Prehabilitation: the ultimate quest

Never mind new year resolutions; how about a quest to getting fitter. Prof Carol-Ann Benn challenges you to the ultimate quest (The Lord of the Rings style): prehabilitation.

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For some, new revolutionary life changes only occur when faced with a crisis. A better way to look at a crisis might be as a quest. Crisis implies (in my head) a problem requiring urgent intervention. In contrast, a quest is more of a seeking along a journey.

It may be a few kilos or a pair of jeans that won’t close; an inability to touch your toes or realising you’re short of breath when climbing the stairs; chest pain and concern regarding your cholesterol levels, blood pressure reading, fasting insulin; fear of ageing; and super awful and scary, a cancer diagnosis.

No matter what the problem is, having a diagnosis is often a sudden life wake-up call to commit to change. The problem is that while desperately wanting to commit to change to manage this, you may need help. It may take a quest thrust upon us to realise that we must get our ducks in a row. And don’t start by saying it’s your fault and that is why you must go on the journey. Frodo didn’t ask for his quest. Frodo wished that none of this had happened but Gandalf responds, “So do all who live to see such times, but that is not for them to decide. All we must decide is what to do with the time that is given to us.”

Although that is a frightening and challenging concept, it’s true of life, every day, more demanding than you think, yet not impossible, particularly if you have the right fellowship team.

What is prehabilitation?

Commonly known as prehab, it offers supported recovery once a cancer is diagnosed. The prehabilitation process helps to optimise your health (physical, nutritional, mental and emotional) before cancer treatment begins and throughout. The most effective prehabilitation programmes provide a holistic approach to promoting patient empowerment, easing the experience, and consequently improving compliance.

We have just had a unit accreditation and are super proud of achieving 100%. The best part being that the unit has run prehabilitation (cancer counselling, exercise and assistance to manage the journey before and during treatment) for the last few years.

Accepting your weaknesses and strengths

I love that in The Lord of the Rings, the chosen ring bearer, Frodo Baggins, isn’t tall and strong but small. Leaving the shire, which he loves so much, fills him with sadness. And I think for anyone diagnosed with breast cancer, the hardest part is accepting the diagnosis and the sadness of having to leave your known and go on a quest.

His weaknesses are his small size and lack of combat skills, which are valid for all diagnosed with cancer, which make him vulnerable to attack. Conversely, his strengths that we may not recognise are determination and his deep sense of duty to his mission. An important prehabilitation step is in understanding your own smallness and lack of combat skills when facing a diagnosis.

Everyone has health-related concerns; some more than others.Some perceive that they have more than they actually have and this creates a stumbling block to starting treatment. Some have no clue as to the problems they have until they do the pre-treatment safety checks.

Age (both chronological and physiological), old or young, provides a backdrop to the lack of combat skills. When older, you may fear your ability to manage treatment, have medical issues you don’t know about, as well as have poor nutrition and lack of physical fitness. Younger people may have to worry about fertility issues, aesthetic-, work- and family issues that hinder their ability to start treatment.

Medically, we look at age not in terms of how many years you have under your belt but rather how many rings you have on your belt. Age today is looked at in terms of functional rather than chronological age.

Once you have a cancer diagnosis, the discussion in the MDM will help determine your options for your quest. You’ll get a feedback plan from your navigator (Gandalf) who’ll be your own wizard while you travel on your cancer journey.

The pyramid of improved well-being

Understandably, your travel destination is cancer-free five-star, however, you’ll need a unique travel itinerary geared just for you. And like in The Lord of the Rings, there may be side stories and unexpected adventures that you’ll need to work through with your prehabilitation team. The essential components of a comprehensive prehabilitation programme include understanding your baseline triangle of mental, physical and emotional capacity as you perceive yourself.

This self-evaluation may not be accurate, but it gives the team an understanding of how you rate your ability to manage. From there, we create the pyramid of improved well-being.

This is done by improving the four pillars of your health pyramid. The aspects to slowly improve are cardiovascular and skeletal muscle fitness training; nutritional management; mental well-being with psychological support; and medical optimisation. This process supports you in preparing for the physiological challenges of your treatments, aiming to improve recovery time, reduce complications from surgery and oncology treatment, and improve compliance.

Let’s prepare for your journey.

Bags packed. Can you carry the weight, or are you like me and need someone to assist with your baggage?

What does the data say?

Exercise has been studied and shown to be of value in all phases of breast cancer treatment: pre-treatment, during treatment, into survivorship and even with people with metastatic breast cancer. Not only is it safe and effective in coping with treatment, but recent studies show it has viable, tangible treatment-related benefits.

Chemotherapy-induced peripheral neuropathy affects approximately 70% of patients treated with neurotoxic chemotherapies. It’s a polyneuropathy that presents with numbness, tingling, and sometimes gait ataxia (failure of muscle coordination); it affects people in a glove and stocking distribution and is probably one of the most common quality of life symptoms I see people complaining of.

The good news is that studies show that a programme of aerobic training, resistance and balance training for a minimum of 90 minutes a week significantly improves these symptoms.

The surprising benefit of exercise seen in patients with post-mastectomy pain syndrome, lymphoedema, bone metastases, and even in people with anthracycline-based cardiac compromise, both in decreasing its frequency and improving cardiac function, is remarkable. There is no disputing the value of reducing weight issues and improving osteoporosis with exercise. Always remember you can’t outrun your fork, so exercise has to be in conjunction with a sensible diet plan.

What is most interesting is a recent study (Dana-Farber Cancer Institute) that showed women given either an exercise intervention programme or a mind-body intervention programme demonstrated changes in genes expressed by tumour cells.

How do you improve and achieve this goal?

Baby steps; walk before you run. Walking is the best and easiest exercise and is free exercise. Obviously, it’s better to have a team approach to achieve this. So, besides Gandalf (navigator) with the map power and who has been on your journey with others before, you need training help. Sam never abandoned Frodo, so find your encouraging friend to help you, and this is usually your prehabilitation specialist.

Boromir, the human training; this can be a professional or group, and most international accredited centres have assistance programmes for you.

It’s essential to have a cardiac assessment and discussion with the unit prehabilitation specialist to ensure coordination around your treatment and the exercises you can and can’t do, including training to determine the maximum heart rate.

An excellent high-intensity training is EMS training. I go to Bodytech once a week, and we offer the training at the unit. This gym in a jar that I have done for the last six years has ensured that a skinny like me has maintained good bone density despite being in menopause for a good while.

Nutritional support, mainly malnutrition is hugely prevalent due to the poor diet that many of us have, is imperative as this aids healing. Being overweight is a form of malnutrition. An integrative specialist who understands what supplements you can or can’t take is also of value.

More useful data

Due to the high prevalence of malnutrition or low cardiorespiratory fitness in elderly cancer patients, prehabilitation is an optimal programme to reduce post-operative complications and enhance recovery from surgical trauma. Evidence suggests that improving nutrition and doing aerobic exercise or strength training before major surgery can help reduce post-operative morbidity, mortality, or length of stay. However, there are still controversies regarding the manner, intensity, or duration of preoperative nutrition and exercise training in elderly patients, as well as the impact on delaying treatment.

Cancer treatment can be debilitating, but there may be ways you can better prepare yourself for the challenges to come.The benefits of exercise in helping patients deal with fatigue, mood swings, and other issues experienced during and after treatment are well-documented.

Patients undergoing major cancer interventions such as primary surgical resection, chemotherapy, radiotherapy, and immunotherapy are prone to the adverse effects of their cancer, as well as to side effects of the treatments designed to cure them. For surgery, despite advancing innovations and the use of more minimal resection techniques, morbidity and mortality rates remain high, particularly amongst the older and most frail patients, who are more likely to adopt sedentary lifestyles. Which includes a graded, evidence-based exercise prescription to give the best opportunity to improve fitness in the constrained time period before cancer treatment.

High-intensity interval training (HIIT) exercise provides a practical, time-efficient approach to increasing fitness. Still, any exercise could be viewed as potentially beneficial for patients. The rehabilitation side of the programme supports patients’ recovery from their cancer interventions and, where necessary, can be used to prepare them for other treatments. Rehabilitation should also aim to support the transition to lifelong exercise and help prevent future cardiovascular and cancer events. Most supporting evidence for prehab has come from surgical patients undergoing colorectal and lung.

Know all of your frailties

So, when you have a quest, you have to deal with your physical, mental or emotional frailties. I was invited on a hike once, and I was an excellent swimmer but, like the little mermaid, had really weak hiking legs, and needed others to carry my bag. I was not hiking trained.

Our physical weaknesses need to be addressed before our quest. The big five are: cardiac, environmental, respiratory, endocrine and metabolic.

Mental wellness

You may have an underlying mental illness you’re on treatment for; consult with your treating specialists to ensure that your medication dosing is in order.

Suppose you haven’t been previously diagnosed with mental illnesses but

are suffering from severe anxiety, depression, or suicidal thoughts around your diagnosis. In that case, you must speak to your navigator or someone you feel safe with. It may mean you need a little extra help and assistance.

Exercise can help manage any quest

Prehab is a special treatment assistance that helps prepare for a journey. So, in our unit we have a prehabilatation rehab specialist to assist.

Oncology exercise is so important; exercise is important. There is no doubt that there is data around exercise benefits. Exercise can help manage almost any quest. Setting up a programme to get through a treatment that is tailored to each person is critical.

Climbing your own pyramid and grasping the star

Firstly, ensure you have as many consults and opinions as possible to ensure you’re comfortable with your decisions and your team. It’s your body and not the doctors’; breast cancers are slow-growing, and you have time for opinions.

Prepare and achieve the five start points of:

  • Mental fortitude
  • Emotional strength and well-being
  • Aerobic fitness
  • Nutritional optimisation
  • Strength improvement

We all have the means to understand our triangle, climb our pyramid, and reach the star. You may think this is a disastar, but actually, you can beat the monstar by working like a rockstar to become the superstar.

We are all small in size when it comes to bearing the cancer ring.If Frodo’s character has a tragic flaw, it has been written that it’s his despondency. And to a great extent, the real tragedy comes from forces beyond Frodo’s control, and this can often be true of a cancer journey.

Prof Carol-Ann Benn heads up an internationally accredited, multi-disciplinary breast cancer centre at Netcare Milpark Hospital. She lectures at Wits University and, in 2002, established the Breast Health Foundation.Prof Carol-Ann Benn heads up an internationally accredited, multi-disciplinary breast cancer centre at Netcare Milpark Hospital. She lectures at Wits University and, in 2002, established the Breast Health Foundation.

MEET THE EXPERT – Prof Carol-Ann Benn

Prof Carol-Ann Benn heads up an internationally accredited, multi-disciplinary breast cancer centre at Netcare Milpark Hospital. She lectures at Wits University and, in 2002, established the Breast Health Foundation.

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