Prehabilitation: Optimizing Patients to Improve Outcomes - Part 1-Prehabilitation_ Optimizing Patients to Improve Outcomes

Prehabilitation_ Optimizing Patients to Improve Outcomes - Pt. 1

Video Transcription

Hello, and welcome to today's webinar, Prehabilitation Optimizing Patients to Improve Outcomes. My name is Catherine Coons, and I'm a nurse practitioner at Penn Presbyterian Medical  Center in the Division of Thoracic Surgery. Welcome you all for coming. I'm your moderator today. And first off, I'd like to introduce you to our panel. Next slide.  First up is Dr. Clarissa Mathias. She is the medical oncologist, NOB Oncoclinicus, at Hospital Santa Isabel.  She's also the president of the Brazilian Society of Clinical Oncology and the chair of the IAC at ASCO. Also joining us today is Zoe Merchant.  Zoe Merchant is a highly specialized occupational therapist and the program lead for the Greater  Manchester Prehab for Cancer and Recovery Program, UK's first regional-wide rehab and prehab service for people affected by cancer.  The service has had over 2,000 patients access it since its inception in April of 2019. So welcome, Ms. Merchant. And last, we have Ms. Catherine Granger.  She is an associate professor of physiotherapy at the University of Melbourne and the head of physiotherapy research at the Royal Melbourne Hospital in Australia.  Her research program focuses on the role of exercise for patients with lung cancer. She was an author of inaugural Cochrane Systematic Review on the topic of preoperative exercise  training for patients with lung cancer. So welcome. I look forward to hearing all of your presentations, and take care. Here are the disclosures.  None of our planners, reviewers, or staff. There we go. An email will be sent to you after the meeting with instructions on how to claim your CME credits.  Polling questions will be used throughout the talk. Please select an answer when a polling pops up on your screen. Answers will be discussed as part of the talks.  All questions are going to be answered through a Zoom Q&A function at the bottom of the screen. You can use this chat for other discussions.  And we actually are going to have a Q&A session at the end after all three presentations are done. And you can enter your questions at any time during these presentations.  And as I said, at the end of all three presentations, we will have a Q&A session. We are not going to be using the raise your hand function. Next slide.  And so I'm going to hand it over now to Dr. Mathias. Good morning, good afternoon, good evening to each one of you. First of all, I would like to thank ISLC for inviting me.  And I'm actually on the board of ISLC. I have the honor of representing Latin America. I'm ending my term now.  So I'm going to talk about the physiological benefits of rehabilitation, the importance of being fit for treatment and surgery. Next, please.  And we're going to start with one polling question, number one. So Mr. G is a 65-year-old male diabetic and obese, who is evaluated at a follow-up visit  three months after completing four cycles of hematopoietic insulin sputum. And it was used to treat a stage 2a non-small cell lung cancer as an adjuvant therapy.  He complains of brutal neuropathy grade 2, and he wants to discuss adhering to a serious exercise program.  He asks you what is the most likely mechanism that could help with impairing, disempairing side effects. And you list several mechanisms that can help him accept.  So promote an anti-inflammatory state, improve muscle fiber recruitment, improve gait and balance, weight control, and decrease bone turnover. So now you can vote.  Okay, so let's now talk about exercise.  Yes, I'll take over now.  Zoe, okay. So my mission today is really to convince you that our patients need to exercise. My guess, okay, let me try to see.  Okay, so one third of major impairment in daily activities  due to their lung cancer. So patients with lung cancer are really physically impaired in a lot of cases. And there is persistent physical and psychological impairment.  Most patients do not meet physical activity recommendations before or after treatment.  The usual care does not normally include exercise training or pulmonary rehab. And it's going to be great to discuss that here today.  So how can we incorporate exercise practices into patients' lives? And actually, I'm going to really show you data  if we can prevent cancer, improve surgical outcomes, and improve symptom management. So let's start by talking about cancer prevention of lung cancer.  So can we prevent lung cancer with exercise? And there are actually 16 studies that examined physical activity and lung cancer risk.  12 cohort studies showed a pooled risk reduction of 23%.  And four case control studies showed a pooled risk reduction of 38%.  Physical activity actually does lead to a risk reduction in a meta-analysis of 11 studies comparing highest versus lower levels of leisure time physical activities,  adjusting for smoking intensity, show that a moderate intensity led to an OR of 0.87 and a vigorous intensity showed an OR of 0.7.  So actually, the relative risk comparing highest versus lowest levels of physical activities was protected in terms of lung cancer risk, if you look here.  So there's actually a lot of data to discuss physical activities with our patients, even after they have lung cancer or even in patients who are smokers and who are at risk.  So the possible mechanistic models, pathways are related to sex hormone production, metabolic hormones, inflammation and adiposity, oxidative stress, DNA repair,  denobiotic enzyme systems, and immune function. And actually during exercise, particularly moderate intense aerobic exercises, we have an increase in T cell population,  NK cell population and neutrophil quantities. And actually you do see an inverted J curve that optimizes the immune function in patients who exercise  with moderate intensity physical activities.  And probably the proposed role of physical activity and exercise is really the mobilization of polarization of tumor-associated macrophages  to M1 phenotypes that do have anti-tumor activities. And when you don't exercise, you actually polarize them to M2 phenotype  that supports tumor growth, local invasion, and metastasis.  Prospective cohort studies do show association between cardiorespiratory fitness, lung cancer incidence, and cancer mortality in men with maximal exercise test female,  almost 5,000 men that were free from malignancy at baseline.  And then at a pretty long follow-up of almost 13 years,  2.1% of the patients were diagnosed with lung cancer and 79% of those died from cancer,  actually four years after the diagnosis. And CRF was independently associated with cancer outcomes. And this is also important to discuss with patients after being diagnosed.  One man increase in categories of moderate and high CRF  showed a decrease in lung cancer incidence and decrease in lung cancer mortality. So actually individuals diagnosed with lung cancer  in at moderate or high CRF categories at baseline exhibited longer survival times. So let's now move to improved surgical outcomes. And actually, Katherine will discuss that  in much more details with you. So I'm just gonna start the flavor of it. So actually, pre-op exercise helps the post-op complication rates in patients with lung cancer.  We do have a systematic review published a few years ago that shows a decrease in complications, let's say an improvement in quality of life for those patients.  So there is actually a decrease with an RR of 0.52  and the length of hospital stay decreased by almost three days.  There is this pro-locus study that was also published a few years ago and actually did have a strong exercise program beforehand  with early intervention. And it was a small study with 40 patients, 124 patients were screened and they were included and randomized to those four groups that I mentioned  in the post-op exercise completion was 73%. So the results show that early exercise programs for patients was safe and feasible. And the fast track setup is pre-op,  a home-based exercise was not feasible for these populations. So we really need to have a mindset change for the lung cancer patients.  The early initiated post-op rehab reduces fatigue in patients with operable lung cancer. This was a randomized trial that showed this two arm control trial  with early initiated post-op rehab or a control arm with late initiated exercise. The primary endpoint was really the change in maximum oxygen consumption from baseline  to post-intervention 26 weeks following liposuction. And we do see here that we have a decrease in pulmonary complications and less of stay again from surgery.  So we do need to sit down with your patients and have them take exercise as a prescription.  Also, we do see improvement in symptom management and that's when we're going to go back to Mr. G  and see that there are lots of deleterious type of treatment. And I mentioned some of them that are most common in lung cancer. So fatigue, deterioration function studies,  functional status and muscle weakness. And we see here that in the cardiovascular system, the chemotherapy really decreases VO2 max, decrease exercise tolerance and movement  and with exercise and lactation, we can see an improvement in hemoglobin, decrease in blood pressure, increase in VO2 max and decrease in resting heart rate.  In terms of respiratory, the chemotherapy and other treatments can, radiotherapy also, can really increase the work of breathing and dyspnea and the exercise training really causes  the decrease in work of breathing. In terms of muscle skeletal, we can relate to cachexia,  decrease muscle strength, endurance, power, bone loss, arthralgia and myalgia. And with exercise, we can really preserve muscle  strength, improve bone turnover and improve joint health. In terms of neurological, we just see, as in Mr. G, peripheral and central neuropathy, cognitive changes  and loss of coordination and balance problems. And we can really, with exercise, improve muscle recruitment and improve gait and balance.  In terms of metabolic, we just see weight gain and dyslipidemia and we can improve oxygen to capacity and weight management. And finally, we do cause hyperinsulinemia  and increase diabetes risk, especially with the steroids. And we can, with exercise, improve insulin sensitivity and decrease cortisol and estrogens.  So really, we can do a lot with exercises related to the chemotherapy. So hopefully I do have convinced you that we are able to improve our patients' lives  by stimulating exercise and preventing cancer, improving symptom management and surgical outcomes. Thank you. And now I'll hand it over to Zoe Martin. Thank you.  Thank you, Clarissa. That was fantastic. Really great to listen to you. So as Clarissa said, I'm really privileged to be with you today doing this presentation. I'm Zoe Martin.  I'm the programme lead for the Prehab for Cancer and Recovery Programme in Greater Manchester, which is what I'm gonna be talking to you about today. So next slide, please.  So just to give you a little bit about my background. So I'm an occupational therapist and the majority of my clinical career has been based doing complex rehabilitation,  mainly in the community with patients  of a wide variety of different comorbidities and conditions.  So actually neuro rehab has been one of my main focuses, but more recently, obviously I've been leading on the prehabilitation and rehabilitation delivery in Greater Manchester,  which I'm gonna go on to speak about.  Alongside me, delivering this region-wide prehab service, I've got quite a brilliant MDT. So we've got Dr. John Moore, who's a consultant anesthetist.  He's our clinical lead. Myself as programme lead and as the allied health professional involved. We've got a primary care GP called Dr. Karen McEwen, who's a Macmillan GP.  And then we've got an exercise specialist, Kirstie Rollinson-Groves, who leads the actual service, delivering the service for the patients. Next slide.  So the polling question that I've put together for you is which of the below would you believe to be the most critical to the successful implementation  of a prehab programme in your local area?  So is it A, skilled workforce already able to deliver the programme? B, stakeholder engagement, including from MDT members, healthcare managers, commissioners, and other colleagues?  C, co-production with people affected by cancer? Or D, a research network to support the evaluation of programme delivery? So if you can please choose which one you think it is.  Brilliant. So actually, the majority have gone for stakeholder engagement which is actually the correct answer. And I will take over control if that's okay.  Great. So yeah, so I'm gonna go on to speak about stakeholder engagement and to some degree in the talk now. But all of these aspects are really important.  But for me, I think the stakeholder engagement is the really key part of the whole process. So I'm gonna go on to speak about the key aspects of stakeholder engagement.  And I think the key aspect of stakeholder engagement is the really key part when you're trying to do quite large-scale prehab delivery.  So hang on just one second.  So I wanted to start by talking about the area of the United Kingdom where we've been delivering prehab for cancer. So for those of you who are familiar with England,  this is up the north up here, Greater Manchester. So it's a really large area. And we have quite a large number of patients  who are from some of the most disadvantaged areas of the UK. So in terms of kind of health inequalities, we really do have a large number of patients  who present late with advanced cancers, but also have poor diets, not great exercise, quite often are smokers and have some alcohol dependency, really high rates of this.  So this is not only are we trying to deliver prehab  but it's also being mindful of the difficulties that some of the patients who are going to be engaging in the service might be faced with.  Oh, hang on a second.  Oh no.  Sorry, I'm just...  Aubrey, can you please take that, can you drop that? That's it, thank you. Next slide, thank you. So in Greater Manchester, we actually have what's called DevoMank.  So for the rest of the country,  the decisions that are made within the National Health Service come from London, but actually we have a devolved health and care system so that for the entirety of the population,  all health and social care decisions are made by the Greater Manchester Health and Social Care Partnership. So we have a mayor who's Andy Burnham,  who's supportive of the delivery of our service. And it's a really large area. We wish it was as small as it seems on the screen. It's a really big area.  The population size is equivalent to, you know, coming up for like New Zealand or some of the other smaller countries in the world. So there's a lot of patients coming through  around 20,000 diagnosed with cancer each year. Next slide, please.  So I won't go into too much detail about what prehabilitation is, because obviously Clarissa's already given a really brilliant instruction around exercise  and the importance of exercise in cancer pathways.  But it's just really, from our perspectives, part of the reasons for why funding was provided for our service was understanding that actually  the physiological and psychological challenges of cancer treatment and how we're really trying to reduce those side effects that patients are potentially gonna experience  going through their cancer pathways. Next slide, please.  Also within the NHS, we have what's called a long-term plan. This is kind of the overarching strategy for the next 10 years. And within that, we've got what's called  the personalised care model, which is really about how you make all healthcare provision to patients in England personalised and holistic to themselves.  So within that, you've got the aim for optimal medical pathways, of which prehab and rehab really should be part of. And then also you've got this aimed  for people to have what's called supported self-management. So really how you empower people to engage in their healthcare provision as much as possible. Next slide, please.  Also, we've got the levers within the literature and the evidence base of which obviously Clarissa has already shown you some of the examples  from studies that have been recently published. But this is a brilliant study from my perspective because what it did is it compared patients  and healthcare professionals in terms of their priorities for their cancer pathways and what their real priority was for treatment.  And whilst the majority of healthcare professionals would always put survival and some of the very clinically based outcomes as the priority,  most patients often say that their priorities are around energy levels, pain, sensation, their physical endurance and their ability to carry out daily routine.  And that really is the crux of prehab and rehab for me, which is why it's been really helpful to have studies like this one completed. Next slide, please.  There's also the recent systematic review, which was an international collaboration which came out of the World Health Organization. And essentially what this was showing  is that you've got some examples of best practice and evidence base around physical activity and exercise in oncology. However, what we do know  is that a large percentage of cancer survivors really do require rehab. And there are small numbers of this being offered to patients. We also know from this systematic review  that it's really important that any kind of prehab or rehab offer is multidimensional and has got an interdisciplinary approach.  And that's what's gonna provide the optimal model of care. Next slide, please.  So within the United Kingdom, we've had the Macmillan Prehab Guidance, which was launched in 2019. This was actually an international approach where we used a Delphi process.  And I was involved in this alongside colleagues from locally and nationally, but also international colleagues as well, where we came together  to synthesize all the existing evidence around prehab and provide some really clear guidance around what should be done for prehab for people who are affected by cancer,  including giving that very clear guidance that people should be exercising. Next slide please.  And we were able to use some examples from patients in Greater Manchester within this documentation, so just giving some vignettes and also just showing some of the kind of  examples of the types of exercises we do in the local gyms with our patients. Next slide please.  So within Greater Manchester, we already have what's called the Enhanced Recovery After Surgery  Plus Scheme. So within all the different major hospitals of which there are 10 in Greater  Manchester, we've got surgery schools, so patients and their family members are invited to come to  an education session in the week or so before their surgery. But what we were finding in these  surgery schools is that actually it's not enough to just give the advice, you really do need to  need to provide a service and a programme for people to engage with, especially when they've just had that very scary diagnosis of cancer. They really do need their hands to be held  through the process. Next slide please. So building on that, GM Cancer, which is the organisation I work for, which is a cancer alliance, came together with GM Active,  which is all the local leisure organisations in the area in Greater Manchester, to deliver the  prehab for cancer service. And just to be clear, we're not trying to turn the gentleman on the left  into the gentleman on the right. What we know is the gentleman on the left has probably led quite  a century lifestyle in advance of his diagnosis of cancer, and is really going to benefit from  quite intensive exercise in the run up to his lung cancer treatment. Whereas the gentleman on the  right, although he might be physically prehabbed, he might deteriorate through new adjuvant  chemotherapy, but also he's going to benefit from the nutritional and the psychological elements of  our programme. Next slide please. So within Greater Manchester, we have different pathway boards for all the different tumour types. So this is all the different MDT members,  consultants, surgeons, oncologists, coming together on a regular basis to try and drive improvement within the NHS for those tumour types. So we already had a lung pathway board,  which is chaired by Matt Everson, who's a respiratory physician. And we were able to use that to create a lung subgroup and subgroups for the other tumour sites that we cover in our  programme, which is colorectal and OG, and bring all the different stakeholders together to really  design this service and implement this service successfully. We also were able then to feed  back up into the health and social care partnership, which I mentioned earlier. Next slide please.  And our aim was really to embed prehab and rehab as part of our cancer treatment pathways within  the NHS. So this is an example of one of the pathways, which is the lung cancer pathway.  And for lung cancer, it's not just the surgical patients, we actually offer it to anyone who's experiencing any kind of curative intent, whether that's radiotherapy, chemotherapy,  or surgery. So any of those patients at the point of diagnosis can be referred into the Prehab for Cancer service via a single point of access, which is an online form. And then  they're contacted within a couple of days of that referral being received. So we only have the time  available within the pathway to do that intensive prehab with them, which might only be two or three  weeks. So we really have very quick turnaround times to make sure that we can see patients really  quickly and do as much prehab with them as possible. And as I said, we've got 10 different  major hospitals who all refer into the service. Next slide please. We've done a lot of co-production  and user involvement. So we did a focus group right at the beginning of the project. And what  we found from that with speaking to patients who've affected by cancer is that they found  prehab to be very acceptable and not burdensome, but they really needed their oncologists and their  surgeons to be the ones who advocated prehab and reassured them about the safety of prehab.  And also that the rehab is really important as well, because they often feel that they drop off  a conveyor belt at the end of coming out of hospital. So it's making sure that whatever  program we designed, there was provision after someone was discharged and not just focusing on  the prehab side. Next slide please. We created a leaflet for patients and family members, which  we co-produced with patients. And this was to really reassure people. Often it can be the family members who are the barrier to people engaging in exercise because their assumption  is that it's not safe to do so. And so this was to really reassure people and to set the  expectations before people joined the service. Next slide please. And we've actually been cited  in this recent literature publication around behavioral science within prehabilitation,  because basically saying how important it is to involve patients in the design and delivery of a prehab for effective service design, but also to encourage really high uptake.  Next slide please. So it's really important to note that for prehab to be effective, it's not just about one profession. For us, it's about involving all the different  interdisciplinary team members. So whilst we have exercise specialists who are the ones who  are delivering our prehab for cancer service, we rely heavily on all the different MDT members to  be involved and to escalate any issues or concerns to. Next slide please. Here are some of the exercise  professionals involved in the delivery of our region wide service. Next slide please.  They all had level four cancer rehab qualifications already, but what we have done is a lot of  upskilling with these exercise specialists. So we've used what's called the stepped care model,  which is around psychological provision and training and competence. So we actually made sure that they were able to do effective communication and empathy and really noticing  distress. So they all had that competency before they started to see patients. And then we also do  reflective sessions with the staff involved in the service every couple of months with a  psychologist pod there. And we do lots of regular CPD sessions as well, trying to really upskill  the exercise professionals involved in the delivery of the service. Next slide please.  There's a national exercise workforce collaboration going on within the UK, which has very much come out of the Macmillan prehab guidance. And this is really looking at  the different exercise professionals that are involved and what kind of registration and competence we want them to have. But it's also being aware of allied health professionals  and understanding the potential extra competencies and trainings that's required, for example, for physiotherapists, occupational therapists and others. Next slide please.  So just going back to what we're delivering in Greater Manchester, so these are all the different leisure organisations in our, in the whole of the region.  And so all of them are working together and we deliver the service within 87 different leisure facilities, local leisure facilities that are publicly owned. So basically gyms and  swimming pools, environments that are just down the road from the patients where they live.  Next slide please. And what we know from all the kind of stakeholder engagement and for the  research we've done is that we really wanted to take the path of least resistance. So we know the  moment that we asked patients to travel a far distance to come and get involved in prehab,  and that we were definitely going to lose the uptake that we wanted. So we've made sure that  patients only have to travel less than five miles or less than half an hour. But normally it's  literally that they're going to their local leisure centre, which is down the road in the suburban area that they might live in. Next slide please.  What we do is we have a range of assessment clinics, and that's at different points in the cancer pathway. So we can make sure that we're delivering personalised prehabilitation and  rehabilitation, but also so we can actually evaluate the delivery of the service and make  the delivery of the service and make sure that patients are actually making the improvements that we would expect. So these are all the different quality of life and physiological  assessments that we do with patients at the different time points. Next slide please.  And what we've done is we've actually used the universal targeted model, which some of you might  be aware of. So it's the idea that not all patients need the same provision. So the universal offer is  very much for the patients who are able to be quite independent and come along to the gyms and  follow an exercise prescription with that occasional check-in from the exercise professionals.  Whereas the targeted offer that we provide is three times a week, supervised sessions in small  groups in the local leisure centres. And that's aimed at the gentleman I showed you on the left  before. So those that come into the programme, probably having led quite sedentary lifestyles and needing a lot of support and intervention to support them to engage in exercise.  Next slide please.  So here's an example of the exercise programmes that we deliver. So depending on the assessments  in the beginning, we really do, we're either doing re-hits or we're doing continuous exercise.  And if somebody's going through chemotherapy and radiotherapy, then we really do drop down what  we're doing and we monitor it quite carefully because obviously we don't want to introduce  any risk or any potential toxicities or anything. So those patients do continue to do the prehab  exercise that they've been prescribed. However, obviously for the surgical patients, they have a  break for their surgery, a short break afterwards, and then they come back and they get, everyone  gets 12 weeks of rehab back at the local leisure centres before they discharge from the service. Next slide please.  We also have a website, prehabforcancer.co.uk, which has got lots of videos of exercises and  it's got descriptions and it's got nutritional and wellbeing information. And we've used a lot  of patients to support us because we recognise that for lots of older patients, it can be quite  off-putting going onto a website and seeing quite young people wearing Lycra doing exercises. So that's available for anyone who wants to access that. Next slide please.  So these are some of the figures from the service. We've had nearly 2000 patients referred in the  first couple of years, referrals from all the different hospitals in Greater Manchester.  And we've got an 80% participation rate from referral, which has actually increased during  COVID. And from the first appointment that patients engage in, we've got a 94% uptake rate.  All patients access the service locally to where they live. And we've had over 1000 patients access our remote service during the pandemic. Next slide please.  And we've had a really high number of older patients access the service. And so I think  sometimes there's a perception that older patients won't be able to engage, whereas actually this  shows you that we have really high numbers of people in their 70s and 80s engaging in the  service. Next slide please. Here's some of the data that's come from our patient reported outcomes.  I mean, this is very early data and we did need to do a lot of further evaluation and statistical  analysis, but so far we're showing absolutely improvements in terms of people's cardiovascular  fitness and in terms of their nutrition. Next slide please. So this is just an example from  the lung pathway. So you really can see from this that we are really making some vast improvements  preoperatively. And then actually when people are in their rehab phase as well, which is logically shows that you're going to have improvements on clinical outcomes as well.  Next slide please. So we're going through a full evaluation at the moment. And what we're trying  to do is really show value for money. We have actually had recurrent funded awarded. So the  service will be continuing for the years to come. However, we do really need to show that we're  providing value for money and that the service almost pays for itself, which we absolutely think  we'll be able to demonstrate. So this is the approach we're taking using all the hospital  outcomes and connecting that with our dataset to show improvements and using legacy cohorts to show  a comparison. Next slide please. We've also been doing an acceptability study with the University  of Manchester. So we actually did semi-structured interviews with quite a few of our participants.  And what that showed was that prehab is absolutely acceptable. Transport is a major consideration. So  it really is about how you make it local for people. And actually patients really benefited from all the psychosocial support they've received from the prehab for cancer team  throughout their cancer pathway. Next slide please. So just in terms of our next steps, we really want to think about some of the much more complex and frail and older patients  and understanding that we need to involve lots of different specialist team members to be able  to deliver that kind of top bit of the triangle. We're looking a lot at digital and what we can do  in a post COVID era. We're looking at the research in terms of mechanisms of prehab and rehab delivery.  And then also we're looking at how we can extend our current offer to other tumour sites within Greater Manchester as well. Next slide please. So here's just acknowledgements  of all the different people that have been involved in the design and delivery of the  prehab for cancer service. And then finally the next slide. This is just some comments from some  of the patients who've engaged. We've got some brilliant videos on our website of people who've  really benefited from engaging. But this was from some focus groups we've done more recently,  really showing how beneficial patients have found it. So I'll now hand over to Catherine.  Thank you very much Zoe for a fantastic presentation about your service. And thank you for the invitation to speak today on specifically on the topic of the exercise  component of prehabilitation for patients with lung cancer. Next slide please.  So I'd like to start with our final polling question for today. Susan is a 70-year-old female who was recently diagnosed with lung cancer. Her presenting symptoms were fatigue,  weight loss and a dry cough. And she's now scheduled to undergo surgery in three weeks time.  She's a past smoker and she's currently active in a small way in terms of doing gardening at home,  but she does not participate in any regular form of exercise or physical activity. So at this point,  what would be the most ideal exercise prescription or exercise treatment for Susan before surgery?  A, to do nothing and not change her exercise behaviour until after surgery. B, to start a  combined aerobic and resistance exercise program with a goal of building towards 30 minutes of  moderate intensity walking or cycling and two sessions of strength and resistance training per week. C, to commence a resistance only exercise program. Or D, to recommend Susan  stop gardening and rest as much as she can before surgery. Please vote on your answer now.  Excellent, 98%. So this group is a group in favour of exercise. So at this point, we would recommend Susan be linked in with some exercise professionals or health professionals  and start a supervised exercise program. And I'll talk today about the rationale for exercise and also the evidence from the literature in terms of the benefits of exercise.  So it's well known to this audience that lung cancer is associated with significant morbidity.  Some examples to show this to you, the data on the screen represent patients diagnosed with lung  cancer following these patients from time of diagnosis before surgery, across to after surgery  and six months after diagnosis. And as you can see on the screen here, when you look at markers of  a function of lung cancer, you can see that there are a number of different signs of lung cancer.  When you look at markers of functional exercise capacity or markers of peripheral muscle strength,  we see a steady decline in these outcomes over time. The other thing you'll notice here on  screen is the red dotted line above the both of the figures represents a predicted performance  of this group of patients based on their age. And what we know is people with lung cancer going  into surgery are already at risk with poorer levels of exercise capacity and poorer muscle  strength as well as many other outcomes compared to their age match peers. So this is certainly a  vulnerable group we're working with before they even have surgery. We also know as Clarissa  highlighted at the beginning of our webinar today, most people with lung cancer do not meet the  physical activity recommendations. Some of the research we've done looking at this to date shows that people, only approximately 40% of people with lung cancer at time of diagnosis  meet the recommended physical activity guidelines. This drops significantly after treatment and over  time. And then one of the groups that is most vulnerable in fact are people with inoperable  lung cancer and I know that's not the focus of the webinar today, but to highlight that's a  particularly inactive group and some of our more recent research has shown that on average  a group of people with inoperable lung cancer only walk about 3,000 steps per day, which shows  this is overall a very inactive group. We also know as our webinar has highlighted and as my talk today will highlight that we have very good data showing that physical activity  and exercise training is effective at improving many outcomes for our patients. But unfortunately  exercise programs are very rare and the program that Zoe has highlighted to you is an outstanding  example of a prehabilitation program and a very successful service in the United Kingdom. But generally these programs are rare and infrequent around the world and we certainly  have a long way to go to improve access for our patients to receive this intervention.  So there are many times when we could intervene with exercise training and now I'm going to really  focus Dan on the exercise component of prehab. If we look across the lung cancer treatment pathway we have evidence and good data to support exercise at all of these time points,  but today we're really focusing on pre-surgery.  The rationale, I'd like to begin by talking actually about the rationale of exercise and  why we might be prescribing exercise at this time point. We have in lung cancer an opportunistic  waiting time where we have a number of days to weeks, it's very short depending on where you're based, often it is less than  a month, but we have this opportunistic time where a patient may be being worked up for surgery, they may be going through diagnostic procedures, there may just be a waiting list  and a time to get into surgery, and we have this time where potentially we could intervene with potentially powerful outcomes.  Now if we don't intervene with anything at this time point, we would assume exercise capacity in this period of waiting time remains stable, there's a big insult to exercise  capacity or VO2 peak at the time of surgery, and then slowly a recovery over time again without intervening.  Now we hope that many patients without intervening with exercise rehabilitation would recover  back to baseline levels of exercise capacity, and certainly there's a cohort of people that  do, but some of our higher quality research coming out of some of the best clinical trials we have in this area are actually showing that the control group or the usual care group  are not recovering back to baseline even after surgery. So therefore the rationale of intervening before surgery is to improve exercise capacity  levels, identify and target any specific impairments. Theoretically the insult of surgery is the same magnitude, but then if we intervene in  the post-op period or without that, we're on a different trajectory recovery to help that patient recover back beyond baseline ideally, to improve their health and reduce  incidence of future impairments. So specifically the rationale of exercise at this time point is to target and improve  functional exercise capacity, and that's the outcome that we're really interested in in looking at how it can relate to surgical outcomes.  What we know from evidence now is that functional exercise capacity is an independent predictor of post-operative pulmonary complications for people with lung cancer.  We also know, and it will be well known to this audience, that there's good data to show the relationship with lower levels of exercise capacity or VO2 peak, and they're related  to an increased risk of complications, and also as Clarice has highlighted, worse long-term survival.  We also understand in this population that post-operative pulmonary complications are associated with a number of adverse outcomes, increased ICU admissions, longer hospital  let-to-stay, readmissions, and also from data from Paul Agostini's group in the UK showing it's associated with early and late mortality in lung cancer.  So therefore, by intervening before surgery with prehabilitation and targeting exercise capacity, we're aiming to improve VO2 peak, and therefore hope that this translates to  improvements in a reduction in complications and improvement in other post-operative outcomes.  So I'd like to go on and share with you the evidence supporting that theoretical rationale of exercise.  Now, a number of years ago, Associate Professor Vin Cavalieri and myself published this Cochrane  review on preoperative exercise training in lung cancer, and as many of you will know, if you're familiar with Cochrane reviews, they get regularly updated.  I'm excited to tell you that we're currently updating it right as we speak now, and hopefully, if we work hard enough, we'll have that published this year, if not early next year.  So I'll highlight a little bit of what we know. We're in the early stages of the update as I go through these slides, but I'm also going  to draw upon some other excellent publications that have come out recently. So my initial preliminary search just late last year showed a huge amount of research  in this area in lung cancer, and the figure here, there's small numbers, but just to highlight how much the research has grown.  If you look back from the early 2000s, there's only a small number of studies coming up on that midline compared to 2018, 2019, 2020, where we're getting lots more hits.  So there's a lot of research, particularly over the last decade, that has really focused on this area, which is exciting for us because we need stronger data to improve access.  And as I mentioned, there's been some outstanding systematic reviews published very recently  in the last year or two summarising this topic, so that if you're interested specifically  in this, please go and have a look at some of these papers in more detail, but I'll highlight some key findings now.  We know there are approximately 15 randomised controlled trials conducted in this area of our highest randomised controlled trial evidence.  These are ones specifically looking at exercise training in the preoperative setting for people with lung cancer. These studies are very small.  The sample sizes range only from 19 to 151 patients, so they're very small studies and they're most commonly being conducted in the United States, China or Europe.  The preoperative exercise programs range a little bit in the studies conducted so far, but generally, I've summarised the interventions generally, so you get an idea of what they  look like. They range in length from five days to eight weeks, and that's really dependent on the time someone is waiting before surgery and the time we have to intervene.  They're generally conducted in a supervised setting, supervised by health professionals, normally in an inpatient or outpatient setting, and often these are individual programs for  one-on-one with a therapist or a patient or a group setting, and they very frequently occur from three times a day for the programs that are being conducted for inpatients, compared  to five times a week for the outpatient program. And for those of you that work in exercise programs with other patient groups, you'll  notice this is a very intensive program, you know, we're exercising with patients very frequently in a short period of time.  So we have a very short period of time to actually intervene. And the programs generally, as highlighted in my question at the start, are focused on  certainly aerobic exercise training, that's critical, we need to focus on aerobic training  to improve exercise capacity, but more often than not include resistance training or strength  training as well, sometimes in spiritual muscle training, and they're focused on moderate to high intensity exercise.  We have some excellent outcomes of early data, and I say it's early because we still have only a small number of trials.  These meta-analyses are from some of the recently published systematic reviews. I'm hoping our new Cochrane review will pull together all of the data and we'll be able  to share that with you as soon as it's ready. But so far, we've got some promising early signs.  You can see here on the screen, we've got improvements in the six-minute walk test and VO2 peak, both measures of exercise capacity, immediately post the programs, reduction in  dyspnea, immediately post exercise programs. And then after surgery, we are seeing reductions in the rate of postoperative pulmonary complications  and a reduction in the length of hospital stay. So there are small numbers that you'll see in the meta-analyses generally, and as I highlighted  before, a small number of participants in the trials, but these are really, really promising early signs of the data we have so far.  One issue that we don't understand well yet in pre-HAB and lung cancer is what are the long-term outcomes?  The evidence I've shown you so far really looks at short-term outcomes, before and after a program change, and then immediately after surgery.  There's been one study from the group from Licker and colleagues who conducted an outstanding randomized control trial in this area and published a number of follow-on papers from  their trial. And this is one example of really, to my knowledge, the only example we have of a group following up to 12 months after a pre-HAB program.  And they didn't find any difference in groups at 12 months in terms of survival, respiratory function or exercise capacity.  And by that point at 12 months, despite having a positive finding of the pre-HAB program early on, both groups, the usual care and pre-HAB group, had a similar decline in exercise  capacity. One of the other big questions for our field in terms of implementation is actually the  cost-effectiveness of these programs, if we're looking at implementing them into practice. Again, we don't have much data on this.  Some of the trials, and this one here is an example from a lovely trial in China, looked at cost-effectiveness as a secondary outcome in a small study of 68 patients.  They reported in their intervention, they had saved a hospital length of stay, a median of five days difference between groups and a reduction in total drug and material costs.  And you can see the figures on the screen. The median intervention cost US just over $7,000, whereas the control was just over US for $8,000.  So we certainly need stronger data and trials looking at primarily at cost-effectiveness. But again, it's a good early sign.  And this is a trial that I'd like to draw your attention to that is currently in progress that I think will really help answer some of these questions.  It's an excellent trial that's providing a multimodal prehabilitation program to moderate to high-risk patients undergoing lung cancer surgery.  The primary outcome is change in hospital length of stay. It's involving an excellent multidisciplinary prehabilitation program beyond just exercise,  which I've talked about, and we'll be looking at cost-effectiveness. So I really look forward to hearing the results of that trial when they become available.  One of the other big questions for our field is actually what is the optimal type of exercise training? This is still unclear.  As I mentioned, most programs include an aerobic exercise component. That seems essential. But then there are other trials including things like inspiratory muscle training and  resistance training and balance training. What we know so far is inspiratory muscle training alone improves some outcomes, but  it's not the best combination, whereas aerobic exercise in combination of inspiratory muscle  training appears to be superior, but we have a lot of questions in terms of designing the ideal program.  And there are many of us doing work in this area at the moment to help address that. And then finally, I just thought I'd pose to you some future research questions.  So recently, Vin Cavalieri and myself wrote this editorial for Respirology, and we proposed seven questions to the field looking at exercise as part of lung cancer therapy.  And three of them I think are pertinent for us to think today. What is the cost-effectiveness of these programs? What is the evidence for delivering it via tele-rehabilitation?  And what is the optimal length of programs? And these are going to help us with implementation in the future.  So in summary, preoperative exercise training in 2020, what we know from the evidence, safe and it's acceptable.  There are certainly questions around feasibility, and I haven't had time to go into this today,  but Zoe has given you an outstanding example of a feasible program, but many of the signals  we're getting from the evidence and certainly from my experience in Australia is it's often not always feasible.  We know it improves exercise capacity and a number of other outcomes. The problem so far is we have small sample sizes in studies, generally they're low quality  and we need longer term outcomes. But clinically, we currently recommend based on all of the evidence we have so far that  exercise training as part of a prehab program be considered for people awaiting surgery. We do not recommend that surgery is delayed for someone already fit for surgery, but we  certainly need more research in this area. So I thank you very much for your time and look forward to questions. Thank you.  Hi. Thank you. They were all wonderful talks. We're now going to open up the Q&A session, which you'll find down at the bottom of your screen.  And also the slides for these talks will be available to anyone that would like to look at them and download them at a later date.  I'm going to look at some of the questions we have here. We have actually a question for Zoe, asking about what percentage of the patients participate in your wonderful program?  I think that's actually been covered already. I think the same person then realized because I did talk about it in the presentation. Oh, OK. Yeah.  But just to reiterate, actually, I didn't actually say it, but during COVID, that has actually gone up because I think because we've been doing it in a way that people really  can access the service. And also, I think because health care professionals have been redeployed into other areas, and  so they've really relied on the service for that kind of support going through the COVID pandemic. I have a question for the whole panel.  So as far as costs, in the United States, we don't have a lot of pre-rehab programs. For patients that really are having a hard time, we can get them into rehab before their  surgery, but it usually means we're going to have to delay their surgery. And it's really difficult to get them into rehab before their surgery.  How are these programs being paid for? In the UK, do you have, does the government, Zoe, does the government pay for these programs? Yeah. Sorry.  So yeah, the program that we're delivering is by the NHS. So it's free at the point of contact, as all kind of health care provision is within the UK.  And there are, it's not just us in Greater Manchester. There are other pre-hab programs that are being delivered in other parts of the country,  but I think it really does vary how, on what scale and for what types of cancer treatment that they are available for. Yeah. Okay. And how about in Australia?  Are there programs available that are paid for or? Very rarely. It's very similar to the United States at the moment for us, unfortunately.  There are a small number of public, of government funded programs, but they're very rare.  Yeah. And in Brazil? So here, we have the same problem, actually, which is like, we need to discuss with the payers because it does decrease complications and length of stay.  So they really need to be implemented. I think we just need more studies to show that it will be more cost effective and then maybe everyone will be on board.  But yes, it is a problem. I agree. There's another question here from Jane. It says, our outpatient rehab is always busy and it takes many days to obtain an appointment.  Thoracic surgeries are scheduled quickly. How do you manage to get in the appointments in before surgery and avoid delays?  Does not seem feasible in our area, though we totally agree it would be incredibly beneficial. So I guess the same kind of question that we all just kind of spoke on.  And then there's another question here about, have any of you done any post-surgery review for scar tissue manipulation?  I don't know, is that something they do in, I don't know, I think that's a... No, nowadays, the scars are really so small. Small. Especially the robotic scars, they're tiny. Yes.  Yes. Thank God, because in the past, this was a major problem. Yes, it was, but not so much anymore. Especially... Go ahead. Oh, no, sorry. Carry on. Sorry.  I was just going to answer the feasibility question that you asked us before. So I was just going to say that we do get that often. People say, how are you able to fit it in?  And I think that's why it's so important to really look at the cancer pathway and make sure that the referral happens as quickly as possible.  But one thing I would say is that a lot of our lung respiratory physicians were trying to refer patients before formal diagnosis, trying to build in more time in the pathway.  But that actually caused a lot of problems, because at that time, patients don't know if they've got the diagnosis or not.  So they're very preoccupied with whether or not they actually have cancer. And it really started them off on the wrong foot coming into the service.  So we've actually had to work very closely with the clinicians that we really do need to wait until patients have got that confirmation of cancer.  And that seems to be the optimal time. But then you do need to have the infrastructure and the mechanism so that you can really maximize  the sessions in between that point and then when this cancer surgery is being delivered. We have a question by Pippa who says, do any of you find there is a difference in the prehab  approach depending on treatment plans, chemotherapy versus surgery as their treatment plan? Are they treated differently in the way you approach their prehabilitation?  From my experience, no, probably the only difference is the time that you have. A little bit like Zoe was discussing, if you know you only have days or weeks, you'll target  it a little bit more intensively. But in terms of the actual intervention, no, the goals are the same before treatment.  Yeah, and I was just going to add, so we do actually continue the prehab offer to people during their treatment, like I said in the talk.  But I think we're really cautious in terms of just, especially people going through radiotherapy when they're literally going for sessions every day for six weeks, we really do make  sure that we drop down and we understand in terms of fatigue, et cetera, really trying to be balancing between what's going to be beneficial versus what's going to cause problems  for the patient.  And then lastly, there is a question about during COVID, how did, this is to Zoe, how did your service adapt during that time and specifically regarding health care?  So that's a question too. So did they close the gyms down and everything? And did you find that patients were able to keep up their exercise home by themselves?  Yeah, so basically we had to turn the service in two days from being one in the gyms to one that's like this via telephones and videos.  But actually what we did do is we set up group exercise timetables so that people could do it because really patients really wanted to be part of a group with other people.  And in the kind of nine months we did that, we had about 1000 attendances of those exercise timetables. So we just, everything's been moved to telephone and video.  And like I say, I think it's really has maintained uptake. But I think Catherine's research question about the evidence of the actual outcomes  that come with tele-rehab versus doing it face to face is so key. Because in terms of informed consent, I really want to be able to say to patients, you  know, it's actually better for you to come and do it face to face. And we know this and we've got the evidence to show that because at the moment, I think  we can't say hand on heart whether actually what we deliver in someone's home is the same as what they get in the gym environment.  So I think that's a really important question from a research perspective.  OK, well, it looks like that's all the time we have. I want to thank all of our speakers. They did a wonderful time, a wonderful job.  I'd like everyone for thank you, everyone, for participating. And again, the slides will be available.  Your CMEs will be coming to you. How to get your CMEs via an email will be sent to you.  And again, thank you, everyone, for for coming.  Thank you. And thank you, Aubrey, you did a great job.  Thank you. Thank you.

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