Fit for Surgery-feasibility of short-course multimodal individualized prehabilitation in high-risk frail colon cancer patients prior to surgery

Abstract

Background: Prehabilitation is a promising modality for improving patient-related outcomes after major surgery; however, very little research has been done for those who may need it the most: the elderly and the frail. This study aimed to investigate the feasibility of a short course multimodal prehabilitation prior to primary surgery in high-risk, frail patients with colorectal cancer and WHO performance status I and II.

Methods: The study was conducted as a single-center, prospective one-arm feasibility study of eight patients with colon cancer between October 4, 2018, and January 14, 2019. The intervention consisted of a physical training program tailored to the patients with both high-intensity interval training and resistance training three times a week in sessions of approximately 1 h in length, for a duration of at least 4 weeks, nutritional support with protein and vitamins, a consultation with a dietician, and medical optimization prior to surgery. Feasibility was evaluated regarding recruitment, retention, compliance and adherence, acceptability, and safety. Retention was evaluated as the number of patients that completed the intervention, with a feasibility goal of 75% completing the intervention. Compliance with the high-intensity training was evaluated as the number of sessions in which the patient achieved a minimum of 4 min > 90% of their maximum heart rate and adherence as the attended out of the offered training sessions.

Results: During the study period, 64 patients were screened for eligibility, and out of nine eligible patients, eight patients were included and seven completed the intervention (mean age 80, range 66-88). Compliance to the high-intensity interval training using 90% of maximum heart rate as the monitor of intensity was difficult to measure in several patients; however, adherence to the training sessions was 87%. Compliance with nutritional support was 57%. Half the patients felt somewhat overwhelmed by the multiple appointments and six out of seven reported difficulties with the dosage of protein.

Conclusions: This one-arm feasibility study indicates that multimodal prehabilitation including high-intensity interval training can be performed by patients with colorectal cancer and WHO performance status I and II.

Trial registration: Clinicaltrials.gov : the study current feasibility study was conducted prior to the initiation of a full ongoing randomized trial registered by NCT04167436; date of registration: November 18, 2019. Retrospectively registered. No separate prospectively registration of the feasibility trial was conducted but outlined by the approved study protocol (Danish Scientific Ethical Committee SJ-607).

Keywords: Colorectal cancer; Elderly; Frail; High-intensity training; Prehabilitation.

Fig. 1

Outline of the course of testing and intervention. Single asterisk indicates the following: all testing consisted of baseline questionnaires (G8 and fried frailty), nutritional screening (PG-SGA) and anthropometric measurement, blood work, cardiopulmonary exercise test (CPET), handgrip strength, leg extension strength test, 6-min walk test, sit to stand test (30 s), and stair climb test (30 s), in that exact chronological order. Double asterisk indicates the following: the intervention consisted of individual training three times a week with a minimum of 10 sessions. Nutritional counseling within the first week of inclusion (1.5 h), 0.4 g/kg bodyweight protein supplement two times a day, and medical optimization. Medical optimization was performed on the same day of baseline testing. Triple asterisk indicates the following: discharge managed through standardized discharge criteria. Adherence to Enhanced Recovery After Surgery (ERAS) was recorded each day during admission

Fig. 2

CONSORT diagram of the inclusion process. APR, abdominoperineal resection. CRC, colorectal cancer. WHO, World Health Organization

Fig. 3

a, b Examples of different issues within training sessions based on maximum heart rate. a Examples of training sessions with continuous measurement of heart rate and Borg’s RPE for three different patients. Horizontal lines represent the time within the interval spent above 90% of maximum heart rate (HR) within each interval. Patient 1 (red) represents the expected course of the HR during a training session. Patient 2 (blue) shows a training session where the HR did not decrease between high-intensity intervals. Patient 3 (orange) shows a patient with known paroxysmal atrial fibrillation, which is suspected to have atrial fibrillation during the training. HR was above 100% of the maximum HR completely during the session. HR during the last 4 min of training was not registered. b Illustrative example of a high-intensity interval training bout of a frail patient with colonic cancer without an expected decrease in heart rate between high intensive interval bouts. Similar to patient two (blue) in Fig. 2 a. The example was produced on Lode Corival rehab ergometer bike (Lode B.V., Groningen NL) on a patient not included in the feasibility study, in order to show the missing decrease in HR in correlation to intervals on a similar patient. The measure of Watt (green line), revolutions per minute (RPM (blue line)), heart rate (beats per minute, BPM (red line)), by time in minutes (x-axis). Oxygen saturation (SpO₂) was not measured. The resting pulse of 75, increased rapidly after the start of the bout, even on 30% of maximum wattage defined by CPET, and reached maximum pulse within the first minute of exercise. The pulse did not decrease in low-intensity phases. CPET, cardiopulmonary exercise test. RPE, Borg’s Rating of Perceived exertion (RPE) 6-20 scale

Fig. 4

Changes in VO₂ peak, workload, and 6-min walk test at baseline, preoperative, and 4 weeks after surgery for each patient