The inequalities and challenges of prehabilitation before cancer surgery: a narrative review

Introduction: Prehabilitation seeks to enhance functional capacity and preparedness before surgery with the aim of improving outcomes; it is generally based on exercise, diet and psychological interventions. While there is obvious appeal to this approach in terms of patient experience and resource use, the interventions are complex and the evidence base for prehabilitation before cancer surgery is heterogeneous. Prehabilitation requires patient understanding and motivation as well as commitment of resources. Programmes are challenging to design and implement, and can generate 'intervention-based inequalities' based on the capacity of patients to engage. We present a narrative review on the inequalities and challenges of prehabilitation before cancer surgery.

Methods: We searched databases of peer-reviewed research to identify appropriate articles. We used the results in combination with iterative searches based on citation tracking, grey literature (e.g. patient information resources) and articles from personal libraries, to develop our discussion.

Results: We describe the uncertainties in the evidence base for prehabilitation before cancer surgery, and the challenges and barriers for healthcare providers, systems and patients. Key findings include that prehabilitation is under-researched in many cancers and that people with lower health literacy, from minority ethnic groups and socio-economically disadvantaged backgrounds, are less likely to engage, despite often having worse peri-operative outcomes.

Discussion: Prehabilitation must be implemented carefully to avoid widening inequalities. More research is needed, both in terms of the impact of interventions and to understand how prehabilitation should account for the social determinants of health.