Dr. Malcolm West

Biography

Associate Professor Malcolm West was appointed to the University of Southampton in 2022 as an Associate Professor in Colorectal Surgery and Prehabilitation Medicine. He is also an Honorary Consultant Colorectal and Advanced Malignancy Surgeon at University Hospitals Southampton NHS Foundation Trust.

Previously, he was an NIHR clinical academic in Liverpool and the Wessex region, completing a PhD in exercise physiology, perioperative risk stratification, and prehabilitation for advanced rectal cancer. He later held an NIHR Academic Fellowship and a Lectureship in Surgery at Southampton. He completed specialist training with the prestigious Royal College of Surgeons Senior Fellowship in complex and robotic colorectal cancer surgery at St Mark’s Hospital, London.

Malcolm leads a translational research programme focused on improving perioperative and long-term outcomes in major cancer surgery. He is a senior investigator with the Fit-4-Surgery Consortium and NIHR Southampton BRC Perioperative and Critical Care theme. His clinical trials explore perioperative risk assessment and multimodal prehabilitation to improve resilience and outcomes after cancer treatment. His research interests include the impact of prehabilitation on fitness, body composition, tumour microenvironment, and immune ecology.

He is the incoming co-chair of the NIHR Research for Patient Benefit programme (Southern England) and the Wessex Cancer Alliance Lead for Early Diagnostics in Colorectal Cancer. He also supervises multiple postgraduate research students at Southampton and across the UK.

Summary of presentation

Prehabilitation is the process of enhancing a patient’s resilience prior to surgery or cancer therapy, has emerged in the United Kingdom as an increasingly important component of perioperative care. Within the NHS, growing surgical waiting lists, an ageing population, increasing surgical complexity and rising multimorbidity have heightened the need for strategies that reduce complications and accelerate recovery. Exercise-based prehabilitation, often combined with nutritional support and psychological preparation, is being implemented across diverse surgical pathways.

Evidence from UK-led trials demonstrates that short-term, high-intensity interval training can improve cardiorespiratory fitness within four weeks, while resistance-based approaches preserve muscle function during preoperative optimisation. Pilot programmes in London, Manchester, and Glasgow have reported feasibility and acceptability across varied socioeconomic groups, with home-based and digitally supported interventions extending accessibility. Mechanistic sub studies in UK cohorts highlight improvements in skeletal muscle mitochondrial function, improved tumour regression, and reductions in systemic inflammation as plausible biological mediators of clinical benefit.

Policy momentum is increasing. NHS England has endorsed prehabilitation within its personalised care agenda, while Macmillan Cancer Support and the Royal Colleges advocate for integration of prehabilitation into standard cancer pathways, with new prehabilitation guidelines set to be released at the International prehabilitation Conference in Vancouver 2025. Despite this progress, challenges remain. Workforce capacity, funding sustainability, implementation barriers, understanding mechanisms of how prehabilitation works and the variation in service models between hospitals create barriers to uniform provision. Furthermore, robust multicentre trials powered for postoperative outcomes, health economics, and equity analyses are still required.

Looking forward, by linking mechanistic science with pragmatic service implementation, and by leveraging digital platforms to deliver scalable programmes, prehabilitation has the potential to drive meaningful changes to patients before surgery to improve both short and more ambitiously longer-term health and economic outcomes.

Summary of presentation

Using preoperative CPET beyond risk assessment

Malcolm West

Cardiopulmonary exercise testing (CPET) is established within the United Kingdom as the gold-standard tool for objective preoperative risk assessment, particularly in major oncological and vascular surgery. By integrating ventilatory, cardiovascular, and metabolic responses to incremental exercise, CPET provides robust predictors of postoperative morbidity and mortality. However, emerging evidence suggests that CPET should be considered not only as a diagnostic and prognostic instrument alone, but also as a dynamic tool to guide optimisation, risk stratify, resource allocate, dose tailor prehabilitation, and monitor intervention efficacy.

Recent UK-based studies demonstrate that prehabilitation programmes—whether hospital-based, community-delivered, or digital—can improve oxygen uptake at anaerobic threshold and peak VO₂ within a matter of weeks. Serial CPET offers a sensitive means of detecting these physiological adaptations, providing feedback to clinicians and patients while informing perioperative planning. Moreover, CPET-derived variables, such as ventilatory efficiency (V_E/VCO₂ slope) and heart rate recovery, may serve as mechanistic biomarkers of training responsiveness, vascular health, and autonomic function. This expands CPET’s role from passive risk stratification to active monitoring of patient readiness.

Integration with multimodal optimisation is another frontier. Nutritional interventions, anaemia management, and respiratory training can all produce measurable CPET improvements, supporting its use as a unifying endpoint across diverse prehabilitation strategies. Beyond surgery, there is potential for CPET to contribute to long-term survivorship planning, particularly in oncology, where exercise-induced improvements in cardiorespiratory fitness may influence treatment tolerance and overall survival.

For widespread adoption, practical barriers, including resource intensity, operator training, and patient burden must be addressed. CPET is not merely a predictor of risk or a single number test generator but a catalyst for personalised perioperative medicine.