For patients who have been diagnosed with cancer, the road to recovery can appear long and daunting. It therefore came as a pleasant surprise to Mr Goh Tong Nang that he found himself up and about walking shortly after his surgery. He was even able to shower independently the morning after. These fast gains in mobility were the fruits of his efforts under Changi General Hospital (CGH)’s cancer prehabilitation programme devised by its rehabilitation medicine specialists.
A one-stop screen-and-intervene initiative, the CGH cancer prehabilitation programme gives newly-diagnosed patients a head-start on recovery, even before their treatment or surgery. By adopting a home-based model and cutting down time spent in the hospital, patients can focus fully on their prehabilitation so as to achieve improved recovery outcomes.
Following a pilot study for newly-diagnosed colorectal cancer patients who had improved functional recovery outcomes after undergoing prehabilitation, CGH expanded the programme to include more patients with liver, pancreatic, gallbladder, prostate, bladder, oesophagal and stomach cancers.
PRIMING FOR THE FIGHT AGAINST CANCER
Patients under the cancer prehabilitation programme undergo a series of assessments to holistically evaluate their health across physical and mental domains during the first prehabilitation consultation, which takes place after their surgical consultation. The comprehensive evaluation — which involves frailty, functional and mental wellness tests — is conducted by a prehabilitation team.
“This ‘window of opportunity’ between diagnosis and treatment is crucial in empowering our patients to play a part in improving their post-surgery outcomes, even from home.”
Clinical Assistant Professor Tay San San Chief and Senior Consultant, Department of Rehabilitation Medicine, CGH
Based on each patient’s results from the evaluative assessments and their medical conditions, the prehabilitation specialist doctor prescribes a personalised, integrated intervention plan. The plan incorporates the optimisation of any pre-existing medical or chronic conditions, an exercise prescription, as well as nutrition and mental wellness advice. Collectively, these interventions are targeted at improving the patient’s capacity to withstand upcoming surgeries or anti-cancer therapies.
Typically, patients are referred to various allied health specialties by the surgeons for prehabilitation. CGH’s rehabilitation physicians involved in this programme are not only certified in exercise prescriptions but are also cross-trained by dietitians and psychologists. This enables patients to have convenient access to a well-rounded care intervention plan. “Under the new cancer prehabilitation framework developed by CGH, most patients will need only two appointments — one for the first consultation, where a comprehensive health assessment is carried out and personalised interventions are prescribed; and another to assess the patient’s condition before treatment starts,” says Clinical Assistant Professor Kwok Kah Meng, Consultant, Department of Rehabilitation Medicine, Changi General Hospital. The CGH multi-disciplinary team’s collaborative approach also ensures that patients with more complex cases can be referred to physiotherapists, dietitians or social workers if required.
Clinical Assistant Professor Kwok Kah Meng (right) and prehabilitation coordinator Christopher Paul (middle) going through the cancer prehabilitation programme with a patient model.
CGH prehabilitation coordinator Christopher Paul administers a hand grip test using a hand dynamometer.
“We aim to help our patients regain their functional independence post-treatment as soon as possible, facilitate their recovery journey from hospital to home, and empower them to develop long-term beneficial health habits, including exercise.”
Clinical Assistant Professor Kwok Kah MengConsultant, Department of Rehabilitation Medicine, CGH
Changi General Hospital's prehabilitation programme has benefited about
200 patients since its pilot in January 2020.
The journey does not end here. In providing continuity of care from hospital to home, CGH’s care team follows up with patients on their recovery progress three months after surgery, and individualises further care plans where necessary.
A PILOT STUDY SHOWS IMPROVED HEALTH AND RECOVERY OUTCOMES FOR PATIENTS IN THE PROGRAMME
A pilot study by CGH on 59 colorectal patients who participated in the cancer prehabilitation programme showed a significant improvement in their mental health, psychological well-being and quality of life*. They also went home earlier by an average of 1.5 days after the surgery, with reduced post-operation complications, readmission and mortality rates.
Their resulting better physical capacity leads to improved ability to tolerate additional therapy given after the main treatment, reducing the chance of treatment disruption or termination. The pre-operation and additional therapy period presents a golden opportunity for lifestyle interventions, as adequate exercise, nutritional diet and the cessation of smoking are known to reduce the recurrence of cancer.
* 2021 Cancer Prehabilitation Framework Study by CGH
A look at some factors that make a big difference in putting patients back on the path of wellness.
Medical optimisation refers to the control of underlying chronic diseases such as hypertension and diabetes, relieving symptoms that can affect one’s ability to participate in the prehabilitation exercise programme. This includes the management and treatment of underlying causes of anemia; smoking cessation as well as the reduction of alcohol intake.
Strengthening and aerobic workouts are key, while flexibility exercises are part of warm-up and cool-down routines. Strengthening exercises help maintain and build strong muscles, increase muscle mass and improve balance. Aerobic exercises — also known as cardio — improve heart and lung function, helping patients feel less tired during and after treatment.
Nutritional prehabilitation interventions consist of two important aspects — a balanced calorie intake and sufficient protein supplementation; as well as ensuring having proper micronutrients supplementation for immunonutrition. Having good nutrition helps ensure patients have sufficient food and liquids that have vitamins, minerals, proteins, carbohydrates, fat and water that the body needs.
Mental health, or psychological interventions, focus on relief techniques and strategies to address stress and anxiety symptoms. These include deep breathing techniques, progressive muscle relaxation and mental imagery techniques. Possessing good mental health encourages positivity and builds one’s mental resilience.
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