The study, led by researchers at the University of South Florida Morsani College of Medicine and Moffitt Cancer Center in Tampa, focused on patients undergoing cancer tumor removal surgery. Its central finding was striking: patients who reported walking or engaging in moderate or vigorous physical activity at least seven times per week had a 50 percent lower risk of developing postoperative delirium compared with their less active counterparts. In a field where interventions to protect the brain during and after surgery have remained elusive, a finding this strong — drawn from something as accessible as walking — has captured the attention of anesthesiologists and oncologists alike.

Postoperative delirium is far more than a fleeting moment of disorientation. It is a temporary but serious disturbance of attention, memory, and thinking that can leave patients unable to recognize where they are, why they are in a hospital, or who is caring for them. Episodes typically emerge in the hours or days following surgery, and their consequences ripple outward: longer hospital stays, delayed recovery, extended rehabilitation, and, most alarmingly, an increased risk of death. For older adults, whose brains are more vulnerable to the stress of anesthesia and surgical trauma, the condition represents one of the most common and costly complications of modern surgical care.

“People may realize that exercise before surgery can help their bodies recover more quickly, but our study also shows that it may protect the brain,” said Melody Haratian, B.S., lead author of the study and a medical student at the University of South Florida Morsani College of Medicine in Tampa. Her comment captures the conceptual shift that the research embodies. For decades, surgical preparation has centered on the body — building strength, optimizing nutrition, managing chronic disease. The idea that the brain, too, can be trained and fortified before the first incision is made marks an important evolution in how clinicians think about perioperative care.

The research team designed their investigation as a retrospective, matched, case-control study, a method that allows researchers to compare patients who experienced an outcome of interest with those who did not. The analysis included 258 patients who underwent cancer tumor removal surgery between 2024 and 2025. Of these, 64 developed postoperative delirium, while 194 did not. Rather than relying on subjective impressions, the researchers identified delirium cases using a positive Confusion Assessment Method test, a widely validated screening tool that helps clinicians detect delirium with reasonable reliability in busy hospital settings. The team also reviewed surgery reports to confirm the clinical context of each case.

One of the study’s most distinctive methodological choices was how it measured physical activity. Instead of counting the number of active days per week — the approach used in many exercise guidelines — the researchers tallied instances of physical activity per week. Participants self-reported how often they walked, engaged in moderate physical activity, or engaged in vigorous physical activity for at least 10 minutes at a time, and also estimated how many hours they spent sitting on a typical day. This frequency-based framing matters because it captures the cumulative rhythm of movement rather than treating exercise as an all-or-nothing habit confined to designated workout days.

The results painted a consistent picture. Patients who went on to develop delirium reported less walking, less moderate activity, less vigorous activity, and less total physical activity on average than those who remained clear-minded after surgery. They also reported more sitting time. When the researchers combined all forms of activity into a single weekly frequency, the pattern became statistically compelling: patients who reported a combined activity frequency of at least seven times per week were significantly less likely to experience postoperative delirium, with the risk reduced by half compared with less active patients. In practical terms, this means that spreading movement throughout the week — a morning walk one day, a brisk errand the next, a moderate workout later in the week — may offer meaningful protection for the brain.

“Preparing for surgery starts before the day of the operation,” said Jeffrey Huang, M.D., FASA, senior author of the study and professor of oncological science and senior member of anesthesiology at Moffitt Cancer Center in Tampa. “Patients should ask their care team about safe ways to stay active and whether a prehabilitation program could help them prepare for surgery and recover faster.” Huang’s advice reflects a growing movement in surgical medicine known as prehabilitation — the practice of preparing patients for surgery through exercise, nutrition, and other strategies in the weeks before the operation. The concept builds on accumulating evidence that patients who enter surgery in better physical condition tend to recover faster, experience fewer complications, and achieve better overall results. The new findings extend this framework to brain health, suggesting that prehabilitation may do more than strengthen muscles and cardiovascular reserves; it may also prime the nervous system to withstand the stress of anesthesia and surgical trauma.

The biological plausibility of this connection is supported by a growing body of research on exercise and the brain. Regular physical activity is known to enhance cerebral blood flow, support vascular health, reduce systemic inflammation, and promote neuroplasticity — the brain’s ability to adapt and reorganize. Delirium is thought to arise when the brain’s reserves are overwhelmed by perioperative stressors, including anesthesia, pain, inflammation, and metabolic disruption. A brain accustomed to the rhythmic stimulation of regular movement may simply have more resilience to draw upon when those stressors arrive. While the current study cannot establish causation — its retrospective, case-control design identifies associations rather than proving that activity directly prevents delirium — the strength and consistency of the association, combined with well-understood mechanisms, make the hypothesis biologically credible and clinically important.

The researchers themselves are careful to note that larger studies are needed before definitive clinical recommendations can be made. The study population was limited to cancer surgery patients at a single institution, and self-reported activity levels, while practical for large-scale research, introduce the possibility of recall bias. Nevertheless, the implications are hard to ignore. Postoperative delirium affects about 20 percent of surgical patients, and no pharmacological intervention has reliably prevented it. If something as simple, safe, and inexpensive as regular walking and moderate exercise in the weeks before surgery can meaningfully reduce that risk, the potential public health impact is enormous — particularly for the growing population of older adults undergoing major operations. For patients, the study authors say the takeaway is practical: people preparing for major surgery should talk with their healthcare team about safe ways to be active or participate in a prehabilitation program. The message from San Diego is clear — the road to a clear-minded recovery may begin long before the hospital, one step at a time.

Subject of Research: Postoperative delirium and preoperative physical activity in cancer surgery patients

Article Title: Could staying active before surgery help prevent postoperative delirium?

Article References: Could staying active before surgery help prevent postoperative delirium?. Original publication (Bibliographic details unavailable.)

Image Credits: AI Generated

DOI: Not provided

Keywords: postoperative delirium, prehabilitation, cancer surgery, physical activity, anesthesiology, brain health, surgical recovery, ANESTHESIOLOGY 2026, staying, active, surgery, help

To understand why this reframing matters, it helps to trace how anesthesiology arrived at its current crossroads. The specialty’s first transformation came in the 1930s and 1940s, when anesthesia matured into a recognized clinical discipline. By abolishing pain and consciousness as barriers to surgery, it made modern operative medicine possible. But the field quickly grew beyond the administration of hypnotic and analgesic drugs. Anesthesiologists became the guardians of metabolic and hemodynamic homeostasis during one of the most profound physiological stresses the human body can endure. Advances in pharmacology and monitoring technology steadily increased the precision and quality of that guardianship, converting what had been an improvised craft into a rigorous, quantitative practice built on ventilator management, fluid stewardship, and real-time physiological control.

The second transformation was driven by a cultural shift within the profession. Anesthesiologists recognized that excellence depended not only on individual skill, the practice of anesthesia as an art, but also on evidence-based knowledge, effective teamwork, communication, and the systematic study of error. Standardized monitoring, airway and crisis management algorithms, simulation-based education, human factors engineering, surgical checklists, international safety standards, and continuous quality improvement programs have together pushed anesthesia-related mortality in many healthcare systems to historically low levels. Artificial intelligence, predictive analytics, closed-loop drug delivery systems, and increasingly sophisticated monitoring promise further gains in intraoperative decision-making. Yet that very success creates the problem the article confronts: when safety is nearly solved, what justifies the specialty’s existence?

The authors’ answer rests on a stark epidemiological reality. Millions of patients each year still experience postoperative complications, prolonged disability, persistent pain, cognitive decline, psychological distress, delayed return to work, and loss of independence. A technically flawless anesthetic can be followed by a patient who never regains the function that surgery was supposed to preserve or restore. People do not undergo operations to survive them; they undergo surgery to live longer, preserve independence, remain cognitively intact, return to their families, resume work, or regain activities that give their lives meaning. The greatest challenge facing anesthesiology, the article argues, is therefore no longer how to guide a patient safely through an operation, but how to shape the weeks, months, and years that follow.

The demographic and clinical context makes this shift urgent. The surgical population is aging and increasingly frail, burdened by multiple chronic diseases, while operative techniques are growing more ambitious and complex. Healthcare systems face unprecedented pressure to deliver high-quality care with limited resources. Meeting these demands requires what the authors call a transition from a process-oriented technical specialty to comprehensive, outcome-oriented perioperative medicine. In this vision, anesthetic care no longer begins in the operating room and ends at the recovery room door. It starts weeks before surgery, with optimization of co-morbid conditions, nutrition, and frailty through shared multidisciplinary decision-making, and continues through individualized physiological management during the operation, then extends beyond discharge with pain management, rehabilitation, functional assessment, complication surveillance, and coordination with primary care and rehabilitation teams. Anesthesiology, in short, has evolved from facilitating an operation to managing a trajectory.

Measurement is a central thread of this argument. The authors emphasize that frailty scores, nutritional screening, functional tests, biomarkers, cognitive evaluations, and patient-reported outcomes only become valuable when they trigger meaningful interventions rather than sitting in charts as passive data. Equally, they challenge the traditional endpoints of perioperative research. Clinical studies have long relied on physiological variables, laboratory parameters, and relatively short-term complications, but these often fail to capture what patients themselves hope to gain. Preserving cognitive function, maintaining independence, returning to work, avoiding chronic pain, recovering physical capacity, and achieving satisfactory quality of life are frequently more meaningful outcomes than conventional clinical measures. The research agenda the authors propose includes refining the evidence linking depth of anesthesia and electroencephalographic monitoring to postoperative cognitive outcomes, individualized hemodynamic management to cardiac and neurological outcomes, perioperative glycemic control to infectious complications, and nutritional interventions to functional recovery and metabolic resilience.

Beneath the clinical questions lies a deeper scientific one: what is recovery, biologically speaking? Despite decades of progress in perioperative medicine, the mechanisms that determine why some patients rapidly regain function while others do not remain incompletely understood. The article describes recovery as a complex, dynamic physiological process involving inflammation, metabolic alteration, resilience, psychological adaptation, and social reintegration. Better characterization of these mechanisms, the authors argue, would open the door to interventions that actively promote recovery rather than merely responding to complications after they appear. They also call for an end to the search for universal perioperative strategies. Future research, they contend, should identify which intervention works best for which patient, under which circumstances, and at which stage of the perioperative journey, an approach that mirrors the precision-medicine revolution already reshaping oncology and cardiology.

Technology and teamwork emerge as accelerants of this third transformation. Artificial intelligence may support risk prediction and real-time decision-making, while wearable devices and digital platforms could enable continuous monitoring beyond hospital walls. Predictive analytics may identify patients who would benefit most from prehabilitation, nutritional intervention, or enhanced postoperative surveillance. But the authors are equally clear that perioperative care has grown too complex for any single discipline. Surgeons, intensivists, nurses, physiotherapists, nutrition specialists, psychologists, geriatricians, primary care physicians, engineers, and data scientists all contribute complementary expertise. Within that constellation, anesthesiologists occupy a unique leadership position: their training in physiology, pharmacology, pain management, critical care, and risk assessment naturally equips them to coordinate multidisciplinary perioperative pathways and ensure continuity across the surgical journey.

Perhaps the most sobering observation in the article concerns evidence that already exists. The greatest challenge, the authors suggest, may not be discovering new interventions at all, but ensuring that proven ones consistently reach patients. Enhanced Recovery After Surgery pathways, standardized bundles of evidence-based perioperative care, have repeatedly demonstrated that coordinated management can substantially improve recovery. Meta-analytic evidence links ERAS guideline adherence to shorter hospital stays, fewer complications, and reduced readmissions, yet implementation remains highly variable across institutions and healthcare systems. Closing this evidence-to-practice gap, the authors argue, should itself become a research priority, treated with the same methodological seriousness as drug trials or device studies. They also make a case for publishing well-conducted negative studies, which refine understanding, prevent unnecessary interventions, and redirect research efforts toward more promising strategies.

The article doubles as a mission statement for Frontiers in Anesthesiology, which the editors hope will serve as a multidisciplinary forum spanning basic and translational science, clinical trials, implementation research, quality improvement, digital health innovation, health systems research, precision perioperative medicine, artificial intelligence, and strategies for empowering patients and their relatives to enhance recovery. For clinicians and patients alike, the message is deceptively simple: putting patients to sleep safely was only ever the first act. The third act of anesthesiology will be judged not by how smoothly an operation goes, but by whether a person walks out of the hospital with their mind, independence, and life intact. As the authors conclude, the specialty should aspire to research that not only explains perioperative physiology but changes clinical practice, informs health policy, and improves the outcomes that matter most to patients.

Subject of Research: Redefining anesthesiology as an outcome-oriented perioperative medicine specialty focused on postoperative recovery

Article Title: Field grand challenge: beyond putting patients asleep: redefining the mission of anesthesiology

Article References: Rousseau, A.-F., & Schricker, T. (2026). Field grand challenge: beyond putting patients asleep: redefining the mission of anesthesiology. Frontiers in Anesthesiology, 5, Article 1967244. https://doi.org/10.3389/fanes.2026.1967244

Image Credits: AI Generated

DOI: 10.3389/fanes.2026.1967244

Keywords: anesthesiology, perioperative medicine, postoperative outcomes, patient safety, ERAS pathways, enhanced recovery, artificial intelligence, cognitive decline, frailty, patient-reported outcomes, prehabilitation, evidence-to-practice gap

The study, led by Wenxue Wan of the School of Nursing at China Medical University in Shenyang, together with colleagues at Kunshan First People’s Hospital, pooled data from sixteen randomized controlled trials encompassing 1,542 participants. Randomized controlled trials are considered the gold standard of clinical evidence because they minimize the confounding that plagues observational research, and by combining them statistically, the researchers gained the power to detect effects that individual small trials might miss. The team searched four major biomedical databases—PubMed, the Cochrane Library, Embase, and CINAHL—and followed established systematic review methodology, with two reviewers independently performing study selection, data extraction, and risk-of-bias assessment. The review was prospectively registered with PROSPERO, the international registry for systematic review protocols, under registration number CRD420251183407.

The interventions examined under the prehabilitation umbrella were diverse but shared a common logic: strengthen and condition the body’s functional reserve before surgical stress depletes it. Most trials centered on pelvic floor muscle training, in which patients learn to consciously contract and relax the levator ani muscles that support the bladder and urethra. Some programs added biofeedback, using sensors to give patients real-time visual or auditory cues about whether they were engaging the correct muscles, a technique designed to overcome the difficulty many men face in identifying these internal muscles without guidance. Other trials incorporated broader exercise regimens, stress management interventions, or combinations of physical and psychological preparation delivered in the weeks between diagnosis and surgery.

The headline finding concerns urinary incontinence, arguably the most feared functional consequence of prostate removal. The meta-analysis showed that prehabilitation significantly reduced the incidence of postoperative incontinence at one month after surgery, with an odds ratio of 0.58 and a 95 percent confidence interval of 0.39 to 0.84. In practical terms, men who trained before their operation were roughly 42 percent less likely to be incontinent at the one-month mark than those who received usual care. The benefit persisted at six months, where the odds ratio of 0.52 (95 percent confidence interval 0.28 to 0.96) indicated a similar magnitude of protection. At three months, the reduction was borderline but did not reach conventional thresholds of statistical significance, and by twelve months after surgery, the difference between the prehabilitation and control groups had disappeared entirely.

That temporal pattern tells a coherent physiological story. Radical prostatectomy involves dissecting the prostate away from the external urethral sphincter and the pelvic floor musculature, causing direct trauma, inflammation, and temporary loss of neuromuscular coordination in the region. In the early recovery phase, continence depends heavily on the compensatory strength and motor control of the remaining pelvic floor muscles. Prehabilitation appears to give patients a head start: men who arrive at surgery with conditioned, well-innervated pelvic floors can recruit those muscles more effectively while the surgical insult heals. As natural recovery proceeds over the following year, the baseline gap between groups narrows, because many men in the control group eventually achieve continence through spontaneous healing and any postoperative rehabilitation they receive. Prehabilitation, in other words, seems to accelerate the trajectory to continence rather than raise its ultimate ceiling.

Notably, the analysis drew a sharp distinction between the incidence of incontinence and its severity. Across all follow-up time points, prehabilitation produced no significant improvement in the severity of leakage among those affected. This suggests that conditioning the pelvic floor before surgery may help more men cross the threshold from leaking to dry, but it does not appear to make the incontinence milder in men who would leak regardless. Whether more intensive or longer preoperative programs could shift severity outcomes remains an open question that the included trials were not designed to answer definitively.

The picture for erectile function was similarly sobering. Despite biological plausibility—improved vascular health and muscle function could theoretically support erectile recovery—no significant benefit of prehabilitation on erectile function emerged at any follow-up time point. This is a clinically important negative finding, because sexual dysfunction after prostatectomy is driven largely by injury to the cavernous nerves that run alongside the prostate, structures that no amount of preoperative exercise can protect. Recovery of erectile function also typically unfolds over one to two years, longer than most trials followed their participants, and it depends heavily on surgical technique, nerve-sparing status, and patient age—factors that may overwhelm any modest prehabilitation effect.

Where the analysis did find durable and meaningful benefit was in quality of life. Prehabilitation significantly improved quality-of-life scores within the first three months after surgery, with a standardized mean difference of negative 0.70 (95 percent confidence interval negative 1.08 to negative 0.32), a moderate-to-large effect by conventional benchmarks. The benefit remained statistically significant at six months, with a standardized mean difference of negative 0.45 (95 percent confidence interval negative 0.74 to negative 0.16). By twelve months, the effect had attenuated to a marginal trend that did not reach statistical significance, with a standardized mean difference of negative 0.33 and a confidence interval of negative 0.66 to 0.00 that just touched the null. Standardized mean differences allow researchers to combine quality-of-life scores measured with different instruments across trials, and values in this range correspond to improvements patients themselves would typically perceive as meaningful.

The authors assessed the methodological quality of the included trials using the Cochrane Collaboration’s RoB-2 tool, the current standard for evaluating bias in randomized trials, and judged the overall risk of bias to be moderate. Statistical analyses were performed with Stata 18.0 software, with the researchers choosing between fixed-effects and random-effects models according to the degree of heterogeneity observed across trials—a crucial step, since the included studies varied in their interventions, comparators, and outcome measures. The team reported no funding for the preparation of the manuscript and declared no competing interests, and no new primary data were generated, as all findings derive from previously published studies.

The implications for clinical practice are tangible. The window between a prostate cancer diagnosis and radical prostatectomy, which can span several weeks while patients await surgery, represents an underused therapeutic opportunity. The findings suggest that even relatively brief preoperative pelvic floor training programs can meaningfully improve the most vulnerable early recovery period, when patients are most distressed by leakage and its impact on daily living. At the same time, the analysis tempers expectations: men should understand that prehabilitation does not appear to prevent long-term incontinence, does not improve its severity, and does not protect erectile function. Future research, the authors’ findings imply, should focus on identifying which patients benefit most, optimizing the dose and duration of preoperative training, and determining whether combining prehabilitation with structured postoperative rehabilitation can extend the early gains into lasting functional recovery.

Subject of Research: Effects of preoperative prehabilitation on urinary continence, erectile function, and quality of life after radical prostatectomy for prostate cancer

Article Title: The impact of prehabilitation on postoperative outcomes in patients undergoing radical prostatectomy for prostate cancer: a systematic review and meta-analysis

Article References: Wan, W., Shen, L., Chang, Y., & Jin, X. (2026). The impact of prehabilitation on postoperative outcomes in patients undergoing radical prostatectomy for prostate cancer: a systematic review and meta-analysis. Supportive Care in Cancer, 34(10), Article 971. https://doi.org/10.1007/s00520-026-11182-z

Image Credits: AI Generated

DOI: 10.1007/s00520-026-11182-z

Keywords: prehabilitation, prostate cancer, radical prostatectomy, urinary incontinence, erectile dysfunction, quality of life, pelvic floor muscle training, biofeedback, meta-analysis, systematic review, postoperative outcomes, supportive care

The research team, led by Alicia Boyd of St John of God Warrnambool Hospital with colleagues from the Integrated Clinical Oncology Network and the Barwon South Western Regional Integrated Cancer Service, analysed electronic medical records at all five health services providing cancer treatment across South West Victoria. The region is served by three public services in Hamilton, Portland and Warrnambool, one private hospital, and a private radiotherapy provider whose patients are invited into the public program in Warrnambool. After screening 1,658 patient records and excluding those who did not meet the criteria, including people whose only diagnosis was surgically treated skin cancer, the researchers assembled a cohort of 898 adults who received cancer treatment during 2023.

The statistical picture that emerged was one of profound underuse. Across 21 cancer diagnosis categories, only 12 were represented among rehabilitation attendees at all. Breast and bowel cancers, the two most common diagnoses among attendees, still saw only 6 percent and 9 percent of their respective patient groups participate. Prostate, bladder and head and neck cancer patients were particularly unlikely to attend. Age and gender showed no statistically significant association with attendance, suggesting the barriers operate at the level of the health system and the treatment pathway rather than the demography of the patient population.

Treatment modality proved to be the strongest predictor of engagement. Patients receiving chemotherapy or immunotherapy, alone or in combination with other treatments, accounted for more than 90 percent of the rehabilitation cohort, compared with 52.5 percent of non-attendees. By contrast, patients whose treatment consisted solely of surgery or radiotherapy attended at a rate of roughly 1 percent. The researchers also found a positive correlation between the number of treatment types a patient received and the likelihood of attending rehabilitation, with attendance rising as treatment complexity increased. Median treatment duration was dramatically longer among attendees, at 148 days compared with 43 days for non-attendees, a difference that was highly statistically significant.

Completion told a more nuanced story. Patients who had undergone multiple treatment modalities were more likely to start rehabilitation but less likely to finish it, with completion rates of 70 percent among those treated with a single modality versus 50 percent among those treated with several. The authors suggest a difficult paradox: the same cumulative treatment burden, side effects and competing appointments that increase a patient’s need for rehabilitation also erode their capacity to sustain attendance. Completers attended sessions over a median of 86 days, compared with just 19 days for non-completers, indicating that sustained engagement over time, rather than brief exposure, characterised successful program completion.

Timing emerged as another critical variable. Most patients, 76.9 percent, began rehabilitation while still receiving active cancer treatment, and only four patients started before treatment began, a strikingly low figure given growing international interest in prehabilitation, the practice of building physical reserve before therapy starts. Interestingly, patients who commenced rehabilitation later in their treatment course were significantly more likely to complete their program, beginning on average 91 days after starting treatment compared with 33.5 days for non-completers. The authors caution, however, that this should not be read as evidence that delayed rehabilitation is superior; national guidelines emphasise benefit across the entire cancer continuum, and early intervention may deliver important gains even when formal completion is not achieved.

The findings land against a backdrop of well-documented rural health inequity. People living in regional and rural Australia experience poorer cancer outcomes and are more likely to die from the disease than their metropolitan counterparts. Previous work cited in the study found that rural cancer survivors carry a high burden of modifiable risk factors, are more likely to be physically inactive, and often travel more than 100 kilometres to access health services. Roughly two-thirds of rural Australian cancer survivors fail to meet recommended physical activity levels. What this new study adds is evidence that engagement in structured, service-based rehabilitation may be even lower than participation in exercise more broadly, implying that barriers extend well beyond the availability of programs.

That availability was never the problem is perhaps the study’s most consequential message. All five cancer services in the region provided or were linked to rehabilitation, including the Cancer Wellness and Exercise Program supported by Cancer Council Victoria, which delivers weekly group exercise and education over eight weeks, and a personalised multidisciplinary program at the private hospital. Yet uptake remained minimal. The authors argue that referral pathways, clinician awareness, patient education about the benefits of rehabilitation, travel burden and competing treatment demands are all plausible levers, and that providing a service alone is insufficient to guarantee engagement. They call for assessment of current referral practices across tumour streams, suggesting that the pathways working well within chemotherapy and immunotherapy services could be replicated for surgical and radiotherapy patients.

The study also surfaced an unexpected cross-border phenomenon: 195 patients who received treatment within the participating services were excluded because they lived outside the region, many in neighbouring South Australia. This raises broader questions about how regional health networks serve populations that straddle state boundaries, and whether patients in border communities face additional obstacles to accessing coordinated cancer care. The authors suggest this pattern warrants investigation across regional Australia to determine whether it is a local quirk or a systemic feature of how cancer services are organised outside metropolitan centres.

Methodologically, the study has clear strengths and acknowledged limits. It is, to the authors’ knowledge, the first to quantify rehabilitation participation and completion across an entire regional cancer network, spanning both public and private sectors and minimising selection bias by including every provider in the region. But the retrospective design, the single calendar year of data, and differences in electronic medical record systems across sites, which required manual cross-checking and may have introduced misclassification, all constrain the analysis. The small number of attendees limited subgroup comparisons, and the study captured only health service-based rehabilitation, not independent exercise or community programs. Even so, the baseline it establishes is sobering: in a region where rehabilitation is available at every cancer service, fewer than six in a hundred patients walked through its door, and the authors argue that telehealth and hybrid models, already proven in other areas of rural health care, deserve urgent evaluation as a route to closing the gap.

Subject of Research: Participation in oncology rehabilitation among cancer patients in regional South West Victoria, Australia

Article Title: Participation in oncology rehabilitation in regional South West Victoria, Australia: a retrospective study

Article References: Boyd, A., Jansen, F., Hawkins, M., & Davis-Lameloise, N. (2026). Participation in oncology rehabilitation in regional South West Victoria, Australia: a retrospective study. Supportive Care in Cancer, 34(11), Article 1093. https://doi.org/10.1007/s00520-026-11319-0

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DOI: 10.1007/s00520-026-11319-0

Keywords: oncology rehabilitation, cancer survivorship, regional health, exercise oncology, rural Australia, health equity, retrospective study, cancer care, prehabilitation, telehealth, supportive care, Victoria

The study, published as an open-access review in the journal Supportive Care in Cancer, evaluated the NUH Prehabilitation Service, a multimodal programme combining exercise, nutritional support and psychological preparation. Rather than offering the same package to everyone, the service follows a tiered, risk-stratified model endorsed by Macmillan Cancer Support, in which patients are allocated to one of three pathways according to clinical need. High-risk patients, identified using factors such as frailty, functional capacity, comorbidity and treatment complexity, were assigned to the Specialised pathway, attending supervised one-to-one or two-to-one exercise sessions with the hospital’s prehabilitation team up to three times a week. Lower-risk patients joined the Targeted pathway, attending community-based group classes led by an external provider that combined modified high-intensity interval training with strength exercises. A third group, the Universal pathway, received an individualised home exercise prescription with weekly check-ins for education and advice — an arms-length offer designed for patients who were already independently active or lived outside the immediate area.

The scale of the programme is striking. Of 1,961 patients referred over the 38-month period, 1,720 were included in the analysis, spanning seven surgical specialities including colorectal, gynaecological oncology, hepatopancreatobiliary, upper gastrointestinal, urology, head and neck, and thoracic surgery. That equates to an average of around 52 eligible referrals per month, a level of uptake the authors interpret as strong engagement from referring clinical teams. The cohort had a median age of 67 years, slightly more women than men, and nearly half were classified as obese. Colorectal surgery accounted for the largest share of participants at 38.5 per cent, followed by gynaecological oncology at 20.3 per cent.

To measure whether the programme worked, the team relied on validated functional and psychological instruments collected as part of routine clinical monitoring. Aerobic capacity was assessed with the Incremental Shuttle Walk Test, an externally paced protocol in which walking speed increases with each audio-cued level until the participant can no longer keep up. Lower-limb strength and endurance were measured with the 60-second sit-to-stand test, and grip strength was recorded with a hand-held dynamometer. Psychological well-being was tracked using two widely used self-report questionnaires: the Patient Health Questionnaire-9 for depression and the Generalised Anxiety Disorder-7 scale for anxiety. Self-reported weekly physical activity and the number of completed strength sessions rounded out the behavioural picture.

The results showed statistically significant improvements across every domain measured. On average, patients walked 57 metres further on the shuttle walk test after the programme, a gain with a moderate effect size that exceeds the minimal important differences of 35 to 53 metres typically reported for rehabilitation in long-term conditions. Sit-to-stand performance improved by six repetitions, roughly double or triple the threshold generally considered clinically meaningful. Depression scores fell by about two points, meeting the minimal clinically important difference established in UK primary care cohorts, while anxiety scores also decreased significantly. Perhaps most dramatically, self-reported weekly physical activity rose by 142 minutes — more than doubling — and the number of weekly strength sessions increased by 2.4, both with large effect sizes.

Importantly, these gains were not confined to the most intensive pathway. Although patients in the Specialised group showed greater improvements in depression scores compared with the Targeted group, and the Universal group increased strength sessions more than the Targeted group, most outcomes — including aerobic capacity, anxiety, grip strength and overall physical activity — showed no statistically significant differences between pathways. For the shuttle walk test, gains exceeded the minimal important difference in all three groups: 43 metres in Universal, 56 metres in Targeted and 64 metres in Specialised. The authors suggest this indicates that a tiered model can deliver meaningful benefit across all starting levels, and that even a low-intensity, arms-length offer may be a viable and scalable option for lower-risk patients when service capacity is constrained.

The findings align closely with other NHS prehabilitation programmes. The Greater Manchester Prehab4Cancer programme, one of the best-known community-based models, previously reported shuttle walk gains of around 50 metres and sit-to-stand improvements of 4.8 repetitions — figures comparable to those seen in Nottingham. The consistency across services strengthens the case that prehabilitation can be delivered at scale within publicly funded healthcare systems, not only in tightly controlled research trials. The Nottingham evaluation is also notable for reflecting routine clinical care rather than a research-driven intervention, which the authors argue enhances its real-world relevance and supports generalisation across a broad cancer population.

Not everything translated into clinically meaningful change. Although anxiety scores fell statistically significantly, from an average of about 6 to 4, the change fell short of the established minimal clinically important difference of four points on the GAD-7 scale, and baseline anxiety in this cohort was already low. The authors also note that research in oncology populations suggests the conventional GAD-7 threshold of 10 may underestimate anxiety in cancer patients, with better sensitivity at cut-offs of around 7 to 8, which calls for cautious interpretation of absolute scores. Depression, by contrast, showed a change that met the clinical significance threshold, and the greater improvement seen in the Specialised pathway hints that structured, individualised psychological support may add value over more generic delivery.

The evaluation is candid about its limitations. The analysis used a complete-case approach, excluding 241 patients with missing data, and assumes that data were missing completely at random — an assumption that, if wrong, could bias effect estimates. The observational design lacks randomisation, so causal inference is limited, and between-group comparisons were unadjusted for baseline differences and are therefore exploratory. Physical activity was self-reported, leaving results vulnerable to recall and social desirability bias. Selection bias may also operate upstream: referral depended on clinician discretion, tumour type and service capacity, and patients allocated to lower-intensity pathways may have been healthier or more motivated to begin with. Notably, the evaluation did not capture postoperative outcomes such as length of stay or complication rates, so it remains unknown whether the preoperative gains translated into downstream surgical benefits — a gap the authors flag as a priority for future data collection.

Engagement data reveal the practical friction points that any national rollout would need to address. A total of 8,250 service sessions were delivered, averaging 4.9 per patient, with median time in the service of 33.4 days — long enough, the authors note, to sit above the three-week threshold associated with improvements in postoperative complications, though benefits can begin to emerge within two weeks. Documented reasons for non-completion included short windows before surgery, non-attendance and discharge after assessment, often reflecting patient preference or a perception of already being fit enough. Reported barriers included travel distance, competing hospital appointments and caring responsibilities. Among 662 patients who completed a three-month postoperative questionnaire, 83.3 per cent agreed that prehabilitation helped them prepare for surgery and 61.1 per cent felt it supported their recovery — although only 31.2 per cent reported being more physically active afterwards, while 38.1 per cent felt less active, underscoring how difficult it is to sustain behaviour change through the surgical period itself.

The authors recommend several service improvements: routinely recording hospital length of stay to strengthen benchmarking and the health-economic case, and mitigating engagement barriers through hybrid delivery, digital follow-up and clearer clinician-led communication about the benefits of prehabilitation. They conclude that a multimodal, tiered prehabilitation service aligned with national guidance was linked to improvements in mood, strength and functional capacity, supporting patients’ surgical preparation and recovery, and that the findings justify integrating prehabilitation into routine cancer care. With 45 million cancer surgical procedures expected annually worldwide by 2030, and systematic reviews suggesting multimodal programmes may shorten hospital stays by around two days while proving cost-effective in a majority of economic evaluations, the Nottingham experience offers a template for how health systems might prepare a growing surgical population — not in the operating theatre, but in the crucial weeks before it.

Subject of Research: Multimodal prehabilitation before cancer surgery delivered through tiered NHS pathways

Article Title: Delivering prehabilitation in cancer surgery: a service evaluation at Nottingham University Hospitals

Article References: Alharbi, A., Haywood, A., & O’Connor, D. (2026). Delivering prehabilitation in cancer surgery: a service evaluation at Nottingham University Hospitals. Supportive Care in Cancer, 34(10), Article 973. https://doi.org/10.1007/s00520-026-11113-y

Image Credits: AI Generated

DOI: 10.1007/s00520-026-11113-y

Keywords: prehabilitation, cancer surgery, NHS, exercise, risk stratification, functional capacity, depression, anxiety, physical activity, service evaluation, Nottingham University Hospitals, Supportive Care in Cancer

The research team, led by Hualong Qiang and corresponding author Huiping Wang, surveyed two hundred adult patients scheduled for elective surgery across multiple surgical specialties between February 2024 and March 2025. Engagement was defined operationally as participation in at least one preoperative experience service, whether an education class, a counseling session or a prehabilitation program. Using structured questionnaires, the researchers collected data on demographics, clinical factors and patients’ own perceptions of the barriers and facilitators shaping their decisions. To add texture to the numbers, the team also analyzed open-ended responses with descriptive qualitative content analysis, allowing patients to explain in their own words why they did or did not show up. The study received ethical approval from the Ethics Committee of The Second Xiangya Hospital of Central South University and was conducted under the principles of the Declaration of Helsinki, with written informed consent from all participants.

The headline number is sobering: only 59.5 percent of patients — 119 of the 200 surveyed — engaged with any preoperative service. That means roughly two in five patients walked into the operating room without the preparation these programs are designed to provide. More striking still was the variation across surgical specialties. Cardiac surgery patients engaged at a rate of 82.4 percent, while neurosurgery patients engaged at only 40.0 percent. This nearly twofold difference hints that the perceived stakes of an operation, the culture of each surgical department, and perhaps the intensity of preoperative counseling routines all shape whether patients seek out preparation services. A patient facing open-heart surgery may feel an obvious urgency to prepare; a patient scheduled for a neurosurgical procedure may, paradoxically, receive less structured encouragement or may respond to fear with avoidance.

When the researchers examined why patients stayed away, two barriers towered above the rest: time and distance. Among patients who did not engage, 69.1 percent reported time constraints, compared with 27.7 percent of those who did engage — a difference that was highly statistically significant. Difficulty traveling to the hospital told a similar story, cited by 54.3 percent of non-engaged patients versus 19.3 percent of engaged patients. In other words, the patients most likely to skip preoperative services were those juggling work obligations or living far from the hospital, precisely the populations that may also face challenges attending follow-up appointments after surgery. These are not exotic findings, but their quantification matters: they suggest that the decision to engage is often a simple cost-benefit calculation about time and transportation, not a considered rejection of medical advice.

Beyond logistics, the survey identified informational and motivational barriers that were significantly more common among non-engaged patients. Lack of awareness that the services existed, low perceived need for preparation, and anxiety or active avoidance of pre-surgical information all distinguished the non-engaged group at statistically significant levels. The qualitative responses put human faces on these statistics. Non-participants repeatedly offered explanations such as having no time due to work or, most damningly for hospital communication systems, that no one told them about the class. That a patient can reach the day of major surgery without ever learning that preparation programs exist points to a failure of outreach rather than a failure of patient motivation — a distinction with clear implications for how hospitals design their information flows.

On the facilitator side, the data were equally decisive. A strong recommendation from a healthcare provider was reported by 66.4 percent of engaged patients but only 23.5 percent of non-engaged patients, and family support showed a parallel pattern, cited by 49.6 percent of the engaged versus 13.6 percent of the non-engaged. Both differences were highly significant. In the open-ended responses, engaged patients emphasized wanting to be prepared and encouragement from doctors and family. Taken together, these findings suggest that patient engagement is not primarily a matter of individual personality or health literacy alone; it is a social process, catalyzed by clinicians who explicitly urge participation and by family members who provide both practical help and emotional reinforcement. A single sentence from a surgeon or nurse — a direct, personalized recommendation — appears to be among the most powerful levers available.

The consequences of engagement showed up in the patients’ psychological states. Those who participated in preoperative services had significantly lower preoperative anxiety scores and higher preparedness scores than those who did not. Anxiety was measured using the six-item short form of the State-Trait Anxiety Inventory, a validated instrument widely used in perioperative research. Lower anxiety before surgery is not merely a matter of comfort; elevated preoperative anxiety has been associated in the broader literature with poorer recovery experiences and higher postoperative pain perception. While a cross-sectional survey cannot prove that engagement causes reduced anxiety — it is equally plausible that less anxious patients are more inclined to engage — the association aligns with the mechanistic rationale for preoperative education and counseling, and it strengthens the case for prospective intervention trials.

To disentangle the independent effects of each factor, the team performed multivariate analysis, and the results sharpened the demographic profile of the engaged patient. Higher education doubled the odds of engagement, with an odds ratio of 2.16 and a 95 percent confidence interval of 1.17 to 3.99. Younger age modestly predicted engagement, with an odds ratio of 0.98 per year of age, and cardiac surgery patients had 3.67 times the odds of engaging compared with general surgery patients, with a confidence interval of 1.27 to 10.63. These predictors paint a familiar picture in health services research: engagement skews toward younger, better-educated patients, raising equity concerns. If preoperative programs genuinely improve outcomes, then the patients least likely to access them — older, less educated, and logistically burdened — may be those who stand to benefit the most, compounding existing disparities in surgical care.

The authors argue that their findings point toward concrete, testable interventions. Flexible scheduling could directly attack the time-constraint barrier, allowing working patients to attend sessions outside standard clinic hours or through remote formats. Enhanced patient education outreach — proactive communication at the moment surgery is scheduled, rather than passive availability of brochures — would address the awareness gap captured by the phrase no one told me about the class. And deliberately involving family supporters, perhaps by inviting a designated relative to education sessions, would harness the social facilitation effect the data reveal so clearly. None of these measures requires new drugs or expensive technology; they are organizational redesigns, which makes them unusually cost-effective candidates for implementation science.

The study’s limitations are worth keeping in view. It was conducted at a single large tertiary hospital in Changsha, so the specific engagement rates may not generalize to community hospitals or to health systems with different referral patterns and insurance structures. The cross-sectional design captures associations at one point in time and cannot establish causal direction between engagement and anxiety. Self-reported barriers are also subject to recall and social desirability biases. Nevertheless, the convergence of quantitative statistics and qualitative testimony gives the findings credibility, and the study was supported by the Medical Science Research Project of Hebei. For hospital administrators and perioperative teams, the message is actionable: the biggest obstacles between patients and better surgical preparation are missed conversations, rigid schedules and long journeys — problems that thoughtful service design can solve. As preoperative optimization programs such as enhanced recovery after surgery pathways continue to spread, ensuring that all patients, not just the young and well-connected, actually walk through the door may become one of the most important quality metrics in surgery.

Subject of Research: Barriers and facilitators to surgical patients' engagement in preoperative experience services

Article Title: Barriers and facilitators to surgical patients’ engagement in preoperative experience services: a cross-sectional survey

Article References: Qiang, H., Song, T., Ren, H., Yang, T., & Wang, H. (2026). Barriers and facilitators to surgical patients’ engagement in preoperative experience services: a cross-sectional survey. BMC Health Services Research. https://doi.org/10.1186/s12913-026-15777-4

Image Credits: AI Generated

DOI: 10.1186/s12913-026-15777-4

Keywords: patient engagement, preoperative care, surgery, health services research, prehabilitation, patient education, preoperative anxiety, cross-sectional survey, health communication, barriers and facilitators, elective surgery, hospital services

The answer, according to the research team led by Xiaoxu Wang of Nanjing Medical University, is more sobering than many clinicians and patients might hope. After screening 4,553 records from English- and Chinese-language databases, the investigators identified 21 randomized controlled trials conducted across 10 countries, most published between 2020 and 2024, with China contributing the largest share at eight trials. The interventions spanned five broad categories: exercise or rehabilitation programs, nutritional supplementation, multimodal interventions combining both, intensive physiotherapy, and even neuromodulation in the form of transcranial direct current stimulation. When all the evidence was synthesized using Bayesian statistical methods that combine direct and indirect comparisons, the headline finding was stark: for frailty and sarcopenia themselves—the two primary outcomes—no intervention showed a clear advantage over usual care.

That null result for the primary endpoints deserves careful unpacking. Only three trials directly measured frailty, and just two measured sarcopenia, meaning the evidence base for these core conditions was thin to begin with. Seven other objective outcomes also failed to separate the interventions from one another: gait speed, the Timed Up and Go test, the sit-to-stand test, the skeletal muscle index derived from CT imaging, and the six-minute walk distance all showed no statistically significant differences among strategies. The certainty of evidence, graded using the GRADE framework, was rated very low for most of these outcomes. In a field where prehabilitation has been widely promoted as a way to prepare patients for the metabolic trauma of major cancer surgery, the analysis delivers an uncomfortable dose of realism about how little high-quality comparative evidence actually exists.

Yet the picture was not uniformly bleak. Two domains did show signals worth attention. For handgrip strength—a key, reliable marker of both frailty and sarcopenia—prehabilitation exercise ranked highest among the evaluated interventions, with a SUCRA score of roughly 94 percent, and was associated with a modest improvement compared with usual care. The pooled effect corresponded to an increase of approximately 5.4 kilograms of grip strength, which sits close to the minimal clinically important difference of 5.0 to 6.5 kilograms established in older populations. Mechanistically, this makes biological sense: resistance-based training enhances neural drive to muscle through more effective motor-unit recruitment and rate coding, while stimulating muscle protein synthesis via anabolic signaling pathways such as mTOR. Preoperative exercise may also exert anti-inflammatory effects and build physiological reserve before the surgical stress that would otherwise accelerate deconditioning.

The second positive signal emerged for subjective physical function—the patient-reported physical function domains drawn from quality-of-life questionnaires. Here, an enhanced nutritional support pathway and intensive physiotherapy both showed small but statistically significant improvements over standard care, with SUCRA rankings of about 85 percent and 82 percent respectively, and this outcome carried the highest certainty rating in the analysis at moderate. The nutritional pathway, tested in patients undergoing esophagectomy, was notably resource-intensive: it included extended preoperative supplementation with 500 to 1000 milliliters of oral nutritional supplements daily, progressive enteral nutrition through a jejunostomy tube during hospitalization, and thirty days of home enteral nutrition after discharge, with dietitians monitoring adherence by telephone. The authors caution that no trial formally evaluated the cost-effectiveness of this approach, and the staffing and follow-up infrastructure it demands may limit scalability in many healthcare systems.

Perhaps the most intriguing finding came from the subgroup analyses examining when interventions are delivered. For handgrip strength, the benefit was most apparent in the early postoperative period—within the first seven days after surgery—where the effect estimate was stable with zero heterogeneity across studies. Preoperative interventions and those delivered more than a week after surgery showed no clear improvements. The researchers suggest this may reflect the realities of enhanced recovery after surgery pathways: prehabilitation is constrained by the limited window between diagnosis and operation, which restricts training dose and adherence, whereas early postoperative mobilization directly targets the immobility-related deconditioning that occurs during a period of heightened surgical stress and catabolism. In other words, the postoperative signal may reflect both a greater opportunity to counteract acute muscle loss and more consistent delivery of an adequate exercise dose, rather than a true absence of preoperative benefit.

Why do interventions that work reasonably well in healthy older adults appear to lose their punch in gastrointestinal cancer patients? The authors point to cancer-specific pathophysiology as the likely culprit. Gastrointestinal malignancies are frequently complicated by cachexia, systemic inflammation, and treatment-related toxicities that induce a state of anabolic resistance—essentially blunting the muscle’s responsiveness to both exercise stimuli and nutritional support. Cancer-related fatigue further reduces patients’ capacity to engage in and adhere to sufficiently intensive programs. Many of the included trials also failed to reach recommended protein targets; current guidelines advise at least 1.0 gram of protein per kilogram of body weight daily for cancer patients, with many experts advocating 1.2 to 2.0 grams under conditions of metabolic stress, and several studies fell short of these thresholds, potentially limiting any measurable anabolic response.

The study has limitations that temper enthusiasm for even its positive findings. Most of the evidence networks were small and star-shaped, meaning trials compared interventions only against usual care rather than against each other, and formal consistency testing was impossible. Blinding of participants and personnel was rated as high risk in more than 71 percent of studies, raising the possibility of Hawthorne effects, and publication bias could not be formally assessed because fewer than ten studies were available for most outcomes. Adherence rates ranged wildly, from 14 percent to 100 percent, and seven of the 21 trials did not report intervention-related safety data at all—though the events that were reported, including nausea, diarrhea, and muscle discomfort, were mild or transient, with no serious adverse events attributed to the interventions.

The research team lays out a detailed agenda for what must come next. Future trials should enroll at least 256 participants to detect moderate effects with adequate statistical power, treat frailty and sarcopenia as primary endpoints using validated definitions, specify exercise modality, frequency, intensity, and protein targets in replicable detail, and run for at least twelve weeks with follow-up extending to six months. Adherence and adverse events should be reported as core outcomes rather than optional extras, and mechanistic substudies examining inflammatory and metabolic biomarkers could explain why some patients respond while others do not. For now, the authors conclude, the evidence is not yet strong enough to translate into routine clinical recommendations. Prehabilitation exercise may modestly strengthen grip, and structured nutrition pathways may help patients feel more capable—but the larger promise of reversing frailty and sarcopenia in gastrointestinal cancer remains, for the moment, unproven.

Subject of Research: Nonpharmacological interventions for frailty and sarcopenia in older adults with gastrointestinal cancers

Article Title: Nonpharmacological interventions for frailty and sarcopenia in older adults with gastrointestinal cancers: A Bayesian network meta-analysis

Article References: Wang, X., Hui, X., Fu, Z., Guo, Y., Duan, L., Shi, W., Dong, Q., Xu, Q., & Xu, X. (2026). Nonpharmacological interventions for frailty and sarcopenia in older adults with gastrointestinal cancers: A Bayesian network meta-analysis. iScience, 29(10), Article 117257. https://doi.org/10.1016/j.isci.2026.117257

Image Credits: AI Generated

DOI: 10.1016/j.isci.2026.117257

Keywords: frailty, sarcopenia, gastrointestinal cancer, network meta-analysis, prehabilitation, exercise, nutritional support, handgrip strength, older adults, physical function, cachexia, Bayesian analysis

Colorectal cancer is the third most common cancer among men and women in the United States, and roughly 55,000 patients are expected to die of the disease by the end of 2026. Surgery remains the most common primary treatment, but it carries a substantial burden: postoperative complications occur in about 35 percent of patients, mortality ranges from 1 to 16.4 percent, and adverse outcomes prolong hospitalization. Identifying who is at highest risk before the first incision is made has therefore become a pressing clinical goal, and the skeletal muscle has emerged as an unexpected prognostic organ, thanks to its secretory and metabolic properties.

The technique at the heart of the study is opportunistic imaging analysis. Using preoperative abdominal CT scans, the researchers measured two quantities at the level of the third lumbar vertebra. The skeletal muscle index, or SMI, quantifies muscle quantity by dividing the cross-sectional area of muscle by the square of the patient’s height. The skeletal muscle density, or SMD, expressed in Hounsfield units, captures the average radiation attenuation of the muscle—essentially a proxy for how much fat has infiltrated the tissue. Healthy muscle attenuates more radiation; fat-invaded muscle reads darker and lower. Segmentation was performed with semi-automated software integrated into the hospital’s picture archiving system, using the standard Hounsfield unit window of −29 to +150, and the measurements proved remarkably repeatable, with an intraclass correlation coefficient of 0.99.

What distinguishes this study from much of the prior literature is its treatment of these variables. Most earlier work dichotomized patients into low versus normal muscle categories using fixed cutoffs, which is clinically convenient but obscures how graded changes in muscle characteristics translate into graded changes in risk. Here, the team modeled SMI and SMD both as continuous predictors, expressed per 5-unit decrease, and as binary variables using two widely applied definitions drawn from Martin and colleagues and from Xiao and colleagues. The cohort of 415 patients had a mean age of 63.7 years, a mean body mass index of 28.2 kilograms per square meter, and underwent laparoscopic, robotic-assisted, or open resection in roughly equal measure.

The results were strikingly one-sided. Each 5-unit decrease in SMD was associated with a 6 percent higher incidence of hospital days after surgery, an association that held whether muscle density was modeled continuously or through clinical cutoffs. Muscle quantity, by contrast, lost its apparent univariate association with length of stay once age, sex, comorbidity burden, tumor stage, neoadjuvant treatment, and surgical approach were adjusted for. A similar pattern emerged for severe complications, defined as grade 3 or higher on the Clavien–Dindo classification: each 5-unit drop in SMD raised the odds by 25 percent, while SMI showed no significant adjusted association. These findings persisted in sensitivity analyses restricted to patients scanned within two months of surgery, a window that best captures muscle status closest to the operation.

Perhaps the most consequential findings concerned where patients went after leaving the hospital. Of 409 patients with discharge data, 30 were sent to a skilled nursing facility, inpatient rehabilitation, or long-term care rather than home. Each 5-unit decrease in SMD was associated with 40 percent greater odds of non-home discharge, and patients classified as having low SMD faced roughly three-and-a-half to eight-and-a-half times the odds of institutional discharge depending on the cutoff definition used. Non-home discharge matters beyond convenience: it is linked to diminished quality of life and higher healthcare costs across surgical populations, making it a meaningful marker of functional recovery.

Mortality data reinforced the same hierarchy. Twelve patients died within 90 days of surgery, and although the small number of events precluded multivariable analysis, each 5-unit decrease in SMD was associated with a 36 percent higher hazard of early death in univariate analysis. Over a median follow-up of 31.6 months, 75 patients—18.1 percent of the cohort—died of any cause. In adjusted Cox regression, each 5-unit decrease in SMD carried a 26 percent higher risk of overall mortality, and low SMD per the Martin criteria was associated with a 93 percent higher risk compared with normal density. Kaplan–Meier curves confirmed significantly worse survival for patients with low values of either measure, but only SMD survived full statistical adjustment.

Why would fat inside muscle outpredict muscle size? The authors point to the biology of myosteatosis, which appears to compound age-related declines in muscle strength and function more aggressively than simple atrophy. Across studies of older adults and patients with cancer, muscle density correlates more strongly than muscle quantity with strength, physical performance, frailty, and comorbidity burden. Myosteatosis is also entwined with systemic inflammation and insulin resistance, mechanisms plausibly relevant to surgical stress, wound healing, and immune defense. Encouragingly, the condition may be modifiable: meta-analytic evidence shows that aerobic and resistance training improve SMD in adults, raising the prospect that prehabilitation programs before cancer surgery could measurably densify muscle and blunt operative risk, though such trials in surgical oncology remain scarce.

The study has limits the authors acknowledge. The cohort was modest, and events for complications, discharge location, and early mortality were few, forcing cautious interpretation and simplified models. Nearly all scans were contrast-enhanced, which modestly overestimates SMD and may underdiagnose myosteatosis, and the researchers lacked data on physical activity, nutrition, and frailty over time. Still, the central message is hard to dismiss: a measurement already sitting inside nearly every preoperative CT scan, requiring no extra radiation, cost, or patient burden, may identify the colorectal surgery patients most likely to struggle. The authors argue that preoperative SMD could guide risk stratification, treatment decisions, and perioperative care, and they call for trials testing whether prehabilitation can improve muscle density before the operating room doors swing open.

Subject of Research: CT-derived skeletal muscle density and mass as predictors of postoperative outcomes after colorectal cancer surgery

Article Title: Associations of CT‐Derived Skeletal Muscle Index and Density With Postoperative Outcomes Following Colorectal Cancer Surgery

Article References: Papadopoulos, E., Irving, B. A., Spielmann, G., Lin, M., & Finan, K. R. (2026). Associations of CT‐Derived Skeletal Muscle Index and Density With Postoperative Outcomes Following Colorectal Cancer Surgery. Journal of Cachexia, Sarcopenia and Muscle, 17(5), Article e70384. https://doi.org/10.1002/jcsm.70384

Image Credits: AI Generated

DOI: 10.1002/jcsm.70384

Keywords: colorectal cancer, skeletal muscle density, myosteatosis, sarcopenia, CT imaging, postoperative complications, length of stay, mortality, prehabilitation, surgical oncology, body composition, risk stratification

The concept behind the approach, known as prehabilitation, is deceptively simple. Surgery imposes an enormous metabolic and inflammatory burden on the body, and patients who enter the operating room with a larger physiological reserve — stronger hearts, lungs and muscles — are better equipped to absorb that stress and recover afterward. Rather than waiting until rehabilitation after surgery, when tissue damage, pain and fatigue make exercise far harder, prehabilitation front-loads the training into the preoperative period, when patients are often still physically capable of meaningful work. The idea has gained traction over the past decade, but evidence has remained fragmented across cancer types, outcome measures and study designs, and the specific contribution of exercise itself has often been obscured in multimodal programs that bundle it with nutrition and psychological support.

To isolate the exercise effect, the researchers restricted their analysis to unimodal exercise trials — programs of aerobic training, resistance training, or a combination of the two — compared against usual care or non-exercise control conditions. They excluded patients receiving neoadjuvant chemotherapy or radiotherapy, whose treatment-related toxicities would confound the results, and they registered the protocol prospectively. Searches across seven databases, supplemented by citation tracking that accounted for roughly 28 percent of the final included studies, yielded 28 articles representing 27 trials. The population skewed toward lung cancer, which accounted for 48.1 percent of studies, followed by gastrointestinal and genitourinary cancers, with a median patient age of 64 years.

The interventions themselves varied widely, reflecting the clinical reality that the time available before surgery can range from a single week to two months. Aerobic programs included treadmill walking, cycle ergometry, interval training and even high-intensity interval training, with intensities prescribed from moderate levels up to 115 percent of maximal cardiopulmonary exercise testing workload in some HIIT protocols. Resistance programs targeted major muscle groups with two to four sets per exercise at moderate to high intensity, while combined programs integrated both modalities. Most interventions — 74.1 percent — were supervised, and durations ranged from approximately one to eight weeks.

When the team applied a three-level mixed-effects meta-analysis, a statistical approach that accounts for multiple dependent effect sizes within the same study, the results were consistent in direction across the key physiological outcomes. Cardiorespiratory fitness, measured through cardiopulmonary exercise testing and related parameters, improved with a standardized mean difference of 0.31, driven almost entirely by preoperative gains. Physical function, assessed through validated performance tests such as the six-minute walk and timed up-and-go, showed the largest and most robust benefit at an SMD of 0.36, with the effect significant both before surgery and — critically — after it. Statistical heterogeneity was low for both outcomes, at 22.3 percent and 11.2 percent respectively, suggesting the benefits were remarkably consistent across different tests, cancer sites and exercise prescriptions.

The postoperative findings may be the most clinically consequential. Physical function typically deteriorates after major cancer surgery, and that decline is independently associated with poorer survival across the cancer care continuum. In this analysis, the functional gains achieved before surgery were not merely lost at the incision; they persisted, with postoperative physical function significantly better in the exercise groups than in controls. For the other outcomes, the pattern was one of preservation rather than improvement: cardiorespiratory fitness, muscle strength, fatigue and quality of life were maintained at or near baseline levels after surgery in exercising patients, effectively attenuating the expected perioperative decline. In perioperative medicine, holding ground is itself a victory.

Fatigue emerged as another notable beneficiary. While the overall effect across all time points did not reach significance, preoperative fatigue was significantly reduced, with aerobic exercise showing larger effects than combined training. This matters because cancer-related fatigue is among the most prevalent and burdensome symptoms in oncology, affecting daily functioning and treatment tolerance, and because fatigue and disability before surgery are associated with roughly a 50 percent higher risk of postoperative complications, including respiratory, cardiovascular and renal events. The authors suggest plausible mechanisms ranging from improved cardiorespiratory fitness and inflammatory regulation to enhanced self-efficacy.

Not every outcome responded equally. Muscle strength showed no significant overall improvement, though the analysis was limited to eight studies and the certainty of evidence was rated very low. Psychological distress was preserved rather than reduced, a finding that contrasts with some earlier meta-analyses and may reflect the shorter intervention durations, the standardized mean difference approach, or the possibility that meaningful mental health benefits require longer programs of six to eight weeks, higher baseline distress, or the addition of formal psychological support. Quality of life improved modestly overall, but the certainty of evidence was very low and small-study effects were detected, warranting caution. The authors themselves note that quality of life in patients awaiting major surgery is shaped by a web of physical, psychological, social and treatment-related factors that brief exercise programs alone are unlikely to transform.

The review is not without limitations, which the authors confront directly. The predominance of lung cancer trials, many involving thoracic procedures with high physiological demands, may limit generalizability. Surgical modality was inconsistently reported, obscuring a key driver of perioperative stress. The exclusion of patients on neoadjuvant therapy, while necessary to isolate the exercise-surgery interaction, leaves open the question for the growing population receiving systemic treatment before surgery. And most outcomes carried low or very low certainty of evidence under the GRADE framework, reflecting risk of bias, imprecision and small numbers of studies for several analyses.

Even so, the overall message is clear and increasingly actionable. Exercise-based prehabilitation appears safe and feasible across oncologic populations, improves the outcomes that matter most for tolerating surgery, and helps patients leave the hospital closer to — not further from — the functional condition they arrived in. The authors argue for a shift in perioperative cancer care toward interventions that prepare patients not just to survive the operation but to recover faster, mobilize earlier, and start adjuvant therapies like chemotherapy or immunotherapy on schedule. Exercise, they suggest, should be a cornerstone of that preparation, ideally embedded within individualized, periodized and multimodal care pathways that pair training with nutritional and psychological support tailored to each patient’s needs and timetable.

Subject of Research: Prehabilitative exercise before oncologic surgery

Article Title: Benefits of prehabilitative exercise on physiological, functional and patient-reported outcomes in patients undergoing oncologic surgery: A systematic review and meta-analysis

Article References: Casagrande, N., Singh, F., Rech, A., Radaelli, R., Paniz, B. M., Silvestro, G. T., Eberhardt, G. N., Brollo, J., Kneubil, M. C., Júnior, C. P., de Almeida, P. W. M., Magalhães, M. C. F., Bettariga, F., & Lopez, P. (2026). Benefits of prehabilitative exercise on physiological, functional and patient-reported outcomes in patients undergoing oncologic surgery: A systematic review and meta-analysis. Journal of Cancer Survivorship. https://doi.org/10.1007/s11764-026-02107-0

Image Credits: AI Generated

DOI: 10.1007/s11764-026-02107-0

Keywords: prehabilitation, cancer surgery, exercise, cardiorespiratory fitness, physical function, fatigue, quality of life, meta-analysis, perioperative care, oncology, randomized controlled trials, cancer survivorship

The physiological case for specialized care begins long before the first incision. Even in the absence of overt disease, aging produces organ-specific changes that erode physiological reserve and impair homeostasis. Cardiovascular stiffness reduces the heart’s ability to buffer the stress of anesthesia, declining renal function prolongs the elimination of drugs and their metabolites, and age-related shifts in body composition alter how anesthetic agents are distributed and cleared. The authors emphasize that these changes mean older patients are exquisitely sensitive to both under- and over-treatment: too little hemodynamic support risks organ injury, while excessive sedation or fluid loading can tip a fragile balance into delirium, kidney failure, or prolonged recovery. Dosing, the 2025 American Society of Anesthesiologists advisory makes clear, should be individualized according to physiological rather than chronological age.

One of the review’s most counterintuitive findings concerns preoperative testing. Despite the multiple comorbidities typical of geriatric patients, one study found that only 12.9 percent presented significant abnormalities in preoperative blood tests, and laboratory findings were not significant predictors of postoperative complications. Excessive testing, the authors warn, may increase distress and delay time-sensitive surgery without improving outcomes. Instead, the evidence supports a targeted approach: a thorough history and physical examination should guide which investigations are actually needed. Resting electrocardiography is recommended for patients aged 65 and over undergoing intermediate- or high-risk surgery, echocardiography is reserved for suspected valvular disease or unexplained dyspnea, and routine stress testing before low-risk procedures is explicitly not recommended. In emergency surgery, where mortality and complication rates are substantially higher, evaluation should focus only on factors that will immediately influence management.

Cardiac risk assessment occupies a central place in the review, and here the authors highlight a critical gap. The Revised Cardiac Risk Index, long the workhorse of perioperative cardiology, incorporates six variables including ischemic heart disease, heart failure, and high-risk surgery. Yet growing evidence suggests that in patients aged 80 and above, the RCRI may systematically underestimate perioperative cardiac risk. To compensate, contemporary guidelines recommend biomarker surveillance: preoperative B-type natriuretic peptide measurement for older patients facing intermediate- or high-risk surgery, and high-sensitivity cardiac troponin measured before surgery and at 24 and 48 hours afterward. The rationale is compelling—perioperative myocardial injury is frequently asymptomatic, and even modest postoperative troponin elevations are independently associated with increased short-term mortality. However, the authors caution that biomarker thresholds have largely been validated in mixed-age populations, leaving their optimal application in the oldest patients uncertain.

Beyond the heart, the review identifies frailty as perhaps the single most important concept in modern geriatric perioperative medicine. Defined as a state of decreased physiological reserve and increased vulnerability to stressors, frailty predicts postoperative complications, prolonged hospitalization, institutionalization, loss of independence, and death more powerfully than age itself. The Clinical Frailty Scale, a simple scoring tool with demonstrated interrater reliability among perioperative clinicians, is emerging as a candidate for routine incorporation into standard preoperative evaluation. Closely related is sarcopenia—low muscle strength, reduced muscle mass, and impaired physical performance—which a meta-analysis of 43 studies linked to a fourfold increase in postoperative complications and a doubling of 30-day mortality after gastroenterological cancer surgery. Crucially, both conditions should be regarded as potentially modifiable rather than fixed: multimodal prehabilitation combining exercise, nutritional optimization, and medication review has been shown in meta-analyses to improve muscle mass, strength, gait speed, and postoperative outcomes in frail older patients.

Nutrition emerges as another underappreciated pillar of preoperative preparation. Malnutrition affects up to 22 percent of hospitalized older adults and 30 percent of those in long-term care, and the surgical period compounds the problem through increased catabolism, reduced appetite, gastrointestinal dysfunction, fasting requirements, and the deleterious effects of medications. Body mass index, the review notes, has limited utility in this population because fluid retention and altered body composition can mask true deficits. Validated screening tools fill the gap: the Nutritional Risk Screening 2002, derived from surgical trial data and endorsed by the American Association for the Surgery of Trauma, the simpler two-parameter Geriatric Nutritional Risk Index, and the widely used Mini Nutritional Assessment, which a recent meta-analysis of over 200,000 geriatric orthopedic patients linked to postoperative complications and mortality. Patients flagged as high risk warrant preoperative counseling, oral nutritional supplements, and, in severe cases, consideration of postponing elective surgery.

Cognitive function and mental health receive equally detailed attention. Cognitive screening should be a routine component of preoperative evaluation, with the three-minute Mini-Cog offering a practical balance of brevity and predictive value for postoperative delirium, while the Montreal Cognitive Assessment and Mini Mental State Examination serve as alternatives with different practical constraints. The review also flags sensory deficits—hearing and vision loss—as independent predictors of delirium, citing a cohort study in which patients deprived of hearing aids and glasses throughout the perioperative period had higher rates of delirium and lower quality-of-recovery scores. Depression, present in up to half of surgical patients, is associated with worse outcomes, yet screening remains inconsistent; one UK prospective study found that two-thirds of patients who screened positive for depression accepted referrals to mental health care. Sleep disturbances, too, contribute to worse cognition, greater pain perception, and falls.

Medication management is framed as a continuous thread running from admission to discharge. Polypharmacy, commonly defined as five or more concurrent medications, is nearly universal among older surgical patients and carries a cumulatively unfavorable benefit-to-risk profile. The STOPP/START criteria and the American Geriatrics Society Beers Criteria offer structured ways to identify potentially inappropriate medications and prescribing omissions, and a brief preoperative review can flag high-risk patients for geriatric referral. Anticoagulants and antiplatelet agents demand particular care: interruption balances procedural bleeding risk against thromboembolic danger, a calculation complicated in the oldest patients by declining renal function that prolongs the elimination of agents such as dabigatran. Discharge represents a second opportunity, when prescribing physicians should reconcile medication lists and deprescribe what was flagged preoperatively.

In the operating room and intensive care unit, the review’s technical recommendations center on hemodynamic stability and anesthetic depth. Intraoperative and postoperative hypotension are associated with myocardial injury, acute kidney injury, stroke, and death, and prolonged or profound blood pressure drops should be avoided whenever possible. Excessive depth of anesthesia, monitored with electroencephalography-based tools such as bispectral index, may contribute to delayed recovery and neurocognitive complications. Regional anesthetic techniques do not show consistent superiority over general anesthesia for mortality or delirium, but may reduce opioid exposure in selected patients. After surgery, enhanced recovery protocols—early mobilization within 24 hours, carbohydrate-containing oral hydration up to two hours before surgery, and early urinary catheter removal—have been shown in meta-analyses of older orthopedic and colorectal patients to reduce complications and shorten hospital stays, though epidural analgesia raises the risk of urinary retention with early catheter removal.

The final and arguably most sobering section addresses what happens after discharge. Postoperative delirium affects up to 50 percent of older surgical patients, compared with 2 to 3 percent of the general population, and a systematic review of more than 20,000 patients linked it to increased mortality, prolonged hospitalization, non-home discharge, and intensive care admission; its economic burden in the United States is estimated at roughly 164 billion dollars annually. Non-pharmacological prevention—geriatric consultation, cognitive stimulation, sensory aid preservation, treatment of underlying causes—remains first-line management, while antipsychotics carry safety concerns and benzodiazepines may worsen outcomes. Nearly 30 percent of older patients experience functional decline in the perioperative period, and for some the decline is irreversible. With no universally recognized post-discharge pathways and ongoing trials still underway, the authors conclude that individualized care plans built by interdisciplinary teams—surgeons, anesthetists, geriatricians, nurses, and rehabilitation specialists—are not a luxury but a necessity for a population whose numbers will only grow.

Subject of Research: Perioperative management of very old surgical patients, focusing on frailty, geriatric syndromes, and individualized interdisciplinary care

Article Title: Perioperative care in older adults: a narrative review

Article References: Szczeklik, W., Pasieka, P., Piotrowicz, K., & Włudarczyk, A. (2026). Perioperative care in older adults: a narrative review. European Geriatric Medicine. https://doi.org/10.1007/s41999-026-01617-5

Image Credits: AI Generated

DOI: 10.1007/s41999-026-01617-5

Keywords: perioperative care, older adults, frailty, sarcopenia, delirium, preoperative assessment, cardiac risk, malnutrition, polypharmacy, prehabilitation, ERAS, geriatric surgery