A Pilot Study of Prehabilitation During the Neoadjuvant Window of Opportunity in Older Women With Ovarian Cancer (FIT4SURGERY)

Ovarian cancer is the deadliest gynecologic cancer with 5-year survival rates of approximately 48%. Standard of care treatment is grueling, requiring a radical "debulking" surgery and 5 months of chemotherapy. Cytoreductive surgery for ovarian cancer is often extensive, due to the necessary removal of all visible cancer. This radical surgery results in major postoperative complication rates as high as 50% in prospective clinical trials, and 75% occur within 2 weeks of surgery. Half of women are greater than 60 years-old and have high rates of hospital readmission and postoperative complications. Aside from immediate morbidity and mortality related to surgery itself, postoperative complications, such as anastomotic leak, sepsis, or pelvic abscess, can delay the onset of adjuvant chemotherapy, resulting in decreased survival. These postoperative complications also lead to increased discharge to a non-home setting, decreased quality of life, increased costs, and mortality.

Although all patients with ovarian cancer undergo this treatment schedule, older women are at particularly high risk for adverse events. Among women with ovarian cancer, more than 50% are over the age of 60 and up to 40% of these older women are defined as frail. Both age and frailty have been shown to be independent predictors of surgical complications, chemotherapy complications, as well as under-treatment with chemotherapy, resulting in inferior cancer-specific survival. Additionally, the definition of aging contains mechanisms beyond the chronological age of the patient. Both a cancer diagnosis and receipt of chemotherapy lead to synergistic biologic and physiologic changes that accelerate aging and increase frailty. Many older women with ovarian cancer are treated with neoadjuvant chemotherapy which is delivered in 3-4 cycles prior to surgery and this time period provides an optimal window to intervene to improve high-risk older patients' surgical outcomes.

Prehabilitation is the process of enhancing an individual's functional capacity prior to a forthcoming stressor, such as a major surgery, with the goal of improving postoperative outcomes. Prehabilitation programs are multimodal and can involve medical optimization, preoperative physical exercise, nutritional support and stress/anxiety reduction. Benefits of prehabilitation include reduced length of stay, fewer postoperative complications and improved postoperative pain. Even small increases in light physical activity or reducing sedentary time has been shown to slow or halt functional decline and improve quality of life. Among advanced cancer patients, physical activity interventions have been shown to be safe and feasible. They have also been associated with improved aerobic capacity, increased strength, and increased physical function. These parameters are important in older ovarian cancer patients to prevent functional decline, reduce frailty, and decrease surgical morbidity.

However, not all prehabilitation interventions or physical activity interventions are effective. There are populations that do not have sufficient time prior to surgery to have a meaningful change in activity or nutrition, this is especially true for cancer patients who often have a short window between diagnosis and surgery. Furthermore, many physical activity interventions in the pre-operative period have used structured, in-person, professionally-led programs with high intensity activity that may not be appropriate for the changing symptom burden of older ovarian cancer patients undergoing chemotherapy.

Instead of a one-size fits all approach, the American Cancer Society recommends that patients with advanced cancer engage in physical activity tailored to their capability. A recent systematic review and meta-analysis of prehabilitation in cancer patients undergoing abdominal operations noted that data specific to older patients are sparse. This study seeks to address this critical research gap by testing a home-based, patient-tailored, physical activity prehabilitation program (FIT4SURGERY) among older women with ovarian cancer undergoing neoadjuvant chemotherapy.