Cancer prehabilitation uses a multidisciplinary approach combining exercise, nutrition and psychological strategies to prepare patients for the challenges of cancer treatment such as chemotherapy, immunotherapy and radiation therapy.

Evidence indicates that prehabilitation of newly diagnosed cancer patients prior to starting treatment can be beneficial. This may include conducting a physical and psychological assessment to establish a baseline function level, identifying impairments and providing targeted interventions to improve the patient’s health, thereby reducing the incidence and severity of current and future impairments related to cancer and its treatment (Silver & Baima 2013).

Medications should be reviewed at this point to ensure optimisation and to improve adherence to medicines used for comorbid conditions.

Where appropriate, fertility issues should be reviewed with the patient.

Screening with a validated screening tool (such as the National Comprehensive Cancer Network Distress Thermometer and Problem Checklist), assessment and referral to appropriate health professionals or organisations is required to meet the identified needs of the patient, their carer(s) and family.

In addition to the other common issues outlined in the Appendix, specific needs that may arise at this time include the following:

Physical

• Fatigue/change in functional abilities is a common symptom, and patients may benefit from referral to occupational therapy.

Psychological

• Many patients with CUP find the uncertainty surrounding their disease and the limited treatment options difficult and would welcome the opportunity to ask questions and learn about others’ experiences (Boyland & Davis 2008).
• Many patients with CUP and their clinicians have a poor understanding of their illness, difficulty in explaining their illness to others, and a sense of frustration in health professionals not having the answers (Boyland & Davis 2008, Karapetis et al. 2017).
• Depressive symptoms are higher in people with CUP when compared with people with cancer of a known origin, so they require more psychosocial support and specific interventions (Hyphantis et al. 2013).
• Information about genomic profiling available via CUP research projects should be provided to patients.
• GPs play an important role in coordinating care for patients, including assisting with side effects and offering support when questions or worries arise. For most patients, simultaneous care provided by their GP is very important (Lang et al. 2017).
• Patients may require help with psychological and emotional distress while adjusting to the diagnosis, treatment phobias, existential concerns, stress, difficulties making treatment decisions, anxiety/depression, loss of previous life roles including driving, and interpersonal problems.

Social/practical

• Patients may need support to attend appointments.
• Patients may need guidance about financial and employment issues (such as loss of income and having to deal with travel and accommodation requirements for rural patients and caring arrangements for other family members).

Information

• Patients with CUP will most likely undergo extensive testing, and support and information should be provided to assist with any distress while undergoing these tests (Wagland et al. 2017).
• CUP patients are more likely to want more written information about their type of cancer and tests received but less likely to understand explanations of their condition (Wagland et al. 2017).
• Patients from culturally and linguistically diverse backgrounds may need information provided in other formats.
• Patients may need advice about safe driving.

Spiritual needs

• Lead clinicians should have access to suitably qualified, authorised and appointed spiritual caregivers who can act as a resource for patients, carers and staff.
• Patients and their families should have access to spiritual support appropriate to their needs throughout the cancer journey.

The lead clinician should:

• ensure the patient understands that they have been diagnosed with CUP and that they understand the ramifications of this diagnosis
• assist the patient in explaining their diagnosis to their family; audio recordings may be a helpful resource for patients (Pitkethly et al. 2008)
• establish if the patient has a regular or preferred GP
• discuss a timeframe for diagnosis and treatment with the patient and carer
• discuss the benefits of multidisciplinary care and make the patient aware that their health information will be available to the team for discussion at the MDT meeting
• offer individualised CUP information that meets the needs of the patient and carer (this may involve advice from health professionals as well as written and visual resources)
• offer advice on how to access information and support from websites, community and national cancer services and support groups for both patients and carers
• use a professionally trained interpreter to communicate with people from culturally or linguistically diverse backgrounds.

The lead clinician should:

• ensure regular and timely (within a week) communication with the person’s GP regarding the treatment plan and recommendations from MDT meetings
• notify the GP and family/carer if the person does not attend clinic appointments
• gather information from the GP including their perspective on the person (psychological issues, social issues and comorbidities) and locally available support services
• ask the person’s GP to contribute to developing a chronic disease and mental healthcare plan as required
• discuss management of shared care with the person’s GP
• invite the GP to participate in MDT meetings (consider using video or teleconferencing).