Background
Surgery is the mainstay treatment for people with newly diagnosed prostate and colorectal cancer (CRC) on a curative pathway. The level of risk associated with surgery has been described in a large European Surgical Outcome Study which showed that the mortality rate for patients undergoing inpatient non-cardiac surgery was higher than anticipated (Pearce and Grocott
2011). However, morbidity following major surgery is more common than mortality, impairs the recovery process post-operatively and is associated with long-term health implications (Moonesinghe et al.
2014). There is a strong evidence base showing that reduced pre-operative physical fitness levels are strongly associated with post-operative morbidity (Older et al.
1993; Hartley et al.
2012; Prentis et al.
2012; West et al.
2016; Thompson et al.
2011; Hennis et al.
2012; Snowden et al.
2010).
The importance of exercise in the cancer journey has been recently highlighted in a report by the Clinical Oncology Society of Australia with the clear recommendation that exercise should be embedded as part of standard practice in cancer care (Cormie et al.
2019). Pre-operative exercise training optimises physical fitness enabling an individual to maintain a better function during and after surgery. It has been shown to significantly improve fitness and health-related quality of life (HRQoL) (Mujovic et al.
2014; West et al.
2014; Barakat et al.
2014), however, much of this work has been reported following hospital-based (Mujovic et al.
2014; West et al.
2014; Barakat et al.
2014) and some home-based (Coats et al.
2013; Gillis et al.
2014) programmes. A recent report demonstrated that a supervised pre-operative exercise programme (as part of a multi-modal prehabilitation programme) showed significant improvements on functional capacity and muscle strength and had two times higher chances of returning to baseline fitness after surgery compared to the home-based exercise group (Awasthi et al.
2018).
Community-based exercise programmes are recommended interventions by the World Health Organization to promote physical activity for people living with an illness. They include a structured set of exercises designed for individuals with specific exercise needs and commonly involve a group of people with similar illnesses exercising under the supervision of a physiotherapist or a fitness instructor, with the goal of promoting and continuing regular exercise in the community (Salbach et al.
2014; Smith et al.
2011; Stuart et al.
2009). Community-based exercise programmes are attractive as they represent a more accessible, scalable, and sustainable alternative to hospital-based programmes and may reduce the burden on the healthcare system. Although few studies have explored community-based training in the pre-operative setting, the early data is encouraging and shows that they are feasible and effective (Rao et al.
2012; Singh et al.
2017).
The aim of this study was firstly to determine the compliance and adherence of a community-based pre-operative exercise training programme (delivered in a leisure centre) using a pragmatic approach (within whatever time interval was available before surgery) and secondly to investigate its effectiveness on selected health-related (HR) components of fitness and HRQoL for people with newly diagnosed prostate and CRC.
Results
Thirty-two participants were recruited (15 prostate and 17 CRC). Baseline characteristics are shown in Table
2. Of the 32, 15 (47 %) had a co-morbidity including hypertension, hypercholesterolemia, type 2 diabetes, heart disease and arthritis, and 13 (41 %) were taking medication. Only one participant reported being a current smoker.
Table 2Participant characteristics
Gender M:F (ratio) | 15:0 | 13:4 | 0.168 | 28:4 |
Age (years) | 64.2 (6.7) | 60.5 (12.1) | 0.047* | 60.5 (10.9) |
Height (cm) | 174 (5.7) | 172 (8.5) | 0.993 | 174.3 (5.9) |
Weight (kg) | 89.6 (12.5) | 87.7 (21.6) | 0.883 | 89.6 (16.4) |
BMI (kg/m2) | 29.7 (3.5) | 29.5 (6.9) | 0.898 | 29.7 (4.8) |
Current smoker┼ | 0 (0) | 1 (6) | 0.343 | 1 (3) |
No. of participants with co-morbidity┼ | 8 (53) | 7 (6) | 0.431 | 15 (47) |
No. of participants taking medication┼ | 7 (47) | 6 (35) | 0.538 | 13 (41) |
Median (interquartile range (IQR) number of days between initial contact with the participant following referral at outpatient clinic (at point of cancer diagnosis) and baseline assessment at MedEx was 2 (1–4) days and 6 (2–8) days for the prostate cancer and CRC group, respectively. Fourteen of the 15 prostate cancer participants (93 %) completed the study (1 dropped out due to change in treatment pathway) whilst 10 of the 17 CRC participants (65 %) completed the study. Of these, 6 were unable to attend for follow-up assessment either due to advancement of the date of surgery (n = 3), work commitments (n = 1), holidays (n = 1) or a medical issue (n = 1) and 1 dropped out due to disease progression. Note: three of the CRC participants that completed the study were scheduled for neoadjuvant cancer treatment (combination of chemoradiotherapy/combination of short course radiotherapy and chemotherapy) in the first instance. Baseline assessment for these participants was taken immediately following completion of cancer treatment, and their exercise training was delivered in the same manner as the other participants in the time window available before surgery.
The median (IQR) duration of pre-operative exercise training was 4 (3-4) weeks and 2 (1–3) weeks for the prostate cancer and CRC participants. Adherence rates to the exercise programme for the prostate cancer participants was mean (SD) 89 (20) % and for the CRC group 81 (21) %. The median (IQR) number of exercise sessions attended was 10 (8–12) and 6 (4–11) for the prostate cancer and CRC groups, respectively.
For the prostate cancer group who completed the exercise programme, the mean (SD) distance from participants home to the MedEx centre was 18.8 (17.1) km whilst for CRC group the mean (SD) distance was 18 (16) km. All participants tolerated the exercise sessions, and there were no adverse events during the pre-operative exercise training programme.
Tables
3 and
4 illustrate selected HR components of fitness at baseline and post-intervention for the prostate and CRC group, and both surgical-oncology groups overall, respectively. From pre- to post-exercise intervention, there was a statistically significant improvement in lower body strength in the prostate cancer group mean difference (95% CI) 2.2 (0.6, 4.3) seconds,
p = 0.045, and in the CRC group: 2.8 (1.5, 4.2) seconds,
p = 0.001 and for both groups overall: 2.5 (1.2, 3.7) seconds,
p = 0.001.
Table 3Health-related components of fitness at baseline and post-exercise intervention for prostate and colorectal cancer participants
Sit-to-stand (s) | 16.4 (6.6) | 14.2 (6.1) | 2.2 (0.6, 4.3) | 0.045* | 16.6 (5.9) | 13.8 (4.9) | 2.8 (1.5, 4.2) | 0.001* |
Handgrip (kg) | 32.6 (9.6) | 33.6 (8.6) | -1.0 (-2.8, 0.8) | 0.259 | 33.7 (8.9) | 35.3 (8.5) | -0.5 (-2.9, 1.9) | 0.637 |
6MTT (m) | 684 (144) | 722 (136) | -38 (-108, 32) | 0.262 | 768 (230) | 779 (220) | -11 (-51, 28) | 0.528 |
Table 4Health-related components of fitness at baseline and post-exercise intervention for both surgical-oncology groups combined
Sit-to-stand (s) | 16.5 (6.2) | 14.0 (5.5) | 2.5 (1.2, 3.7) | 0.001* |
Handgrip (kg) | 33.2 (9.1) | 34.3 (8.4) | − 0.8 (− 2.1, 0.5) | 0.232 |
6MTT (m) | 719 (185) | 746 (173) | − 27 (− 68, 15) | 0.193 |
Although no significant changes were reported for the upper body strength and 6MTT, there was a trend towards improvement from baseline to post-intervention in both surgical-oncology groups.
Tables
5 and
6 illustrates HRQoL at baseline and post-intervention for the prostate and CRC group, and for both surgical-oncology groups overall. For the EORTC QLQ-C30 questionnaire, there was a statistically significant improvement in global health status in the CRC group mean difference (95% CI) − 15.7 (− 28.7, − 2.8),
p = 0.025 and for both groups overall − 10.6 (− 19.6, − 1.6),
p = 0.023. There were similar improvements for emotional health subscale for the prostate cancer group mean difference (95% CI) − 10.9 (− 21.7, − 0.1),
p = 0.048, and for both groups overall − 11.3 (− 21.2, − 1.4),
p = 0.027. Additionally, there was a statistically significant improvement in nausea/vomiting/pain subscale for the CRC group mean difference (95% CI) 2.8 (1.2, 4.4),
p = 0.005; and for both groups overall, 2.2 (0.2, 4.1),
p = 0.030. For the EQ-5D questionnaire, there was a significant improvement in health scale status for the prostate cancer group mean difference (95% CI) − 8 (− 14.4, − 1.6),
p = 0.019, and for both groups overall − 9.3 (− 15.6, − 3.1),
p = 0.006.
Table 5Health-related quality of life at baseline and post-exercise intervention for prostate and colorectal cancer participants
Global health status | 73.1 (19.0) | 80.1 (15.4) | -7.1 (-20.5, 6.4) | 0.276 | 69.2 (15.2) | 83.3 (13.6) | -15.7 (-28.7, -2.8) | 0.025* |
Physical functioning | 93.8 (8.8) | 92.8 (6.9) | 1.0 (-2.2, 4.2) | 0.505 | 94 (10.2) | 94.7 (11.7) | -0.7 (-4.7, 3.3) | 0.677 |
Role functioning | 93.1 (19.4) | 89.7 (19.9) | -1.4 (-16, 13.2) | 0.838 | 90.7 (14.7) | 92.6 (12.1) | -2.1 (-15.9, 11.7) | 0.729 |
Emotional functioning | 73.7 (19.2) | 84.6 (13.1) | -10.9 (-21.7, -0.1) | 0.048* | 75.2 (28.6) | 85 (10.2) | -11.8 (-34, 10.2) | 0.293 |
Cognitive functioning | 89.7 (14.5) | 91.0 (11.0) | -1.3 (-10, 7.4) | 0.754 | 93.3 (11.7) | 100 (0) | -7.4 (-16.7, 1.9) | 0.104 |
Social functioning | 87.2 (26.5) | 92.3 (12.9) | -5.1 (-18.4, 8.1) | 0.416 | 86.7 (18.9) | 90 (11.7) | -3.7 (-19.1, 11.7) | 0.591 |
Functional functioning | 97.7 (3.3) | 97.7 (2.3) | -0.01 (-1.7, 1.7) | 0.985 | 98 (2) | 98.5 (1.2) | -0.6 (-2, 0.8) | 0.359 |
Fatigue | 18.5 (15.2) | 13.7 (10.2) | 5.6 (-3.2, 14.3) | 0.191 | 28.6 (19.1) | 33.3 (40.1) | -5.6 (-61.1, 50) | 0.803 |
Nausea/vomiting/pain | 5.2 (8.0) | 3.2 (4.5) | 1.7 (-1.7, 5.2) | 0.294 | 5.8 (5.3) | 3.3 (4.7) | 2.8 (1.2, 4.4) | 0.005*** |
EQ-5D questionnaire ǂ | | | | | | | | |
Mobility | | | | 0.436 | | | | 1.000 |
No problems | 11 (85) | 12 (92) | | | 7 (78) | 8 (89) | | |
Slight problems | 1 (8) | 1 (8) | | | 1 (11) | 0 (0) | | |
Moderate problems | 1 (8) | 0 (0) | | | 1 (11) | 0 (0) | | |
Severe problems | 0 (0) | 0 (0) | | | 0 (0) | 1 (11) | | |
Usual Activities | | | | | | | | 0.192 |
No problems | 11 (85) | 11 (85) | | 0.674 | 5 (56) | 8 (89) | | |
Slight problems | 0 (0) | 1 (8) | | | 4 (44) | 1 (11) | | |
Moderate problems | 2 (15) | 1(8) | | | 0 (0) | 0 (0) | | |
Self-care (washing/dressing) | | | | | | | | 0.100 |
No problems | 13 (100) | 13 (100) | | | 9 (100) | 9 (100) | | |
Pain / Discomfort | | | | 0.191 | | | | 1.000 |
None | 11 (85) | 7 (54) | | | 6 (67) | 7 (78) | | |
Slight | 1 (8) | 6 (46) | | | 2 (22) | 2 (22) | | |
Moderate | 1 (8) | 0 (0) | | | 1 (11) | 0 (0) | | |
Anxiety / Depression | | | | 0.586 | | | | 0.676 |
None | 6 (46) | 6 (46) | | | 6 (67) | 7 (78) | | |
Slight | 7 (54) | 7 (54) | | | 3 (33) | 2 (22) | | |
Health scale | 71.2 (16.4) | 80.5 (14.5) | -8 (-14.4, -1.6) | 0.019* | 76.5 (15.1) | 86.8 (6.4) | -11.1 (-25.1, 2.9) | 0.104 |
Table 6Health-related quality of life at baseline and post-exercise intervention for both surgical-oncology groups combined
Global health status | 71.4 (17.2) | 81.5 (14.4) | − 10.6 (− 19.6, − 1.6) | 0.023* |
Physical functioning | 93.9 (9.2) | 93.6 (9.1) | 0.3 (− 2, 2.6) | 0.792 |
Role functioning | 92.4 (16.8) | 90.9 (16.8) | − 1.7 (− 11.1,7.8) | 0.716 |
Emotional functioning | 74.3 (23.2) | 84.8 (11.7) | − 11.3 (− 21.2, − 1.4) | 0.027* |
Cognitive functioning | 91.3 (13.2) | 94.9 (9.3) | − 3.8 (− 9.8, 2.2) | 0.204 |
Social functioning | 87.0 (23) | 91.3 (12.2) | − 4.5 (− 13.7,4.6) | 0.315 |
Functional functioning | 97.8 (2.8) | 98.1 (1.9) | − 0.3 (− 1.3,0.8) | 0.614 |
Fatigue | 19.2 (17.6) | 20.6 (25.8) | 1.9 (− 13.7, 17.4) | 0.805 |
Nausea/vomiting/pain | 5.5 (6.7) | 3.3 (4.5) | 2.2 (0.2, 4.1) | 0.030* |
EQ-5D questionnaireǂ | | | | |
Mobility | | | | 0.492 |
No problems | 18 (82) | 22 (100) | | |
Slight problems | 2 (9) | 0 (0) | | |
Moderate problems | 2 (9) | 0 (0) | | |
Severe problems | 0 (0) | 0 (0) | | |
Usual Activities | | | | 0.213 |
No problems | 16 (73) | 19 (86) | | |
Slight problems | 4 (18) | 2 (9) | | |
Moderate problems | 2 (9) | 1 (5) | | |
Self-care (washing/dressing) | | | | |
No problems | 22 (100) | 22 (100) | | |
Pain/discomfort | | | | 0.266 |
None | 17 (77) | 14 (64) | | |
Slight | 3 (14) | 8 (36) | | |
Moderate | 2 (9) | 0 (4) | | |
Anxiety/depression | | | | 0.492 |
None | 12 (55) | 13 (59) | | |
Slight | 10 (45) | 9 (41) | | |
Health scale | 73.5 (15.7) | 83.4 (11.7) | − 9.3 (− 15.6, − 3.1) | 0.006* |
Discussion
This study demonstrated that people with newly diagnosed prostate cancer and CRC facing major invasive surgery, who consented to participate, were amenable to undertaking a community-based pre-operative exercise programme, and were compliant to the exercise programme and the outcome assessments at follow-up. Additionally, the delivery of the programme, using a pragmatic approach, over a relatively short time window had high adherence rates, without any adverse events. The programme had significant effects on HR components of fitness and HRQoL in both surgical-oncology groups.
Pre-operative clinical guidelines and recommendations on exercise training have been recently published that provide practical guidance for providing safe and effective exercise (Tew et al.
2018). One of the guidelines recommends that exercise training should commence as early in the surgical pathway as possible ensuring a minimum training duration of 4 weeks. In the current study, participants commenced the exercise programme within a median (IQR) of 2 (1–4) days and 6 (2–8) days from the time of referral. Additionally, the pre-operative exercise training programme was delivered over a median (IQR) of 4 (3-4) weeks for the prostate cancer group and 2 (1–3) weeks for the CRC participants, in line with the standard local hospital waiting time. The duration of the exercise programme in the current study is similar to other previous pre-operative exercise studies (Mujovic et al.
2014; West et al.
2014; Barakat et al.
2014; Coats et al.
2013; Gillis et al.
2014). However, to our knowledge, the time between referral and commencement of exercise training in this context has not been documented. Our study shows that early access can be facilitated using a referral pathway from the local hospital to the community.
The delivery of the pre-operative exercise programmes vary but have predominantly been hospital-based with some home-based (Mujovic et al.
2014; West et al.
2014; Barakat et al.
2014; Coats et al.
2013; Gillis et al.
2014). Other exercise studies have previously investigated community-based pre-operative exercise training programmes (as a standalone component of prehabilitation) in the surgical-oncology setting (Rao et al.
2012; Singh et al.
2017). One breast cancer study included an exercise intervention (boot camp) during neoadjuvant cancer treatment prior to surgery (
n = 10) and reported a compliance and adherence rate of 100% and > 80%, respectively (Rao et al.
2012). The exercise sessions however were delivered using a one-to-one supervised approach. Another prostate cancer study included exercise programme, delivered in an exercise facility at a university, and reported 100% compliance with moderate adherence with only half of the participants completing more than 80% of the sessions (Singh et al.
2017). In our study, 75% completed the study with an adherence rate of > 80%. Our compliance rates are somewhat lower than previous similar studies (however their sample sizes are lower) (Rao et al.
2012; Singh et al.
2017). Possible explanations for the high compliance rates for the prostate cancer group in the current study may due to participants starting the MedEx programme with a confirmed date of surgery whilst many of the CRC group started the programme with no date confirmed. It is important to highlight that the CRC pathway is more complex as patients who present with a risk of obstruction may require surgery immediately. The adherence rates of > 80 % in the current study are encouraging and appear to be higher than previous home-based programmes which vary widely between 16% (Carli et al.
2010) and 74% (Kim et al.
2009) in CRC studies. In contrast, however, they are similar to hospital-based programmes which have been reported to be > 80% (West et al.
2014; Morielli et al.
2016) in CRC studies, 70–100 % in an abdominal aortic aneurysm study (Kothmann et al.
2009) and 81% in a lung cancer study (Mujovic et al.
2014). The high adherence rates in the current study may be due to the consultant surgeon referring the patient to the programme and the nature of the MedEx programme being medically supervised. Additionally, it may be due to the exercise group being delivered a part of the MedEx exercise programme (group-based). The high adherence rates in the prostate cancer group in our study may be important as a previous study reported that men scheduled for radical prostatectomy had poor adherence to healthy lifestyle recommendations from the World Cancer Research Fund (WCRF) and the American Institute for Cancer Research (AICF). Sixty-seven percent did not fulfil the criteria of a normal healthy weight, 33.5 % reported doing no exercise and 49.6 % were current or ex-smokers (Thederan et al.
2019). Community-based interventions could potentially play an integral role in promoting such recommendations prior to prostatectomy.
Participation in the exercise programme had a positive improvement in lower body strength in both surgical-oncology groups. We also showed improvements in upper body strength and functional exercise capacity, although changes were not statistically significant. Improvements in HR components of fitness may be of importance; however, currently, the evidence base pre-operatively in this area has focused on cardiopulmonary exercise testing (CPET) variables in hospital settings. Participation in the community-based pre-operative exercise programme had a significant improvement on certain domains of HRQoL in both surgical-oncology groups. These findings may be important as psychological variables appear to be associated with early surgical recovery (Mavros et al.
2011). One community-based programme in people with breast cancer reported significant improvements in body mass index and Ki-67 levels (i.e. prognostic and predictive marker of cancer diagnosis) following investigating the effects of a boot camp intervention (Rao et al.
2012). Another study in prostate cancer reported significant improvements in muscle strength and physical performance (6-m fast walk, 400-m walk and repeated chair rise test) following a pre-operative community-based programme which was delivered in the university exercise clinic (Singh et al.
2017). Our findings show that the community-based model is effective in improving HR components and HRQoL.
The recently published pre-operative exercise training guidelines (Tew et al.
2018) state that if resources are limited, priority of pre-operative exercise training referral should go to patients who are at increased risk of peri-operative complications. This community-based model allows for greater accessibility pre-operatively and has the potential to make the programme available to all eligible patients and not just those who are at increased risk. A previous community-based study in people with prostate cancer reported that four out of 14 eligible patients refused to participate in the study citing travelling from their residence to the university exercise clinic where training and assessments took place as a barrier to participation (Singh et al.
2017). A recent qualitative study highlighted that future exercise programmes should include a mixture of supervised group sessions within a hospital- or community-based centre and advice about exercise at home (Crandall et al.
2019). Future community-based programmes, which includes both centre- and home-based exercise programmes, may accommodate patient preferences and circumstances, hence removing barriers to participation. The MedEx model is a sustainable alternative to hospital-based programmes, reducing significant healthcare costs and providing easier access to patients (with the addition of new centres being established nationally). Future work should include health economic analyses to investigate cost savings in this regard.
Strengths of this work include the novelty of the community-based setting. Additionally, the rapid referral and access from the local hospital to the community. However, the study has several limitations. Due to a lack of funding to support this research, there were no resources available to cover personnel costs. Therefore, no study uptake rates (screening logs) were recorded and thus we are unable to report on the number of patients approached versus number of patients who agreed to participate. Note: the cancer prepare service at ExWell (formerly MedEx) now runs daily from Mon-Fri which highlights the feasibility of this exercise-oncology service. Participants in this study had little comorbidity with a reasonable level of functioning; therefore, it is possible they were a motivated group which increases the risk of selection bias (impacting both internal and external validity). Due to the nature of the pilot study, no usual care control group were included. Functional exercise capacity was measured using a field-based measure; howeve CPETr was not possible in the community setting. Three CRC participants completed neoadjuvant cancer treatment in the first instance whilst the remaining were scheduled for surgery only; therefore, heterogeneity exists in this cancer group. Furthermore, data on surgical intervention and patient clinical outcome was not provided as hospital ethics were not obtained. The sample population in the CRC group largely consisted of males (87%) which may be a potential bias as CRC incidence rates in Ireland is 42% for females and 58% for males. Additionally, the mean (SD) age of the CRC group in the current study is 60.5 (12.1) years. However, approximately half of people diagnosed with CRC in Ireland are aged 70 and older (51% of men and 58% of women); therefore, the sample may not be representative and limits the generalizability of our findings.
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