What is Prostate Cancer

Prostate Cancer is the most common cancer in men (1 in 6 males) and in Australia, this accounts for approximately 30% of all new male cancers. The Australian Institute of Health & Welfare (2012) reports it is the 2nd most common cause of cancer death in men.

Because of this, it is recommended men undergo regular screening for detection of any risk factors from the age of 55 (even from 40 if other apparent risk factors are present)

With improvements in technology for cancer detection and our knowledge of risk factors, more men are being diagnosed with the disease at an earlier stage, but on top of this - more men are surviving longer with the effects of prostate cancer and associated treatments. Prostate cancer has one of the highest 5-year survival rates (92%) however, problems and side-effects arising from treatments are known to be quite common.

Diagnosis

– PSA (Prostate Specific Antigen) testing is the gold standard measurement of a blood marker . PSA may also be a marker that is elevated in other conditions such as Benign Prostatic Hyperplasia/BPH and other non-malignant cancers that wouldn’t be life threatening if left untreated.

- PHI (Prostate Health Index) is a more recently developed blood testing method to determine risk for prostate cancer in men with high detected PSA levels.

- Prostate Cancer Urine Tests is another more recently developed method for doctors to look for a gene (PCA3) that can also help better assess prostate cancer risk.

– DRE (digital rectal examination) involves manual palpation/ of the posterior part of the prostate for abnormalities that might require further investigation.

– Biopsy involves small samples of the prostate being removed and then looked at with a microscope to identify abnormal cells and assist in grading the disease progression

- MRI imaging can be done before a biopsy to look for areas in the prostate that are suspicious for cancer

Grading

– The Gleason System (Histological appearance and spread of cancerous cells on biopsy) is the most commonly used tool to classify and stage prostate cancer. This grades the 2 most advanced parts of the cancer found (from 1-5), combines the numbers, and produces a final ‘Gleason Score’ (that will be between 2-10).

Metastasis

(when the cancer cells begin to spread into other tissue)

– Lymph Node Biopsy involves removing a single or multiple lymph nodes for examination and can detect if the cancer has spread to the lymphatic system. Biopsy may also be performed of nearby tissue fro the same reason.

– PET/MRI & bone scans are additional investigations that can pick up on the cancer spreading to other areas, different organs including bone/soft tissues.

Other terminology may be used clinically regarding prostate cancer that may describe the cancer in terms of its size, extent of spread, speed of growth and capacity for treatment.

So how does exercise fit this picture?

If you’re unfamiliar with the idea of “Exercise Oncology’/Exercise Medicine based management of Cancers - check out our Intro to Exercise Oncology resource.

Exercise Medicine in Prevention of Prostate Cancer

There is a growing amount of research to show that physically active people have lower risk for all cancers, with strong protective effects against prostate cancer.

There seems to be stronger effects in older men as well as in those who currently/ have previously performed high levels of vigorous activity physical activity, but the potent responses to exercise in areas such as weight loss, cardiovascular fitness, enhancing immune function and reducing oxidative stress are all mechanisms that likely have a protective effect against prostate cancer for all men.

Preventing or reducing the risk of side effects of treatment and other associated symptoms of prostate cancer is an area exercise can be a useful tool in. Studies also show more physically active men and those who undertake strength training before prostate cancer diagnosis or treatment have better chances of combating some of the negative effects that may be encountered.

Exercise Medicine During Treatment/Active Diagnosis

Men suffering from prostate cancer may encounter a lot of different symptoms, most often related to treatment side effects or ongoing effects following surgical procedures.

Cardiovascular health can be compromised following chemotherapy cycles, in particular with more intensive drugs (eg Anthracyclines) as well as with ongoing ADT. One of the most potent and easy strategies to improve and maintain heart health is through regular exercise.

Continence and bowel/bladder dysfunction - Often, surgical procedures that remove all or part of the prostate can lead to issues with bladder (and occasionally bowel) function, sexual health as well as cause pain at the site of surgery. Radiation directed the prostate can also cause damage and inflammation to the area that can be problematic for some men.

Following surgery (eg, prostatectomy, transurethral resection of prostate/TURP) or local radiation to the prostate/pelvic region are common, especially in the early stages post treatment - 66% of men experience urinary incontinence (Katz & Rodriguez, 2007). Usually, men are provided with resources to explain how/why their procedure may affect their bladder function temporarily as the tissues are healing in the area.

The mainstay of managing these issues circulates arounds specific pelvic floor muscle exercises and retraining the brain-body connection of the muscle that control urination. The pelvic floor muscle group is complex, and because of this is important to have a qualified clinician with knowledge of mens health and cancer care to assess and advise on the optimal prescription of these exercises. This is also an important feature of the rehabilitation process to get right in order to return to regular daily function and physical activity.

Lymphedema/Swelling - Any surgical procedure or radiation to the lymph nodes in the pelvic/groin region will likely inflame the tissues and increase the risk of problems with lymphatic function in the legs/pelvis. This might present as swelling/tightness around the belt line, groin or anywhere along the lower limbs. While there are 100’s of lymph nodes in this region that can usually ‘pick up the slack’ and compensate for any removed or damaged lymph nodes, there is still a chance that lymphedema can develop.

Monitoring or swelling following and during treatment is important to identify any signs/symptoms, but there is good evidence to show that regular exercise can reduce the likelihood of developing lymphedema.

Sexual health and Erectile Dysfunction - Unfortunately, sexual dysfunction is a possibility for nearly all treatment options for prostate cancer, including more recently advanced robotic surgery and drug therapy . As this is a large component of the prostate cancer treatment journey for some, there are a lot of resources, support systems and specialist professionals in this area that are able to guide men and their sexual health during/following prostate cancer treatment. There is research that has shown that specific pelvic floor muscle exercises, regular exercise and weight loss can all play a role in restoring and improving sexual health in prostate cancer.

While it is still an area that has room to develop - there are more recent research findings, especially in more advanced prostate cancer, that give us insight into how exercise might modulate cancer-specific outcomes, may synergistically increase the potency of chemotherapy and radiotherapy and may endogenously and/or mechanically suppress tumour formation, growth and invasion in visceral and skeletal tissue.

Exercise Medicine in Prostate Cancer Survivorship

Different types of exercise can produce different outcomes and can positively influence a range of symptoms experienced by men living with/after being treated for prostate cancer

Bone health is influenced considerably by sex hormones, such as testosterone, so once these hormones are blocked, bones become less dense and are at greater risk of fractures. This is an especially important area that research and clinical practice has been developing in, specifically on how exercise can help men suffering from reduced bone mineral density following ADT which affect hormones that are incredibly important for maintaining bone mass.

Some great work done by an Australian research group in Perth has actually shown HEAVY strength training and impact based exercises such as box jumps, stomping, and heavy weightlifting are not only safe to perform (under careful supervision)- but incredibly effective at slowing down bone mineral density losses in men with prostate cancer and even increasing bone density.

Muscle strength and size can often be reduced in response to ADT’s effects on sex hormones (usually combined with the normal time-associated process of ageing, as well as lower strenuous activity levels). The right type of exercise (strength/resistance training) is a well established treatment method to combat muscle loss and improve body composition. This also often involves reducing body-fat gain that may result from sex-hormone and insulin changes, which can, again, be effectively combated with the right exercise.

Research tells us that beginning a strength training program earlier rather than later following treatment is important to optimise muscle mass, body composition and bone mineral density.

Survival

Brisk walking for 90 minutes or more per week can lower risk of death from prostate cancer by 46%

Burning 12,600 kilojoules (kj) or more a week from doing physical exercise can reduce risk of death by 50%

Exercising vigorously 3 or more hours per week can lower risk of death by 61%

There is an ongoing Australian study (INTERVAL GAP-4 STUDY) investigating the effects of intense exercise on Metastatic Prostate cancer-specific outcomes including disease biology and patient survival, which is actually one of the largest clinical trials in exercise oncology worldwide.

Psychological burden - All the above-mentioned symptoms, in combination with the stressors associated with battling a cancer diagnosis can take a huge toll on a mans mental health. For this reason, its not uncommon to have early psychological intervention offered to provide support and coping strategies with the potential challenges that may arise (or have arisen) during treatment. There are also plenty of resources available for men to assist in maintaining mental and emotional wellbeing throughout their cancer journey.

While there are many ways exercise may assist in alleviating and managing the above symptoms, exercise is also a powerful therapy for managing mental health and can independently have a positive effect on depression/anxiety symptoms the may arise anywhere along the cancer journey. .

Dosage?

Current Exercise is Medicine Australia guidelines recommend:

Maintaining or building up to 150 minutes of exercise each week.
Exercise can be done in sessions as short as 10 minutes and should include either or both aerobic-based exercise and strength/resistance based exercise (including exercises that target all major muscle groups).
It is best to spread exercise sessions out across the week (e.g. 30 minutes on 5 days of the week).
Depending on the intensity of the strength training/resistance based exercise, it may be necessary to avoid doing resistance based exercise on consecutive days.
Additional benefits may be gained by exercising for up to 300 minutes each week, but it is important to gradually progress towards this higher amount as symptoms allow.

Minimal effective dose: Even performing low amounts of resistance exercise at a moderate-to-high intensity seems sufficient to achieve significant fatigue and QoL benefits for men with prostate cancer, while also having positive effects on depression and anxiety symptoms.

Studies comparing differ types of exercise show that resistance, aerobic/cardiovascualr or combined resistance and aerobic exercise cause similar effects on cancer-related fatigue in cancer patients. This shows promising effects of using a relatively low exercise dosage, even when strength training/resistance exercise is prescribed as the only type of exercise in men with prostate cancer.

The key factor in effective exercise medicine prescribing - is finding something sustainable that can develop physically active lifestyle habits and elicit long lasting changes to physical and emotional wellbeing.

When Not to Exercise

Contraindications /when not to exercise for prostate cancer patients include, but are not limited to:

Acute infection/signs of infection
Acute/severe bowel and bladder problems,
Extreme fatigue, ataxia or anemia,
General cardiovascular and respiratory contraindications for an exercise regimen.
Hemoglobin level < 10.0 g/dL
Absolute Neutrophil Count (ANC) < 0.5 x 10^9/L
Platelet Count < 50,000 x 10^9/L

Precautions should be taken in the following situations - this is where guidance from an Exercise Physiologist could be the most beneficial.

Platelets > 50,000–150,000: avoid tests (high impact) or exercise (contact sports) that increase risk of bleeding
White blood cells > 3000–4000: ensure proper sterilization of all equipment
During active treatment (chemotherapy or radiation)
Acute post-operative/post-treatment phase

While there is an ever-growing body of research and new discoveries being made daily in the world of exercise medicine and prostate cancer - there are well established ways that the correctly prescribed exercise can help in preventing and managing the short, medium and long term consequences associated with the disease.

The journey for everyone is different, which is why having an individualised approach to preventative medicine, rehabilitation and survivorship is so important.

If you’d like more information on any of the information above or would like a better understanding of how movement can be medicine for you, keep an eye out for more content like this or get in touch to book an appointment for a personalised plan of action today.

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