The impact of prehabilitation and protein supplementation in improving cancer surgery outcomes

2024 - 16 - 02Medical Nutrition

Research predicts that there will be 28 million new cancer cases worldwide each year by 2040

Cancer Research UK, Worldwide cancer statistics, 2023

, providing current cancer incidence, population growth and ageing trends continue. However, in countries with well-equipped health systems, survival rates of many cancers are improving

World Health Organisation, ‘Cancer’ webpage, accessible at:

. This is thanks largely in part to accessible early detection and improved treatment techniques, including surgeries.

While surgery can be a key treatment path for some patients with cancer, many are not fully fit for surgery due to poor physical health. Factors such as age, sedentary lifestyles, diet, smoking and excessive alcohol consumption make some cancer patients more susceptible to post-operative complications. Despite remarkable advancements in perioperative care, many patients experience new or worsening impairments after surgery, which can persist months after an operation

Lawrence VA, Hazuda HP, Cornell JE, et al. Functional independence after major abdominal surgery in the elderly. J AmColl Surg. 2004;199(5): 762-772. doi:10.1016/j.jamcollsurg.2004.05.280
Stabenau HF, Becher RD, Gahbauer EA, Leo-Summers L, Allore HG, Gill TM. Functional trajectories before and after major surgery in older adults. Ann Surg. 2018;268(6):911-917. doi:10.1097/ SLA.0000000000002659

. And in the instances of some specific cancers, morbidity rates unfortunately remain high, sitting between 19.7% to 37.4%

Sharp SP, Malizia R, Skancke M, et al. A NSQIP analysis of trends in surgical outcomes for rectal
cancer: what can we improve upon? Am J Surg. 2020;220(2):401-407. doi:10.1016/j.amjsurg.2020.


With more than 9 million cancer surgeries performed each year –6 a figure which is estimated to increase 50% by 2040

Perera SK, Jacob S, Wilson BE, et al. Global demand for cancer surgery and an estimate of the optimal surgical and anaesthesia workforce between 2018 and 2040: a population-based modelling study. Lancet Oncol. 2021;22(2):182-189. doi:10.1016/S1470-2045(20)30675-6

 – the associated risks of post-operative complications pose a significant burden to both patients and global healthcare systems. But now, new research is shedding light on an approach that can support cancer patients with improved recovery after surgery – prehabilitation.

In a recent study conducted by Maxima Medical Centre (MMC), FrieslandCampina Ingredients’ Nutri Whey™ Isolate whey protein was used as part of a tailored trial to explore the benefits of prehabilitation. Keep reading to discover more about the outcomes of this study.

What is prehabilitation?

Prehabilitation, or ‘prehab’, is a proactive, multimodal approach to healthcare that focuses on improving a patient’s physical, mental and emotional well-being before undergoing a medical procedure or surgery. The aim is to improve outcomes and help patients retain a high level of function post-surgery by improving health pre-surgery. Prehabilitation programmes take a holistic and structured approach to providing support, seeing the pre-operative period as a ‘teachable moment’ in which patients are more likely to engage with structured behavioural intervention. Typically, prehab programmes focus on issues such as:

  1. Strength and fitness training
  2. Dietary advice and pre-surgery supplements – in particular, often increasing protein intake
  3. Lifestyle modifications – for example, alcohol or smoking cessation support
  4. Mental guidance
  5. Correction of conditions such as anaemia

When it comes to nutrition, increasing protein intake is a key cornerstone of prehabilitation. With critically ill patients susceptible to losing as much as 2% of their muscle mass per day

Heyland D, Earthman C, Compher C. Acute Muscle Wasting Among Critically Ill Patients. JAMA. 2014;311(6):621–622. doi:10.1001/jama.2013.285420

. supporting muscle protein synthesis via supplementation can help patients retain muscle mass, strength, mobility and function, ultimately supporting faster recovery times and improved clinical outcomes.

Diving into the research: the benefits of prehabilitation

Improved patient outcomes 
Recently published in JAMA Surgery, a new research trial conducted by MMC set out to explore the impact of prehabilitation on patients undergoing colorectal cancer surgery

Molenaar et al. Effect of Multimodal Prehabilitation on Reducing Postoperative Complications and Enhancing Functional Capacity Following Colorectal Cancer Surgery. JAMA Surg. 2023: 1-10 doi:10.1001/jamasurg.2023.0198

. The trial aimed to determine whether multimodal prehabilitation before cancer surgery can reduce post-operative complications and support recovery.

About the study
251 adult patients with nonmetastatic colorectal cancer were randomised into prehabilitation or standard care. Those patients, as part of the prehabilitation trial, received a tailored four-week program to improve their pre-surgery health. This included:

  • A curated dietary intervention programme including a daily 30g dose of FrieslandCampina Ingredients’ Nutri Whey™ Isolate whey protein, administered within one hour of the exercise session and again one hour before sleep
  • Three weekly sessions of one-hour aerobic and strength exercises

Post-operative complications were evaluated using the Comprehensive Complication Index (CCI), which measures accumulative complications on a numerical scale from 0 (no complications) to 100 (death). Functional capacity was measured through the 6-minute walking distance (6-MWD) test, which is used to assess heart and lung capacity for frail patients. Results were then compared to the control group receiving standard care.

Key results 
The findings of the trial demonstrated the significant benefits of prehabilitation for patients undergoing cancer surgery. Compared to the control group, patients who participated in the prehabilitation program:

  • Experienced a notable 40% reduction in serious complications (e.g., cardiovascular or respiratory) within 30 days of surgery
  • Were discharged from hospital two days earlier on average
  • Demonstrated faster and better recovery of postoperative functional capacity with better results in the 6-minute walk test after 4 and 8 weeks
  • Displayed increased engagement in exercise both before and after surgery, leading to enhanced strength, confidence and a faster return to an active recovery phase

The impact of prehabilitation on patient adherence to nutritional intervention

Another study published in Nutrients set out to examine patient adherence to nutritional supplementation, which is a key contributor to the efficacy of prehabilitation

van Exter, Sabien H et al. “Adherence to and Efficacy of the Nutritional Intervention in Multimodal Prehabilitation in Colorectal and Esophageal Cancer Patients.” Nutrients vol. 15,9 2133. 28 Apr. 2023, doi:10.3390/nu15092133

.This was investigated as it is often a challenge for some cancer patients to consume an adequate amount of protein.  Specifically, the study set out to demonstrate whether intervention could support patients in achieving a protein intake of ≥1.5 g of protein/kg body weight per day.

In the study, a cohort of 64 participants with either colorectal or oesophageal cancer underwent a personalised multimodal prehabilitation program containing four different modalities: a nutritional intervention, an exercise program, psychological support, and a smoking cessation program. As part of the nutritional intervention, patients received advice to aim for at least two meals per day containing 25g of protein or more. Excluding those that required tube feeding, patients received high-quality whey protein shakes made using FrieslandCampina Ingredients’ Nutri Whey™ Isolate to consume daily before bedtime and after supervised exercise sessions which took place 2-3 times per week.

What does this mean for the future of medical nutrition?

The results of these trials provide further evidence for prehabilitation, signifying its important role in supporting patient adherence to nutritional advice, and reducing the risk of potentially difficult, painful and life-threatening complications after cancer surgery.

But the implications of this research extend far beyond cancer surgery. Prehabilitation programmes in several hospitals across the globe are showing the substantial potential impact on reducing post-surgery complications in various patient groups.

As research gains recognition, it opens doors for improved patient care, enhanced recovery and a reimagining of medical nutrition practices. By embracing and expanding prehabilitation initiatives, including focus on dietary supplementation, we can reduce post-operative complications and revolutionise the way we approach surgical interventions.

At FrieslandCampina Ingredients, we’re dedicated to providing ingredients that help consumers with special dietary needs get the most out of life, always. If you’d like to learn more about our medical nutrition solutions, click here:

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