Cancer prehab: fit for surgery

Robert Millett meets a team in Surrey that runs an innovative prehab pilot for patients with cancer.

Physiotherapists in Surrey are helping people with cancer to get ready for major surgery by preparing them mentally and improving their fitness and diet.
Team lead Rachel Brown and senior physiotherapist Claire Martin play a key part in a two-year pre-habilitation pilot service at Royal Surrey County Hospital NHS Trust in Guildford. The hospital is a specialist centre for cancer treatment, serving more than 1.2 million people in south west Surrey.
It secured funding last year from the charity Macmillan Cancer Support to develop a multi-modal prehab service. The programme, launched in January, provides physiotherapy, occupational therapy and dietetic support, with the aim of improving post-operative recovery. 

Team approach 

Ms Martin, who is employed full-time, works alongside part-time occupational therapist Helen McNamara, part-time dietician Nicola Porter and Lizzie Shaw, a physiotherapist who helps to run exercise classes.
‘As far as we are aware, we are currently the only multi-modal prehab service for this particular patient group,’ she says.
‘And we are very proud of what we have achieved so far.’ In 2015 the team’s lead Mrs Brown, who is currently on maternity leave, set up a pre-pilot trial that paved the way for this service. It offered physiotherapy, without any other interventions, and focused solely on improving patients’ post-operative physical recovery.
‘The data we collected showed that the service helped people from a physical and peer support perspective, as well as by providing them with useful information about what to expect post-operatively,’ says Ms Martin.
‘But we also realised that this patient cohort has many other needs, including issues with anxiety, wellbeing and nutrition.’
As a result, Mrs Brown and her colleagues developed plans for a multidisciplinary prehab service and submitted a funding bid to Macmillan Cancer Support. ‘We pooled evidence from other services we run at the hospital for cancer patients, and from the pre-pilot service, to show the benefits for patients – including reduced length of stay,’ says Ms Martin. 


The service now offers a five-week rolling programme of pre-habilitation to people who are having treatment and awaiting surgery for urological, gynaecological and hepatopancreaticobiliary (HPB) cancers. ‘We predominantly see cervical, pancreatic and bladder cancer patients and get referrals for anything falling under those specialties,’ says Ms Martin.
During initial assessments, team members talk to patients about their treatment, confirm set surgery dates and collect background information about their social history and what physical activities they enjoy.
They also conduct three outcome measures: the six-minute walk test, sit-to-stand in 60 seconds and the handgrip strength test. ‘
We then devise and offer a home exercise programme for each patient, which focuses on strengthening and cardiovascular fitness,’ says Ms Martin.
‘They receive advice on lower and upper limb exercises, and activities like walking, cycling or swimming – whatever exercise appeals and what they are able to do.’ The idea is to empower people, she adds, so they can go home and ‘get on with it’ confidently.

We are trying to prepare people physically and mentally,’ says Ms Martin. ‘And if people can’t attend any of the classes we provide flexibility and offer telephone follow-ups.’

Wellbeing classes 

Patients living locally are also invited to attend twice-weekly exercise classes at the hospital, led by Ms Martin with the help of a technical instructor. Those from further afield receive regular phone calls from the team to check their progress.
Patients are also invited to weekly wellbeing sessions at the hospital, which carers or family members can also attend. These focus on a variety of topics and include talks about fatigue, sleep issues, anxiety management, mindfulness and sessions where patients meet an anaesthetist. 
‘We are trying to prepare people physically and mentally,’ says Ms Martin. ‘And if people can’t attend any of the classes we provide flexibility and offer telephone follow-ups.’
After five weeks, the team speaks to patients about their post-operative recovery and reassess to test if their fitness levels have improved. 

Better outcomes

Data collected from the pre-pilot service produced impressive outcomes, which the team hope to replicate over the next two years. During the trial period, 45 patients enrolled on the five-week programme and 23 finished it. 
‘In some cases their treatment management changed or surgery was brought forward. And occasionally patients didn’t want to partake for their own reasons or became too unwell to complete the course,’ Ms Martin says.
Patients who completed the full five weeks followed home exercise plans and attended exercises classes at the hospital.
Final assessments showed that urology patients demonstrated an average 25 metre increase in the six-minute walk test, an average five-rep increase in the sit-to-stand test, and a two kg increase in handgrip strength.
Similarly, gynaecological oncology patients had an average increase of 66 metres in the six-minute walk test, a six-rep increase in the sit-to-stand test and a 0.7kg increase in handgrip strength.
And patients with HPB experienced a 32 metre increase in the six-minute walk test, a three-rep increase in the sit-to-stand test and no change (but no decrease) to handgrip strength.
‘In all three specialities we demonstrated a good functional improvement in all elements,’ says Ms Martin.
‘In the case of the HPB group, especially, we also found close to a whole day less in length of stay. So if the new service can continue or improve on that it will be a very good outcome for the hospital.’
Over the next two years, the team hopes to collect further data that will allow them to prove the benefits of their multi-modal approach.
‘There is a lack of knowledge about what good prehab is and how it should be delivered,’ says Ms Martin.
‘Outcome measures and regimes have varied in the studies and there’s no gold standard or benchmark yet. We hope the date we collect can help add to the research.’
Once the pilot phase ends, Ms Martin hopes the benefits will lead to long-term funding and an expanded provision of pre-habilitation to other major surgical groups treated at the hospital.
‘Ultimately, we would like this service to help with other specialties,’ she says. ‘The long-term dream is that all patients will be able to be referred to a prehab service.’ fl 


Prehab: the Aintree way

Macmillan Cancer Support has funded a similar service that offers a prehab service in Liverpool. A 12-month pilot, which started last August, is led by Claire Knowles, a band 7 musculoskeletal physiotherapist at Aintree University Hospital NHS Trust.

‘We see patients with head and neck cancer, colorectal cancer and HPB. But other cancer groups are also keen to be involved and we are looking to open it up to some lung and breast patients,’ she says.

Her team, which includes a dietitian and a therapy assistant, provides assessments, nutritional advice and group exercise sessions for patients awaiting surgery.

‘We run two circuit-based classes a week, which are both cardiovascular and strengthening, and patients can come to as many of those as they like.’

Although the service is based in Liverpool, staff receive referrals from as far away as the Isle of Man and Preston.

‘So with those patients we do telephone clinics and use online resources to help them exercise,’ adds Ms Knowles.

Robert Millett

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