Advances in the application of prehabilitation during neoadjuvant therapy for esophageal cancer patients_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

LIU Jiarui ¹ ,  LUO Lei ² , HAN Yongtao ³ , MIAO Yan ³

1. School of Nursing, Chengdu Medical College, Chengdu, 610500, P. R. China;
2. Department of General Affairs, Sichuan Clinical Research Center for Caner, Sichan Cancer Hospital & Institute, Sichuan Cancer Center, University of Electronic Science and Technology of China, Chengdu, 610041, P. R. China;
3. Department of Thoracic Surgery, Sichuan Clinical Research Center for Caner, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, University of Electronic Science and Technology of China, Chengdu, 610041, P. R. China;

Corresponding author：

LUO Lei, Email: 43369334@qq.com

Keywords：

Esophageal cancer; prehabilitation; neoadjuvant therapy; review

DOI：

10.7507/1007-4848.202503054

Video：

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Abstract Full text Figures/Tables Video References Cited by

Surgery following neoadjuvant therapy has become the standard treatment for middle- and late-stage resectable esophageal cancer. However, treatment modalities such as radiotherapy, chemotherapy, and surgery cause physical and psychological harm to patients, reducing their quality of life. Prehabilitation, as an emerging preoperative management strategy, integrates various measures, including exercise training, nutritional support, and psychological support. Its aim is to enhance patients’ physiological and psychological reserves prior to surgery, bolster their tolerance to surgical stress, and thus accelerate the postoperative recovery process. This approach is a key manifestation of the Enhanced Recovery After Surgery (ERAS) concept. This article reviews prehabilitation during neoadjuvant therapy for esophageal cancer patients from 3 aspects: intervention timing, intervention content, and barriers, with the aim of providing a reference for promoting early recovery in patients undergoing esophageal cancer surgery.

1.	Bray F, Laversanne M, Sung H, et al. Global cancer statistics 2022: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin, 2024, 74(3): 229-263.
2.	康晓征, 张瑞祥, 王镇, 等. 局部进展期可切除食管癌的新辅助治疗进展. 中国胸心血外科临床杂志, 2025, 32(2): 153-159.Kang XZ, Zhang RX, Wang Z, et al. Progress in neoadjuvant therapy for locally advanced resectable esophageal cancer. Chin J Clin Thorac Cardiovasc Surg, 2025, 32(2): 153-159.
3.	Lv H, Zhang F, Huang C, et al. Survival outcomes of neoadjuvant immunochemotherapy versus chemotherapy for locally advanced esophageal squamous cell carcinoma. J Cancer Res Clin Oncol, 2024, 150(5): 260.
4.	Sjoquist KM, Burmeister BH, Smithers BM, et al. Survival after neoadjuvant chemotherapy or chemoradiotherapy for resectable oesophageal carcinoma: An updated meta-analysis. Lancet Oncol, 2011, 12(7): 681-692.
5.	Wang P, Wang S, Li X, et al. Skeletal muscle wasting during neoadjuvant therapy as a prognosticator in patients with esophageal and esophagogastric junction cancer: A systematic review and meta-analysis. Int J Surg, 2022, 97: 106206.
6.	Reijneveld EAE, Bor P, Dronkers JJ, et al. Impact of curative treatment on the physical fitness of patients with esophageal cancer: A systematic review and meta-analysis. Eur J Surg Oncol, 2022, 48(2): 391-402.
7.	Xiao X, Fang PH, Zhou JF, et al. Impact of skeletal muscle loss and sarcopenia on outcomes of locally advanced esophageal cancer during neoadjuvant chemoradiation. Ann Surg Oncol, 2024, 31(6): 3819-3829.
8.	王明欣, 周春姣, 嵇星辰, 等. 食管癌患者术后肺部感染危险因素的系统评价与Meta分析. 中国胸心血管外科临床杂志, 2023, 30(10): 1467-1474.Wang MX, Zhou CJ, Ji XC, et al. Systematic review and meta-analysis of risk factors for postoperative pulmonary infection in esophageal cancer patients. Chin J Clin Thorac Cardiovasc Surg, 2023, 30(10): 1467-1474.
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10.	Demmelmaier I, Brooke HL, Henriksson A, et al. Does exercise intensity matter for fatigue during (neo-)adjuvant cancer treatment? The Phys-Can randomized clinical trial. Scand J Med Sci Sports, 2021, 31(5): 1144-1159.
11.	Malveiro C, Correia IR, Cargaleiro C, et al. Effects of exercise training on cancer patients undergoing neoadjuvant treatment: A systematic review. J Sci Med Sport, 2023, 26(11): 586-592.
12.	Doganay E, Moorthy K. Prehabilitation for esophagectomy. J Thorac Dis, 2019, 11(Suppl 5): S632-S638.
13.	Gillis C, Li C, Lee L, et al. Prehabilitation versus rehabilitation: A randomized control trial in patients undergoing colorectal resection for cancer. Anesthesiology, 2014, 121(5): 937-947.
14.	Crandall K, Maguire R, Campbell A, et al. Exercise intervention for patients surgically treated for Non-Small Cell Lung Cancer (NSCLC): A systematic review. Surg Oncol, 2014, 23(1): 17-30.
15.	Samson P, Patel A, Garrett T, et al. Effects of delayed surgical resection on short-term and long-term outcomes in clinical stageⅠ non-small cell lung cancer. Ann Thorac Surg, 2015, 99(6): 1906-12.
16.	Deng T, Song J, Tuo J, et al. Incidence and risk factors of pulmonary complications after lung cancer surgery: A systematic review and meta-analysis. Heliyon, 2024, 10(12): e32821.
17.	Lugg ST, Agostini PJ, Tikka T, et al. Long-term impact of developing a postoperative pulmonary complication after lung surgery. Thorax, 2016, 71(2): 171-176.
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19.	Mantziari S, Hübner M, Demartines N, et al. Impact of preoperative risk factors on morbidity after esophagectomy: Is there room for improvement? World J Surg, 2014, 38(11): 2882-2890.
20.	Boudreaux AM, Simmons JW. Prehabilitation and optimization of modifiable patient risk factors: The importance of effective preoperative evaluation to improve surgical outcomes. AORN J, 2019, 109(4): 500-507.
21.	Batchelor TJP, Rasburn NJ, Abdelnour-Berchtold E, et al. Guidelines for enhanced recovery after lung surgery: Recommendations of the Enhanced Recovery After Surgery (ERAS®) Society and the European Society of Thoracic Surgeons (ESTS). Eur J Cardiothorac Surg, 2019, 55(1): 91-115.
22.	Yoshida N, Baba Y, Hiyoshi Y, et al. Duration of smoking cessation and postoperative morbidity after esophagectomy for esophageal cancer: How long should patients stop smoking before surgery? World J Surg, 2016, 40(1): 142-147.
23.	Shigeeda W, Deguchi H, Tomoyasu M, et al. Optimal period of smoking cessation to reduce the incidence of postoperative pulmonary complications in lung cancer. Interdiscip Cardiovasc Thorac Surg, 2023, 36(6): ivad094.
24.	Yoshida N, Nakamura K, Kuroda D, et al. Preoperative smoking cessation is integral to the prevention of postoperative morbidities in minimally invasive esophagectomy. World J Surg, 2018, 42(9): 2902-2909.
25.	Choe SI, Finley C. Perioperative abstinence from cigarettes: Confronting the negative impact of cigarette smoking on cancer surgery. Curr Oncol, 2022, 29(8): 5869-5874.
26.	Kotta PA, Ali JM. Incentive spirometry for prevention of postoperative pulmonary complications after thoracic surgery. Respir Care, 2021, 66(2): 327-333.
27.	Kokotovic D, Berkfors A, Gögenur I, et al. The effect of postoperative respiratory and mobilization interventions on postoperative complications following abdominal surgery: A systematic review and meta-analysis. Eur J Trauma Emerg Surg, 2021, 47(4): 975-990.
28.	Topp R, Ditmyer M, King K, et al. The effect of bed rest and potential of prehabilitation on patients in the intensive care unit. AACN Clin Issues, 2002, 13(2): 263-276.
29.	Sinclair R, Navidi M, Griffin SM, et al. The impact of neoadjuvant chemotherapy on cardiopulmonary physical fitness in gastro-oesophageal adenocarcinoma. Ann R Coll Surg Engl, 2016, 98(6): 396-400.
30.	Navidi M, Phillips AW, Griffin SM, et al. Cardiopulmonary fitness before and after neoadjuvant chemotherapy in patients with oesophagogastric cancer. Br J Surg, 2018, 105(7): 900-906.
31.	Thomson IG, Wallen MP, Hall A, et al. Neoadjuvant therapy reduces cardiopulmunary function in patients undegoing oesophagectomy. Int J Surg, 2018, 53: 86-92.
32.	Stringer W, Casaburi R, Older P. Cardiopulmonary exercise testing: Does it improve perioperative care and outcome? Curr Opin Anaesthesiol, 2012, 25(2): 178-184.
33.	Suri A, Mishra S, Bhatnagar S, et al. Cardiopulmonary exercise testing as a predictor of postoperative outcome in patients undergoing oesophageal cancer surgery following neoadjuvant chemotherapy. Turk J Anaesthesiol Reanim, 2022, 50(5): 358-365.
34.	Jack S, West MA, Raw D, et al. The effect of neoadjuvant chemotherapy on physical fitness and survival in patients undergoing oesophagogastric cancer surgery. Eur J Surg Oncol, 2014, 40(10): 1313-1320.
35.	刘子嘉, 张路, 刘洪生, 等. 基于加速术后康复的胸外科手术预康复管理专家共识(2022). 协和医学杂志, 2022, 13(3): 387-401.Liu ZJ, Zhang L, Liu HS, et al. Expert consensus on pre-rehabilitation management for thoracic surgery based on Enhanced Recovery After Surgery (2022). J Peking Union Med Coll Hosp, 2022, 13(3): 387-401.
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37.	Christensen JF, Simonsen C, Banck-Petersen A, et al. Safety and feasibility of preoperative exercise training during neoadjuvant treatment before surgery for adenocarcinoma of the gastro-oesophageal junction. BJS Open, 2018, 3(1): 74-84.
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39.	Ikeda T, Noma K, Maeda N, et al. Effectiveness of early exercise on reducing skeletal muscle loss during preoperative neoadjuvant chemotherapy for esophageal cancer. Surg Today, 2022, 52(8): 1143-1152.
40.	Chen MF, Hsieh CC, Chen PT, et al. Role of nutritional status in the treatment outcome for Esophageal squamous cell carcinoma. Nutrients, 2021, 13(9): 2997.
41.	Wang B, Jiang XW, Tian DL, et al. Combination of haemoglobin and prognostic nutritional index predicts the prognosis of postoperative radiotherapy for esophageal squamous cell carcinoma. Cancer Manag Res, 2020, 12: 8589-8597.
42.	Wei J, Jin M, Shao Y, et al. High preoperative serum prealbumin predicts long-term survival in resected esophageal squamous cell cancer. Cancer Manag Res, 2019, 11: 7997-8003.
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44.	Wiwitkeyoonwong J, Jiarpinitnun C, Hiranyatheb P, et al. Impact of weight loss on patients with locally advanced esophageal and esophagogastric junction cancers treated with chemoradiotherapy. Asian Pac J Cancer Prev, 2021, 22(12): 3847-3855.
45.	周华萍, 甘彩芳, 程菁, 等. 营养状态指标对老年食管癌患者化疗耐受性的影响. 中国老年学杂志, 2024, 44(4): 802-805.Zhou HP, Gan CF, Cheng J, et al. Influence of nutritional status indicators on the chemotherapy tolerance of elderly patients with esophageal cancer. Chin J Gerontol, 2024, 44(4): 802-805.
46.	Bo Y, Wang K, Liu Y, et al. The geriatric nutritional risk index predicts survival in elderly esophageal squamous cell carcinoma patients with radiotherapy. PLoS One, 2016, 11(5): e0155903.
47.	Weimann A, Braga M, Carli F, et al. ESPEN practical guideline: Clinical nutrition in surgery. Clin Nutr, 2021, 40(7): 4745-4761.
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1. Bray F, Laversanne M, Sung H, et al. Global cancer statistics 2022: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin, 2024, 74(3): 229-263.
2. 康晓征, 张瑞祥, 王镇, 等. 局部进展期可切除食管癌的新辅助治疗进展. 中国胸心血外科临床杂志, 2025, 32(2): 153-159.Kang XZ, Zhang RX, Wang Z, et al. Progress in neoadjuvant therapy for locally advanced resectable esophageal cancer. Chin J Clin Thorac Cardiovasc Surg, 2025, 32(2): 153-159.
3. Lv H, Zhang F, Huang C, et al. Survival outcomes of neoadjuvant immunochemotherapy versus chemotherapy for locally advanced esophageal squamous cell carcinoma. J Cancer Res Clin Oncol, 2024, 150(5): 260.
4. Sjoquist KM, Burmeister BH, Smithers BM, et al. Survival after neoadjuvant chemotherapy or chemoradiotherapy for resectable oesophageal carcinoma: An updated meta-analysis. Lancet Oncol, 2011, 12(7): 681-692.
5. Wang P, Wang S, Li X, et al. Skeletal muscle wasting during neoadjuvant therapy as a prognosticator in patients with esophageal and esophagogastric junction cancer: A systematic review and meta-analysis. Int J Surg, 2022, 97: 106206.
6. Reijneveld EAE, Bor P, Dronkers JJ, et al. Impact of curative treatment on the physical fitness of patients with esophageal cancer: A systematic review and meta-analysis. Eur J Surg Oncol, 2022, 48(2): 391-402.
7. Xiao X, Fang PH, Zhou JF, et al. Impact of skeletal muscle loss and sarcopenia on outcomes of locally advanced esophageal cancer during neoadjuvant chemoradiation. Ann Surg Oncol, 2024, 31(6): 3819-3829.
8. 王明欣, 周春姣, 嵇星辰, 等. 食管癌患者术后肺部感染危险因素的系统评价与Meta分析. 中国胸心血管外科临床杂志, 2023, 30(10): 1467-1474.Wang MX, Zhou CJ, Ji XC, et al. Systematic review and meta-analysis of risk factors for postoperative pulmonary infection in esophageal cancer patients. Chin J Clin Thorac Cardiovasc Surg, 2023, 30(10): 1467-1474.
9. Low DE, Kuppusamy MK, Alderson D, et al. Benchmarking complications associated with esophagectomy. Ann Surg, 2019, 269(2): 291-298.
10. Demmelmaier I, Brooke HL, Henriksson A, et al. Does exercise intensity matter for fatigue during (neo-)adjuvant cancer treatment? The Phys-Can randomized clinical trial. Scand J Med Sci Sports, 2021, 31(5): 1144-1159.
11. Malveiro C, Correia IR, Cargaleiro C, et al. Effects of exercise training on cancer patients undergoing neoadjuvant treatment: A systematic review. J Sci Med Sport, 2023, 26(11): 586-592.
12. Doganay E, Moorthy K. Prehabilitation for esophagectomy. J Thorac Dis, 2019, 11(Suppl 5): S632-S638.
13. Gillis C, Li C, Lee L, et al. Prehabilitation versus rehabilitation: A randomized control trial in patients undergoing colorectal resection for cancer. Anesthesiology, 2014, 121(5): 937-947.
14. Crandall K, Maguire R, Campbell A, et al. Exercise intervention for patients surgically treated for Non-Small Cell Lung Cancer (NSCLC): A systematic review. Surg Oncol, 2014, 23(1): 17-30.
15. Samson P, Patel A, Garrett T, et al. Effects of delayed surgical resection on short-term and long-term outcomes in clinical stageⅠ non-small cell lung cancer. Ann Thorac Surg, 2015, 99(6): 1906-12.
16. Deng T, Song J, Tuo J, et al. Incidence and risk factors of pulmonary complications after lung cancer surgery: A systematic review and meta-analysis. Heliyon, 2024, 10(12): e32821.
17. Lugg ST, Agostini PJ, Tikka T, et al. Long-term impact of developing a postoperative pulmonary complication after lung surgery. Thorax, 2016, 71(2): 171-176.
18. Overbeek MC, Reijneveld EA, Valkenet K, et al. The association between preoperative inspiratory muscle training variables and postoperative pulmonary complications in subjects with esophageal cancer. Respir Care, 2024, 69(3): 290-297.
19. Mantziari S, Hübner M, Demartines N, et al. Impact of preoperative risk factors on morbidity after esophagectomy: Is there room for improvement? World J Surg, 2014, 38(11): 2882-2890.
20. Boudreaux AM, Simmons JW. Prehabilitation and optimization of modifiable patient risk factors: The importance of effective preoperative evaluation to improve surgical outcomes. AORN J, 2019, 109(4): 500-507.
21. Batchelor TJP, Rasburn NJ, Abdelnour-Berchtold E, et al. Guidelines for enhanced recovery after lung surgery: Recommendations of the Enhanced Recovery After Surgery (ERAS®) Society and the European Society of Thoracic Surgeons (ESTS). Eur J Cardiothorac Surg, 2019, 55(1): 91-115.
22. Yoshida N, Baba Y, Hiyoshi Y, et al. Duration of smoking cessation and postoperative morbidity after esophagectomy for esophageal cancer: How long should patients stop smoking before surgery? World J Surg, 2016, 40(1): 142-147.
23. Shigeeda W, Deguchi H, Tomoyasu M, et al. Optimal period of smoking cessation to reduce the incidence of postoperative pulmonary complications in lung cancer. Interdiscip Cardiovasc Thorac Surg, 2023, 36(6): ivad094.
24. Yoshida N, Nakamura K, Kuroda D, et al. Preoperative smoking cessation is integral to the prevention of postoperative morbidities in minimally invasive esophagectomy. World J Surg, 2018, 42(9): 2902-2909.
25. Choe SI, Finley C. Perioperative abstinence from cigarettes: Confronting the negative impact of cigarette smoking on cancer surgery. Curr Oncol, 2022, 29(8): 5869-5874.
26. Kotta PA, Ali JM. Incentive spirometry for prevention of postoperative pulmonary complications after thoracic surgery. Respir Care, 2021, 66(2): 327-333.
27. Kokotovic D, Berkfors A, Gögenur I, et al. The effect of postoperative respiratory and mobilization interventions on postoperative complications following abdominal surgery: A systematic review and meta-analysis. Eur J Trauma Emerg Surg, 2021, 47(4): 975-990.
28. Topp R, Ditmyer M, King K, et al. The effect of bed rest and potential of prehabilitation on patients in the intensive care unit. AACN Clin Issues, 2002, 13(2): 263-276.
29. Sinclair R, Navidi M, Griffin SM, et al. The impact of neoadjuvant chemotherapy on cardiopulmonary physical fitness in gastro-oesophageal adenocarcinoma. Ann R Coll Surg Engl, 2016, 98(6): 396-400.
30. Navidi M, Phillips AW, Griffin SM, et al. Cardiopulmonary fitness before and after neoadjuvant chemotherapy in patients with oesophagogastric cancer. Br J Surg, 2018, 105(7): 900-906.
31. Thomson IG, Wallen MP, Hall A, et al. Neoadjuvant therapy reduces cardiopulmunary function in patients undegoing oesophagectomy. Int J Surg, 2018, 53: 86-92.
32. Stringer W, Casaburi R, Older P. Cardiopulmonary exercise testing: Does it improve perioperative care and outcome? Curr Opin Anaesthesiol, 2012, 25(2): 178-184.
33. Suri A, Mishra S, Bhatnagar S, et al. Cardiopulmonary exercise testing as a predictor of postoperative outcome in patients undergoing oesophageal cancer surgery following neoadjuvant chemotherapy. Turk J Anaesthesiol Reanim, 2022, 50(5): 358-365.
34. Jack S, West MA, Raw D, et al. The effect of neoadjuvant chemotherapy on physical fitness and survival in patients undergoing oesophagogastric cancer surgery. Eur J Surg Oncol, 2014, 40(10): 1313-1320.
35. 刘子嘉, 张路, 刘洪生, 等. 基于加速术后康复的胸外科手术预康复管理专家共识(2022). 协和医学杂志, 2022, 13(3): 387-401.Liu ZJ, Zhang L, Liu HS, et al. Expert consensus on pre-rehabilitation management for thoracic surgery based on Enhanced Recovery After Surgery (2022). J Peking Union Med Coll Hosp, 2022, 13(3): 387-401.
36. Argudo N, Rodó-Pin A, Martínez-Llorens J, et al. Feasibility, tolerability, and effects of exercise-based prehabilitation after neoadjuvant therapy in esophagogastric cancer patients undergoing surgery: An interventional pilot study. Dis Esophagus, 2021, 34(4): doaa086.
37. Christensen JF, Simonsen C, Banck-Petersen A, et al. Safety and feasibility of preoperative exercise training during neoadjuvant treatment before surgery for adenocarcinoma of the gastro-oesophageal junction. BJS Open, 2018, 3(1): 74-84.
38. Chen F, Chi J, Zhao B, et al. Impact of preoperative sarcopenia on postoperative complications and survival outcomes of patients with esophageal cancer: A meta-analysis of cohort studies. Dis Esophagus, 2022, 35(9): doab100.
39. Ikeda T, Noma K, Maeda N, et al. Effectiveness of early exercise on reducing skeletal muscle loss during preoperative neoadjuvant chemotherapy for esophageal cancer. Surg Today, 2022, 52(8): 1143-1152.
40. Chen MF, Hsieh CC, Chen PT, et al. Role of nutritional status in the treatment outcome for Esophageal squamous cell carcinoma. Nutrients, 2021, 13(9): 2997.
41. Wang B, Jiang XW, Tian DL, et al. Combination of haemoglobin and prognostic nutritional index predicts the prognosis of postoperative radiotherapy for esophageal squamous cell carcinoma. Cancer Manag Res, 2020, 12: 8589-8597.
42. Wei J, Jin M, Shao Y, et al. High preoperative serum prealbumin predicts long-term survival in resected esophageal squamous cell cancer. Cancer Manag Res, 2019, 11: 7997-8003.
43. 孙雪烽, 金芷呈, 杨海华, 等. 新辅助放化疗期间外周血白蛋白值对局晚期食管鳞癌患者预后预测的价值. 现代肿瘤医学, 2023, 31(5): 848-854.Sun XF, Jin ZC, Yang HH, et al. Value of peripheral blood albumin levels during Neoadjuvant Chemoradiotherapy in predicting the prognosis of patients with Locally Advanced Esophageal Squamous Cell Carcinoma. J Mod Oncol, 2023, 31(5): 848-854.
44. Wiwitkeyoonwong J, Jiarpinitnun C, Hiranyatheb P, et al. Impact of weight loss on patients with locally advanced esophageal and esophagogastric junction cancers treated with chemoradiotherapy. Asian Pac J Cancer Prev, 2021, 22(12): 3847-3855.
45. 周华萍, 甘彩芳, 程菁, 等. 营养状态指标对老年食管癌患者化疗耐受性的影响. 中国老年学杂志, 2024, 44(4): 802-805.Zhou HP, Gan CF, Cheng J, et al. Influence of nutritional status indicators on the chemotherapy tolerance of elderly patients with esophageal cancer. Chin J Gerontol, 2024, 44(4): 802-805.
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