Patients with epithelial ovarian cancer most commonly present when their disease has reached an advanced stage. “While primary cytoreductive surgery is a treatment option for some patients, others will undergo neoadjuvant chemotherapy (NACT) followed by interval cytoreductive surgery,” explains Amanika Kumar, MD. “NACT provides a window of opportunity to mitigate perioperative morbidity in patients who are at highest risk.”

In some fields of medicine, clinicians have used “prehabilitation” strategies—many of which include an exercise component—that aim to improve a patient’s fitness before surgery. “The goal of this approach is to increase resilience and decrease perioperative morbidity,” Dr. Kumar says. “However, little is known about the effectiveness and feasibility of these strategies. It’s important to examine the perceptions of patients regarding physical activity during NACT to determine the feasibility and planning of prehabilitation interventions.”

Examining Patient’s Prehabilitation Perceptions

In a qualitative study published in Gynecologic Oncology Reports, Dr. Kumar and colleagues evaluated how patients with advanced ovarian cancer undergoing NACT viewed exercise and physical activity during treatment. “Specifically, we looked at perceptions relating to barriers, motivators, provider influence, and perceived importance,” Dr. Kumar says. “This information is important as we continue to advance personalized treatment strategies to improve outcomes in ovarian cancer.”

For the study, the investigators identified patients who underwent NACT from 2016 to 2018. Patients underwent semi-structured, one-on-one interviews, and transcripts were reviewed to identify themes relating to the patient experience, function, and exercise during chemotherapy. The average age of study participants was 64, and 47% of cases were triaged to NACT for unresectable disease.

Vast Majority of Patients Willing to Participate in Prehabilitation

According to the study, 73% of patients reported not taking part in structured exercise at baseline, but most participants said they could continue performing activities of daily living. “Even though few exercised prior to or during treatment, 93% of patients reported a willingness to participate in structured exercise during treatment,” says Dr. Kumar. The vast majority indicated that they were willing to participate in walking and strength training, and about one-third said they would participate in yoga or stretching (Table).

“Importantly, the majority of patients said that getting a recommendation from their physician to participate in an exercise program was highly motivating,” says Dr. Kumar. “Other important motivators for participating in an exercise program included improvements in overall health, cancer outcomes, and mental health. In addition, our study showed that cancer- and treatment-related symptoms—fatigue, pain, nausea and vomiting, and respiratory distress—were most often identified by patients as barriers to exercise. Access to care and social and mental barriers were also often cited as barriers to exercise.”

Easing Suffering & Improving Resilience

Although patients in the study reported a variety of barriers to prehabilitation, they also voiced a strong desire to participate in structured exercise to benefit overall health or wellness. “Our findings are important, because many patients are unsure about what they can and cannot do as a result of their disease,” Dr. Kumar says. “As clinicians, we should make every effort to help patients live longer but also ensure that they’re living well. Healthcare professionals can play an active role by encouraging patients to take part in prehabilitation to enhance their quality of life. Those who are unfamiliar with prehabilitation or experience challenges when implementing personalized medicine should consider referring patients with ovarian cancer to high-volume centers.”

The study data provide clinicians with unique insights into the hardship patients face, as well as their motivation to persevere despite these barriers. “Our look into patient perceptions, barriers, and motivation for prehabilitation will be important as future interventions are developed,” says Dr. Kumar. “We need to increase our understanding of the depth of these factors when implementing prehabilitation strategies. Efforts are also needed to personalize prehabilitation using technology alongside clinical care.

Based on this research and other studies from Dr. Kumar and colleagues, the study team has opened a prehabilitation clinical trial for advanced ovarian cancer that will seek to create and understand what interventions will ease the suffering of patients. “Ideally, we want to take a holistic approach to designing prehabilitation strategies to ease the suffering of our patients and improve their resilience,” says Dr. Kumar.