Prehabilitation for Esophago-Gastric Cancer
Prior to Surgery, Prior to Induction Therapy, or both?
Enrico M. Minnella, M.D. Ph.D.
McGill University
Level of
Functional
Capacity
Prehabilitation
Control
PREOPERATIVE RECOVERY SURGERY
Carli F, Zavorsky GS. Curr Opin Clin Nutr Metab Care. 2005;8(1):23-
32.
Prehabilitation: the Theoretical Model
• Surgical Extent
• Cardio-Resp Disease
• Emergent Condition
• Steroid Use
• Sepsis
• Creatinine
• Disseminated Cancer
• Pneumonia
• Physical Status
• Weight Loss
• BMI
• Albumin ≤35
• Smoking & Alcohol Use
Risk Factors for Major Cancer Surgery
Cohen ME, et al. J Am Coll Surg. 2009 Dec;209(6):687-93 Minnella EM et al, ERAS Society Textbook, In Press
Prehabilitation & Functional Capacity
Minnella EM et al, JAMA Surg. 2018 Dec 1;153(12):1081-1089
Home-based Exercises
Aerobic exercise
• moderate:12-15 RPE
• 20min, 3/week
Resistance exercise 3/week
Nutrition
• Macronutrients balance
• Whey protein to meet
total protein 1.5 g/kg/d
• Whey protein 20 g after
training
Anxiety Coping
• Assessment
• 1session with psychologist
• Basic coping exercise
• Referral for major
depression
Prehabilitation & Functional Capacity
+ 36.9 + 15.4
- 22.8
- 81.8
van Adrichem EL et al, Ann Surg Oncol. 2014 Jul; 21(7):2353-60
Prehabilitation & PostOp Morbidity
• Esophagectomy for Esophageal Cancer
• Inspiratory muscle training
Yamana I et al, Dig Surg. 2015;32(5):331-7
Prehabilitation & PostOp Morbidity
• Esophagectomy for Esophageal Cancer
• Inspiratory muscle training
Postoperative Pulmonary Complications
Grade > II
OR: 3.99, 95% CI: 1.28-12.4, p = 0.017
Valkenet K et al, Br J Surg. 2018 Apr;105(5):502-511
Prehabilitation & PostOp Morbidity
• Esophagectomy for Esophageal Cancer
• Inspiratory muscle training
NO DIFFERENCE
PostOp Pneumonia
Valkenet K et al, Br J Surg. 2018 Apr;105(5):502-511
Prehabilitation & PostOp Morbidity
• Esophagectomy for Esophageal Cancer
• Inspiratory muscle training
maximum inspiratory muscle strength
76·2 (26·4) to 89·0 (29·4) cmH2O
P < 0·001
Functional Status
Quality of Life
Continuity of Care
Pecorelli N et al, Surg Endosc. 2016 Jun; 30(6):2199-206
Brunelli A et al, Chest 2013;143:e166S
6-min walk test
• Objective, reproducible, cheap, integrated
measure of functional capacity
• 400 meters=
indicator of recovery in major cancer surgery
Hlatky MA et al, Am J Cardiol 1989; 64: 651–4.
Duke Activity Status Index (DASI)
• Measure of physical activity, musculoskeletal strength, frailty, self-imposed,
and physical limitations
• Good association with postoperative cardiac events
< 46
McIsaac DI et al, JAMA Surg 2016; 151: 538–45
Wijeysundera DN et al, Lancet. 2018;391(10140):2631-2640
Exercise stress test with concomitant gas analysis
CardioPulmonary Exercise Testing (CPET)
ADVERSE POSTOPERATIVE
OUTCOME
POOR PREOPERATIVE CARDIORESPIRATORY
FUNCTION (CPET)
CPET
Minnella EM et al, Submitted
• Exercise modality
• Sessions frequency
• Between-session recovery time
• Training duration (~4 weeks)
• Progression
Exercise Prescription: Endurance
Which is the limiting
pathophysiological mechanism
Which is the limiting
pathophysiological mechanism
Wasserman K, Principles of exercise testing and interpretation, 5ed
Exercise Prescription: Inspiratory muscle training
Starting
Intensity Progression
Maximal
intensity Duration Frequency Supervision
20-30%
MIP
Daily,
then maintain
40%
MIP 15 min
6 days
/week 3 days/week
SCREEN
• 6MWD < 400 m
• DASI < 46
• ppoFEV1 / ppoDLCO <60%
• BMI <20 or >30 Kg/m2
• Weight loss ≧10% in 6
months
• Handgrip < 20th percentile
• HADS-Anxiety ≧7
• HADS-Depression ≧5
Adapted from Minnella EM, Carli F. Eur J Surg Oncol. 2018 Jul;44(7):919-926
SCREEN ASSESS
• 6MWD < 400 m
• DASI < 46
• ppoFEV1 / ppoDLCO <60%
• BMI <20 or >30 Kg/m2
• Weight loss ≧10% in 6
months#
• Handgrip < 20th percentile
• HADS-Anxiety ≧7
• HADS-Depression ≧5
• CPET
• Body composition / PG-
SGA
• 3-d dietary intake
↓
Protein and energy
requirement estimation
• Restlessness and
insomnia
• Emotional numbness
• Apprehension,
hypervigilance to
symptoms and events
Adapted from Minnella EM, Carli F. Eur J Surg Oncol. 2018 Jul;44(7):919-926
SCREEN ASSESS INTER
VENE
• 6MWD < 400 m
• DASI < 46
• ppoFEV1 / ppoDLCO <60%
• BMI <20 or >30 Kg/m2
• Weight loss ≧10% in 6
months#
• Handgrip < 20th percentile
• HADS-Anxiety ≧7
• HADS-Depression ≧5
• CPET
• Aerobic exercise
• Resistance exercise
• MIT
• Body composition / PG-
SGA
• 3-d dietary intake
↓
Protein and energy
requirement estimation
Nutrient-based intervention
• Achieve energy requirement
• 3 balanced meals
• Protein intake: 1.5 g/kg IBW/d
• Restlessness and
insomnia
• Emotional numbness
• Apprehension,
hypervigilance to
symptoms and events
Cognitive-behavioral therapy
• Cognitive re-framing
• Promote self-efficacy, personal
control & sense of purpose
• Teach relaxation skills: deep
breathing, guided imagery,
mindful meditation, goal setting
• Referral
RE-ASSESS
Adapted from Minnella EM, Carli F. Eur J Surg Oncol. 2018 Jul;44(7):919-926
Prehabilitation – McGill Approach
PREDICTIVE Medicine
PREVENTIVE Medicine
PARTICIPATORY Medicine
• Screen ALL patients
• Assess to Personalize
• Effective & Safe treatment
Prehabilitation
During Neo-Adjuvant Treatment
???
Xu YJ et al, Oncologist. 2015 Oct;20(10):1216-22
Prehab During Neo-Adjuvant Therapy
• Chemoradiotherapy for Esophageal Cancer
• Walk & Eat
Prehab During Neo-Adjuvant Therapy
Jack S et al, Eur J Surg Oncol. 2014 Oct;40(10):1313-20
Prehab During Neo-Adjuvant Therapy
Jack S et al, Eur J Surg Oncol. 2014 Oct;40(10):1313-20
PREHABILITATION during NAT
Dia
gno
sis
4-8
wee
ks
PREHABILITATION
Star
t N
AT
End
NA
T
Surg
ery
NAT SX
Fun
ctio
nal
Cap
acit
y Le
vel
Knowledge Gaps
• Prehabilitation DURING NAT
Feasibility, safety, and efficacy
• Objective Assessment of Functional Capacity
CPET
• Type of Intervention
Supervised vs. Home-Based Exercise
Prehabilitation
• Planned, structured, and
integrated in cancer care
• Assess > high-risk > Re-Assess
• Personalized
Conclusion
When
• Before Surgery ✓ • During NAT ?
!! RESEARCH AGENDA !!
3rd Canadian Prehabilitation Workshop
For Information please contact
Rashami Awasthi: [email protected]
March 28, 2020
Montreal General Hospital – McGill University
Montreal Canada
Course directors:
Drs. Carli & Minnella
Enrico M. Minnella M.D. Ph.D.