As many of you may know, I have been involved in a project where we train our patients physically and psychologically before their cancer surgery. The project (which I described a couple of years ago in a blog post here) has won many awards, has reduced our length of stay by about 25% and reduced our postoperative complication rate by a staggering 60%. Not only that, but the complications our patients get are now less severe, so fewer of them need to be admitted to the intensive care unit.
What has really impressed me, however is how much more motivated our patients are. They are psychologically much more prepared for the operation – one of the most invasive and extensive that we perform – understanding it better and understanding the hard work they themselves have to put in. This month I had a patient who successfully stopped smoking at the first consultation, and by the time she came to surgery her sheer will to succeed was obvious.
In this week’s BMJ I read an editorial by Giles and Cummins on prehabilitation, discussing particularly its negative aspects. Some of the problems they suggested puzzled me, especially having seen how the patients I’ve treated responded.
Maybe I’ve misunderstood the message that it’s trying to convey, but I find the suggestion that patients may be too upset by their cancer diagnosis to engage in lifestyle modification and pre-habilitation insulting and patronising to our patients, as is the statement that our patients can’t process the additional information because they’re getting information overload already.
So are they really saying that because our patients have just been told they have cancer and need treatment they’re going to be too upset for us to be able to help them stop smoking and increase their exercise levels? In my experience the time of a cancer diagnosis is an immensely valuable moment when people re-assess their life and are very open to lifestyle modifications. To deny our patients this opportunity because they may be “upset” would be do do wrong by them. Our patients love the pre-habilitation programme we provide for them, and one of the points they always mention is how it gives them a chance to be active participants in their care rather than passive recipients.
Further down the article the authors caution against pre-habilitation for lower social class patients as they may be more resistant to interventions such as stopping smoking. I found this bizarre, as in our experience the high success we have in getting our patients to engage in our pre-hab programme is not dependent on social class, and in fact those patients stand to gain more benefit from the programme than better informed health conscious patients who will probably be quite fit to begin with.
The paternalistic tone in the article is something I thought we had left behind in the 1980’s, and I think it’s really important we don’t reinforce the stigma of cancer where we have to protect them from information or additional resources as they may be upset about their diagnosis. It is a difficult time for them, and the structure of a pre-habilitation programme is an immensely positive addition where our patients feel cared for, guided through the programme, and…yes…even loved.
traumagasdoc 
Fascinating read – thanks for sharing.
LikeLike
Interesting post! I totally agree with you regarding the argument that the feeling that patients may be overloaded with information and that they should be spared valuable information regarding how they could improve their recovery seems outdated.
However, I think that the authors in BMJ have a strong point when it comes to the actual scientific evidence for prehabilitation before surgery. To just say that “preoperative physical activity interventions” can improve several aspects of recovery after “cancer surgery” is not far from stating that medications can help people with disease. I would say that there is still a need for further research to make evidence-based recommendations on prehabilitation before cancer surgery, perhaps with the exception of thoracic cancer surgery where inspiratory muscle training seems to be of benefit. What duration is needed? Intensity? Are instructions to perform interventions at home enough or do you need to invest in supervised training several times each week? What about exercise modalities? And what about diagnoses? It is reasonable to think that preoperative breathing exercise may decrease lung complications after lung cancer surgery, but less probable that it would have the same effect after breast cancer surgery or malignant melanoma excision. Without specific interventions that have been shown effective for specific types of operations, I would agree that the authors are, to some degre, right that we shouldn’t add responsibility to the patients, but rather focus on lifestyle interventions that we know are effective in clinical praxis, e.g. smoke cessation. But of course we should aim to increase the scientific evidence for prehabilitation in order to be able to implement it in clinical praxis.
I’m interested in the PREPARE program. Has it been scientifically reported?
LikeLike