Improving Outcomes In Cancer Patients With A Nutritional And Physical Conditioning Prehabilitation Program

Study Overview

Improving Outcomes in Cancer Patients With a Nutritional and Physical Conditioning Prehabilitation Program

Major surgery is a stressful procedure; good recovery after surgery is important to patients and their doctors. Studies done at the McGill University Health Centre (MUHC) with cancer patients awaiting surgery have shown that exercise combined with simple diet recommendations (which may include a supplement) and relaxation techniques before surgery helped speed up the ability to resume walking after surgery. These results have made the investigators aware that exercise and good nutrition are as important before surgery as they are after surgery; while it is common practice to start strengthening the body after surgery (rehabilitation), there may be some advantage to begin this process before surgery (prehabilitation). The purpose of this study is to see if the following program, either before or after surgery, can help patients recover from liver, pancreas or bile duct surgery: 1. Exercise that may help participants move and breath better, 2. Nutrition advice and a supplement to make participants strong, 3. Relaxation and anti-anxiety tips to help cope with the stress of upcoming surgery The investigators will see if following this program will have an effect on participants' ability to walk before and after surgery.

N/A

Pancreatic Cancer
Liver Cancer
Bile Duct Cancer
Hepatobiliary Cancer
Surgery

OTHER: Exercise
OTHER: Nutrition
BEHAVIORAL: Relaxation techniques

prehab_pilot

Study Record Dates

These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.

Study Registration Dates	Results Reporting Dates	Study Record Updates
First Submitted 2017-02-28	Results First Submitted N/A	Last Update Submitted that met QC Criteria 2020-12-06
First Submitted that Met QC Criteria 2018-03-16	Results First Submitted that Met QC Criteria N/A	Last Update Posted (ACTUAL) 2020-12-08
First Posted (ACTUAL) 2018-03-23	Results First Posted N/A	Last Verified 2020-12

Study Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

Design Details

Primary Purpose:
Supportive Care

Allocation:
Randomized

Interventional Model:
Parallel

Masking:
Single

Arms and Interventions

Participant Group/Arm	Intervention/Treatment
EXPERIMENTAL: Prehabilitation Exercise, nutrition and relaxation techniques all beginning four weeks prior to surgery date.	OTHER: Exercise A kinesiologist will provide each patient wih an individualized home-based exercise program including aerobic, resistance and stretching exercises. Patients will also exercise at our clinic once per week under the supervision of the kinesiologist (prehabi OTHER: Nutrition Patients will be asked to fill in a 3-day food diary. A registered dietitian (RD) will review this diary, provide a full nutritional assessment, and ensure patients are following a high-protein diet (1.5 g of protein/kg/day). A whey-protein supplement may BEHAVIORAL: Relaxation techniques Patients will see a psychologist who will provide relaxation techniques (eg. imagery, visualization, deep breathing exercises) to help patients manage anxiety prior to surgery.
ACTIVE_COMPARATOR: Rehabilitation Exercise, nutrition and relaxation techniques all beginning immediately after surgery.	OTHER: Exercise A kinesiologist will provide each patient wih an individualized home-based exercise program including aerobic, resistance and stretching exercises. Patients will also exercise at our clinic once per week under the supervision of the kinesiologist (prehabi OTHER: Nutrition Patients will be asked to fill in a 3-day food diary. A registered dietitian (RD) will review this diary, provide a full nutritional assessment, and ensure patients are following a high-protein diet (1.5 g of protein/kg/day). A whey-protein supplement may BEHAVIORAL: Relaxation techniques Patients will see a psychologist who will provide relaxation techniques (eg. imagery, visualization, deep breathing exercises) to help patients manage anxiety prior to surgery.

Participant Group/Arm

Intervention/Treatment

EXPERIMENTAL: Prehabilitation

Exercise, nutrition and relaxation techniques all beginning four weeks prior to surgery date.

OTHER: Exercise

A kinesiologist will provide each patient wih an individualized home-based exercise program including aerobic, resistance and stretching exercises. Patients will also exercise at our clinic once per week under the supervision of the kinesiologist (prehabi

OTHER: Nutrition

Patients will be asked to fill in a 3-day food diary. A registered dietitian (RD) will review this diary, provide a full nutritional assessment, and ensure patients are following a high-protein diet (1.5 g of protein/kg/day). A whey-protein supplement may

BEHAVIORAL: Relaxation techniques

Patients will see a psychologist who will provide relaxation techniques (eg. imagery, visualization, deep breathing exercises) to help patients manage anxiety prior to surgery.

ACTIVE_COMPARATOR: Rehabilitation

Exercise, nutrition and relaxation techniques all beginning immediately after surgery.

OTHER: Exercise

A kinesiologist will provide each patient wih an individualized home-based exercise program including aerobic, resistance and stretching exercises. Patients will also exercise at our clinic once per week under the supervision of the kinesiologist (prehabi

OTHER: Nutrition

Patients will be asked to fill in a 3-day food diary. A registered dietitian (RD) will review this diary, provide a full nutritional assessment, and ensure patients are following a high-protein diet (1.5 g of protein/kg/day). A whey-protein supplement may

BEHAVIORAL: Relaxation techniques

Patients will see a psychologist who will provide relaxation techniques (eg. imagery, visualization, deep breathing exercises) to help patients manage anxiety prior to surgery.

Primary Outcome Measures	Measure Description	Time Frame
Change in functional walking capacity as measured by the six-minute walk test (6MWT)	The 6MWT evaluates the ability of an individual to maintain a moderate level of physical activity over a time period reflective of the activities of daily living. Subjects are instructed to walk back and forth, in a 20 meter stretch of hallway, for six minutes, at a pace that would make them tired by the end of the walk; encouragement and feedback are given according to published guidelines. They are allowed to rest during the test if needed, but this time is included in the 6 minutes. Reference equations are available for calculating percent of age- and gender-specific norm.	Baseline, pre-operative assessment, 4 weeks post-operative, 8 weeks post-operative

Secondary Outcome Measures	Measure Description	Time Frame
Timed up and go test	Investigators will measure the time required for a participant to stand up from being seated, walk a distance of 3 metres, turn around and walk back to the chair, and sit down. This measure will be administered based on Canadian Society for Exercise Physiology standards.	Baseline, pre-operative assessment, 4 weeks post-operative, 8 weeks post-operative
30-second sit to stand test	Investigators will measure the number of times participants can stand from a seated position in 30-seconds. This measure will be administered based on Canadian Society for Exercise Physiology standards.	Baseline, pre-operative assessment, 4 weeks post-operative, 8 weeks post-operative
30-second arm curl test	Investigators will measure the number of times participants can perform a full arm curl in 30-seconds. Both arms will be assessed, one at a time. This measure will be administered based on Canadian Society for Exercise Physiology standards.	Baseline, pre-operative assessment, 4 weeks post-operative, 8 weeks post-operative
Change in handgrip strength	To be measured using the Jamar hydraulic hand dynamometer. Two measures from each hand will be taken, with patient seated and arm bent at a 90-degree angle. The average of the two measures for each hand will be recorded and compared to normative data.	Baseline, pre-operative assessment, 4 weeks post-operative, 8 weeks post-operative
Change in body composition	Body composition will be measured via dual-energy X-ray absorptiometry (DXA; Lunar Prodigy Advance, General Electric Healthcare, Madison, WI). Studies from the McGill Nutrition and Performance Laboratory group have validated the use of DXA in advanced cancer patients.	Baseline, pre-operative assessment, 4 weeks post-operative, 8 weeks post-operative
Assessment of food intake and change over study period	Participants will be asked to bring a 3-day food diary to their baseline visit to obtain detailed information about the quantity and type of food and beverages consumed during a non-consecutive 3-day period. Overall energy intake, as well as macronutrient distribution (e.g., amount of carbohydrates, fats, proteins, and fibre at each meal) will be calculated using the Food Processor SQL Nutrition Analysis software.	Baseline, pre-operative assessment, 4 weeks post-operative, 8 weeks post-operative
Perioperative data	This data will include operative characteristics, transfusion rates, length of surgery, intraoperative complications and length of stay.	7 days post-operatively
Postoperative complications	Including surgical site infection, other infectious complications (such as pneumonia, urinary tract infection, line sepsis), bile leak, hemorrhage, deep vein thrombosis, etc., will be recorded and scored using the Clavien Classification.	4 weeks post-operatively
Health-related quality of life (HRQL) - assessment of change over time	As measured by the acute (1 week recall period) Functional Assessment of Cancer Therapy (FACT) survey. This questionnaire also has versions that identify symptoms more specific to hepatobiliary and colorectal cancer patients; this is of relevance to this study given liver metastasis occurs in these patients. The questionnaire is separated into five subscales: 1) physical well-being, 2) social/family well-being, 3) emotional well-being, 4) functional well-being, 5) additional concerns (specific to cancer type). Each question is scored 0-4 on a likert scale, with 0 indicating, "not at all," and 4 indicating, "very much." These scores are then reversed where applicable and added. A higher score indicates better QoL.	Baseline, pre-operative assessment, 4 weeks post-operative, 8 weeks post-operative
The Edmonton Symptom Assessment System (ESAS) - assessment of change over time	Currently used at the MUHC Cedars Cancer Centre to assist in the assessment of pain, tiredness, nausea, depression, anxiety, drowsiness, appetite, well-being, and shortness of breath. Each symptom is rated from 0 to 10 on a numerical scale based on severity, with 0 indicating that the symptom is absent and 10 that it is the worst possible severity.	Baseline, pre-operative assessment, 4 weeks post-operative, 8 weeks post-operative
Physical activity level - assessment of change over time	Will be measured through the Community Health Activities Model Program for Seniors (CHAMPS) questionnaire. The CHAMPS is a self-reported measure of physical activity, comprising 41 activities evaluated according to the total number of hours done during an average week. Each physical activity is assigned a metabolic equivalent (MET) value yielding average weekly caloric expenditure for the listed physical activities. There is evidence for the validity of CHAMPS as a measure of postoperative recovery. Data will be categorized as either mild, moderate or intense activity and changes in the number of hours spent performing activities within each category will be assessed.	Baseline, pre-operative assessment, 4 weeks post-operative, 8 weeks post-operative
Nutritional status - assessment of change over time	To be assessed using the Abridged Patient-Generated Subjective Global Assessment (aPG-SGA); a validated questionnaire used to assess the nutritional and functional status of cancer patients. The scoring system allows patients at risk for malnutrition to be identified and triaged for nutritional intervention. The aPG-SGA may also be useful in monitoring short-term changes in nutritional status. A score ≥9 indicates a critical need for nutritional intervention.	Baseline, pre-operative assessment, 4 weeks post-operative, 8 weeks post-operative
Fatigue - assessment of change over time	To be assessed using a visual analog scale (1-10) and the Brief Fatigue Inventory (BFI). The BFI assesses the level of fatigue and its impact on activities of daily living. The test has 9 questions: three questions are designed to assess the patient's fatigue during the immediate waking hours and 6 questions address how fatigue has interfered in the patient's life over the previous 24 hours. Each question uses a scale rating from "0" (no fatigue) to "10" (unimaginable fatigue) for a total of 90 points.	Baseline, pre-operative assessment, 4 weeks post-operative, 8 weeks post-operative
Weight - assessment of change over time	Body weight will be measured (Kg)	Baseline, pre-operative assessment, 4 weeks post-operative, 8 weeks post-operative
Height	Height will be measured with a stadiometer (m)	Baseline
Body mass index - assessment of change over time	Calculated wt (kg)/ht^2 (m)	Baseline, pre-operative assessment, 4 weeks post-operative, 8 weeks post-operative
Blood pressure - assessment of change over time	Systolic and diastolic at rest (mmHg)	Baseline, pre-operative assessment, 4 weeks post-operative, 8 weeks post-operative
Heart rate - assessment of change over time	Beats per minute measured using a pulse oximeter	Baseline, pre-operative assessment, 4 weeks post-operative, 8 weeks post-operative

Contacts and Locations

This section provides the contact details for those conducting the study, and information on where this study is being conducted.

Study Contact

Name: Antonio Vigano, MD, MSc

Phone Number: 514-934-1934

Email: antonio.vigano@mcgill.ca

Participation Criteria

Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person’s general health condition or prior treatments.

Ages Eligible for Study:
ALL

Sexes Eligible for Study:
18 Years

Accepts Healthy Volunteers:

A diagnosis or suspicion of either hepatobiliary or pancreatic cancer (primary or metastatic)
Must be scheduled for surgical resection between 4-6 weeks of recruitment

Persons with American Society of Anesthesiologists (ASA) health status class 4-5
Comorbid medical, physical and mental conditions (eg: dementia, disabling orthopedic and neuromuscular disease, psychosis)
Cardiac abnormalities
Severe end-organ disease such as cardiac failure, chronic obstructive pulmonary failure and hepatic failure (alanine aminotransferase and aspartate aminotransferase >50% over the normal range)
Sepsis
Morbid obesity (BMI >40)
Anemia (hematocrit <30 %)
Other conditions interfering with the ability to perform exercise at home or to complete the testing procedures
Poor English or French comprehension

Collaborators and Investigators

This is where you will find people and organizations involved with this study.

Dr. Franco Carli

Investigators

PRINCIPAL_INVESTIGATOR: Antonio Vigano, MD, MSc, McGill University Health Centre/Research Institute of the McGill University Health Centre

Publications

The person responsible for entering information about the study voluntarily provides these publications. These may be about anything related to the study.

General Publications

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