Transcription:
Training for Cancer Treatment: What is Prehabilitation?

Bill Klaproth (Host): Prehab before surgery or chemotherapy is done to improve outcomes after procedures. Here to tell us more about prehabilitation training for cancer treatment, is Carolyn Miller, Physical Therapist, at Roswell Park Comprehensive Cancer Center. Carolyn, thank you for being on with us. What is prehabilitation before cancer treatment?

Carolyn Miller (Guest): Sure, so cancer prehabilitation is the idea of intervention in the preoperative period or the acute pretreatment period. It’s between the time of the cancer diagnosis and then the beginning of treatment, which could be chemo, it could be radiation, it could be surgery. Prehab is going to establish a baseline functional level, look at any impairments the patient currently has, and then provide interventions that help improve these before the actual treatment that the patient may be receiving.

Bill: So, you’re getting some baseline benchmark-type measurements? Is it similar, then to physical therapy after that, where people are stretching and strengthening, and basically, exercising? Does it entail that, too?

Carolyn: Yeah, so based on the baseline information that we receive – if they have a limitation in balance, we’re going to work on the balance. If it’s a limitation in strength, we’re going to be doing strengthening exercises. If there’s a limitation regarding pain, then we want to address that. The goal of the prehab is basically to – the better you’re feeling and doing and moving before the surgery or chemo, the better you’re going to do after the fact, as well.

Bill: And who is a good candidate for prehab?

Carolyn: Prehab could be good for anyone. We can assess anyone before any of these treatments. Prime candidates are patients who have comorbidities or functional limitations prior to even prior to coming to treatment -- maybe they already need the use of an assistive device, or they already have pain levels that affect their abilities to do their activities of daily living. If they have any comorbidities that might affect the treatment they’re going to be receiving then they’re ideal to be seen. We see patients before all sorts of different treatments.

Bill: Carolyn, do you do this for all cancer treatments or is this only beneficial for certain types of cancers or treatments?

Carolyn: Yeah, so this can be for any type of treatment for any type of cancer. Currently, we’re seeing patients prior to a cystectomy – which is a bladder removal – we’re seeing a lot of those patients before their surgery. We also see patients prior to prostate removal, and we’re working on pelvic floor training with them. We see people before a thoracic surgery and before bone marrow transplants. We see a lot of patients before radiation treatment to improve possibly the range of motion that they need in order to receive the radiation treatment correctly. But we really have the potential to see any type of cancer patient before any type of surgery, chemo, or radiation treatment.

Bill: And how do you personalize these prehab assignments?

Carolyn: When we evaluate a patient here at prehab, we’re looking at the individual and their specific limitations along with any comorbidities that they might have to develop a good treatment plan and optimize their functional status. If a patient comes in – we could have two patients that are both coming for a similar procedure – maybe two patients that are both coming for a bone marrow transplant. One patient may have very different limitations than another, so we have to look at how is their balance, how is their walking, how was their strength, how was their pain levels, and then their treatment plan is going to be based on those impairments for each individual.

Bill: Okay, so afterward, then – you get this baseline, as you say – afterward, then you understand what that baseline is after the cancer treatment and then you work to improve it from there?

Carolyn: Yeah, so we get these baseline measurements the first day that we see the patient, and those are things that we can reassess to see if they are improving. We can reassess specific outcome measures such as how many times you can do a sit-to-stand in 30 seconds. That’s a test of leg strength. We can reassess that in a few week and see if it’s improving, and then we can reassess it again post-surgically, along with seeing how this is affecting patients’ length of stay or if they’re having less complications after the surgery because they had this pre-rehab treatment. And research is good with prehab. It is showing positive effects on these patients with the intervention.

Bill: I would think mentally, prehab would help with rehab because people would be familiar with their physical therapist, the process, how it works, does that play into it too?

Carolyn: Yes, that’s exactly right. A specific population again, bone marrow transplant patients, we see a lot of them before their transplant, and then in the hospital they’re followed by a physical therapist in their inpatient stay, and then they already know the therapist and they’re coming back as an outpatient to again, return to that prior level of function. We see that a lot with those type of patients. The same thing could be true to someone having lung cancer, and I’m seeing them before surgery to increase their exercise capacity, and then they have their surgery, and I’m seeing them postop as well to get them back to all of their normal, daily tasks.

Bill: You were telling us earlier, a list of cancer treatments that you would normally do prehab for, could you tell us what cancers you would not do prehab for?
Carolyn: I don’t know that there is any specific type of cancer that we would be avoiding prehab for. I think the people that may not need prehab is the person who is going into treatment and they haven’t really been affected by cancer. Their functional status is the same as it was, they’re still doing everything that they were doing before, they’re still exercising on a regular basis, then they may not need prehab. Even in those instances, there may be education we’re able to provide to the patient about how important it is to keep moving and specific exercises for them to do during their cancer treatment.

Bill: Even with somebody who has brain cancer, you’re still going to do prehab with them because I imagine sometimes balance might be affected? Is that correct?

Carolyn: Yes, exactly. We do see people here before intervention with brain cancer – or during the intervention. Maybe during their radiation therapy, I’m seeing the patient. You might be working on balance impairments, gait impairments -- the way that they’re walking, there could be strength deficits on one side or the other; there could be coordination problems, and those are all things that we can work on before their treatment, during their treatment, and after their treatment.

Bill: What a wonderful service this is. Can you tell us about the Prehab Services at Roswell Park Comprehensive Cancer Center?

Carolyn: Sure, so basically, we have an outpatient therapist here – it’s usually me, Carolyn – and like I said, we evaluate the patient when they first come in. This is open to all patients that are current patients at Roswell Park. They just need a referral from their doctor. After the evaluation, we determine if the patient needs to come for formal, individualized treatments, or if maybe we need to give them a home exercise program and follow up with them in a few weeks, and just take it from there.

Bill: And how long does Prehab generally last?

Carolyn: It’s ideal to try to see a patient for about four weeks to see any true changes in functional outcomes in impairments like strength and endurance. Everyone is different with how frequently they need to come to rehab – sometimes they only need to come once a week, or maybe they are doing everything at home that we gave them, so I’m just seeing them once every two weeks. Whereas, some people, who are getting closer to the treatment that they might be having, then I might be seeing them two times a week for four weeks until the actual surgery date or the start of their chemotherapy or whatever the plan is for them.

Bill: Carolyn, is this something new, or do most hospitals offer this?

Carolyn: This is definitely more newly established program, and I think Roswell is really getting ahead of the curve by offering this to patients. We are seeing more research now about the effectiveness of prehab on specifically, cancer populations. There has been research in the cystectomy population, so bladder cancer and bladder removal, that the prehab patients – the patients that are receiving the prehab are recovering to at-baseline or above-baseline capacity, 8-weeks postsurgery if they have this prehab.

This is also true in lung cancer populations. The therapy has been shown to increase their oxygen saturation, improve their exercise capacity, and reduce hospital stays. As I said, we also see urinary incontinence problems after and before pelvic floor – like prostate cancer interventions. Prehab has also been shown to improve continence outcomes in those patients as well. There has been a lot more research out about cancer and the effects of prehab and how this can improve outcomes after the patients’ surgery, or chemo, or transplant, radiation therapy, all of those.

Bill: Those are very encouraging numbers. Carolyn, thank you so much, for your time today. For more information, you can visit RoswellPark.org, that’s RoswellPark.org. You’re listening to Cancer Talk with Roswell Park Comprehensive Cancer Center. I’m Bill Klaproth. Thanks so much, for listening.