Abstract
Neoadjuvant chemotherapy (NAC) and surgery improves survival in patients with locally advanced oesophagogastric (OG) cancer. Adequate cardiopulmonary fitness is vitally important to patients undergoing OG cancer resection as this major operation is associated with a large metabolic stress response and significant morbidity. Side effects of NAC are a reduction in cardiopulmonary fitness, skeletal muscle loss, and poor quality of life (QOL). Cardiopulmonary fitness can be objectively measured by cardiopulmonary exercise testing (CPET); an established, non-invasive, and safe method of assessing patients’ cardiopulmonary reserve prior to surgery. Reduced anaerobic threshold (AT) and peak oxygen uptake (peak VO2) are associated with increased morbidity and poor functional outcomes in patients undergoing major surgery. NAC is associated with an AT decrease of 2ml/kg/min in OG cancer patients.
A parallel-arm, randomised, controlled trial was conducted to determine whether a prehabilitation programme improves CPET performance prior to surgery in patients with OG cancer undergoing NAC. Patients were randomised to receive a 15-week prehabilitation programme (Prehabilitation) or standard care (Control). Prehabilitation comprised twice-weekly supervised plus thrice-weekly home exercise sessions (aerobic and resistance based) and six sessions of medical coaching. Secondary outcomes included change in skeletal muscle mass observed via computed tomography following NAC, anthropometric measures including hand-grip strength (HGS), QOL, insulin resistance (using HOMA-IR), and clinical outcomes.
There was a significant difference in peak VO2 change following NAC (Prehabilitation +0.5% versus Control -10.0%;p=0.022). No difference in AT was observed. Prehabilitation subjects experienced less skeletal muscle loss despite NAC and showed improvements in functional outcomes (HGS). There were significant improvements in the Prehabilitation group across a multitude of QOL parameters.
There were no exercise-related adverse events, and good programme compliance was observed. This study has thus shown that an exercise and psychological prehabilitation programme is safe and achievable in OG patients receiving NAC prior to surgical resection.