WHAT IS CANCER PREHABILITATION?

Cancer prehabilitation is the process of care that we initiate before surgery or treatment for cancer.

It consists of a series of assessments and interventions initiated before the cancer treatment (e.g., surgery, chemotherapy or radiotherapy) with the goals of improving the patient's health and fitness. It facilitates post-treatment recovery and helps the patient to tolerate adjuvant treatment better, reducing the chance of treatment disruption or termination.

BENEFITS OF CANCER PREHABILITATION

There is an increasing proportion of surgical patients who are considered high risk due to advanced age and the presence of frailty or multiple comorbidities, making them more likely to have postoperative complications, protracted functional recovery and mortality. The traditional approach is to rehabilitate these patients postoperatively after functional decline has set in.

However, in recent years, there has been a paradigm shift towards preparing patients pre-emptively prior to cancer treatment – which allows improved postoperative functional recovery, reduced postoperative complications and shortened length of hospital stay.

Recent studies and systematic reviews¹ have supported the evidence of these benefits, on top of improving psychological well-being and quality of life measures.

Figure 1a Prevalence of cancer among males in Singapore²


Figure 1b Prevalence of cancer among females in Singapore²

Home-Based Cancer Prehabilitation Programme
at Changi General Hospital

One-stop initiative with reduced hospital visits

Prehabilitation programmes typically target four major domains: medical optimisation, physical activity, nutrition and mental health; and usually require multiple visits to see various healthcare professionals based on their specialised domain (e.g., doctor, physiotherapist, dietitian and mental health professional).

At Changi General Hospital (CGH), our home-based cancer prehabilitation programme consists of a one-stop screen-and-intervene initiative³, which reduces the time spent in the hospital and allows patients to focus fully on the various domains of prehabilitation to reap its benefits prior to treatment.

Personalised intervention plans

Patients are scheduled for visits to a prehabilitation coordinator and rehabilitation physician on the same day, after their visit to the surgeon. They undergo a holistic health assessment comprising frailty, functional and mental wellness tests by the prehabilitation coordinator.

Based on the results and their medical conditions, the rehabilitation physician draws up a personalised intervention plan. The rehabilitation physician is a specialist who manages both medical and functional issues. He is certified in exercise prescription, and through focused cross-training by the dietitian and psychologist, is able to intervene in multiple domains.

This allows patients’ existing chronic conditions to be optimised while they receive dietary and mental health advice, as well as a personalised exercise prescription.

Empowering patients to take charge of their health

To empower patients to take charge of their health at home, the exercise prescription is easily accessible via the Cancer Prehabilitation Exercise Diary on the Health Buddy app. Within the diary, there are exercise videos, reminders and an exercise log.

During the consultation, the prehabilitation coordinator will guide the patient and their caregivers on using the app to watch and follow their customised exercises, according to the rehabilitation physician’s prescription.

Follow-up and support – from hospital to home

Our prehabilitation team continues to care for and support the patient throughout the entire continuum of recovery, from hospital to home. The prehabilitation coordinator follows up with phone calls and a preoperative follow-up clinic visit.

The patient is reviewed inpatient after the surgery and three months post-surgery. The eventual aim is to transit them to community-based resources such as Active SG or Active Health Lab to sustain the healthy lifestyle changes initiated prior to cancer treatment.

THE CGH COLORECTAL CANCER PREHABILITATION PILOT STUDY

In a pilot study of some 60 colorectal cancer patients conducted from January 2020 to June 2021, the patients who have undergone prehabilitation showed statistically significant improvements in several domains. These include functional capacity as measured by the 6-minute walk test, mental health as measured by the Hospital Anxiety and Depression Scale and EQ-5D questionnaires.

Compared to historical data, this group of patients went home 1.5 days earlier and the 30-day readmission and mortality rates were reduced.

The prehabilitation programme has been expanded to include prostate, bladder, liver, biliary, pancreatic, oesophagus and gastric cancer patients planned for surgery at CGH.

Our Care Team

Clin Asst Prof Tay San San
Chief & Senior Consultant, Dept of Rehabilitation Medicine

Clin Asst Prof Kwok Kah Meng
Consultant, Dept of Rehabilitation Medicine

Dr Li Yiding
Associate Consultant, Dept of Rehabilitation Medicine

Dr Insali Soe
Resident Physician, Dept of Rehabilitation Medicine

Mr Christopher De Conceicao Paul
Prehabilitation Coordinator, Dept of Rehabilitation Medicine

Ms Lina Jia
Nurse Clinician, Dept of Rehabilitation Medicine

REFERENCES

1. Perry R, Herbert G, Atkinson C, England C, Northstone K, Baos S, Brush T, Chong A, Ness A, Harris J, Haase A, Shah S, Pufulete M. Pre-admission interventions (prehabilitation)to improve outcome after major elective surgery: a systematic review and meta-analysis. BMJ Open. 2021 Sep 30;11(9):e050806.

2. Singapore Cancer Registry Annual Report 2019

3. San San, Tay & Kah Meng, Kwok. (2021). Setting Up A Cancer Prehabilitation Framework in Singapore. 10.48252/JCR5.