Exercise AS MEDICINE FOR PROSTATE CANCER...
Transcript of Exercise AS MEDICINE FOR PROSTATE CANCER...
Prue Cormie, PhD, AEP
EXERCISE AS MEDICINE FOR PROSTATE CANCER MANAGEMENT
ECU Health & Wellness Institute
Edith Cowan University
Sexual Dysfunction
Treatment Toxicity
Metastatic Disease
Translating into Practice
Mental Health Issues
Role of Exercise for…
Sexual Dysfunction • Up to 90% of men with prostate cancer will
experience sexual dysfunction (Bobber et al. J Clin Oncol 2012)
• ~50% of prostate cancer survivors report unmet sexual health care needs (Smith et al. J Clin Oncol 2007)
– Sexual health ranked as the area with the most unmet need
Bacon et al. Ann Intern Med 2003 Webber et al. Med J Aus 2013
Potential Role of Exercise?
Cormie et al. Nat Rev Urol. 2013; 10(12):731-6.
Potential Role of Exercise?
Cormie et al. Nat Rev Urol. 2013; 10(12):731-6.
Cormie et al. Prostate Cancer Prostatic Dis. 2013; 16(2):170-5.
Sexual Wellbeing - Efficacy
Design RCT (Exercise vs. Usual Care)
Treatment 100% hormone, 37% radiation, 40% surgery
Sample 57 men (age = 69.5 ± 7.3 years)
Intervention 3 months; group-based; AEP supervised
Protocol Resistance & aerobic exercise (2 x weekly)
Primary endpoint Sexual activity (EORTC QLQ-PR25)
Sexual Wellbeing - Efficacy
Hamilton et al. Support Care Cancer. 2015; 23(1):133-42.
Sexual Wellbeing – Patient Perspective
Design Descriptive, qualitative design
Treatment 100% hormone, 83% radiation, 11% surgery
Sample 18 men (age = 61.7 ± 5.4 years)
Intervention 4.3 ± 2.4 months; group-based; AEP supervised
Protocol Resistance & aerobic exercise (2 x weekly)
Outcomes Thematic content analysis
Exercise
Reinforcement of Masculinity
Improved Sexual
Wellbeing
Hamilton et al. Support Care Cancer. 2015; 23(1):133-42.
↑ Body Image
↑ Energy
↑ Mood
Sense of Control
Engage in & Master a Masculine Activity
Sexual Wellbeing – Patient Perspective
Cormie et al. BMC Cancer. 2014; 14:199.
Sexual Wellbeing - Efficacy
Cormie et al. BMC Cancer. 2014; 14:199.
Sexual Wellbeing - Efficacy Design 3-arm randomised controlled trial
Treatment Hormone, radiation and/or surgery
Sample 240 men concerned by sexual wellbeing
Intervention 6 months; group-based; AEP supervised
Primary endpoint Sexual wellbeing (function, libido, satisfaction)
Cormie et al. Nat Rev Urol. 2013; 10(12):731-6.
Preventing ADT Toxicity
Design RCT (Exercise vs. Usual Care)
Treatment Initiating hormone therapy (6 days between 1st ADT injection & baseline test)
Sample 63 men (age = 68.4 ± 7.1 years)
Intervention 3 months; group-based; AEP supervised
Protocol Resistance & aerobic exercise (2 x weekly)
Primary endpoint Body composition (fat & lean mass)
Cormie et al. BJU Int. 2015; 115(2):256-66.
ADT Toxicity – Body Composition
Cormie et al. BJU Int. 2015; 115(2):256-66.
Cormie et al. BJU Int. 2015; 115(2):256-66.
ADT Toxicity – Other Issues
Cormie et al. BJU Int. 2015; 115(2):256-66.
Measure Adjusted Group Differences in Mean Change Over 3 months
Mean 95% CI p
Blood Pressure
Systolic Blood Pressure (mmHg) 0.5 -5.9 7.0 0.869
Diastolic Blood Pressure (mmHg) -2.5 -5.9 0.9 0.147
Blood Biomarkers
C-Reactive Protein (mg/L) -0.58 -1.31 0.14 0.112
Total Cholesterol (mmol/L) -0.05 -0.38 0.29 0.793
LDL Cholesterol (mmol/L) -0.12 -0.41 0.16 0.393
HDL Cholesterol (mmol/L) 0.06 -0.04 0.16 0.226
Triglycerides (mmol/L) -0.04 -0.24 0.16 0.674
Insulin (mU/L) 0.48 -4.05 5.00 0.834
Glucose (mmol/L) -0.29 -0.88 0.29 0.321
Glycated Haemoglobin (%) -0.15 -0.36 0.05 0.133
Alkaline Phosphatase (U/L) -2.62 -7.19 1.95 0.256
P1NP (μg/L) -3.96 -9.93 2.02 0.190
N-telopeptide (nmol BCE/L) 22.2 -195.0 239.3 0.838
Testosterone (nmol/L) 0.07 -0.35 0.50 0.732
PSA (μg/L) 0.18 -0.25 0.60 0.410
ADT Toxicity – Other Issues
Preventing Toxicity - Efficacy
Newton et al. BMC Cancer. 2012; 12:432.
Aerobic Exercise Resistance Exercise Impact Exercise
Newton et al. BMC Cancer. 2012; 12:432.
Design 2-arm randomised controlled trial
Treatment Hormone (androgen deprivation therapy)
Sample 124 men initiating treatment
Intervention 6 months; group-based; AEP supervised
Primary endpoint Bone mineral density
Preventing Toxicity - Efficacy
Preventing Toxicity - Efficacy
Bone Metastatic Disease
Design RCT (Exercise vs. Usual Care)
Treatment 100% hormone, 55% radiation, 20% surgery
Sample 20 men (age = 72.2 ± 7.2 years)
Intervention 3 months; group-based; AEP supervised
Protocol Modular resistance exercise; 2 x week
Primary endpoint Physical function
Cormie et al. Prostate Cancer Prostatic Dis. 2013; 16(4):328-335.
Metastases Site Body Region to Target
Upper Trunk Lower
Pelvis √ √ √b
Axial Skeleton (lumbar) √ - √
Axial Skeleton (thoracic/ribs) √a - √
Femur √ √ √b
All Regions √a - √b
√ - Target exercise region a - Exclusion of shoulder flexion/extension/abduction/adduction; inclusion of elbow flexion & extension b - Exclusion of hip flexion/extension/abduction/adduction; inclusion of knee flexion & extension
Cormie et al. Prostate Cancer Prostatic Dis. 2013; 16(4):328-335.
Bone Metastatic Disease
Safety and Feasibility of Resistance Exercise
Adverse events during the exercise sessions 0
Attendance (out of 24 sessions) 20.2 ± 7.6
Compliance (% of successfully completed sessions) 93.2 ± 6.3
Perceived tolerance of the exercise sessions (0 = intolerable; 7 = highly tolerable)
6.1 ± 0.7
Perceived exercise intensity (session RPE) 13.8 ± 1.5
Severity of bone pain at the start of each session (average of all sessions; 0 = no pain; 10 = very severe pain)
0.6 ± 0.7
Incidence of bone pain negatively affecting the ability to undertake ADL between exercise sessions
0
No change in use of pain medication throughout 3 month intervention
Cormie et al. Prostate Cancer Prostatic Dis. 2013; 16(4):328-335.
Metastatic Disease - Safety
Cormie et al. Prostate Cancer Prostatic Dis. 2013; 16(4):328-335.
Metastatic Disease - Benefits
Metastatic Disease - Efficacy
Galvão et al. BMC Cancer. 2011 Dec 13;11:517.
Metastases Site Resistance Exercise
Upper Trunk Lower Aerobic Exercise
WB NWB
Pelvis √ √ √b - √
Axial Skeleton (lumbar) √ - √ - √
Axial Skeleton (thoracic/ribs) √a - √ √ √
Femur √ √ √b - √
All Regions √a - √b - √
√ - Target exercise region; WB - Weight bearing; NWB - Non-weight bearing a - Exclusion of shoulder flexion/extension/abduction/adduction; inclusion of elbow flexion & extension b - Exclusion of hip flexion/extension/abduction/adduction; inclusion of knee flexion & extension
Galvão et al. BMC Cancer. 2011 Dec 13;11:517.
Design 2-arm randomised controlled trial
Treatment Hormone/radiation/surgery/chemotherapy
Sample 90 men with bone metastatic disease
Intervention 3 months; group-based; AEP supervised
Primary endpoint Physical function
Metastatic Disease - Efficacy
• Increased rate of depression in prostate cancer survivors ______(Australian Bureau of Statistics 2008)
• 2-4 times greater risk of suicide than aged matched men _____ _ (Bill-Axelson et al. Eur Urol 2010, Llorente et al. Am J Geriatr Psychiatry 2005)
• ~10% to 40% of men with prostate cancer are distressed (Chambers et al. Psycho-oncol 2013, Roberts et al. Ann Behav Med. 2010)
• ~50% of prostate cancer survivors report unmet psychological need (Smith et al. J Clin Oncol 2007)
Adult Men
Men with prostate cancer
Mental Health Issues
Patient Experience of Exercise
Design Descriptive, qualitative design
Treatment 100% hormone, 100% radiation, 25% surgery
Sample 12 men (age = 75.3 ± 4.5 years)
Intervention 6.0 ± 3.1 months; group-based; AEP supervised
Protocol Resistance & aerobic exercise (2 x weekly)
Outcome Thematic content analysis
Cormie et al. Oncol Nurs Forum. 2015; 42(1):24-32.
Cormie et al. Oncol Nurs Forum. 2015; 42(1):24-32.
Patient Experience of Exercise
Chambers et al. Prostate Cancer Foundation of Australia and Griffith University, Australia. 2013. ISBN 9780-9923508-3-3.
Exercise can help reduce distress &
improve mental well-being
Managing Mental Health Issues
Cormie et al. Psycho-Oncology. 2015 Jun 18 [Epub ahead of print].
Exercise As A Support Group That Appeals To Men Articulates with idealised masculine values: • Physical prowess • Stoic • Resilient • Independent • Self-reliant • In control
Embodies a masculinised supportive care service: • Action-oriented • Casual environment (non-confrontational) • Positive atmosphere • Humour • Camaraderie
Managing Mental Health Issues
Translating Research into Practice
Patient Support Programs
Patient Support Programs
Community Based Program • 3 month supervised program
for all cancer patients within 2 years of diagnosis
• ~700 cancer patients over the last 4 years
• Administered at 15 clinics &/gyms throughout WA (metropolitan & regional)
• Subsidised (free for patients)
Community Based Program
Cormie et al. J Clinical Oncology 32:5s (suppl; abstract 9533), 2014.
Integration into Clinical Practice
Exercise Group Cancer Group
Acknowledgement by Professional Associations
Research Education Advocacy
Research Team Robert Newton (ECU) Daniel Galvão (ECU) Carolyn Peddle-McIntyre (ECU) Nigel Spry (SCGH, ECU) David Joseph (SCGH, ECU) Suzanne Chambers (GU, ECU) Dennis Taaffe (UWoll, ECU) Frank Gardiner (RBH, UQ, ECU) James Denham (UNew, NMH) Thomas Shannon (HH) Akhlil Hamid (RPH, ECU) Dickon Hayne (FH, UWA) Raphael Chee (Genesis, UWA) Jerard Ghossein (JHC) Gregory Bock (WA Dept of Health) Lisa Ferri (PCFA) John Oliffe, Uni British Columbia Chris Doran, Hunter Medical Res Inst.
Accredited Exercise Physiologists: Mark Trevaskis (ECU) Courtney Ishiguchi (ECU) Kelly Vibert (ECU)
Thank you
Prue Cormie [email protected]
Treatment Previous ADT & RT (5.6 ± 2 years post diagnosis)
Design RCT (Exercise vs. Physical activity education)
Sample 100 men (age = 71.7 ± 6.4 years)
Intervention 12 months (6 months of group-based, AEP supervised)
Protocol 1) Resistance & aerobic exercise (6 months supervised + 6 months home based) vs. 2) Printed physical activity education material
Outcome Measures Cardiorespiratory fitness (400 m walk)
Galvão et al. European Urology 2014
Supervised vs. PA Recommendation
Perc
ent
Dif
fere
nce
Bet
wee
n G
rou
ps
Galvão et al. European Urology 2014
Group Difference in Mean Change Over 12 months
6m p = 0.029 12m p = 0.028
6m p < 0.001 12m p = 0.011
6m p = 0.019 12m p = 0.116
6m p = 0.006 12m p = 0.002 6m p = 0.025
12m p = 0.649
6m p < 0.001 12m p = 0.755
Exercise > PA Recommendation
Supervised vs. PA Recommendation
Supervised vs. PA recommendation
Galvão et al. European Urology 2014 Galvão et al. European Urology 2014
Supervised vs. PA Recommendation