Prehab for Older Adults with Cancer: Enhancing Health and Treatment Outcomes
Older adults with cancer often face challenges related to reduced functional capacity and the presence of secondary or comorbid conditions (additional health concerns that can sometimes complicate how cancer is treated). These factors, combined with sedentary behavior and malnutrition, can lead to a state of frailty that affects the tolerability and safety of cancer treatments, such as surgery.
A growing body of research shows that many older adults with cancer can likely benefit from prehabilitation prior to surgery for cancer, especially people who exhibit signs of frailty. In fact, modern prehabilitation research has largely used older adults and frail individuals as the principal targets for preoperative conditioning because of their elevated risks during surgery and poor postoperative outlook (including chronic disability and institutionalization).
About 20 years ago, a series of studies by Gill and colleagues (2002, 2003, 2004) demonstrated the feasibility, safety, and benefits of home-based prehabilitation for frail adults over the age of 75. In their work, prehab participants engaged in home-based physical therapy exercises and were compared to participants who received education on healthy living, including eating well, medication management, physical activity and exercise, and sleep health. Compared to the group receiving education, prehab participants maintained their ability to perform activities of daily living better and had fewer days spent in a nursing home 12 months after the intervention. These studies paved the way for the application of prehabilitation in the surgical setting, with the aim of minimizing postoperative morbidity and accelerating recovery.
Over the past decade, research on prehabilitation in geriatric oncology has flourished, with studies investigating its effects in various tumor sites. Multimodal prehabilitation, which simultaneously optimizes multiple domains of health, is recommended to maximize peri- and post-treatment benefits. While prehabilitation has primarily focused on surgical patients, emerging data suggest its potential benefits prior to chemotherapy or stem cell transplant. Multiphasic prehabilitation has also been introduced to capture the various and distinct needs for prehabilitation in the context of neoadjuvant and adjuvant therapies before and after surgery, respectively.
A recent systematic review of more than 30 studies on prehabilitation in older adults prior to abdominal cancer surgery found that the current literature should be interpreted cautiously because of methodology limitations; however, some studies observed fewer complication rates, shorter lengths of stays, improved functional capacity in people who engaged in prehab before their surgery. More recently, a large randomized controlled trial by McIsaac and colleagues of more than 200 frail, older adults with cancer found fewer complications, lower disability, and better functional capacity was observed among those who were at least 80% adherent to the prehab intervention.
The importance of adherence combined with the variability of needs, preferences, and medical circumstances related to prehabilitation in older adults with cancer highlights the value of individualized prehabilitation. A needs assessment study found that older adults preferred home-based exercise, prioritized safety and feasibility, and responded well to incentives for participation. Innovative approaches, such as Fit4SurgeryTV, a touchscreen display that encourages exercise and dietary behaviors, have shown promise in pilot assessments.
Research by Barnes and others has also shown that facilitators of prehab in older adults with cancer includes:
1) A suitable program to the older adults with frailty (i.e., accommodating their unique circumstances)
2) The provision of supportive resources to drive engagement
3) Support from others
4) A feeling of control, personal or intrinsic value, and observation of health improvements
5) An enjoyable experience
On the other hand, barriers to prehab participation and engagement were:
1) Other health concerns, low energy and initial fitness levels
2) Poor weather (often as it related to outdoor aerobic exercise, such as humidity or cold weather making it uncomfortable to go for a walk)
3) Guilt and frustration when obstacles prevented their ability to exercise
Many clinicians and researchers support the concept of prehabilitation, recognizing its potential benefits in improving patient outcomes. However, more research is needed to establish definitive evidence of its effectiveness, especially in older and frail patients. Efforts to optimize health with exercise, nutrition, and psychological interventions prior to, and after, surgery are likely best-guided by comprehensive geriatric-focused assessments to ensure safe and appropriate care.
Image Source: https://link.springer.com/chapter/10.1007/978-3-030-89162-6_9
Image Notes and Legend: Suggested model for prehab and rehab assessments and interventions. CPET, cardiopulmonary exercise testing; DASI, Dike activity status index; PA, physical activity; 6MWT, six minutes’ walk test; BMD, bone mineral density; CGA, comprehensive geriatric assessment; ex, exercise; psych, psychology; ADL, activities of daily living; IADL, instrumental activities of daily living; Rx, treatment
Prehabilitation holds great potential in reducing treatment toxicity and improving outcomes for older adults with cancer. While more research is needed to establish its effectiveness, the positive trend of evidence and clinician support suggests that prehabilitation will likely become an integral part of care for aging cancer survivors. By targeting deficits in functional, psychosocial, and nutritional domains, prehabilitation can help older adults with cancer better tolerate and benefit from treatment, ultimately improving their quality of life.
Consider these papers for additional reading on the topic of prehabilitation in geriatric oncology:
Prehabilitation in geriatric oncology
Prehabilitation and Rehabilitation in Older Adults with Cancer and Frailty
