Principles of targeted interventions:

• applicable to those people with cancer with, and at risk of, late effects of disease or treatment and those with other long-term conditions
• those with specific needs identified during screening should be prescribed exercise, nutrition and psychological interventions and behaviour change support by a registered health and care professional according to need and adherence and effectiveness should be monitored

Interventions may be delivered by:

• Physiotherapists (registered, enhanced, advanced)
• Specialised clinical exercise physiologists (registered, enhanced, advanced)
• Rehabilitation/therapy support workers, trained cancer exercise fitness instructors (supportive)
• Therapy assistant practitioner (assistive)

Targeted exercise interventions include:

• appropriate reconditioning and/or prehabilitation exercise programmes should be incorporated into care. Support is based on disease/treatment/side effects/co-morbidities
• Group exercise or one-to-one support in local community gym setting run by cancer exercise specialists such as ‘Move More’ aiming to increase frequency, intensity and duration of exercise incrementally to get as near as possible to 150 minutes of moderate intensity (75 min vigorous intensity or combination) by surgery or other treatment date
• Some supervision and structured exercise may be required for those who are sufficiently active (30–150 minutes per week) or those with low self- efficacy
• Where possible interval training including moderate severe exercise intensities should be included as this has been shown to improve physical fitness

Prehabilitation services throughout the United Kingdom are continuing to provide insight into the feasibility of service implementation and collect data regarding programme efficacy.

Poor pre-operative physical fitness is consistently linked with worse post-operative outcome. Increasing numbers of clinical trials have help inform the design and development of the prehabilitation programmes which have exercise as a fundamental component. These trials and subsequent metanalyses have demonstrated evidence of reduced length of stay, reduced morbidity, reduced pulmonary complications and improved exercise capacity.

Interval training, especially at high intensity, has been shown to improve fitness more rapidly, and work is continuing to establish the minimum clinically important dose. Respiratory muscle training using handheld resistance devices have demonstrated reductions in post-operative pulmonary complications. Study heterogeneity and conflicting findings validates the importance of continued data collection from high quality prehabilitation programmes.

Prehabilitation during COVID-19 has presented multiple challenges. SafeFit was developed in response to the pandemic to support people with cancer to maintain and improve their physical and emotional wellbeing, while following government guidelines. It is a free-of-charge remote trial for UK residents with suspicion of, or confirmed diagnosis of, cancer. The trial is ongoing and formal report of trial results are awaited.

Principles of targeted nutrition interventions:

• advice and guidance is person-centred and based on the nutritional assessment

• focused on the types and amounts of foods/drinks consumed and assumes a functioning gastrointestinal tract

• those identified as being at high risk of malnutrition and/or those who are unable to manage their nutritional needs without specialist support should undergo an objective and quantitative assessment which considers nutritional intake, nutrition impact symptoms, muscle mass, physical performance, and the degree of systemic inflammation.

• aims to improve food intake (quantitatively/qualitatively), address the presence or severity of symptoms that may limit eating and drinking, or to determine adherence with therapeutic advice
• considers other medical conditions affecting dietary intake (e.g. diabetes and other long term conditions that have dietary implications)
• critical components
  • assess the patients’ readiness to change
  • convey reasons and goals for nutritional recommendations
  • motivate the patient to adapt to altered nutritional demand of their disease (see section on Motivational Interviewing)
• if dietary modification is not sufficient, micronutrient supplements, protein supplements or oral nutrition supplements may be used to fortify the diet
  • may be prescribed and/or patient may be fed a controlled diet under supervised conditions e.g., high energy, high protein fortified meal choices advised as part of an inpatient hospital stay

• speech and language therapists work with dietitians to address symptoms that limit nutritional intake
• signpost/refer onto other professional services/agencies when deemed appropriate
• deliver suitable and supportive weight management services that are free from stigma and bias

Preoperative nutrition (by any route) in malnourished patients has been shown to reduce postoperative complications following GI surgery.

Improving protein intake to the suggested 1.5-2g/kg/day has been specifically indicated in reducing lean muscle loss following surgery when combined with other methods of prehabilitation.

Specific psychological factors including depression have been shown to negatively affect postoperative outcomes. A systematic review of psychological interventions prior to surgery for cancer showed that there was no effect on surgical outcomes (e.g. length of hospital stay, complications, analgesia use, or mortality) but that the intervention positively affected patients’ reported outcome measures (PROMS) including psychological outcomes, quality of life, and somatic symptoms. A further systematic review concluded that it was important to stratify care and target interventions at patients who reached ‘caseness’ (meeting the diagnostic criteria for a psychiatric disorder).

Targeted psychological interventions

Level 2

• NICE (2004) describes interventions such as psychological techniques such as problem-solving “delivered by trained and supervised health and social care professionals to manage acute situational crises at key points in the patient pathway. Clinical nurse specialists, among others, might be trained and supported to undertake assessments and to deliver relevant interventions.”
• Level 2 training packages have taught skills such as:
  • distraction and relaxation derived from cognitive behavioural therapy (CBT)
  • acceptance and commitment therapy (ACT)-based approach incorporating exercises designed to promote psychological-flexibility and values-based action (e.g. SWAG training package).
• Monthly supervision requirement for cancer CNSs should be offered. Supervision should also be open to any healthcare professionals offering Level 2 support and delivered by health and care professionals with psychological assessment skills and expertise in psychological support/ e.g., clinical nurse specialist, systemic anti-cancer therapy (SACT) nurses, dietitians, health psychologists, occupational therapists, physiotherapists, radiographers, speech and language therapists (enhanced, advanced, advanced)
• Advanced communication skills would be complimentary to the expertise described above

Level 2 plus (Wessex definition)

This is recognition that services, roles and psychological approaches/techniques have evolved since the publication of NICE guidance outlining levels of psychological practice 1-4 (2004). Within Wessex we acknowledge that there is a group of practitioners with training and experience that sits above the threshold traditionally accepted as Level 2 practice. These practitioners would be providing additional psychological intervention techniques deployed under the supervision of a level 3 or level 4 practitioner to hold and de-escalation.

Supervision would be the same as Level 2.

This level of support could be delivered by nurses or AHPs, possibly those working at consultant level if they have specialised in approaches to promote holistic wellbeing of cancer patients (e.g. I would not view a consultant nurse with a predominantly medical role and limited experience or training in psychological approaches to be working at this level). These members of staff may have undertaken additional training – e.g. a counselling skills course. (Advanced, consultant and possibly pre-registered psychological professions such as assistant psychologist).

Possibly pre-qualified/pre-registered psychological professionals.

Practitioners working at a locally recognised Level 2 plus would have Level 2 psychological skills training plus additional skills (e.g. they may be trained in and regularly deliver Compassion Focussed Therapy (CFT), Acceptance and Commitment Therapy (ACT) and Managing Cancer and Living Meaningfully therapy daily to patients informed by CBT.

Applicable to people with cancer who have complex needs, complex treatment e.g., major surgery, severe impairment and/or disability. These people will need referral to registered professionals to prescribe appropriate exercise, nutrition and psychological interventions and behaviour change support according to need. Adherence and effectiveness should be monitored.

Delivered by :

• Physiotherapists
• Clinical exercise physiologists
• Speech and language therapists
• Prosthetists
• Orthotists
• Lymphoedema practitioner (registered, enhanced, advanced, consultant)

Interventions would include fully supervised exercise interventions (aerobic/endurance/strength) for those very inactive/sedentary/co-morbidities, contemplative/low self-efficacy or treatment related indications (e.g. major surgery).

Interventions may also include services providing pelvic floor services, development and provision of prosthesis, manual lymphatic drainage by lymphoedema practitioners, support for people who have had free flaps as a result of head and neck surgery and reduction/rehabilitation of the body after different procedures and/or as a result of side effects and symptoms of treatment.

Interventions would include Artificial Nutritional Support (ANS) offered by a nutrition/dietetic professional where ANS artificial nutrition support is delivered to the patient via enteral or parenteral nutrition as a result e.g. of location of tumour, swallowing problems (dysphagia), excessive weight loss, management of high output stomas, other long term conditions such as diabetes and intestinal failure.

ANS might be used to supplement the oral intake or used exclusively to meet patients’ needs and includes enteral nutrition delivered by tube (e.g. Nasogastric tube, Jejunostomy tube, Percutaneous Endoscopic Gastrostomy) or delivered intravenously as parenteral nutrition (PN).

• Level 3 would be delivered by psychological professionals such as Psychological Practitioners or Psychological Therapists – see https://ppn.nhs.uk/resources/careers-map
• In practice, this includes counsellors and cognitive behavioural therapists e.g. working in NHS Talking Therapies services or psycho-oncology teams
• Level 3 practitioners may be mental health practitioners (nurse, social worker), dual trained nurses (with current NMC registration as a mental health nurse and working in a role that is focused on psychological support in cancer setting), occupational therapists or a CNS who has gone on to complete formal training as a counsellor and is regularly employing these skills in their role. Those working at this level should receive an induction to working in psycho-oncology (enhanced, advanced, consultant). Clinical supervision varies depending on role and experience
• Level 4 NICE (2004) doesn’t specify any single approach. Psychologists are trained in and/or use CBT, third-wave approaches (Acceptance and Commitment Therapy – ACT, Compassion focussed therapy (CFT), mindfulness-based therapy), Eye Movement Desensitization and Reprocessing (EMDR) and systemic therapy. A formulation-driven approach would be taken while also considering the available evidence-base – e.g. for specific psychological difficulties, NICE guidance may indicate one type of intervention over another
• This could include working with moderate-to-severe levels of distress and people may be seen for a single consultation or for ongoing therapy. They may be seen work with difficulties related to cancer, or with mental health difficulties impacted/impacting on cancer care
• This level would be delivered by practitioner psychologists (see https://ppn.nhs.uk/resources/careers-map) e.g. clinical psychologists, counselling psychologists, health psychologists – with appropriate training and experience. Trainee practitioner psychologists with appropriate supervision. Psychiatrists also feature at this level
• Those working at this level should receive an induction to working in psycho-oncology

Clinical supervision varies depending on role and experience and would not be less than monthly.