Prostate cancer screening and improved treatment options have helped to ensure that there are more than 3.1 million prostate cancer survivors in the United States. After their prostate cancer diagnosis or finishing treatment, many patients wonder about potential lifestyle changes they may make to help them stay healthy as prostate cancer survivors.
It is quite well known that heart disease is the number one cause of death among men in the United States. What is less well known is that heart disease is also the number one cause of death among men with prostate cancer.
Previous research suggests that the emotional impact of a cancer diagnosis can be a “teachable moment” — and much can be gained by using a prostate cancer diagnosis to make lasting healthy lifestyle changes. Recent research also suggests that healthy lifestyle changes can decrease the risk of prostate cancer returning. This article will focus on suggested lifestyle changes or modifications that men should consider once they are diagnosed with prostate cancer.
Diet and Nutrition
Eating healthy, nutritious food helps with a man’s overall health, energy, and mood. While going through prostate cancer treatment, the side effects of treatment may decrease your appetite. This means it is important to get the most nutrition from the foods you eat in order to prevent unwanted weight loss and maintain proper health. Here are several diet tips for men with prostate cancer:
- Eat fruits and vegetables. These contain cancer-fighting and inflammation-reducing substances such as vitamins, polyphenols, minerals, and antioxidants.
- Limit consumption of animal proteins. These include red meat, dairy products, and animal fat.
- Eat more plant proteins. These include beans, flax, and nuts.
- Drink green tea. This contains inflammation-fighting antioxidants such as polyphenols and flavonoids, which are compounds that can help to boost heart health.
- Eat whole greens over processed foods. These include brown rice, oatmeal, corn, whole wheat bread, quinoa, etc. These foods are a source of fiber and magnesium, as well as protein.
- Limit sugary drinks such as pop/soda.
It’s important to understand that these dietary recommendations have not been shown specifically to have benefits in terms of cancer outcomes. But they are very likely to improve your overall health.
Exercise Regularly
Exercise is vital to a healthy lifestyle, particularly after a prostate cancer diagnosis and treatment. Among many benefits, exercise can boost a man’s fitness, energy, immune system, spirits, and outlook on life. Physical activity does not have to include playing a sport or going to the gym — it could include walking, swimming, dancing, or gardening. Regular exercise can help prevent many health issues such as heart disease and type-2 diabetes, in part because it helps to maintain a healthy weight.
The amount of exercise you feel able to do may depend on several things such as the stage of your cancer, your treatments, and your starting strength and fitness level. It is usually safe for men with prostate cancer and those having treatment to be physically active. However, it is still a good idea to check with your family doctor and/or cancer treatment team.
Generally, aiming to exercise 2-3 times per week to start out is reasonable. This should include 10-15 minutes per session, working up to 30 minutes per session, 3-5 days per week. Specifically, for men on hormone therapy or men whose disease has spread to the bone, it is important to avoid activities where you may fall. This is because you are more likely to break a bone if you fall.
Stop Smoking
Smoking raises the risk of other health problems, including the risk of other cancers (i.e., throat, lung, bladder, etc.). It also slows healing and causes harm to the body (which may increase the risk of heart disease, stroke, etc). Importantly, when you stop smoking, the benefit to the body happens nearly right away, including boosting the body’s immune system to help fight cancer. A study from 2011 showed that men who smoke at the time of a prostate cancer diagnosis have an increased risk of death compared to men who did not smoke. Additionally, men who quit smoking for at least 10 years had a similarly reduced risk for prostate cancer-related death compared to men who never smoked.
For men considering surgery for prostate cancer, smoking increases the risks associated with anesthesia and makes recovery more difficult, including increasing your risk of infections.
Decrease Alcohol Intake
The evidence regarding the impact of alcohol on prostate cancer is unclear. However, we do know that too much alcohol can lead to other health concerns including weight gain, heart disease, liver disease, and an increase in the risk of some cancers. Although recommendations may vary (and depend on your general health and other medical problems), it is recommended that men should not regularly drink more than 14 units of alcohol per week. This amount of alcohol is equal to 6 pints of average strength beer or 10 small glasses of wine. It’s also recommended to have some alcohol-free days.
The prostate cancer survivorship journey starts on the day of your diagnosis. Although the time period around your prostate cancer diagnosis, treatment, and follow-up is extremely important from a cancer standpoint, it is equally important to maintain a balanced, healthy lifestyle. This will decrease your risk of other health problems, decrease the risk of prostate cancer recurrence (cancer coming back), and improve your mental health and well-being.
Although prostate cancer is the second leading cause of cancer death (and 11% of all male cancer deaths) in the United States, the most common cause of death among men is still cardiovascular, or heart, disease. This means that even if you are diagnosed with prostate cancer, your physical health is still of utmost importance. Physical activity decreases your cardiovascular risk factors and improves your overall physical health. In addition to managing your weight, maintaining bone and muscle strength, and helping with potential side effects of prostate cancer treatment, it also improves your emotional health.
Several studies have suggested that men with prostate cancer who lead an active lifestyle have improved survival rates compared to sedentary patients. Additionally, men who walk 1-3 hours per week have been shown to cut their risk of aggressive prostate cancer almost in half. And men who vigorously exercise more than 3 hours per week have a 61% reduced risk of prostate cancer death. Physical activity comes in many forms, including traditional ways such as weight lifting, walking, jogging, cycling, and swimming. But you can also enjoy other less traditional ways such as walking 18 holes of golf, mowing the grass, ballroom dancing, and yoga, to name a few.
Physical Health and Treatment for Localized Prostate Cancer
Physical health is important when preparing for a radical prostatectomy (surgery to remove the prostate) as a treatment of localized prostate cancer. Getting aerobic exercise in the weeks leading up to a radical prostatectomy can improve pulmonary (lung) function. This helps with reducing the risk of complications with general anesthesia (i.e., “going to sleep”) during the operation. At the same time, men that quit smoking even weeks before surgery can decrease their risks of cardiopulmonary complications from anesthesia after a radical prostatectomy.
Strengthening the pelvic floor muscles can decrease the incidence and severity of side effects of treatment for localized prostate cancer — specifically urinary incontinence among men undergoing surgery. These muscles run from your pubic bone in the front to your tailbone in the back and support the bladder, prostate, and rectum. Strengthening the pelvic floor muscles before and after surgery can be accomplished by contracting the muscles as if you were holding in your urine stream (these are called Kegel exercises). Prior to surgery, contract these muscles for 10 seconds, followed by a 10-second rest, for a total of five reps three times a day. Following surgery, and after the Foley catheter is removed, you should consult with your surgeon as to when to begin Kegel exercises. To start, less vigorous contractions (contract for 3 seconds followed by a 15-second rest, for a total of five reps three times a day) is likely enough, followed by more strenuous contractions with continued recovery. Additionally, strengthening of the pelvic floor muscles through Kegel exercises can also be done by men undergoing radiation therapy.
Following surgery, it is normal to have fatigue and decreased appetite. Indeed, it may take weeks before you feel back to how you felt before surgery, which is not unexpected. During this time period, it is important to remain as active as possible (most importantly by walking). However, avoid lifting heavy objects more than 10 pounds (or the about the weight of a gallon of milk) for 6 weeks after surgery. This allows the incisions beneath your skin to adequately heal and helps you to avoid a hernia (intestines poking through the abdominal wall).
While waiting for your appetite to return, eating frequent (about 6) small meals of several bites is usually better tolerated compared to three “regular” meals. However, it is important to remember that even when you do not have an appetite, drink enough fluids to remain hydrated (about 2 liters of urine per day). This helps to avoid dehydration, which may cause you to need to be readmitted to the hospital.
Physical Health and Treatment for Advanced Prostate Cancer
The backbone of treatment for advanced prostate cancer therapy is androgen deprivation therapy (ADT). This treatment lowers the testosterone level to very low levels, thus cutting off the “fuel” for prostate cancer cells. However, this very low level of testosterone often also affects many aspects of a man’s quality of life. It can cause fatigue, loss of muscle mass, bone breakdown, and loss of sexual drive (low libido). Although no one wants to exercise when they are tired, maintaining an exercise routine while on hormone therapy is extremely important. Exercise helps to combat many if not all of the side effects of treatment (muscle wasting, bone breakdown, depression, etc.). If it is financially possible for you, joining a gym or hiring a personal trainer may help you stay on track with a workout plan, particularly in the early weeks and months of hormone therapy.
A prostate cancer diagnosis is likely to have a large impact on a man’s life. However, the importance of physical health during the initial diagnosis, preparing for and going through treatment, and combating the side effects of treatment cannot be overstated. A weekly exercise routine is important during this period of your prostate cancer journey. At the same time, it helps to decrease your risk factors for heart disease, which is the most common cause of death among American men.
For patients with high risk localized prostate cancer and advanced prostate cancer, it is important to think about bone health, especially if you will be receiving androgen deprivation therapy (ADT) for a set period of time or as part of your long-term prostate cancer treatment. Many men may take bone health and bone strength for granted.
Yes, prostate cancer can spread to the bones — in fact, it is one of the common locations for prostate cancer to spread. When it does so, it can weaken the bone and increase the risk of breaks, or fractures. Additionally, ADT, which is the mainstay of systemic therapy for patients with locally advanced and metastatic prostate cancer, will also weaken your bones. Other advanced prostate cancer treatments including steroids, novel hormonal therapies, and chemotherapy may also cause bone health problems.
Bone Health Assessments for Patients
There are several assessments that patients should receive before starting ADT and while on ADT. First, it is important to know your fracture risk. A fracture risk assessment can be easily done using the Fracture Risk Assessment Tool (FRAX) at the start of ADT.[1] It is important when you are calculating this score online to select “secondary osteoporosis” as a risk factor, which is a result of receiving ADT for your prostate cancer.
The FRAX score estimates your 10-year risk of hip fracture and major osteoporotic fractures (such as spine, shoulder, or wrist fractures). Patients starting androgen deprivation therapy (ADT), especially if it is expected to be long-term, should generally have a baseline dual-energy x-ray absorptiometry (DEXA) scan at the start of treatment or within a few months of starting.
Ongoing DEXA scans are recommended during ADT based on fracture risk. A DEXA scan measures bone mineral density, which tells your treatment team how strong or dense your bones are. The following table adapted from the NCCN prostate cancer guidelines summarizes the timing of DEXA scans throughout your prostate cancer journey while receiving ADT:
| Clinical Scenario | Recommendation |
|---|---|
| Baseline when starting ADT | A baseline DEXA scan is recommended for most patients starting ADT. In select patients with a low estimated fracture risk based on the FRAX risk assessment tool, a DEXA study does not have to be done |
| During ADT | Repeat DEXA scanning every 1–2 years, with the frequency guided by fracture risk as assessed using the FRAX tool |
| Patients receiving antiresorptive therapy (see below) | Repeat DEXA scanning at 12 months after starting this treatment to assess treatment response and ongoing fracture risk |
Making Your Bones Stronger
There are ways that you can make your bones stronger and protect from fractures while you are receiving ADT:
- All men who are taking ADT should take supplemental calcium and vitamin D. These are critical building blocks for the body to build and maintain bones. You can get these without a prescription from your local pharmacy, and you should take them daily. Patients should generally aim for 800-2,000 international units of vitamin D daily (to maintain a level of 30–50 ng/mL) and 1,000-1,200 mg of calcium per day from diet and/or supplements.
- Weight-bearing exercise is very important. When men lose muscle, the risk of falls increases and this increases the risk of bone fractures. This means an activity that improves strength and puts a (manageable) stress on the bones helps to keep them strong. Walking is a great start. Talk with your doctor first to see if more intense exercise may be helpful too.
- Smoking and excessive alcohol use can weaken bones, so avoiding smoking and large amounts of alcohol are also important.
- Use of antiresorptive (also called “bone-protecting”) medications may be recommended. These medications improve bone density and reduce the risk of fractures and other bone complications. Options include alendronate (Fosamax), denosumab (Prolia for treatment-related bone loss; Xgeva for advanced cancer involving the bones), and zoledronic acid (Reclast for bone loss; Zometa for advanced cancer involving the bones). These medications are used at different doses and schedules depending on your specific situation, so it is important to discuss with your doctor whether treatment is appropriate and which option is best for you.
The following table adapted from the NCCN prostate cancer guidelines summarizes how to optimize your bone health during your prostate cancer journey:
| Patient Population | Category | Intervention |
|---|---|---|
| All patients receiving ADT | Lifestyle modifications | • Weight-bearing exercise (≥30 minutes daily), balance training, and safe movement strategies to reduce fall risk • Limit alcohol consumption • Smoking cessation |
| Calcium and vitamin D supplementation | • Calcium intake of 1,000–1,200 mg daily, preferably from dietary sources with supplementation if needed • Maintain serum vitamin D3 levels of 30–50 ng/mL with supplementation as needed |
|
| Patients receiving ADT with treatment-related bone loss | Antiresorptive agents | • Alendronate 70 mg by mouth weekly, or • Denosumab 60 mg under the skin injection every 6 months, or • Zoledronic acid 5 mg via a vein every year |
| Patients with very advanced prostate cancer (ie. bone mCRPC) for prevention of symptomatic fractures | Antiresorptive agents | • Denosumab 120 mg under the skin injection every 4 weeks, or • Zoledronic acid 4 mg via a vein every 12 weeks |
Patients starting these medications may need a dental evaluation beforehand, as some treatments can affect jaw health.
Unfortunately, bone health is often inadvertently overlooked during treatment of advanced and metastatic prostate cancer, so it is important to have these conversations with your treatment team.
Key Takeaways
- Bone loss is common with ADT and increases fracture risk
- Regular monitoring with DEXA scans is important
- Calcium, vitamin D, and exercise help maintain bone strength
- Bone-protecting medications may be appropriate for some patients
References:
[1] University of Sheffield. FRAX® Fracture Risk Assessment Tool. https://www.fraxplus.org/