Long term follow-up of patients undergoing prehabilitation prior to oesophagectomy: What happens to patients declining or withdrawing from prehabilitation exercise programmes?

Background Prehabilitative exercise prior to cancer surgery can improve survival, health-related quality of life and chemotherapy completion and response rates. Little is known about patients who either drop-out or decline to participate in exercise programmes in oesophageal cancer. This study reports the outcomes of patients who declined or dropped out of the Pre-EMPT trial prior to neo-adjuvant chemotherapy (NAC) and oesophago-gastrectomy. Methods A prospective non-randomised, cohort-controlled trial compared a standard care pathway (control) to a structured prehabilitation exercise programme (intervention) commenced before NAC and surgery for oesophageal cancer. Kaplan-Meier and multivariable Cox regression analyses were used to compare overall and disease-free survival between the trial patients (intervention and control) with patients who declined participation or dropped out of the study (non-participants). Results 21 patients completed the exercise intervention, 20 patients were enrolled in the control group, and 24 patients either dropped out (9) or declined to participate (15). All underwent NAC and oesophago-gastrectomy. Baseline comorbidity, post-operative complication rates and length of stay were similar between all groups. Kaplan Meier survival analysis showed no difference between the intervention and control groups but a significant survival disadvantage in the non-participants (p=0.03). On multivariable analysis mortality hazard ratio was significantly higher in the non-participant group (HR 95%CI3.44; 1.05-11.28). Conclusions Patients who dropped out or declined to participate in the PRE-EMPT study experienced poorer survival compared to both the intervention and control groups. This survival disadvantage is likely to be multifactorial. However, these patients represent an important group, currently inaccessible to prehabilitative programmes, who may have the most to gain from such an intervention.