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Prostate cancer (PCa) is the most common male cancer in many countries.[[1]] With advancements in both screening procedures and treatment options, men are living longer post diagnosis, and more focus is now being placed on survivorship in relation to maintaining and improving the health-related outcomes of PCa survivors.[[1,2]] Because of the prolonged disease course and ongoing treatment associated with PCa, the terms “survivor” and “survivorship” encompass men who are in remission and treatment free as well as men who have incurable PCa and are receiving intermittent or ongoing treatment for their PCa, such as hormone suppression treatment.[[3]]

Physical activity (PA) is a modifiable behaviour that can help improve both the physical and psychological health of PCa survivors during all stages of the PCa continuum, from diagnosis and treatment through to remission and survivorship.[[1,2,4]] Engagement in regular PA has been associated with lower prostate specific antigen (PSA) levels, a delay in the use of hormone suppression therapy and a lower risk of cancer progression and recurrence.[[1,2,5]]

Physical activity can protect men who are currently receiving treatment for their PCa.[[2,4]] This is especially the case for men undergoing hormone-suppression treatment in the form of androgen deprivation therapy (ADT).[[1,2,4]] Physical activity, especially in the form of aerobic and resistance exercise, can help counteract some of the negative treatment-related side-effects associated with ADT. Specifically, these forms of PA may counteract the increases in body fat accumulation (predominately in the abdominal region), which increase the risk for both type 2 diabetes and metabolic syndrome, as well as loss in muscle and bone mass that can become a risk factor for osteoporosis and reduced physical function.[[1,2,4]] Physical activity can also help counteract cancer-related fatigue and depression, which can be more prevalent in men on ADT.[[1,2,4]]

Despite the benefits of regular PA, the majority of PCa patients and survivors are not engaging in sufficient PA to achieve health-related gain.[[4,5–8]] The American College of Sports Medicine (ACSM) roundtable on exercise guidelines for cancer survivors recommends 150 minutes of moderate-intensity PA per week.[[9]] More research is required to identify and examine the barriers to PA that survivors may encounter.[[6]] Limited New Zealand-based research has focused on qualitatively identifying perceived barriers to PA in a cross-section of PCa survivors, such as men who are in remission and treatment free but live with long-term post-treatment related side-effects (ie, urinary incontinence), as well as men who are currently receiving treatment for their PCa. A qualitative approach can provide greater insight into these men’s perceptions of how their PCa diagnosis, and their experience of treatment-related side-effects, impacted on their post-diagnosis and post-treatment PA. The aim of the present study is to qualitatively identify and examine barriers to PA in 16 older-aged PCa survivors who would be more representative of the typical PCa survivor, in relation to their older age and experience of multiple PCa treatments.

Methods

Participants

Men with any stage or grade of PCa, including those in remission, were eligible to participate in the present study. There were no criteria relating to pre-cancer PA levels. We pre-determined a sample of 16 participants, as other qualitative studies that examined various aspects of PA engagement in PCa survivors had similar sample sizes.[[10–12]] At recruitment, 10 participants had not received chemotherapy or radiation or undergone prostate-related surgery within the past 12 months. Six men were on ADT at recruitment. All 16 participants lived in the Auckland region. A summary of the participants involved in the study is presented in Table 1.

Table 1: Participant characteristics and prostate cancer treatments that participants had undergone.

Some participants received more than one type of treatment. ADT: Androgen deprivation treatment

Measure

Members of the research team developed an interview schedule for the present study. Questions were based on relevant literature relating to barriers to PA that PCa patients and survivors can encounter. Questions were open-ended and designed to facilitate discussion. The two main questions were:

  1. How do your levels of physical activity or exercise differ to before you were diagnosed with prostate cancer?
  2. What barriers to physical activity have you experienced since your diagnosis?

Procedure

Information pertaining to the larger study (via a participant information sheet) was included in the content of three of the monthly newsletters that the Prostate Cancer Foundation of New Zealand email to their members. The majority of participants (n=14) were recruited through the Prostate Cancer Foundation. The remaining two participants were recruited via word of mouth by members of the research team. Men who were interested in taking part in the study contacted the first author by email or phone. Once contact had been made and their eligibility to participate confirmed, an interview time and location were arranged. Participants were individually interviewed by the first author at their home, their place of work or the university. All interviews were audiotaped, with the average length of interviews being 40 minutes. Prior to the commencement of each interview, informed written consent was obtained from each participant. Ethics approval for this study was obtained from Northern A Health and Disability Ethics Committee (reference number: 13/NTA/241/AM01).

Data analysis

Interviews were transcribed verbatim and analysed using an inductive thematic approach based on Auerbach and Silverstein’s approach to thematic analysis.[[13]] Four main steps were involved in the analysis process:

  1. Reading and re-reading each transcript several times for each question within a topic area.
  2. Identifying repeating ideas (ie, discursive commonalities in the interview transcripts) in response to a particular question. This involved identifying segments of text whereby participants had used similar words or experiences to convey the same idea.
  3. Coding and naming the repeating ideas. This resulted in the generation of themes. A theme can be defined as an organisation of repeating ideas that is given a name that tries to communicate what participants are trying to convey in their response to a particular research question.[[13]]
  4. Verifying the trustworthiness of the study findings and reduce individual researcher bias. The first author initially analysed the data and identified themes. Both co-authors then independently read the transcripts to validate or invalidate themes. This ensured that participant quotes matched the categories of themes identified.

Results

Data were examined under the main topic area designed to identify barriers to PA post diagnosis. Six main themes were identified:

  1. The effects of the PCa and PCa treatments on PA
  2. Urinary incontinence and bowel control
  3. P-existing comorbid conditions
  4. Increased age
  5. Time constraints
  6. Lack of proximity to PA or exercise venues.

The main themes are outlined below, and direct quotes are provided that illustrate participants’ experiences and views.

Theme 1: The effects of the prostate cancer and prostate cancer treatments on physical activity

This theme involved a number of participants discussing how their PA was affected by their PCa diagnosis and the associated side-effects of their various PCa treatments, which predominantly resulted in loss of strength and increased fatigue. This in turn resulted in a decrease in PA or cessation of PA during the active treatment process:

“Physical activity is curtailed considerably. You can’t be as physical as you were before. You feel so weak when you’ve got prostate cancer. There is no strength left in you.” – Participant 4, Chemotherapy, ADT

“Before [the prostate cancer] I had a lot more strength. I felt as weak as a baby at times. I was told that it had something to do with losing my male hormone count.” – Participant 16, Radiation, ADT

“Over the four-year treatment, there’s been periods when I’ve felt unwell. My level of activity has been up and down. There have been periods when I have been physically inactive because of the medical treatment.” – Participant 1, Radical Prostatectomy, Radiation, Chemotherapy, ADT

“Not exercising because of what was going on with the hormone treatment. I put on weight. I was always an exercise person, that’s why the extra weight didn’t sit comfortably for me.” – Participant 3, Radical Prostatectomy, ADT

Theme 2: Urinary incontinence and bowel control

Physical activity post treatment was also negatively affected by issues relating to incontinence and bowel control. Participants gave accounts of how their PA engagement was reduced or limited as a result of long-term, treatment-related side-effects that continued to result in incontinence:

“I have problems with leakage. I can only walk for a couple of hours now. There was a time I used to walk a lot further. It’s just that I’m wet through with the pad.” – Participant 12, Radical Prostatectomy

“I do have to be careful with my mid-section exercises. I have to be careful that I don’t promote a leakage if I’m exercising that sort of way.” – Participant 3, Radical Prostatectomy, ADT

“Loose bowel motions. When I first had the treatment it was terrible. If I had to go to the toilet, I had to go to the toilet and there was no ifs or maybes. I'm involved at the Maritime Museum taking people sailing. I’ve had to refuse going on some offshore sailing trips.” – Participant 16, Radiation, ADT

Theme 3: Pre-existing comorbid conditions

A number of participants discussed how other health conditions not related to having had PCa acted as barriers to engagement in certain types of PA:

“A physical barrier not to do with the prostate cancer but the heart bypass. There's more physical barriers with that than the prostate cancer.”– Participant 16, Radiation, ADT

“Arthritic problems. Runner’s knee. A bad back is my biggest problem at the moment. I would still run if it wasn’t for my back and knees.” – Participant 7, Radiation

“I have back problems.” – Participant 12, Radical Prostatectomy

Theme 4: Increased age

A number of participants discussed how increased age was a factor in their declining PA levels. Participants cited examples of physical factors, such as reduced balance and flexibility, that affected their ability to engage in certain physical activities. There was also a perception that increased age equated with less need to engage in regular PA:

“I would probably do less now because of my age. I don’t run now, I just walk. It’s nothing to do with the prostate cancer, its old age.” – Participant 7, Radiation

“There is still limit to how much I want to do at 72. I play golf at least once a week with blokes younger than me who can’t walk. I am probably more active than any of my other friends.” – Participant 6, ADT

“I can’t do much in the way of helping in the garden. If I bend down, I’m likely to fall over. So, I don’t do that. My balance is not as good as it used to be.” –Participant 13, currently on ADT

“Getting older, I can’t do all the things I used to because I don’t have the flexibility to do some of the things.” – Participant 14, Radical Prostatectomy

Theme 5: Time constraints

The following quotes illustrate how time constraints acted as barriers to regular PA engagement regardless of whether participants were retired or semi-retired:

“The only barrier would be time. I have to do other things and I haven’t always got time available. That would be the only reason.” – Participant 5, ADT

“The fact is the day gets filled up very quickly.” – Participant 13, ADT

“Time to do it is the barrier. I lead a pretty busy life even though I’m eighty percent retried. There’s a lot going on and I don’t always get the time.” – Participant 14, Radical Prostatectomy

Theme 6: Lack of proximity to physical activity and exercise venues

Lack of proximity to a PA or exercise venue was also identified as being a barrier to engaging in certain types of PA that seemed to best suit the individual needs of certain participants:

“Close proximity to somewhere where we get something like tai chi. It would help if there was something local.” – Participant 13, ADT

“If I lived closer to a gym, I would go to the gym. But I’m 40 [kilometres] from the gym.” – Participant 15, Radiation, ADT

Discussion

The present study identified a number of barriers to PA that PCa survivors can encounter, even when they are more than 12 months post chemotherapy, radiation or prostate-related surgery. Only two of the six barriers identified directly related to having had PCa. The two PCa-specific barriers were (1) the effects of PCa and PCa treatments on PA and (2) urinary incontinence and bowel control, which were long-term, post-treatment-related side-effects. A salient barrier to PA engagement in the context of PCa was the effect of the PCa itself and PCa-treatment-related side-effects on an individual’s ability to engage in regular PA.[[10,11,14,15]]  A number of participants in the present study discussed how their PA was affected by both their PCa diagnosis and the treatment-related side-effects of their various (and in most cases multimodality) PCa treatments (eg, a combination of chemotherapy, radiation, prostate-related surgery and ADT). This in turn resulted in fatigue, feeling weak and having no strength, which resulted in either a decrease in PA or cessation of PA.

A number of previous studies have also cited the effects of the cancer- and various cancer-treatment-related side-effects as being the most salient barriers to PA in both newly diagnosed individuals and in those receiving active treatment.[[11,16,17]]  Side-effects of cancer treatments also impact PA engagement in individuals who are in remission and treatment free, as treatment-related side-effects can linger.[[18]] A growing body of evidence-based research has found PA to be both safe and beneficial along the cancer continuum, from diagnosis and active treatment through to remission and survivorship.[[2,5,9]] Engagement in PA, regardless of cancer type, stage or grade, has been found to be beneficial in maintaining and improving physical function and psychological wellbeing and alleviating treatment-related side-effects, such as cancer-related fatigue.[[1,2,4,5]]

Evidence of the benefits of PA for cancer survivorship is now relatively well understood by health professionals. Australasian cancer nurses are actively involved in the promotion of PA to their cancer patients.[[19]] Healthcare practitioners who treat PCa patients and see PCa survivors on a regular basis for the monitoring of PSA levels and for other conditions are well placed to provide advice or referral for PA and PA programmes. [[20]]

Urinary incontinence and bowel control also affect men’s PA, potentially for many months or years post treatment.[[13,15,9]]  Some studies have reported that urinary incontinence and lack of bowel control have acted as barriers to PA, as men were worried and fearful about possible leakage during PA, or they had experienced embarrassment due to incontinence when engaging in PA.[[15,17,21]] However, other studies have reported that urinary incontinence was experienced at a minor degree, and hence was a minor barrier to PA.[[10,22]]

This was also the case in the present study. Some participants discussed how their PA was reduced (eg, less walking activity because one’s pad becomes more saturated with activity), or how they had to limit other types of PA (eg, sailing) due to bowel-control issues, even if they didn’t completely cease these activities. The findings of the present study highlight how long-term post-treatment-related side-effects can still affect PA more than 12 months after the cessation of certain PCa treatments or prostate-related surgeries. Physical activity in the form of pelvic floor muscle training, as well as aerobic exercise and resistance training before and after prostate-related surgery, can positively influence continence in men following a radical prostatectomy.[[23]]

Some participants in the present study had pre-existing comorbidities, and it was these, not the PCa itself, that were identified as barriers to PA. A number of participants discussed how other conditions (eg, arthritis, back problems) inhibited them from engaging in certain activities. Pre-existing comorbid conditions have also been identified as being barriers to PA in both PCa and other cancer populations, as well as in community-dwelling older adults.[[10,11,15,18,24]] Men with PCa are more likely to have comorbid conditions, which further reinforces the need to better support PCa survivors to become and remain physically active.[[1–3]]

Increased age, like pre-existing comorbidities, was identified as a factor that contributed to a decline in PA for some participants, irrespective of whether they had PCa. A number of participants discussed how physical factors associated with ageing, such as loss of balance, fear of falling, reduced flexibility and increased tiredness, limited their PA engagement. There was also a perception held by some participants that increased age equated with less need to engage in regular PA. These findings are similar to the results of an earlier study that examined factors that influenced PA in 18 PCa survivors, and a study designed to examine quality of life and PA engagement in 14 PCa survivors.[[10,12]] A scoping review designed to identify key facilitators and barriers to PA change in PCa survivors also found increased age to be a barrier to PA.[[15]]

Time constraints is one of the most cited barriers to PA in PCa populations,[[7,8,11,15]] in other cancer populations[[14,9]] and in healthy older adult populations.[[24]] In the present study, a number of participants discussed how time constraints acted as a barrier to PA regardless of their work status (eg, retired, semi-retired or in full time employment). It has been suggested that strategies for changing behaviour could be employed to emphasise the importance of PA. One such strategy could be the use of motivational interviewing to increase adherence to PA by focusing on barriers related to time management.[[21]]

Clifford and colleagues suggested that readily accessible local exercise facilities could be important for helping to counteract time constraints for PA.[[21]] This is consistent with the results of the present study: for example, the oldest participant discussed how he would have liked to have attended tai chi classes that would have aided his balance, though lack of proximity to an organised tai chi venue became a barrier to engaging in this type of activity. Lack of proximity to PA and exercise venues have also been cited as a barrier to PA in both PCa survivors and in other cancer survivor populations.[[14,15,17,25,26]]

A potential limitation of the present study is the small sample size, which may limit the generalisability of our findings. However, other qualitative studies that examined various aspects of PA engagement in PCa survivors had similar sample size.[[10–12]] PCa survivors living in rural New Zealand may encounter more barriers to PA in relation to lack of proximity to PA or exercise venues compared to those who live in urban areas, such as Auckland. There was no ethnic variance in our study; all participants identified as New Zealand European.

A strength of the present study is that a qualitative interview-based approach provided insights regarding barriers to PA that PCa survivors can experience. Employing a cross-section of PCa survivors (ie, men in remission who are treatment free and men who are currently receiving treatment for their PCa in the form of ADT) highlighted that men who are in remission and treatment free can still live with long-term, post-treatment-related side-effects. Treatment-related side-effects, such as urinary incontinence and bowel-control issues, affected participants’ PA more than 12 months after the cessation of certain PCa treatments and prostate-related surgeries.

Conclusions

The present study identified a number of barriers to PA that PCa survivors who are at least one year post cancer treatment can still encounter. Two barriers related to PCa-treatment-related side-effects, and the remining four barriers to PA that have already been reported in the literature as being experienced by older male populations who have not had PCa. With an increase in survivorship, there needs to be an active focus on the role that modifiable behaviours, such as PA, can have in helping maintain and improve both the physical and psychological health-related outcomes of PCa survivors. The findings from this study, combined with existing literature, can be used to develop strategies and programmes that help facilitate and maintain regular PA engagement in PCa survivors.

Summary

Abstract

Aim

Despite the benefits of regular physical activity (PA), many prostate cancer (PCa) survivors are not engaging in sufficient PA to achieve health-related gain. This qualitative study sought to gain further insight regarding barriers to PA in older-aged PCa survivors.

Method

Sixteen participants were individually interviewed, and data were analysed using an inductive thematic approach.

Results

Six main themes affecting perceived barriers for PA post diagnosis were identified: the effects of the PCa and PCa treatments on PA, urinary incontinence and bowel control, pre-existing comorbid conditions, increased age, time constraints and lack of proximity to PA or exercise venues.

Conclusion

Only two of the six barriers identified directly related to having had PCa. With an increase in PCa survivorship, an active focus needs to be placed on the role that PA can have in helping maintain and improve both the physical and psychological health-related outcomes of PCa survivors.

Author Information

Asmita Patel: Research Manager, South Pacific College of Natural Medicine, Auckland, New Zealand. Grant M Schofield: Professor, Faculty of Health and Environmental Sciences, Auckland University of Technology, Auckland, New Zealand. Justin WL Keogh: Associate Professor, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Australia; Faculty of Science, Health, Education and Engineering, University of the Sunshine Coast, Australia; Auckland University of Technology, Auckland, New Zealand; Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, Karnataka, India.

Acknowledgements

We would like to thank the men who took part in this study. We would also like to thank the Prostate Cancer Foundation of New Zealand for their assistance with participant recruitment.

Correspondence

Dr Asmita Patel, South Pacific College of Natural Medicine, PO Box 11-311, Ellerslie, Auckland 1542, 0210349644

Correspondence Email

asmita.patel@spcnm.ac.nz

Competing Interests

This study was funded by Cancer Society of New Zealand through a three-year Prostate Cancer Young Investigator Scholarship.

1) Campos C, Sotomayor P, Jerez D, Gonzalez J, Schmidt CB, Schmidt K, et al. Exercise and prostate cancer: From basic science to clinical applications. Prostate. 2018;78:639-45.

2) Newton RU, Galvao DA. Exercise medicine for prostate cancer. Eur Rev Aging Phys Act. 2013;10:1041-5.

3) Narayan V, Harrison M, Cheng H, Kenfield S, Aggarwal R, Kwon D, et al. Improving research for prostate cancer survivorship: A statement from the Survivorship Research in Prostate Cancer (SuRECaP) working group. Urol Oncol. 2020;38:83-93.

4) Galvao DA, Newton RU, Gardiner RA, Girgis A, Lepore SJ, Stiller A, et al. Compliance to exercise- oncology guidelines in prostate cancer survivors and associations with psychological distress, unmet supportive care needs, and quality of life. Psychooncology. 2015;24:1241-9.

5) Friedenreich CM, Wang Q, Neilson HK, Kopciuk, KA, McGregor SE, Courneya KS. Physical activity and survival after prostate cancer. Eur Urol. 2016;70:576-85.

6) Keogh JWL, Shepherd D, Krageloh CU, Ryan C, Masters J, Shepherd G, et al. Predictors of physical activity and quality of life in New Zealand prostate cancer survivors undergoing androgen-deprivation therapy. NZ Med J. 2010;123(1325):20-9.

7) Ottenbacher AJ, Day RS, Taylor WC, Sharma SV, Sloane R, Snyder DC, et al. Exercise among breast and prostate cancer survivors – what are their barriers? J Cancer Surviv. 2011;5:413-9.

8) Weller S, Oliffe JL, Campbell KL. (2019). Factors associated with exercise preferences, barriers and facilitators of prostate cancer survivors. Eur J Cancer Care. 2019;28(5)-e13135.

9) Schmitz KH, Courneya KS, Matthews C, Demark-Wahnefried W, Galvao DA, Pinto BM, et al, (2010). American College of Sports Medicine Roundtable on Exercise Guideline, Cancer Survivors. Med Sci Sports Exerc. 2010;42(7):1409-26.

10) Craike MJ, Livingston PM, Botti M. An exploratory study of the factors that influence physical activity for prostate cancer survivors. Support Care Cancer. 2011;19:1019-28.

11) Keogh JWL, Patel A, MacLeod RD, Masters J. Perceived barriers and facilitators to physical activity in men with prostate cancer: Possible influence of androgen deprivation. Eur J Cancer Care. 2014;23:263-73.

12) Keogh JWL, Patel A, MacLeod RD, Masters J. Perceptions of physically active men with prostate cancer on the role of physical activity in maintaining their quality of life: Possible influence of androgen deprivation therapy. Psychooncology. 2013; 22:2869-75.

13) Auerbach C, Silverstein L. Qualitative data. An introduction to coding and analysis. New York: New York University Press; 2003.

14) Min J, Yoo S, Kim MJ, Yang E, Hwang S, Kang M, et al. Exercise participation, barriers, and preferences in Korean prostate cancer survivors. Ethn Health. 2019. DOI: 10.1080/13557858.2019.1634184

15) Yannitsos D, Murphy RA, Pollock P, Di Sebastiano KM. Facilitators and barriers to participation in lifestyle modification for men with prostate cancer: A scoping review. Eur J Cancer Care. 2020;29(1):e13193.

16) Catt S, Sheward J, Sheward, Harder H. Cancer survivors’ experiences of a community-based cancer-specific exercise programme: results of an exploratory survey. Support Care Cancer. 2018;26:3209-16.

17) Sheill G, Guinan, E, O’Neil LO, Hevey, D, Hussey J.The views of patients with metastatic prostate cancer toward physical activity: a qualitative exploration. Support Care Cancer. 2018;26:1747-54.

18) Blaney JM, Lowe-Strong A, Rankin-Watt J, Campbell A, Gracey JH. Cancer survivors’ exercise barriers, facilitators and preferences in the context of fatigue, quality of life and physical activity participation: a questionnaire-survey, Psychooncology. 2013;22:186-94.

19) Keogh JWL, Puhringer P, Olsen A, Sargeant S, Jones LM, Climstein M. Physical activity promotion, beliefs, and barriers among Australasian oncology nurses. Oncol Nurs Forum. 2017;44(2):235-45.

20) Patel A, Schofield G, Keogh J. Influences on health-care practitioners’ promotion of physical activity to their patients with prostate cancer: a qualitative study. J Prim Health Care. 2018;10(1):31-38.

21) Clifford BK, Mizrahi D, Sandler CX, Barry BK, Simar D, Wakefield, CE, et al. Barriers and facilitators of exercise experienced by cancer survivors: a mixed methods systematic review. Support Care Cancer. 2018;26:685-700.

22) Bohn SKH, Fossa SD, Wisloff T, Thorsen L. Physical activity and associations with treatment-induced adverse effects among prostate cancer patients. Support Care Cancer. 2019;27:1001-11.

23) Mungovan SF, Carlsson SV, Gass GC, Graham PL, Sandhu JS, Akin O, Scardino PT, Eastham JA, Patel MI. Preoperative exercise interventions to optimize continence outcomes following radical prostatectomy. Nat Rev Urol. 2021;18:259-81.

24) Patel A, Schofield GM, Kolt GS, Keogh WL. Perceived barriers, benefits, and motives for physical activity: Two primary-care physical activity prescription programs. J Aging Phys Act. 2013;21:85-99.

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Prostate cancer (PCa) is the most common male cancer in many countries.[[1]] With advancements in both screening procedures and treatment options, men are living longer post diagnosis, and more focus is now being placed on survivorship in relation to maintaining and improving the health-related outcomes of PCa survivors.[[1,2]] Because of the prolonged disease course and ongoing treatment associated with PCa, the terms “survivor” and “survivorship” encompass men who are in remission and treatment free as well as men who have incurable PCa and are receiving intermittent or ongoing treatment for their PCa, such as hormone suppression treatment.[[3]]

Physical activity (PA) is a modifiable behaviour that can help improve both the physical and psychological health of PCa survivors during all stages of the PCa continuum, from diagnosis and treatment through to remission and survivorship.[[1,2,4]] Engagement in regular PA has been associated with lower prostate specific antigen (PSA) levels, a delay in the use of hormone suppression therapy and a lower risk of cancer progression and recurrence.[[1,2,5]]

Physical activity can protect men who are currently receiving treatment for their PCa.[[2,4]] This is especially the case for men undergoing hormone-suppression treatment in the form of androgen deprivation therapy (ADT).[[1,2,4]] Physical activity, especially in the form of aerobic and resistance exercise, can help counteract some of the negative treatment-related side-effects associated with ADT. Specifically, these forms of PA may counteract the increases in body fat accumulation (predominately in the abdominal region), which increase the risk for both type 2 diabetes and metabolic syndrome, as well as loss in muscle and bone mass that can become a risk factor for osteoporosis and reduced physical function.[[1,2,4]] Physical activity can also help counteract cancer-related fatigue and depression, which can be more prevalent in men on ADT.[[1,2,4]]

Despite the benefits of regular PA, the majority of PCa patients and survivors are not engaging in sufficient PA to achieve health-related gain.[[4,5–8]] The American College of Sports Medicine (ACSM) roundtable on exercise guidelines for cancer survivors recommends 150 minutes of moderate-intensity PA per week.[[9]] More research is required to identify and examine the barriers to PA that survivors may encounter.[[6]] Limited New Zealand-based research has focused on qualitatively identifying perceived barriers to PA in a cross-section of PCa survivors, such as men who are in remission and treatment free but live with long-term post-treatment related side-effects (ie, urinary incontinence), as well as men who are currently receiving treatment for their PCa. A qualitative approach can provide greater insight into these men’s perceptions of how their PCa diagnosis, and their experience of treatment-related side-effects, impacted on their post-diagnosis and post-treatment PA. The aim of the present study is to qualitatively identify and examine barriers to PA in 16 older-aged PCa survivors who would be more representative of the typical PCa survivor, in relation to their older age and experience of multiple PCa treatments.

Methods

Participants

Men with any stage or grade of PCa, including those in remission, were eligible to participate in the present study. There were no criteria relating to pre-cancer PA levels. We pre-determined a sample of 16 participants, as other qualitative studies that examined various aspects of PA engagement in PCa survivors had similar sample sizes.[[10–12]] At recruitment, 10 participants had not received chemotherapy or radiation or undergone prostate-related surgery within the past 12 months. Six men were on ADT at recruitment. All 16 participants lived in the Auckland region. A summary of the participants involved in the study is presented in Table 1.

Table 1: Participant characteristics and prostate cancer treatments that participants had undergone.

Some participants received more than one type of treatment. ADT: Androgen deprivation treatment

Measure

Members of the research team developed an interview schedule for the present study. Questions were based on relevant literature relating to barriers to PA that PCa patients and survivors can encounter. Questions were open-ended and designed to facilitate discussion. The two main questions were:

  1. How do your levels of physical activity or exercise differ to before you were diagnosed with prostate cancer?
  2. What barriers to physical activity have you experienced since your diagnosis?

Procedure

Information pertaining to the larger study (via a participant information sheet) was included in the content of three of the monthly newsletters that the Prostate Cancer Foundation of New Zealand email to their members. The majority of participants (n=14) were recruited through the Prostate Cancer Foundation. The remaining two participants were recruited via word of mouth by members of the research team. Men who were interested in taking part in the study contacted the first author by email or phone. Once contact had been made and their eligibility to participate confirmed, an interview time and location were arranged. Participants were individually interviewed by the first author at their home, their place of work or the university. All interviews were audiotaped, with the average length of interviews being 40 minutes. Prior to the commencement of each interview, informed written consent was obtained from each participant. Ethics approval for this study was obtained from Northern A Health and Disability Ethics Committee (reference number: 13/NTA/241/AM01).

Data analysis

Interviews were transcribed verbatim and analysed using an inductive thematic approach based on Auerbach and Silverstein’s approach to thematic analysis.[[13]] Four main steps were involved in the analysis process:

  1. Reading and re-reading each transcript several times for each question within a topic area.
  2. Identifying repeating ideas (ie, discursive commonalities in the interview transcripts) in response to a particular question. This involved identifying segments of text whereby participants had used similar words or experiences to convey the same idea.
  3. Coding and naming the repeating ideas. This resulted in the generation of themes. A theme can be defined as an organisation of repeating ideas that is given a name that tries to communicate what participants are trying to convey in their response to a particular research question.[[13]]
  4. Verifying the trustworthiness of the study findings and reduce individual researcher bias. The first author initially analysed the data and identified themes. Both co-authors then independently read the transcripts to validate or invalidate themes. This ensured that participant quotes matched the categories of themes identified.

Results

Data were examined under the main topic area designed to identify barriers to PA post diagnosis. Six main themes were identified:

  1. The effects of the PCa and PCa treatments on PA
  2. Urinary incontinence and bowel control
  3. P-existing comorbid conditions
  4. Increased age
  5. Time constraints
  6. Lack of proximity to PA or exercise venues.

The main themes are outlined below, and direct quotes are provided that illustrate participants’ experiences and views.

Theme 1: The effects of the prostate cancer and prostate cancer treatments on physical activity

This theme involved a number of participants discussing how their PA was affected by their PCa diagnosis and the associated side-effects of their various PCa treatments, which predominantly resulted in loss of strength and increased fatigue. This in turn resulted in a decrease in PA or cessation of PA during the active treatment process:

“Physical activity is curtailed considerably. You can’t be as physical as you were before. You feel so weak when you’ve got prostate cancer. There is no strength left in you.” – Participant 4, Chemotherapy, ADT

“Before [the prostate cancer] I had a lot more strength. I felt as weak as a baby at times. I was told that it had something to do with losing my male hormone count.” – Participant 16, Radiation, ADT

“Over the four-year treatment, there’s been periods when I’ve felt unwell. My level of activity has been up and down. There have been periods when I have been physically inactive because of the medical treatment.” – Participant 1, Radical Prostatectomy, Radiation, Chemotherapy, ADT

“Not exercising because of what was going on with the hormone treatment. I put on weight. I was always an exercise person, that’s why the extra weight didn’t sit comfortably for me.” – Participant 3, Radical Prostatectomy, ADT

Theme 2: Urinary incontinence and bowel control

Physical activity post treatment was also negatively affected by issues relating to incontinence and bowel control. Participants gave accounts of how their PA engagement was reduced or limited as a result of long-term, treatment-related side-effects that continued to result in incontinence:

“I have problems with leakage. I can only walk for a couple of hours now. There was a time I used to walk a lot further. It’s just that I’m wet through with the pad.” – Participant 12, Radical Prostatectomy

“I do have to be careful with my mid-section exercises. I have to be careful that I don’t promote a leakage if I’m exercising that sort of way.” – Participant 3, Radical Prostatectomy, ADT

“Loose bowel motions. When I first had the treatment it was terrible. If I had to go to the toilet, I had to go to the toilet and there was no ifs or maybes. I'm involved at the Maritime Museum taking people sailing. I’ve had to refuse going on some offshore sailing trips.” – Participant 16, Radiation, ADT

Theme 3: Pre-existing comorbid conditions

A number of participants discussed how other health conditions not related to having had PCa acted as barriers to engagement in certain types of PA:

“A physical barrier not to do with the prostate cancer but the heart bypass. There's more physical barriers with that than the prostate cancer.”– Participant 16, Radiation, ADT

“Arthritic problems. Runner’s knee. A bad back is my biggest problem at the moment. I would still run if it wasn’t for my back and knees.” – Participant 7, Radiation

“I have back problems.” – Participant 12, Radical Prostatectomy

Theme 4: Increased age

A number of participants discussed how increased age was a factor in their declining PA levels. Participants cited examples of physical factors, such as reduced balance and flexibility, that affected their ability to engage in certain physical activities. There was also a perception that increased age equated with less need to engage in regular PA:

“I would probably do less now because of my age. I don’t run now, I just walk. It’s nothing to do with the prostate cancer, its old age.” – Participant 7, Radiation

“There is still limit to how much I want to do at 72. I play golf at least once a week with blokes younger than me who can’t walk. I am probably more active than any of my other friends.” – Participant 6, ADT

“I can’t do much in the way of helping in the garden. If I bend down, I’m likely to fall over. So, I don’t do that. My balance is not as good as it used to be.” –Participant 13, currently on ADT

“Getting older, I can’t do all the things I used to because I don’t have the flexibility to do some of the things.” – Participant 14, Radical Prostatectomy

Theme 5: Time constraints

The following quotes illustrate how time constraints acted as barriers to regular PA engagement regardless of whether participants were retired or semi-retired:

“The only barrier would be time. I have to do other things and I haven’t always got time available. That would be the only reason.” – Participant 5, ADT

“The fact is the day gets filled up very quickly.” – Participant 13, ADT

“Time to do it is the barrier. I lead a pretty busy life even though I’m eighty percent retried. There’s a lot going on and I don’t always get the time.” – Participant 14, Radical Prostatectomy

Theme 6: Lack of proximity to physical activity and exercise venues

Lack of proximity to a PA or exercise venue was also identified as being a barrier to engaging in certain types of PA that seemed to best suit the individual needs of certain participants:

“Close proximity to somewhere where we get something like tai chi. It would help if there was something local.” – Participant 13, ADT

“If I lived closer to a gym, I would go to the gym. But I’m 40 [kilometres] from the gym.” – Participant 15, Radiation, ADT

Discussion

The present study identified a number of barriers to PA that PCa survivors can encounter, even when they are more than 12 months post chemotherapy, radiation or prostate-related surgery. Only two of the six barriers identified directly related to having had PCa. The two PCa-specific barriers were (1) the effects of PCa and PCa treatments on PA and (2) urinary incontinence and bowel control, which were long-term, post-treatment-related side-effects. A salient barrier to PA engagement in the context of PCa was the effect of the PCa itself and PCa-treatment-related side-effects on an individual’s ability to engage in regular PA.[[10,11,14,15]]  A number of participants in the present study discussed how their PA was affected by both their PCa diagnosis and the treatment-related side-effects of their various (and in most cases multimodality) PCa treatments (eg, a combination of chemotherapy, radiation, prostate-related surgery and ADT). This in turn resulted in fatigue, feeling weak and having no strength, which resulted in either a decrease in PA or cessation of PA.

A number of previous studies have also cited the effects of the cancer- and various cancer-treatment-related side-effects as being the most salient barriers to PA in both newly diagnosed individuals and in those receiving active treatment.[[11,16,17]]  Side-effects of cancer treatments also impact PA engagement in individuals who are in remission and treatment free, as treatment-related side-effects can linger.[[18]] A growing body of evidence-based research has found PA to be both safe and beneficial along the cancer continuum, from diagnosis and active treatment through to remission and survivorship.[[2,5,9]] Engagement in PA, regardless of cancer type, stage or grade, has been found to be beneficial in maintaining and improving physical function and psychological wellbeing and alleviating treatment-related side-effects, such as cancer-related fatigue.[[1,2,4,5]]

Evidence of the benefits of PA for cancer survivorship is now relatively well understood by health professionals. Australasian cancer nurses are actively involved in the promotion of PA to their cancer patients.[[19]] Healthcare practitioners who treat PCa patients and see PCa survivors on a regular basis for the monitoring of PSA levels and for other conditions are well placed to provide advice or referral for PA and PA programmes. [[20]]

Urinary incontinence and bowel control also affect men’s PA, potentially for many months or years post treatment.[[13,15,9]]  Some studies have reported that urinary incontinence and lack of bowel control have acted as barriers to PA, as men were worried and fearful about possible leakage during PA, or they had experienced embarrassment due to incontinence when engaging in PA.[[15,17,21]] However, other studies have reported that urinary incontinence was experienced at a minor degree, and hence was a minor barrier to PA.[[10,22]]

This was also the case in the present study. Some participants discussed how their PA was reduced (eg, less walking activity because one’s pad becomes more saturated with activity), or how they had to limit other types of PA (eg, sailing) due to bowel-control issues, even if they didn’t completely cease these activities. The findings of the present study highlight how long-term post-treatment-related side-effects can still affect PA more than 12 months after the cessation of certain PCa treatments or prostate-related surgeries. Physical activity in the form of pelvic floor muscle training, as well as aerobic exercise and resistance training before and after prostate-related surgery, can positively influence continence in men following a radical prostatectomy.[[23]]

Some participants in the present study had pre-existing comorbidities, and it was these, not the PCa itself, that were identified as barriers to PA. A number of participants discussed how other conditions (eg, arthritis, back problems) inhibited them from engaging in certain activities. Pre-existing comorbid conditions have also been identified as being barriers to PA in both PCa and other cancer populations, as well as in community-dwelling older adults.[[10,11,15,18,24]] Men with PCa are more likely to have comorbid conditions, which further reinforces the need to better support PCa survivors to become and remain physically active.[[1–3]]

Increased age, like pre-existing comorbidities, was identified as a factor that contributed to a decline in PA for some participants, irrespective of whether they had PCa. A number of participants discussed how physical factors associated with ageing, such as loss of balance, fear of falling, reduced flexibility and increased tiredness, limited their PA engagement. There was also a perception held by some participants that increased age equated with less need to engage in regular PA. These findings are similar to the results of an earlier study that examined factors that influenced PA in 18 PCa survivors, and a study designed to examine quality of life and PA engagement in 14 PCa survivors.[[10,12]] A scoping review designed to identify key facilitators and barriers to PA change in PCa survivors also found increased age to be a barrier to PA.[[15]]

Time constraints is one of the most cited barriers to PA in PCa populations,[[7,8,11,15]] in other cancer populations[[14,9]] and in healthy older adult populations.[[24]] In the present study, a number of participants discussed how time constraints acted as a barrier to PA regardless of their work status (eg, retired, semi-retired or in full time employment). It has been suggested that strategies for changing behaviour could be employed to emphasise the importance of PA. One such strategy could be the use of motivational interviewing to increase adherence to PA by focusing on barriers related to time management.[[21]]

Clifford and colleagues suggested that readily accessible local exercise facilities could be important for helping to counteract time constraints for PA.[[21]] This is consistent with the results of the present study: for example, the oldest participant discussed how he would have liked to have attended tai chi classes that would have aided his balance, though lack of proximity to an organised tai chi venue became a barrier to engaging in this type of activity. Lack of proximity to PA and exercise venues have also been cited as a barrier to PA in both PCa survivors and in other cancer survivor populations.[[14,15,17,25,26]]

A potential limitation of the present study is the small sample size, which may limit the generalisability of our findings. However, other qualitative studies that examined various aspects of PA engagement in PCa survivors had similar sample size.[[10–12]] PCa survivors living in rural New Zealand may encounter more barriers to PA in relation to lack of proximity to PA or exercise venues compared to those who live in urban areas, such as Auckland. There was no ethnic variance in our study; all participants identified as New Zealand European.

A strength of the present study is that a qualitative interview-based approach provided insights regarding barriers to PA that PCa survivors can experience. Employing a cross-section of PCa survivors (ie, men in remission who are treatment free and men who are currently receiving treatment for their PCa in the form of ADT) highlighted that men who are in remission and treatment free can still live with long-term, post-treatment-related side-effects. Treatment-related side-effects, such as urinary incontinence and bowel-control issues, affected participants’ PA more than 12 months after the cessation of certain PCa treatments and prostate-related surgeries.

Conclusions

The present study identified a number of barriers to PA that PCa survivors who are at least one year post cancer treatment can still encounter. Two barriers related to PCa-treatment-related side-effects, and the remining four barriers to PA that have already been reported in the literature as being experienced by older male populations who have not had PCa. With an increase in survivorship, there needs to be an active focus on the role that modifiable behaviours, such as PA, can have in helping maintain and improve both the physical and psychological health-related outcomes of PCa survivors. The findings from this study, combined with existing literature, can be used to develop strategies and programmes that help facilitate and maintain regular PA engagement in PCa survivors.

Summary

Abstract

Aim

Despite the benefits of regular physical activity (PA), many prostate cancer (PCa) survivors are not engaging in sufficient PA to achieve health-related gain. This qualitative study sought to gain further insight regarding barriers to PA in older-aged PCa survivors.

Method

Sixteen participants were individually interviewed, and data were analysed using an inductive thematic approach.

Results

Six main themes affecting perceived barriers for PA post diagnosis were identified: the effects of the PCa and PCa treatments on PA, urinary incontinence and bowel control, pre-existing comorbid conditions, increased age, time constraints and lack of proximity to PA or exercise venues.

Conclusion

Only two of the six barriers identified directly related to having had PCa. With an increase in PCa survivorship, an active focus needs to be placed on the role that PA can have in helping maintain and improve both the physical and psychological health-related outcomes of PCa survivors.

Author Information

Asmita Patel: Research Manager, South Pacific College of Natural Medicine, Auckland, New Zealand. Grant M Schofield: Professor, Faculty of Health and Environmental Sciences, Auckland University of Technology, Auckland, New Zealand. Justin WL Keogh: Associate Professor, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Australia; Faculty of Science, Health, Education and Engineering, University of the Sunshine Coast, Australia; Auckland University of Technology, Auckland, New Zealand; Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, Karnataka, India.

Acknowledgements

We would like to thank the men who took part in this study. We would also like to thank the Prostate Cancer Foundation of New Zealand for their assistance with participant recruitment.

Correspondence

Dr Asmita Patel, South Pacific College of Natural Medicine, PO Box 11-311, Ellerslie, Auckland 1542, 0210349644

Correspondence Email

asmita.patel@spcnm.ac.nz

Competing Interests

This study was funded by Cancer Society of New Zealand through a three-year Prostate Cancer Young Investigator Scholarship.

1) Campos C, Sotomayor P, Jerez D, Gonzalez J, Schmidt CB, Schmidt K, et al. Exercise and prostate cancer: From basic science to clinical applications. Prostate. 2018;78:639-45.

2) Newton RU, Galvao DA. Exercise medicine for prostate cancer. Eur Rev Aging Phys Act. 2013;10:1041-5.

3) Narayan V, Harrison M, Cheng H, Kenfield S, Aggarwal R, Kwon D, et al. Improving research for prostate cancer survivorship: A statement from the Survivorship Research in Prostate Cancer (SuRECaP) working group. Urol Oncol. 2020;38:83-93.

4) Galvao DA, Newton RU, Gardiner RA, Girgis A, Lepore SJ, Stiller A, et al. Compliance to exercise- oncology guidelines in prostate cancer survivors and associations with psychological distress, unmet supportive care needs, and quality of life. Psychooncology. 2015;24:1241-9.

5) Friedenreich CM, Wang Q, Neilson HK, Kopciuk, KA, McGregor SE, Courneya KS. Physical activity and survival after prostate cancer. Eur Urol. 2016;70:576-85.

6) Keogh JWL, Shepherd D, Krageloh CU, Ryan C, Masters J, Shepherd G, et al. Predictors of physical activity and quality of life in New Zealand prostate cancer survivors undergoing androgen-deprivation therapy. NZ Med J. 2010;123(1325):20-9.

7) Ottenbacher AJ, Day RS, Taylor WC, Sharma SV, Sloane R, Snyder DC, et al. Exercise among breast and prostate cancer survivors – what are their barriers? J Cancer Surviv. 2011;5:413-9.

8) Weller S, Oliffe JL, Campbell KL. (2019). Factors associated with exercise preferences, barriers and facilitators of prostate cancer survivors. Eur J Cancer Care. 2019;28(5)-e13135.

9) Schmitz KH, Courneya KS, Matthews C, Demark-Wahnefried W, Galvao DA, Pinto BM, et al, (2010). American College of Sports Medicine Roundtable on Exercise Guideline, Cancer Survivors. Med Sci Sports Exerc. 2010;42(7):1409-26.

10) Craike MJ, Livingston PM, Botti M. An exploratory study of the factors that influence physical activity for prostate cancer survivors. Support Care Cancer. 2011;19:1019-28.

11) Keogh JWL, Patel A, MacLeod RD, Masters J. Perceived barriers and facilitators to physical activity in men with prostate cancer: Possible influence of androgen deprivation. Eur J Cancer Care. 2014;23:263-73.

12) Keogh JWL, Patel A, MacLeod RD, Masters J. Perceptions of physically active men with prostate cancer on the role of physical activity in maintaining their quality of life: Possible influence of androgen deprivation therapy. Psychooncology. 2013; 22:2869-75.

13) Auerbach C, Silverstein L. Qualitative data. An introduction to coding and analysis. New York: New York University Press; 2003.

14) Min J, Yoo S, Kim MJ, Yang E, Hwang S, Kang M, et al. Exercise participation, barriers, and preferences in Korean prostate cancer survivors. Ethn Health. 2019. DOI: 10.1080/13557858.2019.1634184

15) Yannitsos D, Murphy RA, Pollock P, Di Sebastiano KM. Facilitators and barriers to participation in lifestyle modification for men with prostate cancer: A scoping review. Eur J Cancer Care. 2020;29(1):e13193.

16) Catt S, Sheward J, Sheward, Harder H. Cancer survivors’ experiences of a community-based cancer-specific exercise programme: results of an exploratory survey. Support Care Cancer. 2018;26:3209-16.

17) Sheill G, Guinan, E, O’Neil LO, Hevey, D, Hussey J.The views of patients with metastatic prostate cancer toward physical activity: a qualitative exploration. Support Care Cancer. 2018;26:1747-54.

18) Blaney JM, Lowe-Strong A, Rankin-Watt J, Campbell A, Gracey JH. Cancer survivors’ exercise barriers, facilitators and preferences in the context of fatigue, quality of life and physical activity participation: a questionnaire-survey, Psychooncology. 2013;22:186-94.

19) Keogh JWL, Puhringer P, Olsen A, Sargeant S, Jones LM, Climstein M. Physical activity promotion, beliefs, and barriers among Australasian oncology nurses. Oncol Nurs Forum. 2017;44(2):235-45.

20) Patel A, Schofield G, Keogh J. Influences on health-care practitioners’ promotion of physical activity to their patients with prostate cancer: a qualitative study. J Prim Health Care. 2018;10(1):31-38.

21) Clifford BK, Mizrahi D, Sandler CX, Barry BK, Simar D, Wakefield, CE, et al. Barriers and facilitators of exercise experienced by cancer survivors: a mixed methods systematic review. Support Care Cancer. 2018;26:685-700.

22) Bohn SKH, Fossa SD, Wisloff T, Thorsen L. Physical activity and associations with treatment-induced adverse effects among prostate cancer patients. Support Care Cancer. 2019;27:1001-11.

23) Mungovan SF, Carlsson SV, Gass GC, Graham PL, Sandhu JS, Akin O, Scardino PT, Eastham JA, Patel MI. Preoperative exercise interventions to optimize continence outcomes following radical prostatectomy. Nat Rev Urol. 2021;18:259-81.

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Prostate cancer (PCa) is the most common male cancer in many countries.[[1]] With advancements in both screening procedures and treatment options, men are living longer post diagnosis, and more focus is now being placed on survivorship in relation to maintaining and improving the health-related outcomes of PCa survivors.[[1,2]] Because of the prolonged disease course and ongoing treatment associated with PCa, the terms “survivor” and “survivorship” encompass men who are in remission and treatment free as well as men who have incurable PCa and are receiving intermittent or ongoing treatment for their PCa, such as hormone suppression treatment.[[3]]

Physical activity (PA) is a modifiable behaviour that can help improve both the physical and psychological health of PCa survivors during all stages of the PCa continuum, from diagnosis and treatment through to remission and survivorship.[[1,2,4]] Engagement in regular PA has been associated with lower prostate specific antigen (PSA) levels, a delay in the use of hormone suppression therapy and a lower risk of cancer progression and recurrence.[[1,2,5]]

Physical activity can protect men who are currently receiving treatment for their PCa.[[2,4]] This is especially the case for men undergoing hormone-suppression treatment in the form of androgen deprivation therapy (ADT).[[1,2,4]] Physical activity, especially in the form of aerobic and resistance exercise, can help counteract some of the negative treatment-related side-effects associated with ADT. Specifically, these forms of PA may counteract the increases in body fat accumulation (predominately in the abdominal region), which increase the risk for both type 2 diabetes and metabolic syndrome, as well as loss in muscle and bone mass that can become a risk factor for osteoporosis and reduced physical function.[[1,2,4]] Physical activity can also help counteract cancer-related fatigue and depression, which can be more prevalent in men on ADT.[[1,2,4]]

Despite the benefits of regular PA, the majority of PCa patients and survivors are not engaging in sufficient PA to achieve health-related gain.[[4,5–8]] The American College of Sports Medicine (ACSM) roundtable on exercise guidelines for cancer survivors recommends 150 minutes of moderate-intensity PA per week.[[9]] More research is required to identify and examine the barriers to PA that survivors may encounter.[[6]] Limited New Zealand-based research has focused on qualitatively identifying perceived barriers to PA in a cross-section of PCa survivors, such as men who are in remission and treatment free but live with long-term post-treatment related side-effects (ie, urinary incontinence), as well as men who are currently receiving treatment for their PCa. A qualitative approach can provide greater insight into these men’s perceptions of how their PCa diagnosis, and their experience of treatment-related side-effects, impacted on their post-diagnosis and post-treatment PA. The aim of the present study is to qualitatively identify and examine barriers to PA in 16 older-aged PCa survivors who would be more representative of the typical PCa survivor, in relation to their older age and experience of multiple PCa treatments.

Methods

Participants

Men with any stage or grade of PCa, including those in remission, were eligible to participate in the present study. There were no criteria relating to pre-cancer PA levels. We pre-determined a sample of 16 participants, as other qualitative studies that examined various aspects of PA engagement in PCa survivors had similar sample sizes.[[10–12]] At recruitment, 10 participants had not received chemotherapy or radiation or undergone prostate-related surgery within the past 12 months. Six men were on ADT at recruitment. All 16 participants lived in the Auckland region. A summary of the participants involved in the study is presented in Table 1.

Table 1: Participant characteristics and prostate cancer treatments that participants had undergone.

Some participants received more than one type of treatment. ADT: Androgen deprivation treatment

Measure

Members of the research team developed an interview schedule for the present study. Questions were based on relevant literature relating to barriers to PA that PCa patients and survivors can encounter. Questions were open-ended and designed to facilitate discussion. The two main questions were:

  1. How do your levels of physical activity or exercise differ to before you were diagnosed with prostate cancer?
  2. What barriers to physical activity have you experienced since your diagnosis?

Procedure

Information pertaining to the larger study (via a participant information sheet) was included in the content of three of the monthly newsletters that the Prostate Cancer Foundation of New Zealand email to their members. The majority of participants (n=14) were recruited through the Prostate Cancer Foundation. The remaining two participants were recruited via word of mouth by members of the research team. Men who were interested in taking part in the study contacted the first author by email or phone. Once contact had been made and their eligibility to participate confirmed, an interview time and location were arranged. Participants were individually interviewed by the first author at their home, their place of work or the university. All interviews were audiotaped, with the average length of interviews being 40 minutes. Prior to the commencement of each interview, informed written consent was obtained from each participant. Ethics approval for this study was obtained from Northern A Health and Disability Ethics Committee (reference number: 13/NTA/241/AM01).

Data analysis

Interviews were transcribed verbatim and analysed using an inductive thematic approach based on Auerbach and Silverstein’s approach to thematic analysis.[[13]] Four main steps were involved in the analysis process:

  1. Reading and re-reading each transcript several times for each question within a topic area.
  2. Identifying repeating ideas (ie, discursive commonalities in the interview transcripts) in response to a particular question. This involved identifying segments of text whereby participants had used similar words or experiences to convey the same idea.
  3. Coding and naming the repeating ideas. This resulted in the generation of themes. A theme can be defined as an organisation of repeating ideas that is given a name that tries to communicate what participants are trying to convey in their response to a particular research question.[[13]]
  4. Verifying the trustworthiness of the study findings and reduce individual researcher bias. The first author initially analysed the data and identified themes. Both co-authors then independently read the transcripts to validate or invalidate themes. This ensured that participant quotes matched the categories of themes identified.

Results

Data were examined under the main topic area designed to identify barriers to PA post diagnosis. Six main themes were identified:

  1. The effects of the PCa and PCa treatments on PA
  2. Urinary incontinence and bowel control
  3. P-existing comorbid conditions
  4. Increased age
  5. Time constraints
  6. Lack of proximity to PA or exercise venues.

The main themes are outlined below, and direct quotes are provided that illustrate participants’ experiences and views.

Theme 1: The effects of the prostate cancer and prostate cancer treatments on physical activity

This theme involved a number of participants discussing how their PA was affected by their PCa diagnosis and the associated side-effects of their various PCa treatments, which predominantly resulted in loss of strength and increased fatigue. This in turn resulted in a decrease in PA or cessation of PA during the active treatment process:

“Physical activity is curtailed considerably. You can’t be as physical as you were before. You feel so weak when you’ve got prostate cancer. There is no strength left in you.” – Participant 4, Chemotherapy, ADT

“Before [the prostate cancer] I had a lot more strength. I felt as weak as a baby at times. I was told that it had something to do with losing my male hormone count.” – Participant 16, Radiation, ADT

“Over the four-year treatment, there’s been periods when I’ve felt unwell. My level of activity has been up and down. There have been periods when I have been physically inactive because of the medical treatment.” – Participant 1, Radical Prostatectomy, Radiation, Chemotherapy, ADT

“Not exercising because of what was going on with the hormone treatment. I put on weight. I was always an exercise person, that’s why the extra weight didn’t sit comfortably for me.” – Participant 3, Radical Prostatectomy, ADT

Theme 2: Urinary incontinence and bowel control

Physical activity post treatment was also negatively affected by issues relating to incontinence and bowel control. Participants gave accounts of how their PA engagement was reduced or limited as a result of long-term, treatment-related side-effects that continued to result in incontinence:

“I have problems with leakage. I can only walk for a couple of hours now. There was a time I used to walk a lot further. It’s just that I’m wet through with the pad.” – Participant 12, Radical Prostatectomy

“I do have to be careful with my mid-section exercises. I have to be careful that I don’t promote a leakage if I’m exercising that sort of way.” – Participant 3, Radical Prostatectomy, ADT

“Loose bowel motions. When I first had the treatment it was terrible. If I had to go to the toilet, I had to go to the toilet and there was no ifs or maybes. I'm involved at the Maritime Museum taking people sailing. I’ve had to refuse going on some offshore sailing trips.” – Participant 16, Radiation, ADT

Theme 3: Pre-existing comorbid conditions

A number of participants discussed how other health conditions not related to having had PCa acted as barriers to engagement in certain types of PA:

“A physical barrier not to do with the prostate cancer but the heart bypass. There's more physical barriers with that than the prostate cancer.”– Participant 16, Radiation, ADT

“Arthritic problems. Runner’s knee. A bad back is my biggest problem at the moment. I would still run if it wasn’t for my back and knees.” – Participant 7, Radiation

“I have back problems.” – Participant 12, Radical Prostatectomy

Theme 4: Increased age

A number of participants discussed how increased age was a factor in their declining PA levels. Participants cited examples of physical factors, such as reduced balance and flexibility, that affected their ability to engage in certain physical activities. There was also a perception that increased age equated with less need to engage in regular PA:

“I would probably do less now because of my age. I don’t run now, I just walk. It’s nothing to do with the prostate cancer, its old age.” – Participant 7, Radiation

“There is still limit to how much I want to do at 72. I play golf at least once a week with blokes younger than me who can’t walk. I am probably more active than any of my other friends.” – Participant 6, ADT

“I can’t do much in the way of helping in the garden. If I bend down, I’m likely to fall over. So, I don’t do that. My balance is not as good as it used to be.” –Participant 13, currently on ADT

“Getting older, I can’t do all the things I used to because I don’t have the flexibility to do some of the things.” – Participant 14, Radical Prostatectomy

Theme 5: Time constraints

The following quotes illustrate how time constraints acted as barriers to regular PA engagement regardless of whether participants were retired or semi-retired:

“The only barrier would be time. I have to do other things and I haven’t always got time available. That would be the only reason.” – Participant 5, ADT

“The fact is the day gets filled up very quickly.” – Participant 13, ADT

“Time to do it is the barrier. I lead a pretty busy life even though I’m eighty percent retried. There’s a lot going on and I don’t always get the time.” – Participant 14, Radical Prostatectomy

Theme 6: Lack of proximity to physical activity and exercise venues

Lack of proximity to a PA or exercise venue was also identified as being a barrier to engaging in certain types of PA that seemed to best suit the individual needs of certain participants:

“Close proximity to somewhere where we get something like tai chi. It would help if there was something local.” – Participant 13, ADT

“If I lived closer to a gym, I would go to the gym. But I’m 40 [kilometres] from the gym.” – Participant 15, Radiation, ADT

Discussion

The present study identified a number of barriers to PA that PCa survivors can encounter, even when they are more than 12 months post chemotherapy, radiation or prostate-related surgery. Only two of the six barriers identified directly related to having had PCa. The two PCa-specific barriers were (1) the effects of PCa and PCa treatments on PA and (2) urinary incontinence and bowel control, which were long-term, post-treatment-related side-effects. A salient barrier to PA engagement in the context of PCa was the effect of the PCa itself and PCa-treatment-related side-effects on an individual’s ability to engage in regular PA.[[10,11,14,15]]  A number of participants in the present study discussed how their PA was affected by both their PCa diagnosis and the treatment-related side-effects of their various (and in most cases multimodality) PCa treatments (eg, a combination of chemotherapy, radiation, prostate-related surgery and ADT). This in turn resulted in fatigue, feeling weak and having no strength, which resulted in either a decrease in PA or cessation of PA.

A number of previous studies have also cited the effects of the cancer- and various cancer-treatment-related side-effects as being the most salient barriers to PA in both newly diagnosed individuals and in those receiving active treatment.[[11,16,17]]  Side-effects of cancer treatments also impact PA engagement in individuals who are in remission and treatment free, as treatment-related side-effects can linger.[[18]] A growing body of evidence-based research has found PA to be both safe and beneficial along the cancer continuum, from diagnosis and active treatment through to remission and survivorship.[[2,5,9]] Engagement in PA, regardless of cancer type, stage or grade, has been found to be beneficial in maintaining and improving physical function and psychological wellbeing and alleviating treatment-related side-effects, such as cancer-related fatigue.[[1,2,4,5]]

Evidence of the benefits of PA for cancer survivorship is now relatively well understood by health professionals. Australasian cancer nurses are actively involved in the promotion of PA to their cancer patients.[[19]] Healthcare practitioners who treat PCa patients and see PCa survivors on a regular basis for the monitoring of PSA levels and for other conditions are well placed to provide advice or referral for PA and PA programmes. [[20]]

Urinary incontinence and bowel control also affect men’s PA, potentially for many months or years post treatment.[[13,15,9]]  Some studies have reported that urinary incontinence and lack of bowel control have acted as barriers to PA, as men were worried and fearful about possible leakage during PA, or they had experienced embarrassment due to incontinence when engaging in PA.[[15,17,21]] However, other studies have reported that urinary incontinence was experienced at a minor degree, and hence was a minor barrier to PA.[[10,22]]

This was also the case in the present study. Some participants discussed how their PA was reduced (eg, less walking activity because one’s pad becomes more saturated with activity), or how they had to limit other types of PA (eg, sailing) due to bowel-control issues, even if they didn’t completely cease these activities. The findings of the present study highlight how long-term post-treatment-related side-effects can still affect PA more than 12 months after the cessation of certain PCa treatments or prostate-related surgeries. Physical activity in the form of pelvic floor muscle training, as well as aerobic exercise and resistance training before and after prostate-related surgery, can positively influence continence in men following a radical prostatectomy.[[23]]

Some participants in the present study had pre-existing comorbidities, and it was these, not the PCa itself, that were identified as barriers to PA. A number of participants discussed how other conditions (eg, arthritis, back problems) inhibited them from engaging in certain activities. Pre-existing comorbid conditions have also been identified as being barriers to PA in both PCa and other cancer populations, as well as in community-dwelling older adults.[[10,11,15,18,24]] Men with PCa are more likely to have comorbid conditions, which further reinforces the need to better support PCa survivors to become and remain physically active.[[1–3]]

Increased age, like pre-existing comorbidities, was identified as a factor that contributed to a decline in PA for some participants, irrespective of whether they had PCa. A number of participants discussed how physical factors associated with ageing, such as loss of balance, fear of falling, reduced flexibility and increased tiredness, limited their PA engagement. There was also a perception held by some participants that increased age equated with less need to engage in regular PA. These findings are similar to the results of an earlier study that examined factors that influenced PA in 18 PCa survivors, and a study designed to examine quality of life and PA engagement in 14 PCa survivors.[[10,12]] A scoping review designed to identify key facilitators and barriers to PA change in PCa survivors also found increased age to be a barrier to PA.[[15]]

Time constraints is one of the most cited barriers to PA in PCa populations,[[7,8,11,15]] in other cancer populations[[14,9]] and in healthy older adult populations.[[24]] In the present study, a number of participants discussed how time constraints acted as a barrier to PA regardless of their work status (eg, retired, semi-retired or in full time employment). It has been suggested that strategies for changing behaviour could be employed to emphasise the importance of PA. One such strategy could be the use of motivational interviewing to increase adherence to PA by focusing on barriers related to time management.[[21]]

Clifford and colleagues suggested that readily accessible local exercise facilities could be important for helping to counteract time constraints for PA.[[21]] This is consistent with the results of the present study: for example, the oldest participant discussed how he would have liked to have attended tai chi classes that would have aided his balance, though lack of proximity to an organised tai chi venue became a barrier to engaging in this type of activity. Lack of proximity to PA and exercise venues have also been cited as a barrier to PA in both PCa survivors and in other cancer survivor populations.[[14,15,17,25,26]]

A potential limitation of the present study is the small sample size, which may limit the generalisability of our findings. However, other qualitative studies that examined various aspects of PA engagement in PCa survivors had similar sample size.[[10–12]] PCa survivors living in rural New Zealand may encounter more barriers to PA in relation to lack of proximity to PA or exercise venues compared to those who live in urban areas, such as Auckland. There was no ethnic variance in our study; all participants identified as New Zealand European.

A strength of the present study is that a qualitative interview-based approach provided insights regarding barriers to PA that PCa survivors can experience. Employing a cross-section of PCa survivors (ie, men in remission who are treatment free and men who are currently receiving treatment for their PCa in the form of ADT) highlighted that men who are in remission and treatment free can still live with long-term, post-treatment-related side-effects. Treatment-related side-effects, such as urinary incontinence and bowel-control issues, affected participants’ PA more than 12 months after the cessation of certain PCa treatments and prostate-related surgeries.

Conclusions

The present study identified a number of barriers to PA that PCa survivors who are at least one year post cancer treatment can still encounter. Two barriers related to PCa-treatment-related side-effects, and the remining four barriers to PA that have already been reported in the literature as being experienced by older male populations who have not had PCa. With an increase in survivorship, there needs to be an active focus on the role that modifiable behaviours, such as PA, can have in helping maintain and improve both the physical and psychological health-related outcomes of PCa survivors. The findings from this study, combined with existing literature, can be used to develop strategies and programmes that help facilitate and maintain regular PA engagement in PCa survivors.

Summary

Abstract

Aim

Despite the benefits of regular physical activity (PA), many prostate cancer (PCa) survivors are not engaging in sufficient PA to achieve health-related gain. This qualitative study sought to gain further insight regarding barriers to PA in older-aged PCa survivors.

Method

Sixteen participants were individually interviewed, and data were analysed using an inductive thematic approach.

Results

Six main themes affecting perceived barriers for PA post diagnosis were identified: the effects of the PCa and PCa treatments on PA, urinary incontinence and bowel control, pre-existing comorbid conditions, increased age, time constraints and lack of proximity to PA or exercise venues.

Conclusion

Only two of the six barriers identified directly related to having had PCa. With an increase in PCa survivorship, an active focus needs to be placed on the role that PA can have in helping maintain and improve both the physical and psychological health-related outcomes of PCa survivors.

Author Information

Asmita Patel: Research Manager, South Pacific College of Natural Medicine, Auckland, New Zealand. Grant M Schofield: Professor, Faculty of Health and Environmental Sciences, Auckland University of Technology, Auckland, New Zealand. Justin WL Keogh: Associate Professor, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Australia; Faculty of Science, Health, Education and Engineering, University of the Sunshine Coast, Australia; Auckland University of Technology, Auckland, New Zealand; Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, Karnataka, India.

Acknowledgements

We would like to thank the men who took part in this study. We would also like to thank the Prostate Cancer Foundation of New Zealand for their assistance with participant recruitment.

Correspondence

Dr Asmita Patel, South Pacific College of Natural Medicine, PO Box 11-311, Ellerslie, Auckland 1542, 0210349644

Correspondence Email

asmita.patel@spcnm.ac.nz

Competing Interests

This study was funded by Cancer Society of New Zealand through a three-year Prostate Cancer Young Investigator Scholarship.

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