Workshop Prehabilitation in cancer care: The latest evidence and prehabilitation in practice

Prehabilitation in HPB surgery Neil Bibby- Macmillan Senior Specialist HPB Dietitian, Manchester Royal Infirmary Prehabilitation in HPB surgery

Why is nutrition important? Numerous studies have shown a clear association between malnutrition and poor surgical outcomes: increased overall mortality and morbidity increased hospital stay, increased intensive care unit admissions, delayed wound healing, surgical site infections, other infectious complications and reduced quality of life Pausch et al. 2012 found preoperative weight loss >10% in 73.9% pancreatic cancer patients awaiting surgery (1) Multiple studies have also shown an association between the presence of sarcopenia and adverse outcome after surgery: prevalence of 55.9% and 63% was reported for pancreatic cancer patients [2,3]. prevalence of 26% and 57.4% for pre-chemotherapy oesophagogastric cancer and 43% and 78.7% for post-chemotherapy oesophagogastric cancer [4,5]. Prehabilitation from diagnosis offers an opportunity to optimise these patients prior to proceeding for surgical intervention

Project Overview Prehabilitation and Enhanced Recovery- An integrated programme of exercise and improved general well-being, nutritional support and psychological screening for HPB cancer patients undergoing surgery This programme spans the four phases of the patient pathway: Prehabilitation Enhanced recovery after surgery Recovery and reablement, and Living with and beyond cancer

Prehabilitation- Case study 78 year old female- newly diagnosed with head of pancreas adenocarcinoma Initial assessment 6/7/17 Weight- 61kg BMI: 23.6kg/m2 Weight loss 19.7% over 2 month Handgrip- 15.1kg (60% of normal) Patient generated subjective global assessment Reduced food intake, no appetite, nausea, taste changes, smells of food putting off eating and early satiety Able to do little activity and spending most of the day in bed/chair last 1 month Overall score 20

Already started on creon- taking 75,000 units with meals and 50,000 snacks. Nil with glasses milk. On going symptoms of malabsorption Started on nutritional supplements, Ensure - dislikes CPET 6/7/17 Does not have adequate reserves Very high risk of either perioperative death or a significant decrement of her quality of life

28 days Prehabilitation 3/8/17 Repeat CPET-Better test and just outside the normal range for her age group Able to proceed to surgery 31/8/17 Weight- 60.2 (stable) Handgrip- 18.3kg (increase 3.2kg) Oral intake and symptoms significantly improved Patient generated subjective global assessment score- 7 (Previously 20)

Project Results- year 1 159 patients had dietetic assessment at baseline 31 patients were deemed to be low nutritional risk and if not proceeding to a whipples/total pancreatectomy they were discharged Patients lost to follow up and repeat outcomes were unable to be obtained. Patients were excluded if they progressed to surgery within 14 days Patients were excluded if they had significant data missing on repeat outcomes.

54 patients met criteria to be included in the PREHAB data Overall 40 of the 54 underwent surgery Median Prehabilitation duration- 34 days (Range 14-165 days) Baseline Review Weight (kg) 64.9 (range 45.1 to 121.7) 68 (range 46.1 to 121) BMI (kg/m2) 22.4 (range 17.7 to 35.5) 23.1 (range 18.8 to 34.3) Weight loss ≥5% (%) 70 4 Weight loss ≥10% (%) 33 Weight change (%) -6.9 (range -27.7 to +10.4) +1.9 (range -5.3 to +33) Handgrip ≤85% (%) n= 35 43 19 Handgrip (kg) 26.4 (range 15.1 to 39.3) 30.6 (range 17.5 to 44.8) Short PG-SGA score 7 (range 0 to 17) 0 (range 0 to 10) Gastro-intestinal symptom score n= 28 12.5 (range 0 to 39) 5 (range 0 to 28)

The Nutrition and Dietetic Patient Outcomes Questionnaire Adult Patient

Patient Interviews n=4 “the intervention really did leave me feeling mentally, spiritually and physically fit in readiness of my surgery” “I would definitely recommend them and I have told everyone I know how good they have been” “it was lovely being able to do something that would benefit me post operatively” “I was very weak and I was told I needed to get stronger for the operation, without their help I wouldn’t be here today” “feeling prepared and fit for an operation beforehand leaves you feeling empowered” “feel the organisation should make this service available to more people”

Post-operative review data- Whipples Weight (Kg) 58.1 (range 42.6 to 106.7) BMI (kg/m2) 21 (range 16.8 to 29.8) Weight change (%) -8.5 (range -19.2 to 2.5) Weight loss ≥5% (%) 84% Weight loss ≥10% (%) 36 Handgrip ≤85% (%) n= 22 68 Short PG-SGA score 8 (range 1 to 21) Gastro- intestinal symptom score n= 25 11 (range 1 to 29)

Achievements Presented at Pancreatic Cancer UK Annual conference 2016 and due to present at Pancreatic Society Great Britian and Ireland Annual Conference Runner-up in the Inspiring innovation poster competition Pancreatic cancer innovation Summit 2016 Chosen best project at trust Transformation event 2017 Secured further 1 year funding

Future Developments Link with other preoperative projects- ESMOS pharmacy project and ERAS + Extend physiotherapy support into postoperative period and beyond Expand into other high risk surgical areas

Questions