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The programme behind the best colorectal result was four weeks long, supervised in hospital, and had four parts: high-intensity exercise three times a week, a nutritional intervention, psychological support, and smoking cessation where it applied. Supervision is the ingredient the trials keep separating out, and the window is what the pathway leaves.
The four-element model is what the trials delivered, not a theory written afterwards. The PREHAB trial describes its own intervention in one sentence: "The 4-week in-hospital supervised multimodal prehabilitation program consisted of a high-intensity exercise program 3 times per week, a nutritional intervention, psychological support, and a smoking cessation program when needed." Alcohol reduction and correction of anaemia are usually listed as a fifth and sixth element in national guidance, and the programme in the corpus record `prehabilitation` lists anaemia correction among them.
Exercise. The question of what kind has been examined directly. A comparative review of eight studies of short programmes under six weeks found that three of four studies of high-intensity interval training produced a statistically significant improvement in peak oxygen uptake beyond the 4.9 per cent coefficient of variation of the measurement, while neither of the two studies of moderate-intensity continuous training did. The review is explicit that the exercise descriptions were too inconsistent to translate into a recommendation, which is a fair warning about reading a prescription out of this literature.
Supervised or at home. A 2026 network meta-analysis of nine randomised trials in gastrointestinal cancer surgery found exercise prehabilitation improved postoperative functional capacity overall by 26.10 metres on the six-minute walk (4.59 to 47.62); split by setting, facility-based programmes retained significance (24.11 metres, 2.01 to 46.22) and home-based programmes did not (32.12 metres, minus 1.70 to 65.93). The point estimate for home-based programmes was larger and the confidence interval crossed zero, so this is a question of precision rather than a demonstration that home programmes do not work. It matters because almost every health system that scales prehabilitation scales the home version.
Nutrition separately. A 2026 systematic review and meta-analysis of 23 randomised trials and 2,182 participants across surgical specialties found exercise or nutrition prehabilitation reduced complications (odds ratio 0.52, 0.35 to 0.78) and length of stay (0.44 days). Comparing the components, nutrition alone shortened stay more than exercise alone (1.09 days against 0.20 days, p equals 0.01), while exercise alone improved quality of life and the nutrition-only trials did not report it.
How long. Four weeks is the commonest protocol and two weeks appears to be the floor: the lung meta-analysis found greater improvement in six-minute walk where the intervention lasted more than two weeks. The widely quoted window of four to eight weeks is a description of what a surgical pathway allows rather than a tested optimum, and no trial has randomised duration.
Who delivers it in the United Kingdom. Macmillan Cancer Support publishes principles and guidance for prehabilitation, which its own page describes as developed with the Royal College of Anaesthetists and the National Institute for Health Research Cancer and Nutrition Collaboration. What is not published, and so is not stated here, is how many patients facing cancer surgery in the United Kingdom are actually enrolled in a programme.
What comes back, and when: fitness rises over the weeks of the programme and is measurable before the operation in almost every trial. Whether it is still there months later depends on whether anything continued after surgery, and in the trials that looked, it usually was not.
The four elements attack four different limits on surgical recovery: aerobic capacity and muscle mass limit the physiological response to the insult, protein and micronutrient status limit wound healing and immune function, anxiety and low mood limit participation in everything else, and smoking and alcohol raise pulmonary and wound complications directly. Supervision works on adherence, which is the variable that separates the positive trials from the null ones.
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