The aims of this cohort study were to report the impact of delivery of a novel method of prehabilitation services to cancer patients and, more specifically, issues related to technology and patients’ experience. The main results showed that telehealth interventions were well received by patients, allowing for greater flexibility in clinical scheduling and exercise interventions. However, challenges remain in its seamless implementation. Notably, hurdles to overcome include the adoption of the technologies by patients and the multidisciplinary team, the difficulty of acquiring accurate data on patient physical activity, and the initial costs of acquiring the new technologies. The patients’ experience also highlighted two aspects of the program: the appreciation for services and the support received and the user-friendliness of the technological system provided.
Addressing the literature gaps
Telehealth has experienced rapid growth since the COVID-19 pandemic (6,9), enhancing its utility for diverse clinical applications. (17). Nevertheless, the literature is lacking with respect to the context of interventions and the clinical populations, more specifically with regard to acute care and elderly patients. Even further, there is a lack of consensus in the literature concerning the optimal technological systems for the successful delivery of teleprehabilitation (9). Two technological approaches have been proposed to overcome technology adoption barriers: 1. readily accessible technologies and 2. combining activity monitoring devices with a secure videoconferencing platform. In the context of the present study, most of the patients were older and had limited access to technologies and the internet.
The Program
Teleprehabilitation is a novel concept, even more so in high-risk surgical cancer patients, prompting the need for increased documentation of its implementation in clinical practice. Two other studies notably documented their delivery of teleprehabilitation programs in this population, both of which were pilot studies with bimodal (exercise and nutrition (18)) and unimodal (exercise-only (19)) interventions. The first study by Bruns et al. provided prehabilitation to frail elderly cancer surgery candidates through a home-based electronic prototype that was created solely for this purpose(18), while the other study by Piraux et al. used a virtual exercise prescription application and an exercise monitoring watch for esophageal cancer patients (19). The exercise interventions in both studies were significantly different (daily 7-minute prerecorded exercise videos and nutritional recommendations (18) vs three sessions weekly, including a 30-minute aerobic, a 30-minute resistance and an IMT training component (19)). Nonetheless, both studies included a weekly phone call to assess adherence (18) (19). Bruns et al. acknowledged that although self-reported adherence was high, the lack of supervision may lead to lower-quality execution and prevent individualization of interventions (18,20). Furthermore, Piraux et al. identified that the application interface may not be suitable for patients with lower technological literacy. Nevertheless, patients reported a high overall level of satisfaction with the teleprehabilitation program, and the authors discussed the added value of reducing transportation burden on patients’ schedules (12,13,21).
In relation to the literature, the current findings reinforce the importance of the appropriate selection of technologies with regard to the simplicity of use (i.e., user-friendly interface) and the possibility of supervising interventions remotely (9). In all studies, patients were satisfied and comfortable with the technologies, with few patients experiencing minor technical difficulties. Distinctly, the current study included synchronous exercise counseling, which was mentioned to be a limitation of the Fit4SurgeryTV program (18). Increased supervision has been shown to yield greater adherence rates and improvements in health and functional outcomes (20). The latter may be attributed in part to increased attention from clinicians who can ensure that patients properly adhere to the exercises prescribed, attaining the appropriate intensity and duration, while applying the necessary modifications and progressions, which aligned with the findings of the current study.
Another novelty of the study was the acquisition of a large variety of exercise metrics from the physical activity watch. Prior to the study, most home-based interventions were reliant on patients’ capacity to self-assess their compliance with the programs (22). Physical activity monitoring devices provide clinicians with important insight into physical activity levels, and unlike phone calls, they offer a more quantitative perspective of movement patterns and behaviours on a day-to-day basis. The technologies create a communication portal between patients and their clinicians, allowing them to better appreciate the patient’s overall exercise volume (i.e., frequency, intensity, time, type). This increased access to information may be helpful in view of adapting and progressing the prescription throughout the preoperative period according to patients’ capacities; however, it brings forth a new challenge for the scientific community to properly quantify and interpret adherence to the program.
Patient’s Experience
The high satisfaction reported in the current study aligns with many telehealth-based interventions in the perioperative field (13,18,19,21). Notably, a telerehabilitation by Kairy et al. aimed to document solely the patient’s perspective of a telerehabilitation program after hip arthroplasty through interviews (13). In both studies, patients emphasized their appreciation for the technology’s ease of use and the reduced need for hospital commutes. Moreover, patients in this retrospective cohort reported a sense of accomplishment in being able to positively impact their respective care trajectories.
Limitations
While this study showed great clinical potential for the implementation of teleprehabilitation, it is not without its limitations, notably related to its design, evaluations, and interventions. First, due to the design based on the need to describe the methodology, this is an exploratory study with a small cohort with diverse demographics, cancer types, pathologies, and disease management approaches. As such, the data documented in the functional and clinical trajectories section should be seen as contextual information, not presented to draw conclusions. Second, given that some patients were unable to visit the prehabilitation clinic, clinicians performed evaluations in surgical clinics or inpatient units. The latter leads to a minimal functional and demographic assessment, as the exercise physiologist cannot always access the material or space to conduct all tests. Furthermore, several patients did not attend follow-up health assessments due to concerns pertaining to commuting, COVID-19 or conflicts with other medical appointments. Last, a major limitation of the described services lies in the fact that videoconferencing interventions were conducted uniquely by exercise physiologists. Not all the members of the multidisciplinary team were trained or equipped to deliver their services using the new technologies. Future studies should investigate the feasibility and impact of videoconferencing multimodal interventions beyond the scope of exercise.