# Implementation and challenges of prehabilitation in gastrointestinal oncology: a national cross-sectional survey in France

Eva Ester Molina Beltran, Nora Dollet Nedellec, Marc Hilmi, Matthieu Delaye, Bruno Raynard, Sandrine Hiret, Damien Vansteene, Florence Carrouel, Claude Dussart, Cindy Neuzillet

► To cite this version:

Eva Ester Molina Beltran, Nora Dollet Nedellec, Marc Hilmi, Matthieu Delaye, Bruno Raynard, et al. Implementation and challenges of prehabilitation in gastrointestinal oncology: a national cross-sectional survey in France. Clinical Nutrition ESPEN, 2025, 70, pp.256-262. 10.1016/j.clnesp.2025.09.018. hal-05300005

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Original article

# Implementation and challenges of prehabilitation in gastrointestinal oncology: A national cross-sectional survey in France

<figure><img src="image_3.png" /></figure>

Eva Ester Molina Beltran<sup>a,b,*</sup>, Nora Dollet Nedellec<sup>a</sup>, Marc Hilmi<sup>c</sup>, Matthieu Delaye<sup>a</sup>, Bruno Raynard<sup>d</sup>, Sandrine Hiret<sup>e</sup>, Damien Vansteene<sup>f</sup>, Florence Carrouel<sup>b</sup>, Claude Dussart<sup>b</sup>, Cindy Neuzillet<sup>a,g</sup>

## ARTICLE INFO

**Article history:**
Received 7 July 2025
Accepted 12 September 2025

**Keywords:**
Prehabilitation
National survey
Gastrointestinal oncology
Supportive care
Cancer surgery
Implementation barriers

## SUMMARY

**Purpose:** To explore the implementation, structure, and challenges of multimodal prehabilitation programs in gastrointestinal (GI) oncology across France, in a context where evidence supports its benefits but national standardization is lacking.

**Methods:** A national cross-sectional survey was conducted from April to July 2024. The 54-item questionnaire, developed by a multidisciplinary group, assessed team demographics, patient selection, intervention modalities, pathway coordination, and barriers to implementation. Descriptive statistics were used for data analysis.

**Results:** Among 92 respondent teams, 19 (20.7 %) reported having a structured prehabilitation pathway. Most included nutritional (94.7 %) and physical activity (74 %) interventions, while only 5.3 % provided systematic psychological support. Program eligibility was generally based on nutritional risk, surgical magnitude, and patient frailty, but varied widely. Prehabilitation was most often coordinated by surgeons (40 %) and dietitians (78.9 %), and typically delivered in day-hospital settings. Key challenges included insufficient human resources (60 %), coordination issues (49 %), and funding limitations (35 %). Despite these barriers, perceived utility and satisfaction with prehabilitation programs were high (median scores of 8/10 and 8.6/10, respectively).

**Conclusion:** Prehabilitation in GI oncology is emerging but remains inconsistently applied across France. To scale these interventions equitably and effectively, national guidelines, enhanced coordination and institutional support are essential. Integration with existing perioperative pathways like ERAS and increased psychological support are also needed to improve patient outcomes. Only one center in our sample offered systematic psychological support.

© 2025 The Author(s). Published by Elsevier Ltd on behalf of European Society for Clinical Nutrition and Metabolism. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

<footnote><sup>a</sup> Medical Oncology, Curie Institute, Saint Cloud, France</footnote>

<footnote><sup>b</sup> UR4129, Lyon University 1, Lyon, France</footnote>

<footnote><sup>c</sup> David M Rubenstein Center for Pancreatic Cancer Research Memorial Sloan Kettering Cancer Center, New York, United States</footnote>

<footnote><sup>d</sup> Supportive Care, Gustave Roussy Institute, Villejuif, France</footnote>

<footnote><sup>e</sup> Medical Oncology, Institut de Cancerologie de l'Ouest, Angers, France</footnote>

<footnote><sup>f</sup> Medical Oncology, Institut de Cancerologie de l'Ouest, Saint-Herblain, France</footnote>

<footnote><sup>g</sup> Versailles Saint-Quentin en Yvelines University, Versailles, France</footnote>

<footnote>* Corresponding author. Medical Oncology, Curie Institute, Saint Cloud, France.</footnote>

<footnote>E-mail addresses: evaester.molinabeltran@curie.fr (E.E. Molina Beltran), nora.dolletnedellec@agroparistech.fr (N. Dollet Nedellec), hilmim@mskcc.org (M. Hilmi), matthieu.delaye@curie.fr (M. Delaye), bruno.raynard@gustaveroussy.fr (B. Raynard), sandrine.hiret@ico.unicancer.fr (S. Hiret), damien.vansteene@ico.unicancer.fr (D. Vansteene), florence.carrouel@univ-lyon1.fr (F. Carrouel), claude.dussart@univ-lyon1.fr (C. Dussart), cindy.neuzillet@curie.fr (C. Neuzillet).</footnote>
**Key messages:**

* What is already known on this topic

Prehabilitation, combining nutrition, physical activity, and psychological support, has demonstrated benefits in surgical oncology, particularly in colorectal and esophageal cancers. However, its implementation in gastrointestinal (GI) oncology is inconsistent and often lacks standardization in practice and structure.

* What this study adds

This national survey provides the first comprehensive overview of prehabilitation practices across GI oncology centers in France. It highlights a significant heterogeneity in implementation, with only a minority of teams offering structured programs—most of which include nutrition and physical activity, but rarely psychological support.

* How this study might affect research, practice, or policy

The findings underscore the urgent need for national clinical guidelines, better coordination, increased staffing, and institutional support to standardize and expand access to prehabilitation. This may enhance patient outcomes and support integration into routine oncologic care.

# 1. Introduction

Patients with digestive cancer are highly susceptible to malnutrition and sarcopenia. The prevalence of these conditions ranges from 39 to 80%, depending on the location of the tumor [1]. These conditions are primarily driven by cancer-induced hypercatabolism and further aggravated by neoadjuvant therapies. Together, they exacerbate metabolic stress and compromise patients' functional status prior to surgery [2]. Malnutrition is a well-recognized factor associated with an increased risk of postoperative complications and reduced long-term survival following major surgical procedures, such as pancreaticoduodenectomy, colectomy, esophagectomy and gastrectomy [3,4].

Surgery remains a cornerstone in the treatment of localized digestive cancers such as pancreatic and esophago-gastric adenocarcinomas, often combined with a triplet chemotherapy regimen. However, the completion rate of this approach remains limited: below 50 % of pancreatic cancer patients [5] and around 46 % of esophago gastric cancer patients [6] receive the full perioperative treatment due to treatment toxicities or altered general condition. These modest outcomes highlight the urgent need to optimize patients'preoperative condition to improve tolerance to treatment and surgical recovery.

In this context, supportive care strategies – including nutrition and physical activity-have gained increasing attention as means to prevent or mitigate cancer-related sarcopenia and malnutrition. Over the past decade, national and international oncology societies have emphasized the importance of integrating these interventions early in the cancer care continuum, ideally in parallel with oncologic treatment [7]. One such approach, known as prehabilitation, combines physical, nutritional, and psychological support to enhance patients' fitness before surgery [8].

**Prehabilitation** is defined as a multimodal intervention aiming to optimize patients' physical and psychological condition before surgery. It typically includes a combination of exercise, nutritional counseling, and mental health support [8]. In oncology, its feasibility, safety and efficacy, has been demonstrated, particularly in improving functional recovery, patient experience, pain management, hospital length of stay and healthcare costs [9,10].

However, in gastrointestinal (GI) oncology, the implementation of prehabilitation remains highly heterogeneous. First, confusion persists between prehabilitation and other perioperative approaches such as physical prehabilitation alone or Enhance Recovery After Surgery (ERAS), despite growing evidence supporting the benefits of comprehensive, multimodal strategies [11]. ERAS is defined as a package of interventions including smoking cessation, alcohol reduction, nutritional optimization, anesthesia techniques and mini-invasive surgery to enhance patient recovery after surgery [12]. Second, the modalities of the interventions-type, duration, intensity and inclusion of psychological support-vary widely across programs [13]. Third, effectiveness remains debated: while many studies reported positive outcomes in terms of physical function and reduced complications, others failed to demonstrate significant benefits [14,15]. Finally, evidence strength varies by cancer site. Solid data support prehabilitation for colorectal and esophageal cancers, showing improvements in functional outcomes and postoperative complications [16,17]. Physical improvement and compliance rate are maintain even during the neoadjuvant chemotherapy period [18]. However, for other GI cancers, high-quality evidence, including randomized controlled trials, is still lacking.

In France, prehabilitation is still an emerging component of perioperative care. Although initial reports date back to 2015, national recommendations were not issued until 2021 [8,19]. Interest in prehabilitation has increased due to the COVID-19 pandemic, which underscored the need to strengthen patients' resilience before major surgery.

In a context marked by the coexistence of ERAS protocols and the lack of standardized prehabilitation guidelines, this study aimed to (i) identify the healthcare teams involved in prehabilitation; (ii) describe the modalities of their interventions and (iii) explore the challenges and barriers they encounter during implementation.

# 2. Materials and methods

This exploratory survey consisted of 54 questions (Appendix 1) focused on care pathways, was divided into five themes: (i) Team demographics (4 questions); (ii) Pathway development and patient selection (12 questions); (iii) Organization of nutrition, physical activity and psychological interventions (11 questions); (iv) Pathway coordination (6 questions); (v) Implementation challenges and satisfaction (11 questions).

A multidisciplinary working group composed of medical oncologists, gastroenterologists, researchers, and an advanced practice nurse developed the questionnaire. The group pre-tested the questionnaire with the UGCI-UNICANCER group. The final version was validated by the research laboratory Health, Systemic, Process (UR4129), University Claude Bernard Lyon 1 and the UGCI-UNICANCER group.

Survey invitations were distributed via email and through professional societies in surgery (FRENCH, ACHBT) and oncology (FROG), and through research groups (GERCOR, PRODIGE, NaCRe, FFCD, UNICANCER) as well as through social networks. Three reminder emails were sent to the different groups to increase the number of responses. Teams were invited to submit one response per unit, a requirement that was clearly stated at the beginning of
the survey to avoid duplicate entries. The survey could be accessed via computer, tablet, or smartphone through the LimeSurvey platform.

All responses were anonymous and confidential. Only the promoting association (GERCOR) had access to the survey platform.

As an exploratory study, no sample size was calculated. The survey was closed after 2 consecutive weeks without new responses. It was opened for 1st April to 1st July 2024.

Descriptive statistics were used to analyze the data. Continuous variables were expressed as means with interquartile ranges (IQR) and categorical variables as frequencies (percentage). Representability was assessed using the Chi² test, with a significance level set at *p* < 0.05. Duplicates answers were minimized through explicit instructions to submit one response per unit, reinforced by distribution via professional societies. The statistical analyses were performed using R as software. Partially completed surveys were included when >80 % of core questions were answered; missing data were handled through pairwise deletion in descriptive analyses.

# 3. Results

## 3.1. Demographics

Among the 92 respondents, 19 teams (20.7 %) reported having a structured prehabilitation pathway, while 6 teams (6.5 %) indicated they did not. The remaining 67 teams (72.8 %) did not respond and were therefore considered as not having such a pathway. The subsequent statistical analysis focuses exclusively on the 19 hospital structures that reported a prehabilitation pathway.

These structures were primarily located in the Auvergne-Rhône-Alpes and Grand Est regions (15.8 % each), followed by Bourgogne, Brittany, Normandy, Occitanie, and Île-de-France (10.3 % each). Hauts-de-France and Provence-Alpes-Côte d'Azur (PACA), were less represented (5.3 %), and some French regions - including Nouvelle-Aquitaine, Pays de la Loire, Centre-Val de Loire, and Corsica - were not represented. The total number of

respondents is shown in Table 1, with a distinction between regions and between teams that have implemented a prehabilitation program.

Among respondents from centers with a prehabilitation pathway, digestive surgeons were the most represented (52.6 %), followed by oncologists (15.8 %) and advanced practice nurses (10.5 %). The remaining respondents included a gastroenterologist, a hepatogastroenterologist, a general practitioner, and a geriatrician.

## 3.2. Pathway creation and patients' selection

Most prehabilitation pathways (68.4 %) were implemented within the past four years (recent pathways). The remaining 26.3 % had existed for 5 years and more (older pathways).

Eligibility criteria varied, with patient inclusion covering a broad range of digestive cancer (Table 2).

The eligibility criteria for prehabilitation were clearly defined in 36.8 % of the centers. The criteria were most often based on malnutrition (57.1 %), major surgery (42.9 %), and age (28.6 %).

## 3.3. Pathway organization and different interventions

### 3.3.1. Referral and coordination

Pathway coordination varied. It was managed by the surgical department in 31.6 % of cases, supportive care services in 21.1 % of cases, and oncology departments in 15.8 % of cases. At individual level, coordination was led by digestive surgeons (26.3 %) and advanced practice nurses (21.1 %), followed by supportive care physicians, nutritionists, oncologists and nurse coordinators.

The most frequent setting was day hospital care (47.4 %), with or without dedicated space (26.3 % vs. 21.1 %). Outpatient consultation was used in 10.5 % of cases and full hospitalization in 5.3 %.

### 3.3.2. Nutritional intervention

Nutritional care was integrated in 94.7 % of pathways. Assessments were mainly face-to-face (68.4 %), with teleconsultation

<table><caption>**Table 1**
Geographical repartition of respondent.</caption><thead><tr><th>Region</th><th>Total of respondents (n = 92)/Prehabilitation teams (n = 19)</th><th>University hospitals</th><th>Cancer Centers</th><th>General hospitals</th><th>Private hospitals</th><th>Regional hospitals</th><th>Missing</th></tr></thead><tbody><tr><td>Auvergne-Rhône-Alpes</td><td>2 (2.1 %)<br>3 (15.8 %)</td><td>2/19</td><td>1/92</td><td></td><td></td><td></td><td>1/92</td></tr><tr><td>Bourgogne-Franche-Comté</td><td>2 (2.1 %)<br>2 (10.5 %)</td><td>2/92</td><td></td><td></td><td>1/19</td><td></td><td></td></tr><tr><td>Grand Est</td><td>2 (2.1 %)<br>2 (10.5 %)</td><td>2/92<br>1/19</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Provence-Alpes-Côte d'Azur</td><td>2 (2.1 %)<br>1 (5.2 %)</td><td>1/92</td><td></td><td></td><td>1/92<br>1/19</td><td></td><td></td></tr><tr><td>Occitanie</td><td>3 (3.2 %)<br>2 (10.5 %)</td><td>1/92</td><td>1/92<br>1/19</td><td>1/19<br>1/92</td><td></td><td></td><td>1/92</td></tr><tr><td>Nouvelle-Aquitania</td><td>1 (1 %)<br>0</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Centre-Val de Loire</td><td>2 (2.1 %)<br>0</td><td>1/92</td><td>1/92</td><td></td><td></td><td></td><td></td></tr><tr><td>Île-de-France</td><td>5 (5.4 %)<br>2 (10.5 %)</td><td>2/92</td><td>1/92<br>1/19</td><td></td><td>2/92</td><td></td><td></td></tr><tr><td>Normandy</td><td>0<br>2 (10.5 %)</td><td>1/19</td><td>1/19</td><td></td><td></td><td>1/19</td><td></td></tr><tr><td>Brittany</td><td>2 (2.1 %)<br>2 (10.5 %)</td><td>1/92</td><td></td><td>1/92<br>1/19</td><td></td><td></td><td>1/19</td></tr><tr><td>Hauts-de-France</td><td>1 (1 %)<br>1 (5.2 %)</td><td>1/92<br>1/19</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Corsica</td><td>0</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Missing region</td><td>54 (58.7 %)<br>1 (5.2 %)</td><td>1/19</td><td></td><td></td><td></td><td></td><td></td></tr></tbody></table>
<table><caption>**Table 2**
Pathologies managed in prehabilitation pathways and integration temporality.</caption><thead><tr><th></th><th>Total</th><th>Recent pathways</th><th>Older pathways</th></tr></thead><tbody><tr><td>Esophagus (before surgery)</td><td>15 (78.9 %)</td><td>46.2 %</td><td>53.8 %</td></tr><tr><td>Gastric</td><td>14 (73.7 %)</td><td>77 %</td><td>23 %</td></tr><tr><td>Rectum (treated with radio-chemotherapy)</td><td>13 (68.4 %)</td><td>69.2 %</td><td>30.8 %</td></tr><tr><td>Pancreas</td><td>13 (68.4 %)</td><td>77 %</td><td>23 %</td></tr><tr><td>Esophagus (treated with radio-chemotherapy)</td><td>10 (52.6 %)</td><td>70 %</td><td>30 %</td></tr><tr><td>Colon (localized)</td><td>10 (52.6 %)</td><td>60 %</td><td>40 %</td></tr><tr><td>Colon (metastatic)</td><td>9 (47.4 %)</td><td>53.8 %</td><td>46.2 %</td></tr><tr><td>Liver (cholangiocarcinoma or hepatocellular carcinoma)</td><td>9 (47.4 %)</td><td>46.2 %</td><td>33.3 %</td></tr><tr><td>Peritoneal location (before surgery)</td><td>7 (36.8 %)</td><td>50 %</td><td>50 %</td></tr><tr><td>Anus (treated with radio-chemotherapy)</td><td>3 (15.8 %)</td><td>23.1 %</td><td>76.9 %</td></tr><tr><td>Other<sup>a</sup></td><td>5 (26.3 %)</td><td></td><td></td></tr></tbody></table>

(31.6 %) and mobile apps (1 %) also used. Follow-up was weekly (26.3 %) or fortnightly (21.1 %); 10.5 % reported monthly follow-up. However, 42.1 % of responses did not specify frequency.

Dieticians led nutritional care in 63.2 % of cases, supported by medical nutritionist (36.8 %) and registered nurses (RNs) or advanced practice nurses (APNs) trained in nutrition (26 %).

Monitoring and assessment tools included: weight tracking (68.4 %), detailed dietary assessment of caloric and protein intake (52.6 %), Grip Strength (42.1 %), Visual Analog Scale (36.8 %), Bio-impedancemetry (26.3 %). No teams used indirect calorimetry or CT-based L3-slice analysis.

Immunonutrition before surgery was prescribed preoperatively in all GI surgeries (26.3 %), selected cases based on specific criteria as major surgery or only colorectal cancer based on the reimbursement conditions in France (42.1 %).

### 3.3.3. Adapted physical activity

The analysis of the frequency of use of physical fitness assessment tools revealed significant variability across facilities, making it difficult to identify clear trends. Physical activity modalities were shown in Fig. 1.

There was high variability in fitness assessment and Adapted Physical Activity (APA) delivery. Supervised sessions occurred mainly in-hospitals (36.8 %) or via external providers (26.3 %). Out-of-hospital sessions were often led by physiotherapists (42.1 %) or APA instructors (10.5 %).

Median session frequency was 4 supervised and 4.7 autonomous sessions per week (range: 1/week to twice daily). Assessment tools included: 6-min walk test (6MWT) (47.3 %), Grip test and Sit-to-stand test (36.8 %), Unipodal balance and Get up and go (31.5 %) and VO2 max (5.2 %). More than one answer were allowed.

<figure><img src="image_4.png" /><figcaption>**Fig. 1.** Physical activity modalities.</figcaption></figure>

<footnote>* Teams were allowed to select more than one answer.</footnote>

<footnote>a Bariatric surgery, sarcoma, ovarian carcinoma and surgery with Hyperthermic Intraperitoneal Chemotherapy (HIPEC).</footnote>
21 % of the respondent complete the assessment with the Inter-national Physical Activity Questionnaire - Short (IPAQ-S).

### 3.3.4. Psychological support

Only 5.3 % of teams (n = 1) provided psychological interventions systematically, while 66.7 % offered them on a case-by-case basis. 16.7 % of teams used a screening questionnaire and 20 % did not propose the intervention at all.

#### 3.3.4.1. Pathway coordination and additional support.
The most involved HP in the prehabilitation pathway were dieticians (78.9 %) surgeons, physiotherapists, and nurses (>50 % of teams) being.

Continuity between prehabilitation and ERAS was ensured by 66.6 % of teams. Pathway coordination was most commonly led by surgeons (40 %), followed by nurse coordinators or advanced practice nurses (31.1 %). From a logistical perspective, 45.3 % of the pathways were delivered in day-hospital settings and financed through day-hospital billing. The rest were conducted via consultations and financed either by institutional support or external project-based funding.

#### 3.3.4.2. Implementation challenges of perceived utility.
When no neoadjuvant treatment was involved, 59.2 % of teams preferred prehabilitation duration under 4 weeks; 40.8 % extended beyond that. Only one team reported no prehabilitation in this context. In contrast, with neoadjuvant treatment, 76 % of teams favored duration over 4 weeks.

Main implementation challenges were the lack of human resources (60 %), the coordination (49 %), logistic issues (37.2 %) and funding (35 %). To improve implementation, respondents suggested to increase staffing and time (69 %), to improve inter-team coordination (49 %) and to enhance coordination with primary care (43 %).

Teams reported a high level of satisfaction, with an average satisfaction score of 7/10 and a median of 8 [Q1 = 6; Q3 = 8]. The average perceived utility score was 8.6/10, and a median of 8 [Q1 = 8; Q3 = 10] for the prehabilitation pathway.

## 4. Discussion

In this national survey, 92 teams involved in digestive oncology were questioned regarding the implementation, organization and challenges of a multimodal prehabilitation program. Only 19 teams among them have implemented such programs, with notable heterogeneity in geographical distribution and operational modalities. Despite this variability, most of the teams that had implemented prehabilitation programs reported incorporating at least two pillars of prehabilitation - nutrition and physical activity- while psychological support remains the least implemented intervention. The main challenges identified were the lack of healthcare professionals and insufficient coordination.

The Grand-Est and Auvergne-Rhône-Alpes regions emerged as the most represented in prehabilitation implementation. The increasing number of prehabilitation programs implemented during the last 5 years aligns with the growing body of scientific literature and heightened awareness supported by the regional health agencies [20,21] around patient conditioning before cancer surgery.

Nearly 40 % of the responding teams reported using eligibility criteria for inclusion, which is consistent with recommendations targeting prehabilitation to patients identified as frail because of a nutritional risk, major surgery, cancer location or patient's characteristics as age or comorbidities. Several studies have confirmed the feasibility, safety and effectiveness of these programs,

particularly in improving physical capacity and postoperative recovery in vulnerable populations [22,23].

Nutritional support emerged as the most systematically implemented component, present in nearly 95 % of pathways. This widespread adoption reflects the well-established role of dietitians in the French healthcare system, especially in oncology [24]. However, the potential contribution of nurses or nurse specialists in nutritional assessment and follow-up appears underexploited, despite evidence supporting their effectiveness in this domain [25]. The development of advanced practice nursing may offer a viable response to the shortage of dietitians and physicians. Furthermore, external service providers are frequently involved in delivering enteral nutrition, in line with current health policy orientations favoring outpatient care models [26]. Follow-up tends to be relatively frequent, with over 45 % of teams conducting weekly or fortnightly assessments, in accordance with oncology nutrition guidelines [27]. Nevertheless, 42 % of teams lack a structured follow-up protocol, underlining the need for national consensus or best follow of international guidelines. While most teams used validated tools for nutritional assessment, practices varied and more advanced methods—such as bioimpedance or CT-based evaluation of sarcopenia—remained underutilized, despite being recommended by recent guidelines [27].

Physical activity is the second most common component, implemented by 74 % of teams. Despite the strong evidence of the benefits of physical activity before surgery, during chemotherapy treatments and after adjuvant chemotherapy, the implementation rate remained uneven [10,19,41]. It may be explained by the lack of physical activity providers as France does not currently have a sufficient number of physiotherapists or APA instructors in relation to its population density [28,29]. Funding can also be an issue as in some regions physical activity is reimbursed out of the hospital, fact that is a recognized barrier to the development of this intervention [30]. Digital tools – such as mobile applications that could facilitate remote monitoring and patient engagement—may hinder the broader deployment of these programs. Hybrid models that combine in-hospital assessments with out-of-hospital training could offer a pragmatic and scalable solution to these challenges [31,32].

Psychological support, though recognized as a fundamental element of multimodal prehabilitation, is rarely implemented in a systematic manner. Only one team reported integrating psychological interventions as part of the routine pathway. Techniques such as relaxation, mindfulness, and cognitive training have demonstrated benefits for postoperative outcomes [33]. Implementing psychological intervention depends on multiples factors such as human resources, patient background and acceptance, and the socio-cultural environment [34]. The systematic use of validated screening tools, such as the Hospital Anxiety and Depression Scale or the Distress Thermometer, could facilitate early identification of patients in need of psychological support [35]. Moreover, motivational interventions delivered by nurses or advanced practice nurses could offer a scalable option for addressing these needs [36].

Although prehabilitation should be conceived as part of a continuum of care that extends into postoperative rehabilitation, only 60 % of teams reported any form of continuity between prehabilitation and rehabilitation, and this link is seldom formalized. Unlike ERAS programs—which benefit from international guidelines, strong institutional support, and a dedicated scientific society—prehabilitation remains fragmented and lacks a unified framework or recognized leadership in France. Despite the evidence and established ERAS methodology, with new health challenges and advances in new technologies, they too are undergoing evolution [12].
Our study was limited by the usual biases of this type of study, mainly a selection bias -since the way the survey is distributed selects particular profiles of respondents and over-represents certain types of structures (university hospital) compared with others (private hospital)- and a reporting bias. Some regions are more represented than others, probably explained than the strongest presence of GI-oncology surgical teams and the historical inclination of certain health agencies to promote this type of intervention, more so than in other regions. Furthermore, our survey did not explore patient's perspective, that will be strongly valuable to explore in the future. Finally, our study was limited to France, where the particularities of healthcare organization and financing make it difficult to apply to other countries.

Despite these limitations, and consistent with existing literature, our study highlights several structural and organizational barriers to implementation, including the lack of trained personnel, weak interprofessional coordination, and insufficient national policy support [30]. Logistical constraints, including surgical scheduling and coordination across various professionals, are also frequently cited as impediments [37]. The involvement of coordinating professionals—such as case managers, advanced practice nurses, or supportive care coordinators—appears critical for improving the fluidity and effectiveness of care pathways [38,40]. More broadly, the successful and equitable scaling-up of prehabilitation in France will require the development of national clinical guidelines, greater institutional support, formal recognition by health authorities, and targeted training programs for healthcare professionals [39].

Future perspectives to integrate prehabilitation in the health pathway requires innovative delivery models that overcome current resource and access barriers. Hybrid approaches—combining in-hospital assessments with community-based or home-based exercise and nutrition interventions—could increase program reach while maintaining clinical oversight. Digital monitoring tools, including mobile applications, wearable activity trackers, and teleconsultations, may enhance patient engagement, enable remote progress tracking, and facilitate timely adjustments to individualized plans. Also involved patients in the pathway conception can improve adherence, feasibility and empowerment. Furthermore, formal integration of prehabilitation within ERAS protocols as a continuous healthcare pathway could provide a standardized framework and promote continuity of care from preoperative optimization through postoperative recovery. Prospective studies evaluating the feasibility, cost-effectiveness, and patient-reported outcomes of these models will be essential to guide large-scale implementation and inform future national policies and guidelines.

## 5. Conclusion

This national survey provides a comprehensive overview of the current landscape of multimodal prehabilitation in gastrointestinal oncology in France. Despite growing interest and evidence supporting its benefits, prehabilitation pathways remain heterogeneously implemented, with only a minority of centres having established programs. Most of the teams that had implemented prehabilitation programs integrated at least nutritional and physical activity components, while psychological support was systematically offered only by one center.

The findings highlight significant barriers to broader adoption, including a lack of human resources, coordination challenges, funding issues, and variability in organizational models. Nonetheless, healthcare professionals expressed strong perceived utility and satisfaction with existing pathways, emphasizing the importance of further development.

To ensure equitable access and standardized practices across the country, there is a need for formal national guidelines, stronger institutional support, and dedicated training for healthcare providers. Prehabilitation should be integrated as a continuum of cancer care, complementing ERAS protocols, and tailored to the specific needs of frail cancer patients. Addressing structural and logistical barriers, alongside reinforcing coordination roles, especially among nurses, will be crucial for the successful and sustainable implementation of prehabilitation programs in gastrointestinal oncology.

## Authors' contribution

EEMB wrote the manuscript, NDD analysed the data and contributes to the discussion.

MH co-designed the survey, analysed the data and wrote support

MD co-designed the survey wrote support

BR, SH, DV co-designed the survey.

FC, CD, CN critically revised and give methodological support

All authors approved the final manuscript.

## Disclosures

EEMB: Consultancies for Fresenius Kabi, Viatris, Nestlé Health Science. Research funding for Fresenius Kabi, Nutricia.

NDD: no disclosures, no competing interests.

MH: Honoraria from Pierre Fabre, AstraZeneca, Amgen, Viatris. Grant from Servier and travel expenses from Astellas.

MD: consulting and/or advisory role and/or invitation as a speaker for Servier and Eisai. Travel accommodation, or expenses from Merck and MSD. Research funding by Servier and AstraZeneca.

BR: Consultancies and honoraria for Fresenius Kabi, Amgen, Eisai, Pfiszer, Nestlé Health Science.

SH: no disclosures, no competing interests.

DV: consultancies and honoraria for Pfizer, Lilly, B Braun, Fresenius Kabi, Homeperf, Bristol-Myers Squibb, Nutricia, MSD, Theradial

FC: no disclosures, no competing interests.

CD: no disclosures, no competing interests.

CN: consultancy and/or honoraria for Amgen, AstraZeneca, Baxter, Bristol-Myers Squibb, Fresenius Kabi, IncyteBiosciences, Merck, MSD, MundiPharma, Mylan, Nestlé Health Science, Novartis, Nutricia, OncoSil, OSE Immunotherapeutics, Pierre Fabre, Roche, Sanofi, Servier, Théradial, Viatris. Research funding for AstraZeneca, Bristol-Myers Squibb, Fresenius Kabi, Nutricia, OSE Immunotherapeutics, Roche, Servier, Viatris

## Declaration of competing interest

The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors. Fresenius Kabi support the publication of this survey.

## Acknowledgements Section

Fresenius Kabi support the publication of this survey.

Thanks to the GERCOR cooperative group for the diffusion of this survey.

## Appendix A. Supplementary data

Supplementary data to this article can be found online at
https://doi.org/10.1016/j.clnesp.2025.09.018.
## References

[1] Hébuterne X, Lemarié E, Michallet M, de Montreuil CB, Schneider SM, Goldwasser F. Prevalence of malnutrition and current use of nutrition support in patients with cancer. JPN - J Parenter Enter Nutr 2014;38:196-204.

[2] Prado CM, Purcell SA, Laviano A. Nutrition interventions to treat low muscle mass in cancer. J Cachexia Sarcopenia Muscle 2020;11:366-80.

[3] Jin J, Xiong G, Wang X, Peng F, Zhu F, Wang M, et al. The impact of preoperative and postoperative malnutrition on outcomes for ampullary carcinoma after pancreaticoduodenectomy. Front Oncol 2021;11:748341. Published 2021 Nov 30.

[4] Jin J, Zhu X, Deng Z, Zhang P, Xiao Y, Han H, et al. Protein-energy malnutrition and worse outcomes after major cancer surgery: a nationwide analysis. Front Oncol 2023;13:970187. Published 2023 Jan 17.

[5] Sohal DPS, Duong M, Ahmad SA, Gandhi NS, Beg MS, Wang-Gillam A, et al. Efficacy of perioperative chemotherapy for resectable pancreatic adenocarcinoma: a phase 2 randomized clinical trial. JAMA Oncol 2021;7(3):421-7.

[6] Al-Batran SE, Homann N, Pauligk C, Goetze TO, Meiler J, Kasper S, et al. Perioperative chemotherapy with fluorouracil plus leucovorin, oxaliplatin, and docetaxel versus fluorouracil or capecitabine plus cisplatin and epirubicin for locally advanced, resectable gastric or gastro-oesophageal junction adenocarcinoma (FLOT4): a randomised, phase 2/3 trial. Lancet 2019;393(10184):1948-57.

[7] Muscaritoli M, Arends J, Aapro M. From guidelines to clinical practice: a roadmap for oncologists for nutrition therapy for cancer patients. Ther Adv Med Oncol 2019;11:1758835919880084. Published 2019 Nov 13.

[8] Fleurent-Grégoire C, Burgess N, McIsaac DI, Chevalier S, Fiore Jr JF, Carli F, et al. Towards a common definition of surgical prehabilitation: a scoping review of randomised trials. Br J Anaesth 2024;133(2):305-15.

[9] Strijker D, Meijerink WJHJ, van Heusden-Schotalbers LAG, van den Berg MGA, van Asseldonk MJMD, Drager LD, et al. Multimodal prehabilitation in patients undergoing complex colorectal surgery, liver resection, and hyperthermic intraperitoneal chemotherapy (HIPEC): a pilot study on feasibility and potential efficacy. Cancers (Basel) 2023;15(6):1870. Published 2023 Mar 20.

[10] McIsaac DI, Gill M, Boland L, Hutton B, Branje K, Shaw J, et al. Prehabilitation in adult patients undergoing surgery: an umbrella review of systematic reviews. Br J Anaesth 2022;128(2):244-57.

[11] Perry R, Herbert G, Atkinson C, England C, Northstone K, Baos S, et al. Pre-admission interventions (prehabilitation) to improve outcome after major elective surgery: a systematic review and meta-analysis. BMJ Open 2021;11(9):e050806. Published 2021 Sep 30.

[12] Bignami E, Leoni B, Domenichetti T, Panizzi M, Diego LA, Bellini V. ERAS and the challenge of the new technologies. Minerva Anestesiol 2025;91(5): 462-71. https://doi.org/10.23736/S0375-9393.25.18746-4.

[13] Bundred JR, Kamarajah SK, Hammond JS, Wilson CH, Prentis J, Pandanaboyana S. Prehabilitation prior to surgery for pancreatic cancer: a systematic review. Pancreatology 2020;20(6):1243-50.

[14] Molenaar CJL, Minnella EM, Coca-Martinez M, et al. Effect of multimodal prehabilitation on reducing postoperative complications and enhancing functional capacity following colorectal cancer surgery: the PREHAB randomized clinical trial [published correction appears in JAMA surg. 2023 Jun 1;158(6):675. JAMA Surg 2023;158(6):572-81.

[15] Steffens D, Nott F, Koh C, Jiang W, Hirst N, Cole R, et al. Effectiveness of prehabilitation modalities on postoperative outcomes following colorectal cancer surgery: a systematic review of randomised controlled trials. Ann Surg Oncol 2024;31(12):7822-49.

[16] Molenaar CJ, van Rooijen SJ, Fokkenrood HJ, Roumen RM, Janssen L, Slooter GD, et al. Prehabilitation versus no prehabilitation to improve functional capacity, reduce postoperative complications and improve quality of life in colorectal cancer surgery. Cochrane Database Syst Rev 2022;5(5): CD013259. Published 2022 May 19.

[17] An KR, Seijas V, Xu MS, Grüßer L, Humar S, Moreno AA, et al. Does prehabilitation before esophagectomy improve postoperative outcomes? A systematic review and meta-analysis. Dis Esophagus 2024;37(3):doado66.

[18] St-Pierre J, Coca-Martinez M, Drummond K, Minnella E, Ramanakumar AV, Ferri L, et al. Multimodal prehabilitation to enhance functional capacity of patients with esophageal cancer during concurrent neoadjuvant chemotherapies-a randomized feasibility trial. Dis Esophagus 2024;37(12): doae087.

[19] Neuzillet C, Anota A, Foucaut AM, Védie AL, Antoun S, Barnoud D, et al. Nutrition and physical activity: french intergroup clinical practice guidelines for diagnosis, treatment and follow-up (SNFGE, FFCD, GERCOR, UNICANCER, SFCD, SFED, SFRO, ACHBT, AFC, SFP-APA, SFNCM, AFSOS). BMJ Support Palliat Care 2021;11(4):381-95.

[20] Order of March 31, 2025 amending the order of December 22, 2021 relating to the "CAMI Sport and Cancer Program: integration and evaluation of adapted physical activity for therapeutic purposes in the acute phase of oncology patients' care pathway" experiment. Consulted on: https://www.legifrance.gouv.fr/loda/id/JORFTEXT000051515756.

[21] Regional Agency of Health Ile-de-France. Call for proposal: "prehabilitation on surgery". Consulted on: https://www.iledefrance.ars.sante.fr/media/112631/download?inline.

[22] Bojesen RD, Jørgensen LB, Grube C, Skou ST, Johansen C, Dalton SO, et al. Fit for Surgery-feasibility of short-course multimodal individualized prehabilitation in high-risk frail colon cancer patients prior to surgery. Pilot Feasibility Stud 2022 Jan 21;8(1):11.

[23] Groen LC, van Gestel T, Daams F, van den Heuvel B, Taveirne A, Bruns ER, et al. Community-based prehabilitation in older patients and high-risk patients undergoing colorectal cancer surgery. Eur J Surg Oncol 2024 Jan;50(1):107293.

[24] Gordon E, van den Brink M, van der Linden N, Ringwald-Smith K, Gardiner B, Murphy-Alford AJ. Pediatric oncology nutritional practices in high-income countries: a survey from the International Society of Paediatric Oncology (SIOP). Pediatr Blood Cancer 2024 Dec;71(12):e31353. https://doi.org/10.1002/pbc.31353. Epub 2024 Oct 3. PMID: 39363500.

[25] Westergren A, Edfors E, Norberg E, Stubbendorff A, Hedin G, Wetterstrand M, et al. Long-term effects of a computer-based nutritional training program for inpatient hospital care. J Eval Clin Pract 2017;23(4):797-802.

[26] Laporte C, Fortin F, Dupouy J, Darmon D, Pereira B, Authier N, et al. The French ecology of medical care. A nationwide population-based cross sectional study. Fam Pract 2024 Apr 15;41(2):92-8.

[27] Muscaritoli M, Arends J, Bachmann P, Baracos V, Barthelemy N, Bertz H, et al. ESPEN practical guideline: Clinical Nutrition in cancer. Clin Nutr 2021 May;40(5):2898-913.

[28] Demographical report of physiotherapists in 2024 : https://www.ordremrk.fr/wp-content/uploads/2024/11/rapport-de-la-demographie-des-kinesitherapeutes-2024_page_a_page.pdf.

[29] Directory of Adapted Physical Activity instructors: https://www.sfp-apa.fr/annuaire/ (accessed 19 May 2025).

[30] Ijsbrandy C, Hermens RPMG, Boerboom LWM, Gerritsen WR, van Harten WH, Ottevanger PB. Implementing physical activity programs for patients with cancer in current practice: patients' experienced barriers and facilitators. J Cancer Surviv 2019 Oct;13(5):703-12.

[31] Robinson A, Slight RD, Husband AK, Slight SP. Designing the optimal digital health intervention for patients' use before and after elective orthopedic surgery: qualitative Study. J Med Internet Res 2021;23(3):e25885.

[32] Moorthy K, Halliday LJ, Noor N, Peters CJ, Wynter-Blyth V, Urch CE, et al. Feasibility of implementation and the impact of a digital prehabilitation service in patients undergoing treatment for oesophago-gastric cancer. Curr Oncol 2023;30(2):1673-82.

[33] Grimmett C, Heneka N, Chambers S. Psychological interventions prior to cancer surgery: a review of reviews. Curr Anesthesiol Rep 2022;12(1):78-87.

[34] Anghel T, Melanie BL, Costea I, Albai O, Marinca A, Levai CM, et al. Review of psychological interventions in oncology: current trends and future directions. Medicina (Kaunas) 2025;61(2):279. Published 2025 Feb 6.

[35] Grassi L, Caruso R, Riba MB, Lloyd-Williams M, Kissane D, Rodin G, et al., ESMO Guidelines Committee. Electronic address: clinicalguidelinese@smo.org. Anxiety and depression in adult cancer patients: ESMO Clinical Practice Guideline. ESMO Open 2023 Apr;8(1):101155.

[36] Carli F, Bousquet-Dion G, Awasthi R, Elsherbini N, Liberman S, Boutros M, et al. Effect of multimodal prehabilitation vs postoperative rehabilitation on 30-Day postoperative complications for frail patients undergoing resection of colorectal cancer: a randomized clinical trial. JAMA Surg 2020 Mar 1;155(3): 233-42. https://doi.org/10.1001/jamasurg.2019.5474. Erratum in: JAMA Surg. 2020 Mar 1;155(3):269.

[37] Heil TC, Verdaasdonk EGG, Maas HAAM, van Munster BC, Rikkert MGMO, de Wilt JHW, et al. Improved postoperative outcomes after prehabilitation for colorectal cancer surgery in older patients: an emulated target trial. Ann Surg Oncol 2023 Jan;30(1):244-54.

[38] Jensen BT, Baldini G. Future perspectives on prehabilitation interventions in cancer surgery. Semin Oncol Nurs 2022;38(5):151337.

[39] Van Dijck S, de Groef A, Kothari J, Dams L, Haenen V, Roussel N, et al. Barriers and facilitators to physical activity in cancer survivors with pain: a systematic review. Support Care Cancer 2023 Nov 3;31(12):668.

[40] Paulo CM, Ali AA, Schmeusser BN, Midenberg E, Helman TA, Diller ML, et al. Barriers and facilitators to physical activity prehabilitation in patients with kidney cancer. Eur J Oncol Nurs 2023 Aug;65:102333.

[41] Journeya KS, Vardy JL, O'Callaghan CJ, Gill S, Friedenreich CM, Wong RKS, et al. Structured exercise after adjuvant chemotherapy for Colon cancer. N Engl J 2025 Jul 3;393(1):13-25.