Multimodal Prehabilitation for Cystectomy Using the Comprehensive Geriatric Assessment: Design and Implementation

To determine the effect of preoperative nutrition and multimodal prehabilitation on clinical and functional outcomes in surgical lung cancer patients. We searched MEDLINE, Cochrane Library and CENTRAL, EMBASE, Scopus, and clinical trial registries ( clinicaltrials.gov , International Clinical Trials Registry Platform and Google Scholar) to identify studies involving a preoperative nutrition-based intervention or multimodal prehabilitation (nutrition with exercise) of at least 7 days, in lung cancer patients awaiting surgery. Studies must have reported results on at least one of the following outcomes: functional capacity, pulmonary function, postoperative complications, and length of hospital stay. The quality of included studies was assessed using the Cochrane risk of bias assessment tool for randomized trials and the modified Newcastle-Ottawa scale for non-controlled trials. Five studies were included (1 nutrition-only and 4 multimodal prehabilitation studies). Due to substantial heterogeneity in the interventions across studies, a meta-analysis was not conducted. Findings suggest that multimodal prehabilitation, compared with standard hospital care, is associated with improvements in both functional walking capacity and pulmonary function during the preoperative period; however it does not appear to have an effect on postoperative outcomes. Rather, the finding of significantly lower rates of postoperative complications in the intervention group was unique to the nutrition-only study. Multimodal prehabilitation programs that combine nutrition and exercise may have beneficial effects on various physical function outcomes in patients with lung cancer awaiting surgery. Optimizing preoperative nutrition may have postoperative benefits which remain to be confirmed.

Prehabilitation worth it? A theoretical algorithmic for the cost-effectiveness of a multimodal prehabilitation program for complex abdominal surgery

BackgroundLifestyle behaviors play a pivotal role across all stages of cancer. Multimodal prehabilitation, incorporating exercise, nutrition, and psychological support before treatment, has demonstrated improvements for short-term postoperative outcomes. Yet, its potential to catalyze sustainable lifestyle change after surgery remains unexplored. Understanding how patients perceive lifestyle changes after the perioperative phase is key to fully realizing prehabilitation benefits and leveraging the teachable moment at diagnosis.ObjectiveTo gain a deeper understanding of patients’ perceptions of lifestyle after undergoing surgery following a multimodal prehabilitation program.MethodsThis phenomenological qualitative study was performed in a university hospital between December 2022 and September 2023. Sixteen patients who have undergone abdominal cancer surgery following Fit4Surgery participation were interviewed using semi-structured interviews and thematic analysis. All interviews were audio-recorded, transcribed verbatim, and analyzed using reflexive thematic analysis.ResultsThe analysis identified five key themes that illustrate how patients with abdominal cancer perceive lifestyle following major surgery: (1) multimodal prehabilitation as a catalyst for lifestyle change, (2) challenges in maintaining a healthy lifestyle post-surgery, (3) the role of motivation and support in sustaining lifestyle change, (4) meaning of health and well-being, and (5) unequal access and personal context influence lifestyle choices.ConclusionMultimodal prehabilitation provides a foundation for lifestyle change, but without ongoing support and realistic timelines, sustained healthy behavior adoption remains challenging, especially for less active patients. Future programs should move beyond clinical endpoints to prioritize long-term behavior change by leveraging motivation, external support, habit formation, and addressing barriers like fatigue and insufficient medical guidance.Supplementary InformationThe online version contains supplementary material available at 10.1007/s00520-026-10661-7.

Higher patient activation (PA) correlates with better surgical outcomes but there is little evidence supporting interventions to improve PA in surgical patients. Multimodal prehabilitation, offers a personalized approach that includes goal-setting, feedback, and coaching, which may enhance PA. This study estimates the extent to which multimodal prehabilitation impacts PA in patients scheduled for elective surgery. This cohort study included patients scheduled for elective surgery and enrolled in a multimodal prehabilitation program in Montreal, Canada. Before and after prehabilitation, patients completed questionnaires focused on PA [patient activation measure (PAM), higher = better, minimal important difference = 5 points], mental health (Hospital Anxiety and Depression Scale, higher = worse), and health literacy (Health Literacy Screening Tool, higher = better). Patients were categorized as having low (PAM ≤ 55.1) or high activation (PAM > 55.1). Data analysis was conducted using linear and logistic regression. One hundred sixty-two patients were included (age 66 [12], 54% female, 73% cancer). Patients completed the prehabilitation program with a median of 11.6 (IQR 6.8-17.6) weeks and a compliance of 90% (IQR 74-100). At baseline, 29% of patients (n = 47) had low PA. After prehabilitation, the PAM score significantly increased in patients with low PA (+ 17.4 [95%CI + 9.94 to + 24.92], p < 0.001) but not in those with high PA (+ 0.91 [95%CI -3.28 to + 5.11], p = 0.67). Patients that improved from low to high PA (n = 24/47; 51%) were more likely to be non-smokers (p = 0.025), have higher health literacy (p = 0.002), and lower levels of depression (p = 0.008) and anxiety (p = 0.011), compared to those who did not improve. Patients with high PA before surgery had a lower risk of respiratory complications (OR 0.21 [95%CI 0.05-0.78]). Multimodal prehabilitation can enhance low levels of PA before surgery. This increase in PA may partially explain the beneficial effects of prehabilitation on postoperative outcomes. Incorporating PA measurement in future trials may offer valuable insights into the benefits of prehabilitation.

Background: Cytoreductive surgery (CRS), in combination with chemotherapy, is the main treatment for advanced-stage ovarian cancer. In vulnerable patients, this extensive surgery has a high complication risk and may lead to clinical decline. There is emerging evidence that prehabilitation could be valuable in optimizing the patient's condition prior to cytoreductive surgery, as is shown in colorectal surgery. However, there is limited evidence in gynecologic oncology. The objective of this study is to evaluate the feasibility and effects of implementing multimodal prehabilitation before cytoreductive surgery in patients with ovarian cancer. Methods: In two Dutch hospitals, 46 patients with ovarian cancer were included during the study period, of whom 32 participated in a multimodal prehabilitation program before CRS. The programs included at least physiotherapy, dietary advice and intoxication cessation. The timing, extent and content of the programs differed. Feasibility was assessed by eligibility and participation rates and adherence to the physiotherapy program. Effectiveness was measured by differences in functional capacity, postoperative outcomes and tolerance to adjuvant chemotherapy. Results: Eligibility rates in both hospitals were 83% and 89%, and participation rates were 68% and 72%. Adherence to the physiotherapy program was moderate and only satisfactory in 55% and 63% of the patients. All fitness endpoint measurements improved compared to the baseline. No significant differences in postoperative outcomes were found between prehabilitation and control patients. Prehabilitation patients appeared to have better tolerance to adjuvant chemotherapy, with fewer dose reductions (21% vs. 73%, p = 0.017) and dose deferrals (39% vs. 46%, not significant) compared to the control group. Conclusions: The implementation of multimodal prehabilitation before CRS is feasible and effective in patients with ovarian cancer with respectable eligibility and participation rates, along with improved functional capacity, even during neoadjuvant chemotherapy.

Patients undergoing open abdominal aortic aneurysm (AAA) repair remain at high risk for postoperative complications, particularly when presenting with limited baseline functional capacity. Prehabilitation, encompassing physical, nutritional, and psychological optimization before surgery, may improve outcomes in this population. However, evidence is limited in the context of open AAA repair. To evaluate the effectiveness of a multimodal prehabilitation program in reducing the incidence of postoperative complications in patients undergoing open AAA repair. This is a multicenter, international, randomized controlled trial. Eligible participants include adults scheduled for elective open AAA surgery. A total of 152 participants will be randomized 1:1 to receive either standard preoperative care or a 6-week multimodal prehabilitation program consisting of supervised exercise training, individualized nutritional support, and psychological counseling. The primary outcome is the rate of postoperative complications as measured by the Comprehensive Complication Index (CCI). Secondary outcomes include length of hospital stay, and readmission rates, changes in functional capacity, health-related quality of life and anxiety & depression. Data will be analyzed on an intention-to-treat basis. The study complies with SPIRIT 2013 guidelines and is registered at ClinicalTrials.gov (NCT05756283). This trial will address a significant evidence gap regarding preoperative optimization in open abdominal aneurysm surgery. Findings will inform best practices for reducing morbidity in this high-risk population and contribute to enhanced recovery strategies in vascular surgery. [NCT05756283].

Multimodal prehabilitation, including exercise training, nutritional therapy and anxiety reduction, has been shown to attenuate functional decline associated with surgery. Due to the growing interest in functional status as a targeted surgical outcome, a better understanding of the optimal prescription of exercise is critical. The objective is to compare peri-operative functional trajectory in response to two different exercise training protocols within a 4-week, supervised, multimodal prehabilitation programme. This was a single blinded, single centre, randomised controlled study. Participants performed four assessments: at baseline, after prehabilitation (just before surgery), and at 1 and 2 months after surgery. Adult patients scheduled for elective resection of nonmetastatic colorectal cancer were included provided there were no absolute contraindications to exercise nor poor language comprehension. Patients followed either high-intensity interval training (HIIT), or moderate intensity continuous training (MICT), as part of a 4-week multimodal prehabilitation programme. Both groups followed the same supervised resistance training, nutritional therapy and anxiety reduction interventions. All patients followed standardised peri-operative management. Changes in oxygen consumption at anaerobic threshold, measured with sequential cardio-pulmonary exercise testing, were assessed and compared between groups. Forty two patients were included in the primary analysis (HIIT n = 21 vs. MICT n = 21), with mean ± SD age 64.5 ± 11.2 years and 62% were men. At 2 months after surgery, 13/21 (62%) in HIIT and 11/21 (52%) in MICT attended the study visits. Both protocols significantly enhanced pre-operative functional capacity, with no difference between groups: mean (95% confidence interval) oxygen consumption at anaerobic threshold 1.97 (0.75 to 3.19) ml kg min in HIIT vs. 1.71 (0.56 to 2.85) in MICT, P = 0.753. At 2 months after surgery, the HIIT group showed a higher improvement in physical fitness: 2.36 (0.378 to 4.34) ml kg min, P = 0.021. No adverse events occurred during the intervention. Both MICT and HIIT enhanced pre-operative functional capacity. ClinicalTrials.gov Identifier: NCT03361150.

Multimodal prehabilitation: a promising strategy in patients listed for heart transplantation

Patients diagnosed with (muscle-) invasive bladder cancer (IBC) are more likely to harbour comorbidities due to their advanced age at diagnosis. Under-nutrition is a predictor for postoperative morbidity and mortality in cancer patients, but under-reported in urology. Understanding the IBC patient profile before major surgery could facilitate and optimise outcome of the surgical patient. To identify preoperative risk factors for early rehabilitation before radical cystectomy (RC). A historical registry-based study of 76 patients referred for RC at Aarhus University Hospital, Denmark (DK) in 2009. Early rehabilitation was defined by length of stay (LOS) postoperatively with a cutoff ≥11 days. High comorbidity was expressed by the charlson comorbidity index score (CCI) ≥3. LOS was calculated by linking the unique Civil Registration Number with the National Patient Registry. Preoperative nutritional risk was identified using the screening tool, nutritional risk score 2002 (NRS) of the European Society of Clinical Nutrition and Metabolism. Multivariate analysis was used to identify risk factors for early rehabilitation. The proportion of patients at preoperative nutritional risk was 26% (95% confidence interval (CI): (95% CI: 17; 37) and 43% of patients held a high CCI (95% CI: 33; 55). Prolonged LOS was independently associated with female gender (P=0.02) and age ≥70 years (P=0.04). NRS and CCI were not associated with LOS. Attention should be focused on women and elderly patients undergoing RC to optimise early rehabilitation and reduce LOS. It is still unknown whether preoperative nutritional risk and comorbidity are obstacles in early rehabilitation of RC patients.

BackgroundMultimodal prehabilitation programs that combine exercise training, nutritional support, and optimize psychological status have demonstrated efficacy in reducing post-operative complications in non-gynecological abdominal surgeries; however, the benefit in advanced ovarian...

Prehabilitation has been shown to improve outcomes for patients undergoing major surgery; benefits include reductions in length of hospital stay and postoperative complications. Multimodal prehabilitation programmes lead to improved patient...

As the population ages, increasing numbers of older adults are undergoing surgery. Frailty is prevalent in older adults and may be a better predictor of post-operative morbidity and mortality than chronological age. This thesis opens with a systematic review of the current literature on frailty and post-operative outcomes in older surgical patients (chapter two). Electronic databases from 2010 to 2015 were searched to identify articles which evaluated the relationship between frailty and post-operative outcomes in surgical patients with a mean age of 75 and older. Demographic data, type of surgery performed, frailty measure and impact of frailty on adverse outcomes were extracted from the selected studies. Quality of the studies and risk of bias was assessed by the Epidemiological Appraisal Instrument. Altogether 60 articles investigated the association between frailty and post-operative outcomes, 37 of them had patients with a mean age under 75 years old. The remaining 23 articles included in the review were assessed as medium to high quality. Participants ranged in age from 75 to 87 years, and included patients undergoing cardiac, oncological, general, vascular and hip fracture surgeries. There were 21 different instruments used to measure frailty. Regardless of how frailty was measured, the strongest evidence in terms of numbers of studies, consistency of results and study quality was for associations between frailty and increased mortality at 30 days, 90 days and one year follow-up, post-operative complications and length of stay. A small number of studies reported on discharge to institutional care, functional decline and lower quality of life after surgery, and also found a significant association with frailty.Though many studies have confirmed that frailty is associated with increased adverse outcome in the surgical population, the time point when frailty was assessed in the current literature was unclear. Whether baseline frailty or inpatient frailty predicts adverse outcome in surgical patients has not been investigated previously. The third chapter of the thesis aimed to derive a baseline and an inpatient frailty index (FI) and examine whether each was associated with adverse outcomes in the surgical population. A retrospective analysis was undertaken which derived baseline and inpatient FI from comprehensive geriatric assessment of 208 general surgical and orthopaedic patients aged 70 and over admitted to four acute hospitals in Queensland, Australia. The association of the FIs with adverse outcomes was examined in logistic regression. The mean (SD) baseline FI was 0.19 (0.09) compared to 0.26 (0.12) on admission, with a predominant increase in domains related to functional status. Both baseline and inpatient FIs were significant predictors of one year mortality, inpatient delirium, and a composite adverse outcome, after adjusting for age, sex and acuity of surgery. Baseline frailty and inpatient frailty, though distinct, are both predictive of adverse outcomes in surgical older patients. Frailty assessed at either time point is valid and useful in predicting adverse outcomes.In the fourth chapter of the thesis, a prospective study evaluated the feasibility of FI-CGA (frailty index based on comprehensive geriatric assessment) in 246 surgical patients aged 70 years and over undergoing intermediate to high risk surgery in a tertiary hospital in Queensland, Australia. Frailty was assessed using a 57-item FI-CGA form, with fit, intermediate and frail patients defined as FI l0.25, g0.25-0.4, and g0.4 respectively. nLogistic regression models assessed the relationship between FI and adverse outcomes, adjusting for age, gender and acuity of surgery. Adverse outcomes of interest were complications, prolonged length of stay, new discharge to residential aged care facility, deaths and unplanned hospital readmissions, ascertained intraoperatively, at 30 days and 12 months post-surgery. Mean age of the participants was 79 (SD 6.5), 52% were female, 91% were admitted from community, 65% underwent orthopaedic operations, and 43% underwent acute surgery. FI-CGA was a feasible tool which took on average 12 minutes to complete at the bedside. There were no statistically significant differences between fit, intermediate and frail groups in peri-operative (17.4%, 23.3%, 19.1% for fit, intermediate frail and frail patients p=0.577) and 30 day post-operative complications (35.8%, 47.8%, 46.8% p=0.183), which may have been a reflection of insufficient sample size. However, greater frailty was associated with increased 12 month mortality (6.4%, 15.6% and 23% for fit, intermediate frail and frail patients, p=0.01) and 12 month hospital readmissions (33.9%, 48.9%, 60%, p=0.004). Using FI-CGA peri-operatively may identify patients at high risk of poor long term outcome.In conclusion, there is strong evidence in the current literature that frailty is a predictor of adverse outcomes in surgical older adults. Frailty both at baseline and during an acute illness is predictive of adverse outcomes. FI-CGA is a potentially useful tool for incorporating into routine pre-operative assessment to help with decision making and to identify vulnerable surgical patients who are at higher risk of adverse outcomes.

Introduction/BackgroundOver 50% of ovarian cancer patients are diagnosed with advanced disease (stage 3+) in Wales (CRUK); treatment typically involves intense chemotherapy, combined with cytoreductive surgery(Coleridge, Elsherbini, NICE) Surgery of this...

8172 Background: Increased age-related prevalence of co-morbidity and functional impairment promote the risk of treatment intolerance and mortality in elderly cancer patients (pts). Clinical studies in these pts have shown the negative impact of coexistent disease on prognosis and disability, but few have underlined the relevance of thorough co-morbidity assessment. The Cumulative Illness Rating Scale-Geriatric (CIRS-G) provides a comprehensive co-morbidity assessment, including the measure of their severity. Methods: Women >70 years with early operable breast cancer were asked to undergo CGA at treatment start. CGA was conducted in the GEMU, according to the American Geriatric Society (AGS) guidelines, by a core team directed by a geriatrician. Assessment included information from various sources (pts, caregivers, general practitioners), and usual screening tools (ADL, IADL, POMA, GDS, MMSE, MNA), complete physical examination, standard lab. tests and X-ray. Co-morbidity was classified using the CIRS-G. Results: Of 76 pts (mean age: 77 +/- 4.7 years), 17% were at risk of cognitive deterioration, 30% of depression, 33% nutritional risk, 28% risk of fall. Most (66%) were fully independent in ADL, 46% in IADL. Median CIRS-G total score was 10. When tested, CIRS-G grade ≥2 co-morbidity was distributed as follows: 62% vascular disease, 31% psychiatric disease, 25% musculoskeletal or tegument disorders, 27% heart disease, and 18% sensory, 16% respiratory, 13% genitourinary, or 12% haematopoietic disorders. Results agree with reports from other geriatric teams using CGA. Conversely, when CGA process was used as a screening tool, median CIRS-G scores were lower. Extermann et al reported a median CIRS-G score of 5 in older breast cancer pts (Extermann, Crit Rev Oncol Hematol 2004). Conclusions: Older pts with early breast cancer have a high prevalence of co-morbidity and disability. CGA, done according to AGS guidelines, improves the quality of health status evaluation in the elderly. This work was supported by grant: PHRC n°98.064 of the Ministry of Health. No significant financial relationships to disclose.

Introduction/BackgroundPrehabilitation programmes aim to optimise the period between cancer diagnosis and treatment, by enhancing an individual’s functional and mental capacity prior to surgery. The aim of this study was to...