Mapping Family Involvement in Prehabilitation for Patients Undergoing Cancer Surgery: A Scoping Review

Abstract

Introduction

Family involvement may enhance adherence to prehabilitation in patients undergoing cancer surgery, but the nature, scope, and effectiveness of family involvement have not been comprehensively mapped.

Objective

This scoping review aimed to map the existing evidence on family involvement in prehabilitation for patients undergoing cancer surgery. It described intervention characteristics, family roles, delivery approaches, and outcome measures. It also identified current research gaps to inform the development and optimization of future family-involved prehabilitation programs.

Methods

This scoping review followed the JBI methodology and the PRISMA-ScR reporting guideline. The PCC framework guided the review question and eligibility criteria. PubMed, Embase, and CINAHL were searched from inception to 29 June 2026 using concepts related to family or caregiver involvement, prehabilitation, and cancer surgery. Data were extracted and synthesized by two reviewers independently.

Results

Current evidence is heterogeneous and remains at an early stage, including pilot interventions, practice protocols, qualitative and mixed-methods studies, digital co-design work, observational studies, quality improvement reports, Delphi studies, and reviews. Most interventions were still primarily patient-centered, with family caregivers commonly described as facilitators, sources of behavioral support, or co-recipients of education. Evidence was limited on how caregiver roles were defined, how family caregivers were trained, how competency was assessed, and how feedback mechanisms were organized. Family involvement in prehabilitation was delivered through face-to-face training, printed or video-based materials, telephone follow-up, social media or web-based platforms, remote guidance, and multidisciplinary outpatient services. Outcome assessment focused mainly on patients themselves.

Conclusion

Family involvement in prehabilitation is a promising approach for patients undergoing cancer surgery. However, its effectiveness, caregiver-related outcomes, intervention fidelity, and practical implementation models require further evaluation.

Introduction

Surgery remains a key treatment option for achieving cure or long-term disease control in many patients with solid tumors. Before surgery, patients with cancer often experience reduced physical capacity, malnutrition, anxiety and depression, frailty, symptom burden, and insufficient social support. Prehabilitation refers to the identification and management of modifiable risk factors before surgery or anticancer treatment, with the aim of improving patients’ ability to withstand surgical stress.^1,2 In recent years, multimodal prehabilitation, mainly consisting of exercise, nutritional support, and psychological support, has become an important component of perioperative oncology care.^1,3,4

Because prehabilitation is often delivered at home before hospital admission, it does not occur only at the level of the individual patient.^1,2 Family members frequently contribute to understanding health information, preparing meals, accompanying exercise, observing symptoms, providing emotional support, arranging transportation, and communicating during follow-up visits; similar family-support tasks have been described in surgical family-involvement work outside the prehabilitation phase.^5,6 Without structured management, family support may remain experiential, fragmented, and reactive. Without clear boundaries and monitoring, family involvement may also lead to incorrect implementation, increased caregiving burden, and safety risks.^5,6 Transforming family members from informal companions into structured prehabilitation partners therefore requires explicit role definition, training, feedback, and safety escalation mechanisms.

Existing studies on family involvement have mainly focused on perioperative communication, discharge preparation, caregiver experience, and caregiver burden, with relatively little attention to the preoperative prehabilitation phase.^5,6 Although family caregivers have increasingly been included in cancer prehabilitation, their roles are still poorly defined. Few studies have described how family caregivers should be trained, what responsibilities they should undertake, or how their performance should be evaluated. As a result, there is limited guidance for developing and implementing a structured family-involved prehabilitation program in clinical practice. This scoping review therefore aimed to map the existing evidence on family involvement in prehabilitation for patients undergoing cancer surgery, describe intervention characteristics, family caregiver roles, delivery approaches, and outcome measures, and identify research gaps to support the development of future family-involved prehabilitation programs.

Methods

Study Design and Protocol

This scoping review was conducted in accordance with the Arksey and O’Malley framework, as further refined by Levac et al and the Joanna Briggs Institute (JBI), and was reported following the PRISMA-ScR guideline.^7–10 A protocol was developed a priori. Although not registered, the protocol followed established frameworks.

Eligibility Criteria

The review question and eligibility criteria were structured using the Population-Concept-Context framework recommended by the JBI methodology for scoping reviews.⁹ The PCC elements are shown in Table 1. All empirical and evidence synthesis designs were considered, including systematic reviews, scoping reviews, randomized and non-randomized intervention studies, study protocols, feasibility studies, qualitative studies, mixed-methods studies, implementation studies, and expert reviews.

Table 1.

Population–Concept–Context Framework for Eligibility Criteria

Element	Definition in This Review
Population	Adults scheduled to undergo cancer surgery and their family members, spouses, partners, adult children, or other primary informal caregivers.
Concept	Family-involved, family-centered, caregiver-assisted, or patient–caregiver dyadic prehabilitation or perioperative self-management interventions, including exercise, nutrition, psychological support, health education, self-management, remote follow-up, digital feedback, caregiver training, or explicit caregiver role assignment.
Context	Preoperative or perioperative pre-rehabilitation, including rehabilitation-related exercises, nutrition, psychological support, health education, self-management strategies, and digital or remote interventions, that are directly relevant to tumor surgery.

Operationally, studies were considered relevant to prehabilitation when they addressed preoperative or perioperative preparation for cancer surgery and included at least one component intended to improve readiness for surgery or recovery, such as exercise, nutrition, psychological support, health education, symptom monitoring, self-management, or recovery preparation. Sources that were relevant to prehabilitation but did not directly evaluate family-involved prehabilitation were treated as indirect or related evidence.

Studies were excluded if they focused exclusively on hereditary cancer screening, family history, or genetic counseling without addressing perioperative care. Studies unrelated to adult cancer surgery, including non-cancer, non-surgical, and pediatric populations, were also excluded. Records with only a title and insufficient information to determine relevance, as well as duplicate records, were excluded.

In this review, “family members” was used as a broad term referring to relatives, spouses, partners, adult children, or other informal supporters of patients. “Family caregivers” referred to family members who undertook specific supportive, caregiving, self-management, communication, or monitoring tasks in the perioperative or prehabilitation context. The term “caregivers” was used as a shortened form of family caregivers when the family context was clear. “Prehabilitation coach” was reserved for studies describing a more structured role in which a family caregiver was trained or expected to actively support prehabilitation-related activities.

Search Strategy

A systematic search was conducted in PubMed, Embase, and CINAHL from inception to 29 June 2026. Search strategies combined controlled vocabulary and free-text terms related to cancer surgery, prehabilitation, and family or caregiver involvement. Full strategies are provided in Supplementary Table S1.

Titles and abstracts were independently screened by two reviewers (You and Gong), and full texts were then assessed for eligibility against the inclusion criteria. The screening process is presented in the PRISMA flow diagram (Figure 1), consistent with PRISMA-ScR reporting principles.¹⁰ A total of 1848 records were identified through database searching. After duplicate removal, 1,397 records were screened, and 26 studies were ultimately included. When necessary, another researcher (Li) resolved disagreements regarding document eligibility. Regular discussions among research team members were conducted to monitor the progress of screening.

Figure 1.

PRISMA-ScR flow diagram of the literature search and study selection process.

Data Synthesis and Analysis

Given the heterogeneity in study designs and outcome measures, the findings were synthesized narratively using a deductive–inductive approach. The deductive–inductive synthesis began with broad categories derived from the review objectives and extraction form, including family roles, specific tasks, prehabilitation components, delivery approaches, outcome indicators, and research gaps. Two reviewers (You and Gong) independently extracted data using the standardized extraction form and developed more specific subcategories. Similar codes were merged or refined through discussion. A third researcher (Li) was consulted when consensus could not be reached.

Among the included studies, empirical studies were the main sources for mapping family roles, intervention components, delivery approaches, outcome measures, and reported findings. Protocol, intervention-development, Delphi, and program-construction studies were used to identify planned or proposed family-involved prehabilitation models. Review-type publications were used to clarify concepts, contextualize findings, identify evidence gaps, and support framework development.

Results

General Characteristics of the Studies

The general characteristics of the included studies are presented in Supplementary Table S2. The included studies spanned a wide temporal range, although the number of relevant publications has increased markedly in recent years. Of the 26 included sources, four provided direct evidence on family-involved prehabilitation or dyadic perioperative interventions relevant to cancer-surgery prehabilitation.^11–14 The remaining 22 sources provided indirect evidence, including perioperative family involvement, caregiver support, self-management, digital or remote prehabilitation design, protocols, qualitative studies, observational studies, reviews, Delphi studies, and expert or contextual evidence.^15–36

Lung cancer self-management, perioperative physical activity, and caregiver support studies contributed much of the dyadic or caregiver-related evidence.^{11–13,15–17} Colorectal and gastrointestinal studies contributed evidence on digital co-design, perioperative experiences and needs, exercise adherence, and family-participatory nursing.^14,18–20 Other included sources addressed bladder, gastric, esophageal, hepato-pancreatico-biliary, or mixed surgical oncology contexts, as well as review, protocol, qualitative, mixed-methods, quality-improvement, Delphi, and observational evidence.^21–36 Overall, the evidence base indicates that this field remains exploratory and at an early implementation stage. Therefore, the findings of this scoping review should be interpreted as a mapping of direct and indirect evidence rather than as evidence of intervention effectiveness.

From “Family Members Present” to “Family Roles Designed”

Across direct and indirect evidence sources, the included studies suggested a movement from family presence toward family role design. In older perioperative oncology studies, family members were often treated primarily as recipients of information or as people who experienced stress during surgery.^21,26 More recent work increasingly described family caregivers as participants in dyadic interventions, co-users of digital tools, behavioral supporters, and potential prehabilitation coaches.^{11–14,18,30} However, many studies still lacked operational details about who trained the family caregivers, how long training lasted, what competence was required, how tasks were monitored, and when concerns should be escalated.^29,30

Family caregivers undertake a range of roles, but these roles vary considerably in their level of definition, support, and task intensity across studies. In many studies, family members were included as co-recipients of education. They learned alongside patients about the surgical pathway, hospitalization, physical activity, diet, symptom management, discharge preparation, and how to contact professionals when problems occurred.^20,21,32 This shared education helped patients and families develop a common understanding of perioperative care.

Family caregivers also acted as behavioral supporters. They reminded patients to complete exercises, accompanied physical activity, helped with transportation, prepared food, recorded symptoms or task completion, and reported barriers to clinicians.^13,24,28,34 Across exercise and physical activity studies, family support was described as one of the important conditions that helped patients participate in prehabilitation.^13,24,34

Some studies treated family caregivers as co-participants rather than only as supervisors. In perioperative physical activity research involving older adults with lung cancer, caregivers were positioned as part of the behavior-change process.^13,24,25 Caregiver support studies in early-stage lung cancer also treated caregiver distress, coping, burden, and quality of life as intervention targets.^12,15

Digital and remote interventions gave family caregivers another role. In co-design, eHealth, web-based prehabilitation, telehealth, and multimedia programs, family members helped patients use information, respond to reminders, monitor symptoms, and communicate with clinicians.^11,13,18,27 In these models, self-management was not separate from prehabilitation; it was the way patients and family caregivers carried out prehabilitation tasks at home.^16,17

The most clearly defined role was that of a trained prehabilitation coach. One Chinese family-participatory nursing study selected a primary family caregiver, provided training, and assessed competence before the caregiver supported home-based prehabilitation. The caregiver supervised walking and resistance exercise, helped prepare nutritionally appropriate meals, completed a prehabilitation diary, joined WeChat-based check-ins, and supported early postoperative mobilization.¹⁴

Tasks Undertaken by Family Caregivers During Prehabilitation

The included studies consistently indicated that family involvement should not be considered an additional component separate from prehabilitation. Rather, it should be integrated into the four core domains of prehabilitation: exercise, nutrition, psychological support, and health education.^14,30,33

Within the exercise domain, family caregivers participated in accompanying patients during walking, reminding them to complete prescribed training, recording exercise dosage, monitoring discomfort, and reporting barriers to participation.^13,14,24 Qualitative evidence further suggested that adherence to home-based prehabilitation is influenced by capability, opportunity, and motivation, with family members primarily contributing by enhancing patients’ opportunities and motivation to engage in exercise.^19,23,34

Within the nutrition domain, family caregivers were involved in food purchasing, meal preparation, dietary intake recording, supervision of oral nutritional supplementation, and reporting nutrition-related problems. This task profile was most explicit in the Chinese family-participatory nursing study and was also consistent with surgical preparedness and caregiver-oriented prehabilitation discussions that emphasized household routines and practical support.^14,30,31

Within the psychological support domain, family caregivers were encouraged to learn supportive communication strategies, participate in breathing or mindfulness-based relaxation exercises with patients, assist in setting short-term rehabilitation goals, and recognize signs of severe psychological distress.^12,14,15,26

Within the health education domain, family caregivers received education alongside patients, provided feedback on training, learned to recognize abnormal symptoms, and developed a clear understanding of recommended and restricted activities.^14,20,21,32 Studies on patient-caregiver co-design, discharge planning, perioperative needs, and multimedia self-management further suggested that educational materials, videos, telephone follow-up, web-based resources, and feedback from healthcare professionals could help patients and family members develop a shared understanding and coordinated approach to prehabilitation.^11,17,18,20

Delivery Approaches: Combining Face-to-Face Training with Digital Continuity

The included studies identified several delivery approaches for family-participatory prehabilitation in patients undergoing cancer surgery, including face-to-face training, printed and video-based educational materials, telephone follow-up, WeChat groups or web-based platforms, remote exercise supervision, and multidisciplinary outpatient services.^{11,13,14,18,27,32} Remote and digitally delivered prehabilitation may improve accessibility, particularly for patients with limited preoperative time, high travel burden, or a need to complete prehabilitation at home.^13,18,27 However, digital delivery should complement rather than replace professional assessment. Intervention effectiveness may be influenced by patients’ and family caregivers’ digital literacy, device access, privacy concerns, platform usability, and the capacity of healthcare professionals to provide timely feedback.^18,27,34

One study from China described a digital pathway to support the continuity of prehabilitation. Nurses delivered individualized educational content through a WeChat group at a fixed time each day, multidisciplinary team members responded to questions within two hours, weekly online question-and-answer sessions were provided, and standardized check-in templates were used to record exercise duration, dietary intake, and emotional status.¹⁴ This approach integrated family participation, professional feedback, and peer support within a single delivery platform, facilitating the monitoring and continuity of home-based prehabilitation.

Outcome Evaluation in Family-Involved Prehabilitation

Existing prehabilitation studies have primarily evaluated patient-level outcomes, including functional capacity, postoperative complications, length of hospital stay, quality of life, and psychological well-being. Frequently reported measures included the 6-minute walk test, handgrip strength, physical activity, nutritional risk, anxiety and depression, symptom burden, hospital readmission, and postoperative complications.^{12–14,24,25}

Studies involving family participation suggested that outcome assessment should extend beyond patient outcomes alone. Perioperative physical activity and lung cancer caregiver support studies evaluated patient-caregiver joint participation, caregiver psychological distress, caregiver burden, coping, quality of life, and caregiver preparedness.^{12,13,15,16,25} Studies evaluating family-involved interventions also assessed caregiver experience, patient recovery, and intervention safety alongside patient outcomes.^11,12,14,33 However, these studies focused on family involvement during the perioperative period and did not always provide targeted evidence for preoperative rehabilitation. These findings indicate that future outcome evaluation should include patient outcomes, caregiver outcomes, and implementation outcomes together. When caregivers are positioned as active components of prehabilitation, evaluations of caregiver burden, preparedness, self-efficacy, psychological distress, and quality of life may help determine whether family involvement is acceptable and sustainable in practice.

Although the included studies described several forms of family involvement, such as co-receiving education, providing behavioral support, participating in digital self-management, and assisting with prehabilitation activities, few studies quantified the degree of family involvement, such as participation frequency, intervention intensity, task completion, or intervention fidelity. In addition, almost no studies compared whether different types of family involvement were associated with differences in patient outcomes, caregiver outcomes, or implementation outcomes. This represents an important evidence gap and should be prioritized in future family-involved prehabilitation research.

Given the heterogeneity of the included evidence, the findings were further organized into an integrative framework rather than interpreted as evidence of intervention effectiveness. This synthesis is summarized in Figure 2, which presents the evidence base and the main domains identified across the included studies. Family roles indicate how family members were positioned, specific tasks describe what they were expected to do, and prehabilitation components show the clinical content to which family involvement was connected. These domains were further linked to delivery approaches and outcome indicators to show how family-involved prehabilitation may be implemented and evaluated. Domain-level counts were allowed to overlap because individual studies could contribute to more than one domain.

Figure 2.

Framework of family involvement in prehabilitation for cancer surgery. Evidence base, family roles, intervention components, delivery approaches, and outcome indicators identified in the included studies.

Discussion

Main Findings

This scoping review found that evidence on family-involved prehabilitation for patients undergoing cancer surgery is emerging but remains at an early stage of development. Direct evidence remains limited, so current findings should be interpreted as a description of possible family roles, tasks, delivery approaches, and outcome domains rather than as evidence of intervention effectiveness. Across the 26 included evidence sources,^11–36 most studies remained patient-centered, with family members primarily described as facilitators of participation, providers of behavioral support, or co-recipients of education, rather than being systematically incorporated as intervention recipients, intervention providers, or subjects of outcome evaluation.

A limited number of studies, either directly or through strong indirect evidence, have begun to conceptualize patients and family caregivers as a joint unit of intervention.^{11–13,18,25} This is consistent with qualitative evidence identifying family support as an important facilitator of participation in prehabilitation.^19,24,34 Nevertheless, the current literature has focused predominantly on intervention acceptability, stakeholder perspectives, digital platform design, and implementation barriers, while providing limited information on family caregivers’ day-to-day responsibilities, training requirements, competency assessment, and feedback mechanisms.^{14,18,29,30,34}

Implications for the Development of Family-Involved Prehabilitation

Given the limited direct evidence, the following implications should be interpreted as considerations for future intervention development rather than as practice recommendations based on established effectiveness. Family-involved prehabilitation for patients undergoing cancer surgery is likely to benefit from a collaborative model involving patients, family members, and the multidisciplinary team.^14,18,30,34 Family roles may need to be explicitly integrated into the exercise, nutrition, psychological support, and health education components of prehabilitation, rather than being described only in general terms as the provision of family support.^14,30,33 Prehabilitation planning should include an assessment of both patient- and family-level factors. Baseline nursing complexity should be considered when tailoring family-involved prehabilitation. Standardized nursing diagnoses may help identify multidimensional care needs and vulnerability that are not fully represented by the underlying oncological condition alone.³⁷ In addition to patients’ physical function, nutritional status, psychological well-being, health literacy, and surgical risk, caregiver willingness, available time, understanding, digital ability, burden, and family relationship quality should be considered.

Based on the mapped evidence, future family-involved prehabilitation models could consider a structured process of training, demonstration, return demonstration, competency assessment, and ongoing feedback to ensure that family caregivers understand their responsibilities, activity restrictions, warning signs, and appropriate pathways for seeking professional support.¹⁴ These requirements may also affect the nursing work needed to support family-involved prehabilitation. Future studies should examine whether structured family involvement modifies nursing care complexity and resource requirements, particularly nursing activities related to caregiver education, supervision, coordination, and safety monitoring.³⁸ Follow-up may be supported through telephone calls, WeChat, or web-based platforms to document task completion, provided that regular professional feedback and clear procedures for risk escalation are maintained.^13,14,18,27 Evaluation of family-involved prehabilitation should include three complementary domains of outcomes: patient outcomes, family caregiver outcomes, and implementation outcomes.^{12–16,25,33}

Safety and Ethical Considerations

Family involvement should be viewed as an extension of professional care rather than a substitute for it. Within family-involved prehabilitation, the roles of family caregivers should be clearly defined. Family members may provide reminders, companionship, monitoring, feedback, and emotional support, but should not independently assess clinical conditions, adjust medications or nutritional prescriptions, require patients to exercise against their wishes, or manage suspected postoperative complications.^14,30,33

Evidence from the Family Involvement Program suggests that family participation should be supported by mechanisms that enable monitoring, supervision, and timely escalation of safety concerns.³³ At the same time, family involvement should not be achieved at the expense of caregivers’ own health and well-being. Family-involved and caregiver-focused interventions have shown that caregiver outcomes, patient experience, psychosocial outcomes, and intervention safety should be evaluated alongside patient recovery.^{11–13,15,16,33} When family members have limited caregiving capacity, strained family relationships, or excessive caregiving burden, alternative professional support should be available to avoid placing unrealistic expectations on the household.

Research Gaps

This review identified several important gaps in the current evidence. Intervention reporting remains incomplete. Many studies provided limited information on caregiver training, including who delivered the training, its duration, educational materials, competency assessment, feedback frequency, intervention fidelity, and procedures for risk escalation.^14,29,30,34 Such information is essential for the replication and implementation of family-involved prehabilitation.

Caregiver outcomes have also received relatively little attention. Most studies focused primarily on patient function and postoperative outcomes, whereas caregiver burden, preparedness, self-efficacy, and quality of life were evaluated less frequently.^{12,13,15,16,25,33}

The available evidence was also unevenly distributed across cancer types. Most studies involved colorectal, lung, prostate, or gastrointestinal cancers, whereas evidence for liver, pancreatic, and head and neck cancers remains limited.^11–36

Overall, research on family-involved prehabilitation is still at an early stage of development. Much of the existing literature consists of intervention development, feasibility, qualitative, or implementation studies.^{11,12,15,18,20,24,27,34,36} Further research using mixed-methods designs, pilot or feasibility randomized trials, and multicenter randomized controlled trials is needed to establish both the effectiveness and implementation of family-involved prehabilitation.

Limitations

This review has several limitations. The included studies contributed unequally to the overall synthesis, and the diversity of cancer populations included in the evidence base warrants caution when interpreting and generalizing the findings.

In addition, family-involved prehabilitation remains an emerging area of research, and direct evidence is still limited. Consequently, some of the conclusions drawn in this review were informed by evidence from studies of family involvement in perioperative care, self-management, and digitally delivered prehabilitation, and require confirmation in future empirical research.^{11–13,15,16,18,21,33}

Although this review was conducted in accordance with established methodological guidance to ensure transparency and methodological rigor,^7–10 a formal review protocol was not prospectively registered, which should also be acknowledged as a limitation.

Conclusion

Family-involved prehabilitation for patients undergoing cancer surgery is an emerging area of research with a developing evidence base. Current evidence suggests that family caregivers have the potential to contribute to structured prehabilitation through roles in self-management, remote support, basic care, and health behavior change. Future research should prioritize intervention development, feasibility testing, and rigorous evaluation of the effectiveness of family-involved prehabilitation across different cancer types and cultural contexts.

Disclosure

Professor Chuan You reports Support for the manuscript from Scientific Research Fund Project of Affiliated Hospital of North Sichuan Medical College (No. 2025LC024), Natural Science Foundation Project of Sichuan Province (No. 2026YFTX0002), during the conduct of the study. Professor Jingdong Li reports Support for the manuscript from Scientific Research Fund Project of Affiliated Hospital of North Sichuan Medical College (No. 2025LC024), Natural Science Foundation Project of Sichuan Province (No. 2026YFTX0002), during the conduct of the study.

The authors report no conflicts of interest in this work.