Prehabilitation improves outcomes for esophagogastric cancer resection

Patients who underwent rehabilitation prior to esophagogastric cancer resection had improved functional capacity before and after surgery, according to results of a randomized clinical trial.

“Poor physical fitness and malnutrition are prevailing adverse effects of esophagogastric cancer and its treatment, with negative consequences for quality of life and care adherence,” Francesco Carli, MD, MPhil, FRCA, FRCPC, associate investigator in the Injury Repair Recovery Program and professor in the department of anesthesia at McGill University, and colleagues wrote. “Therefore, experts have highlighted the urgent need for randomized clinical trials of multidisciplinary interventions aiming to optimize cardiorespiratory fitness in this field.”

Postoperative complications — decreased muscle strength and cardiorespiratory fitness, fatigue, depression, emotional distress, anxiety and poor quality of life — can often compromise a patient’s ability to finish therapy, and surgery alone provides inadequate locoregional control for patients with locally advanced disease.

Carli and colleagues evaluated the effectiveness of prehabilitation — or the process of enhancing physical fitness with preoperative exercise and nutrition optimization before an operation to enable the patient to withstand the stress of surgery — to improve functional capacity in the perioperative period among adults undergoing esophagogastric cancer surgery.

Researchers randomly assigned 68 patients awaiting elective esophagogastric resection for cancer 1:1 to undergo prehabilitation or to a control group.

Change in functional capacity — measured with an absolute change in 6-minute walk distance — served as the study’s primary outcome. Researchers compared preoperative data from the end of the prehabilitation period with postoperative data 4 to 8 weeks after surgery.

The final analysis included 51 patients, 26 of whom (mean age, 67.3 years; 69% men) underwent prehabilitation and 25 of whom (mean age, 68 years; 80% men) were in the control group.

Researchers observed a statistically significant difference in walking distance change between the prehabilitation group and the control group at the preoperative assessment (mean, 36.9 m vs. –22.8 m) and after surgery (15.4 m vs. –81.8 m; P < .001 for both).

The groups appeared comparable for number and severity of complications, length of stay, ED visits and readmission rates. Two patients in each group did not receive the full planned neoadjuvant chemotherapy.

An important limitation of the trial was that it excluded frail at at-risk patients, Brian T. Fry, MS, PA-C, physician assistant at University of Michigan Medical School, and colleagues wrote in a related editorial.

“While exclusion was done to facilitate rigor of the trial, frail and at-risk patients are the patients for whom surgical care carries the greatest risk and presumably who may benefit the most,” Fry and colleagues wrote. “Furthermore, like most prehabilitation clinical trials, this study was not powered to detect improvements in traditional surgical outcomes, such as complication rates, length of stay or readmissions.”

Although trials have shown benefits of prehabilitation, the benefits can be challenging to translate to real-world practices, they added.

“In other words, patients are not randomized in standard practice, and physicians may intuitively prescribe prehabilitation for those patients whom they believe stand to benefit the most,” they wrote. “In addition, it is often unrealistic to delay a patient’s medical care to undergo a prehabilitation program, especially for patients with time-sensitive, surgically amenable conditions. Diverse patients, diverse stakeholders and diverse financing strategies contribute to a complex milieu for care and impede the acceptance and implementation of prehabilitation.”

Still, additional studies like this one may encourage prehabilitation to become the norm.

“The evidence demonstrates that, at worst, prehabilitation does no harm, and it can be a transformative clinical pathway to facilitate a better life for some patients,” Fry and colleagues wrote. – by Alexandra Todak

Disclosures: Carli and the other study authors report no relevant financial disclosures. One editorial author reports being the program director for the Michigan Surgical Quality Collaborative, co-director of the Michigan Opioid Prescribing Engagement Network, and director of the Michigan Surgical and Health Optimization Program.