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Prehabilitation refers to the preoperative period and aims to enhance general health and wellbeing prior to major surgery.1 Prehabilitation is commonly applied prior to oncological treatments, including surgery, to fortify functional reserve and enhance functional capacity to prepare patients for the imminent physiological and psychological stress of treatment.2 An individual's state of health at diagnosis, including obesity, physical fitness and comorbidities, are influencing factors for the occurrence of adverse effects.3 It is well known that those patients who are malnourished have greater surgical morbidity and mortality.4
The key elements of a prehabilitation programme include cardiovascular and strength training, nutritional optimisation and psychological support to prepare patients for the challenges of treatment and to improve post-operative recovery.5 The typical length of prehabilitation programmes are 4–8 weeks in duration. Shorter programmes may be ineffective, while compliance may be a problem with longer programmes.6
The primary goals of nutritional prehabilitation are to optimise nutrition stores and metabolic reserve preoperatively and provide an adequate buffer for the catabolic response of critical illness or surgery.7
The European Society for Clinical Nutrition and Metabolism (ESPEN) guidelines on surgery state that patients with severe nutritional risk shall receive nutritional therapy prior to major surgery even if operations including those for cancer must be delayed. A period of 7 to 14 days may be appropriate.4 A systematic review of prehabilitation in adults diagnosed with cancer found that the timing of nutritional interventions varied between 5–10 days and 3–6 weeks pre‐operatively.3
Nutritional prehabilitation can take different forms including nutritional counselling (optimising intake of macro and micronutrients nutrients from dietary sources), oral nutritional supplements (ONS) (including high energy ONS, protein only supplements and immunonutrition) and enteral feeding.8
Malnutrition has been shown to be a modifiable risk factor associated with post-operative complications, increased levels of mortality, morbidity and length of hospital stay. Therefore, nutritional screening in the prehabilitation period is a key aspect of a prehabilitation programme. Commonly the Malnutrition Universal Screening Tool (MUST) is used to identify those who are malnourished or at risk of malnutrition. However, there is accumulating experience that using MUST in oncological settings does not adequately characterise risk. Therefore, several alternative screening methods are used across cancer centres in the UK. These include those that have been validated for use in people with cancer, such as the patient-generated subjective global assessment short-form (PG-SGA-SF).9 Other examples include the Royal Marsden nutrition screening tool.10 Irrespective of which tool is used, it is important that the same tool is used in all settings for any particular patient, and that it is used from the earliest opportunity to risk stratify and direct care.
All screening tools take into account weight, Body Mass Index (BMI) and weight change. The PG-SGA-SF and Royal Marsden nutrition screening tool also take into account more specific information about symptoms, and change in appetite/food intake.9,10
Those identified as at risk following screening should undergo more formal nutritional assessment. An anthropometric assessment of weight (including weight change), height, and waist circumference are vital components of the comprehensive nutrition assessment. Additionally, body composition assessment has emerged as a crucial component in the evaluation of patients’ nutritional status.11
In the clinical setting, bioelectrical impedance can provide a useful guide for estimating muscle mass. Unfortunately, not all clinicians have access to the tool for measuring body composition. As such, more readily available techniques can be used to measure muscle strength and function. Muscle strength can be measured using handgrip strength, knee extension/flexion or peak expiratory flow. Muscle function can be measured using gait stand, timed up and go test, or the short physical performance battery.12
Prehabilitation interventions can be categorised into universal, targeted and specialist and individuals may need different levels of interventions in different domains of prehabilitation.13 The intervention aims to improve or resolve the nutritional diagnosis.
Energy and protein requirements in cancer are defined as 25-30kcal/kg/day and 1.0-1.5g/kg/day, respectively.14 Further consideration about timing of protein intake may need to be taken into account as evidence grows in this field. Depending on the individual’s dietary intake, meeting these increased nutritional requirements may require the use of prescribed ONS.
In addition to preventing malnutrition and correcting nutrition-identified problems, the nutrition component of a multimodal prehabilitation program should work in synergy with the exercise intervention to support optimal gains in mass, strength, physical fitness, and recovery.11
To evaluate the effectiveness of nutritional intervention, relevant outcomes/indicators need to be measured. The selection of appropriate outcomes/indicators is based on the nutrition diagnosis. For example, intake-related indicators include nutrient adequacy, changes in dietary patterns and compliance to prescribed supplements. Biochemical indicators may also be used alongside dietary intake data.11
ONS are commonly used to address malnutrition in those individuals screened as part of the prehabilitation process. Choice of ONS largely depends on the needs of the individual and the level of malnutrition risk. Patient acceptability and subsequent compliance of ONS should also feed into the decision making process of the dietitian. ONS acceptability and compliance can be categorised into 3 domains: contextual/environmental, personal and product related factors. Acceptability of supplements prepared freshly with milk versus ready-to-use ONS has been shown to have a higher preference in patients with cancer.16
Prehabilitation is part of a continuum in the rehabilitation pathway. It enables people with cancer to make the most of their lives by maximising the outcomes of their treatment whilst minimising the consequences of treatment including symptoms such as fatigue, breathlessness and lymphoedema. The need for prehabilitation, as part of the rehabilitation pathway, starts at the point of diagnosis helping patients prepare for treatment and discharge home.13
The costs of delivering prehabilitation per patient varies in each country, with the overall range in the region of £300–400 per patient in the UK. These costs support the screening, assessment and interventions which could be any combination of the following practitioners within the multidisciplinary team: anaesthesiologists, clinical psychologists, dietitians, exercise physiologists, fitness professionals, gastroenterologists, geriatricians, kinesiologists, nurses, occupational therapists, oncologists, physicians, physiotherapists, support workers and surgeons.17
In order to support the growing number of people living with cancer, effective prehabilitation and rehabilitation programmes can help to support improving outcomes. Providing either universal, targeted or specialist input as part of prehabilitation programmes has been shown to improve functional outcomes, improve health related quality of life and reduce length of stay and surgical complication rates. Dietitians can play an important role in multi-modal prehabilitation programmes.
