We identified a low level of exercise and high level of obesity in men with Prostate Cancer, both risk factors for extra toxicity following ADT, particularly fatigue. Working with patients, health care commissioners and the government body: Skills Active, and a training provider we developed a national level 4 qualification in exercise rehabilitation which empowered local (and national) gym instructors to accept referrals for patients with cancer within the national exercise referral scheme.
All men, with prostate cancer now receive exercise counselling, supported by a written information pack and are offered referral to a 12 week exercise programme which when later audited had a high uptake rate and satisfaction. This project is in line with recommendation 1.4.19 in NG131 which states: Offer men who are starting or having androgen deprivation therapy supervised resistance and aerobic exercise at least twice a week for 12 weeks to reduce fatigue and improve quality of life.
Aims and objectives
1). To establish the level of physical activity and other lifestyle factors such as obesity and smoking among men treated for prostate cancer at our centre in order to highlight the need for an exercise and lifestyle intervention.
2). To develop a national level 4 qualification in exercise and cancer rehabilitation which will empower exercise professionals to confidently take our patients with cancer for a safe 12 week supervised exercise programme.
3). To liaise with and support the management of the local exercise referral scheme to allow men being treated for prostate cancer to access the scheme.
4). To develop an information pack highlighting the benefits of exercise and healthy lifestyle after prostate cancer to aide lifestyle counselling.
5). To prospectively audit the uptake of exercise referral to a 12 week scheme and learn lessons to improve future compliance
Reasons for implementing your project
Previous to this initiative, men being treated for prostate cancer could not be referred to local exercise schemes based upon their cancer diagnosis alone. However it had been identified through a series of evidence reviews conducted and published by ourselves (see attached list of references for further reading) that these men would benefit from a formal exercise programme initiated at the time of the androgen deprivation therapy as it would reduce many of the troublesome side-effects and risks, particularly fatigue.
In addition to this, 440 men who were treated with radical radiotherapy at Addenbrooke's Hospital between 2000-2010 via the Bedford Hospital pathway completed a questionnaire asking them about their physical activity patterns using the General Practical Physical Activity Questionnaire (GPPAQ). They were also asked about late side effects using a Vaizey Rectal Toxicity score, the NCI common toxicity scores for rectal bleeding, erectile function and urinary incontinence as well as questions concerning BMI and smoking. The effect of each lifestyle criteria on rectal toxicity was investigated using a non-parametric ANOVA (Kruskal-Wallis) test and other side effect scores using a chi-squared test (significance level á=0.05). According to the GPPAQ scale 58% of men were inactive, 27% moderately inactive and 15% active. Of more concern, only 4% reported more than 3 hours of moderate activity per week. 7.5% men smoked whilst taking ADT. At the time of the survey, 63% were over-weight or obese (BMI >25); we also found active men had significantly lower rectal toxicity and significantly better erectile and urinary function. This finding was published in the journal Clinical Oncology (R Thomas et al; 2013; 25 (4) pp 246-251).
This is in line with recommendation 1.4.19 in NG131 which states: Offer men who are starting or having androgen deprivation therapy supervised resistance and aerobic exercise at least twice a week for 12 weeks to reduce fatigue and improve quality of life (new 2014).
How did you implement the project
Before the target group of men could be accepted on to existing exercise referral schemes some work had to be done to skill up exercise professionals in cancer rehabilitation and exercise. Therefore a large piece of national work was first done by us with the regulator authority Skills Active to write the national minimal standards for a training course in cancer rehabilitation with an emphasis on exercises which improve common symptoms such as fatigue.
This involved a formal evidence review and national consultation process involving patients, oncologists, fitness instructors and physiotherapists throughout the UK. Following national approval we then worked with a training provider to design a course which was also submitted for certification with skills active. The first UK cohort of exercise professionals were trained at The Primrose Unit Bedford Hospital. All 14 attendees successfully passed the final exam gaining a level 4 qualification. Details of the course which is now run nationally at a cost of £595 per person can be found by clicking here.
Alongside the fitness instructors being trained in cancer rehabilitation, work was done with local commissioners to persuade them to expand the regional exercise referral scheme to include people with cancer (including prostate). This resulted in all eight of the local gyms agreeing to take referrals from the Primrose Unit and from other health professionals. Professor Thomas also gave a series of talks: to local GPs, at the hospital, at local gyms, rugby clubs, golf clubs and patient support groups which raised awareness of the importance of exercise for people being treated for cancer.
Within the Primrose Unit a lifestyle information pack and website were developed at minimal cost in order to help explain the importance of exercise to men and their families. The website also offers the option for patients to see what other physical activity options are available should they prefer to take part in something other than gym based activities such as walking, swimming etc.
With the help of an MSc student from our local university (Cranfield) we then audited the uptake of exercise referral for the first 80 patients using questionnaires and follow up telephone calls.
Prospective service evaluation of the first cohort of patients referred to the 12 week programme at the local gyms which revealed that 40% attended one of the 8 participating gyms within 1 month. A further 30% attended after a follow up phone call or encouragement during a subsequent consultation. All accept 1 patient completed a 12 week programme. 94% were satisfied or highly satisfied with the scheme. This formal evaluation was published at an annual NCRI conference (Is The National Activity for Health Referral Scheme the practical solution for exercise referral for exercise rehabilitation after cancer? Thomas, Pei Ding, Williams. See link
Patient satisfaction to the lifestyle information pack was high and it is now used routinely for all patients. A service evaluation of the methodology used was published in a European conference (Development of a lifestyle exit tool box. R Thomas, T Taylor, M Williams. ECCO 2009 EJC; 7 (2), 210 sup3608).
Key learning points
- The promotion of the benefits of physical activity and exercise for people being treated with cancer needs to be embedded within the culture of all staff at The Cancer Unit and with other health professionals who refer into the service.
- Following appropriate motivational counselling, referring men to the local municipal gym for a 12 week exercise programme supervised by specifically trained level 4 instructors had good uptake, compliance and satisfaction with most men post treatment for prostate cancer participating in low levels of physical activity.
- Uptake can be increased by further follow up contact either by phone or at a subsequent consultation.
- Longer term exercise patterns require further evaluation