Universal prehabilitation is the provision of expert advice on exercise, nutrition and psychological support, along with behaviour change advice, to all individuals before cancer treatment.

Universal prehabilitation (e.g. surgery school) is the foundation of prehabilitation and may involve screening.

It should be noted that generic lifestyle advice alone does not constitute universal prehabilitation.

Universal interventions are applicable to anyone with cancer and should be considered in the first instance.

A universal awareness of the psychological impact of cancer and ability to recognise distress and signpost appropriately is important at this level. The retired NICE (2004) guidance describes interventions at level 1 as the ability to “communicate honestly and compassionately with those affected by cancer; treat patients and carers with kindness, dignity and respect; establish and maintain supportive relationships; inform patients and carers about the wide range of emotional and support services available to them.”

There is no formal requirement for clinical supervision of staff at this level.

Optimum approaches for all those involved in the delivery of universal support and interventions include:

• Using a health coaching approach to support behaviour change, this involves supporting people to plan and reach their own goals rather than focussing on what professionals want them to achieve. It is holistic and focuses on what matters most to the individual. This approach has many benefits including improved adherence to treatment regimens, people are more likely to monitor their own condition and take up recommended care when is needed, clinical outcomes are better and experiences of care is improved
• Developing a holistic understanding of the impact of cancer on the person by using the Holistic Needs Assessment as a screening tool which can be undertaken by any member of the healthcare team
• Active listening (asking and listening can be an intervention in itself)
• Signposting to support that the person feels is relevant
• Communicating with compassion gathering relevant information and discuss onward referral where appropriate
• Adopt Wellbeing conversations advocating for supported self-management. Use Making Every Contact Count (MECC) approaches
• Encourage the use of self-management and health lifestyle websites and/or APPS
• Develop person-led goals

Universal interventions include the promotion of healthy lifestyle in people living with cancer. This will include those areas that can make the greatest improvement to an individual’s health and wellbeing including:

• Healthy eating
• Being physically active and physically fit
• Keeping to a healthy weight
• Improving mental health and wellbeing
• Stopping smoking
• Drinking alcohol only within recommended limits

Support for people with cancer can include:

• A wealth of relevant information on the Cancer Matters Wessex website
• Health and wellbeing support, information and supportive conversations which are part of personalised care
• Can-Empower helps people to manage the psychological and emotional challenges of living with cancer
• Macmillan Cancer Support – Eating well and keeping active has a wealth of resources to support people with cancer with healthy lifestyle advice as well as the management of the symptoms and side effects of cancer and its treatments
• Cancer Research UK has useful information about prehabilitation
• NHS Better Health can help people get healthier and feel better with free tips, tools and support
• Moving Medicine includes resources for health and care professionals and patients with the aim of encouraging behaviour change
• Fitter Better Soon resources will provide patients with the information needed to become fitter and better prepared for surgery

Targeted prehabilitation is assessed and prescribed by a registered healthcare professional with relevant competencies and may be delivered by un-registered or non-healthcare professionals.

Targeted prehabilitation is applicable to:

• those people with cancer with and at risk of late effects of disease or treatment
• those with other long-term conditions
• those with specific needs identified during screening, who should be prescribed exercise, nutrition and psychological interventions and behaviour change

Appropriate reconditioning and/or prehabilitation exercise programmes should be incorporated into care. Any support provided should be needs-based and consider the disease, treatment, side effects and any co-morbidities.

Interventions include:

• 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 minutes of 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
• A combination of aerobic and strength exercise should be prescribed to patients undergoing surgery to increase physical function and exercise capacity and improve perioperative outcomes
• The aerobic exercise component should be performed at moderate-to-high intensity where appropriate (including high intensity interval training)
• Inspiratory muscle training, in combination with aerobic and strength exercises is recommended for patients having lung cancer surgery to improve perioperative outcomes

Take the following action if you are concerned about exercise: Contact with the individual to troubleshoot barriers and self-monitoring of exercise and physical activity.

Interventions should be needs-based with individualised treatment plans.

It is important to:

• assess the patient’s readiness to change
• convey reasons and goals for nutritional recommendations
• motivate the patient to adapt to altered nutritional demand of their disease

Targeted nutrition interventions:

• 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
• Nutrition treatment plans should prioritise the oral route, assuming the person has a functioning gastrointestinal tract, to meet the nutrition prescription and requirements using strategies such as individualised counselling and oral nutritional supplements
• It is recommended that patients unable to meet 50-60% of their energy and protein requirements through oral intake be assessed for enteral or parenteral nutrition
• Other clinical conditions affecting dietary intake (e.g. diabetes and other long term conditions that have dietary implications) should be considered
• The routine use of intentional weight loss interventions for patients preparing for or undergoing acute cancer treatment is not recommended
• It is recommended that patients with malnutrition or those following restrictive diets be assessed for micronutrient deficiencies and receive targeted supplementation

Take the following action if you are concerned about nutrition: Contact with the individual to troubleshoot barriers and self-monitoring of weight, dietary intake and nutrition impact factors is appropriate.

“Professionals operating at this level should be able to screen for psychological distress at key points in the patient pathway, including around the time of diagnosis, during treatment, as treatment ends, and at recurrence”

(from retired NICE Supportive and Palliative Care Guidance from 2004)

Intervention is informed by targeted assessment. It requires broader contextual awareness of the individual and their health: Prehabilitation services should include the systematic early detection of pre-existing mental health difficulties and risk factors which may interact with cancer treatments.

Interventions at this level should involve discreet techniques delivered by trained and supervised health and social care professionals to manage acute situational crises at key points in the patient pathway.

Health care professionals working at this level must have access to specialist psycho-oncology services for psychological skills training, supervision, consultation and escalation.

Specialist prehabilitation is assessed, prescribed and delivered by registered healthcare professionals.

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.

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 due to head and neck surgery
• reduction/rehabilitation of the body after different procedures and/or because of side effects and symptoms of treatment

Take the following action if you are concerned about exercise: The individual may require close monitoring and re-assessment of their activity levels and modified accordingly.

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).

Take the following action if you are concerned about nutrition: The individual may require close monitoring and re-assessment so that the nutrition prescription can be quickly modified if it is not adequately meeting individual needs or achieving expected outcomes.

It is recommended that embedded specialist psycho-oncology services are provided for patients with psychological difficulties that are impacting on, or impacted by, a cancer diagnosis and/or treatment.

Interventions can support access to and tolerance of cancer treatment.

Psychological services are also required for the oversight of targeted interventions and the escalation of concerns. This includes appropriate workforce training and supervision.

Indirect work – for example, consulting with MDTs about a patient’s care, developing within the team a psychological understanding of a patient’s needs and difficulties.

For the integration of a stratified approach to patient care.