Greater Manchester Cancer Implementation of Prehab4Cancer Dr John Moore Clinical Director for Prehab and recovery

John.moore@mft.nhs.uk @mysurgeryandme Advice: -Activity -Muscle strengthening -Chest training -Nutritional -Wellbeing -Anaemia management

Improving Surgical Care www.erasplus.co.uk

@Prehab4cancer for Lung GM Cancer Prehab and Recovery @Prehab4cancer for Lung

What can we do

Regional and National expert group Deliver Prehab to 2000 patients GM Cancer Prehab and Rehab Psychological Nutritional Prehab4cancer Exercise Intervention FITT Regional and National expert group Single referral point 48 hour reply GM wide coverage Deliver Prehab to 2000 patients Upper GI Lung Our 87 leisure and sport facilities are based in neighbourhoods across the city region (33% are in the 10% most deprived neighbourhoods in the country) We see 30million visits every year and contribute to the economy through over £100million in combined expenditure. We run a number of targeted programmes which support around 30,000 users per annum. Colorectal Universal prehab Specialised prehab Head and Neck World leading outcomes

Elective Cancer surgical patient Days Weeks Elective Surgery Complications Later Complications Failure to recover FITNESS HIGH 2 year mortality Elective Cancer surgical patient 2-year mortality

VA hospitals >100,000 patients 1990-1991 NASQIP Review of 8 operations and complications Colorectal Upper gi Vascular Over eight years follow-up 30 day follow-op

Dutch study 4400 patients 6 year follow-up 45% having medium – high risk surgery Looking at what patients died from

No complications Self-limiting complication – small wound dehiscence not requiring intervention Complications requiring intervention- ABS for pneumonia, wound infection – re-operation Major complication – organ failure, associated wiit residual diablity More severe complications more impact on survival Later deaths commonly CVS and cancer

Why patients die later after surgery Normal recovery Loss of lean muscle Altered immune function Complicated recovery Cytokine and oxygen free radical induces apoptosis – reduces organ function Accelerated atherosclerosis

Immediate Reduced functional reserve Longer term consequences Peri-op cardiac event reduces cardiac function Persistent peri-operative inflammation accelerates cardiovascular atherosclerosis and plaque instability Cognitive dysfunction CVA Longer term cognitive dysfunction CVA Acute Neuromuscular weakness Prolonged disability

What can we do Improve care delivery of surgical services =ERAS+/ERAS Patient and family preparation and recovery = PREHAB

the cancer surgical pathway PATHWAY innovation the cancer surgical pathway Measure MORBIDITY PREHAB REHAB 90 day mortality 2 year mortality PATIENT OUTCOMES Prehab4cancer Prehab4cancer QOL COMMUNITY HOSPITAL COMMUNITY

Improving Surgical Care www.erasplus.co.uk

our team

ERAS+ OPTION 06 OUTCOMES PREHAB 02 04 HOSPITAL 03 REHAB 05 01

Optimising medical health

I COUGH Incentive spirometry Coughing Oral Healthcare Understanding Getting out of bed Head of bed elevation I COUGH: reducing postoperative pulmonary complications with a multidisciplinary patient care program Cassidy MR JAMA Surg. 2013 Aug;148(8):740-5.

Surgery school

ACTIVE CHEST TRAINING FAMILY AND FRIENDS NUTRITION Surgery is a big thing for your body and we need to get you as fit as possible Lets get your lungs fit and ready for surgery FAMILY AND FRIENDS NUTRITION Your body is getting ready for Surgery - need to eat well YOU will benefit from good support to help with your prep and recovery

50% reduction 3 day LOS reduction = 500K Moore et al, Anaesthesia 2016 (in print) Moore et al Anaesthesia 72(3) · March 2017

>70% + would like to trial digital support It needs to be simple

Prehab Preparation for planned body stressor Physical activity Nutrition Well-being

A systematic review of trials investigating the effectiveness of preoperative exercise for patients undergoing a range of oncological surgery Most benefit for Lung Cancer Surgery

Summary of prehab Evidence so far We can improve fitness but in studies difficult to relate to improved outcomes and tends to excludes least fit for prehab Highly likely stronger benefit in higher risk patients. We need multi-modal prehab

Dose of exercise intervention fitT principle Frequency Intensity Time – duration of session Type of exercise

@Prehab4cancer for Lung GM Cancer Prehab and Recovery @Prehab4cancer for Lung

What can we do

High Medium Low Surgical risk More frail 50-60% complications Highest mortality short and long-term

Specialised Targeted Universal PREHAB INTERVENTION More frail 50-60% complications Highest mortality short and long-term Can we get NHS England to recognise period of PREHAB as care for these patients

Regional and National expert group Exercise Intervention FITT Regional and National expert group Prehab4Cancer team led by Kirsty and her team 60 level 3-4 PT trained in the exercise intervention Exercise combination of CVS endurance and strengthening Supported by UK Active Progressive programme KPI - Aiming for 3 sessions minimum per week Psychological Nutritional

90 day hospital length of stay GM Cancer Prehab and Rehab Lung Cancer Surgery Phase 1 Evaluation points (6MWT, Strength, EQ5D, self efficacy) PREHAB 01 90 day hospital length of stay REHAB PREHAB 2 year mortality

GM Cancer Prehab and Rehab Surgery Phase 1 Prehab4cancer launches 25th April 115 patients referred to programme since launch >90% patients taking part 14 evaluation sessions across GM Reason for Not Participating:   Patient too high risk for exercise in community Unable to contact patient Already active with private gym and declined the offer Declined the programme

GM Cancer Prehab and Rehab Lung Cancer Surgery Phase 1 Prehab4cancer launches 25th April 34 patients referred to programme >90% patients taking part For less fit patients we are only averaging 2.2 sessions/week Reframe this as Exercise Dose

90 day hospital length of stay GM Cancer Prehab and Rehab Non-surgical Lung Cancer Chemo/Dxt Phase 1 Evaluation points (6MWT, Strength, EQ5D, self efficacy) 90 day hospital length of stay 2 year mortality

90 day hospital length of stay GM Cancer Prehab and Rehab Non-surgical Lung Cancer Chemo/Dxt Phase 1 Evaluation points (6MWT, Strength, EQ5D, self efficacy) PREHAB 01 90 day hospital length of stay REHAB PREHAB 2 year mortality

GM Cancer Prehab and Rehab Lung Cancer Surgical and then chemo Phase 1 Evaluation points (6MWT, Strength, EQ5D, self efficacy) PREHAB 01 REHAB PREHAB