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Considering the growing body of evidence that implicates lifestyle in the role of prostate cancer development and progression, increasing number of men with low- to intermediate risk prostate cancer receive active surveillance (AS) as a primary management strategy. AS includes regular monitoring of prostate-specific antigen (PSA) blood level, physical exam as well as prostate biopsies and imaging tests (every 1 to 3 years). Needless to say, among some men on AS the fear of prostate cancer progression that may require radical treatments, including surgery or radiation therapy may cause psychological distress and anxiety. In turn, that may lead to diminished quality of life and even prompting some to choose radical treatment options despite no evidence of prostate cancer progression.
Although many patients are making changes to their lifestyle to slow or reverse the progression of their prostate disease, appropriate lifestyle modifications would also significantly decrease their risk of death from cardiovascular disease and other lifestyle-associated chronic conditions. This is important because men with prostate cancer who are on AS have higher risk of dying from cardiovascular disease (heart attack and stroke) than prostate cancer.
About 15 years ago, in a randomized clinical trial in duration of 2 years, it was demonstrated that patients in the experimental group of The Prostate Cancer Lifestyle Trial with early-stage prostate cancer on AS who made comprehensive changes in their lifestyle had significant reduction in PSA levels (https://pubmed.ncbi.nlm.nih.gov/16094059/) and experienced better quality of life and sexual function when compared with controls (https://pubmed.ncbi.nlm.nih.gov/16413347/). These findings support the idea that men on AS who actively manage their health by positive lifestyle behaviors may be able to avoid or delay conventional treatments and improve their overall quality of life via enhanced feelings of hope, optimism, and a “fighting spirit”.
The participants in that study were encouraged to adopt a low-fat, plant-based diet of whole, unrefined foods, to exercise (3 hours of aerobic exercise per week), practice stress management (1 hour of yoga and meditation per day) and to attend group support sessions. The control patients received the usual care. Importantly, similar studies show that implementation of comprehensive health-promoting lifestyle modifications in domains of foods, stress relief, physical activity and psychosocial support may reduce the risk of other lifestyle-related conditions such as cardiovascular disease, type 2 diabetes and obesity men on AS may have.
In contrast to continued support that is provided in the setting of clinical studies, in real life situations for many men (and their spouses and families) the idea of simultaneously increasing physical activity, regularly engaging in stress relief practices via Yoga or Tai Chi or formal meditation and modifying food consumption patterns towards eating more vegetables, beans, fruits, whole grains and nuts on their own may be too big a bite. The good news is that improvements in any of these self-care domains separately appear to be beneficial, positively affecting multiple metabolic pathways critical in cancer. Starting with just one self-care domain, being that a plant-predominant eating pattern or a different exercise routine or a new stress relief practice may be more doable and gradual step in overall lifestyle improvement.
About a half of adults responding to Global Consumer Survey listed desire to exercise more in 2022 as their most common New Year resolution. This is not surprising because it is widely understood that regular physical activity, that magic “exercise pill”, supports every system of the body, muscles and brain and heart and other organs. Prostate is not any different. Regardless of their New Year’s resolutions, for those men with prostate cancer on AS researchers at the University of Alberta, Canada, recently provided compelling reasons to put increased physical activity on the top of their “must do” list.
In the ERASE (Exercise during Active Surveillance for Prostate Cancer) randomized clinical trial, 52 patients with prostate cancer (average age of 63 years) on AS were randomized into usual care group that was instructed to maintain their usual physical activity or into high-intensity interval training (HIIT) group. In contrast to universally known workouts in which one maintains pretty uniform intensity level, in HIIT one is alternating between periods of intense, uncomfortable exertion and periods of mild or moderate exertion.
Patients on AS of the HIIT group participated three times per week for 12 weeks in supervised aerobic HIIT on treadmill. They first warmed up for 5 min, then performed walking or jogging for 2 minutes corresponding to 85% to 95% of their, previously determined, maximal exercise capacity (that’s why it is called high intensity for that particular patient and why it could be uncomfortable) followed by 2 minutes of active recovery at 40% and those cycles (high activity/recovery) were repeated 5 to 8 times. Exercise intensity and numbers of intervals during each session progressed over the intervention period. After each session, participants conducted a 5 min cooldown and stretching of lower body muscles for another 5 minutes.
The results were impressive. First, the adherence with HIIT was outstanding 96%! Patients in the exercise group became significantly more cardio-vascularly fit when compared with those in the control group. No surprise here. Compared with the usual care group, patients in the HIIT group had decreased PSA level and PSA velocity (the change in PSA levels over time) and their plasma appreciably inhibited the growth of prostate cancer cells in the test tube experiments (https://pubmed.ncbi.nlm.nih.gov/34410322/). And there is more. Participants in HIIT also reported significantly reduced prostate cancer-specific anxiety, less fear of progression and decreased perceived stress and fatigue and increased self-esteem (https://pubmed.ncbi.nlm.nih.gov/35179044/).
Exercise has been shown to significantly improve anxiety and quality of life in patients with prostate cancer both during and after radical treatments (and patients with other types of cancer, too). Thanks to this study, now we know that patients with prostate cancer on AS may reap similar benefits. If for whatever reason, HIIT does not activate your experimental spirit, do not despair. If you already have a good old-fashioned walking, jogging, biking, swimming or dancing routine you enjoy, feel free to stick with it and kick things up a notch or mix it up with short high intensity intervals.
And if you desire to start your exercise routine from scratch, that is, the couch, make sure to talk with your doctor first and start with something simple, like walking several days a week. Focus on sitting less and moving more – any activity, at an intensity and duration and frequency you can tolerate will make your body and mind stronger. Simply put, every movement matters, every step counts. Take that first step! As stated by Lao Tzu, the ancient Chinese philosopher and writer, "A journey of a thousand miles begins with a single step".
You may also choose to be guided by experienced exercise physiologists and participate in ongoing exercise programs for cancer survivors at Cancer Wellness Clinic (https://www.uchealth.com/en/cancer-center/cancer-survivorship). Or begin the practice of Tai Chi or Yoga via virtual or in-person classes (https://www.uchealth.com/integrative/classes-and-events/). Low intensity practice of Yoga and Tai Chi has been shown to reduce anxiety, depression, fatigue and to improve sleep, balance, muscle strength and flexibility in people with cancer. Experiment! Focus on progress, not perfection! We are here to help you on that journey.
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