A tiered, multimodal prehabilitation service integrated into cancer pathways produced meaningful functional, psychological, and behavioural benefits, supporting broader implementation and improved patient access.
Key Findings
Results
Functional capacity measured by the Incremental Shuttle Walk Test (ISWT) improved significantly across all prehabilitation pathways.
ISWT increased by 57 metres (p < 0.001, d = 0.6), representing a medium effect size
The 60-second Sit-to-Stand (STS) test improved by 6 repetitions (p < 0.001, d = 0.9), representing a large effect size
Improvements were observed across all three pathways: Specialised (n = 329), Targeted (n = 943), and Universal (n = 448)
Functional capacity was assessed using ISWT, 60-s Sit-to-Stand, and grip strength measures
Results
Anxiety and depression scores decreased significantly following multimodal prehabilitation.
Anxiety scores (GAD-7) decreased by a mean of 1.9 points (p < 0.001, d ≈ -0.5)
Depression scores (PHQ-9) decreased by a mean of 2.0 points (p < 0.001, d ≈ -0.5)
Both effect sizes were in the medium range (d ≈ -0.5)
PHQ-9 improved more in the Specialised pathway versus the Targeted pathway, representing one of few significant between-group differences
Results
Physical activity behaviour improved substantially across all prehabilitation pathways.
Weekly physical activity increased by 142 minutes (d = 1.07), representing a large effect size
Strength training sessions increased by 2.4 sessions per week (d = 1.1), also a large effect size
Strength sessions increased more in the Universal pathway versus the Targeted pathway
Physical activity behaviour was self-reported and recorded as part of routine care data
Results
Between-group differences across the three prehabilitation pathways were limited despite different levels of intensity and support.
PHQ-9 (depression) improvement was greater in Specialised versus Targeted pathway
Strength sessions increased more in Universal versus Targeted pathway
No other statistically notable between-group differences were reported
All three pathways showed significant within-group improvements on functional, psychological, and behavioural outcomes
Methods
Of 1961 referred patients, 1720 were included in the analysis across three risk-stratified prehabilitation pathways.
Specialised pathway included 329 patients, Targeted pathway 943 patients, and Universal pathway 448 patients
241 referred patients were excluded from the analysis (reason not specified in abstract)
Data were collected retrospectively from routine NHS care between 2022 and 2025 at Nottingham University Hospitals NHS Trust
The service was multimodal, incorporating exercise, nutrition, and psychological support stratified by risk
What This Means
This research evaluated a structured prehabilitation program for cancer surgery patients at a large NHS hospital in Nottingham, England. Prehabilitation refers to interventions delivered before surgery to improve a patient's physical and mental condition, potentially making them better able to withstand and recover from the operation. The program was delivered through three tiers of care based on patient risk level — Specialised, Targeted, and Universal — and included exercise, nutritional support, and psychological care. Data were collected from nearly 1,800 patients between 2022 and 2025.
The study found meaningful improvements across all three tiers of the program. Patients walked farther on a standardised fitness test, performed more sit-to-stand repetitions, reported less anxiety and depression, and substantially increased their weekly physical activity and strength training. Effect sizes for physical activity and strength training were large, suggesting these were not trivial changes. Notably, the improvements were broadly similar across all three pathways, suggesting that even lower-intensity universal support produced meaningful gains.
This research suggests that integrating tiered prehabilitation into routine cancer surgery pathways is feasible within a real-world NHS setting and can produce functional, psychological, and behavioural benefits for patients prior to surgery. The findings may support arguments for broader implementation of such services and improved patient access to prehabilitation, regardless of which level of care intensity patients receive. Because this was a retrospective service evaluation without a control group, it is not possible to determine how outcomes would have compared without prehabilitation.
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Alharbi A, Haywood A, O'Connor D. (2026). Delivering prehabilitation in cancer surgery: a service evaluation at Nottingham University Hospitals.. Supportive care in cancer : official journal of the Multinational Association of Supportive Care in Cancer. https://doi.org/10.1007/s00520-026-11113-y