151751-Najiba-Chargi

429 Summarizing discussion and future perspectives GENERAL DISCUSSION AND FUTURE PERSPECTIVES This thesis provided key knowledge of the predictive and prognostic impact of low skeletal muscle mass, also referred to as sarcopenia, in head and neck cancer patients. The promising next steps are to develop and implement (automated) time-efficient sarcopeniameasurement tools for clinical practice and to investigate whether improving muscle mass also improves treatment outcomes and prognosis in patients with head and neck cancer. During the past decade several therapeutic interventions to prevent and treat skeletal muscle mass loss are described in literature. These therapeutic interventions include physical exercise, nutritional support and pharmacological interventions. Due to the various factors contributing to low skeletal muscle mass such as malnutrition and reduced physical exercise, optimal pre-ha- bilitation of patients with low SMM requires a multimodal approach and contributions from members of a multidisciplinary team (e.g., physiotherapist, dietician). PHYSICAL EXERCISE For surgically treated patients, focus on enhancing physical fitness before surgery to enable the patient to withstand the stress of surgery has gained increased attention, this is also called pre-habilitation. The effectiveness of rehabilitation programs has already been demonstrated in a variety of medical fields including abdominal 14 , lung 15 and pancreatic cancer 16 surgery. Minnella et al. performed a randomized-controlled trial in patients with esophageal cancer, 26 patients received pre-habilitation consisting of pre-operative exercise and nutrition opti- mization, and 25 control patients received usual care. 17 The primary outcome was a change in functional capacity, measured with an absolute change in 6-minute walk distance. Postopera - tive data from 4 to 8 weeks after surgery were also compared. They found that pre-habilitation significantly improved functional capacity before and after surgery. Faithfull et al. performed a systematic review of studies investigating the effect of pre-habilitation in patients with cancer and found a significant improvement in postoperativemobilization and self-reported physical function in patients who received pre-habilitation. 18 To date, only few small exercise studies were performed in patients with head and neck cancer. Steegmann et al. recently performed a randomized clinical trial in 69 patients undergoing surgical treatment of head and neck cancer. 19 They found that patients in the intervention group (personalized pre-treatment ex- ercise plan) showed significantly less postoperative morbidity and had a significantly shorter hospital stay. In addition, Capozzi et al. have also shown that pre-treatment exercise is safe and feasible in patients with head and neck cancer and can help negate cachexia and improve common cancer adverse effect such as cancer-related fatigue and reduced physical function. 20 Although these small studies show a positive effect of pre-habilitation for treatment out - comes in surgically treated head and neck cancer patients, there is still no consensus whether pre-habilitation contributes to reduction in postoperative complications, faster recovery and improvement in quality of life and on integrating pre-habilitation in clinical practice. Samuel et al. performed a randomized controlled trial in 148 patients with head and neck cancer undergoing chemoradiotherapy to evaluate the effectiveness of exercise on functional ca - 21