An NCI-designated Comprehensive Cancer Center
By City of Hope | November 9, 2017
breakthroughs - Virgina Sun Virginia Sun, Ph.D., R.N., M.S.N.
City of Hope researchers are piloting a new intervention for older patients and their family caregivers to provide “prehabilitation” — a mirror image of the regimen many patients take up after surgery, but begun instead before the operation.
Interdisciplinary and fueled by technology, the program was made possible by an internal grant from the Center for Cancer and Aging.
“The pre-op approach is aiming to better prepare patients,” said co-principal investigator Virginia Sun, Ph.D., R.N., M.S.N., assistant professor in the Division of Nursing Research and Education. “We need to give them the knowledge and skills up front. At the same time, we get the chance to identify and troubleshoot problems earlier.”
Those enrolled in the study, which focuses on lung and gastrointestinal cancers, will consult with City of Hope occupational and physical therapists Sherry Hite and Gouri Varatkar.
The physical therapists will assess patients and customize a simple daily exercise plan of walks and easy strength-building exercises. Patients and caregivers alike will be given wireless fitness trackers and asked to wear them on their wrists. The devices will automatically share data on daily steps with the research team.
Meanwhile, occupational therapists will watch out for overall well-being. Their charge includes addressing issues that raise anxiety, trying to catch problems early and connecting families with any services they may need.
Consultations begin after the decision to perform surgery — usually one to two weeks before the operation — and continue until two weeks after patients return home. The research team plans to enroll 30 patient-caregiver pairs.

Back into the Swing of Things

The investigators expect that more physical activity will lead to better outcomes, and one major focus of the program is getting patients back faster to the kind of life they led before surgery. But older lung and GI cancer patients face special challenges.
Too many older patients with GI cancers fall into a vicious cycle after surgery, explained co-principal investigator Yuman Fong, M.D., professor and chair of surgery and holder of The Sangiacomo Chair in Surgical Oncology.
“Someone doesn’t feel well. They’re not very mobile. They can’t shop and they can’t cook well,” Fong said. “Then they don’t eat well and they get malnourished, which makes them feel even worse. Breaking that cycle somewhere should improve patient outcomes.”
Most lung cancer patients are older adults, observed co-principal investigator Dan Raz, M.D., M.A.S., co-director of the Lung Cancer and Thoracic Oncology Program and assistant professor of thoracic surgery. In addition to greater risk for complications, there are other factors that can deteriorate their health and quality of life after surgery.
“Oftentimes, the patients live alone. There are issues of independence or cognitive issues they weren’t aware of,” Raz said. “So much has to do with their expectations. We hope that by getting them ready for recovery, they’ll make a smoother transition.”

Wireless Connections

In addition to Vivofit pedometer wristbands, the study also will take advantage of video call technology. One occupational and physical therapy session will occur onsite during patients’ time in hospital after surgery; the other three sessions will happen remotely via Zoom videoconferencing.
“The telehealth approach makes it easier to engage patients without burdening their schedule to come to campus,” Sun said. “The video component allows you to have that in-person connection without being in the same location. In my experience, the personal connection is critically important.”
She added, “Of course, it also helps with the assessments — you need to see the patient.”
The program will lend devices such as tablets to patients who do not own one. Patients and caregivers will have access to support using the technology — although that may not be a significant problem.
Said Sun: “We’re mindful of potential barriers. The first thing most people say is, ‘You’re dealing with the older population. They may not be as tech savvy.’ But that’s not the case in our experience. They’re using this technology to communicate with their grandchildren. I think the digital divide is really closing.”

Taking Care of Caregivers

The City of Hope program breaks new ground among prehabilitation studies.
“There are no prehabilitation surgery interventions that include family caregivers,” Sun said. “In many ways we’re doing this for the first time.”
Including family caregivers is meant to prepare them to coach and motivate patients. Meanwhile, encouraging caregivers themselves to be more physically active could help ameliorate some of the emotional challenges that come with looking after loved ones while they recover.
“We really wanted to see whether taking care of the family caregivers will help the patients,” Sun said. “Our hope is that we’ll be able to impact caregiver outcomes, too.”

Precedent and Prospects

The pilot builds on previous research led by Sun. In that study, abdominal cancer patients wore wireless fitness trackers on their wrists before and after surgery. Investigators then correlated their daily step data with quality-of-life surveys. The results appeared in the journal JAMA Surgery.
“The first one was more of an observational proof of concept,” Sun said. “We’re excited to take it to the next level and provide an intervention.”
If this preliminary program finds success, the investigators hope to gain grant funding to expand the scope of the study with randomized trials, a longer timeframe after surgery and more patient-caregiver pairs.

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