Prehabilitation in cancer care: an evolving field

Abstract

Cancer treatment imposes significant physiological and psychological demands on patients whose reserves are already under strain. Prehabilitation, the systematic optimisation of physical, nutritional, and psychological condition prior to cancer treatment, has emerged as a promising strategy to build reserve and accelerate recovery. Yet critical questions remain around patient selection, optimal dose and delivery, and equitable implementation. In this editorial, we outline the current state of evidence, key challenges, and emerging priorities, and invite contributions to BMC Cancer’s “Prehabilitation in Cancer Care” Special Collection.

Cancer surgery and systemic treatment impose extraordinary demands on patients at a time when their physiological and psychological reserves are already under pressure. Prehabilitation, the systematic optimisation of patients’ physical, nutritional, and psychological condition in preparation before cancer treatment, has emerged as a compelling strategy to address this vulnerability. By intervening during the window between diagnosis and treatment, prehabilitation aims to build reserve, attenuate the physiological insult of surgery or neoadjuvant therapies, and accelerate recovery.

The rationale of prehabilitation is well established. Preoperative functional capacity is a strong and independent predictor of postoperative outcomes across cancer types [1], and modifiable risk factors, including deconditioning, malnutrition, and psychological distress, are common in surgical cancer populations. An international survey of 663 hospitals confirmed that prehabilitation is offered to all cancer patients in only 21% of centres, with lack of institutional funding cited as the primary barrier globally, most pronounced in low-income and Sub-Saharan African settings [2]. A 2022 umbrella review of 55 systematic reviews confirmed that prehabilitation may reduce complications, shorten length of stay, and improve functional recovery, though overall certainty of benefit remained low [3]. In 2022, the American Society of Clinical Oncology endorsed prehabilitation for patients with lung cancer alone, showing significant reductions in treatment complications and reduced hospital stays [4]. This BMC Cancer Special Collection arrives at an inflection point: the evidence base is large enough to synthesise rigorously, yet sufficiently heterogenous to demand further investigation.

The most comprehensive synthesis to date, a network meta-analysis of 186 randomised controlled trials with more than 15,000 participants, found consistent directional evidence that exercise-based and nutritional prehabilitation, as well as multicomponent programmes combining these elements, may meaningfully reduce complications, shorten length of stay, and improve health-related quality of life and physical recovery [5].

Several multicentre trials have since sharpened this picture. The PREHAB trial demonstrated that a four-week supervised multimodal programme before colorectal cancer surgery significantly reduced severe and medical postoperative complications and improved functional recovery, though it closed early due to the COVID-19 pandemic [6]. In older patients with frailty undergoing gastric cancer surgery, the GISSG + 2201 trial showed that just two weeks of supervised home-based multimodal prehabilitation, using well-trained family members as a delivery mechanism, significantly reduced overall complication rates (17.2% versus 28.7%), reduced ICU admissions, and improved preoperative functional capacity, with 93.75% adherence [7].

Yet the field must engage honestly with more complex findings. The PREPARE trial, 847 older adults with frailty, 13 centres, and coach-supported home-based prehabilitation, found no significant improvement in disability scores (adjusted mean difference − 1.4; 97.5% CI: -4.9 to 2.0) or complication rates (adjusted odds ratio 1.05; 97.5% CI 0.73 to 1.49) on an intention-to-treat basis [8]. Critically, participants completing more than 75% of prescribed exercises did experience a clinically meaningful benefit, but median per-protocol adherence was 67%, with behavioural and medical barriers dominating. The PHYSSURG-C trial similarly found no effect from a short, unsupervised pre- and postoperative exercise programme in a general colorectal cancer population [9]. Together, these trials clarify that low-intensity, unsupervised, or insufficiently supported interventions are unlikely to generate detectable benefit at the population level. Dose, intensity, supervision, and patient selection all matter. Further, designing trials for clinical implementation must be balanced with experimental rigor and reproducibility.

An international Delphi study involving 165 prehabilitation experts across four continents identified ten consensus research priorities, led by the effect of prehabilitation on surgical outcomes, identifying populations most likely to benefit, and optimal programme composition [10]. This Collection is positioned to advance each of these priorities.

Who benefits most? Higher-risk patients, those with frailty, malnutrition, or poor functional capacity, appear most likely to derive meaningful benefit, yet patient selection and risk-stratified programme design remain underdeveloped. Stratification tools that align programme intensity with individual need are a priority for future research.

What constitutes adequate dose and delivery? The contrast between the two-week GISSG + 2201 programme and the longer-duration programmes in PREPARE and PHYSSURG-C illustrates that duration alone does not determine effectiveness. Supervision, multimodality, adherence support, and context of delivery interact in ways not yet fully understood. The global survey confirms that even where prehabilitation exists, programme design varies substantially and often does not reflect the supervised, tailored approaches associated with benefit [2].

Most prehabilitation trials have enrolled patients from well-resourced, high-income settings [11]. The international survey revealed that access is most limited in Sub-Saharan Africa and other lower-income countries, where modifiable surgical risk factors are most prevalent. Evidence on prehabilitation effectiveness for rural, Indigenous, and low-socioeconomic populations is markedly thin and urgently needed.

The evidence base for prehabilitation before chemotherapy, immunotherapy, and radiotherapy remains far less developed than the surgical literature, yet the biological rationale is equally compelling. This Collection specifically invites contributions from non-surgical oncology contexts.

There is now sufficient evidence to justify implementation of supervised, multimodal prehabilitation in appropriately selected high-risk surgical cancer patients. Translating these findings into real-world practice, at scale, equitably, and across diverse healthcare settings, remains the defining challenge. This BMC Cancer Special Collection invites the global prehabilitation community to contribute original research, systematic reviews, implementation science, and protocol papers that will sharpen the evidence base, inform guideline development, and help close the gap between what is possible and what patients around the world can actually access.

Authors' contributions

DS and CG, JG, and JR conceived the manuscript, DS wrote the original manuscript, and all authors edited the manuscript. All authors read and approved the final manuscript.

Funding

No funding for this manuscript has been received.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors are the Guest Editors of the Collection (Prehabilitation in Cancer).