Previous research has shown exercise to be an effective method to mitigate many adverse treatment-related effects of androgen suppression therapy (AST) but the potential impact of exercise on sexual activity remains unknown. The purpose of this investigation was to report the effect of a 12-week exercise program on sexual activity in prostate cancer patients undergoing AST.
Fifty-seven prostate cancer patients undergoing AST were randomly assigned to an exercise program (resistance and aerobic modes; n=29) or usual care control (n=28). Sexual activity was assessed by the European Organization for Research and Treatment of Cancer prostate cancer-specific quality of life questionnaire (QLQ-PR25).
QLQ-PR25 data were log transformed and analysis of covariance was used to compare sexual activity between groups following the intervention adjusted for baseline activity. No differences in sexual activity were observed between the exercise and control groups before the intervention. There was a significant (P=0.045) adjusted group difference in sexual activity following the 12-week intervention. Patients undergoing usual care decreased sexual activity while patients in the exercise program maintained their level of sexual activity. At baseline, 20.6 and 22.2% of participants in the exercise and control groups reported a major interest in sex (that is, high libido). Following the intervention, the exercise group had a significantly higher percentage of participants reporting a major interest in sex (exercise=17.2% vs control=0%; P=0.024).
Participation in a short-term exercise program resulted in the maintenance of sexual activity in prostate cancer patients undergoing AST.
Androgen suppression therapy (AST) is a mainstay therapy for the management of prostate cancer. However, an adverse effect of AST that causes patients great concern is sexual dysfunction.1 Sexual dysfunction (that is, decreased sexual desire and/or sexual arousal or premature, delayed or absent orgasm) is among the most frequently identified issue of importance to prostate cancer patients2, 3 and men with prostate cancer exhibit a higher prevalence of sexual dysfunction than men without prostate cancer.4 In the Health Professionals Follow-Up Study, approximately 65–90% of men with prostate cancer reported experiencing erectile dysfunction.4 The contrast in the prevalence of erectile dysfunction between men with and without prostate cancer was especially apparent for men <80 years of age and highlights the impact of cancer treatments on sexual health.4
Although considerable research has examined the impact of surgery and radiotherapy on sexual activity in prostate cancer patients,5, 6, 7, 8 less research exists examining the effect of AST on sexual activity. We previously reported a significant decrease in sexual activity following 9 months of AST, with only approximately 50% of this reduction recovered during a subsequent 9-month ‘testosterone recovery’ period.1, 9 The percentage of men who were sexually active at baseline decreased from 46 to 9% following 9 months of AST and those who classified their libido as moderate to high decreased from 28 to 10%.9 The reduction in testosterone and subsequent impact on libido, erectile and ejaculation function is believed to be the primary mechanism associated with the observed decrease in sexual activity.10, 11 However, the indirect effect of altered hormone levels on other factors such as fatigue, depression, anxiety as well as alterations to body composition, body image and quality of life may also contribute to reducing sexual activity in these patients.11, 12
Previous research has demonstrated exercise to be an effective method to mitigate many adverse treatment-related side effects.13, 14, 15, 16, 17, 18 The positive impact of exercise extends across factors believed to be associated with sexual dysfunction in men with prostate cancer, including significant improvements in body composition, fatigue, depression, anxiety and quality of life.13, 14, 15, 17, 18 Although no previous research has directly examined the impact of exercise on sexual activity in prostate cancer patients, physical activity has been associated with lower levels of sexual dysfunction in men without prostate cancer.4, 19, 20, 21, 22, 23 Therefore, exercise may represent an effective therapy to minimize the impact of prostate cancer treatment on sexual activity.
The effect of exercise on sexual activity in men with prostate cancer remains unknown. Although, to the authors’ knowledge, no previous research has examined the role of exercise on sexual health in men receiving AST for the management of prostate cancer, associations have been examined in prostate cancer patients undergoing radiotherapy.24 Dahn et al.24 investigated the relationships among physical activity levels, sexual ‘functioning’ and radiotherapy treatment type in patients with localized disease and reported that the level of physical activity was related to sexual functioning independent of treatment type. Specifically, greater levels of physical activity were significantly associated with better sexual functioning.24 No causal inferences can be made from this cross-sectional study but, coupled with the established benefits of exercise on factors believed to affect sexual activity in patients receiving AST13, 14, 15, 17, 18 and the beneficial effect of exercise on sexual activity in men without prostate cancer,4, 25 these results suggest that exercise may have a role in enhancing sexual activity in men undergoing treatment for prostate cancer. Therefore, the purpose of this investigation was to report the effect of a 12-week exercise program on sexual activity in prostate cancer patients undergoing AST.
Materials and methods
Fifty-seven men aged 55–84 years with prostate cancer participated in this study. Participants had a histological diagnosis of prostate cancer, received AST for at least 2 months, had no PSA evidence of disease activity, were anticipated to remain hypogonadal for the following 6 months and obtained medical clearance from their physician. Patients were excluded if they had established bone metastatic disease, musculoskeletal, cardiovascular and/or neurological disorders that could inhibit them from exercising, were unable to walk 400 m or were involved in regular exercise throughout the previous 3 months (that is, at least 150-min moderate intensity aerobic exercise and two resistance exercises sessions per week). This protocol was approved by the University Human Research Ethics Committee and all participants provided written informed consent.
This study involved a two-armed prospective randomized controlled trial. Treating oncologists identified and referred potential participants (Figure 1). Following baseline testing, participants were randomized into the two arms: exercise or control (usual care) in an allocation ratio of 1:1 using a random assignment computer program. The project coordinator and exercise physiologists involved in assigning participants to groups were blinded to the allocation sequence. Body composition, physical function and quality of life results from this trial have been reported previously.15
The exercise intervention involved twice weekly sessions of moderate to high intensity resistance and aerobic exercise for 12 weeks. Sessions were conducted in small groups of one to five participants supervised by an exercise physiologist. The resistance exercise component of the program involved eight standard exercises targeting the major muscle groups of the upper and lower body (chest press, seated row, shoulder press, triceps extension, leg press, leg extension, leg curl and abdominal crunches). The resistance exercise progressed from 12 repetition maximum to 6 repetition maximum with two to four sets per exercise.14, 15 To ensure the progressive nature of the program, participants were encouraged to work past the specific repetition maximums prescribed and if they exceeded the target then additional resistance was added for the next set and/or session. The aerobic exercise component of the program involved 15–20 min of cardiovascular exercise including walking, jogging and/or cycling. Intensity was set to 65–80% of maximum heart rate and a rating of perceived exertion of between 11 and 13 (Borg 6–20 point scale).14, 15, 26 Participants were encouraged to supplement the clinic sessions with additional home-based aerobic exercise sessions involving walking and/or cycling, with the aim of accumulating a total of 150 min of aerobic exercise each week.14 Participants randomized to the control group were offered the opportunity to participate in the exercise program at the completion of the assessment period.
Outcome measures were assessed at baseline and 12 weeks (that is, post-intervention). The European Organization for Research and Treatment of Cancer (EORTC) prostate cancer-specific quality of life questionnaire module (QLQ-PR25) was used to assess sexual activity and sexual function.27 The sexual activity subscale of the module comprises two items assessing the level of interest in sex (that is, libido) and the level of activity. Specifically, participants were asked to rate what extent they were interested in sex and what extent they were sexually active (with or without intercourse) during the last month. The sexual function subscale of the module includes four items, which are completed only if the participant has been sexually active over the last month and assesses issues relating to comfort and enjoyment of sex as well as erection and ejaculation problems. A linear transformation was used to standardize item responses so that the score for each subscale ranged from 0 to 100, with a higher score representing a higher level of functioning. The EORTC QLQ-PR25 has demonstrated sound psychometric properties for sexual activity (Cronbach’s alpha=0.85)1, 27 and sexual function (Cronbach’s alpha=0.70)27 subscales. The Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) was used to assess general quality of life status.28 Prostate cancer-specific blood markers, testosterone and PSA, were assessed from fasting blood samples measured commercially by an accredited Australian National Association of Testing Authorities laboratory.
Data were analyzed using SPSS Statistics 19 (SPSS, Chicago, IL). Log transformations were used for the domains of the QLQ-PR25. Analyses including standard descriptive statistics, independent t-tests, χ2, analysis of covariance adjusted for baseline values and Spearman rank correlation tests were applied. An intention-to-treat approach was utilized for all analyses. All tests were two-tailed with statistical significance set at an alpha level of 0.05. Results are presented as mean±s.d. or number of participants (percentage of participants) for frequency data, unless stated otherwise.
The two randomized groups were well balanced with no significant differences in characteristics at baseline (Table 1). Furthermore, there were no significant differences between groups at baseline in body composition, cardio respiratory fitness, muscle strength, physical function or quality of life (results reported previously15). One participant in the exercise group withdrew from the study after 2 weeks because of not enjoying the program. One participant from the control group was lost to follow-up. Exercise program compliance was high, with all participants completing at least 18 out of a possible 24 sessions and 80% of participants completing 24 sessions.
The sexual activity subscale (that is, libido and activity) scores at baseline were similar in both groups (Table 2). The change in sexual activity across the 12-week period differed significantly between groups (P=0.045, Table 2). Following the intervention, participants in the exercise group maintained their level of sexual activity, whereas participants in the control group decreased their level of sexual activity. No group differences were observed in any other domain of the QLQ-PR25, testosterone or PSA (Table 2). The change in perceived general health, vitality and physical health composite domains of the SF-36 differed significantly between groups (P=0.022, 0.019 and 0.020, respectively), with beneficial effects in the exercise group (results reported previously15). The change in sexual activity at week 12 was significantly associated with the change in perceived general health (rho=0.335, P=0.011; n=56) as well as role-emotional (rho=0.295, P=0.030; n=56; Figure 2).
Frequency analyses indicated that both groups showed a similar degree of interest in sex (any level of interest P=0.774; major interest P=0.889) and level of activity (any level of activity P=0.854; major activity P=0.762) at baseline (Table 3, Figure 3). Following the intervention, the exercise group had a significantly higher percentage of participants reporting a major interest in sex (exercise=17.2% vs control=0%; P=0.024; Figure 3). Furthermore, there was a trend toward a higher percentage of participants in the exercise group reporting any level of interest in sex compared with control (exercise=58.6% vs control=37%; P=0.106; Figure 3).
No difference in the sexual function subscale existed between exercise and control groups at baseline (exercise=30.9±22.4 vs control=39.7±29.3). The change in sexual function did not differ between groups at 12-weeks (adjusted group difference in mean change=−0.4; P=0.918). The results of the sexual function subscale are based on a small sample and should therefore be interpreted with this in mind. At baseline, a total of 18 participants (32%) reported being sexually active (exercise n=9, control n=9; Table 3) and therefore should have completed questions associated with the sexual function subscale of the QLQ-PR25. However, only 11 participants (19%; exercise n=6, control n=5) completed the sexual function subscale questions. Four of these participants (exercise n=2; control n=2) and three other participants (exercise n=1; control n=2) completed these questions at 12 weeks (that is, 12% of participants).
This is the first randomized control trial investigating the potential impact of exercise on sexual activity in prostate cancer patients. This study examines a clinically meaningful outcome and addresses a clear limitation in the current literature as identified in the American College of Sports Medicine guidelines on exercise for cancer survivors.14 The primary finding of this analysis was that involvement in an exercise program incorporating regular resistance and aerobic exercise helps preserve sexual activity in prostate cancer patients receiving AST.
A recent Cochrane review identified various types of interventions proposed for sexual dysfunction following cancer treatments including psycho-educational, pharmacological, medical devices and complementary medicine.29 Results from the current trial support the concept that exercise has a protective effect on men’s sexual health4, 19, 20, 21, 22, 23 and indicates that exercise may be an effective therapy for reducing sexual dysfunction in prostate cancer patients. The protective effect of exercise was particularly apparent for the sexual activity subscale of the QLQ-PR25, which represents sexual desire (that is, libido) as well as the level of sexual activity. Participants who were involved in the exercise program maintained their sexual activity while those receiving usual care decreased sexual activity. This is an important finding as exercise is an intervention that is non-invasive, relatively inexpensive and highly accessible for prostate cancer patients. Thus, exercise represents an exciting therapy to address sexual health issues faced by patients following cancer treatments especially when coupled with the additional health and lifestyle benefits gained through regular exercise. It is unclear if the positive impact of exercise extends to factors associated with sexual functioning such as the comfort and enjoyment of sex or presence and severity of erection and ejaculation problems. Although no group differences were observed in the sexual function subscale of the QLQ-PR25 following the intervention, the response rate for this subscale was very low. This aspect certainly begs further investigation with larger participant numbers.
The mechanisms responsible for the protective effect of exercise on sexual activity in men receiving AST were not specifically examined in this investigation. However, there are a number of factors theorized to contribute to these observations. The beneficial impact of exercise on quality of life is believed to be a primary factor involved with the maintenance of sexual activity. It is well established that exercise significantly enhances quality of life in prostate cancer patients receiving AST13, 14, 15, 16 and that sexual health is impacted by quality of life.12 In fact, the change in sexual activity following the intervention was observed to be significantly related to the change in the general health and role-emotional domains of quality of life (Figure 2). Furthermore, exercise resulted in significant improvements in body composition, muscle strength and endurance, physical function and vitality as well as a significant reduction in fatigue.15 It may well be that these improvements contributed to the superior sexual activity scores observed in the exercise group by fostering improved feelings of masculinity. Testosterone levels remained unchanged throughout the intervention for both exercise and usual care groups, indicating that changes to sex hormones did not contribute to these findings.
There are several limitations associated with this investigation. The topic of sexual activity may involve a level of emotional discomfort especially for some elderly patients. Despite thorough instructions to respond to the questions as honestly as possible, some patients may not have responded honestly/at all simply because of feeling uncomfortable disclosing this information. Although a reliable self-report measure was utilized, participants’ perception and/or report of sexual activity may have differed from actual behavior. Although no significant differences in marital status were observed between groups, the status or quality of these intimate relationships was not assessed and may have a confounding effect on sexual activity. Other psychosocial factors such as stress, depression, anxiety, self-esteem and body image issues may also have a confounding effect on the results. However, participants were randomly allocated into the two groups and no significant differences were observed across a number of demographic and health factors associated with sexual activity at baseline.
Regular exercise helps maintain sexual activity during AST while usual care alone leads to reduced sexual activity in this population. Exercise should therefore be considered as an adjuvant therapy for prostate cancer patients on AST who are especially interested in optimizing sexual activity. Future research involving trials with larger sample sizes and longer interventions as well as research investigating the potential mechanisms underlying these findings is warranted based on the current observations.
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We thank the Cancer Council of Western Australia for their financial support in running the study. PC thanks the Cancer Council of Western Australia for their support of her position through the postdoctoral research fellowship. DAG is funded by a Movember New Directions Development Award obtained through Prostate Cancer Foundation of Australia’s Research Program. This research was supported by funding from the Cancer Council of Western Australia. Clinical trial registry: resistance and aerobic exercise for reducing treatment side effects in men receiving androgen deprivation therapy for prostate cancer; ACTRN12607000263493; http://www.anzctr.org.au/trialSearch.aspx.
The authors declare no conflict of interest.
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Cormie, P., Newton, R., Taaffe, D. et al. Exercise maintains sexual activity in men undergoing androgen suppression for prostate cancer: a randomized controlled trial. Prostate Cancer Prostatic Dis 16, 170–175 (2013). https://doi.org/10.1038/pcan.2012.52
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