Advances in medicine, together with early detection, are helping men to survive prostate cancer and live longer after diagnosis. But living longer is not the same as living well. Long-term survivors of prostate cancer may suffer from ongoing health issues and have unmet needs in psychological and sexual support. There are numerous programs that propose to help prostate cancer survivors – but do they work? Australian researchers have reviewed the evidence behind prostate cancer survivorship programs.
Prostate cancer survivorship research in Australia
In 2013, a research collaborative was founded that focused on prostate cancer survivorship. The Prostate Cancer Survivorship Research Centre was formed as a collaboration of Griffith University and Prostate Cancer Foundation of Australia. Joined by leading researchers across the country, the Centre was awarded a significant grant from the Australian government in 2016, becoming the NHMRC Centre of Research Excellence in Prostate Cancer Survivorship.
The purpose of the Centre is to undertake strategic research to better understand and meet the survivorship needs of men with prostate cancer, their partners and families. The Centre uses evidence-based outcomes to improve policy and practice for men with prostate cancer. They focus on four key themes:
- Effective delivery of psychosocial and sexual care in prostate cancer
- Integration of tailored exercise medicine into supportive care to improve quality-of-life and extend survival
- Optimisation of clinical pathways for diagnosis and treatment
- Equity in outcomes across geographic and socio-demographic boundaries
The Survivorship Centre aims to be a consumer-driven initiative, guided by the advice and opinion of people affected by prostate cancer. The centre is made up of collaborating researchers from Institutes around Australia. They work together, but not in the same place. These researchers include:
Prof Suzanne Chambers from the University of Technology Sydney. Her research focusses on the supportive care needs of men with prostate cancer and their families.
Prof Daniel Galvão and Prof Rob Newton from Edith Cowan University. Their research focuses on the benefits of exercise for men diagnosed with prostate cancer.
Prof Peter Baade from Cancer Council Queensland. Prof Baade’s research asks why prostate cancer-related outcomes depend on where people live, and what are the key reasons for variations in outcomes.
Dr Melissa Hyde from Griffith University and Cancer Council Queensland. Dr Hyde’s research focusses on men’s experiences and adjustment after prostate cancer diagnosis and treatment, particularly men’s decisions to seek support for their psychological, physical, sexual and practical concerns.
These are just some of the dedicated researchers contributing to the Prostate Cancer Survivorship Centre.
Survivorship care
Survivorship care is a relatively new concept. For prostate cancer, this includes medical, psychological, social and allied health care for men who are long-term survivors of prostate cancer. Survivorship care was formally recognised in 2005 by the Institute of Medicine in the USA. The American Cancer Society published Prostate Cancer Survivorship Care Guidelines in 2014 to promote survivorship care. These guidelines outlined 5 key domains for action:
- Health promotion
- Surveillance for prostate cancer recurrence and screening for secondary cancers
- Management of long-term physical side effects
- Psychosocial management
- Care coordination
Review of interventions for prostate cancer survivorship
One of the first projects undertaken by members of the Prostate Cancer Survivorship Centre was a review of interventions for prostate cancer survivorship. What this means is an analysis of the evidence for the benefits of programs designed to help prostate cancer survivors. The review was done to understand where good evidence underpins specific programs, where it doesn’t, and where it’s missing.
The review project was led by Dr Fiona Crawford Williams from the University of Southern Queensland. The results of this review have recently been published in the Journal Psycho-oncology. This review was labelled A systematic review of reviews. The authors used previous reviews of research to collate and compare all the published evidence for survivorship programs world-wide. They included 44 reviews of interventions in their overall review. The Australian researchers addressed the 5 key domains for care outlined above by the American Prostate Cancer Survivorship Care Guidelines (described above).
Health promotion
The Prostate Cancer Survivorship Care guidelines recommend that survivors maintain a healthy weight, do regular physical exercise, have a healthy diet, avoid or limit alcohol and avoid smoking. A good healthy diet to aim for is one that is high in fruits, vegetables and whole grains.
The Australian review asked whether there was good evidence that health promotion programs supported survivors in meeting these health goals. The researchers reviewed 11 studies of the impact of nutrition and/or exercise interventions. There were no reviews of programs to help men limit smoking and drinking alcohol.
The Australian study found that there was strong, high-quality evidence of the effectiveness of exercise programs. But the evidence was inconclusive for nutritional interventions. What this means is that we have good ways to support men getting fit, but promotions of healthy eating aren’t working as well as we’d like. We know that long-term survivors would benefit from eating a healthy diet, but we don’t know the best ways to support them in changing their eating habits.
Surveillance for prostate cancer recurrence and screening for secondary cancers
The guidelines recommend PSA tests every 6 to 12 months and regular digital rectal exams to test for returning prostate cancer. However, these are American guidelines that are a few years old. Australian survivors should discuss surveillance for return of prostate cancer with their doctors. Prostate cancer survivors may also be at risk of other cancers, such as bladder or colorectal cancers, depending on their age and the treatments they’ve had.
Unfortunately, no reviews of programs for surveillance for long-term survivors have been performed.
Management of long-term physical side effects
The guidelines recommend assessing and managing the long-term side effects of fatigue, anaemia (low red blood cells), urinary problems, bowel problems and sexual problems. They also include addressing risks of osteoporosis, diabetes, heart disease and stroke in survivors.
The Australian study reviewed 16 articles that assessed programs to manage side effects in prostate cancer survivors. There was a high level of evidence to support exercise programs. Effective exercise programs included a combination of aerobic and resistance training, delivered during or after treatment. Resistance training helped to improve muscle strength, combatting the loss of muscle strength often associate with androgen deprivation therapy. Exercise was also effective at reducing the effects of fatigue on survivors. Exercise programs were reported to have positive effects on sexual activity, but not the overall ability to have sex.
For managing incontinence in prostate cancer survivors, pelvic floor exercises after surgery were effective. One review reported that for those doing pelvic floor exercises after surgery, adding more exercises before surgery had no added benefit. Another review found that pelvic floor exercises improved continence early in recovery, but not long-term continence rates. Therefore, the evidence for the specific benefits of pelvic floor exercises was mixed. This finding highlights the need for more research to define the types of pelvic floor exercise programs that will have long-term benefits for continence.
A review examined the evidence for programs addressing sexual issues. This study found that programs including peer support, education and group-based interventions improved outcomes for men with sexual problems after prostate cancer treatment.
Psychosocial management
Psychosocial effects refer to the effects of prostate cancer and its treatment on a man’s mental, emotional and social wellbeing. The guidelines recommend that each year a prostate cancer survivor is asked how they are coping with the physical and psychosocial effects of their cancer. They also recommend regular use of a distress thermometer – a short survey designed to identify men who are experiencing high levels of distress.
Eighteen reviews examined the evidence behind programs to improve the psychosocial wellbeing of prostate cancer survivors. The programs reviewed included exercise, nutritional support and psychosocial support. Five reviews found that psychosocial care improved quality-of-life, depression, anxiety and distress. Two reports that focussed on depression or anxiety found that peer support and psychotherapy had a short-term benefit but not long-term. A particularly comprehensive review of randomised controlled trials reported that programs with combined approaches, such as psychological care, education and peer support, were effective in improving distress, mental health and quality-of-life. Eight reviews also reported that aerobic and resistance exercise training programs had some benefit for psychosocial wellbeing.
Care coordination
The guidelines recommend cancer specialists provide all prostate cancer survivors with a survivorship care plan that includes treatment summaries and follow-up recommendations. Unfortunately, there were no reviews that tested the effectiveness of survivorship care plans.
Conclusions
There are many different programs that aim to improve the lives of men who are long-term survivors of prostate cancer. These programs include exercise, diet/nutrition, psychological care, education, peer-support, screening for prostate cancer return and secondary cancers, pelvic floor exercises and survivorship care plans. The Australian review found that there was good evidence underpinning exercise and psychosocial programs for improving the lives of prostate cancer survivors (in terms of the 5 key domains described above). Nutrition and diet programs were no well supported by evidence – due to their inability to improve the diets of these men. More research is needed to better understand how to best use pelvic floor exercises. There was a lack of studies and evidence for the best programs for surveillance for prostate and other types of cancer, as well as the use of survivorship care plans. This review has highlighted programs that work, and areas where more research is needed to determine the possible benefits.
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