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Cancer is the leading cause of death in Aotearoa New Zealand.[[1]] New Zealand has the second-highest age-standardised cancer incidence rate in the world (422.9 per 100,000 people). As a result, most people in Aotearoa New Zealand will encounter a cancer diagnosis within their lifetime, either directly or through whānau.[[2]] Māori, who make up 16% of the Aotearoa New Zealand population, have a disproportionately high cancer related mortality.[[3,4]]
Historically, rest and outright inactivity were recommended for patients with cancer. However, over the last two decades research has highlighted the benefits of physical activity during the cancer continuum, so much so that the American College of Sports Medicine is running an ‘Exercise Is Medicine’ initiative.[[5]] This cancer continuum is divided into four phases: 1) post-diagnosis to first treatment, 2) active treatment with chemotherapy, radiotherapy, hormonal, and/or immunotherapy, 3) survivorship, after cessation of treatment, and 4) the palliative phase. To date, most rehabilitation related studies have focused on the phases of active treatment and/or cancer survivorship. These have shown that physical activity can mitigate, or even prevent, the short and long-term side effects patients experience due to cancer and its treatment.[[6]] Exercise during adjuvant chemotherapy is associated with improved chemotherapy completion rates.[[7,8]] This, in turn, can influence disease free and overall survival.[[9]]
Far less research has been done into the initial phase of the cancer continuum before surgery, which is dubbed prehabilitation. Prehabilitation in its simplest form is treatment that prepares a patient for an upcoming physiological stress.[[10]] As a concept, prehabilitation is not new. It is an established part of Enhanced Recovery after Surgery (ERAS) protocols that are currently operating in Aotearoa New Zealand hospitals. It can encompass exercise (strength and cardiovascular), nutrition optimisation, smoking cessation, and stress reduction interventions.[[11]] Prehabilitation in cancer can have multiple goals: 1) maintaining pre-operative baseline measurements of function, instead of having a degraded ‘baseline’ after treatment (surgery, and/or adjuvant treatment), 2) improving a pre-existing health problem to better prepare for cancer surgery and/or treatment, and/or 3) improving overall functioning, including psychological health and resilience, to better withstand upcoming treatments.
Prehabilitation programmes for patients with cancer have been shown to be safe and feasible even in a very short interval between diagnosis and treatment.[[12,13]] Potential benefits include improved physical function, quality of life, and psychological health.[[14–16]] These improvements can in turn influence length of hospital stay and reduce post-surgical complications.[[16]] Exercise may even influence tumorgenicity directly via molecular pathways.[[17]]
To date, research into prehabilitation in cancer has been heterogenous in its focus. Small sample sizes across various cancer populations and setting and modes of prehabilitation delivery show benefits, but are incongruous in their generalisability.[[18,19]] Little research has been done on prehabilitation in Aotearoa New Zealand. Patient engagement with prescriptive generalised prehabilitation interventions is mixed.[[20]] It is likely that benefits of prehabilitation are optimised by programmes being tailored to the needs of specific communities.
Current research
To address these issues, we are running a study in Tāmaki Makaurau Auckland to gain insight into the needs of patients with breast cancer in the period between diagnosis and surgery. This qualitative study aims to compare patients’ needs to the perception of prehabilitation held by healthcare providers. In doing so, we hope to understand the relationships and differences in existing narratives.
In this ongoing work, patients who have completed their treatment are invited to focus groups to reflect on what kind of supportive care, if any, they wanted during the period between diagnosis and surgery. The study has an a priori focus on Māori patients with separate hui run for patients and whānau identifying as Māori. Semi-structured interviews with health care providers—oncologists, surgeons, anaesthetists, nurse specialists, and physiotherapists—are underway to gain insight into their perception of prehabilitation for patients with cancer. A similar study with patients who have sarcoma is about to start.
Ultimately, identification of patients’ needs is the first step in our wider research programme, which will include participatory development and co-design of prehabilitation interventions.[[21,22]] In the coming year, patients, researchers and clinical team members will co-design a prehabilitation intervention that can be implemented and evaluated in the clinical setting. The hope is that this co-design process will lead to tailored, and thereby more effective, prehabilitation interventions in Tāmaki Makaurau.[[22]]
Special interest group
We have started a special interest group ‘Supportive care for people with cancer’ within the New Zealand Society for Oncology, in partnership with Te Aka Mātauranga Matepukupuku (Centre for Cancer Research, Waipapa Taumata Rau University of Auckland). Interested researchers from across Aotearoa New Zealand are welcome to contact us for nationwide collaborations (SIGSupportiveCancerCare@auckland.ac.nz ).
Summary
Abstract
Aim
Method
Results
Conclusion
Author Information
Acknowledgements
Correspondence
Correspondence Email
Competing Interests
1) Manatū Hauora – Ministry of Health. New Zealand Cancer Action Plan 2019–2029 [Internet]. Wellington: 2020 Feb 3 [cited 2022 Dec 16]. Available from: https://www.health.govt.nz/publication/new-zealand-cancer-action-plan-2019-2029.
2) Sung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, et al. Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA Cancer J Clin. 2021 May;71(3):209-249. doi: 10.3322/caac.21660.
3) Gurney J, Stanley J, McLeod M, Koea J, Jackson C, Sarfati D. Disparities in Cancer-Specific Survival Between Māori and Non-Māori New Zealanders, 2007-2016. JCO Glob Oncol. 2020 Jun;6:766-774. doi: 10.1200/GO.20.00028.
4) Jeffreys M, Sarfati D, Stevanovic V, Tobias M, Lewis C, Pearce N, et al. Socioeconomic inequalities in cancer survival in New Zealand: the role of extent of disease at diagnosis. Cancer Epidemiol Biomarkers Prev. 2009 Mar;18(3):915-21. doi: 10.1158/1055-9965.EPI-08-0685.
5) Schmitz KH, Campbell AM, Stuiver MM, Pinto BM, Schwartz AL, Morris GS, et al. Exercise is medicine in oncology: Engaging clinicians to help patients move through cancer. CA Cancer J Clin. 2019 Nov;69(6):468-484. doi: 10.3322/caac.21579.
6) Cormie P, Zopf EM, Zhang X, Schmitz KH. The Impact of Exercise on Cancer Mortality, Recurrence, and Treatment-Related Adverse Effects. Epidemiol Rev. 2017 Jan;39(1):71-92. doi: 10.1093/epirev/mxx007.
7) An KY, Arthuso FZ, Kang DW, Morielli AR, Ntoukas SM, Friedenreich CM, et al. Exercise and health-related fitness predictors of chemotherapy completion in breast cancer patients: pooled analysis of two multicenter trials. Breast Cancer Res Treat. 2021 Jul;188(2):399-407. doi: 10.1007/s10549-021-06205-8.
8) van Waart H, Stuiver MM, van Harten WH, Geleijn E, Kieffer JM, Buffart LM, et al. Effect of Low-Intensity Physical Activity and Moderate- to High-Intensity Physical Exercise During Adjuvant Chemotherapy on Physical Fitness, Fatigue, and Chemotherapy Completion Rates: Results of the PACES Randomized Clinical Trial. J Clin Oncol. 2015 Jun 10;33(17):1918-27. doi: 10.1200/JCO.2014.59.1081.
9) Courneya KS, Segal RJ, McKenzie DC, Dong H, Gelmon K, Friedenreich CM, et al. Effects of exercise during adjuvant chemotherapy on breast cancer outcomes. Med Sci Sports Exerc. 2014 Sept;46(9):1744-51. doi: 10.1249/MSS.0000000000000297.
10) Stout NL, Silver JK, Baima J, Knowlton SE, Hu X. Prehabilitation: An Emerging Standard in Exercise Oncology. In: Schmidt, K editor. Exercise Oncology. Switzerland: Springer International Publishing; 2020. p. 111-43. doi: 10.1007/978-3-030-42011-6_6
11) Santa Mina D, Brahmbhatt P, Lopez C, Baima J, Gillis C, Trachtenberg L, et al. The Case for Prehabilitation Prior to Breast Cancer Treatment. PM R. 2017 Sep;9(9S2):S305-S316. doi: 10.1016/j.pmrj.2017.08.402.
12) Brahmbhatt P, Sabiston CM, Lopez C, Chang E, Goodman J, Jones J, et al. Feasibility of Prehabilitation Prior to Breast Cancer Surgery: A Mixed-Methods Study. Front Oncol. 2020 Sep 25;10:571091. doi: 10.3389/fonc.2020.571091.
13) Wu F, Laza‐Cagigas R, Pagarkar A, Olaoke A, El Gammal M, Rampal T. The Feasibility of Prehabilitation as Part of the Breast Cancer Treatment Pathway. PM&R. 2021 Nov 3;13(11):1237-46. doi: 10.1002/pmrj.12543.
14) Toohey K, Hunter M, McKinnon K, Casey T, Turner M, Taylor S, et al. A systematic review of multimodal prehabilitation in breast cancer. Breast Cancer Res Treat. 2023 Jan;197(1):1-37. doi: 10.1007/s10549-022-06759-1.
15) Daniels SL, Lee MJ, George J, Kerr K, Moug S, Wilson TR, et al. Prehabilitation in elective abdominal cancer surgery in older patients: systematic review and meta-analysis. BJS Open. 2020 Sep 22;4(6):1022-41. doi: 10.1002/bjs5.50347.
16) Burnett C, Bestall JC, Burke S, Morgan E, Murray RL, Greenwood-Wilson S, et al. Prehabilitation and Rehabilitation for Patients with Lung Cancer: A Review of Where we are Today. Clin Oncol (R Coll Radiol). 2022 Nov;34(11):724-732. doi: 10.1016/j.clon.2022.08.028.
17) Ligibel JA, Dillon D, Giobbie-Hurder A, McTiernan A, Frank E, Cornwell M, et al. Impact of a Pre-Operative Exercise Intervention on Breast Cancer Proliferation and Gene Expression: Results from the Pre-Operative Health and Body (PreHAB) Study. Clin Cancer Res. 2019 Sep 1;25(17):5398-5406. doi: 10.1158/1078-0432.CCR-18-3143.
18) Esser T, Zimmer P, Schier R. Preoperative exercise and prehabilitation. Curr Opin Anaesthesiol. 2022 Dec 1;35(6):667-673. doi: 10.1097/ACO.0000000000001188.
19) Schier R, Levett D, Riedel B. Prehabilitation: The next challenge for anaesthesia teams. Eur J Anaesthesiol. 2020 Apr;37(4):259-262. doi: 10.1097/EJA.0000000000001167.
20) West MA, Jack S, Grocott MPW. Prehabilitation before surgery: Is it for all patients? Best Pract Res Clin Anaesthesiol. 2021 Dec;35(4):507-516. doi: 10.1016/j.bpa.2021.01.001.
21) Baum F, MacDougall C, Smith D. Participatory action research. J Epidemiol Community Health. 2006 Oct;60(10):854-7. doi: 10.1136/jech.2004.028662.
22) Neuhauser L. Integrating Participatory Design and Health Literacy to Improve Research and Interventions. Stud Health Technol Inform. 2017;240:303-329.
For the PDF of this article,
contact nzmj@nzma.org.nz
View Article PDF
Cancer is the leading cause of death in Aotearoa New Zealand.[[1]] New Zealand has the second-highest age-standardised cancer incidence rate in the world (422.9 per 100,000 people). As a result, most people in Aotearoa New Zealand will encounter a cancer diagnosis within their lifetime, either directly or through whānau.[[2]] Māori, who make up 16% of the Aotearoa New Zealand population, have a disproportionately high cancer related mortality.[[3,4]]
Historically, rest and outright inactivity were recommended for patients with cancer. However, over the last two decades research has highlighted the benefits of physical activity during the cancer continuum, so much so that the American College of Sports Medicine is running an ‘Exercise Is Medicine’ initiative.[[5]] This cancer continuum is divided into four phases: 1) post-diagnosis to first treatment, 2) active treatment with chemotherapy, radiotherapy, hormonal, and/or immunotherapy, 3) survivorship, after cessation of treatment, and 4) the palliative phase. To date, most rehabilitation related studies have focused on the phases of active treatment and/or cancer survivorship. These have shown that physical activity can mitigate, or even prevent, the short and long-term side effects patients experience due to cancer and its treatment.[[6]] Exercise during adjuvant chemotherapy is associated with improved chemotherapy completion rates.[[7,8]] This, in turn, can influence disease free and overall survival.[[9]]
Far less research has been done into the initial phase of the cancer continuum before surgery, which is dubbed prehabilitation. Prehabilitation in its simplest form is treatment that prepares a patient for an upcoming physiological stress.[[10]] As a concept, prehabilitation is not new. It is an established part of Enhanced Recovery after Surgery (ERAS) protocols that are currently operating in Aotearoa New Zealand hospitals. It can encompass exercise (strength and cardiovascular), nutrition optimisation, smoking cessation, and stress reduction interventions.[[11]] Prehabilitation in cancer can have multiple goals: 1) maintaining pre-operative baseline measurements of function, instead of having a degraded ‘baseline’ after treatment (surgery, and/or adjuvant treatment), 2) improving a pre-existing health problem to better prepare for cancer surgery and/or treatment, and/or 3) improving overall functioning, including psychological health and resilience, to better withstand upcoming treatments.
Prehabilitation programmes for patients with cancer have been shown to be safe and feasible even in a very short interval between diagnosis and treatment.[[12,13]] Potential benefits include improved physical function, quality of life, and psychological health.[[14–16]] These improvements can in turn influence length of hospital stay and reduce post-surgical complications.[[16]] Exercise may even influence tumorgenicity directly via molecular pathways.[[17]]
To date, research into prehabilitation in cancer has been heterogenous in its focus. Small sample sizes across various cancer populations and setting and modes of prehabilitation delivery show benefits, but are incongruous in their generalisability.[[18,19]] Little research has been done on prehabilitation in Aotearoa New Zealand. Patient engagement with prescriptive generalised prehabilitation interventions is mixed.[[20]] It is likely that benefits of prehabilitation are optimised by programmes being tailored to the needs of specific communities.
Current research
To address these issues, we are running a study in Tāmaki Makaurau Auckland to gain insight into the needs of patients with breast cancer in the period between diagnosis and surgery. This qualitative study aims to compare patients’ needs to the perception of prehabilitation held by healthcare providers. In doing so, we hope to understand the relationships and differences in existing narratives.
In this ongoing work, patients who have completed their treatment are invited to focus groups to reflect on what kind of supportive care, if any, they wanted during the period between diagnosis and surgery. The study has an a priori focus on Māori patients with separate hui run for patients and whānau identifying as Māori. Semi-structured interviews with health care providers—oncologists, surgeons, anaesthetists, nurse specialists, and physiotherapists—are underway to gain insight into their perception of prehabilitation for patients with cancer. A similar study with patients who have sarcoma is about to start.
Ultimately, identification of patients’ needs is the first step in our wider research programme, which will include participatory development and co-design of prehabilitation interventions.[[21,22]] In the coming year, patients, researchers and clinical team members will co-design a prehabilitation intervention that can be implemented and evaluated in the clinical setting. The hope is that this co-design process will lead to tailored, and thereby more effective, prehabilitation interventions in Tāmaki Makaurau.[[22]]
Special interest group
We have started a special interest group ‘Supportive care for people with cancer’ within the New Zealand Society for Oncology, in partnership with Te Aka Mātauranga Matepukupuku (Centre for Cancer Research, Waipapa Taumata Rau University of Auckland). Interested researchers from across Aotearoa New Zealand are welcome to contact us for nationwide collaborations (SIGSupportiveCancerCare@auckland.ac.nz ).
Summary
Abstract
Aim
Method
Results
Conclusion
Author Information
Acknowledgements
Correspondence
Correspondence Email
Competing Interests
1) Manatū Hauora – Ministry of Health. New Zealand Cancer Action Plan 2019–2029 [Internet]. Wellington: 2020 Feb 3 [cited 2022 Dec 16]. Available from: https://www.health.govt.nz/publication/new-zealand-cancer-action-plan-2019-2029.
2) Sung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, et al. Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA Cancer J Clin. 2021 May;71(3):209-249. doi: 10.3322/caac.21660.
3) Gurney J, Stanley J, McLeod M, Koea J, Jackson C, Sarfati D. Disparities in Cancer-Specific Survival Between Māori and Non-Māori New Zealanders, 2007-2016. JCO Glob Oncol. 2020 Jun;6:766-774. doi: 10.1200/GO.20.00028.
4) Jeffreys M, Sarfati D, Stevanovic V, Tobias M, Lewis C, Pearce N, et al. Socioeconomic inequalities in cancer survival in New Zealand: the role of extent of disease at diagnosis. Cancer Epidemiol Biomarkers Prev. 2009 Mar;18(3):915-21. doi: 10.1158/1055-9965.EPI-08-0685.
5) Schmitz KH, Campbell AM, Stuiver MM, Pinto BM, Schwartz AL, Morris GS, et al. Exercise is medicine in oncology: Engaging clinicians to help patients move through cancer. CA Cancer J Clin. 2019 Nov;69(6):468-484. doi: 10.3322/caac.21579.
6) Cormie P, Zopf EM, Zhang X, Schmitz KH. The Impact of Exercise on Cancer Mortality, Recurrence, and Treatment-Related Adverse Effects. Epidemiol Rev. 2017 Jan;39(1):71-92. doi: 10.1093/epirev/mxx007.
7) An KY, Arthuso FZ, Kang DW, Morielli AR, Ntoukas SM, Friedenreich CM, et al. Exercise and health-related fitness predictors of chemotherapy completion in breast cancer patients: pooled analysis of two multicenter trials. Breast Cancer Res Treat. 2021 Jul;188(2):399-407. doi: 10.1007/s10549-021-06205-8.
8) van Waart H, Stuiver MM, van Harten WH, Geleijn E, Kieffer JM, Buffart LM, et al. Effect of Low-Intensity Physical Activity and Moderate- to High-Intensity Physical Exercise During Adjuvant Chemotherapy on Physical Fitness, Fatigue, and Chemotherapy Completion Rates: Results of the PACES Randomized Clinical Trial. J Clin Oncol. 2015 Jun 10;33(17):1918-27. doi: 10.1200/JCO.2014.59.1081.
9) Courneya KS, Segal RJ, McKenzie DC, Dong H, Gelmon K, Friedenreich CM, et al. Effects of exercise during adjuvant chemotherapy on breast cancer outcomes. Med Sci Sports Exerc. 2014 Sept;46(9):1744-51. doi: 10.1249/MSS.0000000000000297.
10) Stout NL, Silver JK, Baima J, Knowlton SE, Hu X. Prehabilitation: An Emerging Standard in Exercise Oncology. In: Schmidt, K editor. Exercise Oncology. Switzerland: Springer International Publishing; 2020. p. 111-43. doi: 10.1007/978-3-030-42011-6_6
11) Santa Mina D, Brahmbhatt P, Lopez C, Baima J, Gillis C, Trachtenberg L, et al. The Case for Prehabilitation Prior to Breast Cancer Treatment. PM R. 2017 Sep;9(9S2):S305-S316. doi: 10.1016/j.pmrj.2017.08.402.
12) Brahmbhatt P, Sabiston CM, Lopez C, Chang E, Goodman J, Jones J, et al. Feasibility of Prehabilitation Prior to Breast Cancer Surgery: A Mixed-Methods Study. Front Oncol. 2020 Sep 25;10:571091. doi: 10.3389/fonc.2020.571091.
13) Wu F, Laza‐Cagigas R, Pagarkar A, Olaoke A, El Gammal M, Rampal T. The Feasibility of Prehabilitation as Part of the Breast Cancer Treatment Pathway. PM&R. 2021 Nov 3;13(11):1237-46. doi: 10.1002/pmrj.12543.
14) Toohey K, Hunter M, McKinnon K, Casey T, Turner M, Taylor S, et al. A systematic review of multimodal prehabilitation in breast cancer. Breast Cancer Res Treat. 2023 Jan;197(1):1-37. doi: 10.1007/s10549-022-06759-1.
15) Daniels SL, Lee MJ, George J, Kerr K, Moug S, Wilson TR, et al. Prehabilitation in elective abdominal cancer surgery in older patients: systematic review and meta-analysis. BJS Open. 2020 Sep 22;4(6):1022-41. doi: 10.1002/bjs5.50347.
16) Burnett C, Bestall JC, Burke S, Morgan E, Murray RL, Greenwood-Wilson S, et al. Prehabilitation and Rehabilitation for Patients with Lung Cancer: A Review of Where we are Today. Clin Oncol (R Coll Radiol). 2022 Nov;34(11):724-732. doi: 10.1016/j.clon.2022.08.028.
17) Ligibel JA, Dillon D, Giobbie-Hurder A, McTiernan A, Frank E, Cornwell M, et al. Impact of a Pre-Operative Exercise Intervention on Breast Cancer Proliferation and Gene Expression: Results from the Pre-Operative Health and Body (PreHAB) Study. Clin Cancer Res. 2019 Sep 1;25(17):5398-5406. doi: 10.1158/1078-0432.CCR-18-3143.
18) Esser T, Zimmer P, Schier R. Preoperative exercise and prehabilitation. Curr Opin Anaesthesiol. 2022 Dec 1;35(6):667-673. doi: 10.1097/ACO.0000000000001188.
19) Schier R, Levett D, Riedel B. Prehabilitation: The next challenge for anaesthesia teams. Eur J Anaesthesiol. 2020 Apr;37(4):259-262. doi: 10.1097/EJA.0000000000001167.
20) West MA, Jack S, Grocott MPW. Prehabilitation before surgery: Is it for all patients? Best Pract Res Clin Anaesthesiol. 2021 Dec;35(4):507-516. doi: 10.1016/j.bpa.2021.01.001.
21) Baum F, MacDougall C, Smith D. Participatory action research. J Epidemiol Community Health. 2006 Oct;60(10):854-7. doi: 10.1136/jech.2004.028662.
22) Neuhauser L. Integrating Participatory Design and Health Literacy to Improve Research and Interventions. Stud Health Technol Inform. 2017;240:303-329.
For the PDF of this article,
contact nzmj@nzma.org.nz
View Article PDF
Cancer is the leading cause of death in Aotearoa New Zealand.[[1]] New Zealand has the second-highest age-standardised cancer incidence rate in the world (422.9 per 100,000 people). As a result, most people in Aotearoa New Zealand will encounter a cancer diagnosis within their lifetime, either directly or through whānau.[[2]] Māori, who make up 16% of the Aotearoa New Zealand population, have a disproportionately high cancer related mortality.[[3,4]]
Historically, rest and outright inactivity were recommended for patients with cancer. However, over the last two decades research has highlighted the benefits of physical activity during the cancer continuum, so much so that the American College of Sports Medicine is running an ‘Exercise Is Medicine’ initiative.[[5]] This cancer continuum is divided into four phases: 1) post-diagnosis to first treatment, 2) active treatment with chemotherapy, radiotherapy, hormonal, and/or immunotherapy, 3) survivorship, after cessation of treatment, and 4) the palliative phase. To date, most rehabilitation related studies have focused on the phases of active treatment and/or cancer survivorship. These have shown that physical activity can mitigate, or even prevent, the short and long-term side effects patients experience due to cancer and its treatment.[[6]] Exercise during adjuvant chemotherapy is associated with improved chemotherapy completion rates.[[7,8]] This, in turn, can influence disease free and overall survival.[[9]]
Far less research has been done into the initial phase of the cancer continuum before surgery, which is dubbed prehabilitation. Prehabilitation in its simplest form is treatment that prepares a patient for an upcoming physiological stress.[[10]] As a concept, prehabilitation is not new. It is an established part of Enhanced Recovery after Surgery (ERAS) protocols that are currently operating in Aotearoa New Zealand hospitals. It can encompass exercise (strength and cardiovascular), nutrition optimisation, smoking cessation, and stress reduction interventions.[[11]] Prehabilitation in cancer can have multiple goals: 1) maintaining pre-operative baseline measurements of function, instead of having a degraded ‘baseline’ after treatment (surgery, and/or adjuvant treatment), 2) improving a pre-existing health problem to better prepare for cancer surgery and/or treatment, and/or 3) improving overall functioning, including psychological health and resilience, to better withstand upcoming treatments.
Prehabilitation programmes for patients with cancer have been shown to be safe and feasible even in a very short interval between diagnosis and treatment.[[12,13]] Potential benefits include improved physical function, quality of life, and psychological health.[[14–16]] These improvements can in turn influence length of hospital stay and reduce post-surgical complications.[[16]] Exercise may even influence tumorgenicity directly via molecular pathways.[[17]]
To date, research into prehabilitation in cancer has been heterogenous in its focus. Small sample sizes across various cancer populations and setting and modes of prehabilitation delivery show benefits, but are incongruous in their generalisability.[[18,19]] Little research has been done on prehabilitation in Aotearoa New Zealand. Patient engagement with prescriptive generalised prehabilitation interventions is mixed.[[20]] It is likely that benefits of prehabilitation are optimised by programmes being tailored to the needs of specific communities.
Current research
To address these issues, we are running a study in Tāmaki Makaurau Auckland to gain insight into the needs of patients with breast cancer in the period between diagnosis and surgery. This qualitative study aims to compare patients’ needs to the perception of prehabilitation held by healthcare providers. In doing so, we hope to understand the relationships and differences in existing narratives.
In this ongoing work, patients who have completed their treatment are invited to focus groups to reflect on what kind of supportive care, if any, they wanted during the period between diagnosis and surgery. The study has an a priori focus on Māori patients with separate hui run for patients and whānau identifying as Māori. Semi-structured interviews with health care providers—oncologists, surgeons, anaesthetists, nurse specialists, and physiotherapists—are underway to gain insight into their perception of prehabilitation for patients with cancer. A similar study with patients who have sarcoma is about to start.
Ultimately, identification of patients’ needs is the first step in our wider research programme, which will include participatory development and co-design of prehabilitation interventions.[[21,22]] In the coming year, patients, researchers and clinical team members will co-design a prehabilitation intervention that can be implemented and evaluated in the clinical setting. The hope is that this co-design process will lead to tailored, and thereby more effective, prehabilitation interventions in Tāmaki Makaurau.[[22]]
Special interest group
We have started a special interest group ‘Supportive care for people with cancer’ within the New Zealand Society for Oncology, in partnership with Te Aka Mātauranga Matepukupuku (Centre for Cancer Research, Waipapa Taumata Rau University of Auckland). Interested researchers from across Aotearoa New Zealand are welcome to contact us for nationwide collaborations (SIGSupportiveCancerCare@auckland.ac.nz ).
Summary
Abstract
Aim
Method
Results
Conclusion
Author Information
Acknowledgements
Correspondence
Correspondence Email
Competing Interests
1) Manatū Hauora – Ministry of Health. New Zealand Cancer Action Plan 2019–2029 [Internet]. Wellington: 2020 Feb 3 [cited 2022 Dec 16]. Available from: https://www.health.govt.nz/publication/new-zealand-cancer-action-plan-2019-2029.
2) Sung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, et al. Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA Cancer J Clin. 2021 May;71(3):209-249. doi: 10.3322/caac.21660.
3) Gurney J, Stanley J, McLeod M, Koea J, Jackson C, Sarfati D. Disparities in Cancer-Specific Survival Between Māori and Non-Māori New Zealanders, 2007-2016. JCO Glob Oncol. 2020 Jun;6:766-774. doi: 10.1200/GO.20.00028.
4) Jeffreys M, Sarfati D, Stevanovic V, Tobias M, Lewis C, Pearce N, et al. Socioeconomic inequalities in cancer survival in New Zealand: the role of extent of disease at diagnosis. Cancer Epidemiol Biomarkers Prev. 2009 Mar;18(3):915-21. doi: 10.1158/1055-9965.EPI-08-0685.
5) Schmitz KH, Campbell AM, Stuiver MM, Pinto BM, Schwartz AL, Morris GS, et al. Exercise is medicine in oncology: Engaging clinicians to help patients move through cancer. CA Cancer J Clin. 2019 Nov;69(6):468-484. doi: 10.3322/caac.21579.
6) Cormie P, Zopf EM, Zhang X, Schmitz KH. The Impact of Exercise on Cancer Mortality, Recurrence, and Treatment-Related Adverse Effects. Epidemiol Rev. 2017 Jan;39(1):71-92. doi: 10.1093/epirev/mxx007.
7) An KY, Arthuso FZ, Kang DW, Morielli AR, Ntoukas SM, Friedenreich CM, et al. Exercise and health-related fitness predictors of chemotherapy completion in breast cancer patients: pooled analysis of two multicenter trials. Breast Cancer Res Treat. 2021 Jul;188(2):399-407. doi: 10.1007/s10549-021-06205-8.
8) van Waart H, Stuiver MM, van Harten WH, Geleijn E, Kieffer JM, Buffart LM, et al. Effect of Low-Intensity Physical Activity and Moderate- to High-Intensity Physical Exercise During Adjuvant Chemotherapy on Physical Fitness, Fatigue, and Chemotherapy Completion Rates: Results of the PACES Randomized Clinical Trial. J Clin Oncol. 2015 Jun 10;33(17):1918-27. doi: 10.1200/JCO.2014.59.1081.
9) Courneya KS, Segal RJ, McKenzie DC, Dong H, Gelmon K, Friedenreich CM, et al. Effects of exercise during adjuvant chemotherapy on breast cancer outcomes. Med Sci Sports Exerc. 2014 Sept;46(9):1744-51. doi: 10.1249/MSS.0000000000000297.
10) Stout NL, Silver JK, Baima J, Knowlton SE, Hu X. Prehabilitation: An Emerging Standard in Exercise Oncology. In: Schmidt, K editor. Exercise Oncology. Switzerland: Springer International Publishing; 2020. p. 111-43. doi: 10.1007/978-3-030-42011-6_6
11) Santa Mina D, Brahmbhatt P, Lopez C, Baima J, Gillis C, Trachtenberg L, et al. The Case for Prehabilitation Prior to Breast Cancer Treatment. PM R. 2017 Sep;9(9S2):S305-S316. doi: 10.1016/j.pmrj.2017.08.402.
12) Brahmbhatt P, Sabiston CM, Lopez C, Chang E, Goodman J, Jones J, et al. Feasibility of Prehabilitation Prior to Breast Cancer Surgery: A Mixed-Methods Study. Front Oncol. 2020 Sep 25;10:571091. doi: 10.3389/fonc.2020.571091.
13) Wu F, Laza‐Cagigas R, Pagarkar A, Olaoke A, El Gammal M, Rampal T. The Feasibility of Prehabilitation as Part of the Breast Cancer Treatment Pathway. PM&R. 2021 Nov 3;13(11):1237-46. doi: 10.1002/pmrj.12543.
14) Toohey K, Hunter M, McKinnon K, Casey T, Turner M, Taylor S, et al. A systematic review of multimodal prehabilitation in breast cancer. Breast Cancer Res Treat. 2023 Jan;197(1):1-37. doi: 10.1007/s10549-022-06759-1.
15) Daniels SL, Lee MJ, George J, Kerr K, Moug S, Wilson TR, et al. Prehabilitation in elective abdominal cancer surgery in older patients: systematic review and meta-analysis. BJS Open. 2020 Sep 22;4(6):1022-41. doi: 10.1002/bjs5.50347.
16) Burnett C, Bestall JC, Burke S, Morgan E, Murray RL, Greenwood-Wilson S, et al. Prehabilitation and Rehabilitation for Patients with Lung Cancer: A Review of Where we are Today. Clin Oncol (R Coll Radiol). 2022 Nov;34(11):724-732. doi: 10.1016/j.clon.2022.08.028.
17) Ligibel JA, Dillon D, Giobbie-Hurder A, McTiernan A, Frank E, Cornwell M, et al. Impact of a Pre-Operative Exercise Intervention on Breast Cancer Proliferation and Gene Expression: Results from the Pre-Operative Health and Body (PreHAB) Study. Clin Cancer Res. 2019 Sep 1;25(17):5398-5406. doi: 10.1158/1078-0432.CCR-18-3143.
18) Esser T, Zimmer P, Schier R. Preoperative exercise and prehabilitation. Curr Opin Anaesthesiol. 2022 Dec 1;35(6):667-673. doi: 10.1097/ACO.0000000000001188.
19) Schier R, Levett D, Riedel B. Prehabilitation: The next challenge for anaesthesia teams. Eur J Anaesthesiol. 2020 Apr;37(4):259-262. doi: 10.1097/EJA.0000000000001167.
20) West MA, Jack S, Grocott MPW. Prehabilitation before surgery: Is it for all patients? Best Pract Res Clin Anaesthesiol. 2021 Dec;35(4):507-516. doi: 10.1016/j.bpa.2021.01.001.
21) Baum F, MacDougall C, Smith D. Participatory action research. J Epidemiol Community Health. 2006 Oct;60(10):854-7. doi: 10.1136/jech.2004.028662.
22) Neuhauser L. Integrating Participatory Design and Health Literacy to Improve Research and Interventions. Stud Health Technol Inform. 2017;240:303-329.
Contact diana@nzma.org.nz
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Cancer is the leading cause of death in Aotearoa New Zealand.[[1]] New Zealand has the second-highest age-standardised cancer incidence rate in the world (422.9 per 100,000 people). As a result, most people in Aotearoa New Zealand will encounter a cancer diagnosis within their lifetime, either directly or through whānau.[[2]] Māori, who make up 16% of the Aotearoa New Zealand population, have a disproportionately high cancer related mortality.[[3,4]]
Historically, rest and outright inactivity were recommended for patients with cancer. However, over the last two decades research has highlighted the benefits of physical activity during the cancer continuum, so much so that the American College of Sports Medicine is running an ‘Exercise Is Medicine’ initiative.[[5]] This cancer continuum is divided into four phases: 1) post-diagnosis to first treatment, 2) active treatment with chemotherapy, radiotherapy, hormonal, and/or immunotherapy, 3) survivorship, after cessation of treatment, and 4) the palliative phase. To date, most rehabilitation related studies have focused on the phases of active treatment and/or cancer survivorship. These have shown that physical activity can mitigate, or even prevent, the short and long-term side effects patients experience due to cancer and its treatment.[[6]] Exercise during adjuvant chemotherapy is associated with improved chemotherapy completion rates.[[7,8]] This, in turn, can influence disease free and overall survival.[[9]]
Far less research has been done into the initial phase of the cancer continuum before surgery, which is dubbed prehabilitation. Prehabilitation in its simplest form is treatment that prepares a patient for an upcoming physiological stress.[[10]] As a concept, prehabilitation is not new. It is an established part of Enhanced Recovery after Surgery (ERAS) protocols that are currently operating in Aotearoa New Zealand hospitals. It can encompass exercise (strength and cardiovascular), nutrition optimisation, smoking cessation, and stress reduction interventions.[[11]] Prehabilitation in cancer can have multiple goals: 1) maintaining pre-operative baseline measurements of function, instead of having a degraded ‘baseline’ after treatment (surgery, and/or adjuvant treatment), 2) improving a pre-existing health problem to better prepare for cancer surgery and/or treatment, and/or 3) improving overall functioning, including psychological health and resilience, to better withstand upcoming treatments.
Prehabilitation programmes for patients with cancer have been shown to be safe and feasible even in a very short interval between diagnosis and treatment.[[12,13]] Potential benefits include improved physical function, quality of life, and psychological health.[[14–16]] These improvements can in turn influence length of hospital stay and reduce post-surgical complications.[[16]] Exercise may even influence tumorgenicity directly via molecular pathways.[[17]]
To date, research into prehabilitation in cancer has been heterogenous in its focus. Small sample sizes across various cancer populations and setting and modes of prehabilitation delivery show benefits, but are incongruous in their generalisability.[[18,19]] Little research has been done on prehabilitation in Aotearoa New Zealand. Patient engagement with prescriptive generalised prehabilitation interventions is mixed.[[20]] It is likely that benefits of prehabilitation are optimised by programmes being tailored to the needs of specific communities.
Current research
To address these issues, we are running a study in Tāmaki Makaurau Auckland to gain insight into the needs of patients with breast cancer in the period between diagnosis and surgery. This qualitative study aims to compare patients’ needs to the perception of prehabilitation held by healthcare providers. In doing so, we hope to understand the relationships and differences in existing narratives.
In this ongoing work, patients who have completed their treatment are invited to focus groups to reflect on what kind of supportive care, if any, they wanted during the period between diagnosis and surgery. The study has an a priori focus on Māori patients with separate hui run for patients and whānau identifying as Māori. Semi-structured interviews with health care providers—oncologists, surgeons, anaesthetists, nurse specialists, and physiotherapists—are underway to gain insight into their perception of prehabilitation for patients with cancer. A similar study with patients who have sarcoma is about to start.
Ultimately, identification of patients’ needs is the first step in our wider research programme, which will include participatory development and co-design of prehabilitation interventions.[[21,22]] In the coming year, patients, researchers and clinical team members will co-design a prehabilitation intervention that can be implemented and evaluated in the clinical setting. The hope is that this co-design process will lead to tailored, and thereby more effective, prehabilitation interventions in Tāmaki Makaurau.[[22]]
Special interest group
We have started a special interest group ‘Supportive care for people with cancer’ within the New Zealand Society for Oncology, in partnership with Te Aka Mātauranga Matepukupuku (Centre for Cancer Research, Waipapa Taumata Rau University of Auckland). Interested researchers from across Aotearoa New Zealand are welcome to contact us for nationwide collaborations (SIGSupportiveCancerCare@auckland.ac.nz ).
Summary
Abstract
Aim
Method
Results
Conclusion
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Acknowledgements
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Correspondence Email
Competing Interests
1) Manatū Hauora – Ministry of Health. New Zealand Cancer Action Plan 2019–2029 [Internet]. Wellington: 2020 Feb 3 [cited 2022 Dec 16]. Available from: https://www.health.govt.nz/publication/new-zealand-cancer-action-plan-2019-2029.
2) Sung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, et al. Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA Cancer J Clin. 2021 May;71(3):209-249. doi: 10.3322/caac.21660.
3) Gurney J, Stanley J, McLeod M, Koea J, Jackson C, Sarfati D. Disparities in Cancer-Specific Survival Between Māori and Non-Māori New Zealanders, 2007-2016. JCO Glob Oncol. 2020 Jun;6:766-774. doi: 10.1200/GO.20.00028.
4) Jeffreys M, Sarfati D, Stevanovic V, Tobias M, Lewis C, Pearce N, et al. Socioeconomic inequalities in cancer survival in New Zealand: the role of extent of disease at diagnosis. Cancer Epidemiol Biomarkers Prev. 2009 Mar;18(3):915-21. doi: 10.1158/1055-9965.EPI-08-0685.
5) Schmitz KH, Campbell AM, Stuiver MM, Pinto BM, Schwartz AL, Morris GS, et al. Exercise is medicine in oncology: Engaging clinicians to help patients move through cancer. CA Cancer J Clin. 2019 Nov;69(6):468-484. doi: 10.3322/caac.21579.
6) Cormie P, Zopf EM, Zhang X, Schmitz KH. The Impact of Exercise on Cancer Mortality, Recurrence, and Treatment-Related Adverse Effects. Epidemiol Rev. 2017 Jan;39(1):71-92. doi: 10.1093/epirev/mxx007.
7) An KY, Arthuso FZ, Kang DW, Morielli AR, Ntoukas SM, Friedenreich CM, et al. Exercise and health-related fitness predictors of chemotherapy completion in breast cancer patients: pooled analysis of two multicenter trials. Breast Cancer Res Treat. 2021 Jul;188(2):399-407. doi: 10.1007/s10549-021-06205-8.
8) van Waart H, Stuiver MM, van Harten WH, Geleijn E, Kieffer JM, Buffart LM, et al. Effect of Low-Intensity Physical Activity and Moderate- to High-Intensity Physical Exercise During Adjuvant Chemotherapy on Physical Fitness, Fatigue, and Chemotherapy Completion Rates: Results of the PACES Randomized Clinical Trial. J Clin Oncol. 2015 Jun 10;33(17):1918-27. doi: 10.1200/JCO.2014.59.1081.
9) Courneya KS, Segal RJ, McKenzie DC, Dong H, Gelmon K, Friedenreich CM, et al. Effects of exercise during adjuvant chemotherapy on breast cancer outcomes. Med Sci Sports Exerc. 2014 Sept;46(9):1744-51. doi: 10.1249/MSS.0000000000000297.
10) Stout NL, Silver JK, Baima J, Knowlton SE, Hu X. Prehabilitation: An Emerging Standard in Exercise Oncology. In: Schmidt, K editor. Exercise Oncology. Switzerland: Springer International Publishing; 2020. p. 111-43. doi: 10.1007/978-3-030-42011-6_6
11) Santa Mina D, Brahmbhatt P, Lopez C, Baima J, Gillis C, Trachtenberg L, et al. The Case for Prehabilitation Prior to Breast Cancer Treatment. PM R. 2017 Sep;9(9S2):S305-S316. doi: 10.1016/j.pmrj.2017.08.402.
12) Brahmbhatt P, Sabiston CM, Lopez C, Chang E, Goodman J, Jones J, et al. Feasibility of Prehabilitation Prior to Breast Cancer Surgery: A Mixed-Methods Study. Front Oncol. 2020 Sep 25;10:571091. doi: 10.3389/fonc.2020.571091.
13) Wu F, Laza‐Cagigas R, Pagarkar A, Olaoke A, El Gammal M, Rampal T. The Feasibility of Prehabilitation as Part of the Breast Cancer Treatment Pathway. PM&R. 2021 Nov 3;13(11):1237-46. doi: 10.1002/pmrj.12543.
14) Toohey K, Hunter M, McKinnon K, Casey T, Turner M, Taylor S, et al. A systematic review of multimodal prehabilitation in breast cancer. Breast Cancer Res Treat. 2023 Jan;197(1):1-37. doi: 10.1007/s10549-022-06759-1.
15) Daniels SL, Lee MJ, George J, Kerr K, Moug S, Wilson TR, et al. Prehabilitation in elective abdominal cancer surgery in older patients: systematic review and meta-analysis. BJS Open. 2020 Sep 22;4(6):1022-41. doi: 10.1002/bjs5.50347.
16) Burnett C, Bestall JC, Burke S, Morgan E, Murray RL, Greenwood-Wilson S, et al. Prehabilitation and Rehabilitation for Patients with Lung Cancer: A Review of Where we are Today. Clin Oncol (R Coll Radiol). 2022 Nov;34(11):724-732. doi: 10.1016/j.clon.2022.08.028.
17) Ligibel JA, Dillon D, Giobbie-Hurder A, McTiernan A, Frank E, Cornwell M, et al. Impact of a Pre-Operative Exercise Intervention on Breast Cancer Proliferation and Gene Expression: Results from the Pre-Operative Health and Body (PreHAB) Study. Clin Cancer Res. 2019 Sep 1;25(17):5398-5406. doi: 10.1158/1078-0432.CCR-18-3143.
18) Esser T, Zimmer P, Schier R. Preoperative exercise and prehabilitation. Curr Opin Anaesthesiol. 2022 Dec 1;35(6):667-673. doi: 10.1097/ACO.0000000000001188.
19) Schier R, Levett D, Riedel B. Prehabilitation: The next challenge for anaesthesia teams. Eur J Anaesthesiol. 2020 Apr;37(4):259-262. doi: 10.1097/EJA.0000000000001167.
20) West MA, Jack S, Grocott MPW. Prehabilitation before surgery: Is it for all patients? Best Pract Res Clin Anaesthesiol. 2021 Dec;35(4):507-516. doi: 10.1016/j.bpa.2021.01.001.
21) Baum F, MacDougall C, Smith D. Participatory action research. J Epidemiol Community Health. 2006 Oct;60(10):854-7. doi: 10.1136/jech.2004.028662.
22) Neuhauser L. Integrating Participatory Design and Health Literacy to Improve Research and Interventions. Stud Health Technol Inform. 2017;240:303-329.
Contact diana@nzma.org.nz
for the PDF of this article
Prehabilitation for patients with cancer in Aotearoa New Zealand
Historically, rest and outright inactivity were recommended for patients with cancer. However, over the last two decades research has highlighted the benefits of physical activity during the cancer continuum, so much so that the American College of Sports Medicine is running an ‘Exercise Is Medicine’ initiative.
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