Prehabilitation or ‘prehab’ is a new term that has gained a lot of traction over the last few years and encompasses anyone undergoing a medical treatment. Macmillan Cancer Support released guidelines in 2019 in partnership with the Royal College of Anaesthetists and the National Institute of Health Research Cancer and Nutrition Collaboration highlighting the need for prehab before surgery or oncological treatment.
Prehab can start quite early and focuses on the time period from cancer diagnosis with some centres started pre diagnosis to treatment and aims to improve health, fitness and mentally prepare patients for the physical and psychological stress of the treatment they are about to receive. Prehab aims to makes patients feel empowered following their cancer diagnosis and build physical and mental resilience to the effects of treatment and improve recovery from treatment. Even 2 weeks of prehab have been shown to have beneficial outcomes post operatively. Prehab concentrates on 3 main areas which are interlinked. These are:
Exercise and physical activity
Mental Health and wellbeing
In a nut shell if you decided to run a marathon you would prepare for it. You would either increase or start exercising to increase stamina and prepare the body for the stress of the marathons. You would assess your diet, looking at the best way to fuel your body for the race focusing on energy, protein and other nutrients. By training for the marathon you are also mentally preparing yourself for the race, knowing when to dig deep when you get tired and it gets hard, and figuring out what keeps you going to make it to the finish line. Except for prehab the focus is on preparing you for the treatment that you are about to have, the stress the body will experience, the nutrition that you will need for recovery, to ensure patients are fit enough to have treatment and the mental resilience that you need deal with the diagnosis and any changes following treatment. For head and neck cancer patients treatment can be long and protracted, having surgery followed by radiotherapy with or without chemotherapy. As I dietitian I will focus more on a dietary perspective of prehab.
Recent studies in lung, colorectal and upper gastrointestinal cancers have shown prehab to be beneficial in reducing complications post-surgery such as infections, reducing hospital stay, dealing with the side effects of chemo and radiotherapy better, and improving longer term health. Prehabilitation also aims to improve patients rehabilitation following their treatment, helping patients get back to their everyday life quicker.
For the majority of patients general lifestyle advice will be given on how to increase their exercise levels, help to stop smoking and advice around healthy eating and diet. Longer term cutting down on smoking and drinking alcohol can help prevent head and neck cancer returning and in the case of radiotherapy smoking cessation will improve treatment outcomes compared to someone who smokes during treatment. Dietary advice may also be given alongside an exercise programme to help build muscle prior to treatment.
However some patients will need specialised advice due to weight loss, diabetes, malnutrition or frailty. These patients are identified through screening to receive targeted advice. Some patients who are diagnosed with head and neck cancer can become malnourished before treatment due to pain when eating and chewing, reduced mouth opening and reduced tongue movement making eating more difficult and leading to weight loss. For these patients healthy eating advice is not appropriate. Dietitians will work with patients and other MDT members to overcome some of these barriers e.g. addressing pain relief so patients are out of pain when they are eating and drinking and are therefore able to have bigger portion sizes or changing the texture of diet to soft, mashable or pureed options. Patients who are struggling with eating and drinking will be advised on a high protein high energy diet. This is where the focus in on increase the energy and protein content of foods without trying to increase the portion size e.g. adding cheese to soup, jam or golden syrup to porridge or ready break or snacking on yoghurts. Patients may also find that they are advised to have nutritional supplements. These are supplements that are high in protein, energy and vitamins and minerals, correcting and nutritional deficiencies prior to treatment. In some cases enteral feeding (having feed through a feeding tube) may be recommended to build patients up for treatment.
Dietitians may also take various measurements including weight. Dietitians look at weight differently and will take into consideration a patients muscle mass when weighing patients. When patients become malnourished they can lose muscle mass as well as fat mass. In part it is our muscle mass that helps us to recovery and deal with the side effects of cancer treatment better and we aim to preserve and/or increase this prior to treatment.
Some cancer centres have developed their own prehab services and the level of prehab offered nationally differs from centre to centre and who you will see there as part of the team will differ.
Author: Rebekah Smith, May 2022
Specialist Dietitian ENT & Max Facs
Therapy - University Hospitals Birmingham, NHS Foundation Trust Queen Elizabeth Hospital Birmingham
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