Prehabilitation in Adult Cancer Patients Undergoing Chemotherapy or Radiotherapy: A Scoping Review

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

This is a scoping review examining the prehabilitation literature related to cancer patients treated nonsurgically. As the great majority of the cancer prehabilitation literature to date has been conducted in surgical patients, the authors’ focus on nonsurgically treated patients is a logical and important next step.  The paper is generally well written.

Title: Fine

Simple Summary: Fine

Abstract: In the Conclusions section, it is unclear what is meant by “diverse” populations (line 50). Does it relate to cancer types, or to sociodemographic factors such as race, ethnicity or economic factors? Typically, in contemporary parlance, “diversity” often relates to the sociodemographic spectrum, especially in the context of addressing disparities, so the reader might assume that intention, but I’m unsure that that’s the case here. Diversity is not much discussed in the body of the paper, except as relates to the fact that mainly just a few types of cancer inform this literature.

Introduction: Fine

Materials and Methods:

The absence of bias assessment (lines 173-174) limits the authors’ ability to be certain about the trustworthiness of the information they obtain, especially their data on whether outcomes of interventions are beneficial or not. However, while non-ideal, this being a scoping review and not a systematic review, it is within bounds of acceptability not to have the bias assessment.

Results:

It is unclear whether lines 232-234 belong in the draft, as it reads more like directions for the authors to follow.

Lines 252-254 are unclear to me. What is meant by “unique interventions”? Were there some studies that reported the same exact datasets? And the line “3 interventions encompassing 8 studies due to repeated interventions”, is confusing as to its meaning and needs to be expressed more clearly.

With regard to intervention characteristics, exercise is noted to be the most common intervention (lines 253-254). Exercise is considered a “unimodal” intervention but in fact exercise can be of many types, ie truly unimodal such as aerobic-only or strengthening-only, versus combined forms of exercise. Consideration of these nuances of combined versus single forms of exercise seems to be beyond the scope of this study and should be stated somewhere. Basically, there should be an overt statement that for purposes of this analysis, even combined forms of exercise are considered as “unimodal”. Also beyond the scope, and should be noted as such, are other details about the exercise interventions, such as intensity (though it is noted that most studies are in light to moderate range), frequency, adherence, supervision, etc. These concepts are mentioned here and there, and to some extent noted in the tables, but not captured in any sort of information synthesis.

Also, the authors note that they collected data on the nation of origin of the studies, but that data is not presented in the manuscript. It would be interesting to the reader to know this information, as it might relate to the generalizability of the information. For example, if most of the studies are from Europe, and feasibility is noted to be good, does that mean that feasibility is truly good in other parts of the world where health care systems may be very different?

 

Discussion:

Section 4.1 Exercise Interventions (lines 282-293). It would be more effective, here and elsewhere throughout the Discussion section, to better quantitate the information. For example, line 286 states “some studies also incorporated strength or resistance training”. It would be better to state how many studies incorporated this combined exercise approach, rather than the more nebulous “some”. And in lines 285-286 it is stated that walking programs were the most common; how many studies employed walking programs? While it is true that this information is within the tables, the paper would benefit from the aggregation of the information being summarized with better precision. Similarly, many of the programs used home-based exercise, and it is noted that many interventions incorporated technology; it would be helpful to have some more exact numbers (of studies) around these factors as well.

Section 4.2. Line 329. The term “microecological supplementation” should be explained.

Section 4.3.  As in Section 4.1, this section would benefit from improved quantitation in the information synthesis.

Section 4.5. Treatment Types.

Lines 392-401. How many studies had statistical assessment which examined prehabilitation outcomes separately, and not combined prehabilitation/rehabilitation? Was it really just one study out of the 39?

Two additional sections are also labeled as 4.5 (lines 413 and 471) Is this correct, or should this be 4.6 and 4.7?

Author Response

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Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

The topic is exceptionally interesting. The structure of the abstract is appropriate for a review article. The introduction provides sufficient facts to understand the importance of the topic. The objective of the study is clear. The methodology is described in detail. The results are well presented. The conclusion is in agreement with the objective and the results of the study. Relevant references were used in the manuscript. The discussion also addresses the limitations of the study.

 

Author Response

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Author Response File: Author Response.pdf

Reviewer 3 Report

Comments and Suggestions for Authors

General Reviewer Comment

The authors present a timely and well-structured scoping review addressing prehabilitation in adult cancer patients undergoing non-surgical treatments, namely chemotherapy and/or radiotherapy. This is a comparatively underexplored area when contrasted with surgical prehabilitation, and the manuscript therefore addresses a relevant and clinically meaningful gap in supportive oncology and cancer rehabilitation research.

The stated objective (to map existing evidence, describe intervention types, feasibility and reported outcomes, and identify research gaps) is clearly articulated and well aligned with a scoping review design. Key overall strengths include the use of established methodological frameworks (Arksey and O’Malley; Joanna Briggs Institute), prior protocol registration (OSF), involvement of an information specialist, a comprehensive multi-database search strategy, and a detailed descriptive synthesis highlighting the heterogeneity of populations, interventions and outcomes.

 

Abstract

The abstract is well structured and conforms to the standard format of Cancers. It clearly summarises the study aim, methods, volume of literature identified and main conclusions, allowing rapid understanding of the scope of the review. However, several points require refinement to improve methodological precision and conceptual alignment:

• The use of terms such as effectiveness or beneficial effects may be interpreted as an assessment of efficacy, whereas the study design is descriptive and exploratory. The language should be revised to emphasise that these are reported outcomes within the literature.
• It would be advisable to explicitly acknowledge, even briefly, that no formal risk-of-bias or quality appraisal was conducted, to appropriately contextualise the findings from the outset.

 

Introduction

The introduction provides a clear and well-referenced rationale, outlining the functional, physical and psychosocial burden of non-surgical cancer treatments and the potential role of prehabilitation. The contrast between robust evidence in surgical settings and the limited data in chemotherapy and radiotherapy contexts is well articulated. Nevertheless, some conceptual refinements are warranted:

• Statements regarding potential clinical benefits should be phrased more cautiously, explicitly reflecting the exploratory nature of the available evidence.
• The rationale for selecting a scoping review methodology could be strengthened by more explicitly highlighting the heterogeneity and conceptual fragmentation of the existing literature.

 

Methods

The methods section is transparent and robust. Research questions, eligibility criteria, search strategy, independent screening and data extraction processes are clearly described. Adherence to PRISMA-ScR guidance and prior protocol registration enhance methodological rigour and reproducibility. However, several methodological clarifications are required:

• The manuscript states that reporting followed PRISMA-P, which is intended for protocols rather than final reports. This should be corrected to avoid methodological confusion.
• While the exclusion of grey literature is clearly stated, a more explicit justification would be appropriate given the emerging nature of this research field.
• The operational definition of prehabilitation is intentionally broad and includes interventions extending into and beyond treatment. While acceptable for a scoping review, the conceptual overlap with early rehabilitation should be more explicitly acknowledged.
• The absence of formal risk-of-bias assessment is appropriate for the stated objectives, but its implications for interpretation should be consistently emphasised throughout the manuscript.

 

Results

Results are comprehensively and systematically presented. The detailed tables describing study designs, populations, interventions and outcomes represent a major strength of the manuscript. Nevertheless, greater interpretative caution is required:

• Reporting the proportion of studies with “positive” findings may be read as confirmatory. It should be consistently clarified that these are reported findings, without weighting by methodological quality or effect size.
• The substantial heterogeneity of study designs (small RCTs, retrospective cohorts, implementation reports) should be more explicitly foregrounded when summarising results.
• Outcomes such as survival, recurrence or cost-effectiveness require particularly cautious interpretation due to the inherent risk of bias and confounding in several included designs.

 

Discussion

The discussion appropriately situates the findings within the broader literature, particularly in relation to surgical prehabilitation, and identifies important trends such as the predominance of exercise-based interventions and the underrepresentation of older or diverse populations. However, the discussion would benefit from further refinement:

• Some clinical inferences exceed what can be supported by a scoping review without quality appraisal.
• The implications of methodological heterogeneity for comparability and generalisability should be more explicitly addressed.
• Language should be consistently aligned with a descriptive, hypothesis-generating perspective, avoiding causal or confirmatory phrasing.

 

Study Limitations

Key limitations are clearly acknowledged, including heterogeneity, lack of long-term data, absence of formal risk-of-bias assessment and potential publication bias due to exclusion of grey literature. Nonetheless:

• Stronger cross-referencing of these limitations in the Abstract and Conclusions would improve internal coherence.

 

Conclusions

The conclusions accurately summarise the scope of the available evidence and highlight priorities for future research. However, they should be framed more conservatively:

• Emphasis should be placed on the role of these findings in mapping evidence and generating hypotheses, rather than directly informing clinical practice.

 

References

The reference list is comprehensive and appropriate. Points for revision:

• Ensure consistency with MDPI formatting and verify that all key statements are adequately referenced.

 

Tables and Figures

The tables are detailed and represent a major asset of the manuscript. Areas for improvement:

• Some tables are overly dense and could benefit from improved synthesis or visual structuring.
• Figures are largely descriptive and could be optimised to better highlight key messages.

Author Response

Please see the attachment.

Author Response File: Author Response.pdf

Reviewer 4 Report

Comments and Suggestions for Authors

Dear colleagues

I have few concerns to address.

• The abstract mentions 23 were unimodal and 16 were multimodal but later in page 20 exercise was the most common intervention appearing in 30 out of 34 (88%) programs with 16 being unimodal. There is come confusing information here. In my understanding In the abstract and results unimodal (23) + multimodal (16) = 39 but the text states 34 unique interventions.
• Another issue identified is author reported that Studies are classified into neoadjuvant adjuvant definitive others. but some overlap. The results note some studies were included in multiple treatment categories please provide a table or breakdown for transparency.
• No grey literature included pls include paragraph in discussion about this.
• No quality appraisal – I prefer to do it even for scoping review. If not make it a limitation.

 

 

 

 

Author Response

Please see the attachment.

Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

My previous comments have been substantially addressed. Nice work.

Author Response

Thank you for the insightful feedback. No revisions were recommended.

Reviewer 3 Report

Comments and Suggestions for Authors

Dear authors,

 

I would like to congratulate you on the substantial improvements made to the manuscript in response to the previous review. The revised version demonstrates a clear effort to align the interpretative language with the scoping review methodology, to improve methodological transparency, and to contextualise the findings more appropriately within the heterogeneity and exploratory nature of the available evidence. Overall, the manuscript is more coherent, methodologically explicit, and better positioned within the standards expected for a scoping review in Cancers.

 

Abstract

The abstract is well structured and now clearly acknowledges the absence of formal risk-of-bias or quality appraisal, which improves methodological transparency from the outset. The scope, volume of evidence, and descriptive intent of the review are appropriately conveyed. Points to consider:

• While clarified as reported findings, the continued use of aggregated proportions of studies reporting “beneficial” outcomes may still be interpreted as confirmatory. Further softening of this wording could reinforce the descriptive nature of the review.

Introduction

The rationale for focusing on non-surgical prehabilitation is clearly articulated, and the contrast with the surgical prehabilitation literature is well contextualised. The justification for using a scoping review methodology is now explicit and appropriate, particularly in relation to the heterogeneity and conceptual fragmentation of the field.

No major issues remain in this section.

Methods

Methodological reporting is clear, transparent, and well aligned with established scoping review frameworks. The correction to PRISMA-ScR reporting, explicit justification for excluding grey literature, and clear statement regarding the absence of risk-of-bias assessment are appropriate and strengthen methodological rigor.

No further changes are required in this section.

Results

The results are comprehensively presented, and the added clarification that outcomes are reported without weighting by study quality or effect size is appropriate. The description of study designs, populations, and interventions effectively highlights the diversity of the evidence base. Points to consider:

• The repeated emphasis on the proportion of studies reporting positive outcomes, even when appropriately caveated, may still invite overinterpretation. Further de-emphasising these aggregated metrics could enhance interpretative caution.

Discussion

The discussion is more balanced and now better reflects a descriptive, hypothesis-generating perspective. The implications of heterogeneity and methodological limitations are more clearly acknowledged, and causal or confirmatory language has been substantially reduced. Points to consider:

• Minor refinements could further strengthen alignment with the scoping review purpose, particularly when discussing potential clinical implications.

Study Limitations

Key limitations, including heterogeneity, absence of quality appraisal, and limited long-term data, are clearly and appropriately acknowledged. Points to consider:

• Explicit cross-referencing of these limitations in the abstract and conclusions could further improve internal consistency.

Conclusions

The conclusions accurately summarise the mapped evidence and clearly identify priorities for future research. Points to consider:

• Although more cautious than in the original version, some statements may still be read as indirectly informing clinical implementation. Framing the conclusions more explicitly around evidence mapping and hypothesis generation would fully align them with the scoping review methodology.

Author Response

Please see the attachment.

Author Response File: Author Response.pdf