Prehabilitation for Esophago-Gastric Cancer...• Physical Status • Weight Loss • BMI •...
Transcript of Prehabilitation for Esophago-Gastric Cancer...• Physical Status • Weight Loss • BMI •...
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Prehabilitation for Esophago-Gastric Cancer
Prior to Surgery, Prior to Induction Therapy, or both?
Enrico M. Minnella, M.D. Ph.D.
McGill University
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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
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• 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
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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
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Prehabilitation & Functional Capacity
+ 36.9 + 15.4
- 22.8
- 81.8
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van Adrichem EL et al, Ann Surg Oncol. 2014 Jul; 21(7):2353-60
Prehabilitation & PostOp Morbidity
• Esophagectomy for Esophageal Cancer
• Inspiratory muscle training
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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
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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
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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
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Functional Status
Quality of Life
Continuity of Care
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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
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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
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Exercise stress test with concomitant gas analysis
CardioPulmonary Exercise Testing (CPET)
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ADVERSE POSTOPERATIVE
OUTCOME
POOR PREOPERATIVE CARDIORESPIRATORY
FUNCTION (CPET)
CPET
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Minnella EM et al, Submitted
• Exercise modality
• Sessions frequency
• Between-session recovery time
• Training duration (~4 weeks)
• Progression
Exercise Prescription: Endurance
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Which is the limiting
pathophysiological mechanism
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Which is the limiting
pathophysiological mechanism
Wasserman K, Principles of exercise testing and interpretation, 5ed
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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
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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
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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
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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
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Prehabilitation – McGill Approach
PREDICTIVE Medicine
PREVENTIVE Medicine
PARTICIPATORY Medicine
• Screen ALL patients
• Assess to Personalize
• Effective & Safe treatment
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Prehabilitation
During Neo-Adjuvant Treatment
???
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Xu YJ et al, Oncologist. 2015 Oct;20(10):1216-22
Prehab During Neo-Adjuvant Therapy
• Chemoradiotherapy for Esophageal Cancer
• Walk & Eat
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Prehab During Neo-Adjuvant Therapy
Jack S et al, Eur J Surg Oncol. 2014 Oct;40(10):1313-20
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Prehab During Neo-Adjuvant Therapy
Jack S et al, Eur J Surg Oncol. 2014 Oct;40(10):1313-20
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PREHABILITATION during NAT
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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
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Prehabilitation
• Planned, structured, and
integrated in cancer care
• Assess > high-risk > Re-Assess
• Personalized
Conclusion
When
• Before Surgery ✓ • During NAT ?
!! RESEARCH AGENDA !!
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3rd Canadian Prehabilitation Workshop
For Information please contact
Rashami Awasthi: [email protected]
March 28, 2020
Montreal General Hospital – McGill University
Montreal Canada
Course directors:
Drs. Carli & Minnella