Radical prostatectomy: Long-term cancer control and recovery of sexual and urinary function (“trifecta”)

Radical prostatectomy (RP) disrupts the natural history of prostate cancer. However, it could be a significant source of long-term incontinence and potency morbidity. We studied the long-term cancer survival results and the probabilities of achieving ideal "trifecta" outcomes (cancer control, continence, and potency) after this surgical procedure. A total of 1746 intervention-naive patients with clinically localized newly diagnosed prostate cancer underwent RP with curative intent beginning in 1983. The mean follow-up time was 6 years (interquartile range, 3-9). The successive probabilities of achieving ideal trifecta outcomes for up to 24 months following RP versus experiencing biochemical recurrence were estimated using the cumulative incidence method. Additionally, long-term cancer control was assessed by preoperative and postoperative factors. Surgical excision controlled prostate cancer effectively in 1441 (83%) of the 1746 patients studied. At 5, 10, and 15 years, respectively, 82%, 77%, and 75% of patients were free from disease progression. Cancer-specific survival was 99%, 95% and 89%, respectively, at 5, 10, and 15 years. In men with disease progression, the 15-year probabilities of death from prostate cancer versus other causes were similar (32% and 33%, respectively). At 24 months, 60% of patients were potent, continent, and free of cancer, and 12% had experienced recurrence. Use of RP provided excellent long-term cancer control. At 15 years, only 11% of patients had died of prostate cancer. Cancer control was good even for patients with adverse prognostic features. The probability of death from cancer was similar to other causes after disease progression. By 2 years, 60% of men were continent, potent, and cancer free.

Effects of home-based diet and exercise on functional outcomes among older, overweight long-term cancer survivors: RENEW: a randomized controlled trial

CONTEXT

Five-year survival rates for early stage colorectal, breast, and prostate cancer currently exceed 90% and are increasing. Cancer survivors are at greater risk for second malignancies, other comorbidities, and accelerated functional decline. Lifestyle interventions may provide benefit, but it is unknown whether long-term cancer survivors can modify their lifestyle behaviors sufficiently to improve functional status.

OBJECTIVE

To determine whether a telephone counseling and mailed print material-based diet and exercise intervention is effective in reorienting functional decline in older, overweight cancer survivors.

DESIGN, SETTING, AND PARTICIPANTS

Randomized controlled trial of 641 overweight (body mass index > or = 25 and < 40), long-term (> or = 5 years) survivors (aged 65-91 years) of colorectal, breast, and prostate cancer, who were randomly assigned to an intervention group (n = 319) or delayed intervention (control) group (n = 322) in Canada, the United Kingdom, and 21 US states. Individuals were recruited for the Reach out to Enhance Wellness (RENEW) trial from July 1, 2005, through May 17, 2007.

INTERVENTION

A 12-month, home-based tailored program of telephone counseling and mailed materials promoting exercise, improved diet quality, and modest weight loss. The control group was wait-listed for 12 months.

MAIN OUTCOME MEASURES

Change in self-reported physical function on the Short-Form 36 physical function subscale (score range, 0-100; a high score indicates better functioning) from baseline to 12 months was the primary end point. Secondary outcomes included changes in function on the basic and advanced lower extremity function subscales of the Late Life Function and Disability Index (score range, 0-100), physical activity, body mass index, and overall health-related quality of life.

RESULTS

The mean baseline Short-Form 36 physical function score was 75.7. At the 12-month follow-up, the mean function scores declined less rapidly in the intervention group (-2.15; 95% confidence interval [CI], -0.36 to -3.93) compared with the control group (-4.84; 95% CI, -3.04 to -6.63) (P = .03). The mean baseline basic lower extremity function score was 78.2. The mean changes in basic lower extremity function were 0.34 (95% CI, -0.84 to 1.52) in the intervention group compared with -1.89 (95% CI, -0.70 to -3.09) in the control group (P = .005). Physical activity, dietary behaviors, and overall quality of life increased significantly in the intervention group compared with the control group, and weight loss also was greater (2.06 kg [95% CI, 1.69 to 2.43 kg] vs 0.92 kg [95% CI, 0.51 to 1.33 kg], respectively; P < .001).

CONCLUSION

Among older, long-term survivors of colorectal, breast, and prostate cancer, a diet and exercise intervention reduced the rate of self-reported functional decline compared with no intervention.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00303875.

Intensive lifestyle changes may affect the progression of prostate cancer

PURPOSE

Men with prostate cancer are often advised to make changes in diet and lifestyle, although the impact of these changes has not been well documented. Therefore, we evaluated the effects of comprehensive lifestyle changes on prostate specific antigen (PSA), treatment trends and serum stimulated LNCaP cell growth in men with early, biopsy proven prostate cancer after 1 year.

MATERIALS AND METHODS

Patient recruitment was limited to men who had chosen not to undergo any conventional treatment, which provided an unusual opportunity to have a nonintervention randomized control group to avoid the confounding effects of interventions such as radiation, surgery or androgen deprivation therapy. A total of 93 volunteers with serum PSA 4 to 10 ng/ml and cancer Gleason scores less than 7 were randomly assigned to an experimental group that was asked to make comprehensive lifestyle changes or to a usual care control group.

RESULTS

None of the experimental group patients but 6 control patients underwent conventional treatment due to an increase in PSA and/or progression of disease on magnetic resonance imaging. PSA decreased 4% in the experimental group but increased 6% in the control group (p = 0.016). The growth of LNCaP prostate cancer cells (American Type Culture Collection, Manassas, Virginia) was inhibited almost 8 times more by serum from the experimental than from the control group (70% vs 9%, p <0.001). Changes in serum PSA and also in LNCaP cell growth were significantly associated with the degree of change in diet and lifestyle.

CONCLUSIONS

Intensive lifestyle changes may affect the progression of early, low grade prostate cancer in men. Further studies and longer term followup are warranted.

Quality of life in adult survivors of lung, colon and prostate cancer

In a cross-sectional study design, a disease free sample of 57 lung, 117 colon, and 104 prostate cancer survivors who represented short, intermediate and long-term survivors completed a detailed assessment of quality of life (QOL) and rehabilitation needs using the CAncer Rehabilitation Evaluation System (CARES). Demographic and medical data, social support, and a global QOL rating were also assessed. Lung cancer patients showed no differences in QOL with respect to their period of survival. QOL improved for survivors of colon cancer as they lived for longer periods, but declined with time for survivors of prostate cancer. The best predictor of QOL for all groups was KPS, although other variables such as type of hospital, gender, and work status were predictive for survivors of colon cancer. For survivors of prostate cancer comorbidity with other medical illnesses, time since diagnosis and comorbidity due to psychiatric difficulties were predictive of QOL. All groups had significant rehabilitation problems in the domains of physical, psychosocial, sexual, medical interaction, and marital relationships. Lung cancer survivors had more problems than the other cancer survivors. We conclude that patients who survive cancer do not return to a state of normal health. They demonstrate a variety of difficulties with which they must cope as they continue to survive. Greater efforts need to be made early in diagnosis and treatment to understand rehabilitation problems and target interventions in the hope of reducing later sequelae.

Resistance training and reduction of treatment side effects in prostate cancer patients

PURPOSE

To examine the effect of progressive resistance training on muscle function, functional performance, balance, body composition, and muscle thickness in men receiving androgen deprivation for prostate cancer.

METHODS

Ten men aged 59-82 yr on androgen deprivation for localized prostate cancer undertook progressive resistance training for 20 wk at 6- to 12-repetition maximum (RM) for 12 upper- and lower-body exercises in a university exercise rehabilitation clinic. Outcome measures included muscle strength and muscle endurance for the upper and lower body, functional performance (repeated chair rise, usual and fast 6-m walk, 6-m backwards walk, stair climb, and 400-m walk time), and balance by sensory organization test. Body composition was measured by dual-energy x-ray absorptiometry and muscle thickness at four anatomical sites by B-mode ultrasound. Blood samples were assessed for prostate specific antigen (PSA), testosterone, growth hormone (GH), cortisol, and hemoglobin.

RESULTS

Muscle strength (chest press, 40.5%; seated row, 41.9%; leg press, 96.3%; P < 0.001) and muscle endurance (chest press, 114.9%; leg press, 167.1%; P < 0.001) increased significantly after training. Significant improvement (P < 0.05) occurred in the 6-m usual walk (14.1%), 6-m backwards walk (22.3%), chair rise (26.8%), stair climbing (10.4%), 400-m walk (7.4%), and balance (7.8%). Muscle thickness increased (P < 0.05) by 15.7% at the quadriceps site. Whole-body lean mass was preserved with no change in fat mass. There were no significant changes in PSA, testosterone, GH, cortisol, or hemoglobin.

CONCLUSIONS

Progressive resistance exercise has beneficial effects on muscle strength, functional performance and balance in older men receiving androgen deprivation for prostate cancer and should be considered to preserve body composition and reduce treatment side effects.

Outcomes of external-beam radiation therapy for prostate cancer: a study of Medicare beneficiaries in three surveillance, epidemiology, and end results areas

PURPOSE

This study was designed to obtain representative estimates of the quality of life and probabilities of possible adverse effects among Medicare-age patients treated with external-beam radiation therapy for prostate cancer.

METHODS

Patients treated for local or regional prostate cancer with high-energy external-beam radiation between 1989 and 1991 were sampled from a claims data base of the Surveillance, Epidemiology, and End Results (SEER) program from three regions. Patients were surveyed primarily by mail, with telephone follow-up evaluation of non-respondents. There were 621 respondents (83% response rate). The results were compared with data from a previously published national survey of Medicare-age men who had undergone radical prostatectomy.

RESULTS

Although they were older at the time of treatment, radiation patients were less likely than surgical patients to wear pads for wetness (7% v 32%) and had a lower rate of impotence (23% v 56% for men < 70 years), while they were more likely to report problems with bowel dysfunction (10% v 4%). Both groups reported generally positive feelings about their treatments. Radiation and surgical patients reported similar rates of additional subsequent treatment (24% v 26% at 3 years after primary treatment). However, radiation patients were less likely to say they were cancer-free, and they reported more worry about cancer than did surgical patients.

CONCLUSION

The health-related quality of life of radiation and surgical patients, on average, is similar, but the pattern of experience with adverse consequences of treatment differs by treatment.

Interventions to enhance return-to-work for cancer patients

BACKGROUND

Cancer patients are 1.4 times more likely to be unemployed than healthy people. Therefore it is important to provide cancer patients with programmes to support the return-to-work (RTW) process. This is an update of a Cochrane review first published in 2011.

OBJECTIVES

To evaluate the effectiveness of interventions aimed at enhancing RTW in cancer patients compared to alternative programmes including usual care or no intervention.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, in the Cochrane Library Issue 3, 2014), MEDLINE (January 1966 to March 2014), EMBASE (January 1947 to March 2014), CINAHL (January 1983 to March, 2014), OSH-ROM and OSH Update (January 1960 to March, 2014), PsycINFO (January 1806 to 25 March 2014), DARE (January 1995 to March, 2014), ClinicalTrials.gov, Trialregister.nl and Controlled-trials.com up to 25 March 2014. We also examined the reference lists of included studies and selected reviews, and contacted authors of relevant studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of the effectiveness of psycho-educational, vocational, physical, medical or multidisciplinary interventions enhancing RTW in cancer patients. The primary outcome was RTW measured as either RTW rate or sick leave duration measured at 12 months' follow-up. The secondary outcome was quality of life.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion, assessed the risk of bias and extracted data. We pooled study results we judged to be clinically homogeneous in different comparisons reporting risk ratios (RRs) with 95% confidence intervals (CIs). We assessed the overall quality of the evidence for each comparison using the GRADE approach.

MAIN RESULTS

Fifteen RCTs including 1835 cancer patients met the inclusion criteria and because of multiple arms studies we included 19 evaluations. We judged six studies to have a high risk of bias and nine to have a low risk of bias. All included studies were conducted in high income countries and most studies were aimed at breast cancer patients (seven trials) or prostate cancer patients (two trials).Two studies involved psycho-educational interventions including patient education and teaching self-care behaviours. Results indicated low quality evidence of similar RTW rates for psycho-educational interventions compared to care as usual (RR 1.09, 95% CI 0.88 to 1.35, n = 260 patients) and low quality evidence that there is no difference in the effect of psycho-educational interventions compared to care as usual on quality of life (standardised mean difference (SMD) 0.05, 95% CI -0.2 to 0.3, n = 260 patients). We did not find any studies on vocational interventions. In one study breast cancer patients were offered a physical training programme. Low quality evidence suggested that physical training was not more effective than care as usual in improving RTW (RR 1.20, 95% CI 0.32 to 4.54, n = 28 patients) or quality of life (SMD -0.37, 95% CI -0.99 to 0.25, n = 41 patients).Seven RCTs assessed the effects of a medical intervention on RTW. In all studies a less radical or functioning conserving medical intervention was compared with a more radical treatment. We found low quality evidence that less radical, functioning conserving approaches had similar RTW rates as more radical treatments (RR 1.04, 95% CI 0.96 to 1.09, n = 1097 patients) and moderate quality evidence of no differences in quality of life outcomes (SMD 0.10, 95% CI -0.04 to 0.23, n = 1028 patients).Five RCTs involved multidisciplinary interventions in which vocational counselling was combined with patient education, patient counselling, and biofeedback-assisted behavioral training or physical exercises. Moderate quality evidence showed that multidisciplinary interventions involving physical, psycho-educational and vocational components led to higher RTW rates than care as usual (RR 1.11, 95% CI 1.03 to 1.16, n = 450 patients). We found no differences in the effect of multidisciplinary interventions compared to care as usual on quality of life outcomes (SMD 0.03, 95% CI -0.20 to 0.25, n = 316 patients).

AUTHORS' CONCLUSIONS

We found moderate quality evidence that multidisciplinary interventions enhance the RTW of patients with cancer.

A pilot study on the early use of the vacuum erection device after radical retropubic prostatectomy

OBJECTIVE

To evaluate the effect of the early use of the vacuum erection device (VED) on erectile dysfunction (ED) and penile shortening after radical retropubic prostatectomy (RP), as these are important concerns for men choosing among treatment alternatives for localized prostate cancer.

PATIENTS AND METHODS

Twenty-eight men undergoing RP were randomized to early intervention (1 month after RP, group 1) or a control group (6 months after RP, group 2) using a traditional VED protocol. An International Index of Erectile Function (IIEF) score of >11 (no, mild or mild to moderate ED) was required as a baseline criterion for inclusion in the study. Only patients in whom unilateral or bilateral nerves were spared were subsequently randomized. Patients in group 1 followed a daily rehabilitation protocol consisting of 10 min/day using the VED with no constriction ring, for 5 months. Patients were evaluated with the IIEF-5 questionnaire and measurements of penile flaccid length, stretched length, prepubic fat pad, and midshaft circumference before and at 1, 3, 6, 9 and 12 months after RP; the mean (range) last follow-up visit was 9.5 (6-12) months after RP.

RESULTS

The mean (sd) baseline IIEF scores were similar in groups 1 and 2, at 21.1 (4.6) and 22.3 (3.3), respectively (P = 0.54). The IIEF scores were significantly higher in group 1 than group 2 at 3 months, at 11.5 (9.4) vs 1.8 (1.4) (P = 0.008) and at 6 months, at 12.4 (8.7) vs 3.0 (1.9) (P = 0.012) after RP. There were no significant changes in penile flaccid length, prepubic fat pad, or mid-shaft circumference in either group. Stretched penile length was significantly decreased at both 3 and 6 months, by approximately 2 cm (P = 0.013) in group 2. By contrast, stretched penile length was preserved in group 1 at all sample times. At the last follow-up, the proportion of men with a mean loss of penile length of >/= 2 cm was significantly lower in group 1 than group 2 (two/17, 12%, vs five/11, P = 0.044).

CONCLUSIONS

Initiating the use of a VED protocol at 1 month after RP improves early sexual function and helps to preserve penile length.

Body composition, physical fitness, functional performance, quality of life, and fatigue benefits of exercise for prostate cancer patients: a systematic review

CONTEXT

Prostate cancer patients, especially those on androgen deprivation therapy (ADT), experience many symptoms that make it difficult to maintain their independence and quality of life. Because ADT acts by means of reducing testosterone production, exercise may offset many of the ADT side effects and those of the cancer itself.

OBJECTIVES

This systematic review of the literature evaluates whether exercise could reduce symptoms and improve quality of life for prostate cancer patients.

METHODS

Using relevant databases and key words, 12 training studies were found meeting the inclusion and exclusion criteria.

RESULTS

Grade A level evidence was observed for the benefits of exercise in improving muscular endurance, aerobic endurance, and overall quality of life, as well as reducing fatigue in prostate cancer patients. Grade B evidence also suggested that exercise may improve prostate cancer patients' muscle mass, muscular strength, functional performance (walking and sit to stand speed), as well as health-related, social and physical quality of life. These effects appeared greater for group-rather than home-based-exercise, especially if these programs included resistance training.

CONCLUSION

It is recommended that most prostate cancer patients be encouraged to exercise regularly by their clinicians and significant others. Where possible, this exercise should be group-based and include some resistance training. Future research in this area should directly compare group- and home-based, as well as resistance, aerobic, and combined resistance and aerobic training to better elucidate the most effective forms of exercise for this population and what factors affect initiation and adherence to such programs.

Exercise among breast and prostate cancer survivors--what are their barriers?

INTRODUCTION

Despite proven benefits of regular physical activity, estimates indicate that few cancer survivors meet physical activity guidelines. The purpose of this paper is to identify and compare exercise barriers among cancer survivors, both cross-sectionally and longitudinally as they undergo home-based behavioral interventions.

METHODS

Data on a sample of 452 breast and prostate cancer survivors who completed the FRESH START trial were analyzed collectively, as well as separately by cancer type.

RESULTS

More total barriers (3.5 vs. 2.4; p < 0.01) were reported among breast cancer survivors compared with prostate cancer survivors. Commonly reported baseline exercise barriers among both groups were "too busy" (breast, 52% and prostate, 45%) and "no willpower" (breast, 51% and prostate, 44%). At baseline, breast cancer survivors who reported "no willpower" also reported 18.7 fewer minutes of physical activity compared with those not reporting this barrier (p < 0.01). Among prostate cancer survivors, this difference was 39.5 min (p < 0.01). Change in barriers was not associated with change in minutes of physical activity from baseline to post-intervention in either cancer survivor group.

CONCLUSIONS

This is the largest study evaluating barriers and physical activity over time among cancer survivors. There are similarities and differences that both need to be taken into consideration when promoting physical activity among subgroups of survivors.

IMPLICATIONS FOR CANCER SURVIVORS

Knowledge concerning barriers associated with reported physical activity may be helpful in designing optimally targeted physical activity interventions among breast and prostate cancer survivors.

Interventions for promoting habitual exercise in people living with and beyond cancer

BACKGROUND

This is an updated version of the original Cochrane Review published in the Cochrane Library 2013, Issue 9. Despite good evidence for the health benefits of regular exercise for people living with or beyond cancer, understanding how to promote sustainable exercise behaviour change in sedentary cancer survivors, particularly over the long term, is not as well understood. A large majority of people living with or recovering from cancer do not meet current exercise recommendations. Hence, reviewing the evidence on how to promote and sustain exercise behaviour is important for understanding the most effective strategies to ensure benefit in the patient population and identify research gaps.

OBJECTIVES

To assess the effects of interventions designed to promote exercise behaviour in sedentary people living with and beyond cancer and to address the following secondary questions: Which interventions are most effective in improving aerobic fitness and skeletal muscle strength and endurance? Which interventions are most effective in improving exercise behaviour amongst patients with different cancers? Which interventions are most likely to promote long-term (12 months or longer) exercise behaviour? What frequency of contact with exercise professionals and/or healthcare professionals is associated with increased exercise behaviour? What theoretical basis is most often associated with better behavioural outcomes? What behaviour change techniques (BCTs) are most often associated with increased exercise behaviour? What adverse effects are attributed to different exercise interventions?

SEARCH METHODS

We used standard methodological procedures expected by Cochrane. We updated our 2013 Cochrane systematic review by updating the searches of the following electronic databases: Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, Embase, AMED, CINAHL, PsycLIT/PsycINFO, SportDiscus and PEDro up to May 2018. We also searched the grey literature, trial registries, wrote to leading experts in the field and searched reference lists of included studies and other related recent systematic reviews.

SELECTION CRITERIA

We included only randomised controlled trials (RCTs) that compared an exercise intervention with usual care or 'waiting list' control in sedentary people over the age of 18 with a homogenous primary cancer diagnosis.

DATA COLLECTION AND ANALYSIS

In the update, review authors independently screened all titles and abstracts to identify studies that might meet the inclusion criteria, or that could not be safely excluded without assessment of the full text (e.g. when no abstract is available). We extracted data from all eligible papers with at least two members of the author team working independently (RT, LS and RG). We coded BCTs according to the CALO-RE taxonomy. Risk of bias was assessed using the Cochrane's tool for assessing risk of bias. When possible, and if appropriate, we performed a fixed-effect meta-analysis of study outcomes. If statistical heterogeneity was noted, a meta-analysis was performed using a random-effects model. For continuous outcomes (e.g. cardiorespiratory fitness), we extracted the final value, the standard deviation (SD) of the outcome of interest and the number of participants assessed at follow-up in each treatment arm, to estimate the standardised mean difference (SMD) between treatment arms. SMD was used, as investigators used heterogeneous methods to assess individual outcomes. If a meta-analysis was not possible or was not appropriate, we narratively synthesised studies. The quality of the evidence was assessed using the GRADE approach with the GRADE profiler.

MAIN RESULTS

We included 23 studies in this review, involving a total of 1372 participants (an addition of 10 studies, 724 participants from the original review); 227 full texts were screened in the update and 377 full texts were screened in the original review leaving 35 publications from a total of 23 unique studies included in the review. We planned to include all cancers, but only studies involving breast, prostate, colorectal and lung cancer met the inclusion criteria. Thirteen studies incorporated a target level of exercise that could meet current recommendations for moderate-intensity aerobic exercise (i.e.150 minutes per week); or resistance exercise (i.e. strength training exercises at least two days per week).Adherence to exercise interventions, which is crucial for understanding treatment dose, is still reported inconsistently. Eight studies reported intervention adherence of 75% or greater to an exercise prescription that met current guidelines. These studies all included a component of supervision: in our analysis of BCTs we designated these studies as 'Tier 1 trials'. Six studies reported intervention adherence of 75% or greater to an aerobic exercise goal that was less than the current guideline recommendations: in our analysis of BCTs we designated these studies as 'Tier 2 trials.' A hierarchy of BCTs was developed for Tier 1 and Tier 2 trials, with programme goal setting, setting of graded tasks and instruction of how to perform behaviour being amongst the most frequent BCTs. Despite the uncertainty surrounding adherence in some of the included studies, interventions resulted in improvements in aerobic exercise tolerance at eight to 12 weeks (SMD 0.54, 95% CI 0.37 to 0.70; 604 participants, 10 studies; low-quality evidence) versus usual care. At six months, aerobic exercise tolerance was also improved (SMD 0.56, 95% CI 0.39 to 0.72; 591 participants; 7 studies; low-quality evidence).

AUTHORS' CONCLUSIONS

Since the last version of this review, none of the new relevant studies have provided additional information to change the conclusions. We have found some improved understanding of how to encourage previously inactive cancer survivors to achieve international physical activity guidelines. Goal setting, setting of graded tasks and instruction of how to perform behaviour, feature in interventions that meet recommendations targets and report adherence of 75% or more. However, long-term follow-up data are still limited, and the majority of studies are in white women with breast cancer. There are still a considerable number of published studies with numerous and varied issues related to high risk of bias and poor reporting standards. Additionally, the meta-analyses were often graded as consisting of low- to very low-certainty evidence. A very small number of serious adverse effects were reported amongst the studies, providing reassurance exercise is safe for this population.

Active for Life After Cancer: a randomized trial examining a lifestyle physical activity program for prostate cancer patients

BACKGROUND

Active for Life After Cancer is a randomized trial evaluating the efficacy of a 6-month group-based lifestyle physical activity program (Lifestyle) for prostate cancer patients to improve quality of life (QOL) including physical and emotional functioning compared to a group-based Educational Support Program and a Standard Care Program (no group).

METHOD

A total of 134 prostate cancer patients receiving continuous androgen-ablation were randomly assigned to one of the three study conditions.

RESULTS

Results indicated no significant improvements in QOL at 6 or 12 months. Both group-based programs were positively received and yielded good attendance and retention. Lifestyle participants demonstrated significant improvements in most theoretical mediators proposed by the Transtheoretical Model and Social Cognitive Theory to affect physical activity. Despite these improvements, no significant changes were found for most physical activity measures.

CONCLUSIONS

Results suggest a lifestyle program focusing on cognitive-behavioral skills training alone is insufficient for promoting routine physical activity in these patients.

Cancer rehabilitation: particularly with aspects on physical impairments

Cancer can cause multiple impairments, activity limitations and participation restrictions. According to individual case findings and needs, rehabilitation treatment is varied. The review mainly focuses on specific problems. Because of functional deficits cancer patients suffer from persistent emotional and social distress and a reduced quality of life (QOL). QOL encompasses at least the four dimensions of physical, emotional, social and cognitive function, which may be positively influenced by physical exercise. Physical exercise also has been shown to prevent or minimise inactivity/ disuse problems and to reduce fatigue. The management of sexuality dysfunction has to begin with a thorough history taking and a consequent sexuality counselling. The goals of rehabilitation procedures under palliative care are not only to control physical pain but also to help with mental, social and spiritual pain, together with other symptoms. Rehabilitation problems in head and neck cancer, sexuality, lung cancer, prostate cancer, breast cancer and lymphedema can be improved by rehabilitation. The review mainly focuses on impairment and activity limitation. Social, psychological and vocational aspects are left aside in this review.

Impact of a walking intervention on cardiorespiratory fitness, self-reported physical function, and pain in patients undergoing treatment for solid tumors

BACKGROUND

Cancer treatment is associated with decline in measured and self-reported physical function and increased pain. In the current study, the authors evaluated the impact of a walking intervention on these outcomes during chemotherapy/radiation.

METHODS

Patients with breast, prostate, and other cancers (N=126) were randomized to a home-based walking intervention (exercise) or usual care (control). Exercise dose during the intervention was assessed using a 5-item Physical Activity Questionnaire. Outcome measures were cardiorespiratory fitness, expressed as peak oxygen uptake (VO2) measured during treadmill testing (n=85) or estimated by 12-minute walk (n=27), and self-reported physical function, role limitations, and pain derived from Medical Outcomes Study Short Form 36. Linear regression was used to evaluate pre-to-post intervention change outcomes between groups.

RESULTS

The mean (standard deviation) age of the patients was 60.2 (10.6) years. Diagnoses included prostate (55.6%) and breast (32.5%) cancer. Treatment included external beam radiotherapy (52.3%) and chemotherapy (34.9%). Exercise patients reported worsening Medical Outcomes Study physical function role limitations by the end of cancer treatment (P=.037). Younger age was associated with improved Medical Outcomes Study physical function (P=.048). In all patients, increased exercise dose was associated with decreased Medical Outcomes Study pain (P=.046), regardless of diagnosis. The percent change of VO2 between prostate and nonprostate cancer patients when adjusted for baseline VO2 and Physical Activity Questionnaire values was 17.45% (P=.008), with better VO2 maintenance in the prostate group.

CONCLUSIONS

Exercise during cancer treatment improves cardiorespiratory fitness and self-reported physical function in prostate cancer patients and in younger patients, regardless of diagnosis, and may attenuate loss of those capacities in patients undergoing chemotherapy. Exercise also reduces the pain experience.

Prostate cancer patients and their partners: differences in satisfaction indices and psychological variables

INTRODUCTION

Prostate cancer is the most common type of cancer found in American men. Patient adjustment to prostate cancer is not limited to attempts to restore sexual function, a process that can pose significant challenges to couples following most surgical and nonsurgical treatments. Patients often struggle with depression and other relational stressors. Partners also undergo psychosocial, relational, sexual, and quality-of-life changes and their responses to these changes may relate to patient adjustment.

AIM

To evaluate to what extent partners' psychosocial and relational adjustment relates to prostate cancer patient adjustment.

MAIN OUTCOME MEASURES

Partner and patient general and sexual depression; patient relationship satisfaction, quality of sexual communication, sexual satisfaction, and life satisfaction.

METHOD

A total of 77 patients and 57 partners responded to a mail survey that included demographic information, the Beck Depression Inventory, Life Satisfaction Index, Index of Sexual Satisfaction, Relationship Assessment Scale, Dyadic Sexual Communication Scale, Sexuality Scale, and Client Satisfaction Questionnaire.

RESULTS

Patients and their partners differed in their sexual self-esteem, sexual depression, sexual preoccupation, and life satisfaction. Both had greater levels of depression, poorer quality of sexual communication, and more sexual dissatisfaction than the general population. Partners' level of general depression and depression concerning their sex lives were significant predictors of patients' relationship satisfaction, perceived quality of communication about the sexual relationship, and sexual satisfaction after controlling for patients' general and sexual depression.

CONCLUSION

Partners often serve as primary caregivers, thus partner adjustment can be critical to the health of the patient and to his primary relationship. Results suggest the importance of including partners' adjustment in assessing patient adjustment post-treatment. We suggest that physicians working with these patients partner with mental health professionals who can help couples address the challenges they encounter and extend the continuity of care when the need for medical intervention has passed.

Determinants of exercise intention and behavior in survivors of breast and prostate cancer: an application of the theory of planned behavior

The purpose of this study was to evaluate the theory of planned behavior as a framework for understanding exercise intention and behavior in survivors of breast and prostate cancer. Participants were 83 survivors of breast and 46 survivors of prostate cancer who were diagnosed within the previous 4 years and had completed treatment. Each participant completed a mailed self-administered questionnaire that assessed exercise during the previous week, demographic and medical variables, and the theory of planned behavior. For survivors of breast cancer, regression analyses indicated that attitude, subjective norm, and perceived behavioral control explained 45% of the variance in exercise intention with attitude, subjective norm, and perceived behavioral control each uniquely contributing to intention. Furthermore, exercise intention explained 30% of the variance in exercise behavior; however, perceived behavioral control added no unique variance. For survivors of prostate cancer, attitudes, subjective norm, and perceived behavioral control explained 36% of the variance in exercise intention, but only perceived behavioral control made a significant unique contribution. Furthermore, intention explained 36% of the variance in exercise behavior; however, perceived behavioral control added no unique variance. Results suggest that nurses may use the theory of planned behavior as a model for understanding the determinants of exercise intentions and behavior in survivors of breast and prostate cancer.

Interventions for promoting habitual exercise in people living with and beyond cancer

BACKGROUND

The beneficial effects of regular exercise for people living with or beyond cancer are becoming apparent. However, how to promote exercise behaviour in sedentary cancer cohorts is not as well understood. A large majority of people living with or recovering from cancer do not meet exercise recommendations. Hence, reviewing the evidence on how to promote and sustain exercise behaviour is important.

OBJECTIVES

To assess the effects of interventions to promote exercise behaviour in sedentary people living with and beyond cancer and to address the following questions: Which interventions are most effective in improving aerobic fitness and skeletal muscle strength and endurance? What adverse effects are attributed to different exercise interventions? Which interventions are most effective in improving exercise behaviour amongst patients with different cancers? Which interventions are most likely to promote long-term (12 months or longer) exercise behaviour? What frequency of contact with exercise professionals is associated with increased exercise behaviour? What theoretical basis is most often associated with increased exercise behaviour? What behaviour change techniques are most often associated with increased exercise behaviour?

SEARCH METHODS

We searched the following electronic databases: Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 8, 2012), MEDLINE, EMBASE, AMED, CINAHL, PsycLIT/PsycINFO, SportDiscus and PEDro from inception to August 2012. We also searched the grey literature, wrote to leading experts in the field, wrote to charities and searched reference lists of other recent systematic reviews.

SELECTION CRITERIA

We included only randomised controlled trials (RCTs) that compared an exercise intervention with a usual care approach in sedentary people over the age of 18 with a homogenous primary cancer diagnosis.

DATA COLLECTION AND ANALYSIS

Two review authors working independently (LB and KH) screened all titles and abstracts to identify studies that might meet the inclusion criteria, or that cannot be safely excluded without assessment of the full text (e.g. when no abstract is available). All eligible papers were formally abstracted by at least two members of the review author team working independently (LB and KH) and using the data collection form. When possible, and if appropriate, we performed a fixed-effect meta-analysis of study outcomes. For continuous outcomes (e.g. cardiorespiratory fitness), we extracted the final value, the standard deviation of the outcome of interest and the number of participants assessed at follow-up in each treatment arm, to estimate standardised mean difference (SMD) between treatment arms. SMD was used, as investigators used heterogeneous methods to assess individual outcomes. If a meta-analysis was not possible or was not appropriate, we synthesised studies as a narrative.

MAIN RESULTS

Fourteen trials were included in this review, involving a total of 648 participants. Only studies involving breast, prostate or colorectal cancer were identified as eligible. Just six trials incorporated a target level of exercise that could meet current recommendations. Only three trials were identified that attempted to objectively validate independent exercise behaviour with accelerometers or heart rate monitoring. Adherence to exercise interventions, which is crucial for understanding treatment dose, is often poorly reported. It is important to note that the fundamental metrics of exercise behaviour (i.e. frequency, intensity and duration, repetitions, sets and intensity of resistance training), although easy to devise and report, are seldom included in published clinical trials.None of the included trials reported that 75% or greater adherence (the stated primary outcome for this review) of the intervention group met current aerobic exercise recommendations at any given follow-up. Just two trials reported six weeks of resistance exercise behaviour that would meet the guideline recommendations. However, three trials reported adherence of 75% or greater to an aerobic exercise goal that was less than the current guideline recommendation of 150 minutes per week. All three incorporated both supervised and independent exercise components as part of the intervention, and none placed restrictions on the control group in terms of exercise behaviour. These three trials shared programme set goals and the following behaviour change techniques: generalisation of a target behaviour; prompting of self-monitoring of behaviour; and prompting of practise. Despite the uncertainty surrounding adherence in many of the included trials, interventions caused improvements in aerobic exercise tolerance at 8 to 12 weeks (from 7 studies, SMD 0.73, 95% confidence interval (CI) 0.51 to 0.95) in intervention participants compared with controls. At six months, aerobic exercise tolerance was also improved (from 5 studies, SMD 0.70, 95% CI 0.45 to 0.94), but it should be noted that four of the five trials used in this analysis had a high risk of bias, hence caution is warranted in interpretation of results. Attrition over the course of these interventions is typically low (median 6%).

AUTHORS' CONCLUSIONS

Interventions to promote exercise in cancer survivors who report better levels of adherence share some common behaviour change techniques. These involve setting programme goals, prompting practise and self-monitoring and encouraging participants to attempt to generalise behaviours learned in supervised exercise environments to other, non-supervised contexts. However, expecting most sedentary survivors to achieve current guideline recommendations of at least 150 minutes per week of aerobic exercise is likely to be unrealistic. As with all well-designed exercise programmes in any context, prescriptions should be designed around individual capabilities, and frequency, duration and intensity or sets, repetitions, intensity or resistance training should be generated on this basis.

"I wish I'd told them": a qualitative study examining the unmet psychosexual needs of prostate cancer patients during follow-up after treatment

OBJECTIVE

To gain insight into patients' experiences of follow-up care after treatment for prostate cancer and identify unmet psychosexual needs.

METHODS

Semi-structured interviews were conducted with a purposive sample of 35 patients aged 59-82 from three UK regions. Partners were included in 18 interviews. Data were analyzed using constant comparison.

RESULTS

(1) Psychosexual problems gained importance over time, (2) men felt they were rarely invited to discuss psychosexual side effects within follow-up appointments and lack of rapport with health care professionals made it difficult to raise problems themselves, (3) problems were sometimes concealed or accepted and professionals' attempts to explore potential difficulties were resisted by some, and (4) older patients were too embarrassed to raise psychosexual concerns as they felt they would be considered 'too old' to be worried about the loss of sexual function.

CONCLUSION

Men with prostate cancer, even the very elderly, have psychosexual issues for variable times after diagnosis. These are not currently always addressed at the appropriate time for the patient.

PRACTICE IMPLICATIONS

Assessments of psychosexual problems should take place throughout the follow-up period, and not only at the time of initial treatment. Further research examining greater willingness or reluctance to engage with psychosexual interventions may be particularly helpful in designing future interventions.

Radical perineal prostatectomy: cost efficient, outcome effective, minimally invasive prostate cancer management

OBJECTIVE

Localized prostate cancer is a common disease for which minimally invasive treatment methods are being explored. Perineal prostatectomy, as a historical open procedure, is modified to incorporate contemporary surgical ideas. There is relatively little in the literature regarding modern adaptations of perineal prostatectomy. This method of anatomic radical perineal prostatectomy has been developed to accomplish a minimally invasive method of achieving goals of disease control and preservation of genito-urinary functions.

METHODS

Prospective outcome data is accumulated on 508 consecutive radical perineal prostatectomies by a single surgeon. Pathologic stage and PSA detectability are measures of cancer control. Pad use and ability to complete intercourse measure urinary and sexual function. General complications and other outcome measures are evaluated.

RESULTS

Freedom from PSA detectability by pathologic stage is 96.3%, 79.4%, and 69.4% for organ confined, specimen confined and margin positive in the absence of seminal vesical invasion with an average 4 years follow up (3-114 months). Margins are positive in 18% of cases. The average cancer size is 9.4g and 36% of cases have extracapsular invasion. By the first, third, sixth months and one year, 38%, 65%, 88% and 96% are free of pad use and report being dry. While over 80% of nerve-spared patients enjoy the return of spontaneous erectile function, the men with bilateral nerve preservation note earlier and more complete return of function. There are no cardiopulmonary complications or deaths. Transfusions occurred in 1%, none in the past 400 cases. Average total hospital charges are USD$4889.00 in 1999 and 2000. Anterior urethral strictures, anastomotic strictures and fecal urgency/stress flatus occur 2%, 2% and 2-4%, respectively.

CONCLUSIONS

This method of prostatectomy is able to achieve complete cancer resection while preserving urinary and sexual function as well as laparoscopic or retropubic prostatectomy. The simplicity and minimally invasive nature of this procedure contribute to a short recovery and low overall cost of therapy. The anatomic radical perineal prostatectomy is a cost-efficient, outcome effective minimally invasive method of treating men with localized prostate cancer.

Sexual rehabilitation after treatment for prostate cancer

Although there is little evidence that sexual behavior causes prostate cancer, men with prostate cancer often have sexual dysfunction before the cancer diagnosis is made. Each treatment for prostate cancer increases the prevalence of sexual problems. After nerve-sparing radical prostatectomy, the chance of recovering erections is better for men who are younger and in whom both neurovascular bundles can be spared. Definitions of "potency" after nerve-sparing surgery have not specified the rigidity of the erections achieved. Thus, some men classified as "potent" may wish additional sexual rehabilitation. The chance that definitive radiation therapy will cause erectile dysfunction probably has been overestimated. The prevalence rate may be closer to 25% of men with new problems compared with the 50% often cited in the literature. Men are more at risk to have erection problems after radiation therapy if the quality of erections before treatment was borderline. Hormonal therapy has an impact on the central mechanisms mediating sexual desire and arousability. Therefore, with most treatment methods, only approximately 20% of men remain sexually functional. Newer antiandrogenic drugs interfere less with sexual function, but their long-term ability to control prostate cancer is still under investigation. Sexual rehabilitation should be addressed by the primary care team. Sexual partners should be included in brief sexual counseling, even when a mechanical treatment for erectile dysfunction is prescribed.

Biofeedback vs verbal feedback as learning tools for pelvic muscle exercises in the early management of urinary incontinence after radical prostatectomy

OBJECTIVE

To evaluate the comparative effectiveness of electromyographic (EMG) biofeedback with verbal instructions as learning tools of pelvic muscle exercises (PMEs) in the early management of urinary incontinence after radical prostatectomy.

PATIENTS AND METHODS

Forty-two consecutive patients (mean age 64 years, sd 4.2), with urinary incontinence after radical retropubic prostatectomy for localized prostate cancer, were randomized to receive biofeedback (group A, 28 men) or verbal feedback (group B, 14 men) as learning tools for PMEs immediately after catheter removal. Group A received 15 sessions of EMG biofeedback (three times weekly, 30 min each) and group B verbal instructions. Evaluation at baseline and 1, 2, 3 and 6 months included the 1-h pad-test and a questionnaire (number of pads/day and incontinence episodes).

RESULTS

By the last follow-up, 27 patients had received biofeedback and 15 verbal instructions. Data were analysed according to the intention-to-treat principle. Urine loss as assessed by the 1-h pad-test at baseline, 1, 2, 3 and 6 months was 39, 18, 7, 4 and 3 g for group A and 31, 11, 3, 1 and 0 g for group B, respectively (P > 0.05). The number of pads/day was 3.9, 3.4, 1.2, 0.8 and 0.4 for group A and 3.6, 1.8, 0.9, 0.4 and 0.2 for group B, respectively (P > 0.05). The overall continence rate at 6 months was objectively (urine loss > 1 g) 91% and subjectively (0-1 pad/day) 95%.

CONCLUSION

Intensive verbal instructions and biofeedback were both very effective behavioural methods and learning tools for PMEs in the early management of urinary incontinence after radical prostatectomy.

Living after radical prostatectomy for localized prostate cancer: a qualitative analysis of patient narratives

The purpose of this study was to illuminate the experience of living after radical prostatectomy (RP) for localized prostate cancer (LPC). Ten men were interviewed after RP. The interview text was qualitatively analyzed using the content analysis. The men suffered from worry, anxiety, and distress, and longed for life as they had lived it before the diagnosis. Changes in bodily functions after RP include urine incontinence (UI) and/or erectile dysfunction (ED) making the patient feel like a changed man with a lost sex life, with changes in his intimate relations with his wife, and with lowered self-esteem. Most men choose to cope on their own. Coping strategies in our study population included finding new areas of interest and a new focus in the present. In the present study, living after RP meant striving to gain control over, and become reconciled with, the new life situation as a changed man living with an altered self.

Resistance Exercise Dosage in Men with Prostate Cancer: Systematic Review, Meta-analysis, and Meta-regression

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.

Sequelae of definitive radiation therapy for prostate cancer localized to the pelvis

OBJECTIVES

To evaluate sequelae and estimate quality of life utilizing a survey instrument in 133 consecutive patients who have undergone definitive radiation therapy for localized prostate cancer.

METHODS

All patients reported on have been followed for 14 to 60 months (median, 31 months) after radiation therapy and only patients with definitive prostate radiation therapy are included. Of the patients still alive at time of follow-up, 115 were mailed the questionnaire. Data regarding tumor grade and stage as well as treatment were extracted from patient files.

RESULTS

Of the 91% of patients who returned the questionnaire, 11% used a pad and 13% leaked more than a few drops of urine daily. Of all the respondents, 9% stated that incontinence was a problem, and 31% found urinary leaking significantly worsened after radiation therapy compared with before their diagnosis of prostate cancer. With respect to sexual function, 77% recalled being able to have full or partial erections prior to radiation therapy. At some time after radiation therapy, 22% of previously potent respondents were able to have a full erection and 41% were able to have a partial erection. Twenty-nine percent of all patients who were able to establish an erection prior to radiation therapy reported that impotence was a problem at the time of follow-up. Forty-nine percent of patients had abdominal pain, diarrhea, or abdominal cramping during or after radiation therapy and 31% of all patients still had some intestinal symptoms at the time of follow-up. Eighteen percent of all patients were significantly bothered by one or more of these bowel problems. Overall, 31% of all patients reported a persistent degree of physical discomfort that they believed was secondary to their prostate cancer or the effect of treatment. Eighty-one percent were satisfied with radiation therapy and 97% of the patients said they would have radiation therapy again if faced with the decision.

CONCLUSIONS

Utilizing a sensitive questionnaire on patients who had definitive radiation therapy for prostate cancer, we found the incidence of patients bothered by incontinence to be surprisingly frequent and higher than previously reported. The frequency of impotence is similar to previous studies. However, when our incontinence and impotence data were compared to Medicare patients who had undergone radical prostatectomy, the frequencies after radiation therapy were significantly lower. Despite the rates of sequelae, the patients were generally satisfied with the decision to undergo radiation therapy and with the medical treatment received.

Re-constructing masculinity following radical prostatectomy for prostate cancer

Prostate cancer is common in older men. Surgical treatment involving removal of the prostate can result in temporary or permanent erectile dysfunction (ED) and incontinence and have a major impact on men's masculine identity. Seven men were interviewed about their experiences and concerns following prostatectomy, and the transcripts were analysed employing Foucauldian Discourse Analysis to identify the ways in which they constructed their masculinity. Participants drew upon four main discourses when discussing the impact of surgical treatment on their sense of masculinity: masculine identity and sexual activity, ED as a normative experience, mental resilience and vulnerability. Penetrative sex was constructed as central to a masculine identity, but inability to achieve this was normalised in terms of the ageing process. Stereotypically masculine qualities of emotional control and rationality were drawn on in describing their reaction to the diagnosis and treatment of cancer but they also experienced a new-found sense of physical vulnerability. The findings are discussed in terms of their implications for the clinical management of ED post-surgery and helping men adjust to life following treatment.