Exercise Prevents Fatigue and Improves Quality of Life in Prostate Cancer Patients Undergoing Radiotherapy

Article Outline

• Abstract
• Methods
  • Assessment Procedures
    • Cardiovascular fitness
    • Flexibility
    • Strength
    • Fatigue
    • Quality of life
    • Depression
  • Radiotherapy
  • Statistical Analysis
• Results
• Discussion
  • Study Limitations
• Conclusions
• References
• Copyright

Abstract 

Monga U, Garber SL, Thornby J, Vallbona C, Kerrigan AJ, Monga TN, Zimmermann KP. Exercise prevents fatigue and improves quality of life in prostate cancer patients undergoing radiotherapy.

Objective

To show fatigue prevention and quality of life (QOL) improvement from cardiovascular exercise during radiotherapy.

Design

Prospective enrollment (n=21), randomized to exercise (n=11) and control groups (n=10), with pre- and post-radiotherapy between- and within-group comparisons.

Setting

Academic medical center.

Participants

Localized prostate cancer patients undergoing radiotherapy.

Interventions

The interventional group received radiotherapy plus aerobic exercise 3 times a week for 8 weeks whereas the control group received radiotherapy without exercise.

Main Outcome Measures

Pre- and post-radiotherapy differences in cardiac fitness, fatigue, depression, functional status, physical, social, and functional well-being, leg strength, and flexibility were examined within and between 2 groups.

Results

No significant differences existed between 2 groups at pre-radiotherapy assessment. At post-radiotherapy assessment, the exercise group showed significant within group improvements in: cardiac fitness (P<.001), fatigue (P=.02), Functional Assessment of Cancer Therapy–Prostate (FACT-P) (P=.04), physical well-being (P=.002), social well-being (P=.02), flexibility (P=.006), and leg strength (P=.000). Within the control group, there was a significant increase in fatigue score (P=.004) and a decline in social well-being (P<.05) at post-radiotherapy assessment. Between-group differences at post-radiotherapy assessment were significant in cardiac fitness (P=.006), strength (P=.000), flexibility (P<.01), fatigue (P<.001), FACT-P (P=.006), physical well-being (P<.001), social well-being (P=.002), and functional well-being (P=.04).

Conclusions

An 8-week cardiovascular exercise program in patients with localized prostate cancer undergoing radiotherapy improved cardiovascular fitness, flexibility, muscle strength, and overall QOL and prevented fatigue.

Key Words: Exercise, Prostate cancer, Quality of life, Rehabilitation

CANCER RANKS SECOND only to heart disease as the leading cause of death in North America. One in 4 deaths in the United States is due to cancer.¹ Early cancer detection and improved treatments have resulted in increased survival rates over the last few decades.¹ However, declining quality of life (QOL) and increased fatigue remain major concerns in cancer patients.², ³, ⁴, ⁵, ⁶, ⁷, ⁸ In a recent population based survey⁴ of 419 randomly selected cancer patients, 78% reported experiencing fatigue that interfered with their daily routine. According to Piper et al,⁹ fatigue can be the initial manifestation of cancer and may be present before any treatment is initiated. The reported incidence of fatigue as a radiotherapy side-effect ranges from 65% to 100%.⁴, ⁶, ¹⁰, ¹¹, ¹² Fatigue prevalence increases over the course of radiotherapy¹⁰, ¹¹, ¹² and worsening of fatigue at later stages of the disease is possible.⁶

Prolonged inactivity and sedentary lifestyle cause rapid losses in fitness, energy, and physical functioning.¹³ According to MacVicar et al,¹⁴ more than one third of the decline in functional capacity experienced by cancer patients can be attributed to prolonged physical inactivity.

In contrast, studies have shown that exercise improves cardiac fitness, muscle strength, and flexibility. Physical activity also has been reported to decrease anxiety and depression.¹⁵, ¹⁶, ¹⁷ Exercise also has been shown to decrease fatigue and improve sleep among healthy adults.¹⁸, ¹⁹

Despite the known benefits of exercise, few researchers have studied the effects of exercise on patients undergoing cancer treatment.²⁰, ²¹, ²², ²³, ²⁴, ²⁵ In their review of exercise in cancer survivors, Courneya et al²⁶ concluded that preliminary research suggests that exercise may be an effective intervention to enhance QOL in cancer survivors and that further research is needed to extend our knowledge beyond breast cancer survivors. In a recent review of the literature, Friedenreich and Courneya²⁷ urged that future research in the area use valid and reliable assessment methods. They highlighted the need for a thorough assessment of QOL and also suggested the inclusion of additional physiologic measures such as flexibility, endurance, strength, and balance.²⁷ They further emphasized the need for randomized control designs in future research.²⁷ We are unaware of any randomized studies that have prospectively examined the potential benefits of exercise in patients undergoing radiotherapy for localized prostate cancer.

The objective of this prospective randomized study of patients with localized prostate cancer receiving radiotherapy was to prevent fatigue and improve QOL through a cardiovascular conditioning exercise program.

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Methods 

Over a 2-year period, patients referred to the radiotherapy service at the Houston Veterans Affairs Medical Center for radiation treatment of localized prostate cancer were approached for participation in this institutional review board–approved internally funded study. We recruited only patients with a first time cancer diagnosis for participation. If ambulatory and able to complete self-report measures, they were offered enrollment in the study. Exclusion criteria included the following: (1) concurrently receiving chemotherapy; (2) major health problems (uncontrolled hypertension, ie, seated systolic blood pressure >160mmHg or seated diastolic blood pressure >90mmHg, uncontrolled insulin-dependent diabetes mellitus, severe arthritis, and obvious cognitive dysfunction); (3) recent history of sudden onset of shortness of breath on exertion or a recent history of dizziness, blurred vision, or fainting spells; (4) recent history of unstable angina, coronary artery disease, myocardial infarction, or cardiac failure; and (5) bone, back, or neck pain of recent origin, or inability to exercise.

During the study period, 65 patients were treated by the primary investigator (UM) for localized prostate cancer (see table 1 for descriptive statistics of the studied population sample). Twenty-one patients were randomly assigned to either a structured exercise interventional group (n=11) or a usual care control group (n=10). Subjects who reported engaging in regular physical exercise (≥2 times a week) and those who reported not engaging in regular exercise were randomized separately to the 2 groups, so that both would have approximately equal numbers of prior exercisers. All subjects completed self-report measures, had their physical fitness assessed, and had relevant medical data (ie, body weight, prostate specific antigen [PSA] level, hematocrit) recorded prior to the initiation of radiotherapy and at the conclusion of treatment.

Table 1. Descriptive Statistics of Studied Population Sample

Descriptive Statistics	N
Total no. of patients treated with radiotherapy	65
No. of patients excluded⁎	30
Severe degenerative joint disease	12
Clinical evidence of peripheral neuropathy	6
Prior history of cancer	4
Uncontrolled hypertension	5
Uncontrolled diabetes mellitus	4
Recent history of coronary artery disease	5
Recent history of knee surgery	3
No. of patients approached	35
No. agreed to participate	30
No. withdrew after randomization	5
No. discontinued after enrollment	4
No. completed the study	21

Patients in the interventional group participated in an aerobic exercise program at our medical center 3 times a week for 8 weeks. The program was conducted by a staff kinesiotherapist and supervised by a physician (CV). Patients exercised in the morning, before receiving their daily radiotherapy. The exercise protocol consisted of a 10-minute warm-up, a 30-minute aerobic segment consisting of walking on a treadmill, and a 5- to 10-minute cool down period. Patients were instructed to maintain their target heart rate throughout the aerobic component of the program. The following formula was used to calculate target heart rate: (.65) × (maximum heart rate − resting heart rate) + resting heart rate.²⁸

Each patient’s maximum heart rate was calculated during a preparticipation maximal oxygen consumption assessment. During the program, weekly resting heart rate remeasurements and target heart recalculations took place.

The control group received standard care that included patient education and radiotherapy without exercise prescription or participation. Control group patients were aware of the exercise arm of the study.

Assessment Procedures 

We carried out all assessments listed hereafter prior to starting radiotherapy (pre-radiotherapy) and repeated after completion of radiotherapy (post-radiotherapy).

Under the supervision of a physician (CV), patients underwent a modified Bruce treadmill test protocol.²⁹ The test was terminated when subjects were unable to continue the protocol, or when their vital signs warranted discontinuation. Respective metabolic equivalents (METS) were calculated at each stage. Maximum heart rate, used in the calculation of target heart rate, was defined as the highest value achieved during the last 2 minutes of exercise. The protocol was repeated and METS were determined both pre- and post-radiotherapy.

We used the modified sit-and-reach test to measure flexibility.³⁰ Patients were instructed to sit with their legs fully extended and with their feet shoulder-width apart and flat against the end of a standard sit and reach box. After measuring how far their arms extend when they were sitting erect with their back, shoulders, and head against the wall, patients were asked to extend their arms forward with their palms down and one hand on top of the other. Patients extended their fingers as far forward as possible holding the position for at least 2 seconds. Patients were given 3 trials with their best score recorded as the distance (to the nearest centimeter) reached beyond their initial arm extension. Hoeger and Hopkins³¹ have reported internal consistency of .94 and stability of .89 over a 24- to 48-hour time frame using this technique.

The time it takes to stand up and sit down 5 times from an armless chair was used as a measure of lower-extremity strength.³² Patients were seated in a chair of 45.7-cm (18-in) height with feet flat on the floor and arms crossed over the chest. After standing up once to verify the ability to arise without the use of upper-extremity assistance, each patient was instructed to rise and sit 5 times as quickly as possible. The investigator stood in front of the patient for safety and cued him by saying “ready, set, go.” Times were recorded to the nearest tenth of a second and reflect the time interval from when the patient’s buttocks first left the chair seat until the patient’s buttocks came in contact with the seat at the end of the fifth repetition. Nevitt et al³² have reported intra- and interobserver reliability estimates of .89 or higher in community-dwelling elderly.

We used the revised Piper Fatigue Scale (PFS-Revised) to measure fatigue. This instrument was specifically developed to measure fatigue in cancer patients.⁹ The PFS consists of 22 numerically scaled items (0–10) that measure 4 dimensions of subjective fatigue. The dimensions include behavioral/severity (6 items); affective meaning (5 items); sensory (5 items); and cognitive/mood (6 items). Patients respond to each item by using a 0 to 10 rating scale. A total fatigue score is created by summing all 22 item scores. An average of the total score is derived, ranging from 0 to 10. Higher scores indicate greater fatigue. Patients scoring 6 or higher on the PFS could be considered as experiencing fatigue (B. F. Piper, personal communication, May 1998). Internal consistency estimates for the original PFS subscales ranged from .69 for the symptom dimension to .95 for the sensory dimension, in a sample of radiotherapy patients.⁹

We used the Functional Assessment of Cancer Therapy–Prostate (FACT-P) to measure QOL.³³ This self-report instrument, which measures QOL in prostate cancer patients,³³, ³⁴ consists of the 34-item Functional Assessment of Cancer Therapy–General (FACT-G) questionnaire (assessing cancer patients’ physical, social, emotional, and functional well-being, as well as the quality of the relationship with their doctors) augmented by 12 additional items that are of particular relevance to patients with prostate cancer. The FACT-G has well-established validity and reliability.³³, ³⁴, ³⁵ It has been administered to many cancer patients since 1989.³³ The prostate cancer-specific subscale has 12 items, including questions related to sexuality, bowel/bladder function, and pain. Internal consistency estimates of the FACT-P total score were .87 and .89 on 2 samples used to validate the measure. Internal consistency estimates of the 5 general subscales and the prostate-specific subscale ranged from .61 to .84.

We used the Beck Depression Inventory (BDI) to measure depression. It is a brief 21-item self-administered screening inventory that has been widely used and validated on adult as well as older adult populations.³⁶ The 21 statements cover sadness, pessimism, sense of failure, dissatisfaction, guilt, punishment, self-dislike, self-accusation, suicidal ideas, crying, irritability, social withdrawal, indecisiveness, body image change, work difficulty, insomnia, fatigability, loss of appetite, weight loss, somatic preoccupation, and loss of interest in sex. A 4-point response scale (0–3) is used; thus the possible range of scores is 0 to 63. Scores of 0 to 9 are considered to be in the normative range, and 10 to 18 scores denote mild depression. Scores of 19 to 27 and greater than 27 are considered to reflect moderate and severe depression, respectively.³⁷ Comparative validity coefficients with other depressive scales have been reported to range from .32 to .74.³⁸ Test-retest reliability has been reported above .90.³⁶ Spearman-Brown reliability was .93, and internal consistency for test items was .86.³⁹

Radiotherapy 

All patients received radiotherapy for 7 to 8 weeks from a Varian 2100 linear accelerator^a with 18-MV photon beams. We used the closed-box technique of Del Regato, using 4-field prostate irradiation at specific angles: anteroposterior, postero-anterior, right lateral, and left lateral, at 360°, 180°, 270°, and 90°, respectively. Each subject received 68 to 70Gy in 34 to 38 fractions at 1.80 to 2.0Gy per fraction.

Statistical Analysis 

We used SAS^b software to perform all statistical analyses. Statistical significance of between-group differences in demographic and clinical (pretreatment) variables was probed with Wilcoxon rank-sum or 2-sample t tests (table 2). Univariate or multivariate analysis of variance (ANOVA) was used to test the 12 pre- and post-treatment outcome variables. Multivariate analysis was also used to establish that corresponding univariate comparisons were valid. That is, if significant, it was used to justify performing univariate analysis without adjustment of P values for multiple comparisons. Paired-difference and 2-sample t tests (equivalent to univariate ANOVA) were also performed and reported in Table 3, Table 4, Table 5, Table 6. These have the advantage of familiarity to most readers, and provide tests of adequacy for underlying assumptions. Because we could not verify that our variables satisfied distribution requirements for univariate and multivariate ANOVAs, we performed nonparametric Wilcoxon rank-sum and signed-rank tests for comparison purposes and the results were found to agree with the parametric test results (nonparametric test results not shown). Statistical significance for all comparisons was reported for P values of .05 or less.

Table 2. Between Group Pre-Radiotherapy Comparison: Demographic and Clinical Variables

Variables	Exercise Group	Control Group	P (t test)
N (patients)	11	10
Mean age (y)	68±4.2	70.6±5.3	.23
Mean weight (lb)	177.3±29.1	80.1±28.8	.83
Mean education (y)	12.4±3.3	11.6±2.8	.44
Mean PSA	7.4±5.7	6.4±5.0	.60
Mean combined Gleeson	5.5±1.0	5.1±1.2	.55
Mean hematocrit	42.5±1.8	43.0±2.0	.55
Marital status
Married	7	7
Single/separated	4	3
Ethnicity
White	3	4
Black American	7	5
Hispanic	1	1
Medical problems
Hypertension	5	3
Diabetes mellitus	3	3
CAD	2	2
COPD	2	1

NOTE. Values are n or mean ± SD.

Abbreviations: CAD, coronary artery disease; COPD, chronic obstructive pulmonary disease.

Table 3. Between Group Pre-Radiotherapy Comparison: Measured Variables

Table 4. Within-Group Pre- Versus Post-Radiotherapy Comparison: Measured Variables (1-exercise group)

Variables	Time	Mean ± SD	t	P
METS	Pre-RT	7.2±1.2
	Post-RT	9.8±0.9
	Change	2.6±0.9	9.48	<.001
Stand-and-sit test	Pre-RT	12.6±2.3
	Post-RT	11.3±1.9
	Change	−1.3±1.0	−4.69	.000
Flexibility	Pre-RT	12.3±3.6
	Post-RT	14.0±4.0
	Change	1.7±1.6	3.52	.006
PFS	Pre-RT	2.4±2.4
	Post-RT	0.8±1.8
	Change	−1.6±2.0	−2.66	.02
BDI	Pre-RT	3.5±5.4
	Post-RT	2.8±5.5
	Change	−0.7±2.5	−0.97	.36
Physical well-being	Pre-RT	23.8±4.1
	Post-RT	26.1±3.0
	Change	2.3±1.8	4.20	.002
Social well-being	Pre-RT	23.7±4.3
	Post-RT	25.2±4.1
	Change	1.5±1.9	2.67	.02
Relationship with	Pre-RT	7.2±1.3
physician	Post-RT	7.7±0.9
	Change	0.5±1.4	1.32	.22
Emotional well-being	Pre-RT	22.4±2.3
	Post-RT	22.5±2.6
	Change	0.1±2.0	0.15	.88
Functional well-being	Pre-RT	23.0±6.6
	Post-RT	24.8±6.0
	Change	1.8±4.2	1.44	.18
Prostate cancer	Pre-RT	38.1±8.2
symptoms	Post-RT	39.9±4.9
	Change	1.8±5.8	1.05	.32
FACT-P	Pre-RT	138.5±24.1
	Post-RT	145.9±18.3
	Change	7.4±10.4	2.36	.04

Abbreviation: RT, radiotherapy.

Table 5. Within-Group Pre- Versus Post-Radiotherapy Comparison: Measured Variables (2-control group)

Variables	Time	Mean ± SD	t	P
METS	Pre-RT	7.4±2.1
	Post-RT	7.2±2.3
	Change	−0.2±2.5	−0.31	.77
Stand-and-sit test	Pre-RT	10.8±1.6
	Post-RT	11.3±1.6
	Change	0.4±0.7	1.76	.11
Flexibility	Pre-RT	9.6±4.5
	Post-RT	9.2±5.9
	Change	−0.35±1.8	−0.61	.56
PFS	Pre-RT	1.1±1.9
	Post-RT	3.8±2.2
	Change	2.7±2.2	3.91	.004
BDI	Pre-RT	3.6±5.0
	Post-RT	4.2±3.4
	Change	0.6±3.1	0.62	.55
Physical well-being	Pre-RT	25.5±3.0
	Post-RT	24.2±2.6
	Change	−1.3±2.1	−1.95	.08
Social well-being	Pre-RT	24.9±1.9
	Post-RT	23.2±2.9
	Change	−1.7±2.4	−2.28	.05
Relationship with	Pre-RT	7.8±0.4
physician	Post-RT	7.5±1.3
	Change	−0.3±1.4	−0.67	.52
Emotional well-being	Pre-RT	21.6±2.5
	Post-RT	22.6±1.6
	Change	1.0±3.6	0.88	.40
Functional well-being	Pre-RT	24.7±2.5
	Post-RT	22.4±4.3
	Change	−2.3±4.2	−1.72	.12
Prostate cancer	Pre-RT	40.0±2.6
symptoms	Post-RT	38.2±4.8
	Change	−1.8±4.2	−1.34	.21
FACT-P	Pre-RT	144.5±9.2
	Post-RT	138.1±12.7
	Change	−6.4±9.8	−2.06	.07

Table 6. Between-Group Comparison: Within-Group Pre- to Post-Radiotherapy Score Changes in Measured Variables

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Results 

The mean age ± standard deviation (SD) of the patients in the interventional group was 68.0±4.2 years (range, 62–77y) versus 70.6±5.3 years (range, 64–80y) for patients in the control group.

The demographic and clinical (pretreatment) variables for patients in the 2 groups are summarized in table 2. None of the differences between groups was statistically significant. The observed mean values illustrate the exceptionally comparable group assignments.

Similarly, pretreatment values for each of the 12 outcome variables in the exercise and control groups were quite comparable (see table 3). Group comparison by multivariate ANOVA showed lack of statistical significance (P=.28) based on the Wilks λ test. None of the corresponding univariate comparisons was statistically significant, thereby establishing additional pre-radiotherapy comparability of the 2 groups.

Although our primary interest was the comparison of pre- to post-radiotherapy score changes between groups (see table 6), we were also interested in determining whether any of the score changes were statistically significant within each group (see Table 4, Table 5). In the exercise group, 7 of 12 variables (METS, stand-and-sit test, flexibility, PFS, physical well-being, social well-being, FACT-P) showed statistically significant improvement, based on univariate ANOVA. The results compiled in table 4 (based on paired-difference t tests) show that 4 of the 5 other variables (BDI, relationship with the physician, emotional well-being, functional well-being) had changes in the direction of improvement.

In contrast, the control group showed significantly worse post-radiotherapy scores on the PFS and the social well-being scales, compared with pre-radiotherapy (see table 5). Among the 10 variables without statistically significant changes, 8 (METS, stand-and-sit test, flexibility, BDI, physical well-being, social well-being, relationship with the physician, functional well-being) changed in a direction indicating poorer performance.

The primary analysis compared pre- to post-radiotherapy score changes between the 2 groups. Multivariate ANOVA on the 12 variables was highly significant (P=.002) based on the Wilks λ test. Comparisons based on 2-sample t tests (equivalent to univariate ANOVA) are summarized in table 6. Eight of 12 variables (METS, stand-and-sit test, flexibility, PFS, physical well-being, social well-being, functional well-being, FACT-P) showed statistically significant improvement in the exercise group when compared to the control group. Two of the 4 nonsignificant variables (BDI, relationship with the physician) also had relative improvement in the exercise group when compared with the control group.

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Discussion 

This prospective, randomized study describes the beneficial effects of a supervised exercise program in patients undergoing radiotherapy for localized prostate cancer. We are unaware of any other prospective studies describing the beneficial effects of exercise in localized prostate cancer patients undergoing external beam radiotherapy. The findings of improved cardiovascular fitness, flexibility, and muscle strength are similar to the benefits reported in breast cancer patients.¹⁴, ⁴⁰ The impact of a supervised structured aerobic exercise program on fatigue and various dimensions of QOL, such as physical, functional, emotional, and social well-being has not previously been reported. At completion of the study, patients in the exercise group reported less fatigue and improved physical and social well-being. Patients in the control group reported increased fatigue and declined physical and social well-being. At completion of radiotherapy, significant differences in mean score changes of physical well-being, social well-being, functional well-being, and overall QOL were noted between the 2 groups.

Although most research to date has focused on the efficacy of physical activity in cancer prevention, evidence is increasing that exercise also influences other aspects of the cancer experience, including coping, rehabilitation, and survival after cancer diagnosis.⁴¹ There are several anecdotal reports on the benefits of exercise after a cancer diagnosis.⁴², ⁴³, ⁴⁴ Most of the investigational and descriptive studies have examined breast cancer survivors and few studies have been carried out for cancers of other sites.¹⁸, ¹⁹, ²⁰, ²¹, ²², ²³, ²⁴, ²⁵ Many of these studies are retrospective or cross-sectional, raising concerns of poor memory and recall bias. No published exercise research is available for common cancer sites such as prostate, lung, kidney, bladder, and uterus.⁴⁵ Recently, Segal et al⁴⁶ reported on the beneficial effects of resistance exercise in men receiving androgen deprivation therapy for prostate cancer. In their study, the intervention group (n=82) participated in a resistance exercise program 3 times a week for 12 weeks, and the results were compared with a waiting list group.⁴⁶ The authors concluded that resistance exercise reduces fatigue and improves QOL and muscular fitness in men with prostate cancer receiving androgen deprivation therapy, and that this form of exercise can be an important component of supportive care for these patients.⁴⁶

With interventional studies, there is a need for more randomized experimental designs as opposed to quasi-experimental designs. Furthermore, the issue of controlling for prior exercise levels is of paramount importance in interventional studies.

Several other interventions have been reported that may help people cope with cancer and its treatment related experiences. Most of these interventions include cognitive-behavioral therapies (eg, relaxation training), individual counseling or psychotherapy, and social support. Meyer and Mark,⁴⁷ in a recent meta-analysis, reported a significant but small effect of these interventions for the QOL outcomes in the areas of emotional adjustment, functional adjustment, and treatment and disease related symptoms. The weakest effect of these QOL interventions was on functional QOL. Physical and functional well-being are considered by most QOL experts to be essential dimensions of overall QOL.⁴⁸

Study Limitations 

Limitations of the present study include small sample sizes in the 2 groups. When designing the study, we hypothesized that METS and PFS—considered to be the 2 most important variables reflecting the effects of exercise—both would have population effect sizes equal to .75 or greater (difference between population mean score changes, divided by population pooled SD of score changes). On the basis of this hypothesis, we would have needed 30 patients in each group to have a power of 80% or better to find statistical significance in the comparisons of these 2 measures on table 6. However, with population effect sizes equal to +1.55 (for METS) and −2.06 (for PFS) (as found in the study), only 8 patients in each METS group and 5 patients in each PFS group would have been needed to attain a power of 80%. With population effect sizes for all variables equal to the values found in the study, and with sample sizes of 11 and 10 in the 2 groups, 6 of the most important variables (METS, stand-and-sit test, PFS, physical well-being, social well-being, FACT-P) actually have power greater than 80%.

As a result of our exclusion criteria, this study tests a very select population of patients who are relatively healthy, with no acute or uncontrolled medical problems. Prostate cancer patients generally are elderly, and most of them have multiple medical problems. Nearly 50% of the patients considered for the study were excluded because of severe comorbid medical problems. Nine patients (4 after enrollment, 5 after randomization) refused to participate, because they wanted to participate only if assigned to the interventional group. Three of the 5 patients who disenrolled after randomization and initial baseline testing were from the control group. Because of these recruitment and retention problems, the results of this study can not be generalized.

The participating patients were offered a structured exercise program under the supervision of a therapist and a physician in a hospital setting. Taking reimbursement issues into account, this kind of program offering may not be possible for all cancer patients. An ambulatory low intensity exercise program for patients with localized prostate cancer needs to be developed and tested. There is a need for further studies of the role of exercise in fatigue prevention and quality of life improvement. Although cardiovascular exercise in cancer patients is beneficial in improving cardiovascular fitness, flexibility, muscle strength, and in preventing fatigue, it is important to recognize some of the relative contraindications to such exercise programs, for example, recent myocardial infarction, heart failure, and bony metastatic disease.²⁸

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Conclusions 

An 8-week structured exercise program for localized prostate cancer patients undergoing radiotherapy prevents fatigue and improves cardiovascular fitness, flexibility, muscle strength, and overall QOL.

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• b Version 8.2; SAS Institute Inc, 100 Campus Dr, Cary, NC 27513.