Prostate Cancer, Fatigue & Exercise
Does your Surgeon “Warm-up” Before Surgery?
PROSTATE CANCER, FATIGUE & EXERCISE
Several different types of treatment are available for patients with prostate cancer. For most men with early-stage prostate cancer, either surgery or radiation treatment may be selected (in some cases, both types of therapy may be indicated). Each treatment option has its own specific range of potential risks and benefits, and patients should be careful to obtain a full discussion from their doctor regarding the most appropriate treatment for their prostate cancer before making a decision.
For men who choose radiation therapy as the primary treatment for their prostate cancer, a new prospective clinical research study provides important information regarding the role of resistance and aerobic fitness training (also known in some circles as “exercise”) in reducing fatigue and other side effects of prostate cancer treatment.
This study, newly published in the Journal of Clinical Oncology, randomized 121 prostate cancer patients undergoing radiation therapy into 3 groups. The first group of 41 men was not assigned to any fitness training sessions, and this group of men agreed not to initiate an exercise program during the 24-week period of observation. The second group of 40 men was assigned to resistance training for a period of 24 weeks. Resistance training was conducted 3 times per week, and for those of you who are exercise aficionados, the resistance routine consisted of performing two sets of 8 to12 repetitions of 10 different exercises (leg extension, leg curl, seated chest fly, latissimus pull-downs, overhead press, triceps extension, biceps curls, calf raises, low back extension, and modified curl-ups). Resistance weights were then increased by 5 pounds when participants completed more than 12 repetitions. Finally, the 40 men in the third group were randomized to aerobic exercise training for a period of 24 weeks. The aerobic training was also conducted 3 times per week, and consisted of aerobic work-outs using a cycle ergometer, treadmill, or elliptical trainer. Exercise duration began at 15 minutes and was then increased by 5 minutes, every 3 weeks, until it reached 45 minutes. Exercise intensity was standardized using heart rate monitors.
At the end of the 24-week study period, all patient volunteers were assessed for fatigue using a validated cancer therapy fatigue scale. The results of this study indicated that both resistance training and aerobic exercise significantly reduced short-term levels of fatigue in prostate cancer patients when compared to similar patients who did not participate in fitness training. Interestingly, resistance training appeared to provide a longer duration of fatigue reduction when compared to aerobic fitness training in this cohort of middle-aged and elderly men with prostate cancer. Moreover, resistance training not only improved upper and lower body strength, as expected, but it also reduced triglyceride levels in the blood and improved aerobic fitness levels as well. The men who were assigned to the aerobic training group also experienced an improvement in aerobic fitness levels, as expected but, as already noted, they did not appear to experience some of the other health benefits that were observed among the resistance training group. Aerobic fitness training was not only less effective in providing long-term fatigue reduction, but was also, not surprisingly, less effective in improving muscle strength when compared to resistance training (anecdotally, one of the men assigned to the aerobic fitness training group actually experienced a serious adverse health event as a result of aerobic fitness training).
This is an interesting study, and for a couple of reasons. Cancer diagnosis and treatment is very often accompanied by varying degrees of anxiety, depression, and fatigue. We already know that the severity of these cancer-associated affective disorders can be significantly reduced with even moderate levels of exercise. However, the conventional thinking among most exercise physiologists has been that aerobic exercise is the most effective means of attaining good cardiovascular health, as well as all of the other ancillary health benefits that arise from a good cardiovascular work-out (including reductions in anxiety, depression and fatigue). In this small prospective study, a graduated program of resistance training appeared to provide not only increased upper and lower body strength, as expected, but also appeared to provide a longer lasting reduction in fatigue levels while also simultaneously improving aerobic fitness. (Unfortunately, this study did not include a fourth group of men who were randomized to undergo both aerobic and resistance training at the same time.)
As a follow-up to this excellent but small prospective clinical study, I would like to see a large cohort of patients and a longer duration of follow-up. I would also like to see that fourth group added, as well. However, for patients with joint or mobility limitations that preclude moderately vigorous aerobic exercise on a frequent basis, this small study of cancer patients suggests, as have other studies, that a progressive and frequent weight training program can provide both improved muscle strength and significant improvements in aerobic fitness. Other recent non-cancer studies looking at resistance training for older patients have also confirmed clinically significant improvements in body strength, agility, balance and overall vigor.
As soon as I finish this column, I think that I’ll visit the gym…!
DOES YOUR SURGEON “WARM-UP” BEFORE SURGERY?
Given that it is generally thought that performing sham surgical operations on human beings is a bad thing, I rarely include surgical research in this column as there are no randomized, controlled clinical surgery research trials being performed. As I am a surgeon, however, I am always on the look-out for an interesting surgery research study that can be included in this weekly health research column. In the current issue of the Journal of the American College of Surgeons, I came across an interesting little study looking at the value of “preoperative warm-up” exercises by surgeons who are about to go into the operating room to perform a surgical procedure.
Modern surgical procedures require a great deal of both cognitive and motor skills, and there has recently been a new emphasis on borrowing “best practices” guidelines from other professions that, similarly, require the integration of these two high-level skills. For example, today, using “best practices” borrowed from the airline industry, the operating team is required to go through a check-list of at least 7 different patient safety parameters before the surgeon may begin the actual operation. In this particular surgery research study, the authors have sought to learn whether or not a brief period of simulated surgical maneuvers, when performed just prior to the actual operation, can improve a surgeon’s performance during surgery.
Much as professional athletes warm-up before the big game, and practice key skills before facing their opponents on the court or field, the researchers conducting this study hypothesized that a brief period of “preoperative warm-up” exercises, before the big operation, might improve the surgeon’s dexterity and precision during the course of the actual operation. The “warm-up” exercises consisted of simulated laparoscopic surgery procedures whereby surgeons transferred small objects from one place to another while watching a television monitor. A particularly fascinating aspect of this study was the inclusion of surgeons who had been up all night on call, in an effort to determine whether or not “warm-up” exercises can reduce the decrease in cognitive and motor skills that is known to occur in fatigued surgeons.
In this prospective surgery research study, 15 to 20 minutes of simulated practice with simple laparoscopic surgical maneuvers, prior to performing surgery, resulted in significant improvements in performance during the conduct of surgical operations on live patients. Moreover, significant improvements were noted among both very junior and very senior surgeons following completion of these “warm-up” exercises. Interestingly, the performance of surgeons who had been up all night while on call was also significantly improved after performing these “warm-up” exercises. However, although their surgical skills were improved, the “warm-up” exercises still could not restore these surgeons’ skills to the levels that they had demonstrated before starting their on-call shifts.
Certainly, both surgeons and their patients should find the results of this innovative little study to be of interest, although its findings are not particularly surprising. Most surgeons already know that, as with most complex psychomotor skills, surgical performance improves with frequent repetition. Indeed, over the course of a long day in the operating room, most of us are probably unconsciously aware that our movements become more precise and more fluid with each successive operation that we perform.
Disclaimer: As always, my advice to readers is to seek the advice of your physician before making any significant changes in medications, diet, or level of physical activity
is an oncologic surgeon, a professor
of surgery, a widely published author, and the
Physician-in-Chief for Surgical
Oncology at the Kaiser Permanente healthcare system in Orange County,
Robert A. Wascher, MD, FACS.
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