#87. How Prehabilitation Can Improve Cancer Outcomes - Dr. Chris Gaffney

Can preparing the body before cancer treatment improve recovery, reduce complications, and even protect brain function?

In this episode, Sahir sits down with Dr. Christopher Gaffney, Senior Lecturer in Integrative Physiology at Lancaster University, to explore the growing science of prehabilitation. Prehabilitation uses exercise, nutrition, and psychological support to help cancer patients better tolerate surgery, chemotherapy, and radiotherapy.

They discuss how a patient’s baseline fitness can influence treatment outcomes, why exercise is increasingly being viewed as medicine, the emerging evidence around “chemo brain,” and why healthcare may need to shift from reactive treatment to proactive preparation.

A fascinating conversation at the intersection of cancer research, physiology, and preventative medicine.

Topics Covered

•  What prehabilitation is and why it matters 
•  Exercise as medicine in cancer care 
•  How fitness affects surgery and chemotherapy outcomes 
•  The science behind chemo brain and fatigue 
•  Why medicine needs to think earlier, not later

Transcript

0:03

Hello and welcome back to the Smooth Brain Society. Today we're going to be focusing on pre-habilitation and cancer. So when someone hears the word cancer, most of the focus immediately goes to surgery, chemotherapy, radiotherapy, basically the treatment itself. But an increasingly important question being asked in medicine is, can we prepare patients better before treatment even begins? And that's where today's guest comes in. I'm delighted to be joined by Dr. Christopher Gaffney, senior lecturer in integrative physiology at Lancaster University. His research looks at prehabilitation, so that's using exercise, nutrition, psychological support, and lifestyle interventions to make patients fitter, stronger, and more resilient ahead of and during cancer treatment. His work is exploring not only how prehab can shorten recovery and improve surgical outcomes, but also how it may protect physical health, cognitive function, and quality of life during chemo and radiotherapy. This is a fascinating conversation about changing the timeline of cancer care, moving from simply treating illness to actively preparing people to withstand it. Chris, it's great to have you. Welcome to the Smooth Brain Society. Yeah, thank you for having me. Awesome. Just a note, usually people know that I have a co-host. Beth is actually fortunately now Beth has submitted her PhD. She's just on holiday for a little bit and will be joining us soon. But again, I asked everybody on Instagram and on TikTok if they had any questions for Chris. So you guys are going to be my co-host yet again. So thank you for everybody who submitted some questions. All right. So, Chris, we start off with a little bit of uh origin story per se of how you got into your field. So I'll let you take it away and give us a little bit of background into how you got to where you are. Okay, cool. I guess, um, cause we go back to the beginning. So I've always been interested in, uh, sports science is my background. So, um, when I was younger, kind of teenager, I was a, I was a swimmer, um, swim at a reasonably high competitive level nationally for a few years, competed for university. Um, so I've always been interested in kind of how to make the body perform under, under certain circumstances. Um, And so was always fascinated by trying to go into a career where I could kind of combine my love of sport, love of, guess, what has ultimately become physiology and combine the science behind it as well. So I guess I was, I wanted a blend of PE and biology basically, and I wanted something that could do those two things. So in terms of where that led me, I did my undergraduate degree at Liverpool John Moores University in sports science with a specialism in physiology. basically all about how the human body functions. When I'd done my degree, um I still wanted to do the same stuff, but what I didn't want to do was repeat the three years that I'd done. So what I wanted to do was explore different stresses on the human body. So I actually did a master's in space physiology and health down at King's College London, which was pretty cool. Taking that kind of physiology knowledge to a different level. So I did some work with the Russian space agency, just looking at how space stresses the human body. That was quite cool. Got to the end of my masters. I thought I knew a reasonable amount around kind of whole body physiology stuff, but I was, I didn't feel as though I had the depth of knowledge of trying to understand, you know, chemistry, biochemistry. So to try and understand some of the mechanisms of why things change. So I then went on to do a PhD at the University of Nottingham. And my PhD was pretty interesting because I did human-based projects like clinical trials that were looking at um a drug, so a non-steroidal anti-inflammatory drug, and how that affects athletic performance. So very much that kind of sports science, but on a molecular level. So, you know, taking muscle biopsies, bloods, all that sort of stuff, measuring some cool stuff in the lab. But I also did molecular work using something called C. elegans. So a microscopic worm that you can find in the back of your garden. And the thing I found fascinating with that was the muscle of C. elegans is very, very similar to human muscle. So despite the fact that it's, one millimeter in length, you know, the biochemistry is very, very similar. So I did that for the three years and then went on to a couple of postdoc positions. First one, doing a clinical trial in tattoo diabetes. And then the second, second one was doing lots of different things around, around of human physiology. But the second postdoc led me on to do some human space flight work or some work in Spaceflight research was part of the team that led the first UK experiments on board the space station and then 2018 was when I started here at Lancaster. So I've been here now eight years started my own research program here and I guess I've taken those Experiences and stuff that I've had, you know found stuff that I've been interested. I've got brilliant surgical collaborator somebody called Darren Suba who kind of runs all the surgical research down at one of the local trusts. And yeah, I guess the origin story, if you will, of how Darren and I came about was he basically called the medical school to say, know, I'm really interested in this thing called pre-hab. Does anybody know anything about it? And head of the med school kind of knocked on my door and said, you know, Chris, you know, can you speak to Darren and have a conversation about this? um And Darren and I are great friends. been working together ever since, and that's it. That's what's kind of led to this. body pre-habilitation work. So we've run, you know, several kind of clinical trials together and so on. And yeah, it's a fascinating area. And I think in terms of where my career has ended up, I feel as though I'm now in an area where the work has always been really enjoyable. But I think at this phase in life, it's very fulfilling work because, know, we're ultimately, we're helping cancer patients and we're helping them um through a very challenging time in their life. And I think it's really rewarding to be involved in a type of research where you can try and... help people and you can see some of the benefits of that. So yeah. No, that's awesome. And it went through, you went through so many different routes. Can I just ask what, what was your like? You say you're a swimmer. What was your best sort of what's it called race? What area of stroke? What's it called? What is the delineation for swimmers? Yeah, so I guess it kind of, it's not an easy question to answer because it depends when you're asking. So I guess when I was probably the best swimmer for my age, if you will, so as an age group type swimmer, you know, when was I best? I was probably best as a butterfly swimmer. I've always been a sprinter, so 50 meter butterfly. But then when I competed for university, I was a 50 meter breast joker because The, frankly, the Butterfly Swimmers they had and the Free Star Swimmers were far better than I was. But they didn't have many good breaststrokers, so I ended up pivoting to breaststroke. But anything sprint and anything on the front, I'm useless at backstroke. I know I found backstroke. They're like, I know it feels like the one which everybody does in the ocean. feels like a relaxing thing. I don't know why people do it as a race, to be honest. Doesn't seem like the fastest way to get from point A to point B. Yeah, yeah, I'd go with that. I think it's just the thing. I've got long legs so they sink. Okay, to your actual work now after that. um So, great. I find it a very interesting transition, but also makes sense, I guess, in sports, you're always preparing for things. You're trying to keep your body nutrition at the highest level. So it made sense that when somebody knocked on the door asking for somebody who does prehab, they hit you up. Could you explain a little bit more about what prehab is, how it... stands out from rehabilitation work as I think that's the one which most people know, right? Rehabilitation being once an injury occurs or whatever you're trying to get back to your best or the best you can. So yeah. sure. So I guess, I guess just to add first with some of the rehab stuff, you're right. The rehab is once you know what has happened, you're rehabilitating somebody. So you're trying to get them back to where they were before the injury, before the event, whatever that might be. The thing about prehab, it's all about preparedness. So the analogy we always use is again, going back to my sports science roots, you know, we had the London marathon this weekend just gone, you know, we saw, you know, the fastest you know, the sub two has finally been broken in, you know, real world conditions and stuff. You wouldn't run a marathon without training for it. doesn't matter if you're an elite performer or if you and I decided to run a marathon, you we wouldn't just rock up on a weekend and try and do 26 miles. You know, you would train for that and you train for that for a significant amount of time. And if we take surgery or we take chemotherapy treatment, radiotherapy treatment, they're all physiological challenges on the human body. If we take surgery as probably the um more straightforward example, if you will, there's things like blood loss, there's challenges to different systems of the body, there's challenges of the anesthesia, and ultimately some of those challenges that the body faces reflect what would happen in the physiological stress of exercise. It's a different condition, it's a different stress, but there's a lot of parallels between them. um I guess the background of prehabilitation is we know that people are going to be physiologically stressed. If we know somebody is going to have, for example, liver cancer surgery, they're going to have parts of the liver removed. We know what those stresses are going to be. The same as running a marathon, we know what the stresses are going to be. So we can prepare them in a way to maximize their chances of that having a successful outcome. So whether that's improving their cardio respiratory fitness, so increasing the basically how fit they are, that's going to help them. Trying to increase muscle mass, so we know that's something that can potentially reduce the amount of time people stay in hospital when they're recovering. There's a whole host of different things that we can do. But effectively what we're trying to do is optimize people to give them the best possible chance of a good surgical chemotherapy, radiotherapy treatment outcome. No, awesome. What you said there kind of links nicely into one of the questions that we got, which was, is cancer rehabilitation same for all types of cancers? Or does it requires to be specific, like you said, for liver cancer or breast cancer, for example? Yeah, I think it's a fantastic question and I guess there's different ways in answering it. So I think the, I guess if I start off at the top, which is the main thing that the people that benefit most from pre-habilitation are people who, there's a low baseline for wanting a better way of putting it. So people who are, you know, low levels of fitness, for example, if we can get them fit, we know that's going to improve their outcomes. You know, if you've got somebody who's an Ironman triathlete and they get the cancer diagnosis, in terms of pre-habilitation, there's probably very little that we can do to improve their outcomes because they're such an elite state of fitness in advance, they'll have high muscle mass, etc. It's more challenging. So that's the first thing to say that there is a baseline of, you know, from the physical side, training people, that's going to have a benefit from the nutrition side, making sure that they've got all of their... appropriate macronutrients, you know, fats, carbohydrates, protein, micronutrients, all of the small stuff in your diet that again improves things. They're things that are going to have a universal benefit and then psychological support, getting people in the right frame of mind to engage with those processes as well. In terms of the specifics of individual types of cancer, individual types of surgery, yes, you can do things that are absolutely specific. So for example, m one of my PhD students has done some work around gynecological cancers. And if you look at gynecological cancers, there's m specific side effects that would be associated with those type of cancers. And so you can do, for example, exercises to improve the strength of the pelvic floor. And that's something that is always going to be beneficial, but is beneficial to some of the side effects that you may experience with that particular type of cancer. If you are working with somebody who's got lung cancer, example, improving their respiratory system, so their breathing system, is something that you could immediately try and benefit because the smoking, potentially, in a lot of instances with lung cancer, is something that will be detrimental to the lung. So there's specifics that we can do, but there's also things that are general across different types of cancer. good. That makes a lot of sense, right? I guess like the specific organ or region which is damaged trying to strengthen the muscle, not just the muscle around it, but sort of the health associated with it. Similarly, does it change based on the type of treatment again? So again, based on the type of chemotherapy used, I do not, I know there's different types. It's not my area, so maybe you could even tell me what the different types are, but I just know that there's... different treatments for cancers and would that make a difference? I mean, so I'm not clinical by background, you know, like I explained before, my background is in sports science, so we team up with oncologists, surgeons that have their own areas of specialty. I mean, to give a brief overview, you know, when you get a diagnosis of cancer, there's broadly three treatment options that you can go through. So there's a surgical option, which is to have the cancer physically removed. There's the chemotherapy option, which can be before the surgery, after the surgery to try and shrink the tumor that somebody's got. And then there's radiotherapy, which again is a different type of treatment, which again is trying to control the levels. And those can happen at different cycles. And that's where the names come, you know, you're a juvenile, you're a juvenile and so on. In terms of the way that we would treat different individuals. A lot depends on the cancer type. So a lot depends on the cancer type to what treatment they will have. So for example, one of our projects that we're doing at the moment with colorectal cancer, it's treated very aggressively with chemotherapy. So often people will have surgery and then they will have chemotherapy after that. And one of the reasons that we're doing some both pre-habilitation and exercise therapy with that project is people can often go through, you know, six to eight rounds of chemotherapy. So in terms of the the challenge on the human body that's a real big challenge. So we try and build them up before they have the first round of chemotherapy and then in between rounds of chemotherapy, we're trying to keep them as strong and as fit as possible to withstand some of that chemotherapy, which is of course is toxic, not just for the cancer cells, but across the body as well. what you said adds another question to it of, so you, when talking about pre-hab, we're not just talking about in preparation, but we also like between sessions or between like chemotherapy sessions or during treatment, it's just continuing sort of processes. Is that, how much of a challenge is that? Cause I know putting a psychological hat on, you might create. Aversions to certain foods or certain things the moment you link them with chemo, for example, then is it hard to maintain during? Yeah, incredibly difficult. So I think that the one thing that we don't do a lot of in my particular programme of work is the psychosocial support. So the interventions that we do are primarily the exercise and the nutrition. But I think it's fair to say that the way we approach it is we have to think the psychosocial support is the most important part and that comes before the exercise and nutrition. So typically our participants that we work with will have that session with a counselor or somebody who's a trained clinical psychologist, for example, in advance of engaging in the program because the challenge you have is, you you get your cancer diagnosis and then me as a prehabilitation researcher, we want to get the individuals to start exercising nutrition interventions as soon as possible because that's going to give them the best possible outcome. The challenge that all pre-habilitation researchers are faced with is when is that right time? So if gets a cancer diagnosis, of course it's devastating. And even if m there is a suspicion that that's going to happen, so of course, you know, people have tests, you know, they've felt a lump, whatever that might be, there's still going to be the day when they actually receive the diagnosis. And so we work on a basis that that day is probably not the day to say, okay, here's immediately what you need to do. There's differences of opinions with different researchers. But what we try and do is approach those individuals as soon after that when they've had a chance to process it through that psychosocial support to then see if they want to engage. So then hopefully the mindset is moving away from, okay, I've received this devastating news, but what can I do to maximize my chances of a successful recovery? Yeah, I think this is a good time where we can ask you about the, I guess the two research projects that you mentioned because they're slightly different ones on because we've got, I've got quite a few questions around, there differences between sexes in terms of treatment? Are the differences in terms of cancers, in terms of treatment? So maybe if we go through the projects, they kind of give a good idea because maybe we talk about the gynecological cancers research project first and then about the other one. And then that way we kind of get, we can get all sorts of flavors of what. these look like. So do you want to talk a little bit about your PhD students projects there in a bit more detail? So I think, so I think with the, well, if I start off with the, the major project we've got going in our lab at the moment. So, um, we've got a project at the moment that's funded by, Northwest cancer research that's, we've had the involvement of, uh, a celebrity in that. in, in, uh, you, you may remember from, uh, GMTV back in the day, I've missed a motivator kind of doing the, the exercise routines on the TV and stuff. So that's, yep, yep. Derek Evans, so Derek has collaborated with us to develop the exercise videos for that particular project. em And that is, we're using pre-habilitation for people with colorectal cancer that are undergoing chemotherapy. So some of them will have had surgery, some of them won't have had surgery, but all of the participants are going go into a period of having several rounds of chemotherapy. And I think I mentioned earlier that the colorectal cancer is treated quite aggressively with chemotherapy. It's similar in some ways to breast cancer that's also treated quite aggressively with chemotherapy. And the routine that we've come up with is individuals will be training four days per week. They will do three days a week watching the Mr. Motivator videos. One day a week will be supervised by my postdoc who's a cancer and exercise trained specialist. To check that they're the routines okay, checking if they're having any problems and stuff. And then, we get them doing a combination of resistance and aerobic exercise. So again, there's debate in the research literature around what is best. Is it the aerobic exercise? So traditionally this would be going to run, for example, or, you know, going a bike ride, or is it the lifting of weights? And my personal opinion is I think both are important, but I'm erring more towards the side of I think the strength training is more important around functional ability, recovery. There's some really good data from not cancer areas, but for example, A &E admissions, intensive care, and outcomes are predicted by muscle mass. And that's not because, you know, people are bodybuilders that, you know, going into an ICU department, but it's because all the chemical reactions in the body, you know, 70, 80% are taking place in the muscle. So if you've got a better reservoir for those chemical reactions to take place, it gives you a better physiological resilience. when those stresses happen and a better chance of recovery. yeah, so in that project we're doing the prehab, we're doing the exercise to build the body up. But interestingly with that project we're doing something quite novel. There's only a couple of groups around the world doing something similar to this. We're interested in not just the effects on the body, so can it improve their fitness, can it improve their strength? We're also interested in does it protect the brain? So one of the big side effects that people get from chemotherapy is something called chemo brain. So this is where you get forgetfulness, brain fog and so on, slow cognitive processing, and it's something that can persist for a long time, know, several months after the end of treatment. One of the beauties of exercise is it has um not just neuroprotective effects, but effects on neuroplasticity and building the brain as well. So the rationale of this project is can we use prehabilitation to not just build a body, but build the brain as well in terms of neuroplasticity and can this have a neuroprotective effect, so protective effects on the brain during the chemotherapy and so on. And so we've using, I don't know how much this has been covered in your podcast in the past, but using electroencephalography, so EEG, so measuring the particular brain waves and a whole bunch of m cognitive performance tasks to have a see. if the exercise is protective or not. No, that that's incredibly fascinating because I would have thought I mean, this is just me would have thought that for sort of like brain protection, you would have sort of like gotten people to do in the prehab more sort of, you know, like brain related exercise, like trying to get them to do like more reading, more maths, more things like that. But you're saying sort of physical exercise is also really important for this. Yeah, definitely. mean, I think I'm not a neuroscientist, so won't pretend to know about any of the brain training literature and so on. We both know colleagues that would be better qualified to speak on those sort of topics than myself. But I think from my perspective as a physiologist, there's uh loads of cool concepts like stuff like something called cross education. So if you lift a dumbbell with your left arm, so you don't do any training on your right arm, your right arm still gets bigger. And why is that the case? It's that, well, you're still stimulating the nervous system from the brain. You're still getting changes in hormones. You're getting changes in something called myokines. So facts that produce from muscle that create an environment across the body that make the body want to adapt to be physically stronger and so on. And I think that's the case for the brain. So basically all of the exercise that we do just creates an environment where, yeah, neurons want to do their thing and, you know, get a little bit. of neuroprotection during that period. Oh, that's awesome. So like what stage of this project are you in at the moment? So the project started last March, so March 2025, and we're just at the process of about to recruit our first participants. we had ethics approval back in December, and with these cyberclinical trials, there's a series of hurdles you have to jump over with running things within the NHS. So we're running this at four hospital trusts across the Northwest region in the UK. um And there are various different stages, but we're almost at the point of recruiting the first participants to get them in. Nice. Yeah, is it, I guess this is not from this project, but from previous project, is it hard? How hard is it to have people who are participants in such things maintain to stay on track for and keep their prehab up during the period? Because I can imagine it's a really, really tough time. So the added stress of needing to do prehab work is part of a study. It is. think... I mean, I can only speak from our experience of doing these type of trials. And I think we've been very fortunate that the compliance rate has been really, really high. With this particular trial, of course, we're expecting there's going to be instances of when somebody has chemotherapy, they don't exercise for the 48 hours afterwards. That's something that we've developed with oncologists and with people with lived experience of chemotherapy. And they've advised, you know... don't do exercise for the 48 hours after. But the reality is some people respond very differently, some people are good to go almost immediately after chemotherapy and other people can be sick for days afterwards. It does depend. I think the thing that's quite a unique environment with cancer and pre-habilitation is, you know, more often than not, we're talking about individuals that are quite literally fighting for their lives. And this is something that there's a growing body of evidence that it can potentially improve their outcomes. So they're very bought into the process. Now, this is recognizing that I run this from a research perspective. So people that sign up to the trial are quite self-selecting. know, they've chosen to be part of research. They've chosen to try and engage in this. And yes, they can be randomized because we do randomized control trials. They can go to pre-hab. They could go to standard care. So they're actually not doing the pre-hab. But certainly within our hands, the compliance is really good. But I think it's because we've designed it in a way to try and allow the participants to engage as much as possible. mean, there's all different flavors of pre-hab, but one of the reasons we do these online videos is, you know, in Northwest England, I mean, we're a geographically sparse area. So if somebody gets a cancer diagnosis up in Barrow, for example, they could have to come and have some of their treatments around Lancaster and Preston. there's a lot of distances that are involved in traveling and stuff. And when we discussed this with patients, it was, you know, don't want to come to a gym three times a week and so on. And there's some really creative solutions that people are doing in the region around getting buy-in from local leisure centers and so on. So there are solutions there, but I think whatever intervention there is, it's got to be something that patients are, they're realistically going to do. You know, there's no point saying to cancer patients, right, join your local CrossFit gym and you know, can do CrossFit four times a week. be unlikely to happen for most individuals. Whereas a lot of the things that we've created and other colleagues have created in the research field, it's people with lived experience, people at a similar phase of life, you know, they're engaging in it and compliance does tend to be very good. With with that in mind, it's are there are there sort of like specific specific tailoring per participant in terms of like their prehab regimen? Like how does that work? Because again, like you said, you kept you have always mentioned like it depends, but um for other things on the bigger picture. But I guess now we're talking on individual level. Do you like tailor? program specifically for participants. Yeah, everything's tailored to some extent for individuals. So if I take the chemo brain project, for example, that we're doing at the moment, there's the exercise videos that Mr. Motivator has done for us. And his wife came along and did an adjusted set of exercises that I've done from a chair. So for example, anyone that develops hernias as part of their treatment, it's really important that they don't hold a breath when doing exercises or put their abdomen and area under any sort of pressure. So there's adaptations to the exercises that they need to do. So in that example, you know, we have Palmer who's doing um the adapted exercises and the easiest way to adapt them is a lot of the exercises are doing, we're doing with weights. You just have a, you know, a heavier weight or a lighter weight depending on what works for the individual. And the idea of these is that, you know, if people start to engage in the pre-habilitation, It might be that after the first couple of weeks, they're finding the weights quite light, so we can change those to a little bit heavier. And it's just whatever they manage with. And again, you know, they might go through chemotherapy treatment. The weights then seem to be quite significant and we can drop them. So generally in training, we use a concept called progressive overload, which is basically you should be doing a little bit harder than you're doing the week before and you do it in a gradual way. In prehabilitation, that's the principle that that goes behind everything that we do, but at the same time it's got to recognise that there's going to be insults to the human body that's going to mean that that progressive overload doesn't work in the same way. So you've got to make adjustments along the way. So we make it challenging as we reasonably can, but the most important thing is people are moving and moving is medicine. No, awesome. I guess moving a bit forward is a question on how prehabilitation works. We spoke a little bit about the muscles, but I got a question which says, i read prehabilitation works on the gut brain axis Do you think that's via the microbiome? That's a good question. If I'm honest, I'm not aware of um any data that's not been from review articles around the gut brain axis. It's not to they don't exist. I'm just not that familiar with any research. The ones I've read have just been review articles around that. I think it's certainly the case that it probably does work on the gut brain axis. And I think, again, going back to the nutritional element, if you're taking somebody's diet and you're improving their diet, well, that's going to improve the micro- So the microbiome is effectively fed by fiber within the diet. So somebody's had a diet that's deficient in fiber and we feed them lots of fiber, we make sure that's optimized through the dietitians that we work with. That's going to improve things. again, through the physiology lens that I look at things through is you don't adapt to the exercise if the nutrition isn't right. So if you and I went to the gym, for example, and we don't have enough protein in our diet, we don't have enough vitamin D, we're not going to build muscle. So it's making sure those things are optimized to allow the exercise to do its thing. So I guess I see it as a little bit like a building block. So the psychology is the base framework to make sure somebody's psychologically in the right place to engage with the program. Nutrition is then the bedrock to make sure is the fuel appropriate. So is the fuel the right stuff that is going to allow the optimization of exercise? And again, thinking of the chemo brain project, we provide a daily multivitamin throughout treatment just to kind of cover our bases and make sure that everyone is getting the minimum of what they need of all of the different vitamins and minerals in their diet. And then, you know, it's making sure that there's enough protein to protect muscle mass and all that sort of stuff. And then the exercise is the cherry on the cake, if you will, that builds on that solid platform to try and improve the body. No, that makes heaps of sense. guess, going one step further with sort of like nutrition and things like that, ah this is more a cultural question. So do you think nutrition and sort of the support provided need to be socio-culturally planned? So are there socioeconomic issues which come in the way? Are there cultural issues which might come in the way in planning? Yeah, definitely, absolutely. I think it's very easy as a scientist to kind of sit down and say, right, okay, these are the vitamins that you need in your diet. These are the foods that you need to eat. Everyone needs to go and have avocado on toast and then have steamed chicken breast and broccoli for lunch and it'll be really good for you. You have to work with what the individuals are. You have to work within the budget constraints that those individuals are working with because a lot of rehabilitation programs, for example, will make recommendations. but they're not going to provide the food necessarily for several months of treatment. So it's working with what people are going to stick to. The way we do that is through patients and public involvement. So all of our trials we engage with people with lived experience. We do that with different people in communities that we work with. So for example, we're getting the trial set up at a site in Liverpool and that might be very different to a site in Blackpool and it might be very different to a site in Blackburn. It's working with those individual communities, seeing what they want, what works for them, and just making adjustments. And I think m the dieticians that we work with are very good at making those adjustments and recommendations, taking into account both um socioeconomic challenges, but also cultural issues as well in terms of what food types can be substituted and so on. prehab like very common in terms of like across the NHS? Is it like a big thing? Is it a growing thing? I'd say it's a growing thing. I was part of a trial that's just coming towards completion. We're getting all the outputs out at the moment from a project called Parity. So this was an NIHR funded project where we mapped the pre-habilitation services across the UK. And if I remember correctly, I think it was something like 60 % of hospital trusts offer some sort of pre-habilitation service. So I guess by definition you can say it's more common than not that there is some form of pre-habilitation. But the form that the pre-habilitation takes was very diverse. I guess the more established programs that there are, so there's a really good program that's at Liverpool led by Declan Dunn for example, there's some brilliant programs down at Southampton where they're doing the exercise, the nutrition, the psychosocial support and a load of other things. They're, you know, they're fantastic programs. But then there's also other similarly brilliant work, it's stuff that has been badged as pre-habilitation. For example, stop smoking services, which I guess technically are pre-habilitation because they're around optimizing individuals before surgery. But actually they're things that have gone on well before pre-habilitation became a term. And for me as a physiologist, it's slightly different. I think it's part of the conversation. But for example, a stop smoking service, at least for me as an individual, as an individual researcher, it's not quite rehabilitation. It's something slightly different that's part of the mix of optimizing patients' OK, so I guess with just taking that example, would you argue that it's more rehabilitation for, I guess, like a lung cancer where smoking is involved versus others? Or is it just something which is good to do but you would not consider rehabilitation? uh I think it's probably more towards the latter. think it's just an individual research, as my opinion of oh where smoking fits into the mix. think it is regarded by a lot of people as being part of pre-habilitation. I just think for me, it isn't. I think it's something that's important. mean, similarly, could have, you know, reducing alcohol consumption kind of comes. It's behaviour change. So I think behaviour change is part of pre-habilitation. So I guess I do agree that it is part of that. But I think if you have a pre-habilitation service where the prime function is to stop smoking, well, that's a smoking cessation service. It's not a pre-habilitation service. So I think it's important, absolutely. And I think it's not just safe for lung cancer. It's across the board, you know, because it can change cardio respiratory fitness. It can change metabolism. You know, stopping smoking is going to have a massive impact. And I think the thing I'm passionate about from the smoking perspective is actually the ability to stop smoking is probably going to have a bigger impact on physiology than two, three, four weeks of exercise before surgery. So potentially that's low hanging fruit, if you will, if somebody is able to stop smoking, potential massive benefits in terms of their health, their recovery and so on. So I think it's, yeah, it's a debating point around whether it's pre-habilitation or not. m I'm not disputing it's important, it's incredibly important. I think it's just whether it's bad or just pre-habilitation, but it's part of behavior change. So I guess I'm part for part against. I guess it comes to the idea of is it like, is the prehabilitation service like all encompassing? it versus if it it after a specific thing? And I think that's it. It depends on the individual pre-habilitation service. So without, you know, I won't go into any of the specifics of individual trust because of confidentiality and so on, but it just depends what trusts offer. So some of them do have these comprehensive services where they would have smoking cessation, they'd have nutrition advice, psychosocial support, and then they'd be given, you know, leisure passes to work with local gyms and so on. So they get the physical training. They're amazing services, but then the flip side of that is they can be quite expensive. Now, some of the really good evidence that's come out, so there's some published literature from Preab for Cancer, for example. So this is the Preab program that's run in Manchester. And there's really good evidence that shows that if you invest in prehabilitation with those wide ranging programs, the multidisciplinary programs, you actually make a cost saving because if somebody stays in hospital for less time, they recover faster, they get less complications. The NHS makes a saving, but you still need to find the money up front to fund those services and that's where it's challenging, especially in the current climate. Yeah, I was thinking that's the that was one of the big things of like the unfair or unequal delivery, probably across across regions, because I guess the regions which can afford it can give better treatments and then probably saving money in the long run. They can, I mean, if I'm honest, one of the hopes with some of the work that we're doing is because the intervention, particularly the exercise intervention is online, I mean, at the moment until we can confirm that it works, because of course we want to have the empirical evidence to check that it actually improves patient outcomes. But if it does, the vision is to make that more widely freely available to individuals. So anyone, not just in the UK but worldwide who gets, for example, a colorectal cancer diagnosis, so the cancer that we're working with, hopefully we will have demonstrable evidence that it can improve outcomes and then we can make it freely available online, YouTube, something like that. People can just engage from the comfort of their own home and so it's not the postcode lottery of what rehabilitation service is available to them. Anyone can engage with it and... Again within reason the general consensus I think is you know the more exercise people are able to engage with and as long as they get insufficient recovery and stuff the better Yeah, yeah, I the recovery is a big thing. So do you which I was wondering about. So in your in your sort of exercise or when you give these regimens, how do you sort of determine recovery or like standard recovery times? I guess if you're making like online videos, because it's very hard to tell people if it's completely online and you can't necessarily follow up with them as much to be like, OK, this is enough rest. Now do it or you're pushing yourself too much. Stop. kind of thing. Yeah, I mean, I think with the with the intervention that we do, it's important that we have that that face to face session once a week and they get the training and advance of being given the videos to advise on how to pace themselves. So how to listen to their body and know if they're pushing too hard and stuff. And there's cues throughout the videos to say, know, see how you're feeling now might be a time to take a water break and and so on. The individual videos are normally 10 to 15 minutes long and then there's naturally a break when you move on to, you know, training different body parts or doing different forms of exercise. So there are individual breaks there that allow individuals to recover, but a lot I think is the training in our bands to work with individuals to know to look out for the signs, you know, know how hard they're working, know that it's okay. And again, beauty of the videos is you can pause, you can take a breath. go and get a glass of water and then engage a few minutes later. We always advise if possible it's nice to do it with family and friends and stuff. So again, some of the nice things that we've had in the past is when, you know, for example, you'd have a husband and wife that doing the exercise program together and stuff and obviously one of them is battling cancer but the other one's just been that support mechanism of doing it with them. So that's something that's really nice as well when we've had the, you know, the end of study. results and dissemination kind of afternoons and stuff, and we bring everyone back to say what the results of the study are. These are some of the really nice conversations that we have around, know, it's been really nice engaging in those programmes. It's been like a family activity that we've done three, four times a week. And yeah, they're just some of the positive stories to come out of it. Oh, that's that's really cool. I guess I think this fits in nicely to this other question, which is more sort of big picture. Like if you could redesign the patient journey tomorrow, what would your ideal rehabilitation look like for moment? Someone hears the word cancer or like gets a diagnosis. Oh, wow, that's a great question. I think I'd caution with what I'm saying that just to be clear, I'm not clinically trained. And I think any of these redesigns, I think, need to be done with people who are working on the ground. So cancer specialists, cancer nurse specialists, surgeons, oncologists, et cetera. But from my perspective as a researcher, I would like prehabilitation to become standard care. So when somebody gets that cancer diagnosis, there's going to be an understanding that Almost the understanding for a patient now is they know the options are going to be chemotherapy, radiotherapy, surgery. Even if people have not had a lived experience themselves of it, most people know that they're kind of the treatment options. And what I would like to do is be involved in the movement of um cancer treatments so that once that diagnosis is made, it's like, right, okay, we know we're going to go down those treatment routes, but how can we maximise your chances? by getting used to do exercise, nutrition, et cetera, you know, over the next three, four weeks and beyond. And I think there's some really nice opportunities there. Again, there's some, there's not loads of evidence of this in the research literature, but what can be quite nice is if people recover from cancer, there's a lot of evidence to suggest people maintain these lifestyle habits because they've been doing it for several weeks, if not months, during the cancer treatment. And then it's become part, you know, that behavior changes happen, so they maintain it. And that's going to help them in the long term as well. So if I had one hope, it'd be to make rehabilitation part of standard care. So when they get the cancer diagnosis, yes, it's the conversation of, okay, is it going to be chemotherapy, radiotherapy, surgery, but also what type of prehab am I going to be doing to maximize my chances? And in a few years time, you know, my hope is we'll have a precision, personalized medicine approach. So like you mentioned earlier, you know, depending on the cancer type, you'd have a very specific program. that will address those challenges. So if there's a particular type of chemotherapy that we know is perpetuating muscle loss, then we can do something to target that. If we know, for example, with gynecological cancers, we can target pelvic floor exercises. If you're working with colorectal cancer where people have often got hernias, we can work on exercises that are not going to cause stress or exacerbate any of the challenges there. So I think that's what I would like to move towards, but again, recognising in the current NHS, that's a challenging environment. Yeah, well, I guess the other question on that is what are the current major barriers you see to this? know budgets was one which we spoke about uh already before, but are there any other barriers which you see to potentially making prehab uh standard care or part of standard care? think budgets are one of the big ones. um We can develop the research evidence to show that there's a cost saving, but ultimately you still need to find the money upfront. So it's finding the money upfront to make a saving from, you know, reduced ICU time, reduced complication rates. And I guess, again, from an outsider's perspective, there's a degree within the NHS that it's kind of almost like firefighting. It's difficult to do that preventative medicine work when actually you're just dealing with the problems here and now. And I guess that's... somewhat at odds with prehabilitation where it's around trying to prevent the stuff and and again I think if you look at the founding principles of the NHS it was meant to be prevention and treatment and if we you know if we genuinely look at what the NHS does I don't feel it does a lot of prevention does loads of treatments it does it really really well but I would like it if we moved a little bit to do more preventative work as well because if we got people more fit and active then there'd be far less money that's spent on everything else. You know, look at the stuff with, you know, Glip 1s without going off on a complete tangent at the moment. You know, look at Glip 1 receptor agonists. So, Azempic, Monjaro that people are taking at the moment. If people had good diets, if people had, you know, good lifestyles in terms of exercise and so on, the requirement to take those type of drugs wouldn't be the same as it is now. Of course, it's going to be individuals, hormones, imbalances, etc. those of m type 2 diabetes, for example, where they've got that place and they can be incredibly effective. But I think if we got better at the preventative side of stuff and taking responsibility for our own health, I think that would help the healthcare system overall. And probably not just in the NHS, you this is across the world as well. No, brilliant. Like great points. um Yeah, I guess then the very next follow up is more to you and your research is what sort of work we already spoke about the colorectal cancer, but what other sort of projects are going on with you and your team around cancers? So I think one of the exciting projects that we're setting up at the moment is we recently received funding to do... it's badged as pre-habilitation for palliative outcomes. So something called the OPAL trial. The idea of this is palliative treatment is something that's often I think overlooked. And again speaking to oncology, surgical colleagues, the difficulty is when somebody gets a palliative diagnosis it's... the amount of benefit you can have is limited. Of course, the benefit we look at with curative treatment is, you know, can we give them a cure? know, can we get them into remission? Can we cure them? And can we maximise the chance of that happening? But once we know that somebody's got this terminal diagnosis and they're going down a palliative treatment, it's often overlooked. So we've got a project that we're setting up at the moment where we're embedding exercise and nutrition within a palliative pathway to try and improve quality of life. And I think that's something that we're as a team really passionate about because I think when somebody receives that palliative diagnosis, know, it's devastating. But if we could move the needle a little bit in terms of improving quality of life over the weeks, months that somebody has, and I think through exercise, potentially preserving some of their, what we'd call functional capacity. So the ability to walk to the shop and get a paper or something like that, you know, the ability to sit, stand from a toilet on your own, all those sort of things. Again, I think the benefit could be really, really meaningful. Yeah, um, what's it what's it called like giving a little bit of dignity back sort of in that regard? Yeah, definitely. And I think it's, you know, there's several different elements to the palliative work that we're doing. I mean, of course, it presents its own unique challenges working with a palliative cohort because the disease burden that they have is greater than somebody who's going through a curative treatment pathway. So their physical abilities are less. Psychologically, they're more challenged because, speaking bluntly, their hope is gone. You know, it's a different... frame of mind and stuff. But I think there's a lot of work to be done there in terms of optimizing what time people have and trying to, yeah, give them the best quality of life they have for the weeks and months that they have left. Just that's the, mentioned some differences, but how does that sort of translate to in terms of how you would go about preparing, I guess, prehab for such people in palliative care? Again, a lot of this is just working with people with lived experience. So with all of the trials that we've run, we have focus groups, normally multiple focus groups where we work with people who are, they've got lived experience of that particular condition, but also working with caregivers, family members and so on, and trying to get all those perspectives of... what they think the challenges are. So we'll show them the exercise routines and say, you know, do you think you could have done this or do you not think you could do this? We'll try some of the things out. We'll give them the kit. And then we make adjustments that are based on that. And all of the advice, all of the videos, everything, each step of the way is informed by people who've got lived experience and their family in the wider circle. So it's not just me as an academic oncologist, surgeons that are. designing something scientifically that we think is scientifically and clinically is the most effective intervention. We're that to the patients and the patients are saying, okay, that's great, but I can't do this particular exercise. So how can we modify it to give the same scientific and clinical benefit, but something that they can do? So I think it's about getting the buying along the line. again, different cancers are going to have different disease burdens, different challenges, and it's just working with those individuals to accommodate them appropriately. No, awesome. Well, all the best for that. When does that one start the project? So I think we're in the process of um organising contracts at the moment. So probably the end of this year, I think we'll be looking to get started with that one. Awesome. I guess the final question along these lines, which we ask all of our guests is if you if you were given all the budget in the world and ethics had gone on holiday, what would be your sort of dream research project? That's a great question. So I think into, I'm not sure about the ethics going on on holiday stuff. think, I don't know if it's just with my day to day life, I can't see beyond that. But I think in terms of, um I would love to run a trial where, you know, everyone does pre-habilitation. So, know, every single person in the country, when they get a cancer diagnosis, they're enrolled onto a pre-habilitation program and then we'd be able to find out. You know, why do some people respond really well to the pre-habilitation? Why do some people not? Why does it work really well in some cancers and not in other cancers? Why is it that certain types of chemotherapy have a more detrimental effect on the body and the brain than others? know, and pre-habilitation can protect in some and not in others, you know, but the scale of, you know, hundreds of millions and need a million post-docs to run the study and so on. So, Yeah, that'd be my dream project, I guess. I guess this comes back into reality of the question is we've spoken about cancers, but I'm assuming prehab can be really useful for other sort of long term conditions as well, not just cancers. Have you done any work there or is your focus mainly to do with cancers? I mean, my focus is predominantly on um preparing people for cancer treatments and surgery and chemotherapy, but we do do exercise um as a therapy for a whole range of different conditions. We've uh just published a systematic review with one of my collaborators, Dr. Lawrence Hayes, on um MS and having to see how that can alleviate some symptoms. I think the thing is with exercise, there's... There's a phrase that sports scientists always use, is, you know, if exercise was a pill, everyone would take it every day. And I do think that's true. There's a whole host of different benefits, whether this is the prevention of things like type 2 diabetes, cardiovascular disease, but also just the anti-aging effect of exercise. So, you know, particularly as we get older, we're losing muscle mass. Exercise is going to prevent those things. So I think there's a whole host of conditions. I mean, I go out on a limb to say there's probably very few conditions where there's not a benefit to it. And I think even in those conditions, it's around finding the right adaptations of exercise. So if somebody can't do a particular type of program, it's finding what they are able to do, whether that's, you know, walking a few more steps a day or lifting weights or whatever that might be. But yeah, my, my fundamental belief is that exercise is medicine and um Yeah, I think it can benefit a whole host of different conditions. Again, in terms of other projects, got in the pipeline, potentially doing some work with Parkinson's as well and exercise as a therapy for Parkinson's. So, yeah, I get approached with different projects and particularly different medical conditions and, you know, can we apply this framework to a particular disease state and so on? And my starting belief is that it usually can. We just need to make the right accommodations. Yeah, no, makes complete sense. uh The MS one really stuck out to me. So I'm just thinking of what kind of training would be involved in the prehab. Would it be like resistance training or sort of things like that? Or do you know? So I think, so with the MS project, was, it was exercise rather than rehabilitation. And there was some work there that was around resistance programs, aerobic fitness. And if I recall correctly, some of the benefits that we saw from that paper are actually on the um improvement of quality of life. So actually some of the psychological benefits of exercise. So, you know, there's good evidence, for example, around exercise managing mood and... alleviating symptoms of mild depression and things like that. And so I think there's some benefits there. And I think almost halting the progression of MS as well is something that's, so I guess that's the prehab element to it. know, people can engage in exercise, they can potentially slow the progression of the disease. Again, it's not a cure. These are just things that can do as an adjunct to other treatment options that will be prescribed by their medical professional and so on. No, no, awesome. I guess one last, one last question which I had was sort of around, are there anything to do with when we talk about prehab, are there anything to do with sex differences between men, women and so on, or if there's any sort of differences between the age of which you get cancer and how treatment works or things like that. Yeah, it's a really good question. um I think we start off first with the sex differences. think when we think specifically about prehabilitation, I don't think there's enough high quality data out there to really differentiate between the sexes and how people will respond differently to exercising the different conditions. So and I think some of this wraps into the same sort of your question around age as well. One of the difficulties is if somebody was for example going to get a prostate cancer diagnosis in their 30s versus a prostate cancer diagnosis in their 70s the pathophysiology of how that has come about is likely to be different in those two different instances because most instances of prostate cancer tend to be older in age. So something is inherently different with somebody who would say get it in their thirties. And so the difficulty is looking at treatment outcomes and how pre-op factors into the mix around that. It's a very difficult thing to discern the interaction of the intervention with the unique set of circumstances of somebody getting a a cancer diagnosis that's outside of the normal age range, if you will. So I guess I'm giving a non-answer to your question, but it's just to say it's infinitely complex. But I think I'd go back to what I said earlier, that think excess can have a benefit across sexes, across ages. The weight of that benefit will likely be different. And again, from some of the evidence we've seen, it's... The individuals who are less fit potentially have more to benefit. So taking the 30 year old, for example, there's a potential that pre-habilitation might have little benefit to that individual because they may on law of averages likely to be a little bit fitter, a little bit healthier in advance of the diagnosis. So there's less capacity to improve their physiological reserve, how resilient the body is and so on. But again, depends on individuals. Awesome. Great. guess one more thing is, is there anything else going on with you? Any other things you're working on which you'd like to talk about before we wrap up? I guess there's a quick one. So I've recently become a guest editor for a collection on prehabilitation with BMC cancer. So this is going to be a really nice home. So it's working with some guest editors from Australia and America, all prehabilitation experts. And yeah, we're curating a collection of prehabilitation research papers from across the world over the next 12 months. So this is open until January, 2027. And if people are interested in prehab, Hopefully that's going to be a nice home both for academics to submit their work to, but also for people to actually just access and read and learn about some of the latest cutting edge research in the pre-habilitation field. No, awesome. Awesome. Well, thanks. That's all the main questions I've had. And I guess the one other question which we ask everybody is uh if you had and i'll and I'll frame it so that I can actually clip it is, Chris, do you have a hot take about your field before? I guess my hot take, I don't think this is something that's unique to me, but I think rehabilitation, I would say, something that's gone through a really good marketing exercise over the last 20 years, but I actually think it's something that's been going on for decades. So if you look back to really old literature, there's studies that are using exercise to improve cancer outcomes before it was called rehabilitation. And again, when you speak to people in um patient groups and so on. It's kind of always been the case that when people get cancer, you know, they go back home and they say, we know what, I'll try and cut down my alcohol a little bit. I'll try and eat a little bit cleaner. I'll try and move a little bit more. So I guess my hot take is that prehabilitation has always been going on to some degree with individuals. It's just not necessarily been called pre-hab. And that's the branding that we've now got for it. OK, so pre-abs just got a really good marketing team now. That's about it. Now, awesome. Thank you so much, Chris. That was great. um Hope you enjoyed as well. Yeah, it was great. you. Yeah, was nice to, nice to, often you don't get a chance to talk prehab for an hour and stuff outside of conferences. So yeah, great to catch up. Awesome, thanks and thank you everybody for listening and we'll see you in the next episode. So take care.