Prehabilitation: A Smart Step Before Cancer Surgery

When Joanna O'Connell, 52, was diagnosed with breast cancer in the spring of 2023, her care team at City of Hope Orange County Lennar Foundation Cancer Center in Irvine, California included the typical specialists: an oncologist, a surgeon and a radiologist. But she also met with someone unexpected: a physician committed to getting O'Connell moving.

After she started her treatment — an oral medication that she took daily as part of a clinical trial — O'Connell began experiencing numbness and tingling in her limbs, which kept her awake at night. She also felt tremendous fatigue, pain and stiffness in one hip. The symptoms made O'Connell increasingly anxious.

Her oncologist referred her to a fellow physician who specializes in cancer rehabilitation medicine. After scans to confirm that O'Connell's symptoms were not the result of an injury, the cancer rehabilitation specialist had news for her.

"She told me, 'You need to start exercising," O'Connell recounts. Physical activity was a crucial part of an individualized rehabilitation plan the physician designed for O'Connell, who was scheduled to undergo a mastectomy the following November.

Prehabilitation programs are increasingly popular at cancer centers around the United States, a way to help people with cancer build their health and fitness to face the challenges of surgery and treatment.

"Ultimately, we're trying to improve the patient's function upfront so that recovery [from surgery] is faster and easier, and to minimize complication from the oncology treatments," explains An Ngo-Huang, a physical medicine and rehabilitation specialist at MD Anderson Cancer Center in Houston.

In addition to fitness training, many comprehensive prehabilitation programs include help with smoking cessation, nutrition counseling and mental health counseling.

O'Connell had been a runner in the past, but life had been busy, and she'd had some kidney stones, which paused her fitness routine. And then the cancer diagnosis threw her for a loop. "I felt like my world stopped," she says. "I stopped physical activity. I wasn't even walking, except maybe to run an errand. I just didn't want to do the wrong thing."

But O'Connell's rehab specialist told her that physical activity was precisely the right thing for her to do in the months leading up to surgery. The doctor encouraged her to start with 20-minute walks around her neighborhood and gradually increase her moving time. 

O'Connell did as instructed, eventually adding hills to increase the exercise intensity. She now walks several times a week for an hour, listening to music on her walks. "I worked my way up to an hour, and it's been awesome," O'Connell says. Making time to exercise has made her less tired and has reduced her anxiety.

When Ngo-Huang began working in cancer care more than a decade ago, people with cancer were often instructed to minimize physical activity. But that advice has shifted, "I would say there is a big culture change in how people approach physical activity and exercise," she says. "Exercise is now welcomed and encouraged and seen as a valuable component of oncology care." 

A November 2022 study followed patients with lymphoma, or breast, colon, or testicular cancer who completed a 24-week fitness program that included weight training and riding a stationary bike. Half of the patients did the program while they were receiving chemotherapy, and the other half waited until chemotherapy was complete. 

The people who exercised during their treatment felt less fatigue, lost less cardiorespiratory fitness and maintained more muscle strength than those who waited until after chemotherapy to exercise regularly.

• It Prevents Muscle Loss. An exercise routine and a nutrition plan can counter the loss of muscle mass, weight and strength sometimes caused by cancer, Ngo-Huang says. "Patients may have potentially more complications or worse outcomes if they've been diagnosed with low muscle mass and malnutrition," she says. "Prehab could be a potential intervention."
• It Prepares the Body for the Stress of Surgery. A regular exercise routine can also help prepare the body to cope with the challenges of cancer surgery and anesthesiology. "We want to stress the body with the exercise and physical activity instead," Ngo-Huang explains. "We try to get your heart rate up, your breathing rate up, so that when you get on that table for surgery and anesthesia, the stress on your system is not so challenging."
• It Speeds Recovery. Patients who come to surgery in better shape are more likely to recover. A November 2021 study of patients with colorectal cancer found that people who completed a prehabilitation program had shorter hospital stays, reduced complications and fewer readmissions to the emergency room. 
• It Offers a Way to Take Control. This year, Ngo-Huang and her colleagues published findings from a randomized control trial in which they offered standard-of-care or home-based prerehabilitation, including strength training and aerobic exercise, to people with pancreatic cancer weeks before surgery. All of the patients received activity trackers and nutrition counseling. Interestingly, people in both groups were eager to exercise and accumulated roughly 150 minutes of vigorous physical activity each week.

This is likely why researchers did not see significant differences in the outcomes between the two groups, Ngo-Huang says. However, it points to the enthusiasm that some people with cancer have for prehab options. 

O'Connell notes that her walking routine feels good amid the uncertainty of cancer treatment. "It makes me feel like I have something I can control, which is helpful," she says. "I'm not as overwhelmed as I was in the beginning."

If patients have preexisting health problems such as cardiovascular disease or any significant bone or muscle injuries, they should talk to a physician on their care team before they pursue prehabilitation. 

"If they're physically well, they can start slow with short bouts of exercise for five or 10 minutes and listen to their body," Ngo-Huang says. "If that's easy for them, they can start increasing the time." The goal is to do at least 30 minutes of moderate to vigorous physical activity most days of the week and include some muscle strengthening or resistance exercises.

A growing number of cancer centers offer rehabilitation programs. However, patients may need to ask their oncologist or care team about the options for fitness training, nutrition counseling or mental health counseling.

If a hospital-based program isn't available, Ngo-Huang suggests checking the local YMCA for a Livestrong program, offering free or low-cost fitness classes for people diagnosed with cancer, or Silver Sneakers, provided for free through Medicare at gyms nationwide. 

Another option is to look for a fitness trainer certified by the American College of Sports Medicine to work with people who have a cancer diagnosis. YouTube exercise videos are also a good option, Ngo-Huang says: "In the end, we just want to get you moving."

Although she's always been relatively fit, O'Connell believes she is more robust and more flexible than she was at the start of her cancer journey. She's hopeful that this will power her post-mastectomy recovery. "I feel good that I can come out of it stronger," she says.

Erin O'Donnell Journalist Erin O’Donnell covers health, science, and parenting topics. Her work has appeared in WebMD, Cancer Today Magazine, and Harvard Magazine, among many others.

She lives with her husband and sons in Milwaukee, Wisconsin, and loves walking along Lake Michigan. For more of her work, visit http://erinodonnell.net/ or find her on Twitter @ErinODWriter. Read More