Prehab4Cancer

Dr John Moore Prehab4Cancer Clinical Director

Manchester Foundation Hospital

University of Manchester

THE TEAM

PREHAB:

PHYSICAL ACTIVITY

NUTRITION

WELL-BEING

SMOKING

MEDICAL OPTIMISATION

@GMCEducation I #GMCHeadAndNeck2019

Associated with

Poorer chemo response

More post-op complications

Worse outcomes

Increased muscle apoptosis and reduced regeneration

Sarcopenia

@GMCEducation I #GMCHeadAndNeck2019

COMMUNITY BASED PREHAB

Service level agreement – agreed

KPIs

Gym – healthcare team developed

80+ facilities

14 evaluation centres

GM Cancer Prehab and Rehab

Cancer Surgery Phase 1

15 Evaluation clinics

PREHAB

01

REHAB PREHAB

90 day hospital

length of stay

2 year mortality

MD

T d

ecisio

n to

operate

Combination of HIT and Strength

CVS aiming for High intensity

MUSCLE strengthening

Progressive programme

Aiming for 3x week

PREHAB

Supervised

programme

Universal

programme

6MWT

<400m

GM Cancer Prehab - Nutrition

Nutrition advice delivered through community

Supported by specialist dieticians

Weight monitoring during programme wth

safeguards

Move to exercise recovery nutritional

supplementation at gyms

Psychosocial

Support

HOLISTIC NEEDS

ASSESSMENT &

STEPPED CARE MODEL

(NICE 2009)

Level Group Assessment Intervention

1

All the health and social care

professionals

Recognition of

psychological

needs

Effective

information giving

compassionate

communication and

general

psychological

support.

Solution focused.

2

Health and social care

professionals with additional

expertise

Screening for

psychological

distress

Psychological

techniques such as

problem solving,

fatigue

management etc.

3

Trained and accredited

professional

Assessed for

psychological

distress and

diagnosis of some

psychopathology

Counselling and

specific

psychological

interventions such

as anxiety

management and

solution-focused

therapy, delivered

according to explicit

theoretical

framework

4

Mental health specialists Diagnosis of

psychopathology

Specialist

psychological and

psychiatric

interventions such

as psychotherapy,

including cognitive

behavioural therapy

(CBT

Outcome

Measures

Expected

Benefits

Physiological

• Dynamic Test 6MWT/ISWT/CPET

• Height & Weight (BMI)

• Heart rate/BP

• Resistance

• Grip Strength

Patient Reported Outcome Measures • EQ-5D (QOL)

• EORTC QLQ-C30 (cancer specific)

• WHODAS 2.0 (Disability)

• IPAQ-SF (Physical Activity)

• Self-Efficacy Exercise Scale (SEE)

Patient Outcomes

• Complications

• LOS/Mortailty/90 day hospital free period

• Long-term survival

Prehab & Recovery Programme

Sept

2018

Jan

2019

Apr

2019

Sept

2019

Jun

2020

Aug

2020

LAUNCH

Service Design

Referral process

User involvement

MDT visits

GM Active SLA

Prehab4Cancer core team / local teams recruitment &

upskilling

Preparation

Jan - April 2019

Full service delivery

Ongoing evaluation / data collection / research

Digital platform incorporated

Delivery Phase

Sept – Aug 2020

Stakeholder engagement – patient engagement

Understanding the evidence base

Scoping

Sept – Dec 2018

Service delivery

Colorectal, Lung & Upper GI surgical cohorts

Monthly performance review meetings

Confirm digital platform, evaluation & ethics approval

Further stakeholder engagement

Chemo / Rad & other tumour groups

Pilot Phase

April – Aug 2019

Data analysis

Business case

Agree sustainability & evolution of project / service

Revise GM Active service delivery & financial model

Sustainability Phase

Sept – Dec 2018

Version 1

Project Timeline

GM Cancer Prehab and Rehab

Surgery Phase – launches 25th April ‘19

600 patients referred to programme

Upper GI, Lung, Colorectal

>80% attending - Initial results suggest we can improve fitness

Planning H and Neck and Transformation 2

GM Cancer

Head and Neck Chemo/Dxt

PREHAB

01

REHAB MULIT-MODAL PREHAB

PROMS

Completion of

treatment

2 year mortality

MD

T d

ecisio

n to

operate

Primary Care

Cancer Surgical Pathway

PREHAB 01

2 year survival

MD

T d

ecisio

n to

operate

Public Health

95% 5%

DIGITAL DIGITAL 10 year survival

Prevent CVS

events and

cancer

2 w

eek w

ait

Prehab4Cancer

Kirsty Rowlinson-Groves Prehab4Cancer Programme Manager

Specialist for Manchester

Team Structure

Kirsty

Rowlinson-Groves

Programme Manager

Manchester

Nathan Valentine

Administrator

Jack Murphy

Salford & Trafford

Rob Mentha

Wigan, Stockport &

Tameside

Karly Baguley

Bolton & Bury

Sarah-Jayne Hurst

Oldham, Rochdale &

Tameside

prehab.4cancer@nhs.net

GM Active Structure & Staff Development

is a collective of 12 leisure and community organisations from

across Greater Manchester that are all part of the same movement, to get more

people physically active. The group accounts for 87 leisure and sports facilities

across the region which are available for the Prehab4Cancer team to deliver

sessions in. • Each specialist is supported by local instructors

• Huge piece of development work across GM Active to upskill and standardise

training

• Our Local instructors are minimum L3 and will shadow specialist in clinics and

sessions

• GM Active have just hosted a L4 Cancer Rehab course, L4 Pulmonary Rehab

course to upskill instructors

• CPD opportunities held with GM Cancer to upskill locality staff via event days

and training days with guest speakers

Service Model

Prehab up to 12 weeks Rehab 12 weeks

Lung

Colorectal

Upper

GI

Supervised • 3 monitored sessions

per week

• Intensity/Duration/Mode

prescribed by specialist

Universal • 1-1 session with

specialist to prescribe

exercise programme

• Weekly progress

updates

• Independent exercise at

local leisure centre

S

U

R

G

E

R

Y

B

R

E

A K

Post Surgery update

• Contact 4 – 6 weeks post

• Establish plan of action for

commencing rehab with Post

Op Assessment

Patient centred Rehab

• 12 week pass to local gym

• Prescribed exercise

programme and supported

sessions with specialist

• Signposted to local

community activities to

promote long term exercise

adherence and improvement

of health

• Positive exit strategy

A

S

S

E

S

S

M

E

N

T

Assessment Clinic Overview

Referral

Portal 48 Hr Contact

Baseline

Assessment 4 working

days

Post

Chemo

Upper GI only

Pre-Op

Assessment Within 5 days

Post-Op

Assessment 6,8,12 weeks

End of

Rehab

12 Week

intervention

Health checks

• Blood pressure

• Height

• Weight

• Resting HR

• Oxygen stats

Functional Capacity

• ISWT or 6 Min

Walk

• Hand Grip

Dynamometry

• 1 Minute Sit to

stand

Questionnaires

• EQ5D-5L

• IPAQ

• Self Efficacy Scale

• Rockwood Frailty

• WHODAS 2.0

• EORTCQLQ-C30

Each borough of Greater

Manchester hosts 1-3

assessment clinics based

on population make up

and referral numbers

Exercise sessions can

take place in one of the

80+ GM active leisure

centres

Assessment Clinics

Within 5 miles of

residential postcode

but we also host Adhoc

sessions where needed

17 Assessment

Clinics set up and

running across

Greater

Manchester

Assessment Locations

Exercise Prescription

Re-HIIT

• Interval type exercise

• Work : Active

Recovery

• RPE & HR monitoring

• MSE combat

sarcopenia

• 3x weekly sessions

Progressive/Continuous

• Steady State CV

• Progressing intensity

based on HR & RPE

• MSE combat

sarcopenia

• 3x weekly sessions

The screening process

during the assessment

clinic determines the

exercise format and

prescription, taking into

account associated

comorbidities and

potential risk factors

Re-HIIT Progressive

Continuous

• Specialists and referrer’s are able to communicate quickly and easily

• Reports presented at the Clinical Subgroup meetings

• Specialists have attended Subgroup meetings in local hospitals

• Issues raised or concerns fed back to clinical team

• Nutrition database with ‘red flag’ system integrated to monitor patients weight and refer to dieticians

Link between Team and Clinicians

Patient Testimonials

“I have really felt

an improvement in

my fitness”

“I have really enjoyed the

exercises and never

thought I would.

I thought I’d be unable to

do most things but the

instructor took time to make

the exercises suit me but

also push me. I can tell

things are getting better as

I feel less aches and pains.

After a session I feel really

energised!”

“Having the support of the

instructors has been great.

They have really helped

me relax and feel less

stressed out”

“The prehab exercise has been fantastic. It

has built up my confidence and fitness.

The instructor has been wonderful, has

answered my questions on so many

different aspects of my fitness and

reassured me. Thank you so much and I

am looking forward to my rehab sessions”

“The staff have been

amazing. They really

make the exercise

challenging but fun”

Julie P4C Participant

QUESTIONS &

ANSWERS

Interactive Poll: Mr Smith (PABC 1)

Mr Smith is a 68 year old diagnosed with colorectal cancer,

planned for surgery. He runs once a week and enjoys

walking. He had a Cardio Pulmonary Exercise Test (CPET)

with an Anesthetist and was found to have a good level of

fitness.

Would you still refer him to the Prehab4Cancer programme?

YES – I WOULD REFER HIM

NO – I WOULD NOT REFER HIM

Interactive Poll: Mrs Jones (PABC 2)

Mrs Jones has been diagnosed with lung cancer. She was

originally told she was going to have surgery but her treatment

plan has changed and she will now have radiotherapy instead.

She has already been referred to the Prehab4Cancer programme.

Should she still engage in exercise and other interventions via

the Prehab4Cancer programme?

YES – SHE SHOULD STILL ATTEND

NO – SHE NO LONGER NEEDS TO ATTEND

Interactive Poll: Mr Patel (PABC 3)

Mr Smith is an 85 year old diagnosed with oesphago-gastric

cancer, planned for surgery. He has severe osteoarthritis in

his knees, which has led to him to have poor mobility and

sometimes need to use a wheelchair.

Would you still refer him to the Prehab4Cancer programme?

YES – I WOULD REFER HIM

NO – I WOULD NOT REFER HIM

Interactive Poll: Ms Davis (PABC 4)

Ms Davis is a 65 year old diagnosed with lung cancer,

planned for surgery. She has been smoking for 20 years. She

is participating in the Prehab4Cancer programme. Her

specialist instructor has contacted her GP to request

smoking cessation advice.

What would you expect the response from her GP to be?

YES - I will refer her to local smoking cessation services.

NO – She has been unable to quit smoking for a long time and

it is too late to make any difference.