DELIVERING MULTIMODAL PREHABILITATION IN THE NEOADJUVANT WINDOW BEFORE ESOPHAGOGASTRIC CANCER SURGERY: HOME-BASED MODELS, DIGITAL HEALTH, AND IMPLEMENTATION – A NARRATIVE REVIEW
DOI:
https://doi.org/10.31435/ijitss.3(51).2026.6368Keywords:
Prehabilitation; Telemedicine; Mobile Health; Esophagectomy; Neoadjuvant Therapy; Health Services AccessibilityAbstract
Esophagectomy and gastrectomy for esophagogastric cancer are among the most physiologically demanding oncological operations and carry high rates of postoperative morbidity. Because neoadjuvant chemotherapy or chemoradiotherapy now precedes surgery in most patients with locally advanced disease, the preoperative interval offers an opportunity to intervene through multimodal prehabilitation, combining aerobic and resistance exercise, inspiratory muscle training, nutritional optimization, and psychological support. This narrative review synthesizes the rationale and current evidence for prehabilitation during the neoadjuvant window and, in particular, examines how it can be delivered in practice. Prehabilitation consistently improves preoperative functional capacity and respiratory muscle strength, and inspiratory muscle training is associated with fewer postoperative pulmonary complications, although effects on overall morbidity, length of stay, and mortality remain inconsistent. Beyond efficacy, the review foregrounds delivery and implementation: supervised hospital-based programmes are resource-intensive and geographically limiting, whereas home-based and digitally supported models — using smartphone applications, wearable sensors, and telehealth contact — offer a scalable alternative, with early evidence that home-based delivery may be comparable to supervised care. Technology-enabled prehabilitation raises its own questions of access and equity, including digital literacy and connectivity, that determine whether it narrows or widens existing disparities. Prehabilitation timed to the neoadjuvant window is a biologically plausible, feasible, and low-risk strategy to improve preoperative fitness; its translation into routine esophagogastric cancer care now depends as much on delivery model, technology, and implementation as on defining optimal clinical content, and standardized, adequately powered trials are needed to confirm benefit.
References
Agrelli, T. F., de Carvalho Ramos, M., Guglielminetti, R., Silva, A. A., & Crema, E. (2012). Preoperative ambulatory inspiratory muscle training in patients undergoing esophagectomy: A pilot study. International Surgery, 97(3), 198–202.
Allen, S. K., Brown, V., White, D., King, D., Hunt, J., Wainwright, J., Emery, A., Hodge, E., Kehinde, A., Prabhu, P., Rockall, T. A., Preston, S. R., & Sultan, J. (2022). Multimodal prehabilitation during neoadjuvant therapy prior to esophagogastric cancer resection: Effect on cardiopulmonary exercise test performance, muscle mass and quality of life—A pilot randomized clinical trial. Annals of Surgical Oncology, 29(3), 1839–1850. https://doi.org/10.1245/s10434-021-11002-0
Argudo, N., Rodó-Pin, A., Martínez-Llorens, J., Marco, E., Visa, L., Messaggi-Sartor, M., Balañá-Corberó, A., Ramón, J. M., Rodríguez-Chiaradía, D. A., Grande, L., & Pera, M. (2021). Feasibility, tolerability, and effects of exercise-based prehabilitation after neoadjuvant therapy in esophagogastric cancer patients undergoing surgery: An interventional pilot study. Diseases of the Esophagus, 34, doaa086. https://doi.org/10.1093/dote/doaa086
Baimas-George, M., Watson, M., Elhage, S., Parala-Metz, A., Vrochides, D., & Davis, B. R. (2020). Prehabilitation in frail surgical patients: A systematic review. World Journal of Surgery, 44(11), 3668–3678. https://doi.org/10.1007/s00268-020-05658-0
Bausys, A., Luksta, M., Anglickiene, G., Maneikiene, V. V., Kryzauskas, M., Rybakovas, A., Dulskas, A., Kuliavas, J., Stratilatovas, E., Macijauskiene, L., Simbelyte, T., Celutkiene, J., Jamontaite, I. E., Cirtautas, A., Lenickiene, S., Petrauskiene, D., Cikanaviciute, E., Gaveliene, E., Klimaviciute, G., . . . Strupas, K. (2023). Effect of home-based prehabilitation on postoperative complications after surgery for gastric cancer: Randomized clinical trial. British Journal of Surgery, 110(12), 1800–1807. https://doi.org/10.1093/bjs/znad312
Boden, I., Skinner, E. H., Browning, L., Reeve, J., Anderson, L., Hill, C., Robertson, I. K., Story, D., & Denehy, L. (2018). Preoperative physiotherapy for the prevention of respiratory complications after upper abdominal surgery: Pragmatic, double-blinded, multicentre randomised controlled trial. BMJ, 360, j5916. https://doi.org/10.1136/bmj.j5916
Bolger, J. C., Loughney, L., Tully, R., Cunningham, M., Keogh, S., McCaffrey, N., Hickey, W., & Robb, W. B. (2019). Perioperative prehabilitation and rehabilitation in esophagogastric malignancies: A systematic review. Diseases of the Esophagus, 32(9), doz058. https://doi.org/10.1093/dote/doz058
Carli, F., & Scheede-Bergdahl, C. (2015). Prehabilitation to enhance perioperative care. Anesthesiology Clinics, 33(1), 17–33.
Carli, F., Silver, J. K., Feldman, L. S., McKee, A., Gilman, S., Gillis, C., Scheede-Bergdahl, C., Gamsa, A., Stout, N., & Hirsch, B. (2017). Surgical prehabilitation in patients with cancer: State-of-the-science and recommendations for future research from a panel of subject matter experts. Physical Medicine and Rehabilitation Clinics of North America, 28(1), 49–64.
Cemaga, R., Hebda, P., Czapliński, M., Szplit, E., Patalong, M., Pustuła, P., et al. (2026). The role of physical activity in the prevention and management of various cancers. Journal of Education, Health and Sport, 88, 68346. https://doi.org/10.12775/JEHS.2026.88.68346
Christensen, J. F., Simonsen, C., Banck-Petersen, A., Thorsen-Streit, S., Herrstedt, A., Djurhuus, S. S., Egeland, C., Mortensen, C. E., Kofoed, S. C., Kristensen, T. S., Garbyal, R. S., Pedersen, B. K., Svendsen, L. B., Højman, P., & de Heer, P. (2019). Safety and feasibility of preoperative exercise training during neoadjuvant treatment before surgery for adenocarcinoma of the gastro-oesophageal junction. BJS Open, 3, 74–84. https://doi.org/10.1002/bjs5.50110
Dettling, D. S., van der Schaaf, M., Blom, R. L., Nollet, F., Busch, O. R., & van Berge Henegouwen, M. I. (2013). Feasibility and effectiveness of pre-operative inspiratory muscle training in patients undergoing oesophagectomy: A pilot study. Physiotherapy Research International, 18(1), 16–26. https://doi.org/10.1002/pri.1524
Dronkers, J., Veldman, A., Hoberg, E., van der Waal, C., & van Meeteren, N. (2008). Prevention of pulmonary complications after upper abdominal surgery by preoperative intensive inspiratory muscle training: A randomized controlled pilot study. Clinical Rehabilitation, 22(2), 134–142. https://doi.org/10.1177/0269215507081574
Finley, D. J., Stevens, C. J., Emond, J. A., Batsis, J. A., Fay, K. A., Darabos, C., Sacks, O. A., Cook, S. B., & Lyons, K. D. (2021). Potential effectiveness of a surgeon-delivered exercise prescription and an activity tracker on pre-operative exercise adherence and aerobic capacity of lung cancer patients. Surgical Oncology, 37, 101525. https://doi.org/10.1016/j.suronc.2021.101525
Guinan, E. M., Forde, C., O’Neill, L., Gannon, J., Doyle, S. L., Valkenet, K., Trappenburg, J. C. A., van Hillegersberg, R., Ravi, N., Hussey, J. M., & Reynolds, J. V. (2019). Effect of preoperative inspiratory muscle training on physical functioning following esophagectomy. Diseases of the Esophagus, 32(2), doy091. https://doi.org/10.1093/dote/doy091
Halliday, L. J., Doganay, E., Wynter-Blyth, V. A., Hanna, G. B., & Moorthy, K. (2021). The impact of prehabilitation on post-operative outcomes in oesophageal cancer surgery: A propensity score matched comparison. Journal of Gastrointestinal Surgery, 25, 2733–2741. https://doi.org/10.1007/s11605-020-04881-3
Huang, G. H., Ismail, H., Murnane, A., Kim, P., & Riedel, B. (2016). Structured exercise program prior to major cancer surgery improves cardiopulmonary fitness: A retrospective cohort study. Supportive Care in Cancer, 24(5), 2277–2285.
Ikeda, T., Toyama, S., Harada, T., Noma, K., Hamada, M., & Kitagawa, T. (2024). Effectiveness of prehabilitation during neoadjuvant therapy for patients with esophageal or gastroesophageal junction cancer: A systematic review. Esophagus, 21(3), 283–297. https://doi.org/10.1007/s10388-024-01049-9
Janssen, T. H. J. B., Fransen, L. F. C., Heesakkers, F. F. B. M., Dolmans-Zwartjes, A. C. P., Moorthy, K., Nieuwenhuijzen, G. A. P., & Luyer, M. D. P. (2022). Effect of a multimodal prehabilitation program on postoperative recovery and morbidity in patients undergoing a totally minimally invasive esophagectomy. Diseases of the Esophagus, 35(7), doab082. https://doi.org/10.1093/dote/doab082
Kehlet, H. (2021). Prehabilitation in surgery—Need for new strategies? European Journal of Surgical Oncology, 47(5), 929–930.
Low, D. E., Allum, W., De Manzoni, G., Ferri, L., Immanuel, A., Kuppusamy, M., Law, S., Lindblad, M., Maynard, N., Neal, J., Pramesh, C. S., Scott, M., Mark Smithers, B., Addor, V., & Ljungqvist, O. (2019). Guidelines for perioperative care in esophagectomy: Enhanced Recovery After Surgery (ERAS) Society recommendations. World Journal of Surgery, 43(2), 299–330. https://doi.org/10.1007/s00268-018-4786-4
Minnella, E. M., Awasthi, R., Loiselle, S. E., Agnihotram, R. V., Ferri, L. E., & Carli, F. (2018). Effect of exercise and nutrition prehabilitation on functional capacity in esophagogastric cancer surgery: A randomized clinical trial. JAMA Surgery, 153(12), 1081–1089. https://doi.org/10.1001/jamasurg.2018.1645
Moran, J., Wilson, F., Guinan, E., McCormick, P., Hussey, J., & Moriarty, J. (2016). Role of cardiopulmonary exercise testing as a risk-assessment method in patients undergoing intra-abdominal surgery: A systematic review. British Journal of Anaesthesia, 116(2), 177–191.
Mortensen, K., Nilsson, M., Slim, K., Schäfer, M., Mariette, C., Braga, M., Carli, F., Demartines, N., Griffin, S. M., & Lassen, K. (2014). Consensus guidelines for enhanced recovery after gastrectomy: Enhanced Recovery After Surgery (ERAS) Society recommendations. British Journal of Surgery, 101(10), 1209–1229. https://doi.org/10.1002/bjs.9582
Piraux, E., Caty, G., Reychler, G., Forget, P., & Deswysen, Y. (2020). Feasibility and preliminary effectiveness of a tele-prehabilitation program in esophagogastric cancer patients. Journal of Clinical Medicine, 9(7), 2176. https://doi.org/10.3390/jcm9072176
Silver, J. K., & Baima, J. (2013). Cancer prehabilitation: An opportunity to decrease treatment-related morbidity, increase cancer treatment options, and improve physical and psychological health outcomes. American Journal of Physical Medicine & Rehabilitation, 92(8), 715–727. https://doi.org/10.1097/PHM.0b013e31829b4afe
St-Pierre, J., Coca-Martinez, M., Drummond, K., Minnella, E., Ramanakumar, A. V., Ferri, L., Carli, F., & Scheede-Bergdahl, C. (2024). Multimodal prehabilitation to enhance functional capacity of patients with esophageal cancer during concurrent neoadjuvant chemotherapies—A randomized feasibility trial. Diseases of the Esophagus, 37(12), doae087. https://doi.org/10.1093/dote/doae087
Sung, H., Ferlay, J., Siegel, R. L., Laversanne, M., Soerjomataram, I., Jemal, A., & Bray, F. (2021). Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA: A Cancer Journal for Clinicians, 71(3), 209–249. https://doi.org/10.3322/caac.21660
Swaminathan, N., Kundra, P., Ravi, R., & Kate, V. (2020). ERAS protocol with respiratory prehabilitation versus conventional perioperative protocol in elective gastrectomy—A randomized controlled trial. International Journal of Surgery, 81, 149–157. https://doi.org/10.1016/j.ijsu.2020.07.027
Tay, S. S., Zhang, F., & Neo, E. J. R. (2024). The use of technology in cancer prehabilitation: A systematic review. Frontiers in Oncology, 14, 1321493. https://doi.org/10.3389/fonc.2024.1321493
Twomey, R., Culos-Reed, S. N., & Dort, J. C. (2020). Exercise prehabilitation—Supporting recovery from major head and neck cancer surgery. JAMA Otolaryngology–Head & Neck Surgery, 146(8), 689–690. https://doi.org/10.1001/jamaoto.2020.1346
Valkenet, K., Trappenburg, J. C. A., Schippers, C. C., Wanders, L., Lemmens, L., Backx, F. J. G., & van Hillegersberg, R. (2016). Feasibility of exercise training in cancer patients scheduled for elective gastrointestinal surgery. Digestive Surgery, 33(5), 439–447. https://doi.org/10.1159/000445958
Valkenet, K., Trappenburg, J. C. A., Ruurda, J. P., Guinan, E. M., Reynolds, J. V., Nafteux, P., Fontaine, M., Rodrigo, H. E., van der Peet, D. L., Hania, S. W., Sosef, M. N., Willms, J., Rosman, C., Pieters, H., Scheepers, J. J. G., Faber, T., Kouwenhoven, E. A., Tinselboer, M., Räsänen, J., . . . Backx, F. J. G. (2018). Multicentre randomized clinical trial of inspiratory muscle training versus usual care before surgery for oesophageal cancer. British Journal of Surgery, 105(5), 502–511. https://doi.org/10.1002/bjs.10803
van Adrichem, E. J., Meulenbroek, R. L., Plukker, J. T., Groen, H., & van Weert, E. (2014). Comparison of two preoperative inspiratory muscle training programs to prevent pulmonary complications in patients undergoing esophagectomy: A randomized controlled pilot study. Annals of Surgical Oncology, 21, 2353–2360. https://doi.org/10.1245/s10434-014-3612-y
Waterland, J. L., Chahal, R., Ismail, H., Sinton, C., Riedel, B., Francis, J. J., & Denehy, L. (2021). Implementing a telehealth prehabilitation education session for patients preparing for major cancer surgery. BMC Health Services Research, 21, 443. https://doi.org/10.1186/s12913-021-06437-w
Xu, Y. J., Cheng, J. C., Lee, J. M., Huang, P. M., Huang, G. H., & Chen, C. C. (2015). A walk-and-eat intervention improves outcomes for patients with esophageal cancer undergoing neoadjuvant chemoradiotherapy. The Oncologist, 20(10), 1216–1222. https://doi.org/10.1634/theoncologist.2015-0178
Yamana, I., Takeno, S., Hashimoto, T., Maki, K., Shibata, R., Shiwaku, H., Shimaoka, H., Shiota, E., & Yamashita, Y. (2015). Randomized controlled study to evaluate the efficacy of a preoperative respiratory rehabilitation program to prevent postoperative pulmonary complications after esophagectomy. Digestive Surgery, 32(5), 331–337. https://doi.org/10.1159/000434758
Downloads
Published
Issue
Section
License
Copyright (c) 2026 Natalia Zienkiewicz, Jarosław Rachoń, Adela Dzwonkowska, Jakub Dzwonkowski, Alicja Kozłowska, Daria Trocka, Karolina Przybysz, Luiza Stadnik, Natalia Woroniecka, Nicol Szerenos
This work is licensed under a Creative Commons Attribution 4.0 International License.
All articles are published in open-access and licensed under a Creative Commons Attribution 4.0 International License (CC BY 4.0). Hence, authors retain copyright to the content of the articles.
CC BY 4.0 License allows content to be copied, adapted, displayed, distributed, re-published or otherwise re-used for any purpose including for adaptation and commercial use provided the content is attributed.
How to Cite
