Cancer prehabilitation uses a multidisciplinary approach combining exercise, nutrition and psychological strategies to prepare patients for the challenges of cancer treatment such as surgery, systemic therapy and radiation therapy. Team members may include anaesthetists, oncologists, surgeons, haematologists, clinical psychologists, exercise physiologists, physiotherapists and dietitians, among others.

Patient performance status is a central factor in cancer care and should be frequently assessed. All patients should be screened for malnutrition using a validated tool, such as the Malnutrition Screening Tool (MST). The lead clinician may refer obese or malnourished patients to a dietitian preoperatively or before other treatments begin.

Patients who currently smoke should be encouraged to stop smoking before receiving treatment. This should include an offer of referral to Quitline in addition to smoking cessation pharmacotherapy if clinically appropriate.

Evidence indicates that patients who respond well to prehabilitation may have fewer complications after treatment. For example, those who were exercising before diagnosis and patients who use prehabilitation before starting treatment may improve their physical or psychological outcomes, or both, and this helps patients to function at a higher level throughout their cancer treatment (Cormie et al. 2017; Silver 2015).

For patients with colorectal cancer, the multidisciplinary team should consider these specific prehabilitation assessments and interventions for treatment-related complications or major side effects:

• conducting a physical and psychological assessment to establish a baseline function level
• identifying impairments and providing targeted interventions to improve the patient’s function level (Silver & Baima 2013)
• referral to a stoma nurse
• reviewing the patient’s medication to ensure optimisation and to improve adherence to medicine used for comorbid conditions.

Following completion of primary cancer treatment, rehabilitation programs have considerable potential to enhance physical function.

Cancer and cancer treatment may cause fertility problems. This will depend on the age of the patient, the type of cancer and the treatment received. Infertility can range from difficulty having a child to the inability to have a child. Infertility after treatment may be temporary, lasting months to years, or permanent (AYA Cancer Fertility Preservation Guidance Working Group 2014).

Patients need to be advised about and potentially referred for discussion about fertility preservation before starting treatment and need advice about contraception before, during and after treatment. Patients and their family should be aware of the ongoing costs involved in optimising fertility. Fertility management may apply in both men and women. Fertility preservation options are different for men and women and the need for ongoing contraception applies to both men and women.

A diagnosis of colorectal cancer in reproductive-age women may carry a risk of future infertility. Therefore, the risk of infertility, and fertility preservation options, both before and after cancer therapy, should be discussed with patients and their families as part of the initial cancer management planning. This discussion should be ongoing, with firm follow-up arrangements put into place. All discussions should be documented in the patient’s medical record.

Treatment for colorectal cancer may reduce female fertility through damage to the ovaries (from chemotherapy or radiation), damage to the uterus (from radiation) and potentially through damage to the fallopian tubes from abdominal surgery. Chemotherapy, especially with alkylating agents, is likely to reduce ovarian reserve, leading to a reduced fertility window or premature menopause. The type of chemotherapy will determine the extent of infertility associated with follicle loss. Radiation of the pelvis commonly induces permanent ovarian failure and may damage the uterus such that future pregnancy confers risk to the mother and fetus.

Pelvic radiation may also induce vaginal adhesions or stenosis, limiting future sexual activity. This risk can be reduced by using vaginal cylinders and topical oestrogen treatment.

Fertility preservation interventions including egg or embryo freezing and ovarian tissue cryopreservation offer realistic options for having a family, although sometimes egg donation and surrogacy may ultimately be required. Women of reproductive age who are concerned about future fertility should be referred to a fertility specialist to discuss potential fertility preservation interventions. Women with early menopause due to colorectal cancer treatment should be offered hormone replacement therapy and (if possible) managed by a menopause specialist.

Some colorectal cancers may be associated with a genetic risk, and specific gene testing in IVF embryos may reduce transmission risk. Some gastrointestinal cancers may be associated with a high risk of other cancers including uterine cancers. Careful counselling and surveillance are required, especially if future pregnancy is a consideration.

An early, collaborative and multidisciplinary approach with the Medical Services Advisory Committee and the surgical, oncology and fertility preservation teams will maximise the opportunity for best practice care and consideration for future fertility for young women diagnosed with colorectal cancer.

See the Cancer Council website for more information.

See validated screening tools mentioned in Principle 4 ‘Supportive care’.

A number of specific challenges and needs may arise for patients at this time:

• assistance for dealing with psychological and emotional distress while adjusting to the diagnosis; treatment phobias; existential concerns; stress; difficulties making treatment decisions; anxiety or depression or both; psychosexual issues such as potential loss of fertility and premature menopause; history of sexual abuse; and interpersonal problems
• management of physical symptoms such as pain, fatigue (Australian Adult Cancer Pain Management Guideline Working Party 2019), weight loss and altered bowel function
• malnutrition or undernutrition, identified using a validated nutrition screening tool such as the MST (note that many patients with a high BMI [obese patients] may also be malnourished [WHO 2018])
• pre-surgical education with a stomal therapy nurse wherever a temporary or permanent stoma is a possibility
• guidance for financial and employment issues (e.g. loss of income, travel and accommodation)
• requirements for rural patients and caring arrangements for other family members
• support for families or carers who are distressed with the patient’s cancer diagnosis
• support for families/relatives who may be distressed after learning of a genetically linked cancer diagnosis
• specific spiritual needs that may benefit from the involvement of pastoral/spiritual care
• low self-esteem and disturbed body image, which are more prevalent in stoma patients than in non-stoma patients.

Between 32 and 44 per cent of patients report psychological distress following a diagnosis of colorectal cancer, and patients with stomas are at higher risk (El-Shami et al. 2015; Cancer Council Australia Colorectal Cancer Guidelines Working Party 2019). This large number indicates a need for screening patients to identify those at high risk of anxiety or depression at each visit. Provide patients with tailored and accurate information before treatment, and facilitate patient decision making about appearance-altering treatment and meeting others with a similar personal experience (Hong et al. 2014). Consider pre-surgical referral to a psycho-oncologist for support over body image expectations associated with surgical treatment.

Additionally, palliative care may be required at this stage.

For more information on supportive care and needs that may arise for different population groups, see Appendices A and B, and special population groups.

In discussion with the patient, the lead clinician should undertake the following:

• establish if the patient has a regular or preferred general practitioner and, if the patient does not have one, then encourage them to find one
• provide written information appropriate to the health literacy of the patient about the diagnosis and treatment to the patient and carer and refer the patient to the Guide to best cancer care (consumer optimal care pathway) for bowel cancer, as well as to relevant websites and support groups as appropriate
• provide a treatment care plan including contact details for the treating team and information on when to call the hospital
• discuss a timeframe for diagnosis and treatment with the patient and carer
• discuss the benefits of multidisciplinary care and gain the patient’s consent before presenting their case at an MDM
• provide brief advice and refer to Quitline (13 7848) for behavioural intervention if the patient currently smokes (or has recently quit), and prescribe smoking cessation pharmacotherapy, if clinically appropriate
• recommend an ‘integrated approach’ throughout treatment regarding nutrition, exercise and minimal or no alcohol consumption among other considerations
• communicate the benefits of continued engagement with primary care during treatment for managing comorbid disease, health promotion, care coordination and holistic care
• where appropriate, review fertility needs with the patient and refer for specialist fertility management (including fertility preservation, contraception, management during pregnancy and of future pregnancies)
• be open to and encourage discussion about the diagnosis, prognosis (if the patient wishes to know) and survivorship and palliative care while clarifying the patient’s preferences and needs, personal and cultural beliefs and expectations, and their ability to comprehend the communication
• encourage the patient to participate in advance care planning including considering appointing one or more substitute decision-makers and completing an advance care directive to clearly document their treatment preferences. Each state and territory has different terminology and legislation surrounding advance care directives and substitute decision-makers.

The lead clinician has these communication responsibilities:

• involving the general practitioner from the point of diagnosis
• ensuring regular and timely communication with the general practitioner about the diagnosis, treatment plan and recommendations from MDMs and inviting them to participate in MDMs (consider using virtual mechanisms)
• supporting the role of general practice both during and after treatment
• discussing shared or team care arrangements with general practitioners or regional cancer specialists, or both, together with the patient.

Refer to Principle 6 ‘Communication’ for communication skills training programs and resources.