Evidence summary: Prehabilitation strategies for patients with primary liver cancer

Objective: To synthesise and appraise current evidence on prehabilitation strategies for patients with primary liver cancer. Methods: Using the PIPOST framework, we formulated clinical questions and defined eligibility criteria. Guided by the "5S" evidence hierarchy, a comprehensive search was conducted across 20 sources-including clinical decision systems, guideline repositories, bibliographic databases, and professional society websites-from inception to 1 December 2024. Two independent reviewers screened and appraised eligible studies, and evidence synthesis was limited to those meeting predefined quality standards. Nine experts evaluated the evidence through a structured consensus process based on the FAME framework to determine recommendation grades. Results: Twenty studies were included: 1 clinical decision tool, 5 guidelines, 5 systematic reviews, 5 expert consensuses, 3 evidence summaries, and 1 randomised controlled trial. A total of 36 evidence statements were extracted and categorised into six domains: prehabilitation candidates, timing of prehabilitation, nutritional optimisation, physical exercise, psychological support, and health education. Although part of the evidence originated from non-liver cancer populations, extrapolation was considered reasonable due to shared pathophysiological risks across major abdominal surgeries. Of these, 34 evidence statements received strong recommendations after expert appraisal. Conclusions: This study consolidates practical, evidence-based prehabilitation strategies for patients with primary liver cancer, while underscoring the cautious use of extrapolated evidence where liver cancer-specific data are lacking. Despite methodological rigour, conclusions remain constrained by the limited availability of liver cancer-focused studies. Future research should generate direct evidence to refine prehabilitation protocols. Clinical application should integrate both the best available evidence and patient preferences. Systematic review registration: Registered with the Fudan University Evidence-based Nursing Centre (ID: ES20246474).