evidence for prehabilitation in different cancer rehabilitation
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Prehabilitation is a time-limited programme begun after cancer diagnosis and before treatment, usually combining tailored exercise, nutrition support, smoking/alcohol risk reduction, symptom management, and psychological support. The strongest evidence is for patients awaiting major cancer surgery, not for improving cancer control itself.
Evidence by cancer type
| Cancer group | What the evidence supports | Certainty / limitations |
|---|---|---|
| Lung cancer / lung resection | This has the clearest signal. Preoperative exercise improves functional capacity and appears to reduce postoperative complications and hospital stay. An updated review of 32 trials found low-to-moderate certainty evidence for roughly a 50% lower complication rate and about 2.5 fewer hospital days after lung resection. | Trials vary in exercise dose, supervision, and patient risk. Effects on quality of life and survival remain less certain. See the updated exercise meta-analysis. |
| Colorectal cancer | Multimodal programmes can improve preoperative fitness and may reduce complications, particularly among frail or deconditioned patients. In frail patients, a 2025 meta-analysis of five RCTs, mostly colorectal/colon cohorts, found fewer overall postoperative complications: RR 0.82 (95% CI 0.71-0.95). | No clear reduction in major complications or length of stay in that frail-population analysis. A 2024 review found important variation between exercise-only and multimodal programmes. See the frailty meta-analysis and colorectal RCT review. |
| Breast cancer | Physical prehabilitation may improve shoulder range of motion, pain, physical recovery, and some quality-of-life outcomes around surgery. | Evidence is early and heterogeneous. A systematic review included only seven studies, though 1,054 participants overall, and longer-term psychological benefits were not consistently sustained. See the breast cancer review. |
| Upper GI and oesophagogastric cancer | Prehabilitation plausibly improves aerobic capacity and readiness for major surgery. Small studies support functional benefits. | Current evidence has not reliably shown lower complications or shorter stay with exercise-only programmes. Nutrition and sarcopenia management may be particularly relevant, but high-quality multimodal trials are needed. |
| Genitourinary cancers, especially prostatectomy | Pelvic-floor prehabilitation can improve early recovery of urinary continence. General exercise may improve fitness. | Evidence for broader postoperative outcomes is less established than for lung surgery. The broader exercise review did not demonstrate consistent reductions in complications or length of stay. |
| Head and neck cancer | “Prehabilitation” often focuses on swallowing, speech, nutrition, dental care, shoulder function, and psychosocial support before chemoradiation or surgery. It is clinically sensible and may preserve function. | Outcome evidence is less mature and programmes/outcomes are highly cancer-specific. Stronger trials are required. |
| Haematologic, gynaecologic, pancreatic and other cancers | Feasibility and improvements in fitness, symptoms, or treatment tolerance have been reported in selected studies. | Insufficient evidence for reliable claims about surgical complications, chemotherapy completion, recurrence, or survival. |
Overall evidence
A 2024 systematic review and meta-analysis of RCTs across cancers found improvements in:
- 6-minute walk distance: mean difference +38.5 m (95% CI 33.0-44.0)
- Anxiety: lower HADS anxiety score
- Depression: lower HADS depression score
It also reported signals for improved endurance, strength, respiratory function, quality of life, and shorter hospital stays. However, the authors judged the included trials to have substantial risk of bias, so certainty is not uniform across outcomes or cancer sites. See the RCT meta-analysis.
Practical interpretation for cancer rehabilitation
- Offer prehabilitation early, ideally immediately after diagnosis or surgical decision, without delaying time-sensitive cancer treatment.
- Prioritize high-risk patients: frailty, low aerobic capacity, malnutrition/sarcopenia, smoking, respiratory disease, older age, or planned high-risk thoracic/abdominal surgery.
- Use a tailored multimodal programme rather than exercise alone when feasible:
- aerobic and resistance training
- protein and dietitian-led nutrition intervention
- smoking cessation
- respiratory training for thoracic surgery
- psychological support and sleep/symptom management
- site-specific therapy, such as pelvic-floor training for prostate cancer or swallowing therapy for head and neck cancer.
- Measure meaningful baseline and follow-up outcomes, such as 6-minute walk test, sit-to-stand, frailty, nutritional status, PROMs, and postoperative complications.
Bottom line: prehabilitation is best supported for improving function and reducing complications before lung cancer surgery, with promising but more mixed evidence in colorectal and breast cancer. For many other cancer groups, it should be used as individualized rehabilitation-oriented care, while being transparent that definitive evidence for major clinical endpoints is still limited.
Recent evidence to keep in mind: the 2024 cross-cancer meta-analysis (PMID 39438910) and 2025 frail-cancer surgical meta-analysis (PMID 40464827) support functional and overall-complication benefits, but both underscore limitations from heterogeneity and limited high-quality trials.
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Recent guidance is site-specific rather than one universal cancer-prehabilitation guideline. The most useful sources are:
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Lung cancer: ERS/ESTS Clinical Practice Guideline, 2025
The European Respiratory Society/European Society of Thoracic Surgeons guideline addresses fitness for curative-intent lung cancer treatment. It includes the role of prehabilitation alongside pulmonary function testing, exercise testing, cardiac evaluation, comorbidity assessment, and surgical selection. This is currently the most directly relevant recent formal guideline for cancer prehabilitation.
[Practice Guideline . Tier 6 . 2025] Brunelli et al. European Respiratory Society and European Society of Thoracic Surgeons clinical practice guideline on fitness for curative intent treatment of lung cancer. PMID: 41232938. -
Older adults undergoing abdominal cancer surgery: EAES/SAGES, 2024
This evidence-based guideline and expert consensus covers colorectal, upper-GI, and hepatopancreatobiliary surgery in adults aged 65 years or older. It conditionally supports prehabilitation, smoking and alcohol cessation, and anaemia correction before major surgery.
Important qualification: the guideline describes the prehabilitation recommendation as expert opinion, with low to very-low certainty evidence. It should therefore be implemented as individualized risk optimization, not as a mandated uniform protocol.
[Practice Guideline . Tier 6 . 2024] Keller et al. EAES/SAGES evidence-based recommendations and expert consensus on optimization of perioperative care in older adults. PMID: 38942944. -
Cancer nutrition: ESPEN Practical Guideline, 2021
The ESPEN cancer nutrition guideline is not exclusively a prehabilitation guideline, but is a core source for the nutrition component of a multimodal programme. It provides 43 recommendations covering nutritional assessment and support for people with cancer, including those at risk of malnutrition and sarcopenia.
[Practice Guideline . Tier 6 . 2021] Muscaritoli et al. ESPEN practical guideline: Clinical Nutrition in cancer. PMID: 33946039. -
UK cancer-pathway implementation guidance: Macmillan Cancer Support
Macmillan’s prehabilitation principles and implementation resources were developed with the Royal College of Anaesthetists, NIHR Cancer and the Nutrition Collaboration. They support embedding prehabilitation into routine cancer pathways and frame it around:- physical activity and exercise
- nutritional support
- psychological support
- behaviour change and risk-factor management
- personalized assessment and service implementation.
This is particularly useful for setting up a service, although it is implementation guidance rather than a GRADE-based international clinical practice guideline.
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Upper gastrointestinal cancer surgery: UK expert consensus, 2025
A recent nominal-group consensus study found complete agreement that upper-GI cancer prehabilitation should be multimodal and multidisciplinary, combining exercise, nutrition, and psychological support. It is a consensus statement, not a formal guideline, but it offers practical design priorities for oesophageal and gastric cancer pathways.
[Consensus . 2025] Stiger et al. Priorities for prehabilitation for patients with upper gastrointestinal cancer. PMID: 40824317. -
ERAS Society cancer-surgery pathways
The ERAS Society guideline collection includes perioperative pathways relevant to lung surgery, oesophagectomy, gastrectomy, colorectal surgery, pancreatic surgery, radical cystectomy, head and neck surgery, and gynaecologic oncology. These are not always labelled “prehabilitation” guidelines, but they provide the perioperative framework into which prehabilitation is usually integrated.
Practical common recommendations across these documents
- Assess early, ideally immediately after diagnosis or once curative treatment is planned.
- Target modifiable risk: frailty, low fitness, malnutrition/sarcopenia, smoking, hazardous alcohol use, anaemia, anxiety/depression, and poorly controlled comorbidities.
- Use multimodal, individualized care rather than exercise alone: exercise plus dietetic/nutrition intervention, psychological support, and behaviour-change support.
- Do not delay time-sensitive cancer therapy merely to complete a prehabilitation programme.
- Prioritize patients undergoing high-risk thoracic or major abdominal surgery and those with frailty or poor baseline functional reserve.
- Integrate with the cancer multidisciplinary team, surgical pathway, anaesthesia/preoperative assessment, rehabilitation, and ERAS programme.
Important current gap
A broad ASCO/MASCC cancer-prehabilitation guideline does not appear to be published yet. ASCO lists “Prehabilitation” as a new supportive-care guideline priority, so a more universal oncology guideline may emerge, but it should not be cited as an existing recommendation at present.
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Comparison of current cancer prehabilitation guidance
| Source | Population / setting | Main recommendations | Core components | Strength / key limitation |
|---|---|---|---|---|
| Macmillan Cancer Support: Prehabilitation for People with Cancer: Clinical and Implementation Guidelines (2025) | People with cancer across the treatment pathway, not limited to surgery | Embed prehabilitation as a routine, early part of cancer care. Identify needs promptly after diagnosis, offer tailored referral, address inequity of access, and monitor outcomes. | Exercise and physical activity; nutrition; psychological support; behaviour change; symptom management; smoking/alcohol support; social prescribing and digital options where appropriate. | The most broadly applicable current cancer-specific implementation guideline. It emphasizes service design and equitable access as well as individual interventions. Macmillan clinical guidance |
| ERS/ESTS Clinical Practice Guideline on fitness for curative-intent lung cancer treatment (2025) | Patients considered for curative-intent lung cancer treatment, especially lung resection | Perform structured physiological risk assessment using pulmonary function, predicted postoperative function, exercise capacity and cardiac/comorbidity evaluation. Incorporate prehabilitation when functional reserve is limited or modifiable risks are present. | Individualized exercise training, pulmonary optimization, smoking cessation, comorbidity optimization, and multidisciplinary decision-making. | Formal GRADE-based clinical guideline. It evaluates prehabilitation within a broader fitness-for-treatment pathway, rather than providing one fixed exercise prescription. ERS/ESTS lung cancer guideline |
| EAES/SAGES recommendations for perioperative optimization in older adults (2024) | Adults aged 65 years or older having major abdominal surgery, including colorectal, upper-GI and hepatopancreatobiliary procedures | Consider prehabilitation before major abdominal surgery, with smoking and alcohol cessation and correction of anaemia. Use ERAS and minimally invasive surgery where appropriate. | Functional optimization, exercise, nutrition, risk-factor modification, anaemia management and ERAS integration. | Conditional expert recommendation for prehabilitation. Evidence certainty is low to very low, so plans should be individualized and should not delay needed cancer treatment. EAES/SAGES consensus |
| ESPEN Practical Guideline: Clinical Nutrition in Cancer (2021) | All people with cancer, including those at risk of malnutrition, sarcopenia or treatment-related nutritional decline | Screen nutritional status regularly. Assess intake, weight loss, body composition and physical performance. Provide nutrition counselling and oral nutrition support, escalating to enteral or parenteral support when indicated. Combine nutrition with physical activity where feasible. | Nutrition screening and assessment; protein-energy intake support; management of treatment-related symptoms that impair intake; resistance/aerobic activity where safe. | Not a prehabilitation-only guideline, but the main evidence-based nutrition standard underlying multimodal prehabilitation. ESPEN nutrition guideline |
| ERAS Society cancer-surgery guidelines | Cancer-specific surgical pathways, including thoracic, colorectal, oesophageal, gastric, pancreatic, bladder, gynaecologic and head-and-neck surgery | Use a standardized perioperative pathway that includes preoperative education, risk optimization, nutritional planning, smoking cessation, anaemia management, minimally invasive techniques where appropriate, and early postoperative mobilization and feeding. | Preoperative optimization plus intraoperative and postoperative ERAS measures. The precise recommendations differ by operation. | These are surgical pathway guidelines, not universal prehabilitation guidance. They provide the operational setting in which prehabilitation is best integrated. ERAS guideline collection |
| Upper-GI cancer prehabilitation consensus (2025) | Patients undergoing surgery for oesophageal or gastric/upper-GI cancer | Deliver prehabilitation as a multimodal, multidisciplinary intervention. Integrate it into the pathway, support behaviour change and evaluate outcomes and cost-effectiveness. | Exercise, nutrition and psychological support are the three agreed core elements. | Expert consensus rather than a formal practice guideline, but directly applicable to upper-GI cancer service design. Upper-GI consensus study |
Areas of agreement
| Recommendation | Agreement across sources |
|---|---|
| Start early | Refer at diagnosis or when treatment planning begins, allowing time for optimization without delaying oncologic treatment. |
| Use individualized assessment | Assess functional capacity, frailty, nutrition/sarcopenia, comorbidities, smoking/alcohol, psychological distress and treatment-specific risks. |
| Use multimodal care | Exercise alone is usually insufficient. The recurring model is exercise plus nutrition plus psychological/behaviour-change support. |
| Prioritize higher-risk patients | Frail patients, those with poor exercise tolerance, malnutrition, respiratory disease, smoking exposure, major thoracic/abdominal surgery, and older adults warrant particular attention. |
| Integrate with the multidisciplinary team and ERAS pathway | Prehabilitation should be coordinated with oncology, surgery, anaesthesia, physiotherapy/exercise professionals, dietetics, psychology and primary care. |
| Track outcomes | Programmes should monitor uptake/adherence, functional status, nutrition, patient-reported outcomes, complications, length of stay and equity of access. |
Key differences
- Macmillan 2025 is the broadest cancer-specific service and implementation guidance.
- ERS/ESTS 2025 offers the strongest current formal clinical-guideline context for prehabilitation in lung cancer, embedded in physiologic fitness assessment.
- EAES/SAGES 2024 supports prehabilitation in older adults having major abdominal surgery, but acknowledges low-certainty evidence.
- ESPEN specifies the nutritional part of prehabilitation but does not prescribe a whole prehabilitation service.
- ERAS guidelines address the whole perioperative pathway, so recommendations extend substantially beyond the pre-treatment interval.
Recent reviews support this direction but also explain the cautious wording in several guidelines: benefits in function and selected postoperative outcomes are promising, while intervention content, duration and outcome measures remain heterogeneous. The 2024 meta-analysis reported improved 6-minute walk distance and lower anxiety/depression scores, but noted a high risk of bias across included trials (Gennuso et al., 2024, PMID 39438910).
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Latest ASCO and NCCN guidance relevant to cancer prehabilitation
| Organization | Most current relevant guidance | Status for prehabilitation | Practical relevance |
|---|---|---|---|
| ASCO | ASCO lists a new “Prehabilitation” guideline, with MASCC, as a supportive-care guideline development priority. | In development, not yet published as an ASCO clinical practice guideline as of 31 August 2026. | Do not cite ASCO as having a completed, formal prehabilitation recommendation yet. Its guideline priorities page confirms this work is planned. |
| NCCN | NCCN Guidelines® Insights: Survivorship, Version 2.2025. | Published, but not a dedicated prehabilitation guideline. It provides guidance on physical activity, nutrition, and weight management for cancer survivors. | This is the closest current NCCN framework for the key components of prehabilitation, but it does not provide a complete pre-treatment, multimodal prehabilitation pathway. |
| NCCN | NCCN Guidelines for Patients®: Survivorship Care for Healthy Living | Patient-facing survivorship guidance, with physical activity and safe-exercise information. | Useful for patient education and activity advice during and after treatment, rather than for presurgical prehabilitation programme design. |
| ASCO | ASCO-Society for Integrative Oncology guideline update on cancer-related fatigue, 2024 | Not a prehabilitation guideline. | Supports use of exercise and selected supportive strategies for fatigue in adult cancer survivors, which can inform an individualized exercise component but should not be represented as prehabilitation-specific guidance. |
What NCCN currently recommends that can be applied to prehabilitation
The 2025 NCCN Survivorship update focuses on:
- physical activity
- nutrition
- weight management
- screening, evaluation, and management of physical and psychosocial consequences of cancer and its treatment
- wellness and healthy-lifestyle support
This is relevant because these overlap with prehabilitation, especially exercise prescription and nutrition optimization. However, NCCN’s cited document is aimed at survivorship, whereas prehabilitation begins between diagnosis and treatment.
[Practice Guideline . Tier 6 . 2025] Sanft et al. NCCN Guidelines® Insights: Survivorship, Version 2.2025. Journal of the National Comprehensive Cancer Network. PMID: 40499584. The published abstract confirms that the update addresses physical activity, nutrition, and weight management in cancer survivors through the NCCN Survivorship guideline update.
NCCN also states that its guidelines are reviewed at least annually and can receive interim updates, so the full electronic NCCN guideline should be checked locally for the exact active version and recommendation wording. See the NCCN update process.
Bottom line for your comparison table
- ASCO/MASCC: Dedicated cancer-prehabilitation guideline is anticipated but not yet published.
- NCCN: No dedicated cancer-prehabilitation guideline located. Use NCCN Survivorship Version 2.2025 for exercise, nutrition, weight-management, and safe activity principles, with the explicit caveat that it is not a prehabilitation guideline.
- For a formal prehabilitation recommendation today, the more directly applicable sources remain Macmillan 2025, ERS/ESTS lung cancer 2025, EAES/SAGES older-adult perioperative guidance 2024, and ESPEN cancer nutrition guidance.
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site:pubmed.ncbi.nlm.nih.gov prehabilitation cancer systematic review 2025 2026
PubMed search completed for 2025 through 31 August 2026, limited to reviews, systematic reviews, and meta-analyses on cancer prehabilitation.
Priority systematic reviews and meta-analyses
| Year | Review | Cancer group / question | Key finding |
|---|---|---|---|
| 2026 | Cook et al., How Robust is the Evidence for Prehabilitation in Cancer Surgery?: A Systematic Review and Fragility Index Analysis | Cancer surgery, all prehabilitation modalities | Included 76 RCTs. Only 25 of 544 reported complication outcomes were statistically significant, and the median fragility index was 1. This flags that many positive findings are statistically fragile and supports cautious guideline wording. PubMed record |
| 2026 | Hoff et al., Prehabilitation in patients with frailty undergoing cancer-related surgery: a systematic review | Frail patients undergoing cancer surgery | Focuses on the group most likely to benefit, but evidence remains limited and intervention protocols are inconsistent. PubMed record |
| 2026 | Zhang et al., Dropping out or Moving on? A Systematic Review With Meta-Aggregation of the Experience of Prehabilitation Among Patients With Cancer | Patient experience, engagement and adherence | Qualitative synthesis relevant to implementation, acceptability and reasons for non-completion. PubMed record |
| 2026 | Zhang et al., Effectiveness of prehabilitation for patients with colorectal surgery: a systematic review and network meta-analysis | Colorectal surgery | Compares different prehabilitation approaches. Useful when selecting exercise-only, nutrition, or multimodal programmes. PubMed record |
| 2025 | Steffens et al., An Updated Systematic Review and Meta-Analysis of Unimodal Prehabilitation with Exercise Intervention to Enhance Postoperative Outcomes in Cancer Surgery | Lung, upper-GI, lower-GI and genitourinary cancer surgery | 32 trials, 2,304 participants. Low-to-moderate certainty evidence supported exercise prehabilitation before lung resection, with approximately 50% fewer postoperative complications and 2.5 fewer hospital days. Effects were not consistently demonstrated in the other cancer groups. PubMed record |
| 2025 | Bai et al., Prehabilitation in Frail Patients Undergoing Cancer Surgery: A Systematic Review and Meta-analysis | Frail cancer-surgery patients, mainly colorectal/colon cohorts | Five RCTs, 466 participants. Overall postoperative complications decreased, RR 0.82 (95% CI 0.71-0.95), but there was no clear reduction in major complications or length of stay. PubMed record |
| 2025 | Liao et al., Prehabilitation Interventions in Patients Undergoing Colorectal Cancer Surgery: A Systematic Review and Meta-Analysis | Colorectal cancer surgery | Fourteen studies, 2,314 participants. Multimodal prehabilitation was associated with shorter hospital stay, MD -2.47 days, fewer complications, OR 0.74, and earlier flatus. PubMed record |
| 2025 | Mania et al., Comprehensive Multimodal Prehabilitation for Lung Cancer: A Systematic Review of Randomized Controlled Trials | Lung cancer surgery | Ten RCTs. Multimodal programmes were associated with better exercise capacity and fewer complications; effects on length of stay and cognition remained uncertain. PubMed record |
| 2025 | Ambulkar et al., Impact of Prehabilitation in Major Gastrointestinal Oncological Surgery: a Systematic Review | GI and hepatopancreatobiliary cancer surgery | Broad review of programme components, implementation barriers and outcomes in GI/HPB oncology. PubMed record |
| 2025 | Liu et al., Boosting recovery before surgery: The impact of prehabilitation on upper gastrointestinal cancer patients - A quantitative comparative analysis | Upper-GI cancer surgery | Meta-analysis focused on upper-GI surgical outcomes. PubMed record |
| 2025 | Del Rosal Jurado et al., Physical prehabilitation in patients with breast cancer: a systematic review | Breast cancer | Seven studies, 1,054 participants. Objective outcomes improved; subjective outcomes also improved, though psychological benefits were not consistently sustained over time. PubMed record |
| 2025 | Paterson et al., Effect of Prehabilitation Interventions in People Affected by Bladder Cancer on Long-Term Physical, Clinical, and Patient-Reported Outcome Measures: A Systematic Review | Bladder cancer | Assesses long-term physical, clinical and patient-reported outcomes, useful for cystectomy pathways. PubMed record |
| 2025 | Sier et al., Participation and Adherence to Prehabilitation Programs for Colorectal Cancer | Colorectal cancer | Focuses on uptake and adherence, an important limitation in translating efficacy trials into routine services. PubMed record |
| 2025 | Watts et al., Access, acceptance and adherence to cancer prehabilitation: a mixed-methods systematic review | Cross-cancer implementation | Synthesizes access barriers, patient acceptance, and adherence. Relevant to equity, referral and programme design. PubMed record |
Useful scoping and narrative reviews
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[Review . Tier 7 . 2026] Kwan et al. Prehabilitation in Adult Cancer Patients Undergoing Chemotherapy or Radiotherapy: A Scoping Review. PMID: 41595205. This expands the focus beyond surgery to prehabilitation before systemic therapy or radiotherapy. PubMed record
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[Systematic Review . Tier 1 . 2025] Colaço et al. Prehabilitation: preoperative rehabilitation interventions for lung cancer - a scoping review. PMID: 41170317. PubMed record
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[Review . Tier 7 . 2025] Kim et al. Multimodal Prehabilitation for Gynecologic Cancer Surgery. PMID: 39996909. PubMed record
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[Review . Tier 7 . 2025] Stewart et al. The inequalities and challenges of prehabilitation before cancer surgery: a narrative review. PMID: 39775660. PubMed record
Synthesis
The recent review literature supports:
- Best-supported indication: exercise prehabilitation before lung cancer resection.
- Promising evidence: multimodal prehabilitation before colorectal cancer surgery, especially in frail or older patients.
- Likely effective programme model: tailored exercise + nutrition + psychological/behavioural support, rather than exercise alone.
- Main caution: heterogeneity, selective outcome reporting, limited high-quality trials, and fragile statistical findings mean that routine implementation should be individualized and embedded in ERAS and multidisciplinary cancer pathways.
- Major research gap: prehabilitation before chemotherapy or radiotherapy, and long-term outcomes such as treatment completion, recurrence, survival, and health equity.
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PubMed cancer prehabilitation systematic reviews 2025 2026
PRISMA-style evidence table: PubMed reviews of cancer prehabilitation, 2025-2026
Search focus: prehabilitation before cancer treatment, principally surgery.
Databases represented in included reviews: PubMed/MEDLINE, Embase, Cochrane Library, CINAHL, AMED, PsycINFO, and others.
Note: This is a PRISMA-style study-characteristics and findings table, not a PRISMA 2020 flow diagram. A formal flow diagram would require a reproducible, deduplicated export of all database records.
Databases represented in included reviews: PubMed/MEDLINE, Embase, Cochrane Library, CINAHL, AMED, PsycINFO, and others.
Note: This is a PRISMA-style study-characteristics and findings table, not a PRISMA 2020 flow diagram. A formal flow diagram would require a reproducible, deduplicated export of all database records.
| Study | Review type and evidence base | Population / cancer setting | Prehabilitation evaluated | Main outcomes | Key findings | Main limitations |
|---|---|---|---|---|---|---|
| Cook et al., 2026 PMID 40841481 | Systematic review with fragility-index analysis. 76 RCTs; 2,486 records screened. | Major oncologic surgery, multiple cancer types. | Mostly nutritional prehabilitation, 38/76 RCTs; also exercise and multimodal programmes. | Postoperative complications; statistical robustness. | Of 544 complication outcomes, only 25 (4.6%) were statistically significant. Median fragility index was 1 and reverse fragility index 4. | Positive and null findings in the RCT evidence base are often statistically fragile; considerable outcome and intervention heterogeneity. |
| Hoff et al., 2026 PMID 41549884 | Systematic review and meta-analysis. 15 studies, 1,955 patients; 67.7% frail. | Frail adults having elective cancer-related surgery. | Heterogeneous multimodal and/or exercise/nutrition prehabilitation. | Length of stay, function, complications, readmission. | No significant reduction in length of stay: MD -0.29 days (95% CI -0.89 to 0.30). No significant effect on complications: RR 0.76 (0.56-1.04), function, or readmission. | Frailty definitions, programmes, reporting, and study designs varied substantially. |
| Zhang et al., 2026 PMID 41495596 | Systematic review and Bayesian network meta-analysis. 13 RCTs. | Colorectal surgery. | Exercise alone; nutrition alone; exercise plus nutrition; exercise plus nutrition plus psychosocial support. | Length of stay, 6-minute walk test, complications. | The exercise + nutrition + psychosocial programme probably improved 6-minute walk distance: MD +51.57 m (95% credible interval 14.39-88.76). Evidence for reducing complications or length of stay was low to very low certainty. | Most treatment comparisons had few trials and small samples. |
| Steffens et al., 2025 PMID 39383108 | Updated systematic review and meta-analysis of RCTs. 32 trials, 2,304 participants. | Lung, upper-GI, lower-GI and genitourinary cancer surgery. | Exercise-only prehabilitation. | Postoperative complications and length of stay. | In lung resection, low-to-moderate certainty evidence found approximately 50% lower postoperative complications and 2.5 fewer hospital days. No consistent benefit was found for other cancer groups. | Most trials had some risk of bias; evidence is strongest for lung surgery, not cancer surgery generally. |
| Bai et al., 2025 PMID 40464827 | Systematic review and meta-analysis of RCTs. 5 RCTs, 466 patients, mostly colorectal/colon cancer. | Frail patients undergoing cancer surgery. | Prehabilitation, with limited exercise-only evidence. | Any complications, major complications, length of stay. | Reduced any postoperative complication: RR 0.82 (95% CI 0.71-0.95). No clear effect on major complications: RR 0.89 (0.71-1.11), or length of stay. | Small evidence base, mostly colorectal surgery; uncertain effect on major postoperative outcomes. |
| Liao et al., 2025 PMID 40079672 | Systematic review and meta-analysis. 14 studies, 2,314 patients. | Colorectal cancer surgery. | Multimodal programmes. | Length of stay, complications, bowel recovery. | Associated with shorter stay: MD -2.47 days (95% CI -3.56 to -1.39), fewer complications: OR 0.74 (0.59-0.94), and earlier flatus: MD -0.43 days. | Included randomized, prospective, and retrospective studies; component content and duration were not standardized. |
| Mania et al., 2025 PMID 41426234 | Systematic review of RCTs. 10 RCTs from 1,233 identified studies. | Lung cancer undergoing thoracic surgery. | Exercise, nutrition and psychological interventions. Only 3 trials used all three components. | Exercise capacity, complications, quality of life, psychological wellbeing, length of stay. | Improved exercise capacity, including 6-minute walk distance, and fewer postoperative complications were reported. Possible quality-of-life and psychological benefits. | Multimodal delivery was uncommon; programme duration/setting differed; effects on length of stay and cognition remain uncertain. |
| Ambulkar et al., 2025 PMID 40500487 | Systematic review. Literature to June 2024. | Gastrointestinal and hepatopancreatobiliary cancer surgery. | Multimodal programmes, including physical exercise, nutritional therapy and anaemia correction. | Functional capacity, complications, length of stay, recovery, implementation barriers. | Functional and clinical benefits were most consistently reported for colorectal surgery. Supervised inpatient programmes appeared more effective than home-based models, though more costly. | Strength of evidence varied across cancer sites; evidence for upper-GI and HPB surgery was more limited; adherence is a challenge. |
| Liu et al., 2025 PMID 40100884 | Quantitative comparative analysis/meta-analysis. 12 studies included. | Upper-GI cancer surgery. | Various prehabilitation interventions. | Overall and pulmonary complications; ICU readmission. | Lower overall complications: OR 0.59 (95% CI 0.39-0.88), pulmonary complications: OR 0.54 (0.36-0.80), and ICU readmission: OR 0.23 (0.06-0.89). | The review reports associations across heterogeneous interventions and designs; confirmatory high-quality trials are needed. |
| Del Rosal Jurado et al., 2025 PMID 39757306 | Systematic review. 7 studies, 1,054 participants. | Breast cancer. | Physical prehabilitation. | Range of motion, biomarkers, pain, physical/mental recovery, quality of life, psychological outcomes. | Objective outcomes improved in prehabilitation groups; subjective outcomes also improved. Psychological improvements were not consistently maintained long term. | Only seven studies; intervention type and outcome measures varied. |
PRISMA-style synthesis by evidence domain
| Domain | Studies supporting benefit | Interpretation |
|---|---|---|
| Lung cancer surgery | Steffens 2025; Mania 2025 | The most consistent evidence supports preoperative exercise, with potential additional value from multimodal programmes. |
| Colorectal cancer surgery | Liao 2025; Zhang 2026; Bai 2025 | Multimodal programmes improve functional capacity and may improve postoperative recovery. Effects on complications and length of stay vary according to review design and certainty assessment. |
| Upper-GI surgery | Liu 2025; Ambulkar 2025 | Results are promising for complications, particularly pulmonary complications, but evidence is less mature than for lung or colorectal surgery. |
| Frail patients | Bai 2025; Hoff 2026 | Findings conflict. One RCT-only meta-analysis found fewer overall complications; the broader review found no significant effect on major outcomes. Heterogeneity and frailty definition are central issues. |
| Breast cancer | Del Rosal Jurado 2025 | Physical-function and pain-related outcomes may improve; evidence for long-term psychological and oncologic outcomes is insufficient. |
| Evidence certainty and trial robustness | Cook 2026 | The evidence base should not be treated as uniformly definitive. Standardized interventions, outcomes, and adequately powered RCTs are needed. |
Eligibility framework for a formal systematic review
| PICO element | Proposed criterion |
|---|---|
| Population | Adults with a cancer diagnosis undergoing surgery, chemotherapy, radiotherapy, or multimodal cancer treatment. |
| Intervention | Prehabilitation initiated after diagnosis and before treatment: exercise, nutrition, psychological, behavioural, pulmonary, anaemia, or multimodal programmes. |
| Comparator | Usual care, no prehabilitation, alternative prehabilitation modality, or lower-intensity programme. |
| Outcomes | Functional capacity, frailty, nutritional status, treatment completion, postoperative complications, length of stay, readmission, quality of life, distress, and survival. |
| Study design | Systematic reviews, meta-analyses, RCTs, and controlled observational studies. |
| Date range for this table | 1 January 2025 to 31 August 2026. |
Overall conclusion: The current review literature supports implementation of individualized, multimodal prehabilitation, especially before lung and colorectal cancer surgery. However, clinical outcome effects differ by cancer type, patient risk, programme content, and study design. The 2026 fragility analysis indicates that recommendations should remain proportionate to the certainty of the evidence.
Find the full-text papers and extract intervention protocols
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https://pmc.ncbi.nlm.nih.gov/articles/PMC12717860/
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https://pmc.ncbi.nlm.nih.gov/articles/PMC11918424/
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PMC 2025 cancer prehabilitation systematic review intervention protocol table lung colorectal upper gastrointestinal
Reading Web Page
https://pmc.ncbi.nlm.nih.gov/articles/PMC12717860/
Extracted intervention protocols from accessible full-text reviews
I located open-access full texts for the principal 2025 reviews and extracted the intervention details that were reported. The protocols are heterogeneous, so the table identifies reported programme components, not a single validated universal prescription.
| Cancer setting / source | Programme duration and delivery | Exercise protocol | Nutrition protocol | Psychological / behavioural protocol | Notes |
|---|---|---|---|---|---|
| Frailty and cancer surgery: Bai et al., 2025 PMID 40464827 | Usually 3-4 weeks, delivered in home, hospital, community, or mixed home-hospital settings. Frequency ranged from 1-3 supervised sessions/week. | Aerobic, resistance, and stretching exercises. A detailed 4-week programme used daily walking, elastic-band resistance training 3 times/week, and supervised sessions once/week. Intensity was moderate. | Protein supplementation and dietary support, typically delivered by a dietitian. | Personalized coping strategies and relaxation training 3 times/week. A kinesiologist, dietitian, and psychology-trained nurse delivered the multidisciplinary programme. | In one reported programme, adherence averaged 80%. This is a feasible template for frail older adults, but should be adjusted for frailty, falls risk, cardiopulmonary disease, and treatment urgency. |
| Colorectal cancer, PREHAB RCT model: summarized by Ambulkar et al., 2025 PMID 40500487 | 4 weeks, in-hospital supervised programme before colorectal surgery. | High-intensity exercise 3 times/week. | Individual nutritional intervention. The review does not provide a uniform protein/calorie target for this specific trial. | Psychological support; smoking-cessation intervention when required. | This programme was associated with fewer severe complications in the cited trial. All patients also followed ERAS postoperatively. |
| Colorectal cancer, home-based trimodal programme: summarized by Ambulkar et al., 2025 | 4 weeks, home-based programme with a weekly supervised session. | Moderate-intensity aerobic and resistance exercise. | Nutrition counselling plus daily whey-protein supplementation. | Anxiety-reduction strategies. | Useful where travel to supervised services is difficult. The review notes that adding a weekly supervised exercise session did not clearly improve all outcomes over an otherwise home-based programme. |
| Colorectal/abdominal oncology physiotherapy model: Ambulkar et al., 2025 | 2-4 weeks; outpatient physiotherapy twice/week, 60 minutes/session; home activity encouraged with pedometer. | Aerobic endurance training at 55%-75% maximal heart rate, Borg/RPE 10-13/20, for 20-30 minutes. Resistance exercise: lower-limb extensors, 1 set of 8-15 repetitions. Inspiratory muscle training was added. | Not specified as a standard component in this specific programme. | Not specified. | This is the clearest FITT-style exercise description reported in the GI review. It is a practical cardiopulmonary conditioning model for appropriately assessed patients. |
| Older colorectal patients, comprehensive programme: Ambulkar et al., 2025 | 4-6 weeks, supervised by a local physiotherapist, twice/week, 30-45 minutes/session; home and breathing exercises prescribed. | Combined resistance and endurance training. | Targeted protein intake: 1.2-1.5 g/kg/day. | Geriatric and cardiopulmonary assessment, with intervention tailoring. | This combines exercise, nutrition, and geriatric-risk assessment and may be particularly relevant for sarcopenia, frailty, or multimorbidity. |
| Lung cancer, multimodal prehabilitation: Mania et al., 2025 PMID 41426234 | Most programmes lasted 2-3 weeks. Two lasted 1 week; one aligned with surgical waiting time, approximately 3-4 weeks. Delivered in hospital, outpatient, or home-based formats. | Across trials: aerobic training, resistance training, respiratory/breathing exercises, high-intensity interval training in some trials, and inspiratory-muscle training. | Three trials included nutrition. Two specified nutrition counselling with whey-protein supplementation. | Three trials included psychological support: psychological guidance, relaxation through deep breathing and relaxing music, or imagery, visualization, and deep breathing. | Only 3 of 10 RCTs used all three elements, exercise plus nutrition plus psychological support. Most lung-cancer protocols were exercise-focused. |
| Upper-GI cancer, multimodal programmes: Liu et al., 2025 PMID 40100884 | Program duration varied by study; interventions occurred during neoadjuvant therapy and/or before surgery. | Exercise-only protocols used aerobic exercise, resistance exercise, and/or inspiratory-muscle training. | Individualized nutritional support in 7 of 12 included studies. | Psychological counselling in 4 of 12 studies, alongside exercise and personalized nutrition. | The review’s subgroup analysis favored combined exercise, nutrition, and psychological support over exercise-only approaches for postoperative complications. Specific session doses were not consistently reported. |
| GI and HPB surgery, general evidence synthesis: Ambulkar et al., 2025 | Physical programmes generally require 3-6 weeks for measurable functional improvement. | Exercise intensity and improvement in preoperative functional capacity were more consistently linked to outcomes than the exact exercise mode. | Nutritional intervention should be individualized; assess malnutrition, sarcopenia, inadequate intake, and anaemia. | Psychological support is part of multimodal care when distress, poor coping, or adherence barriers are present. | Evidence is strongest in colorectal surgery. Data for upper-GI and hepatopancreatobiliary surgery are less certain. |
Practical multimodal protocol derived from the reported programmes
This is a service-design template, not a substitute for a patient-specific clinical exercise prescription.
| Component | Extracted protocol range |
|---|---|
| Timing | Start immediately after treatment decision. Aim for 3-4 weeks when the treatment timeline permits. Do not delay time-sensitive cancer treatment solely to complete prehabilitation. |
| Baseline assessment | Functional capacity, frailty, falls risk, nutritional status and sarcopenia risk, pulmonary/cardiac risk, smoking, alcohol use, distress, symptoms, treatment plan, and contraindications to exercise. |
| Aerobic exercise | At least 2-3 supervised or structured sessions/week, with additional daily walking or physical activity. One published protocol used 20-30 minutes at 55%-75% of maximal heart rate or RPE 10-13/20. |
| Resistance exercise | 2-3 sessions/week, using bands, weights, bodyweight, or machines, focused on major muscle groups and lower limbs. One reviewed programme used 1 set of 8-15 repetitions for lower-limb extensors. |
| Respiratory training | Add breathing exercises and consider inspiratory-muscle training for lung and upper-abdominal/upper-GI surgery, especially with low pulmonary reserve or respiratory risk. |
| Nutrition | Dietitian assessment and individualized counselling. Reported protocols included daily whey-protein or protein supplementation. A protein target of 1.2-1.5 g/kg/day was reported in one older-adult programme. |
| Psychological support | Coping strategies, brief psychological guidance, relaxation, imagery/visualization, deep breathing, and music-based relaxation. Reported frequency: relaxation 3 times/week in one frailty programme. |
| Risk reduction | Smoking cessation, alcohol reduction, anaemia correction where clinically appropriate, medication review, and comorbidity optimization. |
| Monitoring | Track attendance/adherence, adverse effects, walking capacity or 6-minute walk test, sit-to-stand, symptoms, nutrition/weight, distress, and readiness for treatment. |
Interpretation of the evidence
- The best-defined multimodal protocols are in colorectal cancer and frail surgical populations.
- For lung cancer, exercise and respiratory training are common, but nutrition and psychological support are inconsistently included despite being central to a true multimodal programme.
- For upper-GI cancer, multimodal programmes appear more promising than exercise alone, but exact dose, frequency, and duration remain poorly standardized.
- The 2026 fragility analysis found that much cancer-surgery prehabilitation evidence is statistically fragile, so these protocols should be implemented as individualized optimization rather than as a rigid standard. See Cook et al., 2026.
The accessible full texts were the lung cancer review, frail cancer-surgery meta-analysis, GI oncology review, and upper-GI comparative analysis.
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