Alternative Treatments For Prostate Cancer

its an absolue pleasure to be able to speakto the consortium this morning from vancouver, sunny vancouver, of course. and i just wantto talk a little bit about the research coming out of perth, australia which really focuseson how we use exercise as a medicine or as an adjunct therapy for the management of prostatecancer. and i think most importantly and i think a more important question for patientsto ask is, “can exercise impact survival?” now this isn’t our work but came from theuniversity of california, san francisco who do a lot of epidemiological research and haveestablished through this observational study that there is a link between exercise andprostate cancer survival. now what is interesting is that they have actually looked at the qualityof the exercise. so as you can see here, men

who are particularly participating in overthree hours of vigorous physical activity after their prostate cancer diagnosis hadabout 60% lower risk of prostate cancer mortality. and also about 50% lower risk of all-causemortality. and what you can see in these graphs here is that even for the guys that were participatingin the same volume of exercise, men who were more vigorous in the blue, and they are walkinghere, had a greater protective effect. so this is a very early epidemiological researchwhere the fields moving forward were actually working on a global trial, designing a globaltrial, and at the moment to test this empirically with a randomized control trial as guide withmetastatic disease. but it gives as an indication that the quality of exercises is really importantin terms of the type of outcome that we can

get.so this is what we really work with here with our exercise and using exercise as a medicine.we use a targeted exercise prescription. and what we know from our wealth of exercise scienceliterature is that the specific exercise prescription really dictates the type and magnitude ofphysical adaptation. a really easy comparison here is to look at the patient doing the aerobicexercise which as you can see, is on the left there, walking, cycling, jogging, and whatwe typically think as exercise versus resistance exercise such as lifting weight. so as youcan imagine, the other patients there are really quite different in terms of the aerobicexercise targeting the vascular system and resistance exercise targeting the muscularskeletal system. a very important thing to

think about is prostate cancer and its adverseside effects of the treatments. but what we see from the literature and building on thiswealth of literature from the exercise science field is that the most significant benefitsarise from a targeted exercise prescription, something that is individualized, that ismonitored, that involves the appropriate exercise selection to the outcomes that you want. andof course it involves the right amount of dosage or the volume and intensity and obviouslycontinually increasing the stimulus so the body can adapt.so to move on to our research in exercise and prostate cancer, we look at a range ofside effects caused by common prostate cancer treatments. and this trial was actually performeda little bit performed in my town, my colleagues

from newtown and daniel galvere led this trial.so randomized control trial really targeting the effects that exercise can have on theandrogen and associative loss of muscle mass. so we looked at it for three months and allthe programs were three month programs and were all group-based and were supervised byaccredited exercise physiologist. and as you can see, these were guys with establishedtoxicities caused by adk, by fairly significant periods of time and averaged about fourteenmonths there. so you will see here on the graph that it records the change over the3-month intervention with the exercise group in blue and the usual care group in orange.and we are looking at a range of markets here of muscle mass assessed by a decsor here.so as you can see significant differences

between the two groups and their overall bodymass, appendicular lean mass and upper and lower body lean mass. so the exercise wasable to prompt significant improvements in muscle mass despite the castration or testosteronethere. this was then able to restore then some of the established toxicities.obviously the effectivity of t on bone mass is another concern and this was a trial thatwas started a few years ago and we just finished off very recently, and we are still analyzingthe results which are targeting and have a very specific prescription to target bonemass and minimize the loss of bones, and then to improve some of the outcomes not just specificallytalking about bonal density. obviously we have some other side effects as you can seethere, which are deprivation, we are looking

at some of the cardio-metabolic outcomes whichare quite interesting, so stay tuned for those since the results are coming out very soon.but in terms of looking at bone mass specifically, this is coming into that targeted exerciseprescription. they are really using a type of exercise that acts like a soup-cup weight-bearingexercise. we call it impact exercise and it is a very specific stimulus to promote boneremodeling and to try and prevent the accelerated bone loss associated with anger and depravationtherapy. so as you can see on the videos, these examples are different types of exerciseand impact exercise that are increasing in intensity and are making greater and greaterstimulus for the guys in terms of adaptation to their bone. now this is a very sophisticatedtype of exercise prescription that the guys

participate in, and which we screen very heavilyto make sure it is safe. so we monitor this very heavily, so it is definitely very individualized,we have robust screening protocols so we can modify them to 15-20 reps or as appropriate.we get almost three-quarters of the guys doing at least some form of impact exercise as youcan see here. if you imagine first asking these guys doing these very rigorous exercise,obviously these are guys who are experts and have been doing this for a very long time,and we monitor them in terms of their pain and knees, and their back and ensure thatwe are progressing in accordance to their symptomatic response. so these are some preliminaryresults looking at the comparison between incorporating this modality of exercise throughother types of exercise. so this is looking

at a change in lumbar spine bone mineral densityover a six month period. now this is a very preliminary analysis. the analysis we aregoing for is a one-year data so it’s just very early results. but what you will seehere is that the guys or men who have established adt or have continued adt throughout a twelve-monthperiod. and you can see that these are the guys with usual care and have quite a pronouncedloss of bone mineral density in the three month period. and what is a little bit surprisingto us is that the resistance to aerobic exercise, and this is in rhyme with our goal-strandedexercise prescription needs about cancer survivors at present, wasn’t able to slow the lossof bone at all really over that 6 month period. but we have incorporated a very specific exerciseprescription to target a patient’s bone

and impact exercise. we actually saw a bluntingof the loss of bone density over the six-month period. so it’s very exciting in terms ofthese early results, in terms of what this means and the way we can tailor and targetexercise to really pick out specific side effects and we can start to change.so one of the most pressing issues for men with prostate cancer is the impact that avariety of treatments on sexual well-being. the literature has varying results but i reallythink up to 90% of men with prostate cancer would be worried about their sexual well-beingand will have some form of sexual dysfunction. and you can see here that the range of sideeffects with prostate cancer treatments can really bring about lead to an overall declinein sexual dysfunction. it really is a little

bit of a laundry-list of a lot of direct andmore indirect side-effects that contribute to minimizing, and i suppose, reducing sexualwell-being in any of these guys. now what we have actually proposed and what we aretesting empirically now is that exercise is an innovative intervention that can help tocounteract some of these changes. and actually improve sexual wellbeing. so we will talkabout these, i am guessing and not saying exercise is a fantastic theory and it cansolve everything. it’s not confixed. nerve damage caused by surgery, you know, thereare a lot of things it’s not going to do. but when you look at some of the relativelyindirect sied effects of prostate cancer that contribute to sexual dysfunction, exercisehas established efficacy in counteracting

many of those side effects. so i have talkeda little bit about the changes in muscle mass but the ability of exercise to counteractbody feminization to improve and reduce the conditions of primordial conditions that areassociated with sexual dysfunction. and obviously to change things mentally for these guys,to minimize depression and anxiety, and in turn improve their physical fitness and activitylevel when impact exercise can have in terms of masculine self-esteem and quality of life,and how this leads into an improved sexual wellbeing. so we did some very early workto initialize a secondary analysis with an ongoing previous to really understand andget a first idea of, “can exercise really have an impact on sexual wellbeing?” andhere we specifically looked at sexual activity

and it is sort of a self-report measure ofsexual activity and that’s a combination of how sexually active the guys were and howmuch libido the guys actually had. so you can see these were a sample of 60 guys thatwere on adt and you can see that, you know, that about 37% had previously undergone radiation,40% had surgery previously and we had an extreme group of accredited exercise physiologistswho supervised that program incorporating those two main modalities: resistance exerciseand aerobic exercise. and this is really in that period counteracting those major sideeffects in terms of what’s happening to contribute to sexual dysfunction. so we sawthat exercise really acts to maintain that sexual activity during that three month periodand if you look at these tables here, the

dark bar is the base line and the grey baris after the three month intervention; and the exercise group is on the left and theusual care group is on the right. and you can see the reduction in the usual care groupin terms of their sexual activity and the maintenance in the exercise group. so we sawthat exercise helps to maintain sexual activity with men who are on adt, and we saw that thedifference is really driven by changes in the libido. the borderline difference in libidoin terms of the guys who have had any interest in sex is certainly significant differencewhen we are looking at the proportion of guys who have had a major interest in sex. so afterthat three month intervention none of the guys in the usual care group, the non-exercisinggroup had a high level of libido; but about

17% of the men in the exercise group wereable to maintain a high level of libido. so as you can imagine, this is a very positiveoutcome for the patient. we saw that this was related to the changing quality of life.we also saw that there were range of significant improvements in areas such as body lean composition,physical fitness and function, and those elements certainly played into some of these results.so at the moment, i should say we should try and get a bit of understanding from the patient’sperspective really what drives these changes in libido. we incorporated a mixed-methodapproach, and looked at doing some qualitative research with a sample of 18 men. these wereguys, again, who were on adt. as you can see the different sample there; more men had radiationand only a small proportion had surgery performed.

but they had been exercising in our group-basedexercise run on average, about four and a half months. so we conducted a thematic contentanalysis using interpretative phenomenal logical design in order to cpture the lived experienceof the patient. and i think what’s interesting without going into too much detail here iswhat the patients were telling us about how exercise helped them and helped their sexualwellbeing. and as you can see here and really what one of the main things that emerged wasthe ability of the structured exercise program to relate to the reinforcement of masculinitywhich was associated with this improved sexual wellbeing. and that was driven by a numberof elements that the guys identified: as you can see what’s happening physiologically,what’s happening to their body and how they

are feeling about their body, their vitalitylevels and how they were [14:13-14:16] letting …., what’s happening mentally in termsof their moods and their positivity, as well as some other elements, i suppose, in termsof their ability to engage and master in masculinity and to actually do something to counteractthose side effects associated with prostate cancer treatment. so having a sense of controlreally, allow them feel like they are reinforcing their masculinity. so this is obviously someinteresting kind of area that we are discovering these huge amounts of patient interest, andas you can imagine, a lot of the clinicians we have here involved are very excited aboutthese preliminary results. we are actually now currently running a largerandomized control trial specifically binding

them. so we are actually looking at 240 guysover three or four years and saying that “can exercise can specifically counteract the changesand improve sexual wellbeing on guys with any form of prostate cancer treatment andwithin six months of finishing that treatment.” so just to give a very brief overview, weare actually looking at three armed randomized control group trial design. we are lookingat an exercise only group who are going to be exercising for six months and we will followthem up a year later. and we are actually combining an exercise group with an educationprogram; and this is to start to look at a little bit more about sexual wellbeing ina holistic manner in terms of adding in some education about medical management strategies,as well as what is happening in terms of intimacy,

some issues around stress management, andso on. and this is actually; we have designed it in a way that we could see it work translatingit into practice. so this is a self-management program facilitated by accredited exercisephysiologists, and we have specific training programs to upscale these guys to work through[16:11-16:13] imperials and this is an example of some of the materials there. so it reallygoes through some basics of management and counteracting some of the mental health issuesas well as what’s going on with the sexual well-being. you can see we have somewhat adelayed intervention for our control groups and this is a standard design in order totry and maximize the appearance and compliance with the usual cared group. so we are reallyexcited about this trial and i think that

what we are thinking about these is that thereis definitely a potential to try and use exercise as an adjunct therapy to pharmacological interventionas well as psychological intervention and to really try and optimize the managementof sexual dysfunction; and to try and hit each of the side effects of prostate cancertreatments using the combinations of these potential interventions. so i am sorry thatthese slides are quite small, but using the penile rehabilitation therapy to start andcounteract all the direct side effects of prostate cancer treatments especially thinkingabout function and erectile function, using exercise to counteract those more relativelyindirect side effects, as well as enhancing libido, and counteract that drop in libidoassociated especially with androgen deprivation

therapy. as well as now as we say the mentalhealth benefits caused by exercise treatment as well. as you can imagine, you are incorporatingsome psychological intervention in terms of counteracting the shift to the patient care-giverdynamic, and you know also, intimate relationships and some mental health issues, and certainlywhats happening with you know, the changes that are caused by some of these treatmentsin terms of men feeling more emotional and so on. so we are really excited about thedirection and fate change in the next couple of years and i think we will really have someexciting results here. so to shift you to a little bit, i think,what we really wanted to try and see is that apart from being able to rehabilitate an establishedtoxicity, we wanted to look at the timings

of when exercise could be implemented andspecifically, could we use exercise as a therapy to prevent toxicity. here we are looking atadt toxicity (androgen deprivation therapy). so what we get from this trial can be actuallyintervened with exercise immediately when their first and prior to their first injectionwith adt. so within six days of their first adt injection, we had them do a baseline testand got them exercising. this was the very first time that they were adt patients beforehand.if you can see, there were just over 60 men and again looking at results from a threemonth period in this group based accredited exercise physiologists supervised environment.now we are looking at repeats in aerobic exercise intervention to counteract the primary changesin their body composition, fat mass and also

their lean mass. so as you can see in thenext slide as it comes up, is the change in the three month intervention in the body compositionoutcomes and the first three columns are the outcomes in terms of the fat mass. now whatyou can see is that the exercise groups are in blue and the usual care groups in grey.so intervening in the same time at the commencement of adt with exercise actually prevented gainsin fat mass. overall gains in the body, gains in the trunk, the trunk had adiposity andoverall percentage in fat mass. so no easy to prevent those gains has actually lead toslight reduction in fat mass and you can see the magnitude of difference in terms of rangingbetween a kilo to a kilo and half looking at the trunk body adiposity and the wholebody fat mass. so this is a really exciting

result since we haven’t seen exercise alonebeing able to affect the adt associated increase in fat mass before. so this is really thefirst literature that shown that exercise can prevent the gains in fat mass. now youwill see here with lean mass, with the rapid loss of testosterone and associated rapidloss of muscle mass with androgen deprivation therapy, the exercise wasn’t able to reversethis initial loss over the first three month period. but it was able to attenuate the loss.so actually there was a borderline difference in the lean muscle mass in the whole bodyand as you can see can see there is significant difference in appendicular lean muscle mass.so this is, i think, from the body composition perspective, very exciting results in howwe can blunt and prevent these really initial

changes in body composition that can latchlong term effects in terms of long term risks of chronic conditions such as cardiovasculardisease and diabetes. so this next slide looks at some of the main outcomes in terms of theinteresting findings of, we did a range of other secondary outcomes, to look at a wholerange of different major side effects. so again the exercise group in blue and you cansee that in terms of the fitness level and the strength of the fitness, the exercisegroup was able to respond positively to the exercise intervention, despite what’s happeningto their treatment, leading to a significant difference between groups. mirroring whatwe have seen in our other research, we are saying that the exercise intervention whenit is actually applied immediately at the

convent of adt, helps to attenuate the lossin sexual functioning, and as you can see, you cannot reverse it but there is a significantdifference between the usual care groups and the exercise groups; so it is actually minimizingthe loss. and you can see that both in fatigue and psychological distress, the exercise groupprevented the significant worsening of both those symptoms which is really a positivefinding. and when you think about what is happening socially with these guys, the exerciseguys actually had clinically significant improvements in both mental health and social functioning.so this was another element that helped counteract the psychosocial side effects especially duringthose initial phases of prostate cancer treatment. and now we also did a whole lot of, againterrible terrible too much stuff on this slide

but, blood work up in terms of some of themajor side effects with cardiovascular disease risk, lipid and so on. we also looked at bio-internalmarkers. we didn’t see anything come out of these results during that three month period.it is really interesting to see what will happen with the prolonged convention. buti think importantly what we saw here and what is important out of the blood workup is thatsimilar to the previous research, the exercise did not interfere with the adt effects onpsn and testosterone hormone levels. so we are able to prevent these changes and toxicitieswithout impacting the efficacy of the androgen deprivation therapy.and now in terms of what we are doing now and really progressing it with the currenttrial that we are running, and it’s actually

where this is close to closing enrolment thistrial, but actually looking at a large trial so we are doubling the sample size here toa bit over 120 guys. we are looking over if whether we can in stay over the first sixmonth period to really try and prevent a lot of these toxicities. and what we are doingspecifically is to reduce trial to that longer intervention is also including these impactexercises. we can start to now have a look at can exercise actually have an effect inthat really rapid change in bone mineral density and bone mass association and disperse theinitiation in the androgen deprivation therapy. so, really excited how the preliminary result– i haven’t shared them with you here but – the preliminary result in australiaare ever quite exciting and the guys are tolerating

it well and we’re seeing some very promisingresult. as you can see there’s two armed randomized controlled trial comparing exerciseimmediately initiation of adt, to delayed intervention after six months. we have a smallfollow-up after that as well. so, i think shifting weight, we spent a lotof time talking about a lot of these guys have blood clot disease or locally advanceddisease but it’s really important that we also have to think about what’s happeningwith the guys who are on long-term adt, advanced metastatic disease, and still suffering frommany of the side-effects of prostate cancer treatment over a longer period of time. so,we looked basically in all the research trials that have gone begin exercise in prostatecancer and engaging breast cancer cases as

well. patients with advanced metastatic diseaseand bone metastatic disease are excluded from these trials. so we really have no idea interms of the safetyness of exercise in these patients. so you can see, this is a very smallpilot trial in 20 men with bone metastatic disease and 25:33 are just resistance exercise.so, just lifting weight alone here. what you can see here is, again, 3 month interventionwe’re taking an approach of modular resistance exercise interventionand what i mean by that way, we’re actually individualizing the resistance exercise prescriptionbased on every individual person’s disease. so we look at the bone scan and identify exactlywhere the lesions are, and we prescribe the exercise based on the location of those lesionsso we avoid those areas to maximize safety

and still see if we can elicit some sort ofa physiological adaptation. so you can see we got some broad regions and we have identified,taking a systematic approach in terms of how we intervene exercise with these guys.so, in terms of the safety, it’s usually important that we screen them very effectivelyand we supervise them and really progress them in hardly supervised environment. wedidn’t have any adverse events during the actual exercise sessions. you can see thatwhen we penetrate, these guys are attending at about a similar rate as guys with localizeddisease. i think it’s really important – compliance measure here – a measure of 93% really tellsus that the guys were able to complete the exercise prescription that we actually designedand prescribed for them. there were many cases,

in which they had pain or impairment withfunctions, limited their availability to adhere to those exercise prescription designed. interms of the tolerability and exertion associated with the exercise intervention, the targetrange is between 12 to 16 in this range of exertion – the guys were able to exerciseat a level that we could measure with guys with localized disease. as you can see here,there’s no change in medication, there’s no real issues in terms of bone pain resultingfrom exercise intervention, affecting what they did afterwards. and we screen guys thatanybody had significant bone pain in the first place with baseline was involved with thistrial. so, in terms of the efficacy data, what impactdid these have? this is a little bit confusing

but looking at the percent difference betweenthe two groups, so one bar is the percent difference between exercise group and usualcare group. and anything that’s positive or in blue means favorable change for theexercise group. anything in red means favorable change for the usual care group. you can seethe trend with bone pain would actually be more favorable for the usual care group – nonsignificant though. and we saw a range of improvement in physical function and fitness,in terms of eliciting in short period of time of just resistance exercise, that was reallygood outcome for us. we saw here, as you can see, with quite considerable difference betweentwo groups in terms of their lean muscle mass and this is very promising in terms of maintainingindependence and function as these guys age.

i think it’s really important and very exciting.the physical activity level was an objective measure of physical activity – so, it wasa 7-day period in which they wore an actigraph, so accelerometer around their waist measuringobjective activity levels and how intense it was. basically they wore that before theystarted the exercise program or the intervention and after they finished that. so this is alow intensity physical activity and what we say with this is that, what we theorize withthis is that, guys, after they finish the exercise program, they were able to be lesssuccumbing to the disease and able to live a normal active lifestyle. i think we canuse this as kind of a quality objective measure of fatigue as well – seeing the guys ableto move around a lot more normally in everyday

life. so it’s really favorable outcomeshere in terms of what this means functionally for the guys, in terms of preventing long-termskeletal complications. these are really favorable results. just as a side, we’ve done someresearch with ladies with breast cancer bio-metastatic disease as well and we’re seeing some verypromising result. and that’s almost completely different prescriptions as well because therisk of fracture with ladies with breast cancer almost 4-fold compared to the guys with prostatecancer - due to different types of bone lesions that they have. so that’s really interestingand hope it’s coming up some time soon but what we’ve been doing is, progressingwith this work and this is a trial almost at maturation as well. so we’re lookingat a larger number of guys with bone metastatic

disease. we’ve been aiming at about 90 guysand we’re also involving aerobic exercise in the prescription. as you can see, it’snot just modular resistance exercise prescription, but it’s also a modular aerobic exerciseprescription as well – some basic flexibility. and again, based off of where those lesionsare for men with bone metastatic disease. so still this is a 3 month intervention, 2armed randomized controlled trial with exercise intervention and delayed intervention. soagain, some promising early result, but that will probably be finishing up next year.so i think another really important question is in looking at these interventions and efficacygathering in clinical practices is, is the supervised program really important? becausethis is a lot - at least in australia – to

what would be standard clinical practice ingood setting where a specialist would recommend someone to be physically active, maybe provideeducational materials. in these trials, what would be interesting, guys treated previouslywith adt and radiation therapy you can see in 100 men. this is a trial involving australiaand new zealand which we compared the effects of structures of supervised exercise interventionin a clinic for 6 months with a step down approach to home-based prescription of thesecond 6 month period and we compared that to a control group that was recommended tobe physically active and given some physical activity educational material. so you assumenext slide the result in terms of what impact these intervention had…so again, this slide actually gives you a

difference between two groups – the percentdifference. the dark green is 6 months – so that’s following a structure based programand light green at 12 months following at home-based program. so, of the 12 month periodor the initial 6 month period so this is fitness and strength and pa as well as lean musclemass. we saw pronounced differences between the guys involved in a structured programand guys just involved in physical activity at home. those differences you can see, theydecreased following the home-based portion and you can see with the lean muscle mass,it was no longer significant after 6 months. another interesting element of this was, whatwas happening in terms of psychosocial function – mental health and social functioning – so,of that 6 month period guys were involved

in clinic based program had statisticallysignificant, clinically maintenance improvements in those domains which were not relevant orpresent at 12 month period, that home-based portion. so it really suggested somethinggoing on there with supervised group-based environment. but what’s important aboutthis is that, physical activity levels, the amount of activity these guys were doing weren’tthat different between these two groups. but it was all there again to coming the ideaof targeted exercise prescription and getting the right dosage of that exercise medicinereally impact the results here. again, not much on that slide you can actuallysay but you can look at range of different bloods and there was nothing really in termsof clinically significant meaningful differences

there in terms of what’s happening withtestosterone psa in different guys about 5 years diagnosis so it was long time ago. buteven looking at a range of markers of cardiovascular disease, diabetes disease, metabolic syndromeand so on… so very quickly i just wanted to chat to youabout what patient experience of exercise really is. i think this helps us understandhow we can engage guys in long-term exercise behaviors and what is it about these supervisedgroup based environment that’s important to the guys that allows us to realize thesebenefits. so again, qualitative design – this was in guys on adt and were exercising withus for about 6 month period. so you’ll see in the next slide aboutthree super ornate themes or main themes emerged

from years. and these guys were reportingthat structured exercise program really provided significant health related benefits – itprovided both physical and mental health related benefits and that was quite pronounced. theyalso provided peer support both in terms of getting together with a bunch of guys havehad shared experience with prostate cancer but also a bunch of guys that are about thesimilar age that have similar stage of life issues. so it was ability to connect beyondthat shared experience of prostate cancer which was certainly viewed as important formany of the guys. now i don’t know, so there are learning of 35:05 as well. peer supportwasn’t a hugely important thing for many – probably half the guys – in terms ofon-going patients. i lied, probably not half,

there’s definitely a different responsein terms of couple of the guys first, the actual rest of the group there. but i thinkwhat’s the most common throughout everyone is the role that exercise physiologist hador in canada – probably kinesiologist or physiotherapist. so that was really key interms of shaping the patient experience – the program. and really facilitating health relatedbenefits and generating that piece for positive environment. so not only from the professionalpoint of view in terms of education, a person can provide – exercise physiologist – butalso the support that can be provided by caring about well-being of these patientsso, i think what these early evidence shows us - certainly out of the observation 36:04watching these guys interact, is that, exercise

can definitely and building on that quantitativedata, exercise definitely has impact on psychosocial well-being for these guys and we can see thatthe exercise group certainly can act as a support group or support group on steroids– support group that’s targeted for guys and really kind of plays on these masculinevirtues right? gets the guys to do stuff so it’s activities based. allows the guys tocome together – casual positive environment at the gym. certainly with these australianguys there’s a lot of human, a lot of friendly guys from competition and you’ve got educationsupport provided by exercise physiologists really instills confidence in these guys andprovides a sense of control over what they can do to counteract those side-effects. asi’ve said before, it really helps to extend

the social network. so we’ve been pushingin australia to really have exercise in full component of universal care for all men withprostate cancer and this is, if you’re interested in nursing or psychology, it’s great littlemonograph which is published by prostate cancer foundation of australia by susan chambersso we’ve incorporated exercise. so ideally what we’d like to see in the base of initialresearch is that, ideally these exercise can be applied and supervised prostate cancerspecific group based approach. by doing that, by providing these physical and mental healthbenefits and peer support in a way that actually reinforces masculine self-esteem, this approachmay provide an effective avenue for supportive care that is accessed more frequently by guysand has better engagement even if it’s short-term

engagement by the men. so i think this isreally important in terms of how we can tailor interventions specifically targeting men.so, very quickly, i just want to have a quick chat about what we do in terms of translatingresearch evidence into practice so we’ve worked with a 38:10 pharmaceuticalcompanies – one of them being abbvie – in terms of creating patient support program,it’s called the man plan in australia which allows anyone who’s being prescribed lucrinfor androgen deprivation therapy actually gets the ability to participate in these patientssupported programs just subsidized through pharmaceutical agency. it involves eitherface to face supervised exercise program, a home-based or a home-based exercise programthat’s provided 38:40 – 38:46 the numbers

are probably up to about two-and-half thousandand three thousand people now. we also came in terms of using health care system in 38:56in terms of health subsidized that. so they compared astra zeneca have a patientsupport program now as well – frank that incorporates exercise and we’re developinga specific supervised program to accompany the educational resources in these programs.so these are the two ways that you can get, at least from the pharmaceutical companiesengaged in actually providing some of these services to their patients to prevent someof the toxicity and restore function. and we run with cancer council in wa– aprogram called life now and these are about all cancer survivors but we do get a proportionof men with prostate cancer qualify for these

programs as well. and really, this is a modelof a randomized controlled trial, so looking at a 3 month supervised exercise program.it’s actually administered in the community so in wa in australia – we have 12 clinicsthat run it and they’re basically gyms, fitness centers that are available to thepublic that are administered by exercise physiologist that we upscale and specifically trained torun these programs. we’ve been running it in the last four years as you can see it’sgreat without pay it’s subsidized by 40:11 and council – in australia which is frompublic a funding but it’s a model that we’re able to intervene with exercise have a goodefficacy result in terms of impacting fatigue, distress, quality of life, physical functionsand so on

what we’ve been moving to now and have beenpushing quite hard recently is, integrating exercise clinics within cancer clinics andcancer centers and we have a couple of clinics in perth. one in private hospital within cancercenter, and also within a public hospital, within a cancer center there. so we have specificexercise clinics that are available to actually have patients who are going through radiotherapyprimarily for prostate cancer or chemotherapy for other cancers as well – advanced tobase. exercise during the treatment, what we see here is an example of new men healthclinic being built in melbourne environment and they’re planning to have the exerciseclinic within their facility. so this is kind of the movement we’ve been pushing for inaustralia having exercise clinics both within

the cancer centers and also off treatmentcommunity what we’ve also been pushing in australiais we are pretty large country – not too many people - so we have a little racial remoteareas so, to be able to provide expert support remotely is really important and we’ve beenpartnering with a group out of melbourne, he’s developed a website called prostmatewhich provide resource for patients and clinicians to track their progress to prostate cancerand what we’re actually integrating into this is, online consultation – prostatecancer trained exercise physiology expert. so, this allows patients to access expertiseand but it also allows home-based programs to be supervised through local exercise physiologistsor personal trainers by experts in your area.

just really quickly, i just wanted to, afterall i’m hopping 42:11 what the specific guidelines are and these are groomed fromamerican college of sports medicine that are being reinforced by the american cancer societyand also national comprehensive cancer network. and really the message here is that exerciseis safe during and after treatment if it’s prescribed and supervised effectively. certainlypatients need to avoid inactivity regardless of what kind of treatment they are going onand the general message is that some exercise is better than none. more is better than less.however, if you’re trying to look at significant health benefits, the recommendations are that…aerobic exercise you want to be trying – and that’s the walking, running and joggingandso on. you want to be trying to obtain a goal

of 150 minutes of moderate intensity aerobicexercise each week. so a brisk walk at least 30 minutes a day, five days a weekand also for the resistance exercise, hugely important for men with prostate cancer, butso often overlooked in terms of the exercise recommendation. so this is the lifting weight.let me try to do… 2-3 resistance exercise sessions each week. it’s moderate intensityso it’s hard work; it’s involving major muscle groups in the upper and lower bodyso, this is the fluffy goal for people who’ve never been exercising before but i think thesomething that you progress slowly towards and as individual progression and the biggestthing is – the intensity is individual. so, what’s very hard for someone could bevery easy for someone else, so we can very

much individualize this to ensure they’resafe, easy progression – not easy but steady progression to these guidelines. and certainlycertified exercise physiologists are accredited are much accredited as the physiolgists areor kinesiologists but certainly 44:02 is important so, i think just really briefly, i want tohighlight the role of the clinicians and actually facilitating the patient engagement with exercise.and we certainly see that, involvement of specialists and support staffs are critical.it certainly brings a lot of 44:23 with that prescription if the patient is actually gettinga recommendation and enroll to our program. and what we’re seeing now are then, whilethe provision of educational material is proven, and while the recommendation with physicalactivity is very important, somehow it’s

not enough to mimic the actual efficacy datathat we’re seeing in these supervised trial. so it’s really important that we work asa field to try and implement these programs that are all available for patients with cancerso, i think just to wrap up all this research, what we really say is that, exercise is amedicine and they 44:59 in men with prostate cancer. it certainly offers the greatest potentialas an adjunct therapy to reverse treatment related side-effects, and improve the qualityof life in men with prostate cancer. i think we’ll see in the next 5, 10, 15 years, whatimpact exercise can have on prostate cancer progression and survival in highly controlledclinical trials so i just want to acknowledge the fantasticresearch team that i’m fortunate enough

to work with in australia and throughout ofaustralia. really fantastic multi-disciplinary team – exercise physiologists, clinicians,urologists, radiation oncologists, medical oncologists, health psychologists, nursing,so on. it really is fortunate to work with great multi-disciplinary team and i’d certainlylike to acknowledge their contribution towards all this workthank you very much, i have time for a little bit of questions if anyone has any.