“I think in a perfect world, you’d want to do that,” she says.

From their perspective, some professionals in the cancer rehabilitation field say the time between diagnosis and treatment, as imperfect as it may be, is a valuable window of opportunity for patients to begin “prehabilitation,” the physical and psychosocial interventions to better prepare them for the rigors of treatment.

Optimizing Well-Being

Lori McKitrick, who oversees the cancer rehabiliation program at Bon Secours St. Francis Health System in Greenville, S.C., says prehabilitation involves mental and physical assessments, as well as physical, occupational and speech therapies to shore up deficiencies.

Following on the success of boot camps designed for individuals preparing for hip and knee replacements, experts are proving that cancer patients can reap similar benefits from such programs.

“When prehabilitation was optional for joint patients, we saw a different outcome for those who had undergone the prehab, which included education and strengthening exercises,” says McKitrick, a certified speech therapist. Their length of stay, recovery time and satisfaction level were much better than those of people who didn’t participate. As a result, prehabilitation for joint replacement candidates is now mandatory at St. Francis, she says.

Extending that concept, therapists trained in oncology at St. Francis invited men scheduled for prostate cancer treatment to obtain baseline assessments of their psychosocial and physical conditions, and then taught them appropriate therapeutic exercises in advance of treatment.

The experience boosted not only the men’s physical capacity but also their mental and emotional resilience. It, too, helped reduce anxiety, McKitrick says. Patients gained a better idea of what to expect after surgery, as well as having “another place to get their questions answered.”

“Once you get a cancer diagnosis, everything seems to be out of your control,” McKitrick says. “We are giving [patients] something to take control of, and it is having a positive outcome.”

Competing Priorities

Exercise, in general, is good for anyone, and physically fit people usually fare better during treatment, but the comparison between the cancer and non-cancer patient populations is “apples to oranges,” says Michael Stubblefield, an attending physician in physical medicine and rehabilitation at Memorial Sloan Kettering Cancer Center in New York.

Stubblefield says most of the published research that discusses results of prehabilitation involves patients who have a medical condition other than cancer. He notes that the window of opportunity between diagnosis and treatment for people with COPD (chronic obstructive pulmonary disease) or damaged joints, for example, is much greater than for people who have cancer.

“We have a massive race occurring,” he says. “Changes in physical conditioning take more than a few days or a week. When you have cancer, it needs to be dealt with now. If you have lung cancer, you want to take it out this week, not in four to six weeks.”

One study that looked exclusively at the effect of prehabilitation on functional recovery after colorectal cancer surgery was inconclusive, Stubblefield says. The findings showed that tougher exercise could have had a harmful effect, while simple walking could have benefited an elderly subset of the test group.

Advocating for prehabilitation is premature, especially when resources are insufficient for rehabilitation, says Stubblefield, who has dedicated his medical career to restoring cancer survivors’ quality of life.

Currently, even at prestigious cancer institutions that are recognized for evaluating and taking care of posttreatment complications, too many people who need therapeutic rehabilitation don’t receive it, he adds.

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Julie Silver, a cancer survivor, physiatrist and associate professor at Harvard Medical School in Boston, agrees with Stubblefield about the wide gap between cancer survivors who need rehabilitation and those who actually receive it. But she is a strong proponent of prehabilitation.

The company she cofounded, Oncology Rehab Partners, developed STAR (Survivorship Training and Rehabilitation), a program designed to help hospitals and cancer centers implement rehabilitation protocols that focus on improving outcomes. This includes prehabilitation protocols to help patients with newly diagnosed cancer get ready for upcoming treatments. Among the healthcare centers that have adopted the prehab program is St. Francis Health System, where McKitrick is a certified STAR clinician.

Individualized Interventions

Regardless of the time frame between diagnosis and start of treatment, it’s smart to obtain a baseline screening to identify the targeted interventions that could improve recovery and enhance a survivor’s quality of life, Silver says. These could involve swallowing exercises before surgery for head and neck cancers, smoking cessation to improve breathing function prior to lung cancer surgery or pelvic floor exercises to reduce urinary incontinence after prostate cancer surgery. Interventions also could take the form of a nutritional boost to fight fatigue or balance training exercises to help prevent falls.

A psychological health assessment is also important because, among other reasons, mental health and attitude can affect whether a patient will adhere to a treatment regimen, she adds.

“It’s reasonable to assume that patients will have some level of distress that changes with time,” Silver says. By giving them cognitive-behavioral coping skills, such as guided imagery and muscle relaxation techniques, they can learn to reduce their stress response, which could result in lowering their heart rate and blood pressure before going into surgery, she says.

Though prehabilitation is relatively new for people with cancer and its potential is yet unknown, few would argue against supporting patients prior to treatment in an effort to enhance their recovery. Future studies might show whether early intervention could reduce hospital readmission or lower overall healthcare costs.

Meanwhile, patients should ask their oncologist or other members of their healthcare team if prehabilitation services are available where they are being treated, Silver says. If they are offered, patients should ask how they can access those services as soon as possible, she adds, even if the period between diagnosis and the start of treatment is packed with appointments.

Editor’s Note: During the formation of this article, McKesson Specialty Health, CURE’s parent company, purchased a majority stake in Oncology Rehab Partners. CURE is editorially independent from McKesson.