HOPPER: implementation of a home-based prehabilitation programme with app support for patients undergoing colorectal cancer surgery-a study protocol.

BACKGROUND: Preoperative prehabilitation programmes for patients with colorectal cancer have been shown to reduce complications and hospital length of stay. However, supervised weekly physiotherapy is expensive and timeconsuming for both healthcare professionals and patients, leading to suboptimal implementation of prehabilitation programmes. A previous study demonstrated that offering home-based prehabilitation through an app is feasible and leads to outcomes comparable to supervised prehabilitation programmes. This study was conducted at a single hospital. To expand this promising modality nationwide, it is essential to identify key implementation determinants. We therefore initiated this multicentre study involving a more diverse and heterogeneous patient population. The findings of this study will provide valuable input for scaling strategies for prehabilitation programmes in the Netherlands and beyond. METHODS: In this prospective multicentre cohort study, approximately 300 patients with colorectal cancer scheduled for curative surgery will be enrolled over 12 months. The study adopts a hybrid type 3 design, reporting clinical outcomes while exploring implementation-related factors. Five hospitals with varied profiles (academic, non-academic teaching and general hospitals) and geographical locations (urban and rural, high and low socioeconomic areas) are participating. The primary endpoint is the identification of barriers and facilitators, using both qualitative (interviews) and quantitative (user statistics, questionnaires) data from stakeholders. Secondary endpoints include fitness and clinical outcomes such as complications and mortality. ETHICS AND DISSEMINATION: This study was approved by the METC (Medisch Ethische Toetsings Commissie / Dutch Medical Ethics Committee) and was established not to apply to the Medical Research Involving Human Subjects Act (WMO / Wet Medisch Wetenschappelijk Onderzoek met mensen); submission was 21 April 2025. The app is proven safe and feasible in earlier studies and is CE certified (Conformité Européenne). Informed consent will be obtained from all patients (Supplement 1). Adverse events will be monitored and reported. Only researchers will have access to the final dataset. Results will be disseminated through publications, patient group briefings and implementation feedback to healthcare workers. Plans for sharing deidentified individual clinical trial participant-level data consist of quotes from interviews held on stakeholders. This study protocol adheres to the SPIRIT guidelines.