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

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

3. Improving Surgical Care

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

5. What can we do

6. 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

7. 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

8. 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

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

10. 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

11. 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

12. 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

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

14. 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

15. Improving Surgical Care

16. our team

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

18. Optimising medical health

19. 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.

20. Surgery school

21. 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

24. 50% reduction 3 day LOS reduction = 500K
Moore et al, Anaesthesia 2016 (in print)
Moore et al Anaesthesia 72(3) · March 2017

25. >70% + would like to trial digital support
It needs to be simple

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

30. 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

32. 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

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

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

37. What can we do

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

40. 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

45. 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

46. 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

47. 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

48. 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

49. 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

50. 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

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