Potential of prehabilitation in hepatocellular carcinoma: a narrative review of available evidence

Hepatocellular carcinoma (HCC) is a leading cause of cancer deaths. Patients with HCC are often significantly affected by sarcopenia and cancer cachexia. Prehabilitation, a multimodal pre-operative exercise and nutritional intervention, has been implemented with varying degrees of success in enhancing outcomes among other gastrointestinal (GI) malignancies. However, remarkably little is described how prehabilitation may be beneficial in improving outcomes among those with HCC. Thus, a narrative review is warranted to examine previously developed prehabilitation models and determine how interventions affected sarcopenia as a prognosticator in HCC and other GI malignancies. This article seeks to offer guidance on how prehabilitation may be implemented for those with HCC based on available data published on other GI malignancies and serve as a call for additional research specific to the value of prehabilitation in HCC.

Independent key-term searches were conducted by all authors of various databases (PubMed, ScienceDirect, Google Scholar) for relevant articles examining role, safety, and efficacy of prehabilitation in HCC and/or other GI malignancies. Relevant articles pertaining to sarcopenia, Enhanced Recovery After Surgery (ERAS) guidelines, and prehabilitation models were collected and analyzed. Review authors held multiple meetings to ensure coherence of narrative review process and final product.

Patients with HCC often suffer from sarcopenia and/or cachexia, which are known to be associated with poorer outcomes. The benefits of a prehab program in patients with HCC are not well described in current literature, but in referencing the benefits of prehab programs in other GI malignancies and ERAS protocols on patients undergoing liver resection and liver transplant, there is potential for a similar multimodal program to yield similar benefits and healthcare cost-savings. However, further investigation is needed as HCC has multiple etiologies and affects a wide variety of people.

A multimodal prehabilitation program emphasizing regular aerobic and resistance exercise, nutritional optimization, lifestyle modifications, mental health and wellness practices, with a nurse and rehabilitation physician's oversight may improve outcomes in patients undergoing treatment for HCC. However further investigation into specific exercise models, optimal nutrition regimens and benefit/cost analysis of a multimodal prehabilitation program within this complex patient population is needed.