Table 2 Summary of all studies qualitative and quantitative studies meeting eligibility criteria and subsequently used in the present scoping review
Title and year | Country of origin | Aims/purpose | Study population/sample size | Study design/type | Key findings related to the scoping review objectives | Strengths/limitations |
|---|---|---|---|---|---|---|
SOPHIE Trial: Surgery in Ovarian Cancer with PreHabilitation in ERAS* 2021–2024 [23] | Spain | To determine the efficacy of multimodal prehabilitation in decreasing postoperative complications in patients undergoing gynaecological cancer surgery of high complexity | N = 146 advanced ovarian cancer patients N = 73 in each arm | Randomised controlled trial (PROTOCOL) | Planned outcomes: Aerobic activity, physical activity, post-operative complication, length of stay and associated costs | Strengths: large sample size Cost-effectiveness analysis will be undertaken as part of outcomes Limitations: patients excluded if unable to undertake a minimum of 3 weeks prehabilitation prior to surgery. Not highly translatable due to different surgical pathways |
Prehabilitation in patients with advanced stage ovarian cancer planned for interval debulking surgery (PHOCUS) 2020–2022 [24] | Prague | To comprehensively evaluate a trimodal prehabilitation pathway for patients with extensive ovarian cancer | N = 50 advanced ovarian cancer patients N = 25 per arm | Randomised controlled trial (PROTOCOL) | Planned outcome: change in 6MWT** | Strengths: trimodal prehabilitation programme (nutrition, physical activity, and psychology) Limitations: no detailed description of individual components Relatively small sample size (25 per arm) Those undergoing primary debulking surgery are excluded |
Home-based telemonitoring program for functional recovery and symptoms in gastrointestinal, genitourinary or gynecologic cancer patients undergoing abdominal surgery 2021- 2024 [25] | USA | To compare a home-based telemonitoring multimodal prehabilitation programme to standard surgeon only care in improving recovery and stopping complications within 30 days after surgery in patients scheduled for abdominal surgery | N = 332 cancer patients of various tumour groups and disease stages | Randomised controlled trial (PROTOCOL) | Planned outcomes: change in daily step count and post-operative complications. Qualitative study on the prehab programme. Change in sedentary time, sleep and general symptoms | Strengths: study includes multiple tumour groups within gynaecology Entirely remote prehabilitation programme with the opportunity to connect with the treating team face to face if required Limitations: patients only included if they were able to read/understand English and Spanish |
Prehabilitation plus ERAS vs ERAS in gynaecological surgery 2020–2022 [26] | Brazil | To test the effectiveness of a trimodal prehabilitation programme in addition to ERAS compared with ERAS alone in patients undergoing gynaecologic surgery for diagnosed or suspicious gynaecologic malignancies | N = 194 females diagnosed with or suspicion of gynaecologic malignancy | Single blinded (investigator) randomised controlled trial (PROTOCOL) | Planned outcomes: complications, readmissions, intensive care admissions, health related quality of life, compliance to ERAS protocol, changes in anxiety/depression, changes in functional capacity, changes in muscle strength, change in body mass, hospital stay | Strengths: The consultants are blinded to the intervention, but the allied health professionals are not Prehabilitation intervention is as short as 2–3 weeks which is more translatable to patients with short durations between diagnosis and surgery Includes participants with a suspicion of gynaecologic cancer Not limited to ovarian cancer patients |
Connected Prehabilitation program during neo adjuvant chemotherapy 2022–2027 [27] | France | To investigate whether carrying out a connected supervised home based, tailored programme (using activity watches, scales, and a phone application) during NACT*** improves physical fitness and positively improve post-operative outcomes | N = 136 ovarian cancer patients due to undergo NACT | Randomised controlled trial (PROTOCOL) | Planned outcomes: primary outcome: VO2 max$ comparison between arms Secondary outcomes: muscular strength, Hospital depression and anxiety score, cancer related quality of life, nutritional outcomes | Strengths: Entirely remote prehabilitation programme which is tailored to individual requirements based on activity tracking and smart scales Limitations: participants without access to a computer or smartphone will be excluded |
Gyn Onc Prehab Study 2020–2022 [28] | USA | To examine the impact of a trimodal prehabilitation programme with a unimodal programme (physical activity only) | N = 164 ovarian, endometrial and cervical cancer patients | Randomised controlled trial (PROTOCOL) | Planned outcomes: Primary outcomes: Change in 6MWT and grip strength Secondary outcomes: readmission, complication, patient satisfaction, quality of life, treatment completion | Strengths: first trial within gynaecological cancers to compare trimodal prehabilitation with unimodal prehabilitation Limitations: non-English speaking participants are excluded as well as those with a poor performance status. Not representative of gynaecological cancer patients requiring surgery |
PROADAPT- ovary/ EWOC-2 2020–2023 [29] | France | To determine impact of multimodal prehabilitation in patients over 70 years of age | N = 292 advanced ovarian cancer patients over the age of 70 or over 60 years if they have a significant comorbidity | Randomised controlled trial (PROTOCOL) | Planned outcomes: post treatment complication, health related quality of life. Progression free survival over 2 years. Improved 6MWT. Improvements in SF-36^ and overall survival [2 years] | Strengths: based on the logic change model: the rehabilitation model which has been validated by an expert group Standardised geriatric intervention which is being co-constructed on a multi-professional and multi-disciplinary basis that encompasses the period before surgery, immediately after surgery and discharge |
Training-Ovary 01 multicenter randomized study comparing neoadjuvant chemotherapy for patients managed for ovarian cancer with or without a connected prehabilitation programme 2021–2024 [30] | France | To trial whether a connected prehabilitation programme during NACT will improve physical capacity prior to surgery for advanced ovarian cancer patients | 136 patients with advanced ovarian cancer (stage iii-iv) undergoing NACT N = 66 per arm | Randomised controlled trial (PROTOCOL) | Planned outcomes: primary: to determine whether prehab improves physical conditioning prior to surgery compared with baseline. Outcome measure VO2max Secondary: nutritional status, physical fitness, psychological status | Strengths: Follow up period of 5 years Limitations: excludes those without computers and smartphones |
F4S PREHAB Trial Multimodal intensive Prehabilitation in high impact surgery to reduce postoperative complications 2021–2023 [31] | Denmark | Understand the effects of prehabilitation on clinical outcomes, the underlying mechanism and cost efficiency of prehabilitation | Target N = 2380 Multiple tumour groups including ovarian, endometrial, and vulvar scheduled for high impact surgery | Stepped wedge cluster randomised controlled trial (PROTOCOL) | Planned outcomes: Primary outcome: Post-operative complications (Clavien-Dindo Score and Comprehensive complication Index) Secondary outcomes: Individual patient level: Length of stay (days), physical fitness (VO2 max, SQUASH£ questionnaire), nutritional status (body weight, fat free mass PG SGA-SF#), mental health (SF-36 questionnaire), intervention adherence Mechanistic level: Innate immune response Hospital efficiency level: Costs due to complications, costs due to length of stay, cost-effectiveness Macro-economic level: Changes in patient volumes and shifts in care between 2nd and 1st line healthcare | Strengths:large multicentre trial Multiple outcome measures Limitations: excluded people with an inability to read or understand Dutch No description of individual components of prehabilitation |
Impact of a remote Prehabilitation programme in reducing delays to patients having surgery for advanced gynaecological cancer 2021 [32] | UK | To implement a remote prehabilitation programme to improve physical fitness, emotional wellbeing and reduce delays to surgery | N = 25 ovarian cancer patients undergoing 3–6 cycles of NACT prior to surgery Mean age- unknown | Cohort study (ABSTRACT) | Out of 25 patients who enrolled in the prehabilitation programme, 1 patient had surgery delayed due to lack of optimisation In a cohort of 25 people who did not receive prehabilitation, 6 people had a delay in having surgery | Strengths: both groups had similar demographic variables and treatment pathway as per authors Limitations: no sample data available to view Small patient group, single centre trial |
A tertiary centre experience of prehabilitation for surgical ovarian cancer patients receiving neoadjuvant chemotherapy: The Royal Mile- Marsden Integrated Lifestyle and Exercise programme 2019 [33] | UK | To describe the initial experience of establishing a prehabilitation programme for ovarian cancer patients undergoing NACT at a London based tertiary cancer centre | N = 18 patients with advanced ovarian cancer receiving NACT Mean age- 73 years | Cohort study (ABSTRACT) | 18/18 patients received at home exercise advice and nutrition advice from a nurse specialist 9/18 patients had low haemoglobin of which 6 needed intervention 5/18 patients were malnourished and referred for urgent dietetic review with oral nutritional supplementation 3/18 patients were selected to receive hospital-based exercise but all could not attend due to cancer related symptoms and other comorbidities. Another barrier was transport to the hospital Moving forward, the authors propose an entirely home-based exercise programme | Strengths: pilot (first in the centre) Trialled remote and face-face Limitations: small cohort, single centre No outcomes documented in terms of delays or post-op No data on demographics other than age |
Prehab matters- a prehabilitation service for cancer patients undergoing major abdominal surgery 2019 [34] | UK | To report outcomes of a newly introduced prehabilitation service in Liverpool for patients undergoing major abdominal surgery | N = 1/32 gynaecological cancer patient | Cohort study (ABSTRACT) | Of the prehabilitation cohort, 12/32 suffered a complication post-surgery. Median length of stay in hospital was 6 days At 6 weeks follow up, BMI↓ was maintained, quality of life restored to baseline and 6MWT improved from 484 to 539 m Survey: 91% more able to cope with surgery 86% more like to make long term changes 60% said family likely to do the same | Strengths: prospective study so all data collected in real time Limitations: only 1 gynaecologic cancer patient so relevance of results poor Very poor retention. Of 142 patients who enrolled at baseline, only 33 patients attended post-operative follow up No data to compare outcomes from a cohort who did not receive prehabilitation |
Prehabilitation to enhance post-operative recovery for an octogenarian following robotic-assisted hysterectomy with endometrial cancer 2012 [35] | Canada | To describe the impact of a multimodal prehabilitation programme on an 88 year old’s post-operative outcome | N = 1 endometrial cancer patient | Case study | Improvement in 6MWT and SF-36 at 4 and 8 weeks post surgery Self-reported improvement in concentration and mood Marginal improvement in dietary intake but protein and energy intake remained suboptimal | Strengths: one of the studies to highlight the benefit of prehabilitation for gynaecologic cancer patients Limitations: Case study based on the findings of one patient |
Frequency of sarcopenia, sarcopenic obesity and changes in physical function in surgical oncology patients referred for prehabilitation 2021 [36] | USA | To describe the frequency of sarcopenia and sarcopenic obesity in a cohort of cancer patients referred for prehabilitation | N = 7/99 gynaecological cancer patients Mean age- 72 years | Cohort study | 8/99 people did not have surgery due to poor performance status 9% underweight compared with 34% overweight and 27% obese 49% of patients were sarcopenic based on baseline CT scan, of which 28% fulfilled the criteria of being ‘sarcopenic obese’ Of this, 39% were sarcopenic with abnormal sit to stand and grip strength at baseline Baseline: Entire cohort had 6-min walk test, grip strength and × 5 sit to stand measures below normal for age and sex After following 30–90 days of prehabilitation, there was a significant improvement in above measures in both sarcopenic and non-sarcopenic individuals. The prehabilitation time duration did not significantly impact on distance covered in 6-min walk test Sarcopenia did not limit the potential of patients to improve functionally over the pre-operative period. Focus should be on lower limb training and grip strength as they could impact activities of daily living | Strengths: Study provided unique benefit of prehabilitation—improving function in both sarcopenic and non-sarcopenic patients Limitations: Study uses retrospective data No information on nutrition/weight history Evidence based definition of sarcopenia is required for future Difficult to derive direct impact on gynaecologic cancer patients Non-diverse ethnic sample (majority white) |
Implementing prehabilitation as part of enhanced recovery after surgery (ERAS) efforts at a comprehensive cancer centre: A team-based approach 2018 [37] | USA | To utilise validated screening tools to develop a preoperative pathway incorporating prehabilitation for cancer patients preparing for surgery | N = 27 gynaecological and thoracic cancer patients Mean age – 70 years | Cohort study | All participants were approached at least 3 weeks prior to surgery Baseline function of those referred to the prehabilitation programme were below age-related normal values 6-min walk test = 301 m 5- times sit-to-stand = 12.4 s Dynamic gait index score = 20.1 | Strengths: use of validated screening tools to identify patients suitable for prehabilitation Limitations: Of 27 patients referred for prehabilitation, only 21 patients were actually seen for intervention due to scheduling conflicts |
Prehabilitation in cancer care: patient’s ability to prepare for major abdominal surgery 2021 [38] | Denmark | To investigate what patients with abdominal cancer due for surgery were able to do when provided with multimodal prehabilitation recommendations on physical activity, nutrition, psychological wellbeing, smoking cessation, alcohol cessation and preparedness for surgery | N = 30 ovarian cancer patients Mean age- 60 years | Mixed methods: Quantitative- participants were asked to track their progress on a diary using tick boxes and free-text Qualitative- Semi-structured interviews | Greater than 50% patients adhered to over 75% of recommendations on the prehabilitation leaflet provided Exercise significantly increased by 34% in the ovarian cancer group. Preferred exercises were walking and practical activities that helped preparedness. These activities may not necessarily increase heart rate in the way the recommendations had suggested Number of days with activity ranged from 1–18 days Feeling too unwell to participate was a significant barrier for over 60% of patients None of the smokers successfully stopped smoking | Strengths: Mixed methodology provided understanding of adherence to prehabilitation recommendations and follow up with semi-structured interviews shed light on what was acceptable as well as the barriers to participation Limitations: All data was self-reported so there was a risk of over-reporting amongst participants Interview follow-up with was with a limited number of people n = 5, mixed cohort (ovarian and colorectal) The interviewer and participants had previously met and the participants were aware that the interviewer was involved in designing the leaflet No considerations made about how to improve the smoking cessation aspect of the programme |
What matters to you? An investigation of patients’ perspectives on and acceptability of Prehabilitation in major cancer surgery 2021 [39] | Denmark | To understand perspectives on and acceptability of prehabilitation among patients undergoing abdominal cancer surgery by providing them with a leaflet with prehabilitation recommendations around physical activity, nutrition, psychological wellbeing, smoking cessation, alcohol cessation and preparedness for surgery | N = 12 ovarian ca patients | Mixed methods- quantitative and qualitative Cohort study + semi-structured interviews | The preoperative period: Participants expressed readiness and prehabilitation was deemed feasible. Still had to the capacity to ‘act’ despite several pressures they were facing Short time frame between diagnosis and treatment was a major concern. Prehabilitation is less of a priority In the stressful time, doing meaningful things such as meeting friends/family, work and everyday tasks seemed more important ‘Last chance to live normally’ Attitudes towards prehabilitation: Prehabilitation is beneficial but it needs to fit in to their everyday lives. Need a flexible and “tailor” made plan according to physical/environmental context Motivation for action: The need to ‘report’ activity to healthcare professionals was motivating. Also, the ability to choose their activities meant reduced likelihood of failure The need for support: Whilst freedom and flexibility were important, there was a strong need for guidance and close contact with healthcare professionals Suggestion that facility-based programmes would be more successful however most preferred at home-based interventions due to safety and convenience | Strengths: Patients were interviewed following a trial of written advice (not totally naïve) The generalised recommendations in the leaflet allowed participants to tailor their preparation according to themselves and their everyday lives Limitations: the general recommendations could be considered too vague or irrelevant Homogenous and Dutch speaking sample only, which does not represent a wider, more representative population |
Investigating the experiences, thoughts and feelings underlying and influencing prehabilitation among cancer patients: a qualitative perspective on what, when, where, who and why 2020 [40] | Denmark | To investigate thoughts, experiences, feelings of prehabilitation prior to major abdominal surgery by providing participants with a leaflet of recommendations around physical activity, nutrition, psychological wellbeing, smoking cessation, alcohol cessation and preparedness for surgery | N = 7 ovarian cancer patients Median age- 58 years | Mixed methods: Quantitative- participants were asked to track their progress on a diary using tick boxes and free-text Qualitative- Semi-structured interviews | What: Prehabilitation is not the only way to prepare for surgery. Participants would rather prepare for life and death. Meal preparation, house cleaning, laundry, gardening, writing a will, funeral planning, reviewing insurance were examples of prioritised activities When: Pre-operative period considered both ‘too short’ and ‘too long’ Short time considered positive, meaning patients would be on the other side sooner. However, also considered too short to complete all the tasks they need to do. Of which, prehabilitation was not considered a priority. Some felt that prehabilitation should be introduced earlier. Some suggested delaying treatment but all patients eluded to wanting surgery done sooner rather than later Where: Patients appreciated home-based recommendations Physical symptoms e.g., fatigue, nausea, vomiting and diarrhoea easier to manage at home Psychological issues stopping people leaving the house Able to fit around everyday lives, work, home tasks and family life Already spend too much time in hospital with appointments Travelling to and from hospital is time-consuming d based interventions were potentially more motivating with likely greater chances of success and adherence Support from healthcare professionals and other patients would be an opportunity for ‘community’ and social interaction Who: Prehabilitation was considered unsuitable for those who are either too fit or unfit Relatives considered supportive but patients didn’t want to burden them, hence friends and colleagues more crucial support system More involvement by healthcare professionals requested to force, threaten and encourage/motivate patients to be involved. Could lead to some resistance though if felt pushed Why: Having to fill out a prehabilitation diary was motivating and patients felt obligated to do so Motivated by the positive health outcomes of engaging with prehabilitation i.e., strength body, feeling calm and early discharge | Strengths: All opinions surrounding ‘what’ and ‘when’ and ‘who and ‘why’ were based on real experience with the leaflet Limitations: Relatively young population- not translatable to elderly but highlights issues that even younger patients experience All opinions on ‘where’ were hypothetical |
Advanced ovarian cancer patients identify opportunities for Prehabilitation: A qualitative study 2021 [41] | USA | Investigate potential barriers and facilitators of engaging with prehabilitation during neoadjuvant chemotherapy | N = 15 advanced ovarian cancer patients Mean age -64 years All received chemotherapy over 6–8 cycles | Qualitative – In depth interviews | Physical activity during neoadjuvant chemotherapy: 11/15 participants reported not taking part in structured exercise during chemotherapy at baseline. 14/15 reported continuing activities of daily living 93% of participants were willing to take part in structured exercise during chemotherapy even if they had not done so prior to diagnosis 3–7 days per week, 15-30 min per day of walking, strength training, yoga/stretching was considered acceptable Barriers to structured physical activity: Physical symptoms e.g., fatigue, difficulty breathing, abdominal pain/distension (cancer related), nausea and vomiting, neuropathy, and bone pain (treatment related) Access/social barriers: Distance from home, money, time, needing to work full time Psychosocial barriers: Disengagement with society- feeling low, baldness, not going to the shops to buy groceries Motivators to structured physical activity: The perception of improved overall health and wellbeing i.e., physical and mental. Ability to engage with grandchildren Improvement in cancer related outcomes i.e., surgical outcomes and prognosis Influence of community and providers: support system to encourage and motivate exercise, instructions by healthcare professionals | Strengths: Specific to barriers and facilitators to functional optimisation prior to surgery were highlighted through in depth, rich data from interviews Limitations: Non-diverse cohort (homogenous for race, ethnicity, socio-economic status and language) Prehabilitation naïve and not given information prior to being interviewed No information on education status/employment or living situation |
PRE-surgery thoughts- thoughts on prehabilitation in oncologic gynaecologic surgery, a qualitative template analysis in older adults and their healthcare professionals 2021 [42] | The Netherlands | To investigate possible content and indications for prehabilitation and potential barriers amongst gynaecologic cancer patients and their healthcare professionals | N = 16 patients with a high risk of gynaecologic malignancy Mean age- 70 years N = 20 multidisciplinary professionals- clinical nurse specialist, oncologists, surgeons, allied health professionals | Qualitative -Semi-structured interviews | Thoughts on prehabilitation: Overall positive reaction towards prehabilitation. Patients assumed a positive benefit whilst professionals felt the need to ensure it was evidence based Facilitators: Motivational reasons: Urgency, sense of control, self-efficacy, doing something positive Motivational support: Patients appreciated support through activity trackers, pedometers, and diaries. Human support from family/friends, community and professionals considered crucial too Practical facilitators: Prehabilitation should be part of a routine and encouraged by a motivated and dedicated team Barriers: Patient: Stress (too many appointments), physical condition, lack of knowledge, limited access to digital resources, language barrier Patient practical factors: Travelling to hospital for prehabilitation, time between diagnosis/surgery (as little as 1 week) and negativity surrounding postponement Organisational practical factors: Financial implications, lack of capacity, too much on the gynaecologist, lack of evidence base, lack of knowledge, lack of coordination Suggested model: Screening to be carried out by a physician assistant or nurse specialist. If fit for surgery, then general advice. If not, then referred to specific advice or referral to the multidisciplinary team with nursing support throughout being pivotal to success | Strengths: Convenience sampling followed by purposive sampling for diversity in age, educational level, diagnosis, and physical condition for patients Variety of professionals from multidisciplinary team (except psychologists) from district general and teaching hospitals Interviewer had extensive experience in qualitative research Limitations Patients only provided with a brief of prehabiliation and did not undergo the intervention themselves. Therefore, all answers relating to prehabilitation directly are hypothetical |
Enhanced recovery after gynaecological/oncological surgeries: Current status in India 2020 [43] | India | Establish peri-operative practices performed by several gynaecological and oncological surgeons in India | N = 100 responses: N = 83 surgical oncologists N = 17 gynaecological Oncologists across 59 different institutions in India | Online cross-sectional survey | 100% of respondents educated patients with pre-admission information and counselling prior to surgery 60% educated patients through oral and written communication 37% oral communication only 98% advised prehabilitation Of which 71% advised trimodal approaches 15% advised nutrition only, 12% exercise only and 1% anxiety only 53% advised starting prehabilitation at the time of planning surgery and 42% earlier at the first outpatient department | Strengths: Relatively large number of respondents, multi-site and across specialties Limitations: Limited description of the prehabilitation programmes which are recommended or provided and the respective outcomes Survey was limited to gynaecological and surgical oncologists with no input from the multidisciplinary team |
Enhanced recovery after surgery (ERAS) in cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC): A cross-sectional survey 2021 [44] | India | To capture clinicians’ practices about ERAS (including prehabilitation) in patients undergoing CRS or HIPEC | N = 136 Surgical oncologists, anaesthesiologists, gynaecological oncologists and intensivists | Online cross-sectional survey | The respondents recommend/practice the following: Perform incentive spirometry and corrected anaemia- 94% Smoking cessation- 82% Review alcohol consumption- 80% Encouraged exercise- 76% Recommend immunonutrition- 24% Psychological component considered a ‘non-essential’ part of the working ERAS protocol within prehabilitation | Strengths: Insight in to practices amongst clinicians working across India and specialties Limitations: Did not include programmes or description of facilities available to support Lack of allied health professional involvement |
Prehabilitation for medically frail patients undergoing surgery for epithelial ovarian cancer: a cost effectiveness analysis 2021 [45] | USA | To assess potential cost-effectiveness of prehabilitation in patients undergoing surgery for ovarian cancer Based on the hypothesis that nutrition, functional status, medical co-morbidities, mental health, and social situation all impact frailty Frailty is a key contributor to post-operative complications, increasing length of stay, increased non-home discharges and discharge to care facilities | N = 4415 women with ovarian cancer Estimated based on figures at 66–80% of 22,530 patients diagnosed undergo PDS. Of which 24% are frail according to Mayo clinic. Produces approx. 4,400 patients | Cost-effectiveness analysis | For a cohort of 4415 women: Usual care costs $404.9 million whilst prehabilitation is cost saving at $371.1 million Per patient, cost saving = $9,418 Tornado analysis found that the greatest contributors to the Incremental Cost Effectiveness Ratio of 100,000 dollars per life per year were as follows: -90- day mortality after complication with usual care (0.97) -90-day mortality after complication in those receiving prehab (0.31) -Surgical complication after prehab (0.33) -Surgical complication after usual care (0.21) | Strengths: Only cost-effectiveness analysis in the ovarian cancer cohort Limitations: Theoretical model based on model inputs (limited by their individual precision)- requirements for larger and more prospective trials Cost effectiveness based on care and nursing home residence in Ohio |
Role and Impact of multimodal prehabilitation for gynaecologic oncology patients in an Enhanced Recovery After Surgery (ERAS) programme 2019 [46] | Spain | To review the literature surrounding prehabilitation for gynaecological cancer patients and accordingly suggest a safe and reproducible multimodal prehabilitation model for gynaecologic cancer patients that can be tested in various centres | N/a | Review and proposal of a multimodal prehab model based on current literature | 3 evaluation time-points: -Baseline: 2–4 weeks prior to surgery (screening and referrals) -Pre-operative: 1 week prior to surgery -Post- operative: 8 weeks All participants to record on diary which will evidence compliance All participants fill out SF-12• at each time point Baseline assessment to be carried out thoroughly by consultant and anaesthetist Medical optimisation: Identify and manage comorbidities, stop tobacco and alcohol consumption, hospital pulmonary programme, anaemia- iron correction, frailty- referral to geriatrician, poor social situation- referral to social assistant Physical Activity: 6MWT and VO2 max is calculated. If VO2 max < 12, patient undergoes supervised physiotherapy programme If VO2 max > 12 given home based exercises with aerobic, flexibility and respiratory training Everyone advised inspiratory exercises 10 min every 8 h and mobilisation in hospital as soon as possible Nutritional Intervention: MUST¥ screening and albumin If MUST < 2 general advice to increase calories. MUST > 2 and albumin < 3, patient gets an individual dietary plan and oral nutritional supplements. Everyone is given a recipe book for protein shakes and meal planning Feeding is commenced as soon as possible post-operatively Psychological Intervention: Assess through HADS≠ (total score 21). Score < 7 advised general relaxation and breathing exercises 20 min prior to lunch and dinner. Score > 7 Referral to psychologist. Everyone encouraged to attend free mindfulness session once/week | Strengths: Produced a rigid and descriptive model with time points, treatment pathways and outcome measures Limitations: Fully hypothesised programme based on theoretical evidence Yet to have published outcomes from a trial of this model |