Cancer 'prehab' may provide better post-op outcomes

Can workouts before cancer surgery help patients' recovery? Some doctors think so.

Patients with head and neck cancer learn swallowing exercises. Those with breast cancer work on arm strength and range of motion, and prostate cancer sufferers build pelvic area muscles to control incontinence.

These physical therapy exercises, all practiced before surgery, are the latest in rehabilitative care. Known as "prehabilitation" or "prehab," the exercises are done to prepare patients physically and emotionally for surgical procedures that can impair muscle movements or other abilities.

While prehab has only recently been prescribed to some cancer patients, and promoters acknowledge that it needs more scientific study of its value, the practice is gaining momentum among professionals who know the general benefits of exercise and see a lot of promise.

"It's catching on," said Rochelle Murrell, a physical therapist at Anne Arundel Medical Center's outpatient rehabilitation center. "We're working at trying to catch those patients who could benefit."

The Annapolis medical center is among a few area hospitals to adopt a formal program that requires certification.

Sometimes prehab is used to get patients more fit for a surgery, or to even qualify for one. It also helps establish a patient's current capabilities and determine what physical problems may arise so patient and therapist can get a jump on rehabilitation.

Prehab programs are more established in orthopedic and cardiac care. However, cancer patients with diseased lungs, prostates and colons have been found to recover faster and suffer fewer complications after surgery if they undergo prehab, according to Dr. Julie Silver, a cancer researcher and an associate professor at Harvard Medical School's Department of Physical Medicine and Rehabilitation.

Silver created the program to certify hospitals such as Anne Arundel for cancer prehab and rehab about a decade ago after she was diagnosed with breast cancer and struggled to recover from surgery without any physical therapy afterward.

"I was never offered cancer rehabilitation," Silver said, "and I recognized a huge unmet need which has led to a lot of unnecessary suffering."

The prehab certification program is called Survivorship Training and Rehab, or STAR, and has certified about 500 health care facilities. It requires training for physical therapists, doctors and other specialists who learn how to choose candidates and offer appropriate exercises to individuals.

Training costs can add up, and there is disruption to normal work flows as physical therapists are incorporated on the front end of treatment discussions. But Silver believes prehab programs can help the bottom line in the long run as patients suffer fewer complications and spend less time recovering in hospitals.

Silver said the programs aren't for every patient, as many with cancer can't delay surgery for physical therapy. Prehab also likely won't be widely covered by insurance until there is more data on outcomes. And skeptical or time-pressured doctors may resist referring patients for uncertain benefits.

Patients might also be unable to begin physical therapy safely without other consultations and lifestyle changes. For example, an elderly person recently diagnosed with cancer may not be able to begin exercises without nutritional support and cardiac testing.

"We're not overselling prehab to patients right now because even though it's looking really exciting in some populations, and we're translating research as quickly as we can into clinical models, it's still not widely available and we're still learning a lot about what will work and help patients," Silver said.

"It makes sense to get patients as healthy and prepared as possible prior to treatment," she said. "But it's not a widely available magic bullet."

In addition to Anne Arundel Medical Center, Johns Hopkins Hospital also employs prehab for cancer patients, said Dr. R. Samuel Mayer, vice chair of Hopkins' Department of Physical Management and Rehabilitation. In the past three or four years he's used prehab before chemotherapy, radiation and surgery to get patients in shape to withstand treatments.

Mayer has found fewer complications in colon cancer patients, better range of motion in neck cancer patients, and less swelling and better range of motion in breast cancer patients prepping for reconstruction after a mastectomy.

He often teaches patients exercises they can do on their own so they do not use up the allotment of physical therapy session their insurers will cover. Those sessions may be needed post-procedure.

Mayer plans his own studies that he hopes will extend standard insurance coverage. The potential financial benefit may be huge: Knocking off a day of post-surgery care in the hospital could save $1,500. A therapy session costs about $150.

"We don't have a lot of hard data yet to prove this point," he said. "Just anecdotally, if I do therapy in advance, I have fewer problems afterward."

There also may be a less tangible mental benefit, he said. Exercise prompts release of endorphins that trigger positive feelings and reduce pain. Mayer said exercise can restore a sense of control often lost with a cancer diagnosis.

Lynn Vosburg can attest to this. She was not initially offered prehab by Anne Arundel Medical Center after she was diagnosed with late-stage breast cancer in 2012. Surgery couldn't wait. Complications, however, necessitated several more surgeries in addition to chemotherapy and radiation, and each time rehab became prehab for the next procedure.

The Bowie accountant, now 60, said physical therapy increased her mobility and reduced swelling from lymphedema; it also helped with the weakness, numbness and pain of neuropathy.

With her cancer in check, Vosburg continues in therapy to address cognitive difficulties stemming from chemotherapy. She also spends time volunteering at the hospital and wants other patients to know all their options, including rehab and prehab, even if they choose not to try it.

Everyone copes differently with a cancer diagnosis, she said.

"The rehab in between my surgeries made me more prepared for the next round," Vosburg said. "You can feel sorry for yourself or get up and do something about it. But that means different things to different people."

meredith.cohn@baltsun.com

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