Effect of Short-Term Homebased Pre- and Postoperative Exercise on Recovery after Colorectal Cancer Surgery (PHYSSURG-C): A Randomized Clinical Trial

Onerup A, Andersson J, Angenete E, Bock D, Börjesson M, Ehrencrona C, Olsén MF, Larsson PA, de la Croix H, Wedin A, Haglind E, Sweden

Effect of Short-Term Homebased Pre- and Postoperative Exercise on Recovery after Colorectal Cancer Surgery (PHYSSURG-C): A Randomized Clinical Trial

Ann Surg. 2021 Apr 9. doi: 10.1097/SLA.0000000000004901. Online ahead of print.

PMID: 33843798

What is already known:

The preoperative period may provide an opportunity to increase the physiologic reserve

in the anticipation of surgery with the intention to improve outcomes and accelerate recovery. Therefore, preoperative optimisation or ‘‘prehabilitation’’ can be a compelling

strategy to address modifiable risk factors that impact cancer treatment outcomes.

Prehabilitation is defined differently in different studies, ie only physical training, physical training and nutrition or physical training with many additional interventions before surgery.

Thus, the evidence base is heterogenic which makes it difficult to draw firm conclusions.

So far evidence in favor for prehabilitation before colorectal surgery are indicating improved functional capacity, but evidence for a decrease in complications are weak.

Therefore, prehabilitation could not be fully recommended in colorectal guidelines 2018.

Since 2018, three meta-analyses have been published (major abdominal surgery), two showing a reduced rate of complications (Heger, 2019 and Daniels 2020) and one showing no difference at all in favor for prehabilitation. However, as mentioned above, it is difficult to make conlusions because these studies suffer from heterogeneity issues.

In 2020, Carli et al published a RCT on 110 “frail” patients undergoing multimodal prehabilitation showing no difference in complications or LOS. However, the study was probably underpowered.

The current study is a large, well conducted RCT from Sweden comparing physical training vs standard with self-reported postoperative physical recovery as primary outcome.

What this paper adds:

A randomized, parallel, open-label trial in six university or regional hospitals in Sweden. Participants planned for colorectal cancer surgery were randomized to either a physical activity intervention with aerobic activity and inspiratory muscle training two weeks pre- and four weeks postoperatively or usual care. Six hundred and sixty-eight patients were analysed, 317 in the intervention (I) group and 351 in the control group (C). Self-reported postoperative physical recovery was measured showing no difference between groups with 13% and 15% of participants feeling fully physically recovered in I and C respectively.

The authors conclude that the results from the study call for reconsiderations regarding current recommendations for preoperative physical activity interventions.

Additional comment:

There are a couple of weaknesses in the study that may make the results difficult to interpret. First, homebased exercise is difficult to evaluate because of the risk of lack of compliance. In this study, only 63% of the included patients did report activity. Secondly, the level of exercise in this study must be regarded as low intensity training. High intensity training may have shown a different outcome.

In conclusion, since 2018, the state of evidence in favor for prehabilitation has not been strengthened. But there are several ongoing multicenter RCTs that may answer questions about prehabilitation in the future.