The most effective prehab programs provide a holistic approach to promote patient
empowerment, adherence, and improved experience. This includes a graded, evidence-based exercise prescription to give the best opportunity to improve fitness in the constrained time-period before cancer treatment. High-intensity interval training (HIIT) exercise provides an effective, time-efficient approach to increasing fitness, but any exercise could be viewed as potentially beneficial for patients.
Most supporting evidence for prehab has come from surgical patients undergoing colorectal, lung, and oesphago-gastric resections. There is currently less evidence supporting the use of prehab programs in HPB surgery but preliminary results emerging from ongoing prehab studies in patients undergoing liver resection at The HPB Unit in Manchester (Manchester Royal Infirmary, University of Manchester, UK) have shown improvement in pre-operative physical fitness especially in the least fit groups.
People with cancer often present with low muscle mass/sarcopenia at diagnosis, and this can worsen throughout their treatment or disease progression. Multi-modal prehab may prove to be particularly important in the surgical treatment of pancreatic cancer, a diagnosis often associated with cachexia and malnutrition. Recent evidence from ongoing initiatives in Manchester recommends nutritional assessment and supplementation before and after major pancreas resection. Therefore, a key aim within nutritional prehab is to preserve muscle mass or promote muscle anabolism, alongside exercise therapy. When designing nutritional interventions, it is important to ensure appropriate levels of energy, helping to stimulate protein synthesis, and suppress protein breakdown. Patients with pancreatic exocrine insufficiency (PEI) often suffer from malnutrition and sarcopenia because of malabsorption. Untreated PEI has been linked to worse quality of life and survival among individuals with pancreatic cancer.
NICE guidelines recommend that enteric-coated pancreatin is offered to all patients with unresectable disease, and that it should be considered before and after pancreatic cancer resection. Pancreatic enzyme replacement has also been associated with increased survival following pancreatoduodenectomy for periampullary malignancy. Given its association with malnutrition, sarcopenia, and survival, the treatment of PEI should be seen as a vital component of nutritional prehab in this cohort of patients.
In conclusion, multidisciplinary prehabilitation programs incorporate innovative and comprehensive preoperative risk evaluation and stratification accompanied by structured and personalized interventions with particular attention for those patients at risk. The published data on prehab in older, frail patients is still insufficient to demonstrate a positive impact of the multimodal interventions on clinical outcome. Several reasons such as heterogeneity of outcome measured and different intensity of surgical stress, difficulty to distinguish frailty classifications, and inconsistency of compliance to the protocols by the patients, can explain some of the negative results. The integrated role of preoperative exercise training, adequate nutrition, and psychosocial balance within the perioperative medical and surgical care deserves to receive more attention in the future for our older, frail patients.