In the UK, prostate cancer (PCa) accounts for a quarter of all new male cancer diagnoses (46,690 in 2014) [
In recent years these observations have driven significant interest in physical exercise as an inexpensive and holistic adjuvant therapy that may help to improve physical and psychosocial outcomes [
Thus, efforts are now underway to provide men with PCa with access to structured exercise classes as an adjunct to their usual care. Currently, most studies on exercise for PCa patients have small sample sizes, focus on a specific treatment of PCa, or have used self-report measures such as QoL questionnaires [
Previous qualitative research on men with PCa has provided evidence for physiological and psychosocial benefits of participating in a supervised exercise programme, although to our knowledge there is just one published qualitative study available that has focused on the experiences of an exercise intervention specifically amongst men with PCa. Using semistructured interviews, Cormie et al. [
Cormie et al.’s study highlighted the importance of qualitative approaches to this area by presenting a number of insights that would not naturally translate into quantitative measurements. This influenced our approach; however the aim of the study we present here is not so much to collect evidence of the benefits of a supervised exercise intervention, but to gain further understanding of the best approach to maximising engagement with (and adherence to) exercise in general amongst this population, whether that be via a supervised exercise programme or independent exercise. A multivariate analysis by Courneya et al. [
We included men with either localised or advanced PCa who were recommended by their physicians to engage with a physiotherapy-led structured exercise programme as a complement to their standard of care (Figure
The prostate exercise class structure.
Patients were invited to attend an exercise programme once a week for eight sessions over a 10-week period, allowing for the patient to miss up to two sessions as part of a pragmatic programme design. The rolling exercise programme was attended by 8–12 patients in each session and was modelled from existing published cancer exercise and UK physical activity recommendations [
The intensity, load, and frequency of the exercise training were dependent on the physical function of the patient and also the current cancer treatment phase they were in (see Table
Exercise intensities of low-to-moderate intensity (LMI) and moderate-to-high (MHI) intensity endurance and resistance prescription related to cancer treatment and physical level.
Intensity level | Patient description | HRR | BORG (RPE) 0–10 | 1-RM |
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LMI | (i) On active cancer treatment |
40–60% | 3-4 | 40–60% |
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MHI | (i) On established hormone therapy |
60–80% | 4–6 | 60–70% |
HRR, heart rate reserve; BORG (0–10), modified rating of perceived exertion scale; 1-RM, one-repetition maximum.
In addition, three individualized sessions were provided at week 0 (prior to starting the exercise class), at session 4 (mid programme), and at session 8 (end of programme). These sessions were aimed at setting/reviewing training aims (i.e., workload, intensity, and frequency), applying behavioural motivational counselling techniques to enhance self-efficacy and overcome possible exercise barriers, and informing the patient of available services or resources on completion of the exercise programme.
Patients were encouraged (but not monitored) to complete two additional moderate intensity 30-minute exercise sessions by week 4 and three by week 8 as part of a home walking exercise programme. They were also given a pamphlet containing instructions on how to perform resistance exercises that they had been doing in the supervised sessions. The combination of our supervised exercise session and home-based programme aimed to encourage patients in meeting the recommendations of 150 minutes of physical activity for cancer survivors [
Of the 76 men referred for the cancer exercise programme as of November 2016, 51 consented to involvement in our ongoing pilot study. Each of these men was contacted via phone in order to be interviewed as part of an audit process; all of them were contacted within the space of 2 weeks in November 2016, meaning that the time since completion of the exercise programme differed between participants within a range of approximately 6 months. 41 men were successfully contacted and all of these 41 men were willing to respond to a short telephone survey. None declined to take part in the survey. Men who agreed underwent a short interview about their experience of the exercise programme. Multiple choice questions that were put to the respondents are detailed in Table
As the participant feedback described here was obtained originally for audit purposes, the conversations that took place during the telephone survey were written down by researcher whilst conducting the interview. The information was thus not recorded and transcribed, but whilst we acknowledge that this limits the robustness of the findings presented here, we still obtained a valuable mixture of quantitative and qualitative data. The data proved to be informative with regard to our ongoing efforts to design an exercise intervention for men with prostate cancer. Participants provided responses to predetermined multiple choice questions, and notes were taken by the interviewing researcher that summarised any extra points made by each participant in the ensuing informal conversation. The data produced by this process enabled us to quantify to some extent the heterogeneity of responses to specific questions that we wanted to ask about the delivery of our exercise intervention, whilst leaving participants free to describe to us their first-hand experiences, which were of the utmost value in helping us to refine our intervention design and formulate further research questions. The notes produced by the researchers were analysed using an affinity diagram by another researcher (LF), and these themes were assessed and validated by a third researcher (CB).
An affinity diagram approach is a basic qualitative analysis method commonly used to inform management and planning [
Approval for a process evaluation/audit was obtained through the hospital’s research and development department (project number: 47351).
A description of the final sample of PCa patients that responded to our telephone survey is shown in Table
Description of the final sample of PCa patients on the exercise programme who were contactable and agreed to a phone interview. All values are baseline (preexercise programme).
Total | Localised disease | Advanced disease | |
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41 | 20 | 21 | |
Age | |||
Minimum | 43 | 43 | 52 |
Maximum | 80 | 70 | 80 |
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Initial PSA | |||
Minimum | 0.4 | 0.4 | 4.1 |
Maximum | 3196 | 67.45 | 3196 |
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Initial Gleason score | |||
6 | 10 (24.39%) | 9 (45%) | 1 (4.76%) |
7 | 18 (43.9%) | 10 (50%) | 8 (38.1%) |
8 | 5 (12.2%) | 1 (5%) | 4 (19.05%) |
9 | 7 (17.07%) | 0 | 7 (33.33%) |
10 | 1 (2.44%) | 0 | 1 (4.76%) |
Current/most recent treatment | |||
Active surveillance | 2 (4.88%) | 2 (10%) | 0 |
ADT | 10 (24.39%) | 0 | 10 (47.62%) |
Brachytherapy | 1 (2.44%) | 0 | 1 (4.76%) |
Chemotherapy | 5 (12.2%) | 0 | 5 (23.81%) |
Radiotherapy | 3 (7.32%) | 1 (5%) | 2 (9.52%) |
RALRP | 16 (39.02%) | 13 (65%) | 3 (14.29%) |
Awaiting RALRP | 3 (7.32%) | 3 (15%) | 0 |
TURP | 1 (2.44%) | 1 (5%) | 0 |
Ethnicity | |||
White/Caucasian | 35 (85.4%) | 16 (80%) | 19 (90.5%) |
Black/Afro-Caribbean | 3 (7.3%) | 2 (10%) | 1 (4.8%) |
Asian | 1 (2.4%) | 0 | 1 (4.8%) |
Other | 2 (4.9%) | 2 (10%) | 0 |
Marital status | |||
Married | 28 (68.3%) | 15 (75%) | 13 (61.9%) |
Divorced/separated | 6 (14.6%) | 1 (5%) | 5 (23.8%) |
Widowed | 3 (7.3%) | 1 (5%) | 2 (9.5%) |
Never married | 4 (9.8%) | 3 (15%) | 1 (4.8%) |
Current living circumstances | |||
Alone | 6 (14.6%) | 4 (20%) | 2 (9.5%) |
With partner | 32 (78%) | 16 (80%) | 16 (76.2%) |
With other family | 2 (4.9%) | 0 | 2 (9.5%) |
Other | 1 (2.4%) | 0 | 1 (4.8%) |
Current work circumstances | |||
Full-time | 10 (24.4%) | 8 (40%) | 2 (9.5%) |
Part-time | 5 (12.2%) | 2 (10%) | 3 (14.3%) |
Retired | 24 (58.5%) | 9 (45%) | 15 (71.4%) |
Unemployed | 1 (2.4%) | 1 (5%) | 0 |
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>150 mins of moderate exercise per week | |||
Yes | 35 (85.4%) | 14 (70%) | 21 (100%) |
No | 6 (14.6%) | 6 (30%) | 0 |
Approx. sedentary minutes per week | |||
Minimum | 90 | 90 | 240 |
Maximum | 4800 | 4200 | 4800 |
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Responses to multiple choice questions.
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Yes | 39 | 95.2% |
No | 2 | 4.8% |
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Exercising independently, outside of the hospital | 8 | 19.5% |
Exercising using hospital facilities, with minimal support | 2 | 4.8% |
Structured exercise classes within the hospital | 30 | 73.3% |
No preference | 1 | 2.4% |
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More motivated | 15 | 36.6% |
Less motivated | 23 | 56.1% |
The same | 3 | 7.3% |
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Yes | 14 | 34.2% |
No | 27 | 65.8% |
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More likely to exercise | 4 | 9.8% |
Less likely to exercise | 25 | 61.0% |
The same either way | 12 | 29.2% |
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More likely to exercise | 10 | 24.4% |
Less likely to exercise | 14 | 34.2% |
The same either way | 17 | 41.4% |
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More likely to exercise | 31 | 75.6% |
Less likely to exercise | 2 | 4.8% |
The same either way | 8 | 19.6% |
The input of the physiotherapists was the most frequently identified valuable aspect of the structured classes. Indeed, the ability of the physiotherapists to give the participants exercise
It was apparent from our interviews that when it comes to engaging with physical exercise, the structured and tailored nature of the exercise classes acted as a strong motivating force. Of the 23 participants that told us that they felt
Positive behavioural changes (defined in the context of the transtheoretical model of behaviour change [
One of the aspects of the structured exercise classes that participants were most enthused about was the social value of the classes. Our interviews drew a picture of an environment that is good-humoured and enjoyable. One interviewee referred to fellow class participants as his “friends.” Some also told of the value of having someone to relate to (i.e., other men with PCa). One of the interviewees drew this into sharp focus: he had been told by his doctor that he needed to engage with exercise but had been too depressed to adhere to this advice alone; he went on to say that the class enabled him to talk with another patient who had been through the classes already and had lost weight and got fit. The interviewee described this encounter as a strong antidote to the inertia he was experiencing as a result of his depression.
Both participant feedback and the multiple choice responses indicated that individual personality traits seemed to be strongly influential in determining how useful a structured exercise intervention would be for that person. Most of the participants (73.3%) seemed to prefer the structured classes. This figure is comparable to that of Gjerset et al. (2011), which looked at exercise interests and preferences in cancer survivors [
Some of the individual differences we note are a likely result of our offered exercise intervention not meeting individual preferences. Although our programme design took a proactive approach when determining the intensity, load, and frequency of the exercise training, the chosen mode was a predetermined circuit set of exercises within a supervised group setting. Research has cited that exercise interests and intervention preferences can vary in cancer populations with the most reported preferred types of exercises including walking, resistance exercises, activities of recreation, and exercises of a moderate intensity [
We noted that some of the participants who were already previously engaged with physical exercise still found the classes to be a valuable component of their care, for example, as a way to facilitate reengagement with physical exercise following radical surgery. We also observed that participants’ responses to question 6, “If your doctor recommended exercise to you to improve treatment outcome, and you were not offered exercise classes within the hospital, would you have been more/less likely to exercise (or the same either way)?,” were fairly evenly distributed, highlighting differences between participants in the way in which they might respond to exercise recommendations from their doctor.
Informal feedback from open-ended surveys with the PCa patients in our ongoing pilot study has provided some preliminary insights into how best to devise a structured exercise intervention for all men with PCa. Overall across our sample we observed that participant feedback regarding the structured exercise classes was strongly positive. Our interview responses suggest that there may be multiple benefits to patients of running such a service, namely, the provision of motivation to exercise, exercise guidance, and social support, and it is possibly a catalyst for positive health behaviour change relating to exercise. Some heterogeneity in interviewees’ responses suggested that patients’ individual differences should be taken into account when designing interventions of this type, indicating that personal disposition, personal circumstances, and exercise history may be useful candidates for predicting of the likelihood of adherence to a particular exercise programme, or receptiveness to a particular way of presenting the intervention to them (e.g., via the nursing team rather than the patient’s consultant).
Bourke et al. have assessed the effects of exercise on cancer-specific quality of life and adverse events in PCa trials [
Individual differences were pronounced in the feedback we received. Lifestyle factors and personality traits appeared to influence preference. It could be speculated that men more used to exercising independently may feel that exercising independently gives them more control over their engagement, whereas the reverse may be true for men who were not previously exercising regularly: they may feel as though the structured classes empower, rather than inhibit, them. The latter was certainly true for some of the participants in this study. Preferences for individually tailored interventions have been expressed in previous studies [
Individuals also expressed differences in how they respond to different styles of advice, expressed clearly by the mixed responses that we received to question 6. This was reflected in various comments from participants. According to some, the advice of a consultant would be effective enough to get them to engage with exercise behaviour, whereas others expressed a level of endearment to, and trust of, the nursing team that would make them more likely to adhere to their instructions than their consultant. It is possible that this distribution of responses to question 6 represents both (a) variance in the quality of the participants’ relationships with their particular doctor and (b) variance in dispositional attitudes towards the medical profession amongst participants. Two studies have found that around two-thirds of their cancer patient samples were interested in participating in exercise [
It was clear that some of these men with PCa felt a lack of confidence in their ability to exercise effectively. As well as motivation, the physiotherapy team were able to provide personalised clinical supervision and guidance to patients that let them engage in exercise knowing they were not putting their health at risk. To the best of our knowledge, there is a lack of published research on cancer-related fear avoidance behaviour. Some of our interviewees, however, described what appeared to be fear avoidance behaviours relating to overexertion in light of their cancer diagnosis. We can speculate that the negation of this fear via the support of the physiotherapists is one of the reasons why around three-quarters (73.3%) of our participants expressed a preference for attending structured classes, despite the inconvenience of the weekly travel to the hospital. In other chronic disease settings, it has already been shown that fear avoidance beliefs may be useful in identifying patients at risk of psychosocial problems as well as their pain intensity and physical impairment [
It was clear from the participant feedback that the structured classes provided additional motivation to exercise. The structured nature of appointments, on a certain day and time, made patients feel obliged to attend, which requires less willpower that attempting to engage with exercise independently. In addition, the physiotherapists are skilled at driving patients to push themselves harder physically then they may do otherwise. Around two-thirds (65.8%) of our participants were pushed harder than they had expected to be and yet still maintained their attendance. Furthermore, there is likely a social aspect to motivation: some patients were making friends in the class, which could arguably make attending the classes feel more attractive for some. The opportunity for social interaction within group exercise has been described previously by clinical populations as a motivator to attend [
Our interview responses suggested that, for some men, attending these classes may provide a crucial social support network. Friendships were being formed via attendance at the classes and patients may find particular solace in their social interactions with fellow patients in the class that they may not be able to find elsewhere. This observation is consistent with previous research involving women with breast cancer, which suggested that the action-oriented format of an exercise class may provide a preferable way to acknowledge cancer in a social context, as opposed to simply talking about it [
This study was limited in the sense that, due to constraints on the methodology, the results reported are more descriptive than analytical. However, insight from patients is a necessary component of the development of a complex intervention [
This work on patients’ views and experiences has generated UK data on how best to support PCa patients in terms of exercise empowerment. The spectrum of insights obtained highlighted some components that can be considered when designing exercise interventions for men with PCa, with individual tailoring being the most commonly suggested need. Future research into understanding how best to encourage men with PCa throughout their cancer pathway to undertake exercise should combine emerging insights from immediate feedback with more general qualitative observations and quantitative measurements. Research questions addressing exercise adherence in the PCa population may do well to acknowledge the value of service and facilities provision such as that outlined here, in particular the social aspects of such provision and the role it can play in exercise confidence/fear avoidance behaviour, motivation, and health behaviour change. Our observations suggest that those who are looking to implement this type of service provision should acknowledge these factors, whilst appreciating that preferred approaches to exercise engagement can vary largely between individuals.
The views expressed are those of the authors and not necessarily those of the NHS, TUF, PCUK, the NIHR, or the Department of Health.
The authors declare that there are no conflicts of interest regarding the publication of this paper.
The authors would like to thank all the patients who kindly made time available to participate in their interviews. This research was supported by the Urology Foundation, Prostate Cancer UK, the Experimental Cancer Medicine Centre at King’s College London, and the National Institute for Health Research (NIHR) Biomedical Research Centre based at Guy’s and St Thomas’ NHS Foundation Trust and King’s College London.