Improving Surgical Care: GM Cancer Prehab and Recovery for Lung Cancer

1. Greater Manchester Cancer Implementation of Prehab4CancerDr John MooreClinical Director for Prehab and recovery

2. John.moore@mft.nhs.uk @mysurgeryandme

3. Improving Surgical Care • www.erasplus.co.uk

4. GM Cancer Prehab and Recovery @Prehab4cancer for Lung

5. What can we do

6. GM Cancer Prehab and Rehab Specialised prehab Universal prehab World leading outcomes Psychological Nutritional Prehab4cancer Single referral point 48 hour reply GM wide coverage Deliver Prehab to 2000 patients Exercise Intervention FITT Regional and National expert group Upper GI Lung Colorectal Head and Neck

7. Days Weeks Elective Surgery Later Complications Complications Failure to recover FITNESS HIGH 2 year mortality Elective Cancer surgical patient 2-year mortality

8. VA hospitals >100,000 patients 1990-1991 NASQIP Review of 8 operations and complications Colorectal Upper gi Vascular Over eight years follow-up

9. Dutch study4400 patients6 year follow-up • 45% having medium – high risk surgery • Looking at what patients died from

11. Why patients die later after surgery

12. Immediate Reduced functional reserve Longer term consequences Peri-op cardiac event reduces cardiac function Persistent peri-operative inflammation accelerates cardiovascular atherosclerosis and plaque instability Cognitive dysfunction CVA Longer term cognitive dysfunction CVA Acute Neuromuscular weakness Prolonged disability

13. What can we do Improve care delivery of surgical services =ERAS+/ERAS Patient and family preparation and recovery = PREHAB

14. PATHWAY innovation the cancer surgical pathway Measure MORBIDITY PREHAB REHAB 90 day mortality 2 year mortality PATIENT OUTCOMES Prehab4cancer Prehab4cancer QOL COMMUNITY HOSPITAL COMMUNITY

15. Improving Surgical Care www.erasplus.co.uk

16. our team

17. ERAS+ HOSPITAL 03 OPTION HOSPITAL OUTCOMES PREHAB REHAB 04 06 02 PREHAB PREHAB 01 01 05

18. Optimising medical health

19. I COUGH Incentive spirometry Coughing Oral Healthcare Understanding Getting out of bed Head of bed elevation I COUGH: reducing postoperative pulmonary complications with a multidisciplinary patient care program Cassidy MR JAMA Surg. 2013 Aug;148(8):740-5.

20. Surgery school

21. ACTIVE CHEST TRAINING Surgery is a big thing for your body and we need to get you as fit as possible Lets get your lungs fit and ready for surgery FAMILY AND FRIENDS NUTRITION YOU will benefit from good support to help with your prep and recovery Your body is getting ready for Surgery - need to eat well

24. 50% reduction 3 day LOS reduction = 500K Moore et al, Anaesthesia 2016 (in print) Moore et al Anaesthesia 72(3) · March 2017

25. >70% + would like to trial digital support It needs to be simple

29. Prehab Preparation for planned body stressor Physical activity Nutrition Well-being

30. A systematic review of trials investigating the effectiveness of preoperative exercise for patients undergoing a range of oncological surgery Most benefit for Lung Cancer Surgery

32. Summary of prehab Evidence so far • We can improve fitness but in studies difficult to relate to improved outcomes and tends to excludes least fit for prehab • Highly likely stronger benefit in higher risk patients. • We need multi-modal prehab

34. Dose of exercise interventionfitT principle Frequency Intensity Time – duration of session Type of exercise

35. GM Cancer Prehab and Recovery @Prehab4cancer for Lung

37. What can we do

39. Surgical risk More frail 50-60% complications Highest mortality short and long-term

40. PREHAB INTERVENTION More frail 50-60% complications Highest mortality short and long-term Can we get NHS England to recognise period of PREHAB as care for these patients

45. Exercise Intervention FITT Regional and National expert group Prehab4Cancer team led by Kirsty and her team 60 level 3-4 PT trained in the exercise intervention Exercise combination of CVS endurance and strengthening Supported by UK Active Progressive programme KPI - Aiming for 3 sessions minimum per week Psychological Nutritional

46. GM Cancer Prehab and Rehab Lung Cancer Surgery Phase 1 Evaluation points (6MWT, Strength, EQ5D, self efficacy) PREHAB 90 day hospital length of stay 01 REHAB PREHAB 2 year mortality

47. GM Cancer Prehab and Rehab Surgery Phase 1 Prehab4cancer launches 25th April 115 patients referred to programme since launch >90% patients taking part 14 evaluation sessions across GM • Reason for Not Participating: • Patient too high risk for exercise in community • Unable to contact patient • Already active with private gym and declined the offer • Declined the programme

48. GM Cancer Prehab and Rehab Lung Cancer Surgery Phase 1 Prehab4cancer launches 25th April 34 patients referred to programme >90% patients taking part For less fit patients we are only averaging 2.2 sessions/week Reframe this as Exercise Dose

49. GM Cancer Prehab and Rehab Non-surgical Lung Cancer Chemo/Dxt Phase 1 Evaluation points (6MWT, Strength, EQ5D, self efficacy) 90 day hospital length of stay 2 year mortality

50. GM Cancer Prehab and Rehab Non-surgical Lung Cancer Chemo/Dxt Phase 1 Evaluation points (6MWT, Strength, EQ5D, self efficacy) PREHAB 90 day hospital length of stay 01 REHAB PREHAB 2 year mortality