Prue Cormie, PhD, AEP

EXERCISE AS MEDICINE FOR PROSTATE CANCER MANAGEMENT

ECU Health & Wellness Institute

Edith Cowan University

p.cormie@ecu.edu.au

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 p.cormie@ecu.edu.au

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

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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