Feasibility of Implementation and the Impact of a Digital Prehabilitation Service in Patients Undergoing Treatment for Oesophago-Gastric Cancer
, Laura J. Halliday 1, Nigel Noor 1, Christopher J Peters 1, Venetia Wynter-Blyth 3 and Catherine E Urch 2
Round 1
Reviewer 1 Report
The importance of prehabilitation is extremely highlighted. The COVID era forced all health services to move forward digital solutions. Authors proved equally good effect of digital and in-person method. Congratulation them to find a proper balance in digital mood. Meanwhile I believe nothing can substitute the in-person meetings, but in hazardous cases that is also a possibility that is much more than omitting. In the near future authors have to find the correct place of digital sources.
I found many unfinished text editing according to citation. Following correction I support and accept the manuscript.
Author Response
Reviewer 1
Comment: The importance of prehabilitation is extremely highlighted. The COVID era forced all health services to move forward digital solutions. Authors proved equally good effect of digital and in-person method. Congratulation them to find a proper balance in digital mood. Meanwhile I believe nothing can substitute the in-person meetings, but in hazardous cases that is also a possibility that is much more than omitting. In the near future authors have to find the correct place of digital sources.
Response: Thank you for your view on prehabilitation and the need for in-person support. We agree that just digital alone will not address the needs of patients. As we have stated in the Discussion, cancer patients need professional support. This support can be provided digitally or in-person depending on the risks and the choice of patients.
Comment: I found many unfinished text editing according to citation. Following correction I support and accept the manuscript.
Response: This has been amended now. Thank you for highlighting this.
Reviewer 2 Report
The authors of this article have evaluated a critical aspect of the best outcome of the treatment of oesophageal-gastric cancer. Patients are often poorly "educated" or followed up on their well-being before surgery, making them more vulnerable to post-operative ailments. The study has a high interest in this context. However, some points should be clarified:
- The pre-habilitation program is carried out during the pandemic period. As the authors state in the study's limitations, the choice of the digital program could be somewhat constrained by the impossibility of an alternative. Would the authors have expected the same response rate in a non-pandemic period?
- If the patient chooses what kind of treatment to have, do the authors think the results may have been selection biased?
- How was the minimum sample size calculated in the two groups?
- The flow-chart: there is the impression that the first three lines of the diagram need to be reorganised, and the patient journey flow does not seem very clear
- On page 3, line 120, spell out what "METs" are and why it is subsequently referred to as METS. How were the scores 3.5 for moderate activity and 6 for the intense activity identified in calculating the quantification of time spent per week?
- Table one shows an additional "P" for the p-value between "Cancer" and program groups. Age is expressed as an average; what is the standard deviation of the data? The same for "Hospital stay" expressed as median: what is the I-III quartile range? It is unclear how the stage between the two programs is defined.
- The authors could consider showing the results of the "Physical activity, fitness and psychological well-being" section in a table to show at first sight the significant improvement. It could be valuable.
- How did the authors explain the different median times of the program? What influences the longer 2-week duration of the digital program?
- In the text, there are some formatting typos for references.
Author Response
The authors of this article have evaluated a critical aspect of the best outcome of the treatment of oesophageal-gastric cancer. Patients are often poorly "educated" or followed up on their well-being before surgery, making them more vulnerable to post-operative ailments. The study has a high interest in this context. However, some points should be clarified:
Comment: The pre-habilitation program is carried out during the pandemic period. As the authors state in the study's limitations, the choice of the digital program could be somewhat constrained by the impossibility of an alternative. Would the authors have expected the same response rate in a non-pandemic period?
Response: It is difficult to say but there is evidence that the pandemic resulted in people avoiding travel into hospital. Including people with cancer.
Comment: If the patient chooses what kind of treatment to have, do the authors think the results may have been selection biased?
Response: The patients did get an opportunity to exercise choice at the time of the recruitment. More people chose the digital programme as compared to the in-person programme. This could have been a reflection of the increased acceptance of digital during the pandemic. This has been covered in the first paragraph of the Discussion.
Comment: How was the minimum sample size calculated in the two groups?
Response: As this was a prospective observational cohort feasibility study there wasn’t a formal sample size calculation undertaken.
Comment: The flow-chart: there is the impression that the first three lines of the diagram need to be reorganised, and the patient journey flow does not seem very clear
Response: We have made the necessary changes and we hope this makes it clearer
Comment: On page 3, line 120, spell out what "METs" are and why it is subsequently referred to as METS. How were the scores 3.5 for moderate activity and 6 for the intense activity identified in calculating the quantification of time spent per week?
Response: Thank you for detecting this typo. It should be METs. Ref 10 supports the use of the multipliers for moderate activity (3.5) and intense activity (6). This results in a number of METs minutes per week. We have made the appropriate changes throughout the manuscript.
Comment: Table one shows an additional "P" for the p-value between "Cancer" and program groups. Age is expressed as an average; what is the standard deviation of the data? The same for "Hospital stay" expressed as median: what is the I-III quartile range? It is unclear how the stage between the two programs is defined.
Response: We have made the necessary changes and included the additional data. We used the 8th edition of UICC for the clinical staging of the cancers as Stage I to Stage IV. We have added this in the Table footnote
Comment: The authors could consider showing the results of the "Physical activity, fitness and psychological well-being" section in a table to show at first sight the significant improvement. It could be valuable.
Response: We have added a Table 1.
Comment: How did the authors explain the different median times of the program? What influences the longer 2-week duration of the digital program?
Response: The difference in the median times were purely a reflection of the shorter time on the programme in the in-person programme. In an intention to treat model, we included all patients who started prehabilitation on either pathway, for estimation of the median time on the programme. There were a greater number of people who had disease progression on the in-person pathway. When disease progression is detected and patients become non-surgical they come off the prehabilitation programme either to undergo further investigations, alternate treatments or hospital admissions. We have added a line on this in the Limitations.
Comment: In the text, there are some formatting typos for references.
Response: This has been amended. Thank you for highlighting this
Reviewer 3 Report
In this study the Authors demonstrated the feasibility of delivering a fully virtual cancer prehabilitation service. More interestingly, digital solutions allowed to ‘democratise’ behaviour change interventions and address the ‘post-code’ lottery that can exist in the delivery of patient support services.
Although well done and well written, there is the needing to focus on the several limits of the study highlighting the necessity of caregiver to complete the programm.
Author Response
service. More interestingly, digital solutions allowed to ‘democratise’ behaviour change interventions and address the ‘post-code’ lottery that can exist in the delivery of patient support services.
Although well done and well written, there is the needing to focus on the several limits of the study highlighting the necessity of caregiver to complete the programme.
Thank you for highlighting this extremely important point. Even though the programmes are digitally delivered, the caregiver (coach) supported patients throughout the programme. We have highlighted this in paragraph 2 of the Discussion (References 21 and 22).
