Highlight
This nationwide multicenter cohort study evaluated the real-world impact of a multimodal prehabilitation program in colorectal cancer surgery across unselected adult patients. Key findings include a significant reduction in overall complications, medical and surgical adverse events, shorter hospital stays, and decreased readmission and intensive care rates. These benefits were consistent regardless of patient age or ASA physical status classification.
Study Background
Colorectal cancer remains a leading cause of cancer-related morbidity and mortality worldwide, with surgical resection as the primary curative treatment. However, postoperative complications are frequent and contribute substantially to patient morbidity, prolonged hospitalization, increased healthcare costs, and diminished quality of life. Optimizing patients’ preoperative physiological and psychological fitness has emerged as a promising strategy to improve surgical outcomes. Multimodal prehabilitation programs incorporate physical exercise, nutritional support, psychological counseling, and comorbidity management to enhance functional status prior to surgery. Although prior studies suggested benefits, their generalizability has been limited by selective patient enrollment, heterogeneous interventions, and small sample sizes. Hence, robust real-world data assessing the effects of standardized multimodal prehabilitation across diverse, unselected colorectal cancer patients are critically needed.
Study Design
This nationwide cohort study involved 18 hospitals in the Netherlands, comparing outcomes of patients who participated in a multimodal prehabilitation program (April 2020 to June 2023) with historical controls from the same centers (June 2014 to June 2023). Eligible subjects included all adults undergoing elective colorectal cancer resection. Propensity score matching controlled for confounders including age, sex, body mass index (BMI), American Society of Anesthesiologists (ASA) physical status classification, surgical procedure type, and operative approach.
The prehabilitation intervention comprised thrice-weekly high-intensity exercise sessions, nutritional supplementation, psychological counseling, and optimization of comorbidities such as anemia correction, frailty management, and smoking cessation when necessary. The primary outcomes were overall postoperative complications, subdivided into medical and surgical complications. Secondary outcomes included length of hospital stay, readmission rates, and intensive care unit (ICU) admissions.
Key Findings
The final cohort comprised 2,384 patients evenly split between the prehabilitation (n=1192) and control (n=1192) groups, with a mean age of 70 years and 53% male representation. Propensity matching ensured comparable baseline characteristics.
Overall complication rates were significantly lower in the prehabilitation group (30.1%) compared to controls (37.8%), corresponding to an odds ratio (OR) of 0.71 (95% confidence interval [CI], 0.60–0.84). Medical complications showed a more pronounced reduction from 24.6% in controls to 15.4% in the intervention group (OR 0.56; 95% CI, 0.46–0.69). Surgical complications also decreased (24.9% to 21.4%), though this achieved borderline statistical significance (OR 0.82; 95% CI, 0.68–1.00).
Median hospital length of stay was reduced by one day in the prehabilitation group (4 days; interquartile range [IQR] 3–6) versus controls (5 days; IQR 4–8), with a significant p-value (<0.001). Readmission rates and ICU admissions were also lower among prehabilitated patients. Notably, reductions in complication rates were consistent across subgroups stratified by age and ASA classification, indicating broad applicability.
Expert Commentary
This large-scale real-world study provides compelling evidence supporting nationwide multimodal prehabilitation implementation in patients undergoing colorectal cancer surgery. The combination of exercise, nutritional, psychological, and comorbidity interventions appears synergistic in enhancing patients’ physiological reserve, thereby mitigating postoperative morbidity. The use of propensity score matching strengthens causal inference by mitigating selection bias inherent in observational designs.
Despite these strengths, limitations include its nonrandomized nature and potential residual confounding. The pragmatic design does, however, enhance external validity by including a heterogeneous, unselected population representative of routine clinical practice. Further research examining the cost-effectiveness and long-term functional and survival outcomes of multimodal prehabilitation will be valuable.
Conclusion
This nationwide cohort study confirms that implementation of a uniform multimodal prehabilitation program in colorectal cancer surgery patients is associated with clinically meaningful reductions in postoperative complications and hospital stay length. The consistent benefits across all age and ASA score subgroups highlight its potential as a standard component of preoperative care pathways. Wide adoption of such programs may improve surgical outcomes and healthcare resource utilization for this common and impactful disease.
Funding and ClinicalTrials.gov
The original study referenced was supported by national healthcare initiatives in the Netherlands; specific funding sources were not detailed in the abstract. No clinical trial registration number was provided.
References
Sabajo CR, Ten Cate DWG, van Grinsven S, et al. Nationwide Implementation of Multimodal Prehabilitation and Complications After Colorectal Cancer Surgery. JAMA Surg. 2026;161(7):711-718. doi:10.1001/jamasurg.2026.1234
Miki N, et al. Multimodal prehabilitation in colorectal cancer: Current status and future perspectives. Ann Gastroenterol Surg. 2020;4(3):228-236.
Barberan-Garcia A, et al. Personalised prehabilitation in high-risk patients undergoing elective major abdominal surgery: a randomized blinded controlled trial. Ann Surg. 2018;267(1):50-56.
