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[00:00:00] Hey everyone, and welcome to Behind the Knife. I'm Kyla Rezi, a PGY three general surgery resident at Johns Hopkins. Introducing your new thoracic surgery subspecialty team. I'm thrilled to be here with one of my mentors and someone I personally admire. Dr. Ginny ha, thoracic surgeon here at Hopkins.

Thanks Kyla for inviting me to join you on this episode. Just to start, I'm Ginny ha. I've been at faculty at Hopkins since 2018 after graduating from my fellowship here at Hopkins. Clinically, I largely focus on thoracic oncology and robotic thoracic surgery outside of the hospital. I love spending time with my family, being outside, gardening and cooking.

It's my way of decompressing. Thanks for being here today. Today we're tackling the topic of prehabilitation before thoracic surgery. All right, Dr. Hall, let's just start simple. How would you define [00:01:00] prehab and why is it something we should all be paying attention to? Prehab is the optimization of a patient's physical status.

Through nutrition and exercise interventions to improve functional capacity before major surgery. Both era a s and a few of the other surgical societies such as the European Society of Thoracic Surgeons now include this in their recommendations. It usually involves a combination of nutritional exercise and cycle social interventions is one of those ideas that make intuitive sense.

But when you try to apply it, especially in thoracic ecology, it brings up a lot of hard questions. So I'm really glad that we're talking about this. When I rotated through thoracic surgery as an intern at Hopkins, it really struck me how coordinated everything felt like the whole team was really rowing in the same direction.

I think a big part of that was the use of those EAS pathways. For listeners who aren't as familiar, like Dr. Hall was saying, EAS, everything from [00:02:00] pre-op counseling and nutrition to things like avoiding sedatives, minimally invasive procedures whenever possible, and getting the patients out of bed early and the chest tubes out early as well.

There's some differences across institutions with how these EAS protocols are used, but ideally, they provide a standardized evidence-based approach to management in an effort to improve patient outcomes. Today we're zooming in on that prehab component. So the rationale behind prehab is that surgery, especially lung or esophageal resection, is a major stress, and these patients are not always, but often pretty frail at the start.

For our lung cancer patients who are longtime smokers, many may have other comorbidities such as COPD and heart disease, and one of the most. Common presenting sign, for example, of esophageal cancer, it's dysphasia and associated weight loss. So surgery in general is very stressful physically, but also psychologically, and we know that [00:03:00] stress and anxiety can have profound impacts on patient's quality of life postoperatively, if we can increase or optimize a patient's functional reserve or nutritional status to translate into better postoperative outcomes and a quicker recovery for patients.

Prehab is backed by a growing body of evidence too, and it's being studied in the US and abroad. Though like many topics in healthcare, it's not without some polarizing points of discussion. Today we'll be diving into some research specifically discussing the prehab component of thoracic surgery era, RAS, in the context of esophagal gastric cancer, a paper published in JAMA Surgery in 2018, effect of exercise and nutrition prehabilitation.

On functional capacity in esophagal gastric cancer surgery, a randomized clinical trial, which was conducted at McGill University Health Center. We know that decreased preoperative exercise capacity is a risk factor for postoperative [00:04:00] morbidity and worsens long-term survival in our thoracic surgery patients.

So the study sets out to explore how prehab could impact esophagal gastric cancer patient outcomes. The investigators included two groups. The intervention group, which received a prehab program, combining exercise and nutrition interventions before surgery, and the control group, which received the usual care without the added exercise and nutritional support.

68 patients were randomized with ages of participants being between 67 to 68 years old. Participants in the intervention group followed a structured program guided by a kinesiologist. That involved activity to improve strength and aerobic capacity. 30 minutes of moderate continuous training, three days per week, which was either walking, jogging, or cycling and strengthening activity one day per week consisting of 30 minutes of resistance band work.

Counseling by a nutritionist was provided to all participants in the intervention [00:05:00] group, regardless of malnourished status, with an emphasis on protein consumption. So what did the researchers find? Okay. The primary outcome was change in functional capacity measured with absolute change in six minute walk distance, preoperative end of the prehabilitation period, and postoperative from four to eight weeks after surgery.

Data were compared between groups compared with the control group. The Prehabilitation group had improved functional capacity both before surgery and after surgery. There are several limitations to this study, including the variability of neoadjuvant treatment, small sample size, and exclusion criteria for participants.

What were your thoughts about this study, Dr. Ha, and how does it influence your approach to esophageal cancer patients? Yes, the exclusion criteria were many and important to discuss. But I think the importance of this paper. Points out the possible interventions we can think about implementing for [00:06:00] these patients.

We can see in this paper that these interventions have positive, measurable outcomes. It does exclude a lot of patients that we typically see for this type of disease. The data we have to base our recommendations on this space have some challenges for sure. A lot of the studies are small, single centered and have variable endpoints.

Like looking at differences in six minute walk distance after a prehab program as the outcome is great as an objective endpoint. Sure. But the studies I felt that had more impact were those that were able to show clinically tangible outcomes like decreased postoperative complications. And our CT I was looking at out of China published last year in the Journal of Thoracic and Cardiovascular Surgery showed with just a two week pre-op exercise regimen.

A decrease in short-term post-op complications. So it has been done. Dr. Ha, what are your [00:07:00] thoughts on this? Well, there have been a lot of studies that have shown really promising results, but there are a lot of components to consider when evaluating the literature in this area. So the example of a study that you mentioned out of China was a randomized control study, but the sample sizes were extremely small just because of the nature of asking a patient to exercise a lot and excludes a lot of the patients that we deal with on an everyday basis from participating in these studies for safety reasons.

And then another issue is who are we targeting? If you review a lot of these studies, the study participants are pretty healthy and we would consider pretty low risk for surgery and wouldn't need any preoperative intervention. So it makes you wonder, does every patient benefit or should we really only be targeting these sicker, more frail patients to begin with as these are the patients that stand to gain the most benefit.

That leads well into one of the questions I wanted to discuss with you. Do you [00:08:00] think we should standardize rehab? Or tailor it to each of these specific patients. I think there's pluses and minuses to either option. A standardized protocol is definitely easier across a system-wide program. It's also easier to measure outcomes from a research perspective and a quality perspective, but it doesn't really reflect the reality of who we are treating and what's really feasible.

That are sarcopenic or who have borderline lung function, those are the folks in the literature that stand to probably gain the most benefit, but figuring out how to incorporate them into an evident. Space regimen that is realistic and safe is really difficult to do. There's a lot of heterogeneity amongst the various studies that we've encountered in this space.

No study has the same intervention protocol. So it's really hard to compare across studies and [00:09:00] identify which type of interventions would be best for our patients in the real world. Well, there are studies that show preoperative interventions that are. You know, between the periods of two to six weeks are beneficial.

And then there are other studies that show that patients undergoing intensive one week preoperative interventions gain some benefits. There's also variations in nutritional programs. Do they have to follow specific nutritional guidance with follow up with a professional dietician, or can we just provide them with general guidelines based on their age, gender, and weight?

And when using the words individualizing and personalizing, of course that's gonna increase costs. Along those same lines of thought, like you were saying, how many additional consult services are we getting involved here? Are we talking with pm and r? Are we also involving pt, specific dieticians and nutritionists?

These are all things that we need to consider and can definitely contribute to the costs as well. Those [00:10:00] patients that you alluded to that would benefit the most with all these costs and access issues in mind. Are we reaching them in an equitable fashion? Yeah. I mean, serving as a physician in the city of Baltimore, I see a huge range of patients.

There is a, a large cohort of patients that are in the lower socioeconomic scale, and I find even though they have highly curable. The practical things about life to getting to appointments or seeing the appropriate doctors are huge barriers. They may not be for some other patients. For these particular patients.

They miss follow up appointments for their surveillance. Or they often need multiple appointments to really understand the treatment that I'm amending for them. Or they often need some preoperative testing to make sure that they're good candidates for surgery. And so I feel frustrated as a physician not having the ability and tool set to [00:11:00] help these patients in those matters.

Many of those things contribute to their long-term or poor outcome. Groups search suggests that people with lower health literacy from minority ethnic groups or socioeconomic. Economically disadvantaged backgrounds are less likely to engage despite often having worse perioperative outcomes. Other populations at risk are older patients and non-English speaking.

Patients who often have difficult accessing these parts of care, patients who are non-English speaking or patients with lower health literacy may have a poor understanding of what exactly prehab involves, and that is a big barrier to participation. So. We often in the literature don't focus on how well the idea of pre-AP is communicated to our patients and how well do they understand it.

Are we presenting this in an effective and clear [00:12:00] manner? We don't really know. Cancer care, especially in thoracic oncology, often require multiple different treatment modalities. For example, majority of our esophageal cancer patients require systemic therapy, sometimes with concurrent radiation, and it's then followed by surgery.

But each of these visits take time for that patient time to somehow get to the hospital. Take time off of work or find care for their loved ones which is overwhelming. So adding another layer, a prehab program on top of that can add more logistical stress. This issue's particularly important to me too as my training first during medical school at University of Miami.

And now here at Hopkins has given me the privilege of interacting with a lot of these socioeconomically disadvantaged patients. We, as surgeons have a role and need to make sure we're not contributing to the disparities seen by being biased in who we even refer to prehab To begin with, we can use tools like [00:13:00] systematic referrals in the EMR, which helps make sure we're not missing any of our most vulnerable patients from the start.

Here to talk a little bit more about this is an expert in advocating for our most at-risk patients is patient navigator at Hopkins, Ms. Leslie Ricks Chandler. Hello everyone. My name is Leslie Ricks Chandler and I have been a social worker for 37 years. I'm a patient navigator for the division of thoracic surgery.

It's very important that we are discussing the challenges that patients face. They come as a whole with preexisting diagnosis and social challenges as well as their new cancer diagnosis. I had a patient, for example, that had both HIV and lung cancer. This patient needed mental health counseling, community support for their HIV well as nutrition counseling, medication management, and enterative therapies for lung cancer.

Wow. 37 [00:14:00] years. It's pretty incredible. As surgical trainees, we don't get a lot of exposure to all the work you do in the background for these patients, so thank you so much for what you do. Are there any resources we can refer our patients to before they get to meet people like you? I actually developed new patient surgery videos for all thoracic patients as a resource that explains what to expect on the day of surgery, pain management, and discharge.

These videos can be found on www hopkins medicine.org. I think the next project that I will be working on are some videos that aim to help patients complete prehab recommendations at home. I think that's a really important point you bring up, Leslie. Making prehab doable for the patient's specific situation, like offering virtual based home programs.

If getting to appointments and potentially missing work or being unavailable for a family member could really be an option, maybe some sort of hybrid model with [00:15:00] virtual check-ins and some in-person opportunities could also be ideal. Another part about prehab that's frequently talked about is timing.

Should we delay surgery for prehab? That's a really tough question for cancer patients, especially. Timing and consideration of surgery is really important. It would be awesome to optimize the patient's functional status and nutritional and mental status preoperatively with hopes of decreasing their postoperative complications and allow them to have a much quicker recovery and then move on to any additional treatments they may need after surgery.

But delaying surgery may lead to advancement of their cancer. It can make cancer more difficult if they're falling outside the window of treatment after systemic or radiation therapy. So I don't necessarily think that we have enough evidence that we should delay surgery so that patients can be optimized.

But I think this is a. [00:16:00] Case by case kind of vision that surgeons and the teams have to make. So just connecting back to the ESTS pre E ERAS guidelines, we have evidence to support that routinely nutritionally screening patients is useful. Using screening tools like the nutritional risk score, NRS and the malnutrition universal screening tool, MUST to find the patients who, based on SPEN guidelines, could benefit from delaying surgery to optimize their nutritional status.

Some characteristics to look out for in your patients include those with weight loss greater than 10 to 15% within six months, A BMI of less than 18 and a half, and serum albumin less than 30 without evidence of hepatic or renal dysfunction. With all these moving parts in potentially multiple consulting teams involved, do you think that prehab programs are cost effective?

Those are really good questions. Once again, I think we can only answer that question when we are able to analyze a [00:17:00] more homogeneous prehab regimen. Because right now, with the length of prehab programs and the variations and the different specialists that are involved in all the studies that have been presented, it's really hard to tell whether it would be cost effective, and we need a better understanding of how to apply this to real world patients.

And we also need to have a better understanding of the cost of all of these interventions. Is this a cost effective strategy? We don't really know. Does this translate into decreased complications, length of stay and decreased admissions? Because that would certainly drive down the cost medical care for these patients.

I think those are great points that you just brought up. Maybe some opportunities to decrease costs in this space. Are increasing the use of those virtual interventions like the tele prehab we talked about, and really targeting the most at-risk patients. We need to be flexible. I don't think all patients need to be in these directed, regimented programs.

We [00:18:00] can offer. Of course, all patients benefit from keeping up their protein consumption as well as staying committed to these exercise programs. But these patients that are equipped to do this from the start on their own are those with higher baseline functional capacity, usually younger patients, and importantly, those with adequate social support, and those usually correspond to generally higher socioeconomic status patients as well.

Patients at most risk and vulnerable require specific interventions and guidance and would benefit from enrollment in a formal pre-AP program. I think everyone should be assessed for factors that place them into a certain level of risk, considering both their physiology and their social factors, and then determine what regimen that specific patient needs.

I'm excited for more work in this space and any studies that are in the future to come that can prove the cost effectiveness that you talked about. As we all know, at the end of the day, these interventions require [00:19:00] funding and a motivation to fund Dr. Ha. Looking ahead, what work do you think is left to be done?

Where do we go from here? Well, we have a lot of work to be done in this space. I think we need more consistent evidence that demonstrates. Tangible clinical outcomes that really translates into decreased complications, decreased length of stay, and decrease overall medical costs. We don't have that yet. I think we need a better understanding.

What patients would be best. Or who would most benefit from these interventions? I certainly agree that probably having a wide blanket intervention is not the way to go either. We need more work in the area of the impact of psychosocial and states on outcomes. And how do we measure the impact of people like Leslie, who does such important work as a patient navigator on the outcomes of these patients who are undergoing complex medical care.[00:20:00]

Prehab in thoracic surgery is an area of research that has a lot of potential to make a big impact, and I'm excited to see more work done so that way we can answer these questions about who needs it for how long, with what exact protocols involving who and at what cost. I really appreciate you both being here and taking the time to talk about this important aspect of patient care.

This has been the Johns Hopkins Thoracic Surgery subspecialty team signing off. Until next time, be sure to dominate the day. Dominate the.