For patients with invasive bladder cancer, standard treatment is radical cystectomy, a complex operation associated with high levels of morbidity and mortality. To optimize patients’ abilities to recover from the procedure and cope, attention is now turning to a novel intervention begun well in advance of surgery to “prehabilitate” the patient, taking a holistic approach. Experts say the strategy could be applied across specialties to better prepare patients for a multitude of complex procedures.
“If a person is going to run a marathon, it behooves them to train before the race,” said Woodson Smelser, M.D., a urologic oncology fellow at Vanderbilt University Medical Center. “Our goal is for patients to be strong for surgery, and to be in the best shape both mentally and physically before they go in.”
Moving Beyond ERAS
Prehabilitation represents a needed outgrowth of earlier efforts that have been underway for about 20 years to improve patient outcomes through enhanced recovery after surgery programs, or ERAS, Smelser said.
Although it wasn’t referred to as an ERAS program, the first effort that effectively functioned as an ERAS emerged in the 1990s at Vanderbilt in Urology. That effort was led by Joseph Smith, Jr., M.D. and Michael Koch, M.D., said Sam Chang, M.D., Patricia and Rodes Hart Professor of Urologic Surgery and Chief Surgical Officer at the Vanderbilt-Ingram Cancer Center. “Their work in this area decreased hospital stays by more than 100 percent, decreased costs, and maintained patient satisfaction,” he said. “Vanderbilt was the national lead in urology for this work and gained national prominence for it.”
Today, when it comes to minimizing complications related to bladder removal, most programs still start only after an operation. Those prehabilitation efforts that are currently underway address just one facet of a person’s pre-operative condition, Smelser explains, rather than working with the patient to improve in all the realms that matter, both mental and physical.
“Our goal is for patients to be strong for surgery, and to be in the best shape both mentally and physically before they go in.”
“By reviewing the current evidence on prehabilitation, we found that most of the initiatives offer patients monotherapy in an area such as smoking cessation or exercise,” Smelser said. In contrast, he explained, the prehabilitation program for radical cystectomy patients at Vanderbilt addresses multiple key areas.
A Five-Pronged Approach
First, the prehabilitation program addresses smoking cessation, offering counseling and medication. “We know that even three weeks of quitting before surgery is beneficial,” Smelser said. Second, arrangements are made for patients to have pre-operative, inpatient, and post-operative appointments focused on ostomy education and troubleshooting.
“Helping patients to get strong physically is the third focus area,” Smelser said. Patients may undergo a pre-operative or pre-chemotherapy evaluation within the Departments of Physical Therapy and Physical Medicine and Rehabilitation. “This allows the patients to have pre-op exercises that they can actually achieve,” he said.
Fourth, patients undergo screening for dietary deficiencies and related conditions, including anemia, so their nutritional status can be optimized before surgery. This aspect of the program is in line with earlier efforts at Vanderbilt pioneering the use of perioperative nutritional supplements to improve outcomes for radical cystectomy patients.
“This comprehensive prehab approach has the potential for wide adoption with any surgery that may involve significant morbidity or stress.”
The fifth aspect of the program addresses emotional problems, such as anxiety and depression, which Smelser explained affects many cancer patients. It is only after a patient has completed all five steps that they are approved for radical cystectomy. In total, prehabilitation takes approximately 4-12 weeks, Smelser said, depending upon if a patient is receiving chemotherapy before surgery.
A Widely Generalizable Program
Smelser and his colleagues have been gathering data on an initial group of 52 patients who are enrolled in the radical cystectomy prehabilitation program. His team plans to publish their findings on this initial group, and to continue gathering data on additional patients.
“This comprehensive prehab approach has the potential for wide adoption with any surgery that may involve significant morbidity or stress. It’s appropriate for lots of different types of procedures,” said Chang.
Chang reported fielding inquiries about the approach from Vanderbilt colleagues who perform gynecologic, gastrointestinal and sarcoma operations. He is working with Smelser to adapt the program to the needs of other disciplines.
Clinicians from other institutions have also been seeking information about the program. “They’re asking, ‘What do you do? And how do you do it?’” Chang said, expressing the hope that before too long holistic prehabilitation will be expanded both regionally and nationally, so patients facing all kinds of complex procedures can benefit.