Prehabilitation before cancer treatmentBMJ 2019; 366 doi: https://doi.org/10.1136/bmj.l5120 (Published 14 August 2019) Cite this as: BMJ 2019;366:l5120
All rapid responses
I was interested to read the editorial by Giles and Cummins on prehabilitation before cancer treatment, which discussed particularly its negative aspects. I have been involved in a project where we train our patients physically and psychologically before their cancer surgery. The project has won many awards, has reduced our length of stay and reduced our postoperative complication rate by a staggering rate. Not only that, but the complications our patients get are now less severe, so fewer of them need to be admitted to the intensive care unit.
What has really impressed me, however is how much more motivated our patients are. They are psychologically much more prepared for the operation – one of the most invasive and extensive that we perform – understanding it better and understanding the hard work they themselves have to put in. I have seen patients who successfully stopped smoking at the first consultation, and by the time they come to surgery their sheer will to succeed is obvious. With this in mind some of the problems Giles and Cummins suggested puzzled me, especially having seen how the patients I’ve treated responded.
Maybe I’ve misunderstood the message that it’s trying to convey, but I find the suggestion that patients may be too upset by their cancer diagnosis to engage in lifestyle modification and pre-habilitation insulting and patronising to our patients, as is the statement that our patients can’t process the additional information because they’re getting information overload already.
So are they really saying that because our patients have just been told they have cancer and need treatment they’re going to be too upset for us to be able to help them stop smoking and increase their exercise levels? In my experience the time of a cancer diagnosis is an immensely valuable moment when people re-assess their life and are very open to lifestyle modifications. To deny our patients this opportunity because they may be “upset” would be to do wrong by them. Our patients love the pre-habilitation programme we provide for them, and one of the points they always mention is how it gives them a chance to be active participants in their care rather than passive recipients.
Further down the article the authors caution against pre-habilitation for lower social class patients as they may be more resistant to interventions such as stopping smoking. I found this bizarre, as in our experience the high success we have in getting our patients to engage in our pre-hab programme is not dependent on social class, and in fact those patients stand to gain more benefit from the programme than better informed health conscious patients who will probably be quite fit to begin with.
The paternalistic tone in the article is something I thought we had left behind in the 1980s, and I think it’s really important we don’t reinforce the stigma of cancer where we have to protect them from information or additional resources as they may be upset about their diagnosis. It is a difficult time for them, and the structure of a pre-habilitation programme is an immensely positive addition where our patients feel cared for, guided through the programme, and…yes…even loved.
Competing interests: I am a Council member at the Royal College of Anaesthetists.
I find the idea of a "prehabilitation" phase following a cancer diagnosis and prior to treatment an excellent opportunity to prepare patients for what is most likely to be an immensely challenging time for them and their nearest. I imagine many will be grateful to receive further advice that could potentiate their cancer treatment and increase its chances of success through improving their general health. It appears to me though, that the "prehabilitation" focus is overwhelmingly medical, despite cancer treatment requiring a wholesome, holistic approach. Therefore, I believe that this is the perfect opportunity to introduce the department of Specialist Palliative Care (SPC) to cancer patients and highlight the benefits their involvement can achieve.
Unfortunately, palliative care is still grossly associated with end-of-life care by the general public. SPC provides a holistic approach, aiming to preserve quality of life, regardless of prognosis, by providing physical, psychological, social and spiritual support. Earlier involvement has been associated with greater outcomes, reduced side effects and generally more positive experiences with cancer treatment. Explaining the role of SPC to patients at this "prehabilitation" stage could greatly improve the perception of SPC, improve the utilisation of their services and provide patients with a greater sense of care.
Not all patients will be willing to make the medical, lifestyle changes to improve their health, especially those for whom their treatment will be non-curative. "Prehabilitation" should not exclude this group, including SPC in the process will hopefully ensure that the process is beneficial for all.
Competing interests: No competing interests
We at Macmillan Cancer Support are grateful to Ceinwen Giles and Steven Cummins for their support of our report: Principles and Guidance for Prehabilitation within the Management and Support of People with Cancer (14th August). They highlight some of the barriers to successful implementation, which are issues that we recognise and are working with NHS leaders to address.
We agree that the evidence base for prehabilitation must be strengthened, and our report includes recommendations to build on evidence gaps. An understanding of the patient experience of prehabilitation will be critical to this, including approaches and timings of interventions.
In particular, we share the authors’ concerns about current NHS workforce pressures. We are acutely aware of the challenge of improving cancer care with the finite resources available. In our report, we aimed to balance ambition with realism, proposing that prehabilitation can help achieve positive changes to clinical pathways so care is optimised within current resources. Our discussions with the NHS and Government around the workforce focus on future planning and integration – prehabilitation support will come from the NHS, local authorities, public health teams and the fitness industry among others. There is a need to start thinking differently about how we utilise the workforce and prehabilitation provides great opportunity for this.
We agree that in cancer care there are various levels of health inequalities and that outcomes can be poorer. Our recent policy report ‘Time to Talk’ sets out where there are potential and known inequalities at various points of the cancer pathway. Opportunities for change include the need for an integrated care approach and local and national inequality targets, both which can be assisted through prehabilitation implementation.
We would like to clarify that our prehabilitation recommendations have been underpinned by involvement from people living with cancer. They told us that they find prehabilitation empowering, increasing their resilience and preparing them mentally and physically for treatment. Additionally, people living with cancer told us that peer support was important to them. Macmillan recognises the value of peer support, which is an integral part of behaviour change interventions.
Our guidance is intended to be implemented by health professionals as appropriate to individual patient circumstances. We advise clinicians to complete holistic needs assessments to identify what matters most to patients and inform the best approach to meet individual and changing needs.
Specialist Advisor for Allied Health Professionals
Macmillan Cancer Support
Competing interests: We have read and understood BMJ policy on declaration of interests and declare the following interests: June Davis was an author on the report being discussed in both this letter and the original opinion piece it refers to.
It’s not rocket science guys getting a patient fitter prior to cancer surgery to help with their journey: their chances of a faster smoother recovery and the potential of overcoming any complications is surely not debatable. I’ve been doing this for 15 years. I help the patient by involving the family and should they wish I include other patients that have had a similar journey as peers for encouragement. I give them simple nutritional advice assuming they can swallow and also a simple exercise regimen to follow.
It’s really not hard. Many of us were doing prehab before it even had a name. It works. I have no surgical specific mortality at 1,2 or 3 months with regards to radical cystectomy. This operation carries a mortality of 3-4 % in the best centres. The SEER database for the same operation quotes a mortality of 10% for patients in their 70s and 14.8% if their in their 80s . Seriously don’t make things difficult. I accept patients are all different and realistic medicine must also be practised but let’s try and keep it simple: it certainly works for my patients.
Competing interests: No competing interests
The concern about the potential drawbacks of prehabilitation for people with cancer because prehabilitation “may shift the burden of responsibility to the patient at a time when they are likely to be upset and worried” is wrongly illustrated by fears of “unintended increase in social inequalities in cancer survival … (as) … core components of prehabilitation are behaviour change interventions, such as smoking cessation”.(1)
First, smoking is not a behaviour: cigarette is the worst addictive product, thanks to the nicotine arms race accompanied by the sweetness and flavour intensity arms race.(2) Races began in the 1960s with ammonia to “freebase” nicotine -- “crack nicotine” -- and menthol. Surprisingly, no country has reduced nicotine content or banned menthol yet!
Second, too few patients are adequately assisted for smoking, oncology being only one discipline among others. Only 75% of oncology clinicians assess tobacco use at intake visit, 60% advise patients to quit, and substantially less recommend cessation treatment (3) despite smoking seriously having an impact on outcomes (cancer treatment effectiveness, overall survival, risk of second primary malignancies, quality of life).(4)
I never require smokers to quit, as none want to: all have made serial attempts, always defeats with suffering and despair. Is it empathy or common sense? I explain I allow them to smoke and only require them to take the treatment and increase doses as needed, craving being pain. Smokers simply need reassurance with: a) motivational interviewing, a basic skill,(5) and psychological support, which needs some time and basic skills; b) the “belt and braces” strategy combining nicotine patches with oral “rescue” formulations (i.e. sprays and lozenges), the latter to suppress occasional cravings.
The cornerstone is cognitive bias modification as smokers: a) are wrongly more scared of nicotine than of carbon monoxide, tar and other by-products; b) wrongly believe smoking with patches is more dangerous than without, overlooking the devastating effects of compensatory uptake when trying to reduce smoking without patches; c) fear increasing doses until craving is suppressed.(6) Misconceptions die hard as they are nurtured (1,4,6) but why are basic tools for care such as motivational interviewing and basic pharmacological principles (kinetics and dose/response) for cure overlooked?
Last, I never set a quit date, smokers will stop when they are ready to, after self‐adjustment of doses to stop craving and make cigarettes distasteful. Similarly, I never set a date for being pain free after a prescription of analgesics.
Competing interests: No competing interests
What a right-minded and useful essay. I'm glad it's stirring up some dissent on Twitter so we can get the issues out on the table!
Prehab of various sorts can hardly be viewed as radical or new, but I hope we can view it in every possible domain. When my wife experienced successful bilateral knee replacements, prehab was part of the plan and undoubtedly helped her rapid recovery. In contrast, when she had foot surgery, the surgeon had no interest at all in anything outside the O.R.
Our questions about prehab and preparing for rehab were met with a puzzled look of "Why are you asking me about this?" and an offer to connect us with physical therapy if we thought she might need it.
Yes, it can be tricky ... because guess what, people are different - particularly in the sociological aspects, even more when we weave in economics, as the author says (re social inequalities). I interpret the essay as encouraging us to be mindful of the parts that require attention to the intervention's purpose and to the patient's readiness.
So I hope that rather than mandating a fixed plan, we can view prehab within the greater context of *care* and *caring for*: as the author says, the prospect of cancer treatment may mean the patient's very stressed and thus less able to execute any part of the plan. In my limited experience (just a patient/survivor with friends), such cases require support from others e.g. social support services, family, etc. Again this makes sense if we view it all as part of *caring for* the person who's in trouble; care is not just a matter of administering biological "things" to the victim.
I'll note, too, that clinicians sometimes *discourage* patients from preparing themselves (e.g. coming up with ideas of their own, asking questions), whereas others encourage involvement. In my own near-fatal cancer (2007), my oncologist welcomed my involvement, saying later in The BMJ, "I'm not sure you could have tolerated enough medicine if you hadn't been so prepared." https://www.bmj.com/content/346/bmj.f1990
The World Bank's definition of empowerment (from their work in developing nations) includes increasing people's capacity to take effective actions to achieve the outcomes they want. In that context, offering and encouraging any form of preparation is empowering ... and note that it's conceived around the individual's current situation.
With luck perhaps someday we'll even have a concept of *patient centred* care! Oh wait...
Competing interests: No competing interests