Prehabilitation and Breast Cancer: Preparing Body and Mind Before Treatment
Protecting shoulder function, fitness and energy through surgery and chemotherapy
Breast cancer treatment is rarely a single event. Surgery may be preceded by months of neoadjuvant chemotherapy and followed by radiotherapy or endocrine therapy, a long stretch during which fitness, arm function and energy tend to decline. Prehabilitation uses the period from diagnosis onwards to build reserve through exercise, nutrition and psychological support, so that decline is smaller and recovery is quicker.
What the research shows
• Arm and shoulder function is protected. In the PREOptimize randomised trial, women who exercised during neoadjuvant therapy maintained arm function while the usual-care group deteriorated before surgery; one month after surgery, significantly fewer prehabilitation patients had lost more than 10° of shoulder flexion (11 vs 20, p=0.048).¹
• Fitness improves by a clinically meaningful margin. The same trial recorded a 53-metre advantage in six-minute walk distance before surgery, an advantage still present one and three months afterwards.¹ A separate randomised feasibility trial in 72 women reported a between group difference of 49 metres after chemotherapy.²
• Fatigue falls and activity rises. PREOptimize showed significantly lower cancer-related fatigue and higher moderate and vigorous activity levels in the prehabilitation group, with symptom burden worsening in controls before surgery. Adherence was 92%, with no adverse events.¹
• Preoperative exercise aids upper-limb recovery. A systematic review of preoperative exercise before breast surgery found benefits for shoulder range of motion and functional recovery, and reduced postoperative pain without increasing seroma risk.³
• Mood benefits are consistent. Meta-analysis across cancer types shows prehabilitation significantly reduces anxiety and depression scores as well as improving functional capacity.⁴ Evidence on surgical complications in breast cancer specifically remains limited and is an active research question.⁵
Why a digital programme (digital prehab) fits this pathway well
Women on neoadjuvant chemotherapy are already making frequent hospital trips, often while immunosuppressed and fatigued. Asking them to attend yet another appointment for a gym class is a genuine barrier, and one of the main reasons hospital-based prehabilitation struggles with compliance.⁶ Remote, technology-supported home based prehabilitation has been shown to be feasible and highly acceptable, and lets people train at home at a time of day that suits their treatment cycle.⁷
Personalisation matters especially here. Capacity fluctuates week to week with chemotherapy cycles and blood counts, and the PREOptimize authors themselves noted that linear progression was not possible for every patient and called for interventions tailored using individual physiological inputs.¹ A digital platform can recalibrate intensity continuously in a way a fixed weekly class cannot. The evidence is equally clear, though, that software alone does not sustain engagement: adherence improves substantially when a trusted human coach provides feedback and supportive accountability.⁸ Services designed around this “human-in-the-loop” principle, such as QuestPrehab, which delivers personalised digital prehabilitation remotely within NHS pathways, or through self referrals, seek to pair the flexibility of digital delivery with genuine human contact.
Sources
1. Casanovas-Álvarez A et al. PREOptimize: exercise and educational prehabilitation in breast cancer receiving neoadjuvant chemotherapy — an RCT. Phys Ther 2024;104:pzae151. https://doi.org/10.1093/ptj/pzae151
2. Brahmbhatt P et al. A feasibility randomized controlled trial of prehabilitation during neoadjuvant chemotherapy for women with breast cancer. Ann Surg Oncol 2024. https://doi.org/10.1245/s10434-023-14851-z
3. Yang A, Sokolof J, Gulati A. The effect of preoperative exercise on upper extremity recovery following breast cancer surgery: a systematic review. Int J Rehabil Res 2018;41:189–196. https://doi.org/10.1097/MRR.0000000000000288
4. Efficacy of prehabilitation in cancer patients: an RCTs systematic review with meta-analysis. BMC Cancer 2024;24:1302. https://doi.org/10.1186/s12885-024-13023-w
5. Role of exercise prehabilitation on surgical prognosis in people with breast cancer: a systematic review. medRxiv 2025 (preprint). https://doi.org/10.1101/2025.10.29.25338895
6. Kleve G et al. Digital home-based multimodal prehabilitation (dHOPE): trial protocol. Front Digit Health 2025;7:1609678. https://doi.org/10.3389/fdgth.2025.1609678
7. Blumenau Pedersen M et al. Digital technologies to support home-based prehabilitation: a systematic review. The Surgeon 2023;21:e305–e315. https://doi.org/10.1016/j.surge.2023.05.006
8. Application of the supportive accountability model in digital health interventions: scoping review. J Med Internet Res 2025;27:e72639. https://doi.org/10.2196/72639