A multimodal prehabilitation and rehabilitation program for frail older colorectal cancer patients

As the incidence of colorectal cancer (CRC) is increasing with age and several
surgical developments have been made the past few years, the number of older
patients receiving surgical treatment is increasing. However, the impact of
surgery should not be underestimated in the older CRC patients. Especially the
frail older CRC patients have higher mortality and postoperative complication
rates in comparison to the non-frail patients. Identifying and modifying
vulnerabilities before and after surgery may increase the capacity and decrease
the impact of surgery. Evidence of prehabilitation with or without the
combination of rehabilitation is limited and inconsistent due to studies with
small sample sizes and the inclusion of non-frail patients. This means that a
large cohort study is needed to establish the effect of prehabilitation and
rehabilitation in frail older CRC patients.

The aim is to investigate the effect of a multimodal prehabilitation and
rehabilitation program in frail patients of 70 years or older, undergoing
elective surgery for non-metastatic CRC on

1. One-year mortality
2. Postoperative complications, surgical and non-surgical complications
3. Functional capacity, quality of life (QoL)
4. Physical performance, nutritional status and cognitive status

A multicentre prospective experimental cohort study implemented by a stepped
wedge design.

Patients are included in the control group or in the prehabilitation and
rehabilitation (intervention) group according to a stepped wedge design. In
addition to standard care, all patients in the intervention group will
preoperatively undergo a multimodal program, including a four to six weeks
exercise program including strength and endurance training, diet advice and
nutritional support, psychosocial support, smoking cessation and additional
medical optimization, e.g. iron infusion for iron deficiency anaemia.
Postoperatively, patients will start postoperative rehabilitation, including
minimally four weeks exercise program and nutritional monitoring.

The prehabilitation and rehabilitation program might be demanding, because of
the exercise program and the fact that patients need to visit the hospital more
frequently. Therefore patients might be at risk for overuse complaints, as
fatigue or muscle or joint pain.

The prehabilitation period consists of at least two appointments at the
clinical physiotherapist (30-45min), an appointment at the dietician (45min), a
nutritional evaluation by telephone (15 min), an exercise program of 4-6 weeks
(2-3x p week) and when necessary, patients may receive psychologic support,
smoking cessation and iron infusion. If iron infusion is indicated, it will be
performed under supervision and a patient will stay at least 30 minutes in the
hospital after the infusion has stopped to monitor potential allergic reaction.
An allergic reaction is rare (0.01-0.1%).

In the rehabilitation period, patients need to perform an exercise program of
at least 4 weeks and have nutritional evaluation by telephone. In the follow-up
patients need to perform physical and cognitive tests at 3, 6 and 12 months and
if indicated patients will be monitored by the dietician by telephone or by
hospital visits. As part of the TENT study patients will be contacted to
provide information about QoL, ADL and IADL at 6 and 12 months.