Prehabilitation is a process along the cancer care continuum that occurs after diagnosis but before treatment begins. In a sense, it’s preparing patients for their battle ahead by introducing psychological and physical interventions “that establish a baseline functional level, identify impairments, and provide targeted interventions that improve a patient’s health to reduce the incidence and the severity of current and future impairments,” according Silver and Baima. Patients who participate in prehabilitation are less likely to experience some of the adverse effects from the medication, radiation, surgeries, or chemotherapy for which their treatment plans call.
Proactive Interventions Make a Difference
Initiating prehabilitation just after diagnosis can prevent the potential decline in ability. “It’s very important,” ONS member Lillie Shockney, RN, BS, MAS, administrative director at Johns Hopkins Breast Center in Baltimore, MD, and program director of the Academy of Oncology Nurse Navigators, says. “Why allow patients to become deconditioned as a result of receiving cancer treatment when they can remain physically functional?”
By creating a multidisciplinary approach to managing a patient with cancer, a prehabilitation plan can encourage physical activity like walking, arm exercises, core training, smoking cessation, nutrition counseling, and more.
Shockney says her facility works with the cancer rehabilitation team at Johns Hopkins to identify and coordinate prehabilitation regimens for patients. “Core strengthening for patients having DIEP [deep inferior epigastric perforators] flap reconstruction results in a faster recovery,” Shockney says as an example. “We also know through the research conducted by Vicki Mock that exercise during radiation therapy diminishes fatigue.”
Nurses often find themselves poised to encourage and facilitate prehabilitation plans that are specialized to a patient’s needs. However, it’s not uncommon for the window between diagnosis and treatment to be very short. Shockney says she manages the narrow timing “by having it be part of nurse navigators’ responsibility. They see the patient at the time of the initial consultation. They have the criteria for screening the patient and can make the referral while discussing with the patient the value of having a prehabilitation consultation.”
Including Prehabilitation in Practice
To best incorporate prehabilitation into cancer care, it’s important to establish a multidisciplinary team to implement the interventions. “It is critical to have a team approach and buy in from the entire cancer care team to prioritize the prehabilitation needs,” ONS member Sharon Gentry, RN, MSN, CBCN®, CBEC, breast nurse navigator at Derrick L. Davis Cancer Center in Winston-Salem, NC, says. “It may involve physical therapy, occupational therapy, exercise, nutritional counseling, and psychological interventions to prepare the patient for cancer treatment like surgery, chemotherapy, immunotherapy, or radiation therapy.”
Even though time is short between diagnosis and the beginning of treatment, prehabilitation can still be completed with a coordinated team. According to Gentry, “This window is when the patient is undergoing further testing, seeking second opinions, contemplating treatment options, or just waiting for surgery, radiation, or chemotherapy to begin. It allows time for prehabilitation interventions.”
Once a team is prepared, including patients in the decision-making process is crucial. With transparency and education, patients are far more likely to engage in prehabilitation interventions. “Patients can be extremely anxious prior to therapy. By acknowledging that and implementing personalized strategies, we can help to reduce anxiety,” Gentry says. “Nurses can refer someone to counseling or meditation, helping them understand that prehabilitation is an individualized assessment with the intention to create a healthier environment for future care.”
Overcoming the Obstacles
Prehabilitation interventions are still relatively foreign to most cancer treatment plans. Shockney says, “This type of service still isn’t on oncology specialists’ radar, with the exception of perhaps lymphedema referrals. It can be difficult for cancer rehab therapists or their leadership to make headway without producing evidence-based research results validating its benefit.”
So how can you get the entire multidisciplinary team to buy in? According to Shockney, “Let the data do the talking for you.” By referring to research and reviewed literature, it’s far easier to persuade colleagues to recognize the benefits of prehabilitation.
Unfortunately, there’s always the cost to consider, especially to the patient. This includes a number of different financial burdens from “copays, missing work, travel expenses, or just time in general,” Gentry says. “The team should try to address concerns that the patient is giving as a barrier and arrange care in the least burdensome way. In most cases, it will be covered by third-party payers.”
There is, however, the issue of training time and coordinating a team. Both Shockney and Gentry’s cancer centers use the Survivorship Training and Rehabilitation (STAR) Program. As an evidence-based model of cancer prehabilitation, it provides best practices for a multidisciplinary approach to prehabilitation.
According to Gentry, “STAR personnel assisted in training our multidisciplinary team and helped us implement protocols that focused on improving patient outcomes.” She notes that certification took place at their cancer center, and their staff was provided with online courses, webinars, and ongoing support for outcome assessments.
Patient-Centered Approach to Treatment
Will prehabilitation fully protect patients from the effects of cancer treatment? Not entirely. It does, however, work to lessen their struggle with loss of mobility, fatigue, psychosocial distresses, and more. “By proactively addressing impairments with prehabilitation, we can return a patient to their lifestyle more quickly,” Gentry says. “Both direct and indirect healthcare costs can be reduced.”
Keeping quality care at the center of patient treatment can help produce successful outcomes and lessen the burden to patients with cancer. “Patients should only need to give cancer the time it requires to get rid of it,” Shockney says. “We should not allow it to steal away any more of patients’ time—not their personal time, work time, social time, or family time. Prehabilitation is one way to make that a reality.”