Guest Editor’s Note: Oncology guidelines recommend prehabilitation exercises to minimize postoperative complications. However, the COVID-19 pandemic imposed severe restrictions on patient access to in-person exercise programs offered by hospitals and clinics. In this article, Dr. Krupali Desai describes a study conducted by her group to evaluate the impact of a virtual prehabilitation program on perioperative outcomes in patients with thoracic cancer.
Krupali Desai, MD (Ayurveda), MPH
Thoracic cancer surgery has been associated with an elevated risk of morbidity and mortality, particularly in patients with diminished cardiopulmonary functions.1,2 Low physical activity levels and poor cardiopulmonary fitness before surgery have also been correlated with postoperative complications and prolonged postsurgical recovery.3-7 Consequently, improving fitness before surgery is critical to minimize complications and achieve faster recovery.
Prehabilitation (prehab) is defined as the process of optimizing physical fitness before surgery to enable patients to withstand the stress of surgery.8 Prehab programs have been shown to increase physical activity levels, improve cardiorespiratory fitness and muscle strength, and enhance postoperative recovery in patients undergoing thoracic cancer surgery.4,9,10 A systematic review and meta-analysis also reported improvement in pulmonary function before surgery and reductions in postoperative complications and length of hospital stay after surgery in this population.11
The ASCO clinical guidelines recommend preoperative exercise for patients with lung cancer undergoing surgery.12 However, the COVID-19 pandemic caused massive disruption in patient access to on-site exercise programs. This led to the need for developing virtual programs to meet the needs of this population.
Mind-Body Thoracic Prehabilitation Program
In December 2020, the Integrative Medicine and Thoracic Services at Memorial Sloan Kettering Cancer Center (MSK) developed and implemented a virtual, synchronous, mind-body prehab program to meet the needs of patients with thoracic cancer undergoing surgery. The program was structured as two 45-minute, fitness and mind-body classes each week via Zoom videoconferencing. The program was found to be highly feasible, with high patient satisfaction.13
Guest Editor
Jun J. Mao, MD, MSCE
We conducted a retrospective cohort study at the MSK thoracic oncology surgical department to evaluate the impact of the prehab program on perioperative outcomes. Eligibility criteria included patients aged 18 or older with a thoracic cancer diagnosis and expecting thoracic surgery between December 2019 and December 2021. Patients who attended at least one virtual mind-body prehab class before surgery were included in the analysis (prehabilitation group). Control group consisted of 400 patients randomly selected among those who were not approached to enroll in the prehab program. Cohorts were stratified by cancer type (lung, esophageal, other) to match the cancer type proportions in the prehabilitation group (± 5%). Length of hospital stays and hospital readmission/urgent care center visits within 30 days of discharge were extracted using an electronic database.
A total of 519 patients were included in the analysis, with 119 in the prehab group and 400 in the control arm. Data showed that the prehab group had reduced hospital readmissions (45 of 400 patients [11.3%; 95% confidence interval [CI] = 8.5%–14.8%] vs 4 of 119 patients [3.4%; 95% CI = 1.3%–8.7%; P = .01]). The number of urgent care center visits was also lower, although not statistically significant, with 56 in the control group (14.0%; 95% CI = 10.9%–17.8%) vs 10 in the prehabilitation group (8.4%; 95% CI = 4.6%–15.0%; P = .11). We did not find a significant difference in length of stay between the groups.
A multivariable logistic regression revealed participation in the prehab program to be associated with significantly lower odds of readmission (odds ratio [OR] = 0.26; 95% CI = 0.09–0.75; P = .01) in patients with lung cancer compared with those who had esophageal cancer (OR = 0.46; 95% CI, 0.23–0.92; P = .03).14
Concluding Thoughts
Hospital readmission, an important predictor of the quality of surgical care, is taxing for both patients and providers, and it imposes a significant financial burden on hospitals.15 Patients who participated in our virtual mind-body prehab program had fewer hospital readmissions within 30 days of discharge compared with controls. This program might be a scalable solution to implementing the ASCO clinical guidelines for improving patient outcomes and alleviating financial strain on hospitals. More randomized trials are needed to establish its efficacy.
DISCLOSURE: Krupali Desai reported no conflicts of interest.
REFERENCES
1. Handy JR Jr, Asaph JW, Skokan L, et al: What happens to patients undergoing lung cancer surgery? Outcomes and quality of life before and after surgery. Chest 122:21-30, 2002.
2. Sanchez-Lorente D, Navarro-Ripoll R, Guzman R, et al: Prehabilitation in thoracic surgery. J Thorac Dis 10(suppl 22):S2593-S2600, 2018.
3. Sebio García R, Yáñez-Brage MI, Giménez Moolhuyzen E, et al: Preoperative exercise training prevents functional decline after lung resection surgery: A randomized, single-blind controlled trial. Clin Rehabil 31:1057-1067, 2017.
4. Nagamatsu Y, Shima I, Yamana H, et al: Preoperative evaluation of cardiopulmonary reserve with the use of expired gas analysis during exercise testing in patients with squamous cell carcinoma of the thoracic esophagus. J Thorac Cardiovasc Surg 121:1064-1068, 2001.
5. Coats V, Maltais F, Simard S, et al: Feasibility and effectiveness of a home-based exercise training program before lung resection surgery. Can Respir J 20:e10-e16, 2013.
6. Pinto A, Faiz O, Davis R, et al: Surgical complications and their impact on patients’ psychosocial well-being: A systematic review and meta-analysis. BMJ Open 6:e007224, 2016.
7. Goldsmith I, Chesterfield-Thomas G, Toghill H: Pre-treatment optimization with pulmonary rehabilitation in lung cancer: Making the inoperable patients operable. EClinicalMedicine 31:100663, 2020.
8. Carli F, Zavorsky GS: Optimizing functional exercise capacity in the elderly surgical population. Curr Opin Clin Nutr Metab Care 8:23-32, 2005.
9. Jones LW, Peddle CJ, Eves ND, et al: Effects of presurgical exercise training on cardiorespiratory fitness among patients undergoing thoracic surgery for malignant lung lesions. Cancer 110:590-598, 2007.
10. Sheill G, Guinan E, O’Neill L, et al: Preoperative exercise to improve fitness in patients undergoing complex surgery for cancer of the lung or oesophagus (PRE-HIIT): A protocol for a randomized controlled trial. BMC Cancer 20:321, 2020.
11. Sebio García R, Yáñez-Brage MI, Giménez Moolhuyzen E, et al: Functional and postoperative outcomes after preoperative exercise training in patients with lung cancer: A systematic review and meta-analysis. Interact Cardiovasc Thorac Surg 23:486-497, 2016.
12. Ligibel JA, Bohlke K, May AM, et al: Exercise, diet, and weight management during cancer treatment: ASCO guideline. J Clin Oncol 40:2491-2507, 2022.
13. Mao JJ, Molena D, Desai K, et al: Implementing a virtual mind-body prehabilitation program for patients undergoing thoracic surgery: A quality improvement project. JTCVS Open 14:615-622, 2023.
14. Mao JJ, Molena D, Desai K, et al: Participation in virtual prehabilitation and outcomes following thoracic cancer surgery. JAMA Netw Open 7:e244084, 2024.
15. Rajmohan R, Joy M, Magam SG, et al: The path to sustainable healthcare: Implementing care transition teams to mitigate hospital readmissions and improve patient outcomes. Cureus 15:e39022, 2023.
Dr. Desai is Project Coordinator, Integrative Medicine Service, Memorial Sloan Kettering Cancer Center, New York.
