All Wales Ovarian Cancer Prehabilitation Project (AWOCPP)

Project Title: All Wales Ovarian Cancer Prehabilitation Project (AWOCPP)

Project Lead & Pilot location: Sadie Jones - Consultant Gynaecology Oncology Surgeon

Pilot location: Cardiff and Vale University Healthboard

Inequality Criteria: Location

Objective Criteria: Improve patient experience & Improve survival outcomes

Full Project (10 minute read)

Overview:

The All Wales Ovarian Cancer Prehabilitation Project (AWOCPP) aimed to standardise prehabilitation for ovarian cancer patients in Wales. Key objectives include creating an evidence-based framework, assessing eligible patients for personalised programs (including exercise, nutrition, and emotional support), and evaluating patient acceptability.

The project's focus on evaluating the impact on patient outcomes includes:

a. Length of stay in the hospital: Investigating whether prehabilitation reduces hospitalisation time.

b. Post-operative complications: Assessing if prehabilitation lowers the risk of complications following surgery.

c. Surgery to Chemotherapy Interval (SCI)

Exploring how prehabilitation influences the timing between surgery and chemotherapy.

Additionally, the AWOCPP will generate data to understand the resources needed for implementing prehabilitation as standard care in Wales.

Background:

The All Wales Ovarian Cancer Prehabilitation Project (AWOCPP) sought to address a significant gap in care for ovarian cancer patients in Wales. While prehabilitation's benefits prior to surgery are well-documented and recommended by various medical authorities, Welsh patients had no access to this essential care.

The problem was underscored by concerning statistics. A review of 2 years of Welsh data revealed:
• Mean length of stay in hospital: 7.8 days (range 1-208 days)
• Post-operative complications: 22.5% of patients
• Mean surgery to chemotherapy interval: 49.4 days (range 21-182 days)

Additionally, an audit of patients with stage 3 and 4 ovarian cancer at the Cardiff centre showed:
• 45% had medical co-morbidities or other frailty indicators that would benefit from review and optimisation
• 22.7% had poor nutrition that needed optimisation
• 18.2% had anaemia requiring optimisation

Despite available services to address these issues, they were fragmented and not within a coordinated prehabilitation framework. Enhanced Recovery After Surgery (ERAS) programs were also limited to the peri-operative period, that is the few days before and after surgery. Prehabilitation spanning the time period from diagnosis to surgery (and to completion of chemotherapy) is complimentary to ERAS and the natural next step in further improvement of patient outcomes following surgery.

AWOCPP aimed to create and implement a personalised, multi-modal prehabilitation framework for all ovarian cancer patients undergoing surgery in Wales, drawing on existing literature to craft an evidence-based approach. The project's goal was to improve patient outcomes by providing a comprehensive, efficient, and effective pre-surgical support system.

Project design, planning and implementation

Background Information:

• An article by Miralpeix et al. in 2018 provides evidence indicating that multi-modal prehabilitation, combining physical intervention with nutritional and psychological strategies, has a better impact on functional outcomes compared to single prehabilitation modalities alone. The review includes four studies showing significant improvement in return to baseline functional capacity post-surgery. Miralpeix et al. also offered a recommended algorithm for prehabilitation.
• A recent pilot program in Wrexham hospital showed a 75% acceptance rate. It demonstrated a significant reduction in post-operative complication rates (63% to 15%) and length of stay in hospital (10 days to 8 days). Patient feedback was also positive.
• Prehabilitation is endorsed by various medical organisations, but there is an existing gap in ovarian cancer care in Wales that this funding proposal aims to fill.

Program Design:

The program was led by Sadie Jones and delivered at three cancer centres in Wales – Cardiff, Swansea and Bangor. The team included consultants, nurses, dieticians, occupational therapists, geriatricians, and trainees.

Patient Population:

Targets patients with stage 3 or 4 ovarian cancer, offering prehabilitation both for primary cytoreductive surgery and neoadjuvant chemotherapy, including those who did not proceed to surgery.

Prehabilitation Pathway:

The main goals of the program were to improve care and outcomes for ovarian cancer patients in Wales using a multi-faceted prehabilitation approach. The program aimed to have shortened hospital stays, reduced complications, and potentially enhanced oncological outcomes. It was based on existing evidence and tailored to the needs of the specific patient population.

• Patients are offered prehabilitation between initiation of treatment and surgery, then rehabilitation until chemotherapy completion.
  • The pathway includes at least 3 additional appointments, including a baseline consultation, progress consultation, and final assessment.
  • Adjustments to the program are made as needed, based on assessments and patient feedback.
  • A trainee supports the program at each centre with data collection and analysis.
  

Assessments and interventions framework:

A. Physical activity intervention:
• Three assessments and support from the Welsh National Exercise Referral Scheme, providing guided sessions and exercise information.

B. Nutritional intervention:
• Three nutritional assessments, with generic diet information, daily supplements, and personalised input for 30-50% of patients.

C. Smoking intervention:
• Three assessments with information and a video about smoking cessation provided to smokers.

D. Psychological intervention:
• Assessments include anxiety and depression scoring, with support including exercise sessions and occupational therapy if needed.

E. Frailty, chronic conditions, and polypharmacy intervention:
• Medical history and frailty scoring lead to targeted interventions such as iron supplementation or specialised physician care for around 45% of patients.

Prehabilitation Patient Pathway Adopted

Project Delivery concise summary:

Development involved collaboration between multidisciplinary teams at three gynaecological cancer centres in Wales.

Each centre formed a specialised team to create and deliver a standardised, evidence-based prehabilitation program across Wales. They worked extensively on planning and funding to ensure the project's feasibility and timely completion.

Oversight was maintained by a clinical academic surgeon, and progress meetings were held every two months. Patient representatives were involved to gauge acceptability, and collaboration with the Welsh National Exercise Referral Scheme was established for the exercise component.

The funding was calculated for Wales as a whole, acknowledging some variation between centres. Insights from the project will aid in the future development of more sustainable and cost-effective prehabilitation.

Patient engagement and involvement

Involvement of Patient Representatives:
Three patients were part of the project team, each offering unique perspectives and insights. They were actively involved throughout the project, from design to completion, and played a crucial role in shaping the practical delivery.

The patients were instrumental in various ways, including:

• LK: Offered insights into the Welsh service and helped address geographical challenges, given her personal experience with ovarian cancer and living far from the treatment centre.
• SC: Provided experience and local knowledge as an experienced patient representative aligned with the Wales Cancer Research Centre.
• AL: Shared a different perspective on ovarian cancer care delivered in England.

Their contributions were vital in:
• Preventing over-burdening patients with appointments.
• Making prehabilitation accessible for those unable to regularly attend the hospital (e.g., online classes, phone consultations).
• Troubleshooting initial lack of engagement and transitioning to hospital physiotherapy.

The patient representatives were vital in refining the program by preventing over-burdening, enhancing accessibility, and troubleshooting engagement issues. They also boosted team morale and inspired success. Feedback from patients led to critical adaptations, including switching to hospital physiotherapy and presenting the program as essential care. Feedback surveys were also sent to patients for continuous improvement.

Data & Measures

Summary:

This selection of data measures ensures a robust evaluation of the prehabilitation process and its impact on patients undergoing cytoreductive surgery.

Measures Chosen:

• Length of Stay in Hospital Following Cytoreductive Surgery: Indicates quality of prehabilitation; meaningful to patients and providers.
• Postoperative Complication Rates: Informs about surgery recovery.
• Time Taken to Receive First Postoperative Chemotherapy Cycle: Relevant to oncological outcomes; potentially reduced by prehabilitation.
• Patient Acceptability: Ensures efforts in prehabilitation are not wasted.
• Rate of Smoking Cessation: Enhances recovery and has long-term health benefits.
• Change in Nutritional Status (WAASP Score): Part of personalised patient assessment.
• Change in Physical Status (6MWT): Part of personalised patient assessment.
• Change in Psychological Status (HADS): Part of personalised patient assessment.

Reasons for Selection:

• Length of Stay Following Cytoreductive Surgery, Postoperative Complications: Reflect improvements with good prehabilitation.
• Time to Chemotherapy: Measures impact on delays often caused by complications.
• Patient Acceptability: Ensures the relevance of the program.
• Smoking Cessation: Recognises its importance in recovery and long-term health.
• Changes in Nutritional, Physical, Psychological Status: Determine personalised plans; caution needed in interpretation.

Historical Data:

• Length of stay following surgery: 6.8 days (range 2-204)
• Postoperative complications (Clavien Dindo scale): Ranged from 0.6% to 18.1%
• Time to postoperative chemotherapy: 49.1 days (range 21-150 days)
• Smokers at initial assessment: 6/58 (10.3%) patient

Results

The results below offer valuable insights into the application and impact of a multi-modal, personalised prehabilitation program within the NHS. Potential benefits were observed in areas like hospital stay length, while other aspects, such as time to chemotherapy (SCI) and postoperative complications, require further investigation and contextual understanding.

Patients Recruitment and Referrals:

• 58 patients were recruited across 3 sites over the project course.
• 42/56 (75.0%) needed occupational therapy intervention (HADS score > 7).
• 32/58 (55.1%) required elderly care physician for medical optimisation.
• 31/57 (54.4%) had dietary needs triggering referral to a dietician.

Smoking Cessation:

• 6/58 (10.3%) were smokers; no cessation observed during treatment.

Length of Hospital Stay:

• Reduced from 7.8 days (historical data, range 1-208 days) to 5.6 days (range 3-12 days) during the prehabilitation program.

Time to Chemotherapy (SCI):

• An increase from 49.4 days (historical, range 21-182 days) to 72.1 days (range 25-154 days) during prehabilitation.
• Varying changes across regions (e.g., South West Wales: from 51.6 to 117.0 days).
• The SCI increased significantly in South West Wales - Reasons are being explored but are likely due to relatively small patient numbers from this centre and pressures on the service.

Postoperative Complications:

• Increase from 25.7% (historical) to 43.2% with prehabilitation.
  

More detailed breakdown:

• Clavien Dindo 1: from 6/171 (3.5%) to 6/37 (16.2%), range details to be provided.
• Clavien Dindo 2: from 31/171 (18.1%) to 8/37 (21.6%), range details to be provided.
• Clavien Dindo 3: from 6/171 (3.5%) to 2/37 (5.4%), range details to be provided.
• Clavien Dindo 4 & 5: no significant change.
  • Possible explanation: Real-time data collection by the nurses involved in the patients' care may have led to more accurate recording.

Nutritional Assessment (WAASP Score & Albumin):

• Indicated a trend towards improved scores, especially for those with higher WAASP at baseline.

Notes:
Not all data were available at the time of writing, particularly for patients recruited later in the project. Some increases (e.g., complications) might not represent actual trends but rather differences in data collection methods. Future analysis will provide more comprehensive insights as all data points become available.

Lessons learned

Below is a succinct summary of the lessons learned from the project, highlighting the strengths, challenges, and key insights:

Improved Understanding of Roles:

• Team members gained a profound understanding of each other's roles, leading to more effective collaboration.
• The surgical team learned the value of psychological support from occupational therapy and the diverse interventions by dieticians.
• Allied Health Professionals (AHPs) gained insights into the specific needs of the advanced ovarian cancer population.
• This mutual understanding across different sites will continue to benefit patients and foster quality improvement projects.

Comprehensive Framework:

A key strength was the development of a comprehensive framework (based on Miralpeix et al, with local input), defining clear pathways and triggers for interventions.

This allowed a personalised and standardised approach to each patient, maximising cost- effectiveness and audit potential.

Challenges in Multi-Site Delivery:

Communication was vital across three different sites in Wales, with regular meetings ensuring alignment, motivation, and problem-solving.

Local team meetings in Cardiff and Bangor helped in addressing progress and challenges, leading to success at these sites.

Challenges were faced at the South West centre due to staffing issues, resulting in gaps in patient recruitment and limitations in the project output.

Recognising when no further improvement could be made and accepting limitations was an essential lesson.

Conclusion:
The project yielded invaluable insights into interprofessional collaboration, standardised patient care, and the challenges of multi-site delivery. A harmonised understanding of various roles within the team and a well-defined framework were key strengths that will continue to impact patient care positively. The lessons learned from communication strategies and managing challenges in one centre provide a roadmap for future improvement and project planning.

Limitations

The limitations and insights from the project can be summarised in the following key areas:

Exercise Component:

• Initial Failure: Utilisation of the national exercise referral scheme (NERS) failed to engage patients.
• Adaptations: Modifications were made, such as offering tai chi components and pre-recorded sessions, but didn't have the desired effect.
• Late Success: Switching to an in-hospital physiotherapy approach resulted in 100% engagement but occurred too late to impact outcomes.
• Key Learning: Tailoring exercise components to patient needs and preferences is critical for engagement.

Sample Size:

• Limitation: The small sample size and 12-month project duration limited the ability to test the efficacy of prehabilitation.
• Success: Despite the small size, the results are informing long-term implementation.

Baseline Assessment:

• Challenge: Re-assessment prior to surgery was overwhelming for many patients and confounding factors affected outcome measures.
• Learning: Reducing burdensome assessments and considering contextual factors are important.

Geographic Reach:

• Challenge: The geographic diversity of Wales and the tertiary nature of ovarian cancer care led to accessibility issues.
• Partial Success: Online resources and telephone consultations helped but did not fully overcome the geographic barriers.
• Future Consideration: High-level thinking is needed to ensure cost-effective, quality services reach all patients

Summary of limitations encountered:
If undertaken again, the project would benefit from an earlier emphasis on personalised exercise interventions, a careful approach to patient assessments, and a strategy for overcoming geographic and systemic barriers. These lessons could guide a more effective and wide-reaching prehabilitation program

Conclusion

The project aimed to provide a standardised framework of prehabilitation for women with advanced ovarian cancer, striving to tackle systemic and regional health inequalities in Wales.

The success of the project and its contribution to these aims can be examined in the following areas:

1. Development of an Evidence-Based Framework:
   • Achievement: Created a prehabilitation framework that was standardised and accepted by patients and healthcare providers.
   • Impact: This framework has offered invaluable insights and data for future integration into standard care, aiding in resource allocation and cost-efficacy.
2. Patient Reach and Engagement:
   • Initial Challenges: Some patients declined participation; staff sickness and geographical barriers affected recruitment, especially in the South West.
   • Adaptations: Changed the approach in explaining prehabilitation as an essential service, leading to better patient participation.
   • Learning and Future Considerations: The project revealed the need for larger, robust teams, and emphasised the need for prehabilitation at all hospitals to enhance equality in care provision.
3. Outcome Measures and Data Insights:
   • Challenges: Confounding factors in quality improvement projects made some outcomes hard to interpret, particularly in the South West data.
   • Positive Trends: Data indicated trends towards reduced surgery to chemotherapy intervals and significant improvements in the duration of hospital stays after surgery, contributing to potential cost savings.
   • Considerations for Future Projects: An understanding of realistic expectations from small sample sizes is essential, and ongoing data collection will add validity.
4. Project’s Contribution to Health Inequalities:
   • Contribution to Regional Equality: By reaching a broad spectrum of patients and adapting to their needs, the project has worked towards reducing regional health inequalities.
   • Impact on Systemic Inequality: The creation of a standardised framework and insights into sustainable delivery models has the potential to tackle systemic inequalities.

The project has been successful in achieving its aims, though some challenges were encountered. It has laid a foundation for a standardised, evidence-based prehabilitation model for women with advanced ovarian cancer in Wales. By focusing on personalised care, adapting to feedback, recognising the limitations of small sample sizes, and planning for more robust, widely available services, the project has taken significant strides towards tackling both systemic and regional health inequalities. The final data set (results due in Q1 2024) will further illuminate these achievements and guide the publication and collaboration with other regions.

Project Outputs

Prehabilitation Framework:

Personalised to patient needs by comprehensive baseline assessment, efficient use of resources, and modelling future services around actual needs.

Trigger criteria for different intervention levels

Ability to plan services based on real needs

Patient Information Development:

Extensive guides on general benefits of prehabilitation, nutrition during treatment, and occupational therapy roles.

Nutrition booklet used across Cardiff for all gynae cancer patients

Unique Approach by Welsh Occupational Therapy Team:

Offering sessions on fatigue, stress management, and coping, utilising a rota system across Wales, which won an innovation prise.

Training Session for Allied Health Professionals (AHPs):

Enhancing understanding of ovarian cancer patients, their specific needs, and care pathway; used to educate the Cardiff and Vale health board.

Review of the Additional Project

Welsh Sub-Project on Prehabilitation Engagement

Design:
The IMPROVE programme funded a sub-study to explore the factors influencing patient engagement with prehabilitation for ovarian cancer. This Welsh project was designed to uncover the push and pull factors that can maximise patient participation and benefit in future programs. The research design included qualitative research techniques, semi-structured interviews, and collaboration with a similar work conducted by Mary Wells' team in London.

Implementation:

• Research Fellow Appointment: Funding contributed to the salary and training of a research fellow who specialised in qualitative research techniques.
• Collaboration with London Team: The approach was modified to align with similar work in London, creating an opportunity for collaborative research and a more informative dataset.
• Current Status: The project is in the development phase, including crafting semi-structured interviews, patient screening surveys, and establishing honorary contracts with centres. Completion is anticipated by the end of March 2024.

Results and Spill over Effects:

• Increased Awareness of Services: The project has significantly increased awareness among staff about the roles and services available to patients, leading to potential improvements in patient care.
• Building Collaborative Relationships: The IMPROVE program facilitated collaboration among prehabilitation teams, leading to shared learning, brainstorming, and idea exchange. The teams have begun working on national guidelines for prehabilitation in ovarian cancer and are planning a conference to share learning.
• Continuation of Prehabilitation Efforts: The learning from this project is continuing to guide prehabilitation for ovarian cancer patients in the North and South East within larger setups.

Conclusion:

This Welsh sub-project, part of the IMPROVE UK programme, represents an important investigation into the factors affecting patient engagement with prehabilitation programs.

Through collaboration, qualitative research, and shared learning, the project aims to enhance future prehabilitation efforts.

The project's impact extends beyond the core study, fostering a cooperative environment among professionals, enhancing awareness of services, and guiding continued prehabilitation efforts in the North and South East. It stands as a key initiative in the field, with potential implications for improved patient care.