Dr Kwok Kah Meng, Consultant from the Department of Rehabilitation at Changi General Hospital (CGH), answers your questions about prehabilitation care for cancer patients.
Prehabilitation is care initiated before a patient receives cancer treatment or surgery.
Prehabilitation helps to facilitate and optimise the patient's return to health following treatment.
The prehabilitation process begins when patients are newly diagnosed with cancer. Next, patients undergo frailty, functional, and mental wellness tests performed by the Prehabilitation team helmed by a Rehabilitation Specialist Doctor, who then draws up a personalised intervention plan that includes exercise prescriptions as well as advice relating to nutrition and mental wellness.
In the case of
Changi General Hopital's (CGH) home-based programme, the hospital offers a one-stop solution in order to reduce the number of patient visits for pre-operation assessment and subsequently to allow patients to do their prehabilitation at home. This eliminates the need for patients to make multiple visits to the hospital. For more on CGH's prehabilitation programme, read the article
here.
If you have questions about prehabilitation care, don't hesitate to ask Dr Kwok Kah Meng, Consultant from the
Department of Rehabilitation at CGH, a member of the
SingHealth group, in this month's ‘Ask the Specialist’ Q&A forum.
This 'Ask the Specialist' forum has closed. Thank you for your interest and participation.
1. Posted by T*****
Dear Dr Kwok,
1.Why is prehabilitation important for cancer treatment? Is prehabilitation a process that all cancer patients (regardless of type of cancer) need to go through?
2.Can you elaborate on what are the various tests involved and how are they able to access a patient to see if he/she is suitable for cancer treatment?
3.If not suitable, what other treatment options are available to the patient?
Answered by Dr Kwok :
1. While cancer treatment is critical to manage or eradicate the cancer, some side effects can happen. In some patients, these can cause functional decline and a delayed recovery. Cancer prehabilitation is the process of care, initiated before surgery or treatment for cancer, where patients’ physical, nutritional, medical and mental health domains are optimised, so as to facilitate their return to pre-treatment state of health.
Changi General Hospital (CGH)’s Cancer Prehabilitation Programme is a one-stop screen-and-intervene initiative which gives newly diagnosed patients a head-start in recovery before their cancer treatment or surgery. By adopting a home-based model and cutting down time spent in the hospital, patients can focus fully on their prehabilitation so as to achieve improved recovery outcomes.
CGH carried out a pilot study of some 60 colorectal cancer patients, which found that patients who have undergone prehabilitation showed significant improvement in physical tests measuring their functional capabilities. This also translated to better functional recovery after surgery. The patients also had a significant improvement in their mental health, and went home earlier by an average of 1.5 days after the surgery, with reduced readmission and mortality rates.
The CGH Cancer Prehabilitation Programme team will continue to care for the patients even after their cancer treatment (surgery, chemotherapy, radiotherapy) ends. It comes in the form of individualised follow-up plans that will leverage on the progress achieved (eg. in improvement of physical fitness) and to promote longer-term health benefits. In general, most types of cancer can benefit from prehabilitation.
2. The assessment to determine the suitability of a patient for cancer treatment is carried out by both the surgeon and anaesthetist if the treatment involves surgery or the oncologist if the treatment involves chemotherapy or radiotherapy. The purpose of prehabilitation is to optimise the health status of the patient before their cancer treatment commences, with the goal to facilitate subsequent recovery post-treatment and improvement to long-term health.
The surgeon or oncologist will typically recommend patients to the Cancer Prehabilitation Programme led by a rehabilitation medicine doctor. Patients are mostly seen on the same day for their first prehabilitation consultation. They will undergo a holistic health assessment comprising frailty, functional and mental wellness tests by the prehabilitation team. Based on the results and their medical conditions, the rehabilitation doctors will draw up a personalised intervention plan in four areas, including optimisation of pre-existing chronic conditions, an exercise prescription, and specific advice relating to nutrition and mental wellness.
At the second consultation, prior to their cancer treatment, patients will undergo the same set of assessment tests to measure their progress. We will continue to monitor their recovery after their surgery, chemotherapy or radiotherapy sessions.
3. In general, for the prehabilitation programme, we try to include all patients by working around these limitations in whichever possible ways, based on available resources and setting.
CGH has expanded its prehabilitation programme to include more patients with liver, pancreas, gallbladder, prostate, bladder, oesophagus and stomach cancers. We aim to include as many patients as possible based on resources and settings.
As for suitability pertaining to a particular cancer treatment, the managing surgery/oncology team will be in a better position to advise on alternatives. As cancer types and conditions vary for individuals, it is recommended that you seek advice from your oncology or surgery team, who will be able to advise on treatment options.
2. Posted by k**
Hello Dr,
1.What can a patient do to prepare his/her body for cancer treatment?
Are there certain foods to eat and avoid?
2.What about exercises?
3.Any other things a patient or loved ones can do to increase the chances of a better outcome?
Thank you for your advice.
Answered by Dr Kwok :
1. Protein is required for wound healing after a surgery. However, the body's ability to use protein effectively can be affected when one has cancer or if one has to undergo surgery. To overcome this, we will usually prescribe a protein-rich diet before surgery. Examples of protein-rich food include eggs, meat, milk or milk products, legumes and nuts, but this will need to be individualised based on the patient's needs and preferences. The commonly known "healthy diet" rules still apply, and one should avoid food that contain excessive salt, sugar and fat.
2. Exercising is one of the most important ways to build up your body for cancer treatment. In our Cancer Prehabilitation Programme, exercise forms an important component because it contributes to a faster recovery post-operation. For patients who experience challenges in starting exercises due to their medical conditions, they can undergo a prehabilitation consultation where the doctor can work out an individualised, practical, home-based exercise plan for them.
3. We also recognise the importance of maintaining mental wellness of patients undergoing cancer treatment. Noting that patients may feel stressed, anxious or depressed after a cancer diagnosis, we included a mental health assessment as one of the key areas in our prehabilitation consultation. Together with the patient’s family, we can then help advise them on coping strategies and reinforce positive behaviour in the areas of exercises and dietary intake. Under our multi-disciplinary approach, we may consider a referral to a medical social worker or a psychiatrist (very rarely) based on our assessment of their condition.
3. Posted by J***
Dear Dr Kwok,
What are the physical and psychological effects that a patient can expect to face while undergoing cancer treatment?
How does prehabilitation prepare a patient for these effects?
Answered by Dr Kwok :
The types of side effects depend on the mode of cancer treatment.
◦Surgery
One may experience pain after surgery and functional decline, particularly if prolonged bedrest is required. Painkillers are typically used to relieve the pain which should reduce gradually, and patients are actively mobilised as soon as possible post-operatively to minimise muscle weakening from prolonged bed rest.
◦Chemotherapy and radiotherapy
Side effects arising from these treatments are very much dependant on the type of medications and body area targeted for treatment. On top of that, it is common for patients to feel tired more easily, as both the cancer and the treatment can affect multiple body systems. Prehabilitation will help improve cancer patients’ capacity to better withstand their upcoming surgery or anti-cancer therapies.
About Dr Kwok Kah Meng
Clinical Assistant Professor (Dr) Kwok is a Consultant Rehabilitation Physician with the Department of Rehabilitation Medicine in Changi General Hospital. He graduated from National University of Singapore (NUS) in 2008, completed his postgraduate Masters of Medicine (NUS) and MRCP(Edinburgh) in 2013, and his specialty training in Rehabilitation Medicine in 2017 and received the Outstanding Resident Award for that year.
His research interest is in Cancer Prehabilitation and he is the Clinical Champion pioneering the Cancer Prehabilitation Program in CGH, which was set up in the beginning of 2020. He is also actively involved in other committee work, such as the CGH Research Committee, CGH Telemedicine Workgroup, CGH Department Assessment and Standards Committee, and Saint Andrews Community Hospital (SACH) Falls Prevention & Management Quality Assurance Committee.
He is also the Departmental Chairman of Morbidity and Mortality Rounds, and had been previously consulted as a Subject Matter Expert by the National One-Rehab Community Rehab Transformation Workgroup.
Apart from clinical work, Dr Kwok is also passionate about teaching and has teaching positions in both NUS Yong Loo Lin and Duke-NUS medical schools.
Ref: J22
