Conversations With Prostate Cancer Experts

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Prostate Cancer Vaccine Clinical Trials

Dr. James Gulley is the Head of the Immunotherapy Section and the Director of the Medical Oncology Service at the National Cancer Institute’s Center for Cancer Research in Bethesda, MD.

Prostatepedia spoke with him recently about ProstVac and open prostate cancer vaccine clinical trials.

There is a vaccine that was under investigation called ProstVac. Can you tell us a little about that vaccine and whether or not it has been effective? 

Dr. Gulley: ProstVac is a pox viral-based therapeutic vaccine that has the genes for PSA, as well as three different human T-cell co-stimulatory molecules. What that means is that the vaccine is something that we can give that can train the patient’s immune system to recognize and attack cells that make PSA. Normal prostate cells or prostate cancer cells can make PSA. There are cancer patients who have had their prostates removed. The only cells left behind that would express PSA are the cancer cells.

There are two basic viruses that are used. One is vaccinia for the initial vaccine. It’s a really good jolt to the immune system. All the subsequent boosting vaccines are given with fowlpox that again contain the same genes for PSA and co-stimulatory molecules. That can continue to boost an immune response.

There were initial studies done with this agent that showed that it was safe to give in patients with advanced cancer and that when given it could generate immune responses to PSA in those patients. If you took cancer cells with the immune cells from those patients, those immune cells could recognize and kill those cancer cells that make PSA.

We then did additional studies looking at this activity, including one randomized Phase II study that was double-blinded. 125 men received vaccine versus placebo. In that study, we found that there was no difference in progression-free survival, but there was an improvement in overall survival, which was our secondary endpoint.

This is very similar to what was seen with Provenge (sipuleucel-T). So we followed this up with a larger study to confirm whether or not these findings are correct. We embarked on a 1,200-patient study that over enrolled. There were 1,297 patients enrolled on that study. We presented the results at the conference of the American Society of Clinical Oncology in 2018: there was no improvement in overall survival with the vaccine.

I should mention a little bit about the trial design. There were three arms in the study: one group received the vaccine plus GM-CSF. This was used in the Phase II trial and showed an improvement in survival. GM-CSF, or Granulocyte-macrophage colony-stimulating factor, can further boost immune response. We don’t know if it is required for the vaccine or not. Interestingly, because of the difficulty in getting this outside of the United States and because we didn’t know if it was needed or not, we did one arm with GM-CSF and another with no GM-CSF. The third arm got a placebo. The placebo vaccine was just comprised fowlpox vector.

What we saw in that study, which showed no improvement in survival, is that we don’t really have a clear explanation of what happened or why we saw a difference in the Phase II study. It could be that the Phase II study was just under-powered and the results we saw were based on chance. (I’m just going to lay everything out here.) It could be that the vaccine was effective and that it did generate immune responses, but that those immune responses did not translate into improved survival for a variety of different reasons.

First, multiple agents have been approved since the initiation of the drug; Zytiga (abiraterone), Xtandi (enzalutamide), Jevtana (cabazitaxel), Xofigo (radium-223), and Provenge (sipuleucel-T) were all approved after that study was designed. It’s possible that when these agents are used afterwards they delete out any treatment effect.

If you look at the overall survival data from Xtandi (enzalutamide) and Zytiga (abiraterone), you’ll see huge improvement in survival in the post chemotherapy setting. In the pre-chemotherapy setting it’s very difficult to see an improvement in survival. In fact, there was no statistically significant improvement in survival with Zytiga (abiraterone) in the pre-chemotherapy setting, suggesting that that could be another explanation for why an improvement in survival just wasn’t seen. The lines are really overlapping. Finally, it could be that the vaccine was generating an immune response. That immune response went to the tumor, but those cells were held in check because of regulation of PD-L1 or something like that. It turns out that when you have activated T-cells that recognize a tumor, they make gamma interferon and cause the other T-cells there to recruit other cells, but that gamma interferon will cause up-regulation of PD-L1. (PD-L1 is a stop sign to T-cells.)

As soon as the T-cells see that stop sign, then they stop everything and they can’t do anything while that’s there. If you come in with an immune checkpoint inhibitor and block either the PD-1 or the PD-L1, you basically cover that stop sign and those T-cells go back to work.

Perhaps that is what’s going on. We did a study in the neo-adjuvant setting where we gave a ProstVac vaccine to patients undergoing surgery. We did see immune cells getting into the prostate, but often not into the tumor, so it may not just be the PD-L1. There are other things excluding the T-cells from the tumor, for example there may be no HLA-A2 expression. Maybe there is up-regulation of TGF-beta. These are still things we’re grappling with, things we’re trying to understand. We’re also trying to come in with other clinical studies to address these different aspects of what might be going on in the tumor microenvironment to lead to a better outcome.

You’re still looking for explanations?

Dr. Gulley: Correct. There are ongoing studies looking at ProstVac in men with a biochemical recurrence. There are ongoing studies in active surveillance—with patients who don’t need treatment.

There are ongoing studies in combination with other agents, like ProstVac and Opdivo (nivolumab). We’ve looked at that combination in men with metastatic disease. I mentioned earlier two of the twelve patients had good responses. Ten of them didn’t. We’re trying to understand that better, so we’re taking it into the neoadjuvant setting. We’ve enrolled one out of the seventeen patients we need to understand a combination of a vaccine plus Opdivo (nivolumab). We’re getting biopsies and comparing that with the prostatectomy specimen to see if there is an increase in immune cells. Do we get more of an increase in immune cells from that combination than we get from the vaccine alone? How do we improve upon that?

If a man reading this is interested in joining a trial, there are multiple options for him to consider?

 Dr. Gulley: Absolutely.

Join us to read about additional trials that Dr. Gulley and his colleagues are running.


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Who Is Dr. James Gulley?

Dr. James Gulley is the Head of the Immunotherapy Section and the Director of the Medical Oncology Service at the National Cancer Institute’s Center for Cancer Research in Bethesda, MD.

Join us to read Dr. Gulley’s comments about prostate cancer vaccine clinical trials.

Why did you become a doctor?

Dr. James Gulley: I think this has to go back to my high school biology teacher. His name was Vernon McNeilus. He was a retired orthopedic surgeon who just found a way to instill inspiration and that sense of curiosity about life. He drove us to really be excited and interested in science and in biology in particular. I had decided that I wanted to do something in science or medicine, but there was no way that I was going to go spend all that time to become a doctor. I’d been in school long enough. One of my friends decided he was going to go into medicine. I said if he can do it, I can certainly do it.

Then it actually evolved even further than that because during my stint in college I got the opportunity to do a summer research program. I decided I liked research, so I applied to MD/PhD programs and got accepted into two. I decided to go to Loma Linda.

What is it about medicine that keeps you interested?

Dr. Gulley: I think the thing that really drives me is how fascinating it is to understand how things work. I’ve always been fascinated in what makes things work. As a little boy I would take things apart trying to figure out what made them work and then put them back together again. If something was broken in the house, my mom would just give it to me and I’d tinker with it and get it to work again.

To me, the ultimate machine is the human body and one serious puzzle is to figure out ways to bring back health from sickness. Not just a puzzle for curiosity’s sake, but because of the effect that cancer can have on families, to uncover ways to effectively treat cancer. I think it’s truly something that I have seen patients who were close to death who have had remarkable and prolonged clinical responses. That, to me, begs the question that if we can do it for some people, then why can’t we do it for all people? That is what I am passionate about.

Are there any patients you’ve had over the years whose cases changed how you see your own role or the art of medicine?

Dr. Gulley: I’ve had several patients that have been exceptional responders; that really has changed how I view things. One of my more recent exceptional responses from this past year is a retired army surgeon who has advanced metastatic castrate resistant prostate cancer. I have been treating him since 2005. He was initially treated with radical prostatectomy. It turned out that he had a high Gleason disease. He had radiation therapy, but he had recurrence of his disease, unfortunately. He was treated with hormonal therapy, with chemotherapy, with Provenge (sipuleucel-T), and Xtandi (enzalutamide).

He came to me last year having had multiple therapies including other experimental immunotherapies. He was clearly not doing well. His PSA was going up very quickly with a doubling time of less than a month. His symptoms were getting substantially worse. He articulated to me that even going to church every week was becoming difficult: one week he was able to sing the songs and the next week he was too tired to sing. Then the next week he was almost too tired to stand up.

We were able to enroll him in a study combining a vaccine with checkpoint inhibition. When we gave him that combination, his PSA dropped dramatically. It has now gone to undetectable. His lesion in his bladder, which was causing local symptoms so that he had to have a chronic indwelling Foley catheter, shrunk away. When we biopsied it there was no evidence of tumor there. He has some lesions that are seen on bone scan, but I’m not sure if that represents viable tumor or not.

He is now over a year out from when he started treatment. His energy level hasn’t been better since before he was diagnosed. He is out doing everything he wants to do. To me that is amazing. It is amazing we can see responses like that.

From a scientific standpoint, of course, I was stunned to see this and wondered could he have micro-satellite instability that leads to lots of mutations. It turned out that he had micro-satellite instability in his cancer, suggesting that the immune system was able to see his cancer much more readily, so all we need to do is allow those immune system cells to be functional with the Opdivo (nivolumab).

We also had one other patient that didn’t have micro-satellite instability with this combination who also had a really nice 90% or so drop in his PSA. It’s not undetectable, but he hasn’t had the immune checkpoint inhibition for well over a year now. He’s just on vaccine alone because he had some bleeding in his urine from the checkpoint inhibitor. To me, having responses like that changes my outlook. It says the immune system, even in patients with prostate cancer, can be harnessed to attack the tumor. We just have to figure out ways that we can make this more applicable to all patients.

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Immunotherapy: Looking Ahead to 2019

Dr. Charles G. Drake is the Director of Genitourinary Oncology, Co-Director of the Cancer Immunotherapy Program, and Associate Director for Clinical Research at the Herbert Irving Comprehensive Cancer Center, New York-Presbyterian/ Columbia University Medical Center.

He spoke with Prostatepedia about the current state of affairs for immunotherapy for prostate cancer and what he anticipates happening in 2019.

“Over the past year, we’ve looked at early data from several anti- PD-1-based immunotherapy combinations. In 2019, we’ll be looking to see more results from these combination studies, to see which combinations will actually work in patients. It’s pretty clear that although PD-1 blockade has some activity, it doesn’t have a lot of activity. The idea is if you combine PD-1 blockade with some of the more standard therapies for prostate cancer, you might get more activity.

One of the more interesting combinations is PD-1 blockade plus a PARP inhibitor like Lynparza (olaparib). PARP inhibitors have activity in prostate cancer, particularly in patients who have mutations and proteins that repair DNA; these mutations are called called homologous repair defects. These patients have a good response to PARP inhibitors. A combination of PD-1 plus PARP inhibitors is being tested both in patients with the mutations and in patients without the mutations.

What has emerged in other diseases likes ovarian and breast cancer is that if one blocks PD-1 and treats with a PARP inhibitor, sometimes it looks like it doesn’t matter if the tumor has those DNA repair mutations or not. There are ongoing trials combining several of the anti-PD-1 / PD-L1 agents like Keytruda (pembrolizumab), Opdivo (nivolumab), and Imfinzi (durvalumab). All these drugs will be combined with PARP inhibitors. The question is whether that combination will lead to objective responses similar to what has been seen in other tumor types. Interesting early data from the NIH group suggest that the PARPi / anti- PD-L1 combination is active.

The second interesting combination involves PD-1 / PD-L1 blockade with hormonal therapy. We showed a while ago that hormonal therapy seems to at least temporarily block tolerance to prostate tumors in murine (mouse) studies. A vaccine plus hormonal therapy can lead to improved responses. The idea is that by giving initial hormonal therapy with immunotherapy, or adding an immunotherapy when you switch hormonal therapies, you will get better responses.

One randomized Phase III trial already tested this combination. The study enrolled patients who were on Zytiga (abiraterone) and then randomized them either to Xtandi (enzalutamide) or the combination of Xtandi (enzalutamide) plus a PD-L1 blocking antibody called Tecentriq (atezolizumab). I’m on the steering committee for that trial. Those patients were pretty healthy in general, though, and so it’s probably going to take a couple of years until we read out whether the combination leads to an improvement in survival.

Other PD-1 or PD-L1 blocking agents will be combined with hormonal therapy as well. At Columbia, we’re doing a really great trial called Magic-8. We’re giving anti-PD-1 in combination with the first hormonal therapy. This is for patients who have had surgery or radiation, who have evidence of a rising PSA, and have a fast doubling time. They will get the anti-PD-1 Opdivo (nivolumab) plus hormonal therapy with degarelix for a short course. Patients will first get two doses of immunotherapy— a prime and a boost. A month after that, they will get the combination of immunotherapy plus hormonal therapy with degarelix. They only get four months of hormonal therapy and then we stop everything to see if they can recover their testosterone and not have a PSA relapse.

To enroll in Magic-8, patients have to have had primary therapies, so they had to have either surgery or radiation. Then they have to have a PSA that’s rising quickly, with a PSA doubling time less than 12 months. Immunotherapy, as you know, is not without risk, so this trial is not for everyone. Patients have to have a reasonable indication that their recurrent prostate cancer is aggressive. They have to have a testosterone level greater than 200, so that their cancer will respond to androgen ablation. One thing that’s a bit different from other trials is that we don’t care if the patient has radiographically detectable metastases or not. If they have metastases, we’re asking them to agree to get a biopsy because we want to try to understand in which patients this combination works. Their PSA also has to be reasonable. It has to be more than 2 but less than 50. This trial is open and accruing.

Not a member? Join us to read the rest of his comments and to find out about other immunotherapy trials looking for patients.

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Immunotherapy For Prostate Cancer

In January, we’re talking about immunotherapy for prostate cancer. Dr. Charles Myers introduced the issue for us.

Not a member? Join us to read this month’s conversations about immunotherapy.

The goal of this issue is to capture the current state of the art in immunotherapy of prostate cancer. We live in a time when immunotherapy is making major contributions to the treatment of many malignancies. The Nobel Prize was recently awarded for the discovery of checkpoint inhibitors that have revolutionized the treatment of melanoma. Chimeric antigen receptor T (CAR T) cell therapy represents a major advance in the treatment of B-cell lymphoma.

Unfortunately, immunotherapy has not yet had such a dramatic impact on prostate cancer treatment. The Provenge (sipuleucel-T) vaccine has been approved for prostate cancer treatment because it results in a modest improvement in the survival of patients with advanced disease. The checkpoint inhibitors have not shown useful activity in prostate cancer, although a small group of patients have had dramatic responses. The current situation may be best summarized by saying that immune response to prostate cancer can be demonstrated in patients, but various factors appear to limit cancer cell kill.

In this issue, we feature conversations with investigators who are doing interesting research on how to overcome factors limiting the effectiveness of immunotherapy in prostate cancer.

Dr. Charles G Drake talks about the state of immunotherapy in 2018 and looks ahead to what we can expect to happen in 2019.

Dr. James Gulley talks about why the initial trials with the prostate cancer vaccine ProstVac didn’t prove as promising as we’d all hoped. He also outlines a number of prostate cancer vaccine clinical trials looking for patients.

Dr. Julie Graff discusses clinical trials—both completed and those looking for patients—that combine Keytruda and Xtandi.

Dr. Fatima Karzai tells us about clinical trials at the National Institute of Health that combine PARP and PD-L1 Inhibitors.

Dr. Bruce Brown, Chief Medical Officer of Dendreon, discusses a clinical trial that looks at using sipuleucel-T in men on active surveillance.

Each conversation this month includes information on clinical trials that are recruiting prostate cancer patients. If you think you may be a fit, please don’t hesitate to contact the investigator.

Join us for more information.

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Exercise Interventions For Men With Prostate Cancer

Winters-Stone headshot

Dr. Kerri Winters-Stone, an exercise scientist and Professor in the School of Nursing at the Oregon Health & Science University (OHSU), is the Co-Director of the OHSU Knight Cancer Institute’s Community Partnership Program and Co-Leader of the OHSU Knight Cancer Institute’s Cancer Prevention and Control Program. She is keenly interested in how physical activity can help us prevent and manage chronic diseases and specifically cancer.

Prostatepedia spoke with her about a clinical trial she’s running in conjunction with Movember that looks at how to deliver physical and nutrition advice to men with prostate cancer using digital technology.

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How did you come to study physical activity in cancer survivors? What path led you to where you are now?

Dr. Winters-Stone: I’m trained as an exercise scientist with a focus in skeletal physiology, so my original research was aimed at figuring out how we use exercise as a way to prevent osteoporosis and osteoporosis-related fractures in later life, around primary prevention. My research had little to do with cancer, and then I ended up collaborating with an oncology nurse scientist who was a cancer survivor and also a researcher. She was interested in using exercise for cancer symptom management, around acute symptoms when people were undergoing treatment, but at the time, research was identifying more of the long-term late effects of many cancer treatments, such as bone fractures.

In particular, we focused on breast and prostate cancer, and as men and women were being studied for longer periods of time, there was an increasing recognition that bone fractures were now among the many side effects that those cancer patients may experience. So this investigator and I ended up collaborating together because I brought my expertise in osteoporosis prevention into the cancer setting.

We were able, at first, to take the exercise programs and prescriptions that we knew were effective at preventing osteoporosis-related fractures in the general population, which is mainly in women, and see whether or not they would be as effective in preventing fractures associated with cancer treatment.

Interesting. Usually you hear a mentor bringing someone in, but not a colleague.

Dr. Winters-Stone: She became a mentor. I was completely new to cancer, so she taught me a lot.

Why is it important for prostate cancer patients or survivors to think about diet and exercise?

Dr. Winters-Stone: Diet and exercise are important for everybody, right? The new physical activity guidelines for all Americas were released today. They highlight the importance of physical activity for chronic disease prevention, including cancers but also as chronic disease management. One of the things that makes exercise particularly compelling for people with cancer is its ability to help manage adverse effects of not just the illness but also the treatments that accompany the illness. Over the last twenty years, we’ve learned the ways that staying active and moving can help prevent some of the acute symptoms, the GI distress, the fatigue, and the sleep problems that people get when they go through treatment.

Exercise is wonderful because it affects both physical and mental health. It can also help address some of the mental health changes that happen when someone gets a cancer diagnosis, by reducing anxiety and depression. It can be helpful in the short term, so that’s just helping you cope with treatment.

People also tend to decondition over a treatment period, so even if they’re not regularly exercising, they become even more inactive and sedentary. That impacts their day-to-day functioning. When someone is trying to recover from illness, now they’re more detrained from their day-to day-life, and it can be hard to do things like go back to being independent, taking care of yourself, going back to work, and taking care of children. Regular activity can help buffer the deconditioning that happens with treatment.

There’s more and more exciting evidence that suggests that exercise may even play a role in changing the course of the disease. There may be a good reason to view regular physical activity in terms of adding another component to a person’s long-term care. This is something that patients can do for themselves in terms of their prognosis. They can stay active and manage their weight.

Multiple reasons.

Dr. Winters-Stone: There are many reasons. Everybody should do it. It’s particularly important for people who are going through a chronic illness. In the case of cancer, people are usually older and experiencing some declines due to aging, so there’s yet another reason to exercise.

Can you tell us about the trial that you’re running in partnership with Movember?

Dr. Winters-Stone: This is a project that came about as part of an initiative from Movember that was aimed to develop novel and scalable approaches to addressing the problems that men face the most in survivorship.

One of those identified problems was around maintaining a healthful lifestyle. We already know, from well-controlled trials, that a healthy diet, managing weight, and getting enough exercise has benefits for men with prostate cancer, but we’ve not been effective at translating that information into action.

The number of men who still report unhealthy diets and low levels of physical activity remains high even though this information is available. There’s an implementation problem or a dissemination problem. We’re either not getting the information out there, or men are getting the information, but they don’t know how to act on it.

Part of this initiative for Movember seeks to ensure that interventions are scalable to as many men as possible so that access isn’t as much of an issue. Movember required that any interventions or programs be deliverable online or through technology.

In addition to our exercise expertise, we’ve teamed up with my colleagues at University of California, San Francisco (UCSF), who are experts in diet and prostate cancer progression, to develop a web-based diet and exercise intervention program. There are a lot more eHealth and mHealth types of interventions that give everyone a Fitbit and expect people to completely overhaul their lifestyle. But we still don’t know what are the magic ingredients that will translate information into action and change.

Besides developing a way to deliver that information online so it can get to any man anywhere, as part of the study design, we wanted to know how much and what kind of information and support men need for this program to be effective.

There are levels of intervention components that are part of the study design. They go from a low dose and low touch, which provides readable information on the internet, to increasing levels of interactivity.

The next level is to customize a diet and exercise plan for each man. We’re not just going to tell you to go get active; we’re going to tell you what to do with actionable information that’s going to be based on what you tell us about yourself. In effect, we digitize an exercise and diet planner for you.

In case that may not be enough, the next level adds low-cost tech-based motivational tools, like text messaging and a Fitbit, which don’t necessarily require a live professional, but which may add the motivation that someone needs.

Some may need some human contact to put this all in context, so the fourth level includes all of what I’ve said before plus access to a health coach. They get a phone call, a consult, and ongoing advice. We’re trying to understand how effective these different approaches are at improving men’s physical activity levels and dietary habits, with an eye for scalability. You want the most scalable, low-cost yet effective combination. Once Movember gets the results of all of these different interventions that are applied for different outcomes, they will have a web-based suite of support tools and services for men with prostate cancer.

Are you enrolling already?

Dr. Winters-Stone: This trial aimed to enroll 200 participants, and we have enrolled 206. We’re currently following all of these men. They get exposure to the website, whatever level of support they’ve been assigned to, for three months, and we assess them before they get into the website, after three months, and then again three months later.

At that point, will you be reporting out?

Dr. Winters-Stone: Yes. We should have the last man exited with his six-month follow-up in March of 2019.

Right now we can’t yet report on any study results, but we should have an article on the study published in late 2019. But already we’ve heard a few men say, “this has been so helpful,” or “I’ve lost three pounds already.” It’s nice to see at least some individual success stories.

Are there other similar trials that you’ll be running?

Dr. Winters-Stone: This is the only trial that I’m involved with that is completely online, which is more of a distance-based approach than what we usually do. We run a lot of supervised exercise trials, where men come to a facility to exercise, but we also know that not all men may be able to participate in supervised group exercise programs so finding ways to get information out to men regardless of their access to professionals or facilities is important.

Right. Are all of the participants close by, or because it’s web-based, does it matter where they’re located?

Dr. Winters-Stone: They’re all over the country. We have three recruitment sites.

At Oregon Health & Science University (OHSU), we’ve used a hospital registry, so because we’re a tertiary care center, we get guys from all over the state and some neighboring states. We’re trying to capture some of the men who live in more rural locations because that’s typical of our Oregon population.

UCSF recruited through a large epidemiologic study that they have been running, so we have men through who live all across the country. Because their outreach is across the United States, hopefully we’ll get better socioeconomic and racial representation.

And then UC Denver is the other participating site, so we’ve got a lot of men around Colorado. They’re trying to enroll more Latino men because those individuals are in their demographic and we need to ensure that our program can work for men with prostate cancer regardless of race/ethnicity or geography.

Any comments for men about the trial that you’re running or about the idea of this remote monitoring of patients in terms of exercise and diet?

Dr. Winters-Stone: The charge is on the medical and fitness communities to make sure that when men get diagnosed with prostate cancer, they get a recommendation to aim for a healthy lifestyle. There’s probably not an audience member of yours who doesn’t think he should exercise, but he may not know what to do and have trouble getting started.

Well, there’s thinking you should do it and then actually doing it.

Dr. Winters-Stone: Yes, and I’ve heard from so many men that motivation is the barrier. They are knowledgeable, and they know exercise is something that they should do, but they struggle to find the mental and physical motivation to do it. That could be because a lot of the men who I talk to have advanced cancer, and their treatments are just very fatiguing.

So my advice is—and this is out in the new physical activity recommendations—that something is better than nothing. To start, sit less and move more. That is the first step in behavior change.

Even though we have targets and recommendations, the first step is small, especially if that’s where someone is, simply dealing with getting off the couch. Interjecting short periods of standing or some movement for short periods of time would be a good first goal.

The next thing I would say is figure out what motivates you, and enlist that tool. It may be a buddy. It may be your wife or partner. It may be being accountable to somebody. It may be writing down your goals or writing down what you eat. That tends to be very effective.

I’ve known a lot of people who have signed up for My Fitness Pal and lose weight because they had to write things down. Apple Watches and Fitbits can be good in the short term to get someone moving more. Trying to figure out the one thing that might help get you motivated and then taking some action on that.

That’s actually great advice because often we don’t know what motivates us and what doesn’t. You can choose to include that in your life or not, right?

Dr. Winters-Stone: Yes, you can avoid it. It’s like it doesn’t happen, but once you start writing down what you eat, all of a sudden, you have to face the fact that you snack a lot.


Dr. Winters-Stone: Another thing that we have found can be helpful is to try not to go it alone. Loved ones are often asking what they can do to help someone diagnosed with cancer. Maybe they can go for a walk with you.

It’s a positive thing they can do.

Dr. Winters-Stone: It’s good for everybody, and it gives people the time and space to breathe, think about something else, and have good conversation. So maybe that’s the message to give caregivers, friends and family. Instead of asking what you can do, ask to go for a walk.

Then you get the exercise and the socialization too.

Dr. Winters-Stone: Yes. There’s a video a good friend of mine just showed me called Phil’s Camino. It’s about a man with cancer who used walking as his therapy and as his way to come to terms with his cancer. I highly recommend it.

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Exercise Recommendations For Prostate Cancer Patients

Robert Newton Headshot 2018Professor Rob Newton is the Associate Dean of Medical and Exercise Sciences and the Co-Director of the Exercise Medicine Research Institute, School of Medical and Health Sciences at Edith Cowan University in Perth, Australia.

Dr. Newton offers exercise recommendations for men with prostate cancer.

Join us to read the rest of this month’s conversations about diet, lifestyle, and prostate cancer.

Have you had any patients whose cases have changed the way you view your role as a clinician or how you approach talking about exercise with prostate cancer patients?

Dr. Robert Newton: Definitely. One fellow in particular had never exercised since he was a young boy, was quite overweight, and had very low fitness. When diagnosed with prostate cancer his urologist told him, “Don’t worry about having cancer, because you are going to die of a heart attack long before your prostate causes you problems.” I worked with the dietician in our team to develop a very low caloric diet and a relatively high volume exercise program for him. He lost 21 kg of fat in eight weeks. The transformation in his health and fitness was phenomenal. His urologist could not believe the change and commented that the prostatectomy was much easier and more successful than he expected.

This, and many other experiences supporting men with prostate cancer, has convinced me of the massive difference that an appropriate exercise prescription can have for these patients. We can definitely improve their outcomes.

What do we know about the impact of exercise on prostate cancer progression? What do we know about the impact exercise can have on how men with prostate cancer withstand specific treatments—surgery, radiation, hormonal therapy, etc?

Dr. Newton: As yet, there is not definitive clinical trial evidence of the impact of exercise on prostate cancer progression. We are currently running a world first trial in men with localized disease specifically to address this question.

However, preclinical experiments involving prostate cancer cell lines have demonstrated up to 30% suppression of growth. There are now several animal studies demonstrating similar cancer suppression. What is more clearly supported by multiple human trials is that specific exercise reduces complications and side-effects of surgery and various treatments and may also actually enhance the effectiveness of radiation therapy and chemotherapy.

For example, work from our team has shown that exercise leading up to prostatectomy surgery results in less incontinence and much better fitness and health.

There is less evidence with regard to exercise improving tolerance of radiation therapy, however, there are strong theoretical mechanisms by which exercise performed immediately prior to a radiation therapy session may actually enhance the effectiveness of the radiation, resulting in greater cancer cell death. This occurs by increasing blood flow through the tumor, facilitating the oxygen enhancement effect of the radiation.

By far, the strongest evidence as to the benefit of exercise is for men on ADT for their prostate cancer. There are now many large randomized controlled trials clearly proving that exercise reduces the toxicities of ADT. In particular, exercise slows or prevents muscle and bone loss and limits the onset of metabolic diseases such as diabetes and cardiovascular disease, which are common side effects of ADT.

Do you suggest men with prostate cancer see a trainer to help them set up an exercise program?

Dr. Newton: Ideally, men with prostate cancer would seek the assistance of a qualified exercise professional, such as a clinical exercise physiologist. These allied health professionals are university trained and have specific knowledge and skills in exercise assessment and prescription for people with chronic diseases like cancer. I do recommend that patients go through this process to ensure that they have an optimal exercise prescription that addresses the morbidities and risk of mortality in a prioritized strategy. This means designing an exercise prescription tailored for the individual and the problems that they are experiencing.

What type of exercise program do you recommend for men on Active Surveillance?

Dr. Newton: Unless there are other comorbidities and provided that the men are relatively healthy, then my recommendation would be for them to try and meet the American College of Sports Medicine guidelines for healthy older adults: 75 to 150 minutes per week of moderate to vigorous aerobic exercise and two or more resistance training sessions exercising all of the major muscle groups. This does not really need the input of a qualified exercise professional, but could be pursued under self-management or in a local fitness center.

What type of exercise program do you recommend for men on ADT?

Dr. Newton: Men on ADT may experience considerable toxicities, which impact their physical structure and function as well as greatly increase the risk of chronic diseases such as diabetes and cardiovascular disease. These men really need a tailored exercise prescription that targets the health issues causing them the greatest morbidity. For example, loss of muscle mass is a major problem for men on ADT. It requires a highly specific program of resistance training involving higher volume (or dosage) combined with a protein intake of at least 1.6 g per kilogram body weight per day. Maintaining muscle mass in these men is very important because it is a strong predictor of cancer recurrence and mortality.

Another ADT side-effect is bone loss which places the patient at considerable risk of skeletal fracture. In this instance, a highly specific exercise prescription incorporating resistance training and special impact loading consisting of skipping, jumping, and hopping is recommended as recent research has demonstrated that other forms of exercise have absolutely no benefit in terms of ameliorating the bone loss. However, such programs are highly advanced and must be closely monitored requiring supervision by a qualified exercise professional.

What type of exercise program do you recommend for men after surgery?

Dr. Newton: Post surgery, the patient will be considerably deconditioned in terms of muscle and strength loss and reduced cardiorespiratory fitness. They may also have some surgical complications, the most common of which is urinary incontinence. Exercise should be commenced as soon as possible after surgery to reduce further decline, albeit at a relatively modest dosage of aerobic and resistance training. As the patient recovers from surgery, exercise volume and intensity should be increased as tolerated. In particular, if urinary incontinence is experienced then targeted exercise prescription including pelvic floor exercises as well as exercises for the large muscle groups around the pelvis should be included. Just because a man has urinary incontinence, he should not avoid exercise and must perform resistance training even if he experiences some leakage. Resistance training has been demonstrated to enhance recovery of continence.

What type of exercise program do you recommend for men on radiation therapy?

Dr. Newton: Patients should continue to exercise throughout the course of radiation therapy even when experiencing treatment-related fatigue. If fatigue is a major problem, than the volume of exercise should be reduced and the intensity increased with a greater emphasis placed on resistance training and a reduced volume in particular of aerobic exercise of low intensity. In our clinic, we provide a specific exercise program of 10 to 20 minutes incorporating aerobic exercise and resistance training of the muscles of the pelvic area (e.g. squat, lunge, step-up) advising the patient to complete this program immediately before they enter the room to receive the radiation therapy. As noted above, there is emerging evidence that this strategy may greatly increase the effectiveness of radiation therapy to destroy cancer cells.

What type of exercise program do you recommend for men on chemotherapy?

Dr. Newton: Patients should exercise throughout the course of chemotherapy, however this should be auto-regulated. What this means is that the intensity and volume of exercise in a given session is adjusted up or down depending on how the patient feels on that particular day. The exercise program should be designed specifically to address key health issues facing the patient in a priority order.

Similar to radiation therapy, there is good evidence that performing a short exercise bout immediately before receiving chemotherapy may enhance its effectiveness by increasing blood flow through the tumor, thereby delivering more of the drug. It appears that there is a strong relationship between chemotherapy tolerance/side effects and the muscle mass of the patient. Patients with low muscle mass experience more chemotherapy side effects and are more likely to require a dose reduction. Receiving less than the plan dose of chemotherapy reduces overall effectiveness.

What type of exercise program do you recommend for men on drugs like Xtandi (enzalutamide), Zytiga (abiraterone), Erleada (apalutamide) or even Xofigo (radium-223)?

Dr. Newton: We are currently leading an international trial of highly targeted exercise in men with advanced prostate cancer, many of which are receiving the latest super anti-androgens such as Zytiga (abiraterone) and Xtandi (enzalutamide). The trial is in progress, but our initial results are that these men are tolerating the exercise program and reporting excellent improvements in quality of life and physical function. Until this and other trials in this patient population are completed, it is not known the degree of benefit of exercise in men on these drugs. Regardless, exercise confers considerable benefit to all patients in terms of both mental and physical health.

Do you have any other final thoughts about exercise for men with prostate cancer?

Dr. Newton: As a final note, it is absolutely critical that men with prostate cancer do some exercise on most if not every day of the week regardless of the stage of their disease and even when undergoing difficult treatments. The outdated recommendation of rest is now completely rejected. However, the exercise prescription must be tailored to the specific health issues of the individual patient, prioritizing those morbidities causing the greatest problems and risk of mortality.

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