Pilot prehabilitation programme reduces re-admission for lung cancer patients
Guy’s and St Thomas’ NHS Foundation Trust has piloted a prehabilitation programme designed to ensure patients feel more prepared for surgery, have improved fitness, and are better able to manage their symptoms.
What is prehabilitation and why is it important for cancer patients?
Lung cancer is the leading cause of cancer death in the UK, and 41% of patients who undergo lung cancer surgery are re-admitted to hospital.
There are now advanced surgical interventions for those with locally advanced lung cancer. For certain interventions, such as anatomical lung resections, the patients considered are increasingly elderly and have multiple comorbidities. Many of these patients have also already undergone treatment in the form of previous surgery, chemo-radiotherapy or immunotherapy. Following surgery, many can experience symptoms such as breathlessness, chronic pain and fatigue.
Due to the vulnerability of these patients, it is important that steps are taken to ensure they are in the best possible mental and physical state prior to surgery, and prehabilitation programmes can help achieve this.
Prehabilitation aims to improve the patient’s functional and physiological state prior to major surgery. A bespoke programme can help patients improve exercise capacity and reduce complications, dependence, disability, and cognitive impairment. In doing so, this can reduce the length of time patients need to stay in hospital following their surgery and lower the chance of re-admission.
The key pillars of effective prehabilitation are:
- Personal empowerment and quality of life
- Physical and psychological resilience
- Positive health behaviour change
- Effective use of resources
About the prehabilitation programme at Guy’s and St Thomas’ NHS Foundation Trust
The team at Guy’s and St Thomas’ NHS Foundation Trust identified a need to ensure that the health of patients is optimal prior to surgery. To address this, a pilot a prehabilitation programme in thoracic surgery was established at the trust. The programme enrolled more than a hundred patients, with 93% patient engagement. To date almost 70 patients have been operated on and discharged home safely.
Patients are pre-screened with a health questionnaire and any necessary investigations are booked. During their prehabilitation consultation, patients are assessed by a surgeon who engages in a shared decision-making conversation regarding their cancer treatment and liaises with their families where appropriate.
The assessments that are carried out include cardiovascular risk, fitness level and a cognitive assessment. Additional assessments also check for any undiagnosed underlying conditions such as chronic obstructive pulmonary disease (COPD), sleep apnoea or anaemia. Patients with complex pain or difficulty airways are referred to the senior anaesthetic team and a holistic assessment of physical function, exercise capacity, dyspnoea, fatigue, risk of malnutrition and psychological wellbeing is carried out. This is all in addition to standard pre-assessment including blood tests, ECGs, lung function and CT imaging.
Through these assessments, clinicians are able to determine if and where patients need to be referred for additional support. This could be, for example, organising counselling to help patients quit smoking or reduce alcohol intake, or a review of medications and their efficacy. Patients are also provided with an individually tailored exercise programme and management plan that can help optimise their diet. By meeting with a physiotherapist on a weekly basis, patients can discuss their programme and address any issues.
The results of the pilot
Following the implementation of this pilot programme, re-admission for prehabilitation patients at the trust surveyed at 90 days is 8%, compared to a national average of 41%. A significant reason for this is that clinicians have been able to identify and address previously undiagnosed disease such as critical coronary artery disease, pericardial effusions, heart failure, COPD and sleep apnoea.
The baseline fitness (as assessed by the one-minute sit-to-stand test) improved by 30% during the period of intervention. The follow up questionnaire highlighted that the large majority of patients felt that the programme prepared them better for surgery, improved their fitness, and helped them manage their symptoms.
One patient who engaged in the prehabilitation pilot stated:
I never exercised before so a new regime for me has been fantastic. I will carry this on for the future and have enjoyed it.
It is clear that both physically and psychologically, prehabilitation offers an excellent opportunity to engage patients in improving their health prior to undergoing major surgery. During the COVID-19 pandemic, cancer patients have also been increasingly at risk of anxiety and distress; this programme offers the opportunity for regular contact and support with their managing team.
Although prehabilitation has not been widely adopted across the UK at this stage, the benefits it can have in improving the quality of life for patients suggests that it is likely to become a new standard in surgical care, beyond thoracic surgery. Guy’s and St Thomas NHS Foundation Trust has recently begun a pilot project for colorectal cancer to demonstrate this translation of the programme into other specialties.
As a European Comprehensive Cancer Centre, the King's Health Partners Cancer Clinical Academic Group brings together world-class clinical services, research and education for the benefit of cancer patients in south east London and beyond.