prehabilitation for esophago-gastric cancer...• physical status • weight loss • bmi •...

Prehabilitation for Esophago-Gastric Cancer

Prior to Surgery, Prior to Induction Therapy, or both?

Enrico M. Minnella, M.D. Ph.D.

McGill University

Level of

Functional

Capacity

Prehabilitation

Control

PREOPERATIVE RECOVERY SURGERY

Carli F, Zavorsky GS. Curr Opin Clin Nutr Metab Care. 2005;8(1):23-

32.

Prehabilitation: the Theoretical Model

• Surgical Extent

• Cardio-Resp Disease

• Emergent Condition

• Steroid Use

• Sepsis

• Creatinine

• Disseminated Cancer

• Pneumonia

• Physical Status

• Weight Loss

• BMI

• Albumin ≤35

• Smoking & Alcohol Use

Risk Factors for Major Cancer Surgery

Cohen ME, et al. J Am Coll Surg. 2009 Dec;209(6):687-93 Minnella EM et al, ERAS Society Textbook, In Press

Prehabilitation & Functional Capacity

Minnella EM et al, JAMA Surg. 2018 Dec 1;153(12):1081-1089

Home-based Exercises

Aerobic exercise

• moderate:12-15 RPE

• 20min, 3/week

Resistance exercise 3/week

Nutrition

• Macronutrients balance

• Whey protein to meet

total protein 1.5 g/kg/d

• Whey protein 20 g after

training

Anxiety Coping

• Assessment

• 1session with psychologist

• Basic coping exercise

• Referral for major

depression

Prehabilitation & Functional Capacity

+ 36.9 + 15.4

- 22.8

- 81.8

van Adrichem EL et al, Ann Surg Oncol. 2014 Jul; 21(7):2353-60

Prehabilitation & PostOp Morbidity

• Esophagectomy for Esophageal Cancer

• Inspiratory muscle training

Yamana I et al, Dig Surg. 2015;32(5):331-7

Prehabilitation & PostOp Morbidity

• Esophagectomy for Esophageal Cancer

• Inspiratory muscle training

Postoperative Pulmonary Complications

Grade > II

OR: 3.99, 95% CI: 1.28-12.4, p = 0.017

Valkenet K et al, Br J Surg. 2018 Apr;105(5):502-511

Prehabilitation & PostOp Morbidity

• Esophagectomy for Esophageal Cancer

• Inspiratory muscle training

NO DIFFERENCE

PostOp Pneumonia

Valkenet K et al, Br J Surg. 2018 Apr;105(5):502-511

Prehabilitation & PostOp Morbidity

• Esophagectomy for Esophageal Cancer

• Inspiratory muscle training

maximum inspiratory muscle strength

76·2 (26·4) to 89·0 (29·4) cmH2O

P < 0·001

Functional Status

Quality of Life

Continuity of Care

Pecorelli N et al, Surg Endosc. 2016 Jun; 30(6):2199-206

Brunelli A et al, Chest 2013;143:e166S

6-min walk test

• Objective, reproducible, cheap, integrated

measure of functional capacity

• 400 meters=

indicator of recovery in major cancer surgery

Hlatky MA et al, Am J Cardiol 1989; 64: 651–4.

Duke Activity Status Index (DASI)

• Measure of physical activity, musculoskeletal strength, frailty, self-imposed,

and physical limitations

• Good association with postoperative cardiac events

< 46

McIsaac DI et al, JAMA Surg 2016; 151: 538–45

Wijeysundera DN et al, Lancet. 2018;391(10140):2631-2640

Exercise stress test with concomitant gas analysis

CardioPulmonary Exercise Testing (CPET)

ADVERSE POSTOPERATIVE

OUTCOME

POOR PREOPERATIVE CARDIORESPIRATORY

FUNCTION (CPET)

CPET

Minnella EM et al, Submitted

• Exercise modality

• Sessions frequency

• Between-session recovery time

• Training duration (~4 weeks)

• Progression

Exercise Prescription: Endurance

Which is the limiting

pathophysiological mechanism

Which is the limiting

pathophysiological mechanism

Wasserman K, Principles of exercise testing and interpretation, 5ed

Exercise Prescription: Inspiratory muscle training

Starting

Intensity Progression

Maximal

intensity Duration Frequency Supervision

20-30%

MIP

Daily,

then maintain

40%

MIP 15 min

6 days

/week 3 days/week

SCREEN

• 6MWD < 400 m

• DASI < 46

• ppoFEV1 / ppoDLCO <60%

• BMI <20 or >30 Kg/m2

• Weight loss ≧10% in 6

months

• Handgrip < 20th percentile

• HADS-Anxiety ≧7

• HADS-Depression ≧5

Adapted from Minnella EM, Carli F. Eur J Surg Oncol. 2018 Jul;44(7):919-926

SCREEN ASSESS

• 6MWD < 400 m

• DASI < 46

• ppoFEV1 / ppoDLCO <60%

• BMI <20 or >30 Kg/m2

• Weight loss ≧10% in 6

months#

• Handgrip < 20th percentile

• HADS-Anxiety ≧7

• HADS-Depression ≧5

• CPET

• Body composition / PG-

SGA

• 3-d dietary intake

↓

Protein and energy

requirement estimation

• Restlessness and

insomnia

• Emotional numbness

• Apprehension,

hypervigilance to

symptoms and events

Adapted from Minnella EM, Carli F. Eur J Surg Oncol. 2018 Jul;44(7):919-926

SCREEN ASSESS INTER

VENE

• 6MWD < 400 m

• DASI < 46

• ppoFEV1 / ppoDLCO <60%

• BMI <20 or >30 Kg/m2

• Weight loss ≧10% in 6

months#

• Handgrip < 20th percentile

• HADS-Anxiety ≧7

• HADS-Depression ≧5

• CPET

• Aerobic exercise

• Resistance exercise

• MIT

• Body composition / PG-

SGA

• 3-d dietary intake

↓

Protein and energy

requirement estimation

Nutrient-based intervention

• Achieve energy requirement

• 3 balanced meals

• Protein intake: 1.5 g/kg IBW/d

• Restlessness and

insomnia

• Emotional numbness

• Apprehension,

hypervigilance to

symptoms and events

Cognitive-behavioral therapy

• Cognitive re-framing

• Promote self-efficacy, personal

control & sense of purpose

• Teach relaxation skills: deep

breathing, guided imagery,

mindful meditation, goal setting

• Referral

RE-ASSESS

Adapted from Minnella EM, Carli F. Eur J Surg Oncol. 2018 Jul;44(7):919-926

Prehabilitation – McGill Approach

PREDICTIVE Medicine

PREVENTIVE Medicine

PARTICIPATORY Medicine

• Screen ALL patients

• Assess to Personalize

• Effective & Safe treatment

Prehabilitation

During Neo-Adjuvant Treatment

???

Xu YJ et al, Oncologist. 2015 Oct;20(10):1216-22

Prehab During Neo-Adjuvant Therapy

• Chemoradiotherapy for Esophageal Cancer

• Walk & Eat

Prehab During Neo-Adjuvant Therapy

Jack S et al, Eur J Surg Oncol. 2014 Oct;40(10):1313-20

Prehab During Neo-Adjuvant Therapy

Jack S et al, Eur J Surg Oncol. 2014 Oct;40(10):1313-20

PREHABILITATION during NAT

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PREHABILITATION

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NAT SX

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Knowledge Gaps

• Prehabilitation DURING NAT

Feasibility, safety, and efficacy

• Objective Assessment of Functional Capacity

CPET

• Type of Intervention

Supervised vs. Home-Based Exercise

Prehabilitation

• Planned, structured, and

integrated in cancer care

• Assess > high-risk > Re-Assess

• Personalized

Conclusion

When

• Before Surgery ✓ • During NAT ?

!! RESEARCH AGENDA !!

3rd Canadian Prehabilitation Workshop

For Information please contact

Rashami Awasthi: rashami.awasthi@gmail.com

March 28, 2020

Montreal General Hospital – McGill University

Montreal Canada

Course directors:

Drs. Carli & Minnella

Enrico M. Minnella M.D. Ph.D.

enrico.minnella@gmail.com