"Really? You want me to go to the gym?"
That's what Randall Brown thought when the surgeon who would operate on his pancreatic cancer recommended that he meet with a trainer and start exercising before the surgery.
Brown, a 68-year-old resident of Houston, had worked in the oil fields his whole life. With such a physical job, he never went to a gym. And he was skeptical about starting to work out now, with a cancer diagnosis.
"But I thought, you know, my doctor knows a lot more than I do, so I will do what she says," Brown says. "I'm sure glad I did. It was one of the best decisions I ever made."
Like Brown, working on your fitness probably isn't at the top of your mind when you find out that you have cancer. There's already plenty to do, like finding out what stage it is, considering treatment options, and sharing the news with your loved ones.
But maybe it should be on your radar.
Here's why: For some people with cancer, there is a window of opportunity before starting treatment when improving your physical fitness matters.
It's called cancer prehabilitation, or prehab, and it helps prepare you for surgery or treatments like chemotherapy, radiation, and stem cell transplants. It's becoming more common – but it's not standard yet, and it's not for every person with cancer. Is this type of pre-treatment training right for you?
What Is Cancer Prehab?
Most people know about physical rehabilitation, the process of healing and regaining function after an injury or surgery. Prehab, on the other hand, happensbefore surgery or treatment, to prep your body and mind for what's to come. It's common in areas of health care like sports medicine and cardiac care.
Within the last 10 to 15 years, prehab has gained more traction in the field of cancer care. Research shows that if someone with cancer is weaker or has trouble doing daily activities, they're at a higher risk of complications both during and after surgery, such as a longer stay at the hospital, needing to go on a ventilator, or blood clots.
"Prehab is an exercise intervention or a nutrition intervention that aims to prepare a patient for an upcoming medical procedure such as surgery or chemotherapy," says Jessica Scott, PhD, an associate member in the exercise oncology program at Memorial Sloan Kettering.
While these procedures and treatments are effective, and even life-saving, they can take atoll on the body. In some cases, the side effects are crippling.
By optimizing your strength and fitness beforehand, you build up a greater physiological reserve to help you handle the stress of the surgery or other treatment and, ultimately, to recover better.
Benefits of Cancer Prehab
Exercise offers many benefits for people with cancer. It can improve cancer-related fatigue, quality of life, physical function, mood, bone health, and tissue swelling, according to the American College of Sports Medicine.
One study checked on patients who were getting treatments such as chemotherapy or chemoradiation to shrink a tumor before surgery. Some of them also took part in an at-home cancer prehab exercise program. Those patients kept up their muscle mass. Others, who weren't doing the prehab training program, lost muscle mass. An Ngo-Huang, DO, a physical medicine and rehabilitation doctor at the University of Texas MD Anderson Cancer Center, and colleagues reported their findings in Integrative Cancer Therapies.
"If patients can at least maintain muscle mass, it places them at less risk for de-conditioning and other functional declines so they can recover from surgery more quickly," Ngo-Huang says.
Being in better physical shape may also shorten your stay in a hospital after an operation. For example, people who took part in a prehab program before surgery for gastrointestinal cancer stayed in the hospital, on average, seven days less than those who didn't do prehab. There can be fewer complications, too. A recent clinical trial found that the risk of complications 30 days after surgery was more than 40% lower among high-risk patients who did prehab before elective colorectal surgery.
Prehab may also affect tumor activity, according to a preliminary study from Memorial Sloan Kettering of men with prostate cancer showed tha. "This is one of the first studies to show that there's potential benefit for controlling tumors as well," Scott says.
Who Is Cancer Prehab Best For?
Scott says that prehab can be good for anyone, but most research has focused on cancers that have a higher risk of complications or whose treatment may be crippling. That includes gastrointestinal cancers, lung cancer, and blood cancers.
At MD Anderson Cancer Center, Ngo-Huang says her team sees people with gastrointestinal cancers like pancreatic cancer or cholangiocarcinoma, a cancer of the bile duct. "These patients are at risk for losing weight and muscle mass, malnutrition, and complications like peripheral neuropathy, which might place them at risk for falls, so our oncologists and surgeons will send patients to us first," she says.
Studies show that among people newly diagnosed with pancreatic cancer, more than 50% had low muscle mass and about 25% were frail – which is linked to a greater chance of complications.
Prehab can also benefit people with breast cancer – not only to prep you for surgery, but to make sure you're ready for radiation afterward, too.
"A woman might need prehab not just because she's a little more sedentary but because she has a frozen shoulder. After surgery, can she lie in the radiation machine with her arm up?" Ngo-Huang says. "Our colleagues are thinking ahead."
When Should You Prehab?
If your doctor thinks that prehab exercise training would help, it might not take a lot of time to start to make a difference.
"Research has shown that it can be as short as seven days up to nine weeks," Scott says. "It really depends on the interval between diagnosis and the next medical procedure, whether that's surgery or starting chemotherapy."
For example, for patients getting chemotherapy, there's usually a shorter time window for prehab, since the medical team will typically want to start treatment soon after diagnosis.
With surgery, there may be a longer period of time between diagnosis and your procedure when you can start an exercise program. You can prehab for surgery even if you get chemotherapy to shrink your tumor before surgery.
If you're going to get a stem cell transplant or CART-cell therapy, you may be able to take advantage of the time while your medical team looks for a bone marrow donor or while your Tcells are prepped for treatment, respectively.
One month before a procedure is a good amount of time, Ngo-Huang says, because it gives you enough time to commit to the prehab program and make progress. But consult with your doctor and don't delay your treatment.
What to Expect in Cancer Prehab
Prehab programs can vary among medical centers, and your team may consist of physical therapists or doctors, like physical medicine and rehabilitation specialists.
At MD Anderson, Ngo-Huang tells her prehab patients that the program typically involves three to four visits. It begins with an evaluation that looks at your body makeup – particularly, your muscle mass – whether you're getting enough nutrients, and how you do on a few basic tests, like a six-minute walk test to check your exercise capacity, a sit-to-stand test to gauge your legs' stamina, and a handgrip test. They'll also look for any symptoms that might get in your way. "We may manage pain by prescribing medication, or I might prescribe a brace if they have back pain," Ngo-Huang says.
Then the team develops a program tailored for you, keeping in mind the stage of your cancer and any other things such as neck or shoulder pain or nerve and muscle conditions. The prehab team teaches you how to do exercises with resistance bands or refers you to exercise videos. You do the moves at home and typically return before surgery or treatment and afterward to ensure that you're recovering well.
At Memorial Sloan Kettering, the exercise oncology team runs structured exercise programs for cancer patients across the range of care. They'll even deliver treadmills to a patient's home with an exercise scientist supervising training remotely. It's like a Zoom call where the trainer can modify the exercise session based on how the patient feels that day.
Brown's doctors at MD Anderson set him up with the prehabilitation team. His treatment plan called for chemotherapy and radiation before surgery. During that time, Brown met with Tyler, his physical therapist, remotely twice a week for an hour. Guided by Tyler, Brown did a variety of exercises using a resistance band. He also started jogging, working up to three miles. He even showed off his leg muscles to friends, saying he'd never been healthier in his life. In all, Brown and Tyler completed over 50 hour-long sessions together.
How to Get Started
Before starting a new exercise program, be sure to get your doctor's OK.
"The current guidelines recommend 30 minutes of moderate-intensity aerobic activity, five times a week," Scott says. "If you're already at that level, you can keep going." Strength or resistance training is also recommended twice a week.
If you're not active now, start with a little bit of aerobic activity each day, like a walk around the block, and gradually do more. As you start to build your fitness, you can add resistance training.
If you're looking for a supervised exercise program, Scott recommends looking for a fitness professional who, for example, is certified by the American College of Sports Medicine as a cancer exercise specialist. The YMCA also offers a program in partnership with the Livestrong Foundation for patients with cancer. Programs like Silver Sneakers also offer accessible fitness programs.
"Exercise can be a powerful medicine. You don't need to be an Ironman triathlete to get benefits. It's never too late to start," Scott says.
"I would not have survived that surgery had it not been for the physical training we did. There's no doubt in my mind it's a big part of why I'm here right now," Brown says.
