Table 1.

Recommendations and suggestions for use, further exploration, and generation of hypotheses to strengthen prehabilitation as a standard of care and generate the political will to reimburse the medical intervention.

Category	Recommendation/suggestion
Risk assessment and safety considerations	#1: To generate comparable and measurable baseline data of patient risk, the standard patient history should be complemented by at least two different risk assessments like the Risk Assessment Index, the Charlson Comorbidity Score, the ASA or ECOG score, and the measurement of sarcopenia and/or the assessment of the 6-MWT or the TUG. This is suggested to be implemented into the structured patient pathway to surgery in every setting to avoid double-documentation and mitigate waste of time.
Exercise recommendations: type, duration, frequency	#2: Unfit patients should try to increase their exercise capacity to at least 75 min of vigorous (conversation is difficult but breathing fast) or 150 min of moderate (conversation possible, breathing increased) intensity per week. Sedentary time should be reduced, and stabilization and resistance training should be done at least 2 times per week.
	#3: A specific exercise program before surgical procedures is suggested to be performed for at least 3–6 weeks and might consist of 3–4 times per week moderate aerobic interval training when performed remotely, and moderate to vigorous training when performed in a completely supervised setting. The sessions should last between 30 and 60 min. Patient progress should be monitored or supervised with adequate measures and safety interventions, especially when done remotely.
Exercise testing	#4: The 6-MWT is suggested to be performed as a baseline and post-prehabilitation exercise testing tool in a clinical setting. A CPET might be considered in case that the infrastructure is easily available. The Karvonen method is suggested to calculate the individual program that might be adjusted considering additional individual risk factors like heart rate modulating drugs.
	#5: The extension of an exercise program beyond 4 weeks in patients undergoing neoadjuvant or bridging therapies to the operation might be considered. Patients not undergoing these kinds of strategies should be operated after 4 weeks of preparation at the latest.
Outcome measures	#6: Patients require a baseline risk assessment including exercise testing and a preoperative/post-prehab assessment to measure improvement or deterioration. This might include real-time exercise measurements as well as patient-reported outcomes.
	#7: Surgical outcomes should be measured in a structured way. The following outcome parameters should be considered: diagnosis (ICD), procedure (OPS-coded), complication assessment with the Dindo–Clavien score or the comprehensive complication index®, and 90-day overall survival. Long-term follow-up, impact on oncologic outcomes per indication, as well as in-depth analysis of the individual complications are suggested.
Nutrition	#8: Patients should be screened with the standardized nutritional risk surveys on the patient pathway either directly or as a (digitized) self-reporting tool. Based on the results, professional nutritional consulting should be performed. Protein-enriched (immune) nutrition might be generally considered while a patient is in the prehabilitation program.
Patient–blood management	#9: All patients in prehabilitation programs should undergo a structured patient blood management pathway, and anemic patients should receive special focus and attempts to correct the anemia.
Mental wellbeing	#10: Patients in prehabilitation programs should undergo a quality-of-life assessment before and after the program to measure improvement or deterioration. Every patient should be asked whether they want psycho-oncologic counseling. Stress reducing and motivational behavior strategies might increase general compliance, motivation, and surgical success.
Economic potential	#11: Key performance indicators for the economic success of a prehabilitation program should include an individual and detailed complete cost-revenue calculation for each patient including stays in normal wards, intermediate care wards, and ICUs, and readmission. Long-term costs might be considered by payers to measure the effects on oncologic success. Payers should analyze the potential of establishing reimbursement codes to implement prehabilitation as a refundable medical service.

ASA, American Society of Anesthesiology Score; ECOG, Eastern Co-operative Oncology Group; 6-MWT, 6-Minute Walking Testing; TUG, Timed Up and Go Testing; CPET, cardiopulmonary exercise testing; ICUs, intensive care units; ICD, international statistical classification of diseases and related health problems; OPS, operations and procedures key (Schluessel).