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Should exercise be prescribed to men with prostate cancer?

Covid19 has reinforced and accelerated so many behavioural and health trends from pre-pandemic times – and a commitment to regular exercise is one of them, as “allowed” daily exercise has become an escape from lockdown. The evidence building on links between Covid19 and obesity, and between exercise and mental health has put a spotlight on the pursuit of physical exercise over the last year, focusing our minds on how exercise builds and maintains good health .

Few dispute that exercise supports good overall health, but what is debated is how to promote and support the takeup of exercise programmes amongst individuals and groups that are resistant, compromised, unconfident or unmotivated. Like most people, men with prostate cancer can benefit in multiple ways from regular exercise, but many feel afraid or demoralised about their health, and some resist. What might motivate and support these men, and would prescribing exercise as an element of prostate cancer care drive takeup?

A quick look at clinical evidence and engagement with prostate cancer exercise advocates begins to help us formulate a view.

1. Evidence

A 2018 internationally led review of studies linking exercise and prostate cancer from basic science through to clinical applications concluded overwhelmingly that exercise benefits men in the prevention and treatment of prostate cancer.

“Exercise is one of the environmental factors that have been shown to influence cancer risk. Moreover, systemic reviews and meta-analysis have suggested that total physical activity is related to a decrease in the risk of developing PCa. In addition, epidemiological studies have shown that exercise, after diagnosis, has benefits regarding PCa development, and positive outcome in patients under treatment.”

The authors concluded that the review “provides evidence indicating that exercise could complement, and potentiate, the current standard treatments for advanced PCa, probably by creating an unfavorable microenvironment that can negatively affect tumor development, and progression.”

Exercise and Active Surveillance

Evidence is building on the impact of exercise on men undergoing Active Surveillance, and an ongoing RCT investigating this link has recently published pre-results in the BMJ.

The investigators present the contextual aspects of AS:

“Unfortunately, many men with PCa on AS eventually experience disease progression and require radical treatments. Approximately 30% of men on AS receive radical treatments within 3 years and about 55% within 10 years. Moreover, even without an objective progression of their disease, many AS patients experience anxiety and fear of cancer progression based on having an untreated tumour with a chance of progression. Fear of cancer progression and uncertainty of illness are associated with a poor quality of life which may prompt these men and their doctors to opt for radical treatments as a way of managing the fear and anxiety”

And conclude that

“Evidence shows that exercise may be beneficial to men with PCa on AS in three potential pathways … First, exercise that is sufficient to improve cardiorespiratory fitness may be linked to slower PCa progression. Several possible biological mechanisms have been studied in animals and human models, including improved immune activity through aerobic exercise which may play a critical role. However, these findings have not been confirmed in men with PCa. Second, exercise has been shown to improve health-related fitness, treatment-related side-effects, physical functioning, body composition, fatigue, and quality of life during and after radical PCa treatments, but few studies to date have focused on the AS setting or examined fear of cancer progression. Last, given the eventuality of receiving radical treatment for many PCa patients on AS, exercise may help these men improve overall physical condition/function prior to impending radical treatments (ie, prehabilitation) which may reduce anticipated treatment-related side-effects. “

Exercise and Mental health

The first randomized controlled trial to examine the long-term effects of different exercise on psychological distress in men with prostate cancer undergoing androgen deprivation therapy (ADT) was published last month.

Researchers randomly selected 135 prostate cancer patients aged 43–90 years on ADT to receive either twice weekly supervised resistance exercise or aerobic exercise for 12 months. Their levels of psychological distress were measured during that time.

“We now have the data to support the long-term effect of different exercise modes on psychological distress in men with prostate cancer undertaking ADT,” the investigators reported. “Whether you do aerobic exercise or resistance exercise it doesn’t matter, as long as it’s at moderate to high intensity, it’s beneficial for reducing symptoms of depression and anxiety.”

The study concluded that exercise benefits people with cancer, and further suggests that prescribed exercise programmes should become a standard element of patient care.

2. Exercise Advocates

We’ve engaged with a number of inspiring men who have been or are currently undergoing prostate cancer treatment and offer their experience, advice and support to others. Two stand out:

Gogs Gagnon, a Canadian prostate cancer survivor and author of “Prostate Cancer Strikes: Navigating the Storm” , provides support to men globally on all aspects of the disease, including exercise. His recent piece discusses the importance of a measured approach to exercise post-diagnosis:

“Since I was no stranger to exercise, I hit the gym hard and hired a personal trainer. But my long absence required starting at the beginning. My mind thought I was still in shape, but my body strongly disagreed”, he says.

Tony Collier is well known amongst the UK prostate cancer community as a passionate advocate for early screening and exercise post-diagnosis. A keen runner, he often writes about the challenges he faces with prostate cancer. In a recent article he says

“The impact on me as a runner has been huge. Weight gain due to steroids, loss of muscle mass due to no testosterone – so it’s much hard to power the runs – reduced bone density, and horrendous fatigue etc.”

He continues

“But I am thankfully still able to run and I’ve run or hiked (some days both) every day since May 1. I’m loads slower, can’t run as far, but I’m still doing something I love and I took my coaching badge so that I can stay involved when I can no longer participate.”

There’s no question exercise benefits both physical and mental health, and for many men this isn’t up for debate – but what many struggle with is how to begin a programme, particularly if one hasn’t been physically active or dedicated to exerciser before diagnosis, or has had or is undergoing treatment that’s affecting his physical and mental strength and endurance. Prescribing could be a way for men like these to have the structure and support required to beneficially take up and adhere to an exercise programme.

There are lots of resources to help these men – with emphasis on all abilities, and situations and circumstances. Indeed, a benefit of prescribing could be simply to curate these resources and offer men a range of programme choices.

Advocates offer one route – Tony Collier is a Prostate UK ambassador and has built a large following on social media which has become a community of support to men with prostate cancer and their families. Follow him on twitter at @ethansgrumps. Gogs also supports a large community of followers and is on twitter @GogsGagnon.

Exercise communities – online and offline – are another. Tony is an active participant in Parkrun and there are others focused on cycling, walking and yoga.

Podcasts are growing all the time in availability, specificity and relevance, and are a convenient way to listen, learn and motivate while out for a walk or in the car. This is one example of an exercise podcast aimed at older men.

Video series and channels also abound for those seeking motivation and instruction on exercise. Beginner programmes for over 50s can be a good place to start for those new to exercise programmes. Others are designed specifically for men with prostate cancer.

What is your relationship with exercise? Do you think prescribing is a good idea? We’d like to hear your views.

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