Cancer prehabilitation pathway

Cancer prehabilitation for healthcare professionals
Centre for Sustainable Delivery

In 2025, Macmillan published ‘Prehabilitation for people with cancer: Clinical and implementation guidelines.’ These guidelines were developed in collaboration with the NIHR Southampton Biomedical Research Centre, the Centre for Perioperative Care, the Royal College of Anaesthetists, the NIHR Cancer Nutrition Collaborativeand the World Cancer Research Fund. Within these guidelines prehabilitation has been defined as:

“Prehabilitation is a needs-based multimodal intervention, before and during cancer treatment. The aim of prehabilitation is to optimise physical, nutritional and psychological status, enhance readiness for and tolerance of treatments, and improve recovery and/or quality of life. Prehabilitation involves screening before needs-based assessment, enabling individualised prescription of exercise, nutrition and psychological interventions supported by behaviour change techniques.” 

The following are specifically excluded from prehabilitation: medical management of long-term conditions (e.g. anaemia management, diabetes management), rehabilitation and geriatric medical management of frailty. These are related but distinct activities.

This section aims to support implementation of cancer prehabilitation as outlined in the latest updated clinical and implementation guidelines.

Step 1: Screening

Identification of prehabilitation need (i.e. screening) should occur as early as possible after diagnosis and in advance of each treatment. Where appropriate, screening may precede a confirmed diagnosis. Early symptom control may also be required to maximise the potential for prehabilitation. When need is identified, validated tools should be used for more detailed assessment. This will inform the prescription of targeted or specialist interventions.

 

Complete national cancer prehabilitation screening tool

(Additional tumour specific screening tools can be used alongside as required).

  • Physical activity - Duke Activity Status Index (DASI)
  • Nutrition - Patient Generated-Subjective Global Assessment (PG-SGA short form)
  • Psychological support - Patient Health Questionnaire - 4 (PHQ-4)
  • Lifestyle - this questionnaire provides healthcare professionals with an overview of a patients general lifestyle. There is no screening outcome for this questionnaire.

Professional toolkit

This has been designed for a professional to complete with the patient during an appointment/consultation. After completing the screening questionnaires, a level of prehabilitation need outcome will be provided for each pillar. Outcomes should be recorded at MDT level alongside performance status (PS).

Patient toolkit

Also available on the Right Decision Service. This has been designed for patients to complete independently. Patients will be provided with a score, but not a level of prehabilitation (universal, targeted or specialist). If patients are completing the prehabilitation screening independently via the patient platform, ensure the patient is provided with instructions on how to submit the screening information to the healthcare team e.g. local email, print and return. It is also the responsibility of the local team to ensure follow-up information is provided to the patient (e.g. explanation of score, referral for assessment) where applicable. Outcomes should be recorded at MDT level alongside performance status (PS).

 

Screening outcomes – level of prehabilitation need:

'Universal prehabilitation’ - is the provision of expert advice on exercise, nutrition and psychological support, along with behaviour change advice, to all individuals before cancer treatment. ‘Universal prehabilitation’ (e.g. surgery school) is the foundation of prehabilitation and may involve screening. Generic lifestyle advice alone does not constitute universal prehabilitation.

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

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

 

Screening checklist

After completing prehabilitation screening all patients (regardless of screening outcome) should be provided with universal prehabilitation by:

Patients should also be referred to the local Improving Cancer Journey (ICJ) team if not already.

Patients needs can change and therefore, patients should be re-screened throughout the cancer pathway. The time point at which a patient is re-screened will be decided by the local MDT.

 

Step 2: Needs-based assessment

Any patient who scores at targeted or specialist level at screening should be referred for assessment for the particular pillar(s). Individualised assessment, when indicated, should encompass comprehensive evaluation of needs identified during screening using validated clinical measurement techniques. Assessments should inform the individualised prescription of exercise/activity, nutrition and psychological interventions.

Referrals are not automated through the Right Decision Service (RDS) and it is the responsibility of the local team to generate the referral to the appropriate service.

 

Recommendations for targeted / specialist assessment

Below are some recommendations and resources to support targeted/specialist assessment. Local teams will choose the assessment(s) most suitable to their patient group and pathway. The outcome should be recorded at MDT.

Physical activity

  • 6 Minute Walk Test (6MWT) and/or 30 Second Sit-To-Stand (30 STS)
  • Hand grip – while not a measure of physical activity, it is recommended to record hand grip strength where it is not possible for a patient to complete 6MWT or 30STS to provide an outcome measure for assessment

Nutrition

  • Patient Generated – Subjective Global Assessment (PG-SGA) full assessment

Further information on nutrition assessment can be found in the ‘Nutrition Framework for People Affected by Cancer’

Psychological support

  • Patient Health Questionnaire-9 (PHQ-9)
  • Hospital Anxiety and Depression Scale (HADS)

Further information on assessment can be found in the Psychological therapies and support framework for people affected by cancer

 

Step 3: Intervention

Based on the outcomes from screening and assessment (where required), all patients should be provided with a co-produced personalised prehabilitation programme. Required interventions should be categorised into universal, targeted and specialist. They should start as early as possible and in advance of any cancer treatment (not just the first cancer treatment) for curative or palliative intent. Programme delivery should consider preferences of the individual e.g. social or cultural preferences. These programmes should be monitored and adapted as required throughout prehabilitation and cancer pathway.

 

Monitoring and evaluation

Monitoring of interventions should be proportionate to need. Universal interventions should be self-monitored and recorded via the Holistic Needs Assessment (HNA) or equivalent process. The impact of targeted and specialist interventions should be monitored using appropriate validated measures. The outcome of those measures should be recorded electronically and reported to monitor impact of intervention and inform service development.

 

References