Stronger Before Surgery: Better Pre-Surgical Fitness Could Improve Recovery

When J. Timothy Sherwood, M.D., a thoracic surgeon at Mary Washington Healthcare in Fredericksburg, Virginia, sees new patients slated for lung cancer surgery, he has his own preliminary assessment system: Can they climb up and down a flight of stairs? “It’s an easy, effective way to find out if patients are ready for surgery,” Sherwood says.

Beth Ann Palmento, 79, failed the test — she could barely make it up one flight of stairs. She had received a diagnosis of stage 1A lung cancer in 2015 and had a good prognosis from the stand point of her cancer. But she also had a range of other health problems, including chronic obstructive pulmonary disease (COPD) and arthritis. Therefore, Sherwood thought she might do even better if she participated in a program being piloted at Mary Washington: prehabilitation, or prehab, which focuses on getting patients in shape before surgery to make it easier for them to recover afterward. In addition to exercise, prehab might include nutrition counseling, smoking cessation and stress reduction.

Sherwood’s initial suspicions were confirmed following a more comprehensive assessment. He found that Palmento had several issues, including arthritis, limited mobility due to knee and back problems, and shortness of breath. “I told her that she would likely experience poor outcomes following surgery and would need to go to a rehabilitation facility to recover,” Sherwood recalls. “After hearing that news, she decided to try prehab.”

Twice a week for about six weeks, Palmento went to Mary Washington for an exercise session. Her regimen included walking on a treadmill and riding a stationary bike to increase aerobic endurance and using resistance bands to build strength. Although Palmento diligently attended her exercise sessions, when she went back for her second assessment, she received disappointing news. “I still wasn’t ready,” she says.

After another week, Sherwood gave the green light for surgery and performed the procedure. Palmento did even better than expected. “She was out of the hospital in two days and was able to go home, not to a rehab facility,” Sherwood says. “And she only needed oxygen at home for about three weeks. After four weeks of outpatient rehab at Mary Washington, she returned to the YMCA to continue regular exercise in her community.”

Palmento is grateful that she had prehab before her surgery. “I still have my health problems,” she says. “I have COPD and allergies, but I’m cancer-free and able to live a full life. Prehab made me strong enough for the surgery. I feel very lucky.”

THE VALUE OF PREHAB

The pilot program at Mary Washington, although small, showed that prehab could improve outcomes. Of the 12 patients referred to the program over a 17-month period, six completed the full program. These patients showed a 21 percent improvement in their ability to walk or the distance they could cover. Importantly, their length of stay in the hospital was shortened, from the average duration of five days to three days.

“A shorter period of time in the hospital is good news for insurance companies,” Sherwood says. “That means they’re more likely to cover prehab because it will save money in the long run. Insurance coverage removes a key barrier for patients.”

Other researchers have reported similar outcomes. Roberto Benzo, M.D., a pulmonary and critical care physi­cian at Mayo Clinic in Rochester, Minnesota, and colleagues conducted a small study of 19 patients, published in Lung Cancer in 2011, comparing the standard of care exercise protocol for patients with COPD and lung cancer with a customized protocol. The customized version took place over 10 sessions and included exercise, muscle training and slow breathing, which not only expanded lung function but also served as a stress-reduction activity. Like the pilot program at Mary Washington, the findings showed that the customized plan led to a shorter length of stay following surgery and fewer days when patients needed a chest tube. The researchers concluded that short-term prehab may improve outcomes following surgery.

Julie Silver, M.D., an associate professor of physical medicine and rehabilitation at Harvard Medical School and associate chair at the Spaulding Rehabilitation Network, both in Boston, was instrumental in spreading the word about prehab. She and a colleague conducted the first literature review on prehab in 2013, which brought this topic front and center for the cancer community. “Prehab has been around for a while,” Silver says. “During World War II, programs were in place to help soldiers become stronger before going into a war zone. By placing prehab as the first phase in the cancer care continuum, we’re hoping to show that it can make patients stronger before having surgery or another form of treatment.”

Silver believes that in a perfect world, prehab would be more than just exercise. Patients with cancer should follow a regimen similar to that of runners training for the Boston Marathon. “Runners supplement their diet with protein to help build up their muscle mass, which cancer patients should do as well,” Silver says. “If anyone in either group is still smoking, those individuals should stop. Lifestyle changes like these can help both groups cross the finish line, either by completing the race or having a better recovery following treatment.”

Although not yet widespread, prehab can be found in some community programs in addition to academic institutions. About 10 years ago, Carol Michaels, a cancer exercise specialist trainer based in West Orange, New Jersey, saw a need for both prehab and rehab after many friends and neighbors received a cancer diagnosis. “(They) were told not to do a whole lot,” Michaels says. “But I knew that inactivity and staying in bed was the wrong approach and could cause other problems.”

After doing her own research and working with family members who were physicians, Michaels created a program called Recovery Fitness, which emphasizes breathing, stretching and aerobic exercise. The aerobic component might be an easy walk outdoors with a friend or family member.

“For lung cancer patients not in optimal physical condition, I see prehab as mandatory,” Michaels says. “If nothing else, prehab can provide a baseline fitness level that can be used as a point of comparison down the road. But I’ve also seen many benefits, including increased lung capacity, improved endurance and strength, less fatigue and a higher overall quality of life.”

THE DEBATE

Not all oncologists and surgeons are convinced that prehab is the best approach for patients with lung cancer. One area of concern is the timing — prehab can delay when the patient undergoes surgery. For Sherwood, however, the benefits outweigh that concern. “Patients are often getting other tests during the period immediately following diagnosis,” he says. “Given that these patients have a more meaningful treatment plan, I don’t see the time lag as problematic.”

Other surgeons disagree. An Ngo-Huang, D.O., a physi­cian specializing in physical medicine and rehabilitation at The University of Texas MD Anderson Cancer Center in Houston, notes that the center’s thoracic surgeons often offer surgery soon after diagnosis of early-stage lung cancer but would consider delaying for prehab if patients were frail or weak.

However, some findings suggest that intensive exercise during that two-week pre-surgical period can be effective. For example, a study conducted in China in 2016 with 101 patients with lung cancer showed that intensive daily exercise over a seven-day period increased the distance they were able to walk over a six-minute period and improved their lung capacity. It also reduced their length of hospital stay and the occurrence of post-operative complications.

There are barriers to prehab. “Insurance companies typically cover only two to three days of prehab per week,” Ngo-Huang says. “Another issue at our institution is that many patients are from out of town. They don’t have the time to stay for two additional weeks to have prehab, and even if we write them a prescription for prehab at home, we have no way of knowing if they follow through.”

MD Anderson has a randomized prehab clinical trial for patients with early-stage pancreatic cancer, which is a home-based, remote exercise program supervised by Ngo-Huang and the multidisciplinary team, which includes a surgical oncologist, medical oncologist, kinesiologist, dietician and cancer biologist. Participants often undergo four to six weeks of chemotherapy or radiation to shrink the tumor before surgery, followed by a rest period. Because there is a built-in time lag between treatment and surgery, the medical and radiation oncologists and surgeons on the team feel comfortable using this period for prehab. In fact, this window has proved to be the optimal time to initiate a prehab program. Regardless of cancer type, the American Cancer Society and American College of Sports Medicine recommend that cancer survivors engage in 150 minutes of moderate-intensity exercise and two sessions of strengthening exercises each week. The patients with pancreatic cancer in the prehab trial at MD Anderson are following these recommendations. Ngo-Huang also advises patients with lung cancer, who can exercise safely, to follow these recommendations. The exercise may be as simple as going for a 30-minute walk each day.

Just as the care for patients with pancreatic cancer is shifting, so too is it for patients with lung cancer. What is making a difference is the use of low-dose computed tomography (LDCT) screening. As a result of 2013 guidelines that recommended annual LDCT screening for adults age 55 to 80 who have a history of smoking, currently smoke or quit within the past 15 years, Medicare now covers LDCT. But even three years before these guidelines took effect, the National Lung Screening Trial showed a 16 percent reduction in lung cancer mortality because of LDCT screening.

LDCT screening also has another benefit — more patients receive a cancer diagnosis when the disease is at an earlier stage, increasing their chances for long-term survival. What’s more, because their cancer burden isn’t as great as that of those diagnosed at a later stage, these patients may be healthier and in better physical shape.

These factors will likely play a role in how prehab evolves. Although the findings are still emerging, some researchers think that prehab may be a key player in this changing environment. In a 2017 paper, researchers concluded that more patients would be eligible for prehab, but their better health status at the time of diagnosis could result in modifications to the program. For example, the length of time of prehab may need to be shortened. More research is needed to determine the optimal degree of prehab and the best candidates.

In the meantime, thoracic surgeons like Sherwood remain fans of prehab. “I’m passionate about this program,” Sherwood says. “When I see cancer-free patients like Beth Ann who, four years out, are vibrant and physically active, it’s pretty inspiring. Patients like her are the reason why we’re doing all this.”