The implementation of a standardized multimodal prehabilitation program prior to elective colorectal cancer surgery may be associated with a shorter postoperative hospital stay and greater patient participation.
In a study, researchers included 401 patients who underwent elective surgical resection for primary colorectal cancer (CRC) between January 2022 and April 2024. They compared outcomes from a nonstandardized prehabilitation approach with those from a standardized multimodal prehabilitation program. Overall, 198 of the patients underwent prehabilitation. The researchers evaluated participation, referral patterns, physiotherapy outcomes, postoperative complications, hospital length of stay, and 90-day mortality.
Participation in prehabilitation increased from 40% during the nonstandardized period to 59% following the implementation of the standardized program. Documentation of the rationale behind the decisions not to refer patients for prehabilitation also improved, increasing from 44% to 67%. Common reasons for not pursuing prehabilitation included when the surgery was scheduled within 3 weeks of diagnosis, patients were already achieving adequate levels of physical activity, a bowel obstruction was present, patient refusal was a factor, or patients were unable to participate because of cognitive or physical limitations.
Among the patients who participated in physiotherapy, measures of physical fitness improved during the prehabilitation period. The median maximal work capacity on the steep ramp test increased from 160 W to 213 W, while median one-repetition maximum leg press strength increased from 100 kg to 135 kg. More than 50% of the patients completed at least nine supervised physiotherapy sessions, the target established by the program.
The researchers found that the median postoperative hospital stay decreased from 4 days during the nonstandardized period to 3 days following implementation of the standardized program. However, the rates of postoperative complications and 90-day mortality were similar between the two periods, with complications occurring in about one-quarter of the patients in both groups and 90-day mortality remaining low.
When the outcomes were analyzed according to the receipt of prehabilitation, patients who followed the program had less favorable baseline characteristics compared with those who did not. The participants in this group were older, more likely to smoke, had lower preoperative hemoglobin levels, and had higher American Society of Anesthesiologists classifications. Despite these differences, the complication and 90-day mortality rates were similar between those who did and did not undergo prehabilitation.
In a subgroup analysis, the patients who were not referred for prehabilitation because they were considered physically fit experienced fewer postoperative complications compared with those who underwent prehabilitation and those who were not referred for other reasons. These patients were generally younger, had lower American Society of Anesthesiologists classifications, were less likely to smoke, and had higher hemoglobin levels.
The researchers noted several limitations. The study was retrospective and conducted at a single center, and referral decisions were based on surgeon judgment rather than standardized objective criteria. They acknowledged that this approach may have introduced selection bias and that documentation of referral decisions may have been incomplete. They also noted that the findings may not be generalizable to other settings.
In their conclusion, Elize W. Lockhorst, of Amphia Hospital Breda and Erasmus MC University Cancer Institute in the Netherlands, and colleagues wrote that standardized prehabilitation "[Standardized prehabilitation] appears beneficial and safe, improving participation, referral justification and outcomes, particularly in high-risk [patients with CRC]," wrote lead study author Elize W. Lockhorst, of the Department of Surgery at the Amphia Hospital Breda in the Netherlands, and colleagues.
The researchers emphasized that prospective studies are needed to confirm the findings and further define the role of standardized prehabilitation in routine clinical practice.
The study authors reported no conflicts of interest and no study-specific funding.
Source: Journal of Surgical Oncology