Exercise vs. Usual Care Among Men Opting for Active Surveillance for Prostate Cancer - June Chan
January 15, 2020
June M. Chan, ScD, Professor of Epidemiology & Biostatistics; Department of Urology, University of California, San Francisco.
Charles J. Ryan, MD, the President and Chief Executive Officer of The Prostate Cancer Foundation (PCF), the world’s leading philanthropic organization dedicated to funding life-saving prostate cancer research. Charles J. Ryan is an internationally recognized genitourinary (GU) oncologist with expertise in the biology and treatment of advanced prostate cancer. Dr. Ryan joined the PCF from the University of Minnesota, Minneapolis, where he served as Director of the Hematology, Oncology, and Transplantation Division in the Department of Medicine. He also served as Associate Director for Clinical Research in the Masonic Cancer Center and held the B.J. Kennedy Chair in Clinical Medical Oncology.
Charles Ryan: Hello from PCF 2019. I'm delighted to be joined by Dr. June Chan, who is Professor of Epidemiology and Biostatistics and Urology, where she is the Stephen and Christine Burd-Safeway Distinguished Professor at the University of California, San Francisco. She also holds the title of Vice Chair for Education in the Department of Epidemiology and Biostatistics.
Let's talk about your work in patients on active surveillance for prostate cancer. This is a group where lifestyle modification may have a significant impact, and tell us about what you're doing there.
June Chan: Sure. First of all, thank you very much, Chuck, for having me here. So we do a couple of different studies for patients following an active surveillance regimen. We have a decision support trial going on right now just to see if we can help patients feel like they're getting better information about prostate cancer before they make a management decision. And then, we also have a study right now that is focused on increasing aerobic exercise in men who have choosing active surveillance. And the goal there is really to see whether or not a remote program can help people increase their cardiovascular fitness over a four-month period. And then we'll also be looking at cancer-related and biomarker outcomes.
Charles Ryan: The epidemiological data that you've worked on, and Stacey Kenfield and others, suggest that there's a benefit to exercise for men diagnosed with prostate cancer in terms of their longterm outcome. But that didn't really address an active surveillance population.
June Chan: That's true. So some of the earliest research that I got a chance to work on with Dr. Kenfield was looking at exercise practices in men initially diagnosed with localized disease across all different types. So it wasn't just in men on active surveillance, it was people seeking surgery, et cetera. And then looking at the outcomes of recurrence as well as prostate cancer death. And there did seem to be a benefit, but we didn't have enough numbers in those specific studies to zero in on active surveillance per se.
Although I can mention that earlier back there had been some studies looking at a combination of diet, exercise, group support, stress reduction, the Inman on active surveillance that suggested benefits for prostate cancer recurrence. So those are studies done by Dr. Peter Carroll and Dean Ornish, quite a while back.
Charles Ryan: Tell us a little bit more about the intervention that is taking place.
June Chan: Sure. So we have a study right now that is, we call it ASX for Active Surveillance Exercise study. And this is a four-month, 16-week intervention. So the goal here, based on our observational data, was really focused on increasing aerobic exercise. They come in for a baseline CPET, cardiopulmonary exercise test, so a full test to assess what their baseline cardiorespiratory fitness is. And then they receive a tailored program from an exercise physiologist to increase their fitness level gradually over time. And so it's really tailored to each individual where they're at.
They then are given a heart rate monitor that syncs to an app on a phone. And our exercise trainers have visibility on the account and then they check in by phone once a week with these men. And so the whole goal is to sort of make sure they understand their program, they can stay on their program. And the whole program right now is really focused on brisk walking, because that, we thought, was very accessible for everybody. Things people can do, low cost, wherever they're at. And so it's a brisk walking program.
Charles Ryan: Do you define brisk walking by what changes to the heart rate or how fast the person walks?
June Chan: Yeah, so in general, in our research studies, that's a good question. Brisk walking, if you're asking it on a survey, is walking faster than 15 minutes per mile. But in these cases where we have all the full data, it's really tailored to them. So it's based on their heart rate getting to certain zones. So we defined zones for them. If they have an exercise orientation for their first workout with the exercise trainer and they're told, "Yeah, hit zone three. Hit zone four. Hit zone five."
Charles Ryan: Based on effort?
June Chan: Based on their own heart rate. Based on the test that they took at baseline, so what gets them to that zone.
Charles Ryan: Okay. And so for men on active surveillance who can't be part of your study who are wondering what should they be doing, what does the data suggest, what do you tell them?
June Chan: Right now, I think the data are actually very heartening and it does suggest that exercise after diagnosis could help with delaying or deterring prostate cancer recurrence or progression. Even studies showing benefits for prostate cancer death. And since our earlier studies... So we published two studies in 2011. There are at least three more now looking at pretty hard outcomes, like prostate cancer death outcomes, all suggesting that exercise has a benefit. Our studies pointed towards needing to do pretty vigorous exercise. I would say the subsequent studies that have come out since then are even suggesting less intense exercise has a benefit. I can say that even in our work there was a benefit for prevention of death, right, at about three hours of walking per week, so very moderate.
Charles Ryan: It doesn't take a lot to impact your survival by brisk walking, which is, I think, a key.
June Chan: Something that gets your heart rate up a little bit.
Charles Ryan: Right, right. Well, congratulations on that work. It's really important. The patient community is hungry for this type of data, and I hope very willing to participate in your trials and help to sort of describe and define what we can do from a lifestyle perspective to reduce our risk of dying of prostate cancer, which is obviously critically important. So thank you for joining me.
June Chan: Thank you.