Dr. Daniel Galvão: Exercise As Medicine For Prostate Cancer

In October’s Prostatepedia, we’re talking the impact diet, exercise and lifestyle can have on prostate cancer.

Dr. Daniel Galvão, a Professor of Exercise and Sports Science and Co-Director of the Edith Cowan University Health and Wellness Institute in Australia, is crusading research into how exercise influences prostate cancer patients’ quality of life, ability to weather treatment side effects, and time to progression.

Prostatepedia spoke with him recently about the exercise program he recommends for prostate cancer patients.

Daniel_Galvao

Prostatepedia: Let’s start by talking a little bit about you: where you trained and the focus of your current research.

Dr. Daniel Galvão: I’m an exercise physiologist. My background is in clinical exercise science. I did my Bachelor in Physical Education degree in Brazil, Masters in Clinical Exercise Science at the University of Queensland, Australia and a PhD in Exercise Science and Prostate Cancer at Edith Cowan University, Australia.

My research interest is in applications of exercise as medicine for the prevention and management of prostate cancer treatment side-effects and survival. I always had a lot of interest in the aging process and the health issues older men face. Of course, prostate cancer is a major clinical issue. I was very interested in exercise gerontology—exercise in aging and was mentored by a leading international Exercise Gerontologist Prof Dennis Taaffe during my time at the University of Queensland, Australia. This was a natural link to prostate cancer where I was very fortunate to be mentored during my doctoral studies by international leaders and close colleagues today Professor Robert Newton and Clinical Professor Nigel Spry, where we brought the disciplines of exercise science, gerontology, and clinical oncology and prostate cancer together as the basis of our future work aiming to answer meaningful research questions in this novel field of exercise-oncology.

At the time I was doing my PhD, this approach was extremely novel. We used resistance training, or strength training, an anabolic exercise mode in men undergoing therapy for prostate cancer. In particular, men treated with androgen deprivation therapy (ADT), a well-known type of therapy that suppresses testosterone. ADT, or hormonal therapy, is an important tool to control prostate cancer. It is used across a range of different settings from men with local aggressive disease to men with advanced disease. Hormonal therapy leads to a number of side effects that can substantially affect quality of life: erectile dysfunction, muscle loss, a potential increase in cardiovascular and metabolic complications, and loss of bone mass.

Our intention was to trial interventions such as exercise as medicine to offset or mitigate these issues and toxicities. This was really the first study looking at physiological and physical outcomes in patients on hormonal therapy. That study was published nearly ten years ago; it has been quite an influential study in the area.

Prostatepedia: Can you talk about the study design?

Dr. Galvão: It was a single cohort pilot study—single arm, and a relatively small study. We were testing the feasibility and efficacy of exercise in these men. Can patients do it? Can they tolerate resistance training while receiving testosterone suppression? Is it safe? Is it effective?

We found that exercise was indeed safe. Exercise didn’t change levels of testosterone, which could potentially be a concern for clinicians. (If the aim of therapy is to reduce testosterone, we don’t want to raise testosterone with exercise.)

At the same time, there were no injuries and no adverse events. Patients were able to substantially improve muscle strength. This translated into improvements in functional performance for activities of daily living. They were able to do things during the day more easily than they could before. They also substantially improved their quality of life.

We subsequently extended this study and undertook a randomized controlled trial that was published in the Journal of Clinical Oncology back in 2010 that combined resistance training with aerobic training which also extended the work from our colleagues in Canada (Prof Segal). Aerobic training is walking, cycling, or running. We combined the two exercise modalities in a comprehensive clinical trial. There were two arms: an arm of men who did exercise while on ADT and a control arm of men who were only on ADT without exercise.

We looked at a range of different parameters. For the first time, we reported that exercise could actually stop muscle loss which can be clinically meaningful and relevant to patients. Normally, you lose one to two kilos or two to four pounds during the initial nine months in the first year on ADT. Patients in our study were able to gain nearly two pounds of muscle on therapy. That is a clinically important change for patients. In addition, men in the study substantially improved their muscle strength.

They improved their aerobic capacity or aerobic fitness, which is an important predictor for cardiovascular mortality. The result is that they have an improved cardiorespiratory reserve capacity.

Patients also improved their dynamic balance. If these men fall, because they have low bone mass and low muscle mass, they have a greater chance of fracture and subsequent complications. By improving balance and function, they have a decreased chance of falling, and if they do fall, a reduced chance of fracture. That is important.

During the course of these studies, we undertake objective measurements of changing physical capacity and function, but we also look at other aspects of the patient. In this particular study, patients improved their vitality quite substantially with statistically and clinically meaningful changes. We also reduced their levels of fatigue by roughly 30%. (A third of patients on ADT experience significant levels of fatigue; patients were actually reducing fatigue with exercise.)

Another interesting finding from that study was that patients also reduced a marker of inflammation called C-reactive protein (CRP), which is potentially linked to cancer progression. Systemic inflammation was reduced.

Prostatepedia: What does all this mean for patients? Is there a specific program you recommend for men on hormonal therapy?

Dr. Galvão: We recommend patients aim for 150 minutes of moderate aerobic exercise per week. This could be broken down into five sessions of thirty minutes, for example. In particular for men on ADT who experience loss of muscle and adverse metabolic effects, resistance training is critical. We think the best prescription for men with prostate cancer is resistance AND aerobic training.

Aerobic training targets the cardiovascular system and metabolic outcomes such as blood pressure parameters, cholesterol, etc. Resistance training targets the musculoskeletal system to preserve muscle, preserve physical function, and improve muscle strength. We think the combination is probably best for men with prostate cancer.

We also have a trial whose results we haven’t published yet. We’re looking at the data at the moment. In that study, we compared different exercise modalities: the combination of resistance training plus aerobic training against impact loading, which is a more sophisticated type of prescription. Our results should be published soon where we incorporate aspects of impact loading as part of their training regimen with the aim to prevent bone loss.

But what we know today and is well established is that the combination of resistance training and aerobic training in men with prostate cancer is quite important and it is currently the recommendations of the American College of Sports Medicine and American Cancer Society.

Prostatepedia: Should men on ADT seek out a professional who can help them design an exercise program that is right for them?

Dr. Galvão: Exactly. These are just general recommendations. Ideally, you want to see a clinical exercise physiologist and have him or her develop an individualized program. Many men with prostate cancer have comorbidities and you want to make sure it is okay for you to exercise. For instance, make sure your blood pressure is under control before you initiate an exercise program.

Our general recommendation is 150 minutes of moderate aerobic activity, but some patients may benefit from a more or less intense program. We also recommend two days a week of resistance training—i.e. lifting weights. But you have to make sure you have the right technique and the right prescription to ensure a safe environment and derive the benefits we expect.

Having said that, the benefits of exercise far outweigh the risks. We say it is important to have a proper prescription and proper supervision, but it’s also important not to create too many barriers to exercise, otherwise it becomes too difficult. The benefits are huge.

We use the term ‘exercise is medicine’. This means using exercise to treat and help patients. Exercise is Medicine is an initiative launched in 2007 by the American College of Sports Medicine, which has rapidly gathered acceptance within the health and medicine field and has been expanding globally.

Prostatepedia: Do you have any ongoing studies currently enrolling?

Dr. Galvão: We have several ongoing trials: a particular study looking at men with bone metastases. Traditionally, all of these exercise studies have been done in patients with local disease. Patients whose prostate cancer has spread to bones are usually excluded for clinical trials on exercise because of concerns about fractures and the bones becoming very weak.

We designed and published pilot work and are now completing a larger trial that uses an exercise program with modular components. We target patients bone mass—those men who normally would be excluded from an exercise trial. We’re designing prescriptions that don’t target the zones that have cancer. For instance, if someone has a lesion in their proximal femur or lumbar spine, we’re using exercise for the upper arms instead.

This is actually quite interesting, because a lot of men deteriorate very quickly when they have bone metastases. Some of these men will be on other drugs in addition to ADT, like Docetaxel or chemotherapy agents. We’re trying to understand if exercise can also be prescribed in this setting.

Another study that we’re running at the moment looks at improving sexual health in men with prostate cancer. We’re using resistance and aerobic training as a way to facilitate improvements in sexual health in all prostate cancer patients, post-therapy including those on ADT.

We also recently completed a study as part of Dr. Favil Singh’s PhD work on pre-operative exercise undertaken several weeks before prostatectomy — to improve body composition, reduce body fat, and potentially improve outcomes in terms of continence and sexual health. We call this prehabilitation: getting patients exercising before they have surgery so that they deteriorate less after surgery. These are patients already scheduled for surgery. There is usually a window of six to eight weeks between scheduling and the actual procedure. This preliminary study is showing great promise to use exercise medicine to potentially improve patient outcomes post surgery.

Prostatepedia: What about men on active surveillance?

Dr. Galvão:  This is a very interesting and novel area from an exercise science perspective. There has been some great early work undertaken by the group at UCSF using intense lifestyle interventions. Larger trials are needed to confirm and expand on these early studies. Exercise might have a role in delaying progression of the disease. What is really well established in the area of prostate cancer is that exercise plays a major role in mitigating the effects of ADT and radiation therapy.

Prostatepedia: What about older men who completed prostate cancer therapy?

There is a study we recently published in European Urology. This was a long-term study, which was novel because most exercise studies are short term. Most of the patients were 70 or older. A lot of the other trials looked at men in their 60s. We had 13 exercise clinics in Australia and New Zealand. There were 100 participants who were randomized. This is quite a lot for a lifestyle/behavioral change exercise trial.

We looked at the role of exercise in patients who had completed therapy. We looked at men five years post-diagnosis after they’ve had a combination of ADT, radiation therapy and bisphosphonates. Some of these men have late effects of therapy.

We compared ways of delivering exercise in this prostate cancer population—either supervised with an exercise physiologist or by just giving patients educational materials about physical activity. After six months, the group that had supervised training was doing a lot better than those who only received educational materials. After six months, the group that was supervised graduated to an at-home exercise program. By twelve months, they were able to maintain a lot of the changes that they had attained at six months with the home program. This is important, because you can’t have all patients come to an exercise clinic; it’s just not feasible. What we’ve shown is that it is possible to provide initial supervision and then have patients carry on the activity at home.

Prostatepedia: Does the program include aerobic and resistance exercises?

Dr. Galvão: Yes, the prescription was similar to that of the previous trial published in the Journal of Clinical Oncology: a combination of resistance and aerobic training.

Prostatepedia: Is there anything else you think patients should know about exercise for prostate cancer patients?

Dr. Galvão: It is important to keep in mind that we’re talking about controlling symptoms and potential toxicities. What is very interesting and exciting in this area of exercise oncology and prostate cancer is that now we have studies indicating that there might be a protective effect after a prostate cancer diagnosis. Patients might have a protective effect in terms of all-cause mortality and prostate cancer-specific mortality. There is about a 50% reduction in risk of all-cause mortality and about 60% reduction in prostate cancer specific death if prostate cancer patients are more physically active, in particular intense type of activities. This means they are less likely to die from any cause and less likely to die from prostate cancer specifically. This report comes from the Harvard Health Professionals’ Follow-up study that was published a few years ago in the Journal of Clinical Oncology.

It is of interest that this work was recently replicated by a group in Sweden: a study of 5,000 participants also showed that more physical activity has a protective effect against all-cause mortality and prostate cancer-specific mortality. These data from observational studies report associations and form an interesting basis for undertaking randomized clinical trials.

What is also interesting is that we and other researchers are trying to understand mechanistically how this protective effect is actually taking place. Is it inflammation, the endocrine system, or growth factors? We don’t understand what leads to this potential protective effect.

For example, a few years ago a group in Sweden looked at blood serum from healthy adults who had undertaken aerobic training acutely for one hour. They put the blood serum into prostate cancer cell lines and found that the aerobic serum seems to reduce the proliferation of prostate cancer cells. This was an in-vitro experiment, in the lab. It’s difficult to translate this to humans at this stage, but it provides pre-clinical evidence and it is encouraging when combined with observational studies pointing to similar directions.

Prostatepedia: Is there any downside to exercise for prostate cancer patients?

Dr. Galvão: It is hard to see any downside.


10 Comment

Maurice Dwyer

I attended the special exercise clinic at University of Queensland for over 12 months and seemed to be containing my prostrate cancer as well feeling very healthier. For some unexplained reason the gym was suddenly closed down and an entirely new facility was opened in the football dressing pavilion. None of the “patients” that I spoke to found this facility (under a private firm) to be conducive to wanting us to continue with our programs there.
I have investigated many gyms since but have not found any that are as suitable for me as the one at U of Q.

Could you kindly let me know why this gym was closed?
Exercise physiologists undertaking postgraduate studies supervised us and I believe my health and
containment of my prostate cancer would have better served if that particular facility had remained open.
Please let me know what purpose was served by its closing.

Thanking you,

Maurice Dwyer.

Posted: Nov 06, 2015

John Gibon

I live in Perth, Western Australia and participated in a trial conducted by Dr Galvao in 2008 and have continued to apply what I learnt then ever since. That is, aerobic and resistance exercise training for a minimum of two one hour sessions each week for over 7 years. This has been of great benefit to me and I have remained well, physically active and symptom free throughout that period despite ongoing treatments for mcrpc. In particular it has been of great benefit to mental function helping me to maintain a positive attitude and to continue to enjoy life.

Posted: Oct 19, 2015

rick davis

I have been advocating exercise for PCa treatment since my own diagnosis in 2007. I was a major innovator and catalyst to stimulate interest and further research at UCSF (with June Chan, Peter Carroll, Chuck Ryan) including the preparation of a UCSF pamphlet http://cancer.ucsf.edu/_docs/crc/SDCAN0300Exercise.pdf and an exercise counseling program for all cancers.

I have been trying to extend the counseling program but funding as ever is the problem – see www.medafit.org . This site also includes an extensive list of articles and clinical research. I first reached out to RoAnn Segal more than 5 years ago. Btw, she was a PT before becoming a med onc.

Onward & upwards, rd

Posted: Oct 16, 2015

mike tippmann

I was treated with ADT for 3 years ago after radical surgery. I train at a gym and have been cancer free for 12 years. I do both aerobic and weight training 5 hours per week and have ever since my surgery. My gleason score was 7. Good study;.

Posted: Oct 16, 2015

Richard Pelon

I have just started to do some exercise and after reading your page I intend to exspand to include some more walking Thanks

Posted: Oct 15, 2015

Dutch

Was given a year over six months ago, and still playing golf, going to gym, dentist,and theater! Pass 90 a year ago and still here

Posted: Oct 14, 2015

Robert Isbell, MD

I am 78, 5 years post robotic prostatectomy for Gleason 8 prostate cancer and 50 months post IMRT for biochemical failure. I began my third cycle of ADT 3 months ago, having been on an intermittent schedule since November, 2011 I have always been active and have no known co-morbidities. Utilizing a program of resistive and aerobic training, alternating walking, tennis, gym workouts including core exercises, and swimming I judge my quality of life, mood, level of engagement, cognitive status, and energy to be excellent. I exercise early each morning and I rarely take anti-inflammatory meds and follow a modified Mediteranean diet. My average work-out time is 1 1/2 hours. Thus far, I have no evidence of macro-metastases. Whether my ultimate prostate cancer specific survival is lengthened or not by this routine, my enjoyment of life, family, friends, and community would compel me to pursue it for the rest of my life.
Robert G. Isbell, MD

Posted: Oct 14, 2015

Gerry Pielsticker-Oakville, Ontario, Canada

What a great article and I agree with every word.
16 years ago I was diagnosed with Prostate Cancer and had surgery. 5 years later I had radiation. My PSA is 0 today and it was 11 before the operation.

I exercise almost every day and eat a healthy diet. Currently I am on a self imposed diet to lose 20 pounds.My life is active and fun at 71 years and I can still wear out the grand kids at hockey. There is NO downside to exercise

Posted: Oct 14, 2015

David Markham

Having had a Gleeson score of 4/5 and had a radical prostectomy in June 2010, they found the cancer had spread outside the capsule and I subsequently had radio- therapy on the infected pelvic area. Since Jan 2011 I have been using a trainer who has worked with me to reduce % body fat and build muscle through lifting weights. I also cycle and still run a bit, but not to the extent I did before my operation. I am on Androgen treatment, “prostrap” and have had a psa reduction from 42 down to a reading of 0.003 for about 4 years.

I am convinced that strong physical goals and good diet are a contributory factor to my continuing good health.

An excellent article – would like more detail

Posted: Oct 14, 2015

Bob

I’m stage pt3b Makes sense to me. Exercise also reduces depression which can be a factor with cancer patients. The tough part is forcing oneself to exercise when you’re experiencing fatigue or joint pain from ADT; but once you feel better from exercise it tends to make it easier to decide to keep doing it. I’m on my second round of radiation and ADT for mets to pelvic lymph nodes so anything that makes it easier to handle suits me fine.

Posted: Oct 14, 2015

Leave A Comment

Search

Mailing List

Transcripts

Purchase transcripts of Dr. Snuffy Myer’s videos.

Buy Transcripts

Popular Posts

September Prostatepedia

Dr. Snuffy Myers talks further about CT scans and cancer risk.

Posted: Sep 07, 2016

Comments: (0)

Patient Conference: Sept 9-11 in LA

Dr. Snuffy Myers talks further about CT scans and cancer risk.

Posted: Aug 25, 2016

Comments: (1)

Stay Connected