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
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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.
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Dr. Desai is Project Coordinator, Integrative Medicine Service, Memorial Sloan Kettering Cancer Center, New York.