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

We sincerely appreciate the valuable and constructive comments regarding our recent article, “Prehabilitation Interventions in Patients Undergoing Colorectal Cancer Surgery: A Systematic Review and Meta-Analysis.” [1]. We are pleased that the significance of multimodal prehabilitation in improving outcomes for older adults undergoing colorectal cancer surgery has been recognized, and we thank the authors of the letter for highlighting several important issues that warrant further discussion. First, we are grateful for the reviewer's insightful observations and comments regarding the methodological heterogeneity in our study. We agree that the findings on the effects of multimodal prehabilitation on hospital length of stay indeed exhibit heterogeneity. In our analysis, we performed moderator analyses and meta-regression to explore potential sources of this heterogeneity [2]. The moderator analyses compared study design (randomized controlled trials [RCTs] vs. non-RCTs), exercise modality (supervised vs. unsupervised), and intervention duration (< 4 weeks vs. ≥ 4 weeks), while the meta-regression examined the influence of continuous variables (e.g., the proportion of male participants) on effect sizes. These approaches helped identify and partially explain the observed heterogeneity. With respect to study design, although non-RCT studies appeared to show a greater reduction in hospital length of stay compared with RCTs, the overall meta-analysis still demonstrated that both types of studies consistently supported prehabilitation as providing superior clinical benefits compared with control groups. However, these findings should be interpreted with caution due to variations in the quality of the included studies. We agree that future research should prioritize high-quality RCTs to minimize methodological bias and enhance the comparability and reliability of evidence. Second, we fully agree that achieving an appropriate balance between enhancing preoperative functional capacity and avoiding unnecessary delays in cancer surgery is of critical clinical importance for patients undergoing surgical oncology procedures. The aim of our study was also to examine the impact of prehabilitation program duration and content composition on postoperative clinical outcomes in patients undergoing colorectal cancer surgery, with the goal of providing evidence to inform optimal program design and guide clinical implementation. Regarding the duration of intervention, our moderator analysis showed no statistically significant difference in postoperative length of stay between programs lasting less than 4 weeks and those lasting 4 weeks or longer (−7.17 vs. −2.57 days, p = 0.50), which may be related to the sample size imbalance (184 vs. 2019) and limited statistical power. This result should be interpreted with caution and does not indicate true equivalence between the two groups. Notably, emerging prospective studies on short-term prehabilitation have demonstrated improved patient compliance and a lower incidence of postoperative ileus [3, 4]. Future studies and meta-analyses will be essential to confirm the effectiveness of short-term prehabilitation and to guide the determination of the optimal intervention duration. Furthermore, in terms of intervention components, we observed that prehabilitation programs incorporating supervised exercise were significantly associated with a shorter postoperative length of stay compared with unsupervised exercise programs, suggesting that structured and supervised exercise training may provide additional clinical benefits for postoperative recovery. Third, our study did not conduct an in-depth evaluation of psychological support strategies. Although psychological interventions are considered an integral component of multimodal prehabilitation, methodological heterogeneity and variations in outcome measures across the included studies limited our ability to assess their independent effects. The psychological support strategies identified primarily included psychological counseling and training patients to manage surgical anxiety and practice relaxation techniques. Moderator analysis indicated that psychological support did not show a significant effect on reducing hospital length of stay, and two studies also reported no significant differences in Hospital Anxiety and Depression Scale (HADS) scores [5, 6]. These findings may have been influenced by other confounding factors. Previously reported fixed risk factors—such as gender, age, cancer type, disease stage, pain, social support, and financial burden—may contribute to psychosocial distress [7, 8] and limit the effectiveness of these interventions in improving clinical outcomes. Although current evidence is limited, the clinical value of psychological support should not be underestimated. Future research should identify key factors influencing psychological distress and develop targeted strategies to enhance multimodal prehabilitation. Finally, multimodal prehabilitation, which integrates exercise, nutrition, and psychological care, can enhance patients' physiological reserve, reduce postoperative complications, and accelerate recovery. Its effectiveness depends on multidisciplinary collaboration and individualized care planning. As patient-reported outcome measures (PROMs) have become increasingly important in evaluating patient-centered outcomes, incorporating PROMs into perioperative care can further optimize strategies and strengthen patient-centered care. Future research should explore how prehabilitation can be integrated into clinical pathways and guidelines to maximize its benefits and further enhance patient-centered outcomes. Sincerely, Heng-Hsin Tung Yi-Shu Liao: writing of original draft. Heng-Hsin Tung: supervision, review and editing of draft. 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 Guo and Pan. To view this article, visit https://doi.org/10.1111/jgs.70200.