Comment on “Prehabilitation Interventions in Patients Undergoing Colorectal Cancer Surgery: A Systematic Review and Meta‐Analysis”

We read with great interest the article by Liao et al. titled “Prehabilitation Interventions in Patients Undergoing Colorectal Cancer Surgery: A Systematic Review and Meta-Analysis” [1]. This work makes an important contribution by evaluating how multimodal prehabilitation can reduce hospital stays, decrease complications, and promote bowel recovery in older adults undergoing colorectal cancer surgery. Multimodal prehabilitation can aim to mitigate the heightened surgical risk for those older adults with frailty, malnutrition, and multimorbidity. In this regard, the study offers valuable insights for both clinical decision-making and the development of comprehensive perioperative care programs. We applaud the authors for their thorough analysis and believe that several aspects of their findings merit further discussion. Below, we highlight a few key considerations that could enhance both the interpretability of the current findings and the design of future research. First, a central issue in interpreting the conclusions of this meta-analysis lies in the substantial heterogeneity observed across the included studies. The authors report that randomized controlled trials (RCTs) tended to show smaller reductions in hospital length of stay compared with non-RCTs. This is a crucial observation because it highlights the risk that methodological differences may partly explain the variability in reported outcomes. Non-RCTs often provide valuable real-world data, but their inherent susceptibility to confounding and bias must be acknowledged. For example, patients selected for prehabilitation in non-RCTs may have had higher baseline motivation or greater access to health resources, factors which could artificially enhance apparent benefits. Moreover, several RCTs included in the review lacked complete blinding or adequate allocation concealment, both of which could influence results. To better establish the true clinical effectiveness of prehabilitation, future research should prioritize rigorous trial design [2], particularly in terms of randomization procedures, concealment strategies, and standardized reporting of outcomes. By improving methodological consistency, subsequent studies will allow for more reliable comparisons and a clearer understanding of how prehabilitation influences recovery [3]. Another important consideration is the length of prehabilitation programs. The authors found no significant difference between interventions lasting less than 4 weeks [4] and those lasting longer, suggesting that shorter programs may be equally effective. It is possible that the absence of observed differences reflects limited sample sizes or insufficiently sensitive outcome measures, rather than a true equivalence of short and long interventions. In addition, the clinical relevance of program length may vary according to patient characteristics. Frail older adults or those with multiple comorbidities, for instance, might require longer periods of targeted intervention to achieve meaningful improvements in physiological reserve [5]. The question of duration is particularly relevant in surgical oncology, where balancing the benefits of prehabilitation against the risks of delaying cancer surgery is critical [6]. Future trials should not only compare short versus long programs but also consider individualized approaches, tailoring intervention duration to baseline functional status, nutritional needs, and psychosocial factors [7, 8]. Such stratified strategies could maximize the benefits of prehabilitation while minimizing unnecessary treatment delays. A third area deserving greater emphasis is psychological support. Liao et al. identify exercise and nutritional optimization as core elements of multimodal prehabilitation, but the role of psychological interventions is less fully explored. This relative underrepresentation is notable given the well-established links between psychological well-being and postoperative recovery [9]. Anxiety, depression, and reduced resilience can negatively affect adherence to exercise or dietary regimens, increase perceived pain, and prolong recovery trajectories. Several of the included studies incorporated components such as counseling, relaxation training, or mindfulness, yet their specific contributions remain difficult to isolate from the broader multimodal programs [10]. Moving forward, future research should delineate independent and combined effects of psychological, physical, and nutritional interventions. Scalable strategies like cognitive behavioral therapy show promise. Structured caregiver involvement—through education, communication, and peer support—may enhance adherence, coping, continuity of care, and multimodal prehabilitation effectiveness on surgical outcomes. In summary, the systematic review and meta-analysis by Liao et al. [1]. represents a valuable contribution to the literature on perioperative care in colorectal cancer surgery. Their findings support the promise of multimodal prehabilitation, particularly in reducing complications and promoting faster recovery in older patients. At the same time, our commentary highlights areas where further work is needed: addressing heterogeneity arising from study design, clarifying the optimal duration of interventions, and expanding the evidence base for psychological support. Future research that builds upon these points will help strengthen the evidence base and guide clinicians in implementing prehabilitation in a way that is both effective and patient-centered. We thank the authors for their important contribution and look forward to seeing continued advances in this field. Mengjiao Guo: writing – original draft. Dongfeng Pan: supervision, writing – review and editing. The authors have nothing to report. The authors declare no conflicts of interest. This publication is linked to a related Letter to the Editor by Liao and Tung. To view this article, visit https://doi.org/10.1111/jgs.70199.