The model of delivery for prehabilitation should take into consideration:
- Patient populations
- Geography
- Resources
- Setting.
In many health systems and centres it is not always possible to provide all of the prehabilitation components to all people with cancer presenting for surgery. It is often necessary to screen individuals for modifiable risk factors and identify those at higher risk from their surgery.
The MacMillan model
The Macmillan Cancer Support prehabilitation guidelines, first developed in 2018, recommends a stepped approach to interventions, and categorises these into universal, targeted and specialist care, based upon screening and assessment of individuals with cancer.
Universal prehabilitation targets all people with cancer and focuses on educating them before surgery. Risk factor triggers identify individuals with cancer requiring targeted or specialist levels of prehabilitation, centred on exercise, and nutritional and psychological support.
Figure 1. Modified from MacMillan Prehabilitation interventions triangle1
Core components
Due to the complex presentation and differing needs of people with cancer, guidelines suggest that cancer prehabilitation should be needs-based and provided as early as possible after diagnosis1. To achieve this, programs are recommended to include screening, assessment, intervention and evaluation measurement1.
- Macmillan Cancer Support, UK
Medical assessment and optimisation
View medical optimisation section
Although considered “usual care” for patients undergoing surgery, this process is integral to informing the safety and effectiveness of a prehabilitation program.
Medical assessment involves a thorough review of a patient’s medical, physical, nutritional and psychosocial status to identify potential risks associated with surgery and medical complexity, and tailor interventions accordingly. Risk stratification should consider:
- Surgical complexity
- Medical complexity: Refers to optimising modifiable risks (e.g. anaemia, respiratory conditions, heart failure, pain relief) to facilitate prehabilitation
- Safety to exercise: Refers to the initial decision regarding whether it is safe and timely to proceed with prehabilitation (e.g. acute chemotherapy induced cardiomyopathy or recent COVID infection)
- Level of prehabilitation required: The above process are all integral to the broader concept of cancer prehabilitation, which seeks to enhance the overall wellbeing of patients before they undergo surgery, with the aim of improving surgical outcomes and postoperative recovery.
Determining the allied health prehabilitation intervention required
Screening (view screening section)
- Once a patient is deemed eligible for a prehabilitation program, screening is undertaken to determine which health discipline(s) the patient requires referrals to.
Automatic inclusion for discipline intervention
- Health services may also consider whether inclusion in the allied health prehabilitation program is warranted, regardless of screening outcome.
- This may be based on factors such as complexity of surgery and heightened risk of complications, associated disfigurement, or resultant changes in functional ability post-surgery:
- For example, a hospital may decide that individuals receiving specific surgeries are automatically referred to some or all the allied health disciplines
- Examples of such surgeries may include oesophagectomies, pelvic exenterations or other significant, complex and/or disfiguring surgeries. Other clinical or social risk factors may also be considered (e.g. existing chronic pain).
Assessment and intervention (view assessment and intervention sections)
- Those individuals screened for targeted or specialist exercise, nutrition and/or psychological support, will be referred for assessment and intervention by the appropriate disciplines.
Those not eligible for targeted or specialist intervention will receive universal education.
High level service overview
Figure 2. A high-level service view of how the core prehabilitation components occur within the context of the standard care pathway to surgery.