Published: 16 February 2021
Dr Steve Wootton, Associate Professor of Nutrition, University of Southampton, and Deputy Chair of the NIHR Nutrition and Cancer Collaboration, explains why we are funding research into prehabilitation in cancer.
On receiving a cancer diagnosis, people face many challenges. For some, the disease may already have affected them physically, nutritionally and psychologically, well before treatment starts. These changes can decrease their resilience to cancer, and affect their response to surgery and treatment. Put simply, being physically, nutritionally and psychologically ‘unfit’ can lead to increased risks and complications during treatment.
Prehabilitation identifies those at risk, and helps prepare them before their treatment starts, in order to reduce their risks and complications. This includes personalised management of exercise, nutrition, and psychological support, and the promotion of healthy behaviours intended to increase their resilience to treatment, and to improve their long-term health.
Bringing together the evidence to inform practice
Prof Mike Grocott, NIHR Senior Investigator; Designate Director of the Southampton BRC, and June Davis of Macmillan Cancer Support, invited me in my role as Deputy Chair of the NIHR Nutrition and Cancer Collaboration, to collaboratively work with them and other stakeholders to review the existing evidence, in order to inform the development and delivery of prehabilitation.
After publishing principles and guidance for prehabilitation within the management and support of people with cancer, we acknowledged that the evidence of effectiveness of prehabilitation interventions was highly variable in quality, with much more evidence available for some tumour and treatment types than others. This emphasised the importance of further research. Three key areas for research that came out of the review were:
- We need to know more about the effects of poor nutrition, being physically unfit, and stress on cancer treatment and outcomes, and the difference prehabilitation can make, as well as the mechanisms that underlie the response.
- Knowing more about how best to identify those most at risk, and the nature of the interventions themselves, eg: the intensity and effects of dosing, timing, type of cancer, and treatment.
- Investigating effectiveness and implementation; how best to deliver the intervention at each of the three levels of personalised care (universal, targeted or specialised).
NIHR commissioned call for prehabilitation research
NIHR has now committed to this area of healthcare by launching the commissioned call, 20/142 Prehabilitation: Living with and beyond cancer. The call focuses on increasing the evidence base to support health and care services for people with a new cancer diagnosis, and the role of prehabilitation in their treatment pathway.
The call offers a great opportunity to address each of the above key areas across four programmes (Health Technology Assessment, Efficacy and Mechanism Evaluation, Health Services and Delivery Research, and Public Health Research). Once this call has closed, the programmes will continue to consider applications that address prehabilitation, through their researcher-led workstreams.
The research community’s response
NIHR will only support high-quality research. Much of the earlier work considered in the review would not be considered of sufficient quality. Our own analysis has revealed that national and global research funding over the last decade is largely fragmented, with interventions mainly focused on exercise. Studies are also mainly under-powered feasibility and pilot studies, that in themselves cannot reliably inform clinical practice.
Current research on prehabilitation also lacks standardised and validated methodology, defined goals for each element of the intervention, as well as monitoring of the intervention, especially in terms of adherence and biological dose. These gaps need to be addressed in future studies.
We also strongly recommend the development, adoption and application of a standardised set of validated screening, assessment, adherence, efficacy and core outcome measures that could be used across all studies. Above all else, given the wide scope of existing prehabilitation research and the need to consider different tumour types and stages, we can only take full advantage of this unique funding opportunity by working together across the infrastructure to deliver the highest quality research.
The NIHR Cancer and Nutrition Collaboration, together with the Oncology Translational Research Collaboration and National Cancer Research Institute Living With and Beyond Cancer Group, can assist in developing your application to the call. For help, please contact us by emailing Fiona.Davey@nihr.ac.uk.
Dr Steve Wootton – Associate Professor of Nutrition, University of Southampton, and Deputy Chair of the NIHR Nutrition and Cancer Collaboration.