Well begun is half done : preoperative physical performance and home-based exercise in older adults undergoing abdominal cancer surgery

The proportion of older adults continues to increase in Sweden and globally. Consequently, we are seeing an increase in diseases associated with aging, such as cancer. The primary treatment for abdominal cancer is surgery, and older adults receive surgery to a greater extent today. However, they have more requirements and other outcomes than younger people due to different physiology, limited reserve capacity, heterogeneity and a greater presence of comorbidities with increasing chronological age. Physical performance is a modifiable preoperative factor. If optimized, it might have the potential to reduce adverse postoperative events, which is important for both the individual and economically for society. The overall aim of this thesis was to determine how preoperative physical performance was associated with postoperative outcomes, and to increase knowledge regarding supervised home-based physical exercise as a potential intervention prior to abdominal cancer surgery in older adults.

This thesis consists of four papers based on three clinical studies, including people ≥ 70 years of age undergoing abdominal cancer surgery. In study A (papers I and II), a prospective cohort study (n=197, and subgroup n=140), we showed that better preoperative physical performance was associated with reduced adverse postoperative outcomes. On both the micro (complication severity and in-hospital mobility), and meso levels (discharge destination, and length of stay). These results indicate that screening of physical performance (in combination with conventional preoperative risk assessments) can provide additional information for decision-making regarding each patient’s surgical pathway, and hopefully facilitate shared decision-making with the patient. In study B (paper III), a feasibility study with a randomized control design (n=23), we reported that a short-term, supervised, home-based exercise program at a high level of exertion was feasible with respect to compliance and acceptability, in older adults prior to colorectal cancer surgery. However, recruitment was low and needs to be improved to reduce the risk of recruitment bias. When further investigating preoperative exercise, in a qualitative interview study (study C, manuscript IV, n=17), the patients described a gap between awareness of the benefits of being physically active and actually being physically active prior to surgery. The patients perceived multiple influencing factors and expressed a need for active support and guidance from health care to enable action, which should be considered during the preoperative period.

The findings of this thesis emphasize the importance of physical performance rather than chronological age. It addresses the additive value of a functional approach regarding both objectively measured physical performance and physical exercise in preoperative care, to place the older individual in focus. Perceptions from older adults scheduled for abdominal cancer surgery underlines the importance of preoperative guidance and support to enable physical activity and exercise. In addition, the thesis adds information regarding the magnitude of short-term physical decline and factors associated with postoperative mobility, which is important to understand in regard to postoperative recovery.

List of scientific papers

I. Karlsson E, Egenvall M, Farahnak P, Bergenmar M, Nygren-Bonnier M, Franzén E, Rydwik E. Better preoperative physical performance reduces the odds of complication severity and discharge to care facility after abdominal cancer resection in people over the age of 70—A prospective cohort study. Eur J Surg Oncol. 2018;44:1760-1767.
https://doi.org/10.1016/j.ejso.2018.08.011

II. Karlsson E, Franzén E, Nygren-Bonnier M, Bergenmar M, Rydwik E. Short-term postoperative physical decline and patient-reported recovery in people aged 70 or older undergoing abdominal cancer resection. J Geriatr Oncol. 2019;10:610-617.
https://doi.org/10.1016/j.jgo.2019.01.004

III. Karlsson E, Farahnak P, Franzén E, Nygren-Bonnier M, Dronkers J, van Meeteren N, Rydwik E. Feasibility of preoperative supervised home-based exercise in older adults undergoing colorectal cancer surgery: A randomized controlled design. PLoS ONE. 2019;14(7):e0219158.
https://doi.org/10.1371/journal.pone.0219158

IV. Karlsson E, Dahl O, Rydwik E, Nygren-Bonnier M, Bergenmar M. Mind the gap between awareness and action: Older patients’ attitudes towards, and perceptions of, preoperative physical activity and exercise prior to colorectal cancer surgery—a qualitative study. [Submitted]