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Hu S, Xiong X, Qiu S, Li J, Xu H, Zhou X, Wang S, Wei Q, Yang L. Comparing Efficacies of Different Exercises on Androgen Deprivation Therapy Adverse Effects in Prostate Cancer Patients: A Network Meta-Analysis. Urol Int 2024; 108:298-313. [PMID: 38432212 DOI: 10.1159/000538114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 01/31/2024] [Indexed: 03/05/2024]
Abstract
INTRODUCTION Previous studies showed exercise have efficacies for androgen deprivation therapy (ADT) adverse effects. To compare the efficacies of different exercises on ADT adverse effects, we conducted the network meta-analysis (NMA). METHODS Literature retrieval was performed in PubMed, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL). Nineteen studies (1,184 participants) were included. All analyses were performed in R 4.1.2 or RevMan 5.4.1. RESULTS NMA results showed that compared with the control group, both aerobic + resistance training (ART) (MD = 5.92, 95% CI: 0.38; 11.46) and resistance exercise (RE) (MD = 5.62, 95% CI: 2.70; 8.55) improved quality of life (QoL). ART (P score: 0.72) may have superiority over RE (P score: 0.7). ART (MD = -10.89, 95% CI: -17.67; -4.11) significantly improved the performance of 400-m test. RE could significantly improve leg strength (MD = 118, 95% CI: 78.75; 157.25) and chest strength (MD = 13.30, 95% CI: 4.07; 22.53). RE ranked first for strength improvements of leg and chest. CONCLUSION ART showed better efficacy for the QoL and significantly improved the performance of 400-m test. RE might be superior for the strengths of leg and chest. ART may be appropriate for patients with less significant muscle strength decline but also other adverse effects of ADT, such as decreased cardiopulmonary function.
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Affiliation(s)
- Siping Hu
- Department of Urology, Institute of Urology and National Clinical Research Center for Geriatrics, West China Hospital of Sichuan University, Chengdu, China,
- West China School of Clinical Medicine, West China Hospital, Sichuan University, Chengdu, China,
| | - Xingyu Xiong
- Department of Urology, Institute of Urology and National Clinical Research Center for Geriatrics, West China Hospital of Sichuan University, Chengdu, China
- West China School of Clinical Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Shi Qiu
- Department of Urology, Institute of Urology and National Clinical Research Center for Geriatrics, West China Hospital of Sichuan University, Chengdu, China
- Center of Biomedical Big Data, West China Hospital, Sichuan University, Chengdu, China
| | - Jiakun Li
- Department of Urology, Institute of Urology and National Clinical Research Center for Geriatrics, West China Hospital of Sichuan University, Chengdu, China
- Institutes for Systems Genetics, Frontiers Science Center for Disease-related Molecular Network, West China Hospital, Sichuan University, Chengdu, China
| | - Hang Xu
- Department of Urology, Institute of Urology and National Clinical Research Center for Geriatrics, West China Hospital of Sichuan University, Chengdu, China
- West China School of Clinical Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Xianghong Zhou
- Department of Urology, Institute of Urology and National Clinical Research Center for Geriatrics, West China Hospital of Sichuan University, Chengdu, China
- West China School of Clinical Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Sheng Wang
- Department of Urology, Institute of Urology and National Clinical Research Center for Geriatrics, West China Hospital of Sichuan University, Chengdu, China
- West China School of Clinical Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Qiang Wei
- Department of Urology, Institute of Urology and National Clinical Research Center for Geriatrics, West China Hospital of Sichuan University, Chengdu, China
| | - Lu Yang
- Department of Urology, Institute of Urology and National Clinical Research Center for Geriatrics, West China Hospital of Sichuan University, Chengdu, China
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Zhu Q, Xiong X, Zheng Q, Deng Q, Hao Y, Liu D, Zheng J, Zhang G, Li J, Yang L. High-intensity interval training versus moderate-intensity continuous training for localized prostate cancer under active surveillance: a systematic review and network meta-analysis. Prostate Cancer Prostatic Dis 2024:10.1038/s41391-024-00801-7. [PMID: 38378977 DOI: 10.1038/s41391-024-00801-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Revised: 01/21/2024] [Accepted: 01/25/2024] [Indexed: 02/22/2024]
Abstract
BACKGROUND High-intensity interval training (HIIT) and moderate-intensity continuous training (MICT) have been increasingly adopted for localized prostate cancer (PCa) under active surveillance (AS). However, it is unclear which training modality is the most favorable in terms of cardiorespiratory fitness and biochemical progression. METHODS We searched PubMed, Cochrane and Embase for relevant RCTs. PRISMA guideline was adopted to ensure optimal conduct of this study. Serum prostate specific antigen (PSA) and peak VO2 were selected as primary outcomes and PSA doubling time (PSADT) and testosterone were selected as secondary outcomes. Only articles written in English were included. Cochrane risk-of-bias tool was used for risk of bias evaluation. RESULTS A total of 501 studies were selected. Six RCTs with 222 patients were included for data extraction and analysis. High-intensity interval training (HIIT) group demonstrated significantly lower PSA compared with usual care (UC) (MD = -1.4; 95%CI = -2.77 to -0.03) and moderate-intensity continuous training (MICT) group (MD = -1.67; 95%CI = -3.30 to -0.05). Both HIIT and MICT showed significantly improved peak VO2 compared with UC. No significant difference was observed in PSADT and testosterone among different training modalities and UC. Regarding peak VO2, MICT had the highest surface under cumulative ranking curve (SUCRA) scores (98.1%). For serum PSA, HIIT had the highest probability (97.8%) to be the training with the highest efficacy. The potential source of bias mainly came from poorly performed allocation concealment and blinding strategies. CONCLUSIONS The present study indicated that HIIT and MICT showed considerable cardiorespiratory benefits for localized PCa. HIIT was preferred over MICT in biochemical progression control in terms of decreasing serum PSA levels. However, MICT was favored over HIIT regarding cardiorespiratory benefits. The findings of this study may facilitate future lifestyle intervention, particularly in the form of physical training, for individuals diagnosed with localized PCa under AS.
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Affiliation(s)
- Qiyu Zhu
- Department of Urology, Institute of Urology, West China Hospital of Sichuan University, No. 37, Guoxue Alley, Chengdu, Sichuan, PR China
| | - Xingyu Xiong
- Department of Urology, Institute of Urology, West China Hospital of Sichuan University, No. 37, Guoxue Alley, Chengdu, Sichuan, PR China
| | - Qian Zheng
- West China School of Medicine, Sichuan University, Chengdu, Sichuan, PR China
| | - Qi Deng
- West China School of Medicine, Sichuan University, Chengdu, Sichuan, PR China
| | - Yun Hao
- West China School of Medicine, Sichuan University, Chengdu, Sichuan, PR China
| | - Dingbang Liu
- West China School of Medicine, Sichuan University, Chengdu, Sichuan, PR China
| | - Jiaming Zheng
- West China School of Medicine, Sichuan University, Chengdu, Sichuan, PR China
| | - Guangyue Zhang
- West China School of Medicine, Sichuan University, Chengdu, Sichuan, PR China
| | - Jiakun Li
- Department of Urology, Institute of Urology, West China Hospital of Sichuan University, No. 37, Guoxue Alley, Chengdu, Sichuan, PR China.
| | - Lu Yang
- Department of Urology, Institute of Urology, West China Hospital of Sichuan University, No. 37, Guoxue Alley, Chengdu, Sichuan, PR China.
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Yang U, Harikrishna A, Preda V, Chen J. Efficacy of multidisciplinary interventions in preventing metabolic syndrome and improving body composition in prostate cancer patients treated with androgen deprivation therapy: A systematic review and meta-analysis. Clin Nutr ESPEN 2023; 58:27-49. [PMID: 38057016 DOI: 10.1016/j.clnesp.2023.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 09/01/2023] [Indexed: 12/08/2023]
Abstract
BACKGROUND Exercise is known to reduce adverse side effects of androgen-deprivation therapy (ADT) on quality of life, bone health and fatigue for prostate cancer (PCa) patients. We conducted a systematic review with meta-analysis to evaluate the effect of multidisciplinary interventions on body composition and metabolic syndrome (MetS) in ADT-treated PCa patients. METHODS A systematic review and meta-analysis were conducted based on searches of EMBASE, MEDLINE, CENTRAL and Scopus databases from inception to March 2023. Participants included ADT-treated PCa patients who received multidisciplinary interventions including exercise, diet, nutrition, pharmacotherapy, bariatric surgery, or psychological/behavioural therapy. Primary outcomes were changes in body composition and MetS, with prostate-specific antigen (PSA) as a secondary outcome. After meta-analysis, results were reported in mean difference, 95% confidence interval and p-value, with forest plots. Additionally, we conducted subgroup analyses to compare the effect of different interventions. RESULTS Thirty-three articles met the eligibility criteria out of 1443 articles and 28 studies were included in meta-analysis. Of 33 studies, 17 included exercise-only interventions and 10 included exercise + diet/nutrition interventions, but no studies included diet/nutrition-only interventions. All studies employed multidisciplinary approaches in developing or delivering the interventions. Most studies (85%) had low-moderate risk of bias, thus providing good evidence to this review. Overall, interventions had a positive effect on body composition measures; lean mass (LM):0.82 kg (95% CI:0.47,1.17;p < 0.00001), body fat mass (BFM):-0.68 kg (95% CI:-1.12,-0.24;p = 0.002), fat-free mass:0.75 kg (95% CI:0.14,1.37;p = 0.02) and body fat percentage (BFP):-0.99% (95% CI:-1.29,-0.68;p < 0.00001), as well as on MetS; waist circumference:-1.95 cm (95% CI:-3.10,-0.79;p = 0.0009), systolic blood pressure:-3.43 mmHg (95% CI:-6.36,-0.50;p = 0.02) and diastolic blood pressure:-2.48 mmHg (95% CI:-4.19,-0.76;p = 0.005). Subgroup-analyses showed that a combined approach including exercise + diet/nutrition was most effective in improving BFP, WC, SBP and DBP whereas exercise was more effective in improving LM and BFM. CONCLUSIONS In ADT-treated PCa patients, multidisciplinary interventions, especially those combining exercise and diet/nutrition, can improve body composition and metabolic health.
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Affiliation(s)
- Uhjin Yang
- Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW, Australia.
| | - Athulya Harikrishna
- Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW, Australia
| | - Veronica Preda
- Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW, Australia
| | - Juliana Chen
- Discipline of Nutrition and Dietetics, Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia; Charles Perkins Centre, The University of Sydney, Camperdown, NSW, Australia
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Lopez P, Newton RU, Taaffe DR, Winters-Stone K, Galvão DA, Buffart LM. Moderators of resistance-based exercise programs' effect on sarcopenia-related measures in men with prostate cancer previously or currently undergoing androgen deprivation therapy: An individual patient data meta-analysis. J Geriatr Oncol 2023; 14:101535. [PMID: 37229882 DOI: 10.1016/j.jgo.2023.101535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 04/24/2023] [Accepted: 05/16/2023] [Indexed: 05/27/2023]
Abstract
INTRODUCTION Older men with prostate cancer are commonly affected by reductions in lean mass and physical function following androgen deprivation therapy (ADT). Resistance-based exercise programs are critical to counteract the musculoskeletal toxicities derived from prostate cancer treatment and aging. However, there is significant variability in the effects of exercise interventions. Examining demographic and clinical moderators of exercise effects in this patient group can assist in identifying which subgroups of patients benefit most. Therefore, we examined the effects and moderators of resistance-based exercise programs on sarcopenia-related outcomes that included lean mass, skeletal muscle index, physical function, and muscle strength in older men with prostate cancer. MATERIALS AND METHODS Data were retrieved from the Predicting OptimaL cAncer RehabIlitation and Supportive care (POLARIS) consortium. For the present study, we included data from trials that examined the effects of supervised resistance-based exercise interventions on lean mass outcomes, muscle strength, and physical function in patients with prostate cancer previously or currently treated with ADT. Linear mixed models were undertaken to analyse the effects of resistance-based exercise programs considering the clustering of patients within studies. Effects were evaluated by regressing the study group on the post-intervention value of the outcome adjusted for the baseline value, while potential moderators were examined by adding the moderator and its interaction term into the regression model. RESULTS A total of 560 patients with prostate cancer (age: 69.5 ± 7.8 yrs.; body mass index: 28.6 ± 4.0 kg.m-2) previously or currently treated with ADT were included. Resistance-based exercise programs resulted in significant effects on whole-body and appendicular lean mass and the skeletal muscle index (P < 0.05), with improvements observed across different characteristics. Improvements were also observed in 400-m walk and 6-m backwards tandem walk (P < 0.05), with patients presenting with lower baseline levels deriving greater exercise effects on 400-m walk (-19.4 s, 95% confidence interval [CI]: -36.6 to -2.3) and 6-m backwards tandem walk tests (-3.0 s, 95% CI: -5.7 to -0.3). For relative muscle strength, significant exercise effects were observed, with greater effects in younger patients (0.35 kg.kg-1, 95% CI: 0.22 to 0.48). DISCUSSION Resistance-based exercise programs effectively improve well-known markers of sarcopenia in men with prostate cancer, with specific subgroups of patients, such as those younger and presenting with lower baseline levels of physical function, deriving greater effects on muscle strength and physical function, respectively.
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Affiliation(s)
- Pedro Lopez
- Exercise Medicine Research Institute, Edith Cowan University, Joondalup, Western Australia, Australia; School of Medical and Health Sciences, Edith Cowan University, Joondalup, Western Australia, Australia; Pleural Medicine Unit, Institute for Respiratory Health, Perth, Western Australia, Australia
| | - Robert U Newton
- Exercise Medicine Research Institute, Edith Cowan University, Joondalup, Western Australia, Australia; School of Medical and Health Sciences, Edith Cowan University, Joondalup, Western Australia, Australia
| | - Dennis R Taaffe
- Exercise Medicine Research Institute, Edith Cowan University, Joondalup, Western Australia, Australia; School of Medical and Health Sciences, Edith Cowan University, Joondalup, Western Australia, Australia
| | - Kerri Winters-Stone
- Knight Cancer Institute, Oregon Health and Science University, Portland, OR, USA
| | - Daniel A Galvão
- Exercise Medicine Research Institute, Edith Cowan University, Joondalup, Western Australia, Australia; School of Medical and Health Sciences, Edith Cowan University, Joondalup, Western Australia, Australia
| | - Laurien M Buffart
- Exercise Medicine Research Institute, Edith Cowan University, Joondalup, Western Australia, Australia; Department of Physiology, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, Netherlands.
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5
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Sheill G, Brady L, Hayes B, Baird AM, Guinan E, Vishwakarma R, Brophy C, Vlajnic T, Casey O, Murphy V, Greene J, Allott E, Hussey J, Cahill F, Van Hemelrijck M, Peat N, Mucci L, Cunningham M, Grogan L, Lynch T, Manecksha RP, McCaffrey J, O'Donnell D, Sheils O, O'Leary J, Rudman S, McDermott R, Finn S. ExPeCT: a randomised trial examining the impact of exercise on quality of life in men with metastatic prostate cancer. Support Care Cancer 2023; 31:292. [PMID: 37086362 PMCID: PMC10122616 DOI: 10.1007/s00520-023-07740-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 04/07/2023] [Indexed: 04/23/2023]
Abstract
PURPOSE All patients living with cancer, including those with metastatic cancer, are encouraged to be physically active. This paper examines the secondary endpoints of an aerobic exercise intervention for men with metastatic prostate cancer. METHODS ExPeCT (Exercise, Prostate Cancer and Circulating Tumour Cells), was a multi-centre randomised control trial with a 6-month aerobic exercise intervention arm or a standard care control arm. Exercise adherence data was collected via heart rate monitors. Quality of life (FACT-P) and physical activity (self-administered questionnaire) assessments were completed at baseline, at 3 months and at 6 months. RESULTS A total of 61 patients were included (69.4 ± 7.3 yr, body mass index 29.2 ± 5.8 kg/m2). The median time since diagnosis was 34 months (IQR 7-54). A total of 35 (55%) of participants had > 1 region affected by metastatic disease. No adverse events were reported by participants. There was no effect of exercise on quality of life (Cohen's d = - 0.082). Overall adherence to the supervised sessions was 83% (329 out of 396 possible sessions attended by participants). Overall adherence to the non-supervised home exercise sessions was 72% (months 1-3) and 67% (months 3-6). Modelling results for overall physical activity scores showed no significant main effect for the group (p-value = 0.25) or for time (p-value = 0.24). CONCLUSION In a group of patients with a high burden of metastatic prostate cancer, a 6-month aerobic exercise intervention did not lead to change in quality of life. Further exercise studies examining the role of exercise for people living with metastatic prostate cancer are needed. TRIAL REGISTRATION The trial was registered at clinicaltrials.gov (NCT02453139) on May 25th 2015.
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Affiliation(s)
- Gráinne Sheill
- Discipline of Physiotherapy, School of Medicine, Trinity College Dublin, Trinity Centre for Health Sciences, St James's Hospital, Dublin 8, Ireland.
| | - Lauren Brady
- Department of Histopathology and Morbid Anatomy, Trinity Translational Medicine Institute, Trinity College Dublin, Dublin, Ireland
| | - Brian Hayes
- Department of Histopathology, Cork University Hospital, Cork, Ireland
- Department of Pathology, University College Cork, Cork, Ireland
| | - Anne-Marie Baird
- Department of Histopathology and Morbid Anatomy, Trinity Translational Medicine Institute, Trinity College Dublin, Dublin, Ireland
| | - Emer Guinan
- School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Rishabh Vishwakarma
- School of Computer Science and Statistics, Trinity College Dublin, Dublin 2, Ireland
| | - Caroline Brophy
- School of Computer Science and Statistics, Trinity College Dublin, Dublin 2, Ireland
| | - Tatjana Vlajnic
- Institute of Pathology, University Hospital Basel, Basel, Switzerland
| | | | | | - John Greene
- Department of Histopathology and Morbid Anatomy, Trinity Translational Medicine Institute, Trinity College Dublin, Dublin, Ireland
| | - Emma Allott
- Centre for Cancer Research and Cell Biology, Queen's University Belfast, Northern Ireland, Belfast, UK
| | - Juliette Hussey
- Discipline of Physiotherapy, School of Medicine, Trinity College Dublin, Trinity Centre for Health Sciences, St James's Hospital, Dublin 8, Ireland
| | - Fidelma Cahill
- School of Cancer and Pharmaceutical Sciences, Translational Oncology and Urology Research (TOUR), King's College London, London, UK
| | - Mieke Van Hemelrijck
- School of Cancer and Pharmaceutical Sciences, Translational Oncology and Urology Research (TOUR), King's College London, London, UK
| | - Nicola Peat
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Lorelei Mucci
- Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Moya Cunningham
- Department of Radiation Oncology, St Luke's Hospital, Dublin, Ireland
| | - Liam Grogan
- Department of Oncology, Beaumont Hospital, Dublin, Ireland
| | - Thomas Lynch
- Department of Urology, St James's Hospital, Dublin, Ireland
| | - Rustom P Manecksha
- Department of Urology, St James's Hospital, Dublin, Ireland
- Department of Surgery, Trinity College Dublin, Dublin, Ireland
| | - John McCaffrey
- Department of Oncology, Mater Misericordiae Hospital, Dublin, Ireland
| | | | - Orla Sheils
- Department of Histopathology and Morbid Anatomy, Trinity Translational Medicine Institute, Trinity College Dublin, Dublin, Ireland
| | - John O'Leary
- Department of Histopathology, St James's Hospital, Dublin, Ireland
| | - Sarah Rudman
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Ray McDermott
- Department of Oncology, Tallaght University Hospital, Dublin, Ireland
| | - Stephen Finn
- Department of Histopathology and Morbid Anatomy, Trinity Translational Medicine Institute, Trinity College Dublin, Dublin, Ireland
- Cancer Trials Ireland, Dublin, Ireland
- Department of Histopathology, St James's Hospital, Dublin, Ireland
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Lopez P, Newton RU, Taaffe DR, Winters-Stone K, Buffart LM, Galvão DA. Effects and Moderators of Exercise Medicine on Cardiometabolic Outcomes in Men With Prostate Cancer Previously or Currently Undergoing Androgen Deprivation Therapy: An Individual Patient Data Meta-analysis. Crit Rev Oncol Hematol 2023; 186:103995. [PMID: 37080399 DOI: 10.1016/j.critrevonc.2023.103995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 03/16/2023] [Accepted: 04/11/2023] [Indexed: 04/22/2023] Open
Abstract
PURPOSE To examine the effects and moderators of exercise effects on cardiometabolic outcomes in men with prostate cancer previously or currently undergoing androgen deprivation therapy (ADT). RESULTS Seven trials including 560 patients were examined. Exercise resulted in significant effects on whole-body and regional fat mass (P≤0.001). For whole-body fat mass, significant exercise effects were observed in patients who were unmarried (-1.4kg, P<0.05) and who presented with higher fat mass levels (-1.0kg, P<0.05). For diastolic blood pressure and low-density lipoprotein (LDL), younger (-4.7mmHg, P<0.05) and older patients (-0.2mmol.l-1, P<0.10) achieved greater effects, respectively. Regarding high-density lipoprotein (HDL), patients undertaking ADT + prostatectomy + radiotherapy derived significant exercise effects (0.3mmol.l-1, P<0.05). CONCLUSIONS Exercise effectively reduces fat mass across subgroups of men undergoing or following ADT with different characteristics. For diastolic blood pressure, HDL and LDL, groups based on age and treatment history could be specifically targeted with exercise medicine.
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Affiliation(s)
- Pedro Lopez
- Exercise Medicine Research Institute, Edith Cowan University, Joondalup, Western Australia, Australia; School of Medical and Health Sciences, Edith Cowan University, Joondalup, Western Australia, Australia
| | - Robert U Newton
- Exercise Medicine Research Institute, Edith Cowan University, Joondalup, Western Australia, Australia; School of Medical and Health Sciences, Edith Cowan University, Joondalup, Western Australia, Australia; School of Human Movement and Nutrition Sciences, University of Queensland, St. Lucia, Queensland, Australia
| | - Dennis R Taaffe
- Exercise Medicine Research Institute, Edith Cowan University, Joondalup, Western Australia, Australia; School of Medical and Health Sciences, Edith Cowan University, Joondalup, Western Australia, Australia
| | - Kerri Winters-Stone
- Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon, USA; Department of Physiology, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, Netherlands
| | - Laurien M Buffart
- Exercise Medicine Research Institute, Edith Cowan University, Joondalup, Western Australia, Australia; Department of Physiology, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, Netherlands.
| | - Daniel A Galvão
- Exercise Medicine Research Institute, Edith Cowan University, Joondalup, Western Australia, Australia; School of Medical and Health Sciences, Edith Cowan University, Joondalup, Western Australia, Australia
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Trommer M, Marnitz S, Skoetz N, Rupp R, Niels T, Morgenthaler J, Theurich S, von Bergwelt-Baildon M, Baues C, Baumann FT. Exercise interventions for adults with cancer receiving radiation therapy alone. Cochrane Database Syst Rev 2023; 3:CD013448. [PMID: 36912791 PMCID: PMC10010758 DOI: 10.1002/14651858.cd013448.pub2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/14/2023]
Abstract
BACKGROUND Radiation therapy (RT) is given to about half of all people with cancer. RT alone is used to treat various cancers at different stages. Although it is a local treatment, systemic symptoms may occur. Cancer- or treatment-related side effects can lead to a reduction in physical activity, physical performance, and quality of life (QoL). The literature suggests that physical exercise can reduce the risk of various side effects of cancer and cancer treatments, cancer-specific mortality, recurrence of cancer, and all-cause mortality. OBJECTIVES To evaluate the benefits and harms of exercise plus standard care compared with standard care alone in adults with cancer receiving RT alone. SEARCH METHODS We searched CENTRAL, MEDLINE (Ovid), Embase (Ovid), CINAHL, conference proceedings and trial registries up to 26 October 2022. SELECTION CRITERIA We included randomised controlled trials (RCTs) that enrolled people who were receiving RT without adjuvant systemic treatment for any type or stage of cancer. We considered any type of exercise intervention, defined as a planned, structured, repetitive, objective-oriented physical activity programme in addition to standard care. We excluded exercise interventions that involved physiotherapy alone, relaxation programmes, and multimodal approaches that combined exercise with other non-standard interventions such as nutritional restriction. DATA COLLECTION AND ANALYSIS We used standard Cochrane methodology and the GRADE approach for assessing the certainty of the evidence. Our primary outcome was fatigue and the secondary outcomes were QoL, physical performance, psychosocial effects, overall survival, return to work, anthropometric measurements, and adverse events. MAIN RESULTS Database searching identified 5875 records, of which 430 were duplicates. We excluded 5324 records and the remaining 121 references were assessed for eligibility. We included three two-arm RCTs with 130 participants. Cancer types were breast and prostate cancer. Both treatment groups received the same standard care, but the exercise groups also participated in supervised exercise programmes several times per week while undergoing RT. Exercise interventions included warm-up, treadmill walking (in addition to cycling and stretching and strengthening exercises in one study), and cool-down. In some analysed endpoints (fatigue, physical performance, QoL), there were baseline differences between exercise and control groups. We were unable to pool the results of the different studies owing to substantial clinical heterogeneity. All three studies measured fatigue. Our analyses, presented below, showed that exercise may reduce fatigue (positive SMD values signify less fatigue; low certainty). • Standardised mean difference (SMD) 0.96, 95% confidence interval (CI) 0.27 to 1.64; 37 participants (fatigue measured with Brief Fatigue Inventory (BFI)) • SMD 2.42, 95% CI 1.71 to 3.13; 54 participants (fatigue measured with BFI) • SMD 1.44, 95% CI 0.46 to 2.42; 21 participants (fatigue measured with revised Piper Fatigue Scale) All three studies measured QoL, although one provided insufficient data for analysis. Our analyses, presented below, showed that exercise may have little or no effect on QoL (positive SMD values signify better QoL; low certainty). • SMD 0.40, 95% CI -0.26 to 1.05; 37 participants (QoL measured with Functional Assessment of Cancer Therapy-Prostate) • SMD 0.47, 95% CI -0.40 to 1.34; 21 participants (QoL measured with World Health Organization QoL questionnaire (WHOQOL-BREF)) All three studies measured physical performance. Our analyses of two studies, presented below, showed that exercise may improve physical performance, but we are very unsure about the results (positive SMD values signify better physical performance; very low certainty) • SMD 1.25, 95% CI 0.54 to 1.97; 37 participants (shoulder mobility and pain measured on a visual analogue scale) • SMD 3.13 (95% CI 2.32 to 3.95; 54 participants (physical performance measured with the six-minute walk test) Our analyses of data from the third study showed that exercise may have little or no effect on physical performance measured with the stand-and-sit test, but we are very unsure about the results (SMD 0.00, 95% CI -0.86 to 0.86, positive SMD values signify better physical performance; 21 participants; very low certainty). Two studies measured psychosocial effects. Our analyses (presented below) showed that exercise may have little or no effect on psychosocial effects, but we are very unsure about the results (positive SMD values signify better psychosocial well-being; very low certainty). • SMD 0.48, 95% CI -0.18 to 1.13; 37 participants (psychosocial effects measured on the WHOQOL-BREF social subscale) • SMD 0.29, 95% CI -0.57 to 1.15; 21 participants (psychosocial effects measured with the Beck Depression Inventory) Two studies recorded adverse events related to the exercise programmes and reported no events. We estimated the certainty of the evidence as very low. No studies reported adverse events unrelated to exercise. No studies reported the other outcomes we intended to analyse (overall survival, anthropometric measurements, return to work). AUTHORS' CONCLUSIONS There is little evidence on the effects of exercise interventions in people with cancer who are receiving RT alone. While all included studies reported benefits for the exercise intervention groups in all assessed outcomes, our analyses did not consistently support this evidence. There was low-certainty evidence that exercise improved fatigue in all three studies. Regarding physical performance, our analysis showed very low-certainty evidence of a difference favouring exercise in two studies, and very low-certainty evidence of no difference in one study. We found very low-certainty evidence of little or no difference between the effects of exercise and no exercise on quality of life or psychosocial effects. We downgraded the certainty of the evidence for possible outcome reporting bias, imprecision due to small sample sizes in a small number of studies, and indirectness of outcomes. In summary, exercise may have some beneficial outcomes in people with cancer who are receiving RT alone, but the evidence supporting this statement is of low certainty. There is a need for high-quality research on this topic.
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Affiliation(s)
- Maike Trommer
- Department of Radiation Oncology, Cyberknife and Radiotherapy, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Simone Marnitz
- Department of Radiation Oncology, Cyberknife and Radiotherapy, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Nicole Skoetz
- Cochrane Cancer, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Ronja Rupp
- Internal Medicine I, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Timo Niels
- Internal Medicine I, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Janis Morgenthaler
- Department of Radiation Oncology, Cyberknife and Radiotherapy, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Sebastian Theurich
- Internal Medicine III - Hematology/Oncology, University Hospital Munich, Munich, Germany
| | | | - Christian Baues
- Department of Radiation Oncology, Cyberknife and Radiotherapy, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Freerk T Baumann
- Internal Medicine I, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
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8
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Luo H, Galvão DA, Newton RU, Tang CI, Hart NH, Singh F, Dean A, Jasas K, Johansson M, Yusoff I, Spry N, Taaffe DR. Evaluation of a Clinic-Based Exercise Program in Patients with Pancreatic Cancer Undergoing Nonsurgical Treatment. Med Sci Sports Exerc 2023; 55:9-19. [PMID: 35941522 DOI: 10.1249/mss.0000000000003019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Evidence regarding the role of exercise in pancreatic cancer (PanCa) is limited and is derived exclusively under tightly controlled research conditions. This study aimed to quantify adherence, adverse events, and changes in physical and psychological outcomes in any patients with PanCa referred to undertake exercise during nonsurgical treatment. METHODS The study involved 22 patients with localized or metastatic PanCa undertaking a clinic-based exercise program during chemotherapy or chemoradiotherapy. The program included supervised aerobic and resistance exercise undertaken twice weekly for 12 wk and a 12-wk follow-up with supervised exercise optional dependent on patient preference and condition. Patients were monitored for adherence and adverse events. Objective and patient-reported outcomes were assessed at baseline, 12 wk, and 24 wk. RESULTS A total of 251 sessions were attended by 19 patients over the first 12 wk (attendance rate, 55%). Complete case analyses indicated significant ( P < 0.05) improvements in functional ability (5.2%-17.2%), muscle strength (16.9%-25.1%), and static balance (6.8%). There were no significant changes in body composition or patient-reported outcomes except for sleep quality, which deteriorated; however, at an individual level, several patients had clinically relevant improvements in cancer-related fatigue and quality of life. Patients who continued with supervised exercise to week 24 largely preserved improvements in functional ability, muscle strength, and static balance. No serious adverse events resulted from the exercise program. CONCLUSIONS Individualized, supervised aerobic and resistance exercise in a clinic-based setting appears to be safe and may improve or maintain physical and psychological health in patients with PanCa undergoing nonsurgical treatment.
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Affiliation(s)
| | | | | | | | | | | | - Andrew Dean
- Department of Oncology, St John of God Subiaco Hospital, Subiaco, WA, AUSTRALIA
| | - Kevin Jasas
- Department of Medical Oncology, Sir Charles Gairdner Hospital, Nedlands, WA, AUSTRALIA
| | - Mikael Johansson
- Department of General Surgery, Sir Charles Gairdner Hospital, Nedlands, WA, AUSTRALIA
| | - Ian Yusoff
- Department of Gastroenterology, Sir Charles Gairdner Hospital, Nedlands, WA, AUSTRALIA
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9
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Shao W, Zhang H, Qi H, Zhang Y. The effects of exercise on body composition of prostate cancer patients receiving androgen deprivation therapy: An update systematic review and meta-analysis. PLoS One 2022; 17:e0263918. [PMID: 35167609 PMCID: PMC8846498 DOI: 10.1371/journal.pone.0263918] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 01/29/2022] [Indexed: 12/24/2022] Open
Abstract
Androgen deprivation therapy is a common treatment for prostate cancer. However, this therapy is associated with various adverse effects, such as increased body fat and decreased bone mineral density. Exercise may be useful for ameliorating these adverse effects, although it is not completely effective. This review aimed to clarify how exercise interventions influenced body composition and bone mineral density and to explore the most effective exercise program among prostate cancer patients who received androgen deprivation therapy. We searched the PubMed, EMBASE, Web of Science, EBSCO, and Cochrane Library databases for reports of randomised controlled trials that were published until October 2021. All studies involved prostate cancer patients who received androgen deprivation therapy and completed aerobic exercise, resistance exercise, and/or impact exercise training. Outcomes were defined as lean body mass, body fat mass, body fat rate, regional and whole-body bone mineral density. Thirteen reports regarding 12 randomised clinical trials (715 participants) were included. Relative to the control group, exercise intervention provided a higher lean body mass (mean difference: 0.88, 95% confidence interval: 0.40 to 1.36, P<0.01), a lower body fat mass (mean difference: -0.60, 95% confidence interval: -1.10 to -0.10, P<0.05), and a lower body fat rate (mean difference: -0.93, 95% confidence interval: -1.39 to -0.47, P<0.01). Subgroup analyses revealed greater efficacy for exercise duration of ≥6 months (vs. <6 months) and exercise immediately after the therapy (vs. delayed exercise). No significant differences were observed in the bone mineral density outcomes. Exercise can help ameliorate the adverse effects of androgen deprivation therapy in body composition, with combination exercises including resistance exercise, 8–12 repetition maximum of resistance exercise intensity, prolonged exercise duration, and performing exercise immediately after therapy providing better amelioration. And the combination of resistance and impact exercise appears to be the best mode for improving the bone mineral density.
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Affiliation(s)
- Wenjuan Shao
- School of Sport Science, Beijing Sport University, Beijing, China
| | - Hanyue Zhang
- Key Laboratory of the Ministry of Education of Exercise and Physical Fitness, Beijing Sport University, Beijing, China
| | - Han Qi
- School of Sport Science, Beijing Sport University, Beijing, China
| | - Yimin Zhang
- Key Laboratory of the Ministry of Education of Exercise and Physical Fitness, Beijing Sport University, Beijing, China
- * E-mail:
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10
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Andersen MF, Midtgaard J, Bjerre ED. Do Patients with Prostate Cancer Benefit from Exercise Interventions? A Systematic Review and Meta-Analysis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:972. [PMID: 35055794 PMCID: PMC8776086 DOI: 10.3390/ijerph19020972] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 01/06/2022] [Accepted: 01/12/2022] [Indexed: 01/02/2023]
Abstract
Men diagnosed and treated for prostate cancer experience severe adverse effects on quality of life (QoL) and metabolic health, some of which may be preventable or reversible with exercise, the benefits of which healthcare providers and patients increasingly acknowledge, though existing evidence on its effects varies in significance and magnitude. We aimed to review the effect of exercise on QoL and metabolic health in a broad prostate cancer population. A systematic search was conducted in nine databases and eligible trials were included in the meta-analytic procedure. All outcomes were stratified into aerobic exercise, resistance exercise, and a combination of both. The review identified 33 randomised controlled trials (2567 participants) eligible for inclusion. Exercise had a borderline small positive effect on cancer-specific QoL (standardised mean difference (SMD) = 0.10, 95% confidence interval (CI) -0.01-0.22), and a moderate to large effect on cardiovascular fitness (SMD = 0.46, 95% CI 0.34-0.59) with aerobic exercise being the superior modality (SMD = 0.60, 95% CI 0.29-0.90). A positive significant effect was seen in lower body strength, whole-body fat mass, general mental health, and blood pressure. No significant effect was seen in fatigue, lean body mass, and general physical health. We thereby conclude that exercise is effective in improving metabolic health in men diagnosed with prostate cancer, with aerobic exercise as the superior modality. The effect of exercise on QoL was small and not mediated by choice of exercise modality.
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Affiliation(s)
- Martin Færch Andersen
- Department of Physiotherapy, University College of Northern Denmark, Selma Lagerløfs Vej 2, DK-9200 Aalborg, Denmark
| | - Julie Midtgaard
- Mental Health Centre Glostrup, University of Copenhagen, Nordstjernevej 41, DK-2600 Glostrup, Denmark;
- Department of Clinical Medicine, University of Copenhagen, Blegdamsvej 3B, DK-2200 Copenhagen, Denmark
| | - Eik Dybboe Bjerre
- The University Hospitals’ Centre for Health Research, Rigshospitalet, Ryesgade 27, DK-2200 Copenhagen, Denmark;
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11
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Zaorsky NG, Allenby T, Lin J, Rosenberg J, Simone NL, Schmitz KH. Exercise Therapy and Radiation Therapy for Cancer: A Systematic Review. Int J Radiat Oncol Biol Phys 2021; 110:973-983. [PMID: 33220396 DOI: 10.1016/j.ijrobp.2020.11.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 10/27/2020] [Accepted: 11/09/2020] [Indexed: 12/12/2022]
Abstract
PURPOSE Exercise therapy (ET) is shown to improve toxicity and surrogates of survival for patients receiving chemotherapy. Current National Comprehensive Cancer Network (NCCN) guidelines lack recommendations for concurrent radiation therapy (RT) and ET. The main objective was to determine the impact of concurrent ET + RT with respect to (1) acceptability, feasibility, safety; and (2) to demonstrate how incorporating ET in cancer treatment can enhance patient-reported outcomes (PROs) and physical function-defined as strength or exercise capacity. METHODS AND MATERIALS A PICOS/PRISMA selection protocol was used to search PubMed, Cumulative Index of Nursing and Allied Health Literature (CINAHL), and Cochrane Review for prospective randomized controlled trials evaluating concurrent ET + RT, including >10 patients and with 1 or more study arms. Acceptability, feasibility, and safety rates were calculated. PROs were assessed with study-specific metrics. Physical function was defined as improvements in strength or range of motion. Statistically significant improvement was defined by P <.05. RESULTS Twenty-six of 693 screened studies including 1563 patients (831 receiving exercise, 732 controls) with localized breast cancer (67.1% of patients), prostate cancer (27.4%), head and neck cancers (2.8%), and spinal metastases (2.8%) were assessed. Objective 1: Among 3385 patients approached for ET, 1864 (55.1%) accepted the treatment; of those, 1563 patients (83.9%) completed the trials. Objective 2: Statistical improvements were noted in these PROs: quality of life (14 of 15 studies), fatigue (12 of 16 studies), mood/depression (9 of 13), and anxiety (6 of 7). Physical function improved statically in 16 of 16 studies. CONCLUSIONS Combination ET + RT is safe and well-tolerated with improvements in PROs and physical function. Additional studies are needed in patients with metastatic cancers to assess survival and to compare effectiveness of different exercise regimens.
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Affiliation(s)
- Nicholas G Zaorsky
- Department of Radiation Oncology, Penn State Cancer Institute, Hershey, Pennsylvania; Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania.
| | - Taylor Allenby
- Department of Radiation Oncology, Penn State Cancer Institute, Hershey, Pennsylvania
| | - John Lin
- Department of Radiation Oncology, Penn State Cancer Institute, Hershey, Pennsylvania
| | - Jennifer Rosenberg
- Department of Radiation Oncology, Penn State Cancer Institute, Hershey, Pennsylvania
| | - Nicole L Simone
- Department of Radiation Oncology, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Kathryn H Schmitz
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania
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12
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Lopez P, Taaffe DR, Newton RU, Buffart LM, Galvão DA. What is the minimal dose for resistance exercise effectiveness in prostate cancer patients? Systematic review and meta-analysis on patient-reported outcomes. Prostate Cancer Prostatic Dis 2021; 24:465-481. [PMID: 33219369 PMCID: PMC8134054 DOI: 10.1038/s41391-020-00301-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 10/22/2020] [Accepted: 11/04/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Active treatments for prostate cancer are well known to result in several adverse effects such as fatigue, depression and anxiety symptoms, impacting the overall quality of life (QoL) and wellbeing of a considerable proportion of patients. Resistance-based exercise interventions have shown positive effects to reduce or mitigate these treatment-related side effects. However, the minimal dosage required to derive these benefits is unknown. We systematically reviewed the resistance training effects in prostate cancer patients to determine the minimal dosage regarding the exercise components (mode, duration, volume and intensity) on fatigue, QoL, depression and anxiety. METHODS Using PRISMA guidelines, MEDLINE, CINAHL, EMBASE, SPORTDiscus and Web of Science databases were searched. Eligible randomised controlled trials examined prostate cancer patients undertaking resistance-based exercise programs during or following treatment. Meta-analysis was undertaken when more than three studies were included. Associations between resistance exercise components and its effects were tested by meta-regression analysis. RESULTS Eighteen trials involving 1112 men with prostate cancer were included. Resistance-based exercise programs resulted in significant effects on fatigue (effect size = -0.3, 95% CI: -0.4 to -0.2, P < 0.001) and QoL (effect size = 0.2, 95% CI: 0.0 to 0.4, P = 0.018), with significant effects in specific questionnaires and domains of these outcomes. Resistance-based exercise effects on depression (effect size = -0.3, 95% CI: -0.7 to 0.0) and anxiety symptoms (effect size = -0.3, 95% CI: -0.5 to 0.0) were positive but not significant (P = 0.071 to 0.077). Meta-regression indicated no significant association between resistance exercise components with fatigue and QoL outcomes (P = 0.186-0.689). CONCLUSIONS Low volume resistance exercise undertaken at a moderate-to-high intensity is sufficient to achieve significant fatigue and QoL benefits for men with prostate cancer and also mitigate depression and anxiety symptoms. A lower resistance exercise dosage than usually prescribed may help enhance adherence by reducing exercise barriers.
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Affiliation(s)
- Pedro Lopez
- Exercise Medicine Research Institute, Edith Cowan University, Perth, WA, Australia.
- School of Medical and Health Sciences, Edith Cowan University, Perth, WA, Australia.
| | - Dennis R Taaffe
- Exercise Medicine Research Institute, Edith Cowan University, Perth, WA, Australia
- School of Medical and Health Sciences, Edith Cowan University, Perth, WA, Australia
| | - Robert U Newton
- Exercise Medicine Research Institute, Edith Cowan University, Perth, WA, Australia
- School of Medical and Health Sciences, Edith Cowan University, Perth, WA, Australia
- School of Human Movement and Nutrition Sciences, University of Queensland, Brisbane, QLD, Australia
| | - Laurien M Buffart
- Exercise Medicine Research Institute, Edith Cowan University, Perth, WA, Australia
- Department of Physiology, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - Daniel A Galvão
- Exercise Medicine Research Institute, Edith Cowan University, Perth, WA, Australia
- School of Medical and Health Sciences, Edith Cowan University, Perth, WA, Australia
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13
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LOPEZ PEDRO, TAAFFE DENNISR, NEWTON ROBERTU, GALVÃO DANIELA. Resistance Exercise Dosage in Men with Prostate Cancer: Systematic Review, Meta-analysis, and Meta-regression. Med Sci Sports Exerc 2021; 53:459-469. [PMID: 32890199 PMCID: PMC7886340 DOI: 10.1249/mss.0000000000002503] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE Resistance exercise improves an array of treatment-related adverse effects in men with prostate cancer; however, the minimal dosage required is unknown. We systematically reviewed the resistance training effects in prostate cancer patients to determine the minimal dosage regarding the exercise components (type, duration, volume, and intensity) on body composition, physical function, muscle strength, cardiorespiratory fitness, body mass index, and prostate-specific antigen. METHODS Using PRISMA guidelines, MEDLINE, CINAHL, EMBASE, SPORTDiscus, and Web of Science databases were searched. Eligible randomized controlled trials examined prostate cancer patients undertaking resistance-based exercise programs during or after treatment. Meta-analysis was undertaken when more than three studies were included. Associations between mean differences and exercise components were tested by univariate and multivariate meta-regression analysis. RESULTS Twenty-three articles describing 21 trials and involving 1748 prostate cancer patients were included. Exercise improved fat mass (-1% in body fat and -0.6 kg in fat mass), lean mass (~0.5 kg in lean and appendicular lean mass), functional capacity (i.e., chair rise, 400-m test, 6-m fast walk, and stair climb tests), and fitness outcomes (i.e., V̇O2peak and muscle strength) (P = 0.040-<0.001) with no change in body mass index or prostate-specific antigen (P = 0.440-0.735). Meta-regression indicated no association between exercise type, resistance training duration, weekly volume and intensity, and primary outcomes (P = 0.075-0.965). There was a significant association between exercise intensity and chest press muscle strength (favoring moderate intensity, P = 0.012), but not in other secondary outcomes. CONCLUSION In untrained older men with prostate cancer initiating an exercise program, lower volume at moderate to high intensity is as effective as higher volume resistance training for enhancing body composition, functional capacity, and muscle strength in the short term. A low exercise dosage may help reduce barriers to exercise and enhance adherence.
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Affiliation(s)
- PEDRO LOPEZ
- Exercise Medicine Research Institute, Edith Cowan University, Perth, Western Australia, AUSTRALIA
- School of Medical and Health Sciences, Edith Cowan University, Perth, Western Australia, AUSTRALIA
| | - DENNIS R. TAAFFE
- Exercise Medicine Research Institute, Edith Cowan University, Perth, Western Australia, AUSTRALIA
- School of Medical and Health Sciences, Edith Cowan University, Perth, Western Australia, AUSTRALIA
| | - ROBERT U. NEWTON
- Exercise Medicine Research Institute, Edith Cowan University, Perth, Western Australia, AUSTRALIA
- School of Medical and Health Sciences, Edith Cowan University, Perth, Western Australia, AUSTRALIA
- School of Human Movement and Nutrition Sciences, University of Queensland, Queensland, AUSTRALIA
| | - DANIEL A. GALVÃO
- Exercise Medicine Research Institute, Edith Cowan University, Perth, Western Australia, AUSTRALIA
- School of Medical and Health Sciences, Edith Cowan University, Perth, Western Australia, AUSTRALIA
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14
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Fankhauser CD, Wettstein MS, Reinhardt M, Gessendorfer A, Mostafid H, Hermanns T. Indications and Complications of Androgen Deprivation Therapy. Semin Oncol Nurs 2020; 36:151042. [PMID: 32773255 DOI: 10.1016/j.soncn.2020.151042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To review the indications for and side effects of androgen deprivation therapy (ADT) in men affected by prostate cancer. DATA SOURCES National guidelines, evidence-based summaries, peer-reviewed studies, and websites. CONCLUSION Indications for ADT include men with (1) intermediate- to high-risk localised prostate cancer undergoing radiation therapy, (2) biochemical recurrence after radical prostatectomy treated with salvage radiation therapy, or (3) metastatic prostate cancer. Several forms of ADT are available. To support self-management, body weight, diet, physical activity, alcohol consumption, and smoking should be discussed during clinical consultations. Important side effects of ADT may include flare-up phenomena of GnRH analogues, local reactions at injection sites, cardiovascular events, bone loss/fractures, drug-drug interactions, urinary tract dysfunction, hot flashes, cognitive impairment, seizure falls, and liver impairment. IMPLICATIONS FOR NURSING PRACTICE Nurses have a role in personalized cancer care and should be familiar with indications, side effects, and interventions to optimize quality of life for men affected by prostate cancer receiving ADT.
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Affiliation(s)
| | | | - Michèle Reinhardt
- Department of Urology, University Hospital, University of Zürich, Zürich, Switzerland
| | | | - Hugh Mostafid
- Department of Urology, Royal Surrey Hospital, Guildford, Surrey, UK.
| | - Thomas Hermanns
- Department of Urology, University Hospital, University of Zürich, Zürich, Switzerland
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15
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Toohey K, McKune A, Nahon I, Kavanagh PS, Newton RU, Paterson C. Improving Physical and Mental Health in Patients with Prostate Cancer Undergoing Androgen Deprivation Therapy: Strategies to Promote and Improve Physical Activity Quality and Quantity. Semin Oncol Nurs 2020; 36:151051. [PMID: 32682582 DOI: 10.1016/j.soncn.2020.151051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE Prostate cancer continues to be one of the highest-incident cancers among men. Reducing serum testosterone with androgen deprivation therapy (ADT) is a common effective treatment. While well-demonstrated for cancer suppression, there are numerous adverse effects caused by ADT that can contribute to short- and long-term prognosis. Increased levels of physical activity (PA) during treatment may reduce these side effects. However, uptake of PA is low. The purpose of this review is to identify and evaluate the current literature on strategies to promote and increase the levels of PA in patients with prostate cancer undergoing ADT. DATA SOURCES Electronic databases including CINAHL, MEDLINE, PsychINFO, Scopus, and grey literature were searched using Google Scholar up until April 2020. CONCLUSION At present the most appropriate modes and dosages of PA for specific ADT toxicities is not known. It is established that some PA in the form of exercise, whether aerobic or resistance, is better than being sedentary for improvements in physical health, but beyond this prescription specifics have not been established. Further research is required to understand the impact of PA on the mental and physical health of men with prostate cancer undergoing ADT. IMPLICATIONS FOR NURSING PRACTICE Being physically active and avoiding sedentary behaviour is important for men with prostate cancer undergoing ADT, especially the implementation of strength training. PA in the form of exercise can assist in reducing the adverse physical side effects in the short- and long-term, with limited understanding of the effects on mental health. PA improves mental health outcomes across populations, which may also translate to men with prostate cancer, although further research is required. An important strategy to improve PA within the prostate cancer population is to provide an early referral to an exercise professional, such as an accredited exercise physiologist/clinical exercise physiologist or physical therapist/physiotherapist, and is supported by research as best practice for people affected by cancer undergoing active treatment.
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Affiliation(s)
- Kellie Toohey
- Faculty of Health, University of Canberra, Canberra ACT, Australia; Prehabilitation, Activity, Cancer, Exercise and Survivorship (PACES) Research group, University of Canberra, Canberra ACT, Australia.
| | - Andrew McKune
- Faculty of Health, University of Canberra, Canberra ACT, Australia; Prehabilitation, Activity, Cancer, Exercise and Survivorship (PACES) Research group, University of Canberra, Canberra ACT, Australia; Research Institute of Sport and Exercise (UCRISE), Faculty of Health, University of Canberra, Canberra ACT, Australia; Discipline of Biokinetics, Exercise and Leisure Sciences, School of Health Sciences, University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa
| | - Irmina Nahon
- Faculty of Health, University of Canberra, Canberra ACT, Australia; Prehabilitation, Activity, Cancer, Exercise and Survivorship (PACES) Research group, University of Canberra, Canberra ACT, Australia
| | - Phillip S Kavanagh
- Faculty of Health, University of Canberra, Canberra ACT, Australia; Justice and Society, University of South Australia, Magill SA, Australia
| | - Robert U Newton
- Exercise Medicine Research Institute, Edith Cowan University, Joondalup WA, Australia
| | - Catherine Paterson
- Faculty of Health, University of Canberra, Canberra ACT, Australia; Prehabilitation, Activity, Cancer, Exercise and Survivorship (PACES) Research group, University of Canberra, Canberra ACT, Australia
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16
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Cormie P, Zopf EM. Exercise medicine for the management of androgen deprivation therapy-related side effects in prostate cancer. Urol Oncol 2020; 38:62-70. [DOI: 10.1016/j.urolonc.2018.10.008] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Revised: 07/23/2018] [Accepted: 10/03/2018] [Indexed: 12/23/2022]
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17
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Newton RU, Galvão DA, Spry N, Joseph D, Chambers SK, Gardiner RA, Wall BA, Bolam KA, Taaffe DR. Exercise Mode Specificity for Preserving Spine and Hip Bone Mineral Density in Prostate Cancer Patients. Med Sci Sports Exerc 2019; 51:607-614. [PMID: 30395051 DOI: 10.1249/mss.0000000000001831] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
PURPOSE Androgen deprivation therapy (ADT) in men with prostate cancer (PCa) is associated with an array of adverse effects, including reduced bone mineral density (BMD) predisposing patients to increased fracture risk. Our purpose was to examine the effects of targeted exercise modes on BMD in men with PCa undergoing ADT. METHODS Between 2009 and 2012, 154 PCa patients 43-90 yr old on ADT were randomized to exercise targeting the musculoskeletal system (impact loading + resistance training [ImpRes], n = 57) supervised for 12 months, cardiovascular and muscular systems (aerobic + resistance training, n = 50) supervised for 6 months followed by a 6-month home-based program, or delayed aerobic exercise (DelAer, n = 47) received exercise information for 6 months followed by 6 months of supervised aerobic exercise (stationary cycling). End points were lumbar spine, hip and whole-body BMD measured by dual-energy x-ray absorptiometry with secondary end points of lean and fat mass, appendicular skeletal muscle mass, and neuromuscular strength. ANOVA was used to compare the exercise groups with DelAer at 6 and 12 months. RESULTS There was a between-group difference in BMD for ImpRes and DelAer at the spine (6 months, P = 0.039; 12 months, P = 0.035) and femoral neck (6 months, P = 0.050), with decline attenuated in ImpRes (~-1.0% vs ~-2.0%). Compared with DelAer, ImpRes increased appendicular skeletal muscle at 6 months (0.3 kg, P = 0.045) and improved muscle strength at 6 and 12 months (P ≤ 0.012) by 9%-34%. A limitation was inclusion of well-functioning patients. CONCLUSION Combined impact loading and resistance exercise attenuates bone loss at the spine and enhances overall musculoskeletal function in PCa patients undergoing ADT.
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Affiliation(s)
- Robert U Newton
- Exercise Medicine Research Institute, Edith Cowan University, Joondalup, WA, AUSTRALIA.,School of Medical and Health Sciences, Edith Cowan University, Joondalup, WA, AUSTRALIA.,Institute of Human Performance, The University of Hong Kong, HONG KONG.,School of Human Movement and Nutrition Sciences, University of Queensland, Brisbane, QLD, AUSTRALIA
| | - Daniel A Galvão
- Exercise Medicine Research Institute, Edith Cowan University, Joondalup, WA, AUSTRALIA.,School of Medical and Health Sciences, Edith Cowan University, Joondalup, WA, AUSTRALIA
| | - Nigel Spry
- Exercise Medicine Research Institute, Edith Cowan University, Joondalup, WA, AUSTRALIA.,Genesis CancerCare, Joondalup, WA, AUSTRALIA.,Faculty of Medicine, University of Western Australia, Nedlands, WA, AUSTRALIA
| | - David Joseph
- Exercise Medicine Research Institute, Edith Cowan University, Joondalup, WA, AUSTRALIA.,Faculty of Medicine, University of Western Australia, Nedlands, WA, AUSTRALIA.,Department of Radiation Oncology, Sir Charles Gairdner Hospital, Nedlands, WA, AUSTRALIA
| | - Suzanne K Chambers
- Exercise Medicine Research Institute, Edith Cowan University, Joondalup, WA, AUSTRALIA.,Menzies Health Institute Queensland, Griffith University, Gold Coast, AUSTRALIA.,Centre for Research in Cancer Control, Cancer Council Queensland, Brisbane, QLD, AUSTRALIA.,Prostate Cancer Foundation of Australia, Sydney, NSW, AUSTRALIA
| | - Robert A Gardiner
- Exercise Medicine Research Institute, Edith Cowan University, Joondalup, WA, AUSTRALIA.,School of Human Movement and Nutrition Sciences, University of Queensland, Brisbane, QLD, AUSTRALIA.,Department of Urology, Royal Brisbane and Women's Hospital, Brisbane, AUSTRALIA
| | - Brad A Wall
- School of Psychology and Exercise Science, Murdoch University, Murdoch, WA, AUSTRALIA
| | - Kate A Bolam
- Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, SWEDEN
| | - Dennis R Taaffe
- Exercise Medicine Research Institute, Edith Cowan University, Joondalup, WA, AUSTRALIA.,School of Medical and Health Sciences, Edith Cowan University, Joondalup, WA, AUSTRALIA.,School of Human Movement and Nutrition Sciences, University of Queensland, Brisbane, QLD, AUSTRALIA
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18
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Mareschal J, Achamrah N, Norman K, Genton L. Clinical Value of Muscle Mass Assessment in Clinical Conditions Associated with Malnutrition. J Clin Med 2019; 8:jcm8071040. [PMID: 31319519 PMCID: PMC6678556 DOI: 10.3390/jcm8071040] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 07/08/2019] [Accepted: 07/16/2019] [Indexed: 01/06/2023] Open
Abstract
Malnutrition results from a reduction of food intake or an alteration of nutrient assimilation and leads to decreased lean mass. Strong evidence shows that malnutrition associated with loss of muscle mass negatively impacts clinical outcomes. The preservation or improvement of muscle mass represents a challenge. This review aims to (1) describe current methods to assess muscle mass in clinical practice, (2) describe the associations between muscle mass and clinical outcomes, and (3) describe the impact of interventions aiming at increasing muscle mass on clinical outcomes. It highlights the importance of assessing muscle mass as part of the screening and the follow-up of malnutrition in clinical practice.
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Affiliation(s)
- Julie Mareschal
- Clinical Nutrition, Geneva University Hospitals, 1205 Geneva, Switzerland.
| | - Najate Achamrah
- Department of Clinical Nutrition, Rouen University Hospital, Normandie University, 76000 Rouen, France
| | - Kristina Norman
- Research Group on Geriatrics, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, 13347 Berlin, Germany
- Department of Nutrition and Gerontology, German Institute for Human Nutrition Potsdam-Rehbrücke, 14558 Nuthetal, Germany
| | - Laurence Genton
- Clinical Nutrition, Geneva University Hospital, 1205 Geneva, Switzerland.
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Chen Z, Zhang Y, Lu C, Zeng H, Schumann M, Cheng S. Supervised Physical Training Enhances Muscle Strength but Not Muscle Mass in Prostate Cancer Patients Undergoing Androgen Deprivation Therapy: A Systematic Review and Meta-Analysis. Front Physiol 2019; 10:843. [PMID: 31333495 PMCID: PMC6618665 DOI: 10.3389/fphys.2019.00843] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 06/19/2019] [Indexed: 02/05/2023] Open
Abstract
Introduction: Androgen deprivation therapy (ADT) is considered the basic treatment for advanced prostate cancer, but it is highly associated with detrimental changes in muscle mass and muscle strength. The aim of this meta-analysis was to investigate the effects of supervised physical training on lean mass and muscle strength in prostate cancer patients undergoing ADT. Methods: A systematic literature search was performed using MEDLINE, Embase, and ScienceDirect until October 2018. Only studies that examined both muscle mass and strength in prostate cancer patients undergoing ADT were included. Outcomes of interest were changes in lean body mass (surrogate for muscle mass) as well as upper and lower body muscle strength. The meta-analysis was performed with fixed-effects models to calculate mean differences between intervention and no-training control groups. Results: We identified 8,521 publications through the search of the following key words: prostate cancer, prostate tumor, prostate carcinoma, prostate neoplasm, exercise, and training. Out of these studies, seven randomized controlled trials met the inclusion criteria and where included in the analysis. No significant mean differences for changes in lean mass were observed between the intervention and control groups (0.49 kg, 95% CI: −0.76, 1.74; P = 0.44). In contrast, the mean difference for muscle strength was significant both in chest (3.15 kg, 95% CI: 2.46, 3.83; P < 0.001) and in leg press (27.46 kg, 95% CI: 15.05, 39.87; p < 0.001). Conclusion: This meta-analysis provides evidence that low- to moderate-intensity resistance and aerobic training is effective for increasing muscle strength but may not be sufficient to affect muscle mass in prostate cancer patients undergoing ADT. The underlying mechanisms for this maladaptation may in part be explained by an insufficient stimulus induced by the training regimens as well as a delayed initiation of training in relation to the start of ADT. When interpreting the present findings, one should bear in mind that the overall number of studies included in this review was rather low, emphasizing the need for further studies in this field.
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Affiliation(s)
- Ziyuan Chen
- Department of Physical Education, Exercise, Health and Technology Centre, Shanghai Jiao Tong University, Shanghai, China
| | - Yuan Zhang
- The Key Laboratory of Systems Biomedicine, Ministry of Education, and The Exercise Translational Medicine Centre, Shanghai Center for Systems Biomedicine, Shanghai Jiao Tong University, Shanghai, China
| | - Chunyan Lu
- Department of Endocrinology, West China Hospital, Sichuan University, Chengdu, China
| | - Hao Zeng
- Department of Urology, West China Hospital, Sichuan University, Chengdu, China
| | - Moritz Schumann
- Department of Physical Education, Exercise, Health and Technology Centre, Shanghai Jiao Tong University, Shanghai, China.,The Key Laboratory of Systems Biomedicine, Ministry of Education, and The Exercise Translational Medicine Centre, Shanghai Center for Systems Biomedicine, Shanghai Jiao Tong University, Shanghai, China.,Department of Molecular and Cellular Sport Medicine, Institute of Cardiovascular Research and Sport Medicine, German Sport University, Cologne, Germany
| | - Sulin Cheng
- Department of Physical Education, Exercise, Health and Technology Centre, Shanghai Jiao Tong University, Shanghai, China.,The Key Laboratory of Systems Biomedicine, Ministry of Education, and The Exercise Translational Medicine Centre, Shanghai Center for Systems Biomedicine, Shanghai Jiao Tong University, Shanghai, China.,Faculty of Sport and Health Sciences, University of Jyväskylä, Jyväskylä, Finland
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Short-term androgen suppression and radiotherapy versus intermediate-term androgen suppression and radiotherapy, with or without zoledronic acid, in men with locally advanced prostate cancer (TROG 03.04 RADAR): 10-year results from a randomised, phase 3, factorial trial. Lancet Oncol 2018; 20:267-281. [PMID: 30579763 DOI: 10.1016/s1470-2045(18)30757-5] [Citation(s) in RCA: 73] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 10/03/2018] [Accepted: 10/04/2018] [Indexed: 01/23/2023]
Abstract
BACKGROUND The optimal duration of androgen suppression for men with locally advanced prostate cancer receiving radiotherapy with curative intent is yet to be defined. Zoledronic acid is effective in preventing androgen suppression-induced bone loss, but its role in preventing castration-sensitive bone metastases in locally advanced prostate cancer is unclear. The RADAR trial assessed whether the addition of 12 months of adjuvant androgen suppression, 18 months of zoledronic acid, or both, can improve outcomes in men with locally advanced prostate cancer who receive 6 months of androgen suppression and prostatic radiotherapy. This report presents 10-year outcomes from this trial. METHODS For this randomised, phase 3, 2 × 2 factorial trial, eligible men were 18 years or older with locally advanced prostate cancer (either T2b-4, N0 M0 tumours or T2a, N0 M0 tumours provided Gleason score was ≥7 and baseline prostate-specific antigen [PSA] concentration was ≥10 μg/L). We randomly allocated participants in a 2 × 2 factorial design by computer-generated randomisation (using the minimisation technique, and stratified by centre, baseline PSA concentration, clinical tumour stage, Gleason score, and use of a brachytherapy boost) in a 1:1:1:1 ratio to four treatment groups. Patients in the control group received 6 months of neoadjuvant androgen suppression with leuprorelin (22·5 mg every 3 months, intramuscularly) and radiotherapy alone (short-term androgen suppression [STAS]); this treatment was either followed by another 12 months of adjuvant androgen suppression with leuprorelin (22·5 mg every 3 months, intramuscularly; intermediate-term androgen suppression [ITAS]), or accompanied by 18 months of zoledronic acid (4 mg every 3 months, intravenously) starting at randomisation (STAS plus zoledronic acid), or both (ITAS plus zoledronic acid). All patients received radiotherapy to the prostate and seminal vesicles, starting from the end of the fifth month of androgen suppression; dosing options were 66, 70, and 74 Gy in 2-Gy fractions per day, or 46 Gy in 2-Gy fractions followed by a high-dose-rate brachytherapy boost dose of 19·5 Gy in 6·5-Gy fractions. Treatment allocation was open label. The primary endpoint was prostate cancer-specific mortality and was analysed according to intention-to-treat using competing-risks methods. The trial is closed to follow-up and this is the final report of the main endpoints. This trial is registered with ClinicalTrials.gov, number NCT00193856. FINDINGS Between Oct 20, 2003, and Aug 15, 2007, 1071 men were enrolled and randomly assigned to STAS (n=268), ITAS (n=268), STAS plus zoledronic acid (n=268), and ITAS plus zoledronic acid (n=267). Median follow-up was 10·4 years (IQR 7·9-11·7). At this 10-year follow-up, no interactions were observed between androgen suppression and zoledronic acid so the treatment groups were collapsed to compare treatments according to duration of androgen suppression: 6 months of androgen suppression plus radiotherapy (6AS+RT) versus 18 months of androgen suppression plus radiotherapy (18AS+RT) and to compare treatments according to whether or not patients received zoledronic acid. The total number of deaths was 375 (200 men receiving 6AS+RT and 175 men receiving 18AS+RT), of which 143 (38%) were attributable to prostate cancer (81 men receiving 6AS+RT and 62 men receiving 18AS+RT). When analysed by duration of androgen suppression, the adjusted cumulative incidence of prostate cancer-specific mortality was 13·3% (95% CI 10·3-16·0) for 6AS+RT versus 9·7% (7·3-12·0) for 18AS+RT, representing an absolute difference of 3·7% (95% CI 0·3-7·1; sub-hazard ratio [sHR] 0·70 [95% CI 0·50-0·98], adjusted p=0·035). The addition of zoledronic acid did not affect prostate cancer-specific mortality; the adjusted cumulative incidence of prostate cancer-specific mortality was 11·2% (95% CI 8·7-13·7) with zoledronic acid vs 11·7% (9·2-14·1) without, representing an absolute difference of -0·5% (95% CI -3·8 to 2·9; sHR 0·95 [95% CI 0·69-1·32], adjusted p=0·78). Although safety analysis was not prespecified for this 10-year analysis, one new serious adverse event (osteonecrosis of the mandible, in a patient who received 18 months of androgen suppression plus zoledronic acid) occurred since our previous report, bringing the total number of cases of this serious adverse event to three (<1% out of 530 patients who received zoledronic acid evaluated for safety) and the total number of drug-related serious adverse events to 12 (1% out of all 1065 patients evaluable for safety). No treatment-related deaths occurred during the study. INTERPRETATION 18 months of androgen suppression plus radiotherapy is a more effective treatment option for locally advanced prostate cancer than 6 months of androgen suppression plus radiotherapy, but the addition of zoledronic acid to this treatment regimen is not beneficial. Evidence from the RADAR and French Canadian Prostate Cancer Study IV trials suggests that 18 months of androgen suppression with moderate radiation dose escalation is an effective but more tolerable option than longer durations of androgen suppression for men with locally advanced prostate cancer including intermediate and high risk elements. FUNDING National Health and Medical Research Council of Australia, Novartis Pharmaceuticals Australia, AbbVie Pharmaceuticals Australia, New Zealand Health Research Council, New Zealand Cancer Society, Cancer Standards Institute New Zealand, University of Newcastle (Australia), Hunter Medical Research Institute, Calvary Mater Newcastle Radiation Oncology Fund, and Maitland Cancer Appeal.
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