Multimodal Prehabilitation – the road to personalized surgery

Multimodal Prehabilitation – the road to personalized surgery

by Rasmus Dahlin Bojesen, PhD student, MD

It is almost intuitive that low functional capacity, weight loss, malnutrition, anemia, and neuropsychological problems all are associated with an increased risk of complications after surgery. Undergoing surgery is a major physical performance, which takes a toll on the physical reserves of the patients and through the physical trauma introduces inflammation and immunosuppression. Even under the best of care many of the vulnerable patients still develop complications. For younger and fit patients, a complication can for most cases be rehabilitated, however for the elderly and vulnerable patient the consequences are often permanent loss of function, decline in quality of life, increased risk of recurrence and long-term mortality.

If low physical fitness is associated with increased risk of complications by the trauma of surgery surpassing the physical capacity of the patient, why not increase the physical fitness of these patients and make them fit for surgery?

Preoperative optimization through non-pharmacological means, such as physical training, dietary optimization, and psychological coping with the aim of improving the functional capacity prior to surgery have been coined Prehabilitation. The central idea is to consider the surgery as any major physical performance, and the preoperative period as an opportunity for training and optimization of the physical reserve. As any athlete knows, this requires the right training, the right mindset, the right diet, protein, vitamin, and minerals supplementation. Recent studies and meta-analyses have shown that there is substantial synergy between these interventions and that the interventions should be individually tailored to the patient. By using this approach, studies have shown that individualized multimodal prehabilitation can reduce the risk of complications and may reduce the risk of recurrence in cancer patients. However, it remains unclear, who would benefit the most from which interventions and in which combinations.

We have long known that increased physical capacity is associated with decreased risk of developing cancer. But the underlying biological mechanisms have not been known until recently. Recent evidence suggests that exercise and training improve the part of the immune system that is able to ‘fight’ cancer cells and reduce chronic inflammation. This could maybe explain why patients that undergo prehabilitation have reduced risk of recurrence, however little is currently known, and further investigation is needed. 

CSS is currently conducting several trials with the focus on prehabilitation and participating in the international randomized clinical multicenter study ‘PREHAB’ with colleagues from the Netherlands, Canada, Spain and Italy. We are exploring the immunological effects of the prehabilitation and will strive to identify which patients should receive prehabilitation which will be the first step on the road to trully personalized surgery.