Journal of Cancer Research and Practice 3 (2016) 31e33

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Journal of Cancer Research and Practice

journal homepage: http://www.journals.elsevier.com/journal-of-cancer-
research-and-practice

Review article

Colorectal cancer rehabilitation review

Chui-Lee Wong a, *, Henry Hsin-Chung Lee b, c, Shih-Chang Chang b
a
Department of Physical Medicine and Rehabilitation, Cathay General Hospital, Taipei, Taiwan
b
Division of Colorectal Surgery, Department of Surgery, Cathay General Hospital, Taipei, Taiwan
c
Graduate Institute of Translational and Interdisciplinary Medicine, College of Health Sciences & Technology, National Central University, Taoyuan, Taiwan

a r t i c l e i n f o a b s t r a c t

Article history: The purpose of this article was to present in a consolidated way the various issues associated with
Received 13 March 2015 colorectal cancer care, many of which have already been widely surveyed and published. However, most
Accepted 9 July 2015 clinicians probably neither recognize nor incorporate this clinically beneficial information into the
Available online 19 March 2016
routine care of their colorectal cancer patients. These issues include prehabilitation, fast-track rehabil-
itation, and the impacts of exercise and physical activity on patient functional capacity, quality of life,
Keywords:
cancer recurrence and survival.
Colorectal cancer
Copyright © 2016, The Chinese Oncology Society. Production and hosting by Elsevier B.V. This is an open
Exercise
Physical activity
access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Prehabilitation
Rehabilitation

1. Introduction exercises and physical activity on colorectal recurrence and survival

In current rehabilitation practice for most clinicians, restorative,
supportive and palliative rehabilitation are the primarily courses of
treatment for colorectal cancer (CRC) patients in Taiwan. When the
end result of treatment for any patient is a fully functional recovery,
restorative rehabilitation helps to integrate the patient back into
society, the community, school or work. For patients in whom cancer
per se or cancer treatment has resulted in permanent deficits, the
purpose of supportive rehabilitation is to gain functional indepen-
dence to the greatest extent possible. When the patient is facing the
end of life, the goal of palliative rehabilitation is to maximize patient
comfort and caregiver support.1 Several special issues, however, have
been highlighted in the existing literature in the past decade;
namely: 1) prehabilitation, 2) fast-track rehabilitation, and 3) the
positive effects of exercise and physical activity on patient functional
capacity, quality of life, cancer recurrence and survival.
2. Methods
We extensively searched PubMed and The Cochrane Library for
studies and relevant literature concerning colorectal cancer reha-
bilitation, prehabilitation, fast-track rehabilitation, effects of
* Corresponding author. Department of Physical Medicine and Rehabilitation,
Cathay General Hospital, No. 280, Section 4, Renai Road, Taipei 106, Taiwan.
E-mail address: clwong7755@yahoo.com.tw (C.-L. Wong).
Peer review under responsibility of The Chinese Oncology Society.
outcome.
3. Results
Mayo and colleagues found that one third of patients with
benign or malignant colorectal lesions who improved their physical
function after performing exercise (either by stationary bicycling
plus weight training or increasing walking coupled with breathing
exercise, while waiting for scheduled colorectal surgery) had their
mental health, vitality, and self-perceived health enhanced, and
their peak exercise capacity increased significantly. A full 77% of the
patients recovered their baseline walking capacity at a mean of 9
weeks postperatively. Those who deteriorated in physical function
during prehabilitation were at greater risk of complications
requiring reoperation and/or intensive care management.2 Gillis
et al also noted the same meaningful changes in the postoperative
functional exercise capacity of CRC patients after implementing
moderate aerobic and resistance exercises, nutritional counseling
with protein supplementation and relaxation exercises before
surgery.3
In a meta-analysis of 6 RCT with a total of 655 patients, Li et al
concluded that fast-track rehabilitation had a lower risk ratio as
compared with the conventional care group arising from laparo-
scopic colorectal resection surgery. Fast-track rehabilitation had
fewer complications and a similar incidence of re-admission after
one month.4

http://dx.doi.org/10.1016/j.jcrpr.2015.07.001
2311-3006/Copyright © 2016, The Chinese Oncology Society. Production and hosting by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).
32 C.-L. Wong et al. / Journal of Cancer Research and Practice 3 (2016) 31e33
Brigid and colleagues reported that only 53% of the patients
were sufficiently active (physical activity level 150 min of at least
moderate intensity per week) before diagnosis of colorectal cancer.
Those who achieved at least 150 min of physical activity per week
had an 18% higher quality of life score than those who reported no
physical activity.5,6 In a RCT, Pinto et al observed that 46 patients
with stage IeII CRC who participated in moderate intensity exercise
significantly increased caloric expenditure and saw improvements
in estimated VO2.7 In a meta-analysis of a total of 52 studies, Wolin
et al found that there was a significant 24% reduction in the risk of
colon cancer recurrence among the most active individuals.8
Meyerhardt et al reported that physical activity of more than 18
MET-hours per week appears to reduce the risk of cancer recur-
rence and mortality.9 Schmid et al and Leitzmann et al, in a meta-
analysis, also stated an increment of physical activity of 10 Met-
hours per week after diagnosis was associated with a 28% reduc-
tion in total mortality risk.10 For patients with stage III colon cancer
with recurrence, Jeon et al also observed that those reporting more
than 18 MET-hours of physical activity per week benefitted from a
29% improvement in mortality.11 As for stage IV CRC patients, ex-
ercise is still beneficial in ameliorating fatigue, and improving
mobility and sleep quality.12e14
Guadagni et al found that serum leptin levels were higher and
serum adiponectin levels were lower in CRC patients. Additionally,
the leptin/adiponectin (L/A) ratio was significantly (eight-fold)
greater in CRC patients.15 Wolpin and colleagues reported that
lower levels of prediagnosis plasma insulin growth factor binding
protein-1 (IGFBP-1) was associated with increased mortality among
surgically resected CRC patients.16 A South Korean pilot study re-
ported that insulin resistance and the cytokine, tumor necrosis
factor-a were significantly reduced, and adiponectin significantly
increased in stage IIeIII CRC patients after participating in 12-week
exercise.17
4. Discussion
“Prehabilitation” is a program to enhance functional capacity
and psychological health to enable patients to withstand an up-
coming stressor, e.g. surgery. It is intended to reduce treatment-
related morbidity and/or mortality, to decrease length of hospital
stay and/or re-admission, and to increase available treatment op-
tions.18 Prehabilitation should be considered as a meaningful
regimen preoperatively to enhance functional capacity of patients
during the period when they are waiting for scheduled surgery,
searching for a second opinion, or psychologically unable to readily
deal with the primary cancer treatment, especially for those with
poor physical capacity.2,3
Fast-track rehabilitation was developed by Kehlet and Basse
et al during the mid-1990 s. It is a recovery enhancing rehabili-
tation in an attempt to alleviate stress response, reduce compli-
cations, facilitate postoperative mobilization, speed up recovery
and shorten the hospital stay, all without compromising patient
safety.19,20 Early postoperative mobilization is one of the essential
parts of fast-track rehabilitation. For example, the protocol for
early mobilization developed by Lee et al consisted of getting the
patient to sit in the chair over an hour on the day of surgery; then
progressing to sit in the chair over 3 h and to walk in the ward for
more than 400 m on postoperative day one; and finally, continuing
to walk for more than 600 m on postoperative day two.21 The
meta-analysis reported by Li et al has initially shown that lapa-
roscopic fast-track rehabilitation is safe and efficacious for CRC
patients.4
Exercise and physical activity interventions are beneficial to
increase survivors' physical activity levels and submaximal aero-
bic fitness, and enrich their quality of life.5e7,12e14 Physical activity
performed before or after cancer diagnosis is thought to be related
to a reduced recurrence and mortality risk among CRC
survivors.8e11
Insulin resistance, insulin growth factor binding protein-1 (IGFBP-
1), cytokines, leptin and adiponectin have been proposed as factors
that may influence the prognosis of colorectal cancer. Leptin may act
as a potent mitogen and antiapoptotic cytokine in colon cancer and
facilitate the invasion of cancer cells. In contrast, adiponectin has
antiproliferative effects and is a direct angiogenesis inhibitor. CRC
patients were found to have higher serum leptin, lower serum adi-
ponectin, and greater leptin/adiponectin (L/A) ratio than the controls.
Leptin and adiponectin are theorized to be involved in the patho-
genesis of gastrointestinal cancer, and L/A ratio is considered as an
independent predictor for CRC survival. In addition, lower level of
IGFBP-1 were found to be associated with increased mortality.
Increasing physical activity may potentially have an effect on level of
the predictive biomarkers for the outcome of colorectal cancer.15e17
In addition to reconstructive, supportive and palliative rehabil-
itation, general physical exercise and physical activity have an
important ongoing role to play throughout the continuum of
colorectal cancer care, even before patients undergo the primary
active cancer treatment such as surgery. Larger prospective RCTs,
which are generally undertaken for the purpose of presenting
concrete evidence within larger bundles of studies, have shown
that exercise or physical activity can have tremendous benefits in
CRC patients, including improving physical functional capacity, fa-
tigue, quality of life and mood, reducing cancer recurrence, and
improving survival.
If there is no contraindication for the CRC patients to pursue
exercise,22 they should be encouraged to engage in more exercise,
just to increase or at least maintain their physical activity level. A
great majority of studies employ aerobic exercise, using ergometry,
stationary bicycling, walking programs, muscle strength training,
REST exercise12 and elastic band exercise. Exercise programs can be
conducted as either center-based or home-based. Physical activity
participation includes household and yard work activities, occu-
pational activity, walking or cycling for transport, walking at home
and at work, and leisure time physical activity as well as sedentary
activity. For patients who felt too tired or “weak” to mobilize soon
after surgery or during chemotherapy, the ten exercises recom-
mended by The Christie NHS Foundation Trust are appropriate.23
The patients' physical activity level can be assessed by either self-
administered questionnaire24 or monitored by physical therapists,
well-trained nurse specialists or case managers through telephone-
delivered intervention, which has been shown to be feasible,
convenient, flexible, wide-reaching and potentially low cost.
In Taiwan, the crude incidence rate of colorectal cancer among
male and female populations increased from 49.98 to 69.90, and
39.48 to 51.36 per 100,000 people, respectively, during the period
between 2006 and 2011. The observed 2-year survival rates of colon
cancer in 2004e2006, 2007e2009 and 2010e2011 were 72.92,
73.05 and 74.22, respectively. Furthermore, the observed 5-year
survival rate of colon cancer was 55.92 in 2004e2006, and 55.59
in 2007e2009.25 Albeit the observed survival rate did not increase
significantly during the surveyed periods, the number of CRC sur-
vivors will increase because of the increasing incidence rate and the
potential improvement of cancer treatments in the future. This
population might draw considerable attention in the treatment of
cancer, general health care and rehabilitation. Based on the results
that emerged from the current research, the benefits of exercise
and general participation in physical activity should be clearly
stated to the patients. Physicians should consider counseling CRC
survivors to adopt a physically active lifestyle, recommending that
they be more active and remain active, and incorporate physical
activity into their daily routines.
 C.-L. Wong et al. / Journal of Cancer Research and Practice 3 (2016) 31e33
5. Conclusions
Exercise or physical activity has positive effects on the func-
tional capacity of patients in preoperative prehabilitation, in the
early postoperative period and for the duration of their survival.
Exercise or physical activity appears to reduce the risk of cancer
recurrence and mortality, and is capable of improving patient
mobility, fatigue and sleep quality, thereby enriching the overall
quality of life of advanced or stage IV CRC patients. It may also
potentially have an effect on the level of predictive biomarkers for
the outcome of CRC survivors. Physical activity of at least 18 MET-
hours per week is considered to be a rational intensity of physical
activity for CRC survivors to achieve a better outcome.
Conflict of interest
The authors declare no conflict of interest.
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