Home-based exercise prehabilitation to improve disease-free survival and return to intended oncologic treatment after cancer surgery in older adults with frailty: a secondary analysis of a randomized trial

Daniel I McIsaac; Nathaniel Neilipovitz; Gregory L Bryson; Sylvain Gagne; Allen Huang; Manoj Lalu; Luke T Lavallée; Husein Moloo; Barbara Power; Celena Scheede-Bergdahl; Carl van Walraven; Colin J L McCartney; Monica Taljaard; Emily Hladkowicz

doi:10.1007/s12630-024-02835-w

Home-based exercise prehabilitation to improve disease-free survival and return to intended oncologic treatment after cancer surgery in older adults with frailty: a secondary analysis of a randomized trial

Can J Anaesth. 2024 Nov;71(11):1525-1534. doi: 10.1007/s12630-024-02835-w. Epub 2024 Sep 5.

Authors

Daniel I McIsaac^{1

2

3

4

5}, Nathaniel Neilipovitz⁶, Gregory L Bryson^{7

8

6}, Sylvain Gagne^{7

8

6}, Allen Huang^{6

9

10}, Manoj Lalu^{7

8

6}, Luke T Lavallée^{6

11}, Husein Moloo^{6

12}, Barbara Power^{6

9

10}, Celena Scheede-Bergdahl¹³, Carl van Walraven^{6

10}, Colin J L McCartney¹⁴, Monica Taljaard^{6

15}, Emily Hladkowicz⁶

Affiliations

¹ Department of Anesthesiology and Pain Medicine, Faculty of Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, ON, Canada. dmcisaac@toh.ca.
² Department of Anesthesiology, The Ottawa Hospital, Ottawa, ON, Canada. dmcisaac@toh.ca.
³ Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, ON, Canada. dmcisaac@toh.ca.
⁴ School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada. dmcisaac@toh.ca.
⁵ Department of Anesthesiology, The Ottawa Hospital Civic Campus, Room B311, 1053 Carling Ave., Ottawa, ON, K1Y 4E9, Canada. dmcisaac@toh.ca.
⁶ Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, ON, Canada.
⁷ Department of Anesthesiology and Pain Medicine, Faculty of Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, ON, Canada.
⁸ Department of Anesthesiology, The Ottawa Hospital, Ottawa, ON, Canada.
⁹ Division of Geriatric Medicine, Faculty of Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, ON, Canada.
¹⁰ Department of Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, ON, Canada.
¹¹ Division of Urology, Department of Surgery, Faculty of Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, ON, Canada.
¹² Division of General Surgery, Department of Surgery, Faculty of Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, ON, Canada.
¹³ Department of Kinesiology and Physical Education, Faculty of Education, McGill University, Montreal, QC, Canada.
¹⁴ Department of Anesthesiology and Pain Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada.
¹⁵ School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada.

PMID: 39237725
DOI: 10.1007/s12630-024-02835-w

Abstract
in English, French

Background: Improving survivorship for patients with cancer and frailty is a priority. We aimed to estimate whether exercise prehabilitation improves disease-free survival and return to intended oncologic treatment for older adults with frailty undergoing cancer surgery.

Methods: We conducted a secondary analysis of the oncologic outcomes of a randomized trial of patients ≥ 60 yr of age with frailty undergoing elective cancer surgery. Participants were randomized either to a supported, home-based exercise program plus nutritional guidance or to usual care. Outcomes for this analysis were one-year disease-free survival and return to intended oncologic treatment. We estimated complier average causal effects to account for intervention adherence.

Results: We randomized 204 participants (102 per arm); 182 were included in our modified intention-to-treat population and, of these participants, 171/182 (94%) had complete one-year follow up. In the prehabilitation group, 18/94 (11%) died or experienced cancer recurrence, compared with 19/88 (11%) in the control group (hazard ratio [HR], 1.25; 95% confidence interval [CI], 0.66 to 2.34; P = 0.49). Return to intended oncologic treatment occurred in 24/94 (29%) patients the prehabilitation group vs 20/88 (23%) in the usual care group (HR, 1.53; 95% CI, 0.84 to 2.77; P = 0.16). Complier average causal effects directionally diverged for disease-free survival (HR, 0.91; 95% CI, 0.20 to 4.08; P = 0.90) and increased the point estimate for return to treatment (HR, 2.04; 95% CI, 0.52 to 7.97; P = 0.30), but in both cases the CIs included 1.

Conclusions: Randomization to home-based exercise prehabilitation did not lead to significantly better disease-free survival or earlier return to intended oncologic treatment in older adults with frailty undergoing cancer surgery. Our results could inform future trials powered for more plausible effect sizes, especially for the return to intended oncologic treatment outcome.

Study registration: ClinicalTrials.gov ( NCT02934230 ); first submitted 22 August 2016.

RéSUMé: CONTEXTE: L’amélioration de la survie des personnes atteintes de cancer et de fragilité est une priorité. Nous avons cherché à estimer si la préadaptation physique améliore la survie sans maladie et le retour au traitement oncologique prévu pour les personnes âgées fragiles bénéficiant d’une chirurgie du cancer. MéTHODE: Nous avons effectué une analyse secondaire des issues oncologiques d’une étude randomisée de patient·es âgé·es de 60 ans ou plus atteint·es de fragilité bénéficiant d’une chirurgie carcinologique non urgente. Nous avons randomisé les personnes participantes à un programme d’exercice à domicile accompagné de conseils nutritionnels ou à recevoir les soins habituels. Les critères d’évaluation de cette analyse étaient la survie sans maladie à un an et le retour au traitement oncologique prévu. Nous avons estimé les effets moyens causaux d’observance pour tenir compte de l’adhérence à l’intervention. RéSULTATS: Nous avons randomisé 204 participant·es (102 par bras); 182 personnes ont été incluses dans notre population modifiée en intention de traiter et, parmi ces participant·es, 171/182 (94%) ont fait l’objet d’un suivi complet à un an. Dans le groupe préadaptation, 18/94 (11%) personnes sont décédées ou ont connu une récidive du cancer, contre 19/88 (11 %) dans le groupe témoin (rapport de risque [HR], 1,25; intervalle de confiance [IC] à 95%, 0.66 à 2.34; P = 0.49). Le retour au traitement oncologique prévu a eu lieu chez 24 patient·es sur 94 (29 %) dans le groupe préadaptation vs 20/88 (23 %) dans le groupe de soins habituels (RR, 1.53; IC 95%, 0.84 à 2.77; P = 0.16). Les effets moyens causaux d’observance ont divergé directionnellement pour la survie sans maladie (RR, 0.91; IC 95%, 0.20 à 4.08; P = 0.90) et augmenté l’estimation ponctuelle du retour au traitement (RR, 2.04; IC 95%, 0.52 à 7.97; P = 0.30), mais dans les deux cas, les IC comprenaient 1. CONCLUSION: La randomisation pour la préadaptation physique à domicile n’a pas entraîné d’amélioration significative de la survie sans maladie ou de retour plus précoce au traitement oncologique prévu chez les personnes âgées fragiles bénéficiant d’une chirurgie du cancer. Nos résultats pourraient éclairer de futures études alimentées par des tailles d’effet plus plausibles, en particulier pour le critère de retour prévu au traitement oncologique. ENREGISTREMENT DE L’éTUDE: ClinicalTrials.gov ( NCT02934230 ); première soumission le 22 août 2016.

Keywords: cancer; exercise; frailty; prehabilitation; randomized trial.

Publication types

Randomized Controlled Trial

MeSH terms

Aged
Aged, 80 and over
Disease-Free Survival
Elective Surgical Procedures / methods
Exercise Therapy / methods
Female
Follow-Up Studies
Frail Elderly
Frailty*
Home Care Services
Humans
Male
Middle Aged
Neoplasm Recurrence, Local / prevention & control
Neoplasms* / surgery
Preoperative Exercise*

Associated data

ClinicalTrials.gov/NCT02934230

Abstract in English, French

Publication types

MeSH terms

Associated data

Grants and funding

Abstract
in English, French