prehabilitation to improve

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Introduction 3

Part 1: Principles and benefits 4

Part 2: Putting it into practice 8

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Clinical CollectionPrehabilitation to improve lung cancer outcomes

A Nursing Times supplement

Editor: Ann Dix, clinical editor

Managing editor: Eileen Shepherd, senior clinical editor

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3Nursing Times | Clinical Collection | Prehabilitation

Prehabilitation gives patients newly diagnosed with cancer a chance to improve their fitness levels before embarking on treatment. This includes patients in my own speciality of lung cancer. In the UK, prehabilitation programmes of targeted and

personalised exercise have been available to patients pre-surgery for a number of years and many regions have advocated this type of programme to optimise health, and even improve cancer outcomes, through enhancing recovery and fitness.

Prehabilitation first came to my attention when I heard colleagues present on their experiences of running prehabilitation programmes and the effect on patient outcomes at the British Thoracic Oncology Group conference in 2019 and at the National Lung Cancer Forum for Nurses (now Lung Cancer Nursing UK). Nurses were promoting the benefits of tailored exercise programmes pre-surgery and advocating that this process should be adopted across the UK. Now, in many areas of the UK, prehabilitation programmes are well established as the optimal pathway prior to cancer surgery and are included as part of the surgical National Optimal Lung Cancer Pathway endorsed by the UK Lung Cancer Coalition.

In Greater Manchester, a multimodal prehabilitation programme, Prehab4Cancer, run by Greater Manchester Cancer is well established and has continued its success as a virtual online programme during the coronavirus pandemic. The programme consists of a personalised care package, combining exercise, nutritional advice and psychological wellbeing for newly diagnosed cancer patients to enhance and support their individual experience before, during and after treatment. Currently the programme can be accessed by all lung cancer patients with stage 1, 2 or 3 tumours undergoing workup for surgery, chemotherapy and radiotherapy. The programme identifies that optimising an individual’s physical and mental health prior to treatment can help speed up recovery times and provide benefits, such as increasing people’s quality of life, with just a few improvements to fitness levels and attitudes to exercise.

Moving forward, it is vital to explore providing cancer prehabilitation services at scale and ensuring equitable access for all our patients. We also need to collect good quality data on the effectiveness of prehabilitation in an oncology treatment setting. The benefits for patients established so far are well documented and it would be prudent to offer prehabilitation to all patients with lung cancer regardless of their stage of disease, particularly as, sadly, most lung cancer is still diagnosed at a late stage (stage 4). Work is already in progress exploring the widening of lung cancer prehabilitation programmes to give patients with advanced cancer an opportunity to participate. At the same time, it is important to continue to gather the evidence of the benefits of prehabilitation to people with lung cancer. The UK government has highlighted how important improving health and fitness is for the wellbeing of the nation and a willingness to fund prehabilitation programmes across the UK is surely one way to improve not only cancer outcomes, but the wellbeing of our patient population.

Jackie Fenemore is lung cancer nurse clinician at The Christie NHS Foundation Trust and chair of Lung Cancer Nursing UK

Prehabilitation in lung cancer

IntroductionPrehabilitation to improve lung cancer outcomes

With the aim of improving treatment effectiveness, cancer survival and quality of life, “‘prehabilitation’

prepares people for cancer treatment by optimising their physical and mental health through needs-based prescribing of exercise, nutrition and psychological inter-ventions” (Giles and Cummins, 2019). Pre-habilitation is suitable for anyone embarking on cancer treatment and is a process tailored to an individual (Bloom, 2017). However, although the principles of it are well established before surgery, there is an unmet need relating to inoperable cancers: prehabilitation could be intro-duced to systemic treatment pathways.

According to Cancer Research UK (CRUK), the UK sees more deaths from lung cancer than any other cancer, with over 35,000 people dying from the disease every year. Lung cancer is linked to depri-vation and 44% of new cases are in people aged 75 years and over. Around three-quar-ters of cases are diagnosed at a late stage, with less than half (41%) of people

diagnosed surviving for one year or more, and only around 10% surviving 10 years or more, despite advances in treatment (Bit.ly/CRUKLungCancer).

Earlier diagnosis is vital to improve lung cancer survival rates (United Kingdom Lung Cancer Coalition (UKLCC), 2020). Prehabilitation, by enabling people to optimise their health before treatment, could also be used to improve health out-comes and quality of life. As with other cancers, in lung cancer prehabilitation is well established in the lung cancer surgical pathway; however, it is less widely seen as the standard of care in inoperable disease pathways, such as those for late-stage cancer (stages 3 and 4).

The benefits of prehabilitation Evidence is growing that patients with cancer who follow a prehabilitation pro-gramme may: ● Have improved survival;● Cope better with challenging treatment

regimens;● Have fewer complications from surgery

Keywords Cancer/Prehabilitation/ Lung cancer This article has been double-blind peer reviewed

Key points Cancer prehabilitation enables people to optimise their health before treatment to improve outcomes and quality of life

A prehabilitation programme involves an individualised plan comprising psychological support, exercise and nutritional advice

Prehabilitation has mostly been used before surgery but is suitable for patients at all stages of the cancer pathway

People with inoperable but treatable lung cancer, including those whose cancer is at a late stage, could benefit from prehabilitation

Smoking cessation may also form part of a multidisciplinary approach to prehabilitation for patients who have lung cancer

Prehabilitation to improve lung cancer outcomes 1: principles and benefits

Authors Jackie Fenemore is lung cancer nurse clinician, The Christie NHS Foundation Trust; Josie Roberts is Macmillan lung cancer nurse specialist, The Rotherham NHS Foundation Trust.

Abstract Prehabilitation prepares patients with cancer for treatment through physical and mental health training to improve health outcomes and quality of life. Although the principles of prehabilitation are well established for operable cancers, there is an unmet need for inoperable cancers, for which prehabilitation could be introduced to systemic treatment pathways. This series of two articles explores introducing prehabilitation for inoperable cancers, using the example of advanced lung cancer. In this first article, we outline the principles and benefits of cancer prehabilitation before treatment for lung cancer.

Citation Fenemore J, Roberts J (2021) Prehabilitation to improve lung cancer outcomes 1: principles and benefits. Nursing Times; 117: 10, 30-33.

In this article...● Reviewing the evidence for cancer prehabilitation● What a prehabilitation programme should include● Role of the clinical nurse specialist in supporting patients with lung cancer

Clinical PracticeDiscussionCancer

4 Nursing Times | Clinical Collection | Prehabilitation

Citation for this article: Fenemore J, Roberts J (2021) Prehabilitation to improve lung cancer outcomes 1: principles and benefits. Nursing Times; 117: 10, 30-33.

including motivation and skills, as well as social, educational, cultural and economic needs. Shared decision making is key, with prehabilitation delivered in partnership with the patient (Bloom, 2017). The case study in Box 2 shows how prehabilitation for patients with advanced metastatic lung disease can enable them to access the treat-ment they need, and outlines the role of the CNS and multidisplinary team.

Prehabilitation interventionsPrehabilitation programmes may include one or more of the following components: ● Exercise; ● Smoking cessation;● Dietary intervention; ● Psychological assessment and

intervention; ● Medical optimisation (Shukla et al, 2020).

Some of these interventions are dis-cussed below for patients with lung cancer, although the optimal combination for this patient group has yet to be established (Shukla et al, 2020).

ExerciseA review by Crevenna (2021) suggested that regular physical activity, such as prescribed exercise, is beneficial for people living with cancer. It found exercise increased func-tional health, which improved physical performance, mental health and quality of life, and increased survival rates in some types of cancer. The researchers concluded that most patients with cancer, whatever their comorbidities, medications or burden of disease, could benefit from tai-lored exercise programmes.

Cancer prehabilitation aims to prevent complications of cancer treatment by

This requires the involvement of a multi-disciplinary team – including dietitians, physiotherapists, psychologists, occupa-tional therapists, fitness instructors, nurse specialists and healthcare assistants – working within a recognised framework of support (Macmillan Cancer Support, 2020). There is growing evidence that: ● A multimodal multidisciplinary

approach may be more effective for someone living with cancer than addressing just one aspect of health (such as exercise);

● Supporting psychological, as well as physical, health can help speed up recovery and improve long-term health by engendering both short- and long- term behavioural change (Molenaar et al, 2019; Silver and Baima, 2013). One such model provided in Greater

Manchester is the Prehab4Cancer pro-gramme (prehab4cancer.co.uk ) (Box 1).

Role of the clinical nurse specialist The clinical nurse specialist (CNS) is often the first point of contact in the cancer care pathway and is, therefore, pivotal in: ● Promoting and signposting a patient

towards prehabilitation services;● Liaising with the multidisciplinary team.

A diagnosis of cancer is often considered a ‘teachable moment’, when patients may be receptive to making positive lifestyle changes, such as stopping smoking and taking more exercise. The CNS is ideally placed to have these discussions and begin the process of change with a patient before treatment (Macmillan Cancer Support, 2020).

Achieving lasting and meaningful behavioural change requires the full assessment of an individual’s needs,

or radical treatment (Crevenna, 2021; Healthy London Partnership, 2020). The efficacy and benefits of prehabilita-

tion have been studied in several cancer survivor populations (Crevenna, 2021; Bloom, 2017): in patients with breast cancer, prehabilitation can improve chemotherapy dose tolerance, resulting in greater chemo-therapy completion, as well as increasing the shoulder mobility needed for chemo-therapy application and improving toler-ance to radiotherapy (Crevenna, 2021). Tré-panier et al (2019) found that patients who followed a prehabilitation programme before colorectal cancer surgery: ● Had reduced complications relating to

treatment;● Had improved five-year survival rates;● Were more psychologically prepared

for intense treatment regimens.Few studies have explored prehabilita-

tion for patients with advanced lung cancer, but a Cochrane review of the evidence sur-rounding exercise training for this popula-tion concluded that there may be some ben-efits to quality of life, even though evidence to date has not shown effectiveness overall (Peddle-McIntyre et al, 2019).

The ‘four pillars’ of prehabilitationPrehabilitation is “a process on the con-tinuum of care that occurs between the time of cancer diagnosis and the begin-ning of acute treatment, includes physical and psychological assessments that estab-lish a baseline functional level, identifies impairments and provides targeted inter-ventions that improve a patient’s health to reduce the incidence and severity of cur-rent and future impairments” (Silver and Baima, 2013). Macmillan Cancer Support recommends that prehabilitation is tai-lored to the individual and empowers people to take an active role in their own recovery and wellbeing; it suggests that initial assessment is needed to identify potential risk factors and provide a base-line against which to measure patients’ progress to ensure the best possible out-comes and build on the limited evidence base (Bloom, 2017).

When designing a suitable programme, a multimodal approach should be consid-ered, based around the ‘four pillars’ of pre-habilitation:● High-intensity endurance and strength

training;● High-protein nutrition and

supplements;● Smoking cessation; ● Psychological support (Van Rooijen et

al, 2019).

This article was fully funded by MSD, who had editorial input

Box 1. Prehab4Cancer programme The Prehab4Cancer scheme in Greater Manchester gives access to prehabilitation before curative treatment – including surgery, chemotherapy or radiotherapy – for patients with a cancer diagnosis. The programme recognises and supports the secondary symptoms of cancer, including anxiety, low mood and fatigue, and uses this knowledge to build on widely understood principles relating to positive benefits from exercise in the reduction of such secondary symptoms. The positive mindset that is engendered helps to enhance recovery times and allows people to resume independence and pre-treatment activities, such as activities of daily living, self-care and a return to work.

Early evaluation has demonstrated the programme’s “feasibility and excellent uptake, and improved patient experience”, while validated fitness and quality-of-life measures “show promising trends towards improvement for surgical lung cancer patients” (Bradley et al, 2021).

“Improving lung cancer survival rates is vital and prehabilitation, by enabling people to optimise their health before treatment, could potentially improve health outcomes and quality of life”


Clinical PracticeDiscussion


Approximately 22% of lung-cancer deaths are associated with cachexia, so nutri-tional support in patients with lung cancer is essential (Zhu et al, 2019).

The CNS should discuss nutrition with the patient at the earliest opportunity; referral to a dietitian at the time of diag-nosis is encouraged and often required. No one diet is suitable for everyone, as each patient’s nutritional needs, treatment plan and activity levels are different; the goals of nutrition need to be discussed at each step of the journey. Dietary plans also need to consider cultural differences and indi-vidual habits and preferences.

Generally, patients should be advised to eat little and often, opting for foods that are rich in proteins and vitamins. Pro-moting the consumption of soft, easily digestible foods, such as eggs, yoghurt and cheese, can help maintain adequate calorie intake. For patients experiencing weight loss or anorexia (a common feature of cachexia), drinking nutritional supple-ments that are high in protein or adding healthy fats can boost calories.

Encouraging patients and their carers to try novel foods and improve the visual appearance of a meal on their plate can make meals more appetising (Neskey, 2020). A useful resource is Life Kitchen (lifekitchen.co.uk), which provides free cookery classes for people living with taste and smell loss. Use of physical activity can also help stimulate the appetite and increase nutritional intake (Macmillan Cancer Support, 2020).

Smoking cessationSmoking cessation is essential in the man-agement of lung cancer, but many patients are unaware of the harms caused by

of treatment-related side-effects (Neskey, 2020; Ravasco, 2019). Patients with lung cancer are prone to unintended weight loss and can find it difficult to eat and drink due to the tumour and impact of cancer treatment. Malnutrition is common and is associated with reduced treatment com-pletion, survival, physical function and quality of life (Kiss, 2016).

Cancer cachexia is a wasting syndrome, often present at lung cancer diagnosis; it affects up to 80% of patients with non-small cell lung cancer (the most common form of lung cancer) and is associated with lower response rates to treatment com-pared with non-cachectic patients (Agelaki et al, 2019). People with cachexia lose weight even when eating normally and cachexia cannot be fully reversed by con-ventional nutritional support (Fearon et al, 2011). Cachexia also makes it difficult to treat with anti-cancer therapies that can cause toxicities such as nausea, dysgeusia (changes in taste) or mucositis (sore and inflamed mouth or gut) (Neskey, 2020).

applying exercise alone or as one part of a multimodal strategy. A growing body of evidence supports the effects of exercise in cancer prehabilitation, but this needs to be recommended on an individual basis (Cre-venna, 2021).

People living with lung cancer, particu-larly late-stage disease, are often vulner-able to extreme lethargy, weight loss or cachexia, shortness of breath, pain and low mood. Therefore, exercise needs to be part of a holistic framework to ensure that the bespoke programme meets individual needs. In the right environment, such a programme of exercise may be helpful and motivating for the patient (Shukla et al, 2020). People with metastatic disease or stage 4 cancer should always be offered the support of a qualified physiotherapist to guide them with physical activity.

NutritionA well-balanced diet before, during and after cancer treatment can improve strength, recovery time and reduce the risk

Box 2: Case studyMrs Green*, aged 65 years, presents to accident and emergency with sudden-onset twitching of the left-hand side of her face and dysphagia. Investigations confirm metastatic adenocarcinoma, the most common type of non-small cell lung cancer. Before admission, Mrs Green had a good performance status but is now limited to sitting down for most of the day. She has a medical history of chronic obstructive pulmonary disease and myocardial infarction. She had smoked 25-30 cigarettes a day from the age of 14, but stopped smoking in 2012. She shares a house with her husband and has good family support.

Mrs Green is aware that she has metastatic, incurable lung cancer, but is keen to have treatment to extend and improve her quality of life. Initially, she was offered palliative radiotherapy to try and achieve some control of her brain metastases and prescribed a reducing dose of steroids. Following radiotherapy, she does not improve clinically and remains in bed most of the day.

Mrs Green is reviewed by the lung clinical nurse specialist (CNS) and told she needs to improve physically to be well enough for chemotherapy. The lung CNS refers her to a dietitian, occupational therapist and physiotherapist. Mrs Green reports she has low mood and has lost confidence in walking and climbing stairs. She is given information about a high-calorie diet and supplement drinks to improve her energy, along with support from physiotherapy to improve her posture and mobility, and a walking frame and perching stool from occupational therapy. Telephone support/further support from the community palliative care team is discussed, but Mrs Green feels well supported by her family.

At her clinic review with the lung CNS two weeks later, Mrs Green is feeling much better, her speech and appetite has improved, and she is eating better. She is still struggling with her mobility but has been using her walking aids at home and her confidence is improving. She is upset she is still not fit enough to start chemotherapy, but reassurance is given about her progress and two weeks later she walks into clinic unaided. She is managing much better at home, has gained 2kg in weight and is offered chemotherapy.

Mrs Green completes two cycles of chemotherapy. She has one episode of nausea and vomiting, as well as mild mucositis, but continues to eat, drink and follow her exercise regime, which helps her fatigue.*The patient’s name has been changed.

Points for reflectionThink about a patient you have nursed with cancer and undergoing treatment, and use the following points to reflect on the benefits of prehabilitation:● How would you explain the benefits of prehabilitation to your patient?● What concerns do you think they might express and how would you respond?● What questions would you ask about smoking and smoking cessation? ● Who would you refer your patient to for help and advice?● How could you involve the patient’s family in supporting the principles of prehabilitation in daily life?


Daniel M et al (2009) Persistent smoking after a diagnosis of lung cancer is associated with higher reported pain levels. Journal of Pain; 10: 3, 323-328.Fearon K et al (2011) Definition and classification of cancer cachexia: an international concensus. Lancet Oncology; 12: 5, 489-495.Giles C, Cummins S (2019) Prehabilitation before cancer treatment. BMJ; 366: l5120.Healthy London Partnership (2020) Covid-19: Cancer Prehabilitation Toolkit. Healthy London Partnership. Herschbach P et al (2008) Psychological distress in cancer patients assessed with an expert rating scale. British Journal of Cancer; 99: 1, 37–43. Jassem J (2019) Tobacco smoking after diagnosis of cancer: clinical aspects. Translational Lung Cancer Research; 8: Suppl 1, S50-S58.Kiss N (2016) Nutrition support and dietary interventions for patients with lung cancer: current insights. Lung Cancer (Auckl); 7: 1-9.Macmillan Cancer Support (2020) Principles and Guidance for Prehabilitation within the Management and Support of People with Cancer. Macmillan Cancer Support.Molenaar CJL et al (2019) Prehabilitation, making patients fit for surgery: a new frontier in perioperative care. Innovative Surgical Sciences; 4: 4, 132-138.National Institute for Health and Care Excellence (2019) Lung Cancer: Diagnosis and Management. NICE. Neskey M (2020) Nutrition and lung cancer. Journal of Oncology Navigation and Survivorship; 11: 3. Parsons A et al (2010) Influence of smoking cessation after diagnosis of early stage lung cancer on prognosis; systemic review of observational studies with meta-analysis. BMJ; 340: b5569.Peddle-McIntyre CJ et al (2019) Exercise training for advanced lung cancer. Cochrane Database of Systematic Reviews; 2: 2, CD012685.Ravasco P (2019) Nutrition in cancer patients. Journal of Clinical Medicine; 8: 8, 1211.Shukla A et al (2020) Attitudes and perceptions to prehabilitation in lung cancer. Integrative Cancer Therapies; 19: 1534735420924466. Silver JK, Baima J (2013) Cancer prehabilitation; an opportunity to decrease treatment-related morbidity, increase cancer treatment options, and improve physical and psychological health outcomes. American Journal of Physical Medicine and Rehabilitation; 92: 8, 715-727. Trépanier M et al (2019) Improved disease-free survival after prehabilitation for colorectal cancer surgery. Annals of Surgery; 270: 3, 493-501. United Kingdom Lung Cancer Coalition (2020) Early Diagnosis Matters: Making the Case for the Early and Rapid Diagnosis of Lung Cancer. UKLCC. Van Rooijen SJ et al (2019) Making patients fit for surgery: introducing a four pillar multimodal prehabilitation program in colorectal cancer. American Journal of Physical Medicine and Rehabilitation; 98: 10, 888-896.Warren GW et al (2013) Smoking at diagnosis and survival in cancer patients. International Journal of Cancer; 132: 2, 401-410. Zhu R et al (2019) Updates on the pathogenesis of advanced lung cancer-induced cachexia. Thoracic Cancer; 10: 1, 8-16.

patients never having smoked. This can contribute to a sense of fatalism (UKLCC, 2020) and reduce people’s engagement in prehabilitation programmes.

The CNS is pivotal in providing encour-agement and support to patients and carers, as part of a personalised approach to prehabilitation. This includes: ● Inspiring people that treatment options

are available;● Showing them how they can improve

their fitness for treatment and optimise their health and wellbeing;

● Explaining the help that will be offered to them at each stage. National Institute for Health and Care

Excellence (2019) guidelines recognise the importance of the CNS having level 2 psy-chological training to support patients and carers with their psychological dis-tress and help understand when further psychological support is needed.

ConclusionThere is increasing evidence to support prehabilitation for all patients with cancer, not just those eligible for surgery. A multi-modal approach that includes both phys-ical and psychological interventions may be most effective in this respect. Prehabili-tation can support patients with lung cancer, including those with advanced cancer, to take an active role in optimising their health and wellbeing to improve their response to treatment and give better out-comes. The second article in this series will look at how prehabilitation for late-stage lung cancer could be introduced as part of integrated lung cancer services. NT

References Agelaki S et al (2019) Cancer cachexia, sarcopenia and hand-GRIP strength (HGS) in the prediction of outcome in patients with metastatic non-small cell lung cancer (NSCLC) treated with immune checkpoint inhibitors (ICIs): a prospective, observational study. Journal of Clinical Oncology; 37: 15 suppl, 9099-9099.Bloom E (2017) Prehabilitation Evidence and Insight Review. Macmillan Cancer Support. Bradley P et al (2021) Abstract P212 Prehab4Cancer: an innovative regional lung cancer prehabilitation service. Thorax; 76: A204-A205.Cataldo JK et al (2010) Smoking cessation: an integral part of lung cancer treatment. Oncology; 78: 5-6, 289-301.Crevenna R et al (2021) Cancer prehabilitation: a short review. Magazine of European Medical Oncology; 14, 39-43.

continued smoking after a cancer diag-nosis and health professionals often do not encourage patients to quit or offer smoking cessation (Jassem, 2019).

Actively smoking tobacco contributes to 71% of cases of lung cancer (Bit.ly/ CRUKlungcancerrisk), accounting for nearly 90% of lung cancer deaths (Jassem, 2019). Around 40-50% of patients with lung cancer in one study reported smoking at the time of diagnosis, with around half quitting post diagnosis (Daniel et al, 2009).Continuing to smoke after a lung cancer diagnosis can increase side-effects and reduce the effectiveness of treatment, and increase the likelihood of secondary can-cers or recurrence of cancer at the primary site (Jassem, 2019; Warren et al, 2013). Par-sons et al (2010) found that continuing to smoke after a diagnosis of early-stage lung cancer nearly doubled the risk of dying.

Positive effects of smoking cessation for patients with lung cancer include reduced risk of disease, improved survival time, reduced post-operative complica-tions, increased efficacy of chemotherapy, fewer radiation therapy complications and improved quality of life (Cataldo et al, 2010). Immediate benefits of smoking ces-sation, such as decreased fatigue and shortness of breath, as well as increased activity level and mood, are particularly important for people with lung cancer because of their high symptom burden.

Smoking-cessation methods include psychosocial and pharmacological inter-ventions. Psychological or social support mechanisms can include counselling, self-help material, and individual or group behavioural support. Pharmacological interventions include all forms of nicotine replacement therapy. A combination of strategies is encouraged.

Health professionals caring for patients with lung cancer should familarise them-selves with clinical practice guidelines for tobacco cessation and dependence, and have well-organised, sustainable ways to put them into practice.

Psychological supportPsychological issues include limitations in everyday activities, anxieties and worries, dysthymia (chronic depression) and moti-vation problems (Herschbach et al, 2008). These can be particularly pronounced in patients with lung cancer because of late presentation and poor prognosis, a high symptom burden, and stigma caused by a perception that lung cancer is ‘untreatable’ and exclusively a ‘smokers’ disease’ (UKLCC, 2020); this is despite 10-15% of

Prehabilitation to improve lung cancer outcomes

Part 1: Principles and benefits OctPart 2: Putting it into practice Nov

CLINICAL SERIES

>35,000Number of deaths from lung cancer in the UK each year

QUICK FACT




Undertaking prehabilitation before cancer treatment can help patients to improve their health and fitness, with the aim of opti-

mising treatment outcomes and improving their quality of life. In lung cancer, as in other cancers, the principles of prehabilitation are fairly well estab-lished for patients who are eligible for sur-gery. However, there is an unmet need for inoperable cancers, particularly late-stage cancer (stage-3 and stage-4 disease), in which prehabilitation could improve patients’ performance status, quality of life and their access to systemic anti-cancer treatment.

In the first of this series of two articles, we outlined the principles and benefits of cancer prehabilitation and, using the example of lung cancer, highlighted the case for introducing it for non-operable cancers. In this second article, we discuss how prehabilitation for late-stage lung cancer could be introduced into systemic treatment pathways and holistic needs assessments as part of an integrated lung cancer service.

Prehabilitation for patients with lung cancerEpidemiological studies suggest comor-bidities and poor health are correlates of poorer survival in patients with cancer (Faithfull et al, 2019). In people with lung cancer, frequent and severe physical symp-toms such as pain, fatigue and breathless-ness, along with psychological distress, have also been associated with impaired quality of life (Mosher et al, 2015).

As described in part 1 of this series – Fenemore and Roberts (2021) – prehabilita-tion offers a route to improving a patient’s physical status and wellbeing between the time of cancer diagnosis, and treatment and post-treatment recovery. The primary goal of prehabilitation is to prevent or reduce the severity of anticipated treat-ment-related impairments that may cause significant disability (Faithfull et al, 2019). It is associated with optimising a patient’s condition and should include lifestyle interventions that promote physical and psychosocial health to prepare for treat-ment and future impairments (Macmillan Cancer Support, 2020). Prehabilitation

Keywords Cancer/Prehabilitation/ Lung cancer This article has been double-blind peer reviewed

Key points Epidemiological studies suggest comorbidities and poor health are correlates of poorer survival in patients with cancer

A structured prehabilitation programme can help patients manage their symptoms and improve their fitness for treatment

Introducing prehabilitation for late-stage lung cancer before systemic treatment could increase access to treatment, as well as improving patients’ health outcomes and quality of life

Prehabilitation should be tailored to the individual and empower patients to take an active role in improving their own wellbeing

Prehabilitation to improve lung cancer outcomes 2: putting it into practice

Authors Josie Roberts is Macmillan lung cancer nurse specialist, Rotherham NHS Foundation Trust; Paula Shepherd is lung cancer clinical nurse specialist, Liverpool University Hospitals NHS Foundation Trust.

Abstract Prehabilitation helps patients who have cancer to prepare for treatment through physical and mental health training to improve health outcomes and quality of life. In the first part of this two-part series, we looked at the principles and benefits of individualised prehabilitation before cancer treatment and the case for establishing this for non-operable cancers, using the example of advanced lung cancer. In this article, we discuss how prehabilitation for late-stage lung cancer could be integrated into lung cancer services.

Citation Roberts J, Shepherd P (2021) Prehabilitation to improve lung cancer outcomes 2: putting it into practice. Nursing Times; 117: 11, 25-28.

In this article...● Exploring prehabilitation for patients with inoperable lung cancer● Patient engagement considerations● What to take into account when planning and delivering a prehabilitation service

Clinical PracticeDiscussionCancer


Citation for this article: Roberts J, Shepherd P (2021) Prehabilitation to improve lung cancer outcomes 2: putting it into practice. Nursing Times; 117: 11, 25-28.

by the stigma surrounding lung cancer, as well as associated comorbidities such as COPD, which is itself associated with high rates of anxiety and depression (Gore et al, 2000). Levels of anxiety and depression also depend on patients’ coping ability; despite extensive studies on coping with cancer, few focus on patients with lung cancer (Mosher et al, 2015).

Organisational barriersOrganisational barriers to setting up preha-bilitation programmes include the lack of a robust evidence base, particularly around outcomes, effectiveness and cost effective-ness (Bloom, 2017), funding constraints, cli-nician knowledge and acceptability (Granger et al, 2017; Granger et al, 2016).

Evidencing the benefits of prehabilita-tion is also important in enabling patients to understand why they are having preha-bilitation and how it can improve their treatment and quality of life.

Offering prehabilitationThe National Optimal Lung Cancer Pathway was designed to provide a fast, efficient and patient-centred pathway to improve poor survival rates for lung cancer; it emphasises the key role of the lung CNS “in communication, coordina-tion and as a point of contact throughout the patient journey” (NHS England, 2020). This includes assessing and supporting the patient throughout the pathway, ensuring holistic care is provided, and supporting patients and carers with dis-tressing and complex physical, psycholog-ical, social, spiritual and financial needs. Providing access to prehabilitation is a part of this.

Health providers should ensure preha-bilitation is a standard process in the con-tinuum of care that forms an intrinsic part of the patient pathway and is available for anyone undergoing cancer care. This includes patients undergoing chemo-therapy with curative and palliative intent, radiotherapy and surgical interventions. Care needs to be tailored to individual needs and patients must have specialist support to manage their condition. This can empower them to take an active role in improving their overall wellbeing, leading to better outcomes (Macmillan Cancer Support, 2020).

There is no clearly defined model of pre-habilitation, but Bloom (2017) suggests it comprises three different stages:● Pre-assessment – used to measure the

patient’s baseline, identify risk factors, inform patients about their treatment,

COPD may have already accessed pulmo-nary prehabilitation programmes and whether their experience was positive or negative may affect their attitude to preha-bilitation. Their COPD may also mean they are physically deconditioned and less resil-ient emotionally; the lung clinical nurse specialist (CNS) has a role in supporting patients to understand the importance of managing and improving their symptoms before undergoing cancer treatment.

The diagnostic pathway in lung cancer is also complex, involving multiple inves-tigations often at different hospital sites. This places an extra burden on patients in terms of travel time and costs, and may present a further disincentive for them to attend a prehabilitation programme if this cannot be provided locally.

StigmaPatients with lung cancer, more than those with other cancers, may feel stigmatised by their disease; this can increase their subjec-tive distress and may negatively influence help-seeking behaviours and overall patient outcomes. In lung cancer, health-related stigma often results from the: ● Association with smoking;● Perception that the disease is ‘self-

inflicted’, has high mortality, and people’s preconceptions of the type of death that may be experienced (Chambers et al, 2015). Prehabilitation at diagnosis and

throughout treatment could: ● Help patients manage the distress and

stigma associated with the disease;● Support individual coping strategies;● Improve quality of life (Jabbarian et al,

2019).

Anxiety and depressionThe increased burden of physical symp-toms experienced by patients with advanced lung cancer increases their likeli-hood of mental ill health, which could make it harder for them to engage with, and adhere to, a prehabilitation pro-gramme. As an example, patients with lung cancer experience high rates of dysp-noea (breathlessness), which is associated with an increased prevalence of anxiety and depression (Dudgeon et al 2001; Smith et al, 2001). Problems can be further exacerbated

should be patient centred and tailored to the individual, building resilience and empowering people to change their behav-iours.

There is a growing requirement to include prehabilitation as part of the cancer pathway (Macmillan Cancer Support, 2020). However, evidence that prehabilita-tion translates into better long-term patient outcomes beyond the initial 30 days’ post-treatment complications is lacking, requiring further patient-focused research.

Prehabilitation programmes may include one or more of the following: ● Exercise;● Smoking cessation;● Dietary interventions;● Psychological assessment and

intervention;● Medical optimisation (Fenemore and

Roberts, 2021). Currently, prehabilitation programmes

for lung cancer are mainly targeted at patients awaiting lung resection, with the primary goal being to increase functional exercise capacity. Systematic reviews dem-onstrate that prehabilitation across several cancer sites, including lung cancer, may be associated with improved functional exer-cise capacity and patient-reported out-comes (Shukla et al, 2020). Given this, pre-habilitation could potentially benefit those with inoperable cancer before sys-temic anticancer treatment, including patients with advanced-stage cancer.

We discuss below how prehabilitation for late-stage lung cancer could be intro-duced as part of an integrated lung cancer service, along with some factors that should be considered.

Patient engagement considerationsHigh symptom burdenPatients with end-stage lung cancer have a high symptom burden, often complicated by coexisting health conditions such as chronic obstructive pulmonary disease (COPD) (Peddle-McIntyre, 2019). The effect of living with long-term respiratory symp-toms, which can adversely affect exercise tolerance and the ability to live indepen-dently, may reduce engagement with pre-habilitation programmes. Late diagnosis is more likely to result in a patient being deconditioned and the window of oppor-tunity for prehabilitation may be small if treatment is needed urgently.

COPD is common in patients with lung cancer due to the shared risk factor of ciga-rette smoking. Patients diagnosed with advanced lung cancer who have existing



“There is a strong argument for prescribing prehabilitation and considering it as a treatment”



NHS clinical practice (Moore et al, 2021). Notably, few centres offer it for inoperable lung cancer, particularly that which is late stage (Peddle-McIntyre et al, 2019; Driessen et al, 2017). More research is needed on patient experience and quality of life to develop prehabilitation models for late-stage lung cancer.

Prehabilitation services for lung cancer vary, with many centres using established pulmonary prehabilitation services because of their knowledge of chronic res-piratory conditions, and due to funding constraints. However, the standard length of pulmonary prehabilitation programmes does not fit in the timescales and targets of the cancer pathway; as such, this is less suitable for patient with lung cancer (Peddle-McIntyre et al, 2019).

Ricketts et al (2020) attributed the vari-able content and length of prehabilitation programmes nationally to obstacles such as lack of funding and resources. One suc-cessful model is Prehab4Cancer (prehab-4cancer.co.uk), a large-scale, multimodal prehabilitation programme, developed and adopted as a standard of care by Greater Manchester Cancer (Fenemore and Rob-erts, 2021). There is a real opportunity for such standards to be adopted by other UK authorities, although further evaluation is needed to assess the programme’s transfer-ability nationally (Moore et al, 2021).

In Rotherham, re- and prehabilitation is provided for people with respiratory condi-tions, including lung cancer, in conjunc-tion with a well-established pulmonary rehabilitation service for people with COPD; the service is called BreathingSpace (Bit.ly/RotherhamBreathing). In addition, a prehabilitation programme at Nottingham University Hospitals NHS Trust is aimed at patients receiving systemic anti-cancer treatment (SACT) and provides a structured approach to developing a prehabilitation

England’s (2016) Achieving World Class Cancer Outcomes identifies key areas for prehabilitation; demonstrating the value of this to support business cases for lung cancer prehabilitation is vital.

Useful resources for preparing a busi-ness plan are given in Box 1, and some prac-tical tips are outlined in Box 2.

Models for developing a serviceCancer prehabilitation continues to be evaluated in multicentre trials (Moore et al, 2021; Rooijen et al, 2019). However, despite increasing evidence of the bene-fits, it has yet to become adopted as core

make joint decisions and establish what interventions are needed;

● Prehabilitation regime – this should be personalised to maximise improved post-treatment outcomes;

● Follow-up post treatment – used to determine progress made and ensure appropriate follow-up support is in place.Data is lacking on the ideal length or

setting for prehabilitation programmes, but the latter may depend on the area and facilities available. In rural areas, a person-alised home-based training programme could overcome problems around service availability and transportation, enhancing patient motivation and adherence, espe-cially for vulnerable and/or older patients (Bade et al, 2015).

Prehabilitation may follow an ‘opt-in’ or ‘opt-out’ system, but there is a strong argu-ment for prescribing prehabilitation and considering it as a treatment as this strengthens the message that it is an important part of the treatment regime and could lead to greater concordance (Bloom, 2017). However, as discussed, indi-vidually tailored interventions should be provided depending on the severity of the patient’s needs (Bloom, 2017).

Prehabilitation is best used with popu-lation-health data to tackle health inequali-ties; this includes designing tailored multi-dimensional and multimedia programmes (Healthy London Partnership, 2020).

Preparing a business caseThe lung CNS, cancer team and business managers should prepare a business case justifying the service need, funding and workload implications, focusing on the potential benefits for optimising patients’ treatment, improving health outcomes and quality of life, and reducing health and social care costs, among other factors (Healthy London Partnership, 2020). Evi-dence should be drawn from other can-cers, as well as lung cancer, and an out-come-based evaluation of the programme should be built in, including the identifi-cation of any research funding. NHS

Box 2. Top tips for preparing a business case for cancer prehabilitation● Evidence the benefits – Healthy London Partnership (2020) gives a useful summary of key findings ● Show patient need – conduct simple audits using patient screening tools● Consider the benefits in the timeframe before treatment – some patients can experience benefit in as little as two weeks (Macmillan Cancer Support, 2020)● Develop simple outcome measures for each element of prehabilitation – for example, improvements in weight and appetite, activity and performance status ● Use what you already have – is there capacity in existing services, staff who can coordinate/support prehabilitation, interventions clinical nurse specialists are doing already to help patients manage symptoms and improve their quality of life? ● Do your sums – consider resourcing, additional staffing needs and anticipated financial savings

Box 1. Business case support The following resources may be helpful in preparing a business case for a lung cancer prehabilitation service:● Covid 19: Cancer Prehabilitation Toolkit – Bit.ly/NHSCancerPrehab● Prehabilitation Evidence and Insight Review – Bit.ly/MCSPrehabReview● Prehabilitation for People with Cancer: Principles and Guidance for Prehabilitation within the Management and Support of People with Cancer – Bit.ly/MCSPrehabGuide● Cancer Prehabilitation: Building a Business Case – Bit.ly/businesscaselungprehab

Principles and guidance for prehabilitation within the management and support of people with cancer

In partnership with



caregivers. Supportive Care in Cancer; 23: 7, 2053-2060.NHS England (2020) National Optimal Lung Cancer Pathway: For suspected and Confirmed Lung Cancer: Referral to Treatment. NHSE. NHS England (2016) Achieving World Class Cancer Outcomes. NHSE. Peddle-McIntyre CJ et al (2019) Exercise training for advanced lung cancer. Cochrane Database of Systematic Reviews; 2: 2, CD012685. Ricketts WM et al (2020) Feasibility of setting up a pre-operative optimisation ‘pre-hab’ service for lung cancer surgery in the UK. Perioperative Medicine; 9: 14.Shukla A et al (2020) Attitudes and perceptions to prehabilitation in lung cancer. Integrative Cancer Therapies; 19: 1-6.Smith EL et al (2001) Dyspnea, anxiety, body consciousness, and quality of life in patients with lung cancer. Journal of Pain and Symptom Management; 21: 4, 323-329.Van Rooijen S et al (2019) Multimodal prehabilitation in colorectal cancer patients to improve functional capacity and reduce postoperative complications: the first international randomized controlled trial for multimodal prehabilitation. BMC Cancer; 19: 1, 98.

programme. Further information can be found at Bit.ly/PrehabSACT.

Measuring effectivenessEvidence for the effectiveness of prehabili-tation in advanced-stage lung cancer is limited, mainly due to the small number of centres offering this nationally (Moore et al, 2021). Effectiveness of prehabilitation has traditionally been measured against specific outcomes, such as reduced length of stay, enhanced quality of life, reduced complications, improved cardiovascular fitness and nutritional status (Bloom, 2017); however, Moore et al (2021) recom-mend further ‘real-world’ evaluation. The case study in Box 3 shows how prehabilita-tion can potentially improve patient access to and suitability for treatments.

When measuring effectiveness, it is important to clarify a patient’s concord-ance with prehabilitation and why patients might not fully adhere to their pro-gramme, as this can distort the outcome (Macmillan Cancer Support, 2020). Whether a patient is willing to commit fully or can adhere to the programme can also affect the choice of care pathway. Monitoring adherence using validated tools to measure outcomes in a standard-ised way is the only way to evaluate the effectiveness of interventions (Macmillan Cancer Support, 2020; Driessen et al, 2017).

ConclusionA prehabilitation programme can help patients with cancer manage their symp-toms and improve their fitness for treat-ment, but is currently only well established for operable cancers. Introducing prehabil-itation for late-stage lung cancer could improve patients’ fitness for systemic treatment, as well as health outcomes and quality of life for this group NT.

ReferencesBade BC et al (2015) Increasing physical activity and exercise in lung cancer: reviewing safety, benefits and application. Journal of Thoracic Oncology; 10: 6, 861-871.Bloom E (2017) Prehabilitation Evidence and Insight Review. Macmillan Cancer Support. Chambers SK et al (2015) Psychological distress and quality of life in lung cancer: the role of health-related stigma, illness appraisals and social constraints. Psycho-Oncology; 24: 11, 1569-1577.Driessen EJ et al (2017) Effects of prehabilitation and prehabilitation including a home-based component on physical fitness, adherence, treatment tolerance and recovery in patients with non-small cell lung cancer: a systemativ review. Critical Reviews in Oncology/Hematology; 114: 63-76.Dudgeon DJ et al (2001) Dyspnoea in cancer patients; prevalence and associated factors. Journal of Pain and Symptom Management; 21: 2, 95-102.Faithfull S et al (2019) Prehabilitation for adults diagnosed with cancer: a systematic review of long-term physical function, nutrition and patient

Prehabilitation to improve lung cancer outcomes

Part 1: Principles and benefits OctPart 2: Putting it into practice Nov

CLINICAL SERIES


Box 3: Case study Mr Leonard* is a 68-year-old male admitted to the emergency department with increased shortness of breath, fever, fatigue, productive cough with green sputum and three episodes of haemoptysis. Flu-like symptoms starting three weeks earlier had worsened over recent days. The patient has a medical history of COPD, depression and hypertension. He is an ex-smoker of 10 years and lives with his wife. He is normally mobile and self-caring with a World Health Organization PS of 1 (0 = fully functional, 4 = bedridden) and manages stairs without difficulty.

Following a chest X-ray, he is treated for community-acquired pneumonia, but his condition deteriorates, and a CT scan shows a large, right upper lobe mass in his lung, extensive lymphadenopathy and a metastatic liver deposit. An endobronchial ultrasound confirms metastatic adenocarcinoma of the lung. On discharge after a prolonged hospital stay due to the co-existing pneumonia, he is less mobile and independent, with a PS of 3. Multidisciplinary team discussion confirms stage-4 cancer. The plan is to offer him systemic treatment, but only if his PS improves.

At review two weeks post discharge, his PS remains at 2-3, his appetite is poor and his cancer diagnosis has exacerbated his depression. He is reviewed by the lung cancer CNS and told that, given his poor PS, he is not fit enough for treatment but could be supported to improve his fitness and general wellbeing. Alongside ongoing support from the lung cancer CNS, Mr Leonard is referred to a dietitian, occupational thera-pists, clinical psychology, and a palliative care team.

At a telephone follow-up two weeks later, Mr Leonard reports some improvement in his general wellbeing; his PS is now 2, but his mood is still low and his antidepressants have been increased. He agrees his reduced mobility and fatigue could be mood-related and consents to more input from clinical psychology and the CNS team.

An oncology review two weeks later notes further improvement: his PS is now close to his baseline at 1-2. The oncologist agrees to commence an initial systemic anti-cancer therapy (SACT). Mr Leonard completes four cycles of this treatment, and then continues on a maintenance SACT. He continues his exercise regime and psychological support throughout treatment, and has few side-effects, except mild nausea and fatigue.

*Patient’s name has been changed. CNS = clinical nurse specialist; COPD = chronic obstructive pulmonary disease; CT = computed tomography; PS = performance status.

reported outcomes. European Journal of Cancer Care; 28: 4, e13023.Fenemore J, Roberts J (2021) Prehabilitation to improve lung cancer outcomes 1: principles and benefits. Nursing Times [online]; 117: 10, 30-33. Gore JM et al (2000) How well do we care for patients with end stage chronic obstructive pulmonary disease (COPD)? A comparison of palliative care and quality of life in COPD and lung cancer. Thorax; 55: 12, 1000-1006.Granger CL et al (2017) Understanding factors influencing physical activity and exercise in lung cancer: a systematic review. Supportive Care in Cancer; 25: 3, 983-999.Granger CL et al (2016) Barriers to translation of physical activity into the lung cancer model of care: a qualitative study of clinicians’ perspectives. Annals of the American Thoracic Society; 13: 12, 2215-2222.Healthy London Partnership (2020) Covid-19: Cancer Prehabilitation Toolkit. HLP.Jabbarian LJ et al (2019) Coping strategies of patients with advanced lung or colorectal cancer in six European countries: insights from the ACTION study. Psycho-Oncology; 29: 2, 347-355.Macmillan Cancer Support (2020) Prehabilitation for People with Cancer: Principles and Guidance for Prehabilitation within the Management and Support of People with Cancer. MCS. Moore J et al (2021) Implementing a system-wide cancer prehabilitation programme: the journey of Greater Manchester’s ‘Prehab4cancer’. European Journal of Surgical Oncology; 47: 3 Pt A, 524-532. Mosher CE et al (2015) Coping with physical and psychological symptoms: a qualitative study of advanced lung cancer patients and their family


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