Understanding Prehabilitation, with Arash Asher, MD, and An Ngo-Huang, DO

April 21, 2016
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In today’s podcast, Cancer.Net Advisory Panelist Dr. Arash Asher talks to Dr. An Ngo-Huang about prehabilitation and why it is becoming a more common element of cancer treatment. 



ASCO: You are listening to a podcast from Cancer.Net. This cancer information website is produced by the American Society of Clinical Oncology, known as ASCO, the world's leading professional organization for doctors that care for people with cancer.

After cancer treatment, our rehabilitation program can help a person regain strength, physical functioning, and independence. However, there has recently been a new interest in prehabilitation, which is a personalized program of nutrition, exercise, and emotional support to help a person diagnosed with cancer prepare for treatment, such as surgery or radiation therapy.

In today's podcast, Cancer.Net Advisory Panelist Dr. Arash Asher talked to Dr. An Ngo-Huang about prehabilitation and why it is becoming a more common element of cancer treatment. Dr. Asher is the director of the Cancer Survivorship and Rehabilitation program at Cedars-Sinai Health System, and Dr. Ngo-Huang is an assistant professor in the Department of Palliative, Rehabilitation and Integrative Medicine at the University of Texas MD Anderson Cancer Center. ASCO would like to thank Dr. Asher and Dr. Ngo-Huang for discussing this topic.

Dr. Asher: Good morning, my name is Dr. Arash Asher. I am a cancer rehabilitation physician working at Cedars-Sinai Medical Center and I am delighted to have a chance to talk to Doctor Ngo-Huang and I'm going to let you introduce yourself.

Dr. Ngo-Huang: Good morning. My name is Doctor An Ngo-Huang. I am also a cancer rehabilitation specialist. I am working at the University of Texas MD Anderson Cancer Center.

Dr. Asher: And today we're going to have a chance to talk about a topic that I think we would both agree hasn't received as much attention as it probably should have because it just makes common sense. Hopefully this will resonate with our audience today. And the topic is prehabilitation. A word that you may have not heard before. But Doctor Ngo-Huang, can you just describe in basic terms what is prehabilitation? What does it mean to a patient who may be going through cancer treatment?

Dr. Ngo-Huang: We've been doing rehabilitation for patients, especially our cancer patients. They have significant needs as you would agree Dr. Asher. But we've been actually doing prehab for a very long time. As rehab specialists we see patients who have joint replacements, ones who've prepared for major heart surgeries. And they actually go through prehabilitation programs to prepare for these surgeries. So this is something that we use for our cancer patients. Our cancer patients go thorough significant treatment programs, and a prehab program would include exercise, nutrition, or psychological interventions to help prepare these patients for potentially stressful events such as surgery. And our programs such as exercise programs can help enhance their recovery from surgery and it's a straight forward concept.

Dr. Asher: I'm just going to clarify one point. It's a word we use often, so when you say “prehab,” that is our lingo for prehabilitation. Correct?

Dr. Ngo-Huang: Correct. Yes.

Dr. Asher: If we walked through this from our patients’ perspective, let's say I were recently diagnosed with breast cancer, for example. And I knew I was going to be having surgery and the chemotherapy, and these things are being tied together by my medical team and oncology team, how could prehabilitation apply to me?

Dr. Ngo-Huang: Yes, it's a straight forward concept. Like you said, you're a breast cancer patient, you come and see your medical oncologist who prescribes the chemotherapy program for you, and then you see a surgeon who is going to prepare you for surgery. And so the patient would come and see someone who could prescribe a prehab program, prehabilitation program, to prepare them for surgery. As we know, surgery can be very taxing and stressful for the body, so what we do is we put the patient on an exercise program to help prepare for the surgery. The program may stress the heart and lungs and condition it for the big event such as the surgery. Particularly for breast cancer patients, we'll give them a tailored exercise program to help strengthen their arms, their upper back, so that once they have surgery and potentially radiation, that it will limit some dysfunction or problems that they may develop in their joints and their shoulders and their chest area after surgery, and after radiation also.

Dr. Asher: So, if I could summarize for you, traditionally, that if I had a patient with breast cancer, they would go through the surgery, potentially chemotherapy and radiation and then at some point, they may interact with the rehabilitation professional after they've through all this treatment and potentially already experiencing some of the weakness and deconditioning that could occur. And really the tenant of prehabilitation is to begin working with them before that happens. To try to prevent or medicate some of these things from happening in the first place.

Dr. Ngo-Huang: Exactly. So if we could get in very early on, we can address if patients have any even pre-existing conditions. If someone has a shoulder injury from a sports related event, we could go in and actually help address that issue ahead of time and then hopefully eliminate or limit any issues that may result from after surgery, any complications.

Dr. Asher: Dr. Ngo-Huang, why do you think it's taken us this long to begin integrating prehabilitation? It kind of seems to make sense and there is more and more research demonstrating some of the effectiveness of something like this. But why did we not start doing prehabilitation years ago?

Dr. Ngo-Huang: I think because we've been focused on - in terms of the oncology community - has been very focused on just even getting patients through their oncology treatments. So a lot of the focus has been on drug development, on fine tuning surgical techniques. And, as rehab specialists, we're seeing patients who are going through a lot more treatments. A lot of patients are surviving their cancers, which is great, and patients are becoming older and we're seeing side effects from their cancer treatments. So now, we're actually looking back and seeing, "Well, how can we prevent some of this? What can we do to help patients so that they can undergo their treatments and recover more quickly and be candidate for more treatment options in the future also?"

Dr. Asher: And I imagine there may have been very real reimbursement issues in that historically, insurance companies may not have wanted to support strengthening someone who necessarily already isn't a strengthening problem at the onset. But I think as the research is demonstrating that this can actually prevent problems down the line, that hopefully we're going to see more of this in the future.

Dr. Ngo-Huang: That's a great point in terms of insurance reimbursement. That's the whole set of issues that we can definitely--

Dr. Asher: It's been a barrier. I mean it's been a barrier for sure. And I think one of the goals of people like you who are doing research in this area is to really demonstrate that not only can it potentially save the system money in the long line, but you're actually really making a difference in the quality of life of our patients. Now, do you imagine or foresee any risks that come with prehabilitation?

Dr. Ngo-Huang: So, I think with the prehabilitation, ideally you'd like to have someone who is experienced in seeing patients who've undergone a variety of cancer treatments. We just have to look at their medical comorbidities and design a program that is personalized for some of our patients. As you are aware, Dr. Asher, some of our patients become very deconditioned during their cancer treatments. They lose their muscle mass, they have very poor endurance, some of them develop peripheral neuropathy, and it could place them at risk for balance issues and increase their fall risks. And so, with some of these patients, seeing a rehabilitation specialist who's experienced in these conditions, we could design a program that would be more safe for these patients. Also, some of our patients undergo very toxic chemotherapy programs where their blood counts are decreased. They have low platelets, which means they could be at risk of bleeding if they exercise too aggressively. Ones who have low blood counts in terms of their low hemoglobin could become very fatigued and could be at risk of passing out or falling. So, these patients need to be monitored and given appropriate guidance with their exercise program. We definitely want them up and moving, but we have to balance the intensity of the program to increase their compliance, also.

There was a study at McGill University in Canada, colorectal cancer patients. And they actually put these patients, one group in a very intense strengthening program, and then the second group had a walking and breathing program. And they found that the patients who had the more intense strengthening  program, they actually didn't have any adverse effects, but there was low compliance in that group, and they found the patients who had walking and breathing program actually benefited more from the exercise program. So in designing these programs and seeing these patients, we just have to weigh whether or not patients would be compliant so that they could reap the most benefits from these programs.

Dr. Asher: So, I think the bottom line is that it needs to be tailored to each individual. And we could imagine if one person has prostate cancer and they're going through one set of treatments that we know we can anticipate certain musculoskeletal complications, we can target the pre-abilitation towards that, whereas, let's say, the breast cancer individual that we talked about earlier, we can probably anticipate having some shoulder problems and we could, again, tailor the rehabilitation to try to prevent those shoulder problems, for example. So I think to your point, individualizing this and not making it one prehab program for every single patient that may be touched by cancer really just makes the most sense.

Dr. Ngo-Huang: Correct. I mean, in clinic's instance, I most recently had a patient who had an oral cancer, head and neck surgery, and so her program differed very much from our patients who had esophageal cancer and who had part of her esophagus removed and reconstructed, you know. Our head and neck cancer patients, we had to focus a lot on her swallowing, her nutrition, giving a lot of guidance with her nutritional intake because, with her treatment, she ended up losing a lot more muscle mass. She had voice issues. There were a lot of body image concerns, and she developed significant depression through her treatment. But, with our prehab program, we gave her very close follow-up in our rehab clinic. She saw our physical therapist. We did a lot of exercises looking at her posture, and her neck and shoulder, so that we could potentially prevent those issues that come up in the future with some of our patients who have head and neck cancer.

Dr. Asher: So you bring up a good point, because you brought up the importance of nutrition, which I think many people can also view as a critical part of prehabilitation because we know we want to optimize one's nutrition before going into surgery, for example. And I think there's been some studies showing that optimizing your nutrition before chemotherapy, before surgery, can improve outcomes. But, it also brings up the question of the different types of professionals that can be involved in prehabilitation. So can you speak to that a little bit, in terms of what kind of health care professions can be involved in carrying out these prehabilitation plans?

Dr. Ngo-Huang: Of course, Dr. Asher.  In our field as physical medicine and rehab specialists, we work with a multidisciplinary team, meaning we work with a lot of specialists , and we help coordinate the programs for our patients. So in a prehab program, we have our rehab specialists. We have, potentially, physical therapists, occupational therapists. The physical therapists will help with the patient's walking, strengthening of their legs. An occupational therapist will help with their upper limbs, in terms of their arm range of motion, strengthening their arms, helping them with daily activities, or helping prepare them for, potentially, loss in certain activities using their hands - depending on the type of surgery or side effects that may occur. Also, a part of this group is the clinical dietitian. In a lot of our clinics here we have a clinical dietitian that sees our patients up front and they provide guidance in terms of looking at the patient's weight, what their target weight should be, giving them advice on caloric intake, and how much protein they should be consuming, also. Specifically, in our prehab programs we want patients to increase and gain their muscle mass. So, part of the program is to have the patients increase their protein intake, and we have specific recommendations for that, also too.

Also important in this program is to have a psychologist or a counselor available to help prepare these patients. The new diagnosis of cancer can be very stressful to the patients, and their family members, and loved ones. So, having the availability of a counselor to provide some guidance is very important for these patients. There are, actually, some recent studies showing, specifically, in cancer patients that psychologic intervention early on is very helpful because it will help reduce stress hormone such as cortisol. It will help the patient in terms of well-being and techniques to help reduce the stress through their program. Some of these studies have also shown that if you're able to help reduce stress in the patients that they'll have improved immune function and even improved wound healing in some of these patients. As part of a comprehensive prehab program, again, we have multiple people involved: a physical, medicine, and rehab specialist help oversee the program, our physical therapist, occupational therapist, a nutrition specialist, and potentially a psychologist also.

Dr. Asher: I think it really speaks to the idea that prehabilitation really has the capacity to be truly holistic in that we could be addressing someone's physical needs, someone's emotional needs, someone's nutritional needs and really trying to take advantage of something that our oncology colleagues refer to as "the teachable moment," in the sense that when we have something serious come up in our lives, we have the opportunity to potentially really make a difference in terms of how we're living our lives and really trying to maximize our function and quality of life within the circumstances that we may find ourselves in, and I think in that sense that is one of the overarching goals of prehabilitation. We mentioned that there's been a lot more research in this area in the last three to four years or so, and I think much more is going to be emerging in the following years. You are performing research at your own institution regarding prehabilitation. Can you speak to that a little bit?

Dr. Ngo-Huang: Yes. We have a research study here, I'm working very closely with Dr. Matthew Katz who is a surgeon who specializes in pancreatic cancer. We've developed a prehab study where we're currently enrolling patients here at the University of Texas MD Anderson Cancer Center. The study is currently in progress for still enrolling patients, but we have some very promising and exciting information from even the first 20 patients that re-enrolled in the study. Typically, what happens where the study is that a patient comes to MD Anderson. They're seen by one of the surgery teams. If the surgeon thinks the patient’s potentially a surgical candidate, they will have the patient enrolled on a study. The study involves an exercise program that we've developed where the patient has an aerobic exercise component where they're instructed to walk 30 minutes a day. Then we also have the side of exercises that talk to the patients. These are exercises using exercise fans to strengthen their arms, legs and their abdominal muscles. We give them a DVD and handouts on exercises and then we provide them with exercise logs also.

During this visit, the patient's also seen by the clinical dietitian. The dietitian gives them instructions on diets, on their target goals of calories and then we talk about the protein supplementation.  So our goal with this study was just to see if the patients would even be able to exercise. All of these patients receive chemotherapy or chemotherapy and radiation. And that's one of our inclusion criteria was, we wanted to see if patients who are receiving chemotherapy or chemo and radiation, are they even able to exercise during these treatments before their surgery? And so for these first 20 patients, 15 of them were able to exercise regularly. Our goal was to have them exercise 120 minutes per week and it looks like right now we have patients exercising from a range of 110 to 160 minutes per week. And so, it's very promising because we're seeing that during chemotherapy, and this is a very toxic program of chemotherapy that they're receiving, that they're able to exercise but at lower levels. But, if in the next stage, when they're receiving chemotherapy and radiation they're beginning to exercise moreso and during the four week rest period that they have before surgery, we have patients exercising anywhere from 150 to 160 minutes per week. So imagine that. We have these patients who are newly diagnosed with pancreatic cancer and the average age of these patients are about 65 years old and they're exercising regularly during this very heavy duty program of chemotherapy and chemotherapy and radiation. So we're quite excited for these patients and the patients are I mean so far, anecdotally, they're very excited. They're very motivated. They have their families on board to exercise with them and this is all done at home. A lot of our patients are from out of town, and so they're able to take this program with them. Our research staff calls and checks up on them periodically. And right now, actually, with the current study, patients are logging online and filling out logs online in terms of recording their exercise activity.

Dr. Asher: So this is really exciting because I think it's going to speak to this very simplistic principle that the stronger you are going in to the surgery or the chemotherapy or the radiation or combinations of thereof. The stronger you are going in, the stronger you're going to be going out. And I think that is the fundamental goal. The challenge is going to be, I think, for our community to integrate this because it is kind of a game changer in terms of how we think about rehabilitation to integrate it earlier on in the process rather than after you're done with all the treatments. And I think the type of work that you and others are doing is hopefully going to help kind of move the role of rehabilitation earlier and earlier into the prehabilitation domain.

Dr. Ngo-Huang: These patients did the exercise program for 11 weeks, which is a long time. I mean, we had a patient who had chemo and radiation for a long time. It was for nearly 6 months actually. And they were actually pretty diligent on doing the exercise. I think reflecting back on what you mentioned earlier, Dr. Asher, in terms of looking at whether insurance companies will pay for this, I think once we have more information from  our studies here in terms of looking at their length of stay and their rates of complications after surgery and all that, we're able to pull together this information and present it to our insurance payers and show that if they're able to just put in this little effort up front, that it will yield a lot of long-term benefits in terms of decreasing length of stay in the hospital, decreasing their rates of complication, and making it bottom line for the insurance companies a lot more inexpensive if they're going to have to pay for pretty expensive programs for these patients. And also from, like you said, the quality of life standpoint, a lot of our patients go into surgery feeling a lot better about themselves, they're less stressed and worried about the complications of surgery because they physically feel better about themselves.

Dr. Asher: Well, I think this is very important and, Dr. Ngo-Huang, I think your research and the work of others in this area is going to make a big impact. And I think we can stop here perhaps, unless there's anything else that you wanted to relay to our audience?

Dr. Ngo-Huang: I think this is a very important topic and an important emerging field for our cancer patients. I think the movement now is to look at ways to help patients' quality of life through their treatment and this is definitely one field where there's ongoing research and we're definitely seeing benefits. Patients and families are very appreciative of these programs.

Dr. Asher: Great. Thanks so much.

Dr. Ngo-Huang: Thank you Dr. Asher.

ASCO: Thank you Dr. Asher and Dr. Ngo-Huang. Visit www.cancer.net/healthyliving for more information about healthy living during and after treatment. And for more expert interviews and stories from people living with cancer, visit the Cancer.Net Blog at www.cancer.net/blog.

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