Men Just Want to Have Fun in Prostate Cancer Trial

"I would rather die on the football field than in a hospice, no doubt about that." — Lasse, 80 years old

"When we're out there...you might hear it...we become kind of like boys again, you know? And you think you can conquer the world!" — Patrick, 73 years old

Men with prostate cancer just want to have fun — and play football/soccer instead of doing cancer-specific exercises, preferably while wearing a spiffy team uniform.

This and other unorthodox clinical pearls come from a first-of-its-kind clinical trial among 214 men with prostate cancer in Denmark. The men, with an average age of 68, were randomized to play football twice a week for 6 months or to usual care.

At 1-year of follow-up, the football group had significant improvements in mental health and body mass index and fewer hospital admissions compared with controls, report the investigators, led by Eik Dybboe Bjerre, PhD, postdoctoral scientist, University Hospital of Copenhagen, Denmark.

Also, there was no increased risk of fracture among the footballers, which was important because 19% of participants had skeletal metastases at baseline.

Once the study, which took place at football clubs (FC) in five towns and is known as the FC Prostate Community trial, showed acceptable safety, the Danish Football Association started the initiative at 15 additional clubs in other locations.

Both in the trial, which ran from 2015 to 2018, and afterward, recruitment was through posters and fliers in local urology departments.

At the twice-a-week hourly sessions, the men divided up and played five vs five against each other. Games were monitored by two volunteer coaches, who received minimal education about prostate cancer. The players at some locations paid for their own uniforms to formalize their gear.

The Osterbro team in the FC Prostate trial.

The new 1-year data were published online October 1 in PLOS Medicine.

The trial defies conventional wisdom about cancer patients and exercise, suggested Bjerre.

"The men's primary motivation is not being healthy," Bjerre told Medscape Medical News. Instead, they were motivated by "having fun with peers" and being in a structured environment, he said.

"They don't talk about prostate cancer or health when they come," he observed.

Being a footballer, commented Bjerre, is the antithesis of being a cancer patient: "The men said that playing football means they are not in a passive patient role."

Importantly, among patients allocated to the football group in the clinical trial, 59% chose to continue playing after the 6-month intervention. That was significant, said Bjerre.

"We all know exercise is healthy for you, but don't really know how to promote this behavior, especially among men," he commented.

The trial indicates that team sports may be a good health promotion for cancer patients — and encourage long-term adherence.

Arjun Gupta, MD, oncology fellow, Johns Hopkins University, Baltimore, Maryland, who highlighted the study on Twitter, agreed.

"Sport, especially team-based, is more fun, engaging, and affords the opportunity to build community and be meaningful after that hour is over," he told Medscape Medical News in an email.

Exercise in the form of prescribed, repetitive activity is uninspiring for many patients, he suggested.

Gupta offered himself as an example: "Having personally been minimally compliant for several years with an exercise and physiotherapy regimen for a torn knee meniscus, I can attest to how boring routine exercise can be."

Masculinity an Issue Among Men With Prostate Cancer

For older men, team sports recall their youth and masculinity, several experts commented to Medscape Medical News.

That's invaluable for men living with prostate cancer, according to Anna Campbell, MBE, PhD, professor, Clinical Exercise Science, Edinburgh Napier University, UK, who was not involved in the study. She observed that 40% of study participants were on hormonal therapy that aims to lower androgens to castration levels.

"A lot of these guys are on androgen deprivation therapy, which means their testosterone is lower. They develop breasts, put on weight, get emotional," she told Medscape Medical News. "When they are back playing football, they are doing something manly."

When they are back playing football, they are doing something manly. Dr Anna Campbell

An internationally recognized expert, Campbell is very familiar with the Danish clinical trial results as well as qualitative research about the men's motivations in the trial. That research resulted in, among other things, the above-cited quotes from participants, who revealed a deep passion for the game of football.

Campbell said that 50% of cancer patients in the UK opt for conventional cancer-specific exercise programs and the other 50% prefer more idiosyncratic, personalized activity such as joining a local walking group or playing badminton. The men in the Danish study, she suggested, were akin to the latter group.

"In Europe, soccer is the major sport," said Bjerre. In the FC Prostate Community Trial, 60% of participants had played in their youth. However, only 4% had played football in recent years, so the trial brought many men back to their recreational roots.

"If you were going to do the trial in the United States, you would probably pick another sport," acknowledged Bjerre.

There have been multiple studies of football as a health intervention among adults with disease, including cancer, but always at university facilities with considerable oversight, said Bjerre. The new study is the first study among cancer patients in local communities or the "real world."

"We can utilize local existing structures that are in our communities to enable low cost and accessible physical activity," he said. Cost was minimal, with about $1800 expended at each club for expenses such as balls and cones.

The trial took place at local Danish clubs Lyseng IF, Fremad Valby, Østerbro IF, EfB, and KFUM Odense, which are among 1600 football clubs in the small nation.

There are 98 municipalities that provide cancer rehabilitation as part of Denmark's national health program. Thus, with 20 clubs now offering football for men with prostate cancer, the intervention is currently available in one out of five municipalities in Denmark. Bjerre believes it may be the only national effort of its kind in Europe.

Injury a Badge of Honor

Playing football in the latter decades of life is not without risk. There were "quite a lot of minor sports injuries" in the football group — especially muscle strains, said Bjerre.

But Campbell emphasized that the men, in the qualitative research, had an unusual response to that risk. In what amounted to another unorthodox clinical pearl from the trial, the men suggested minor injuries can be a boon to mental health.

Campbell explained: "Even when they got an injury, they would say: 'Yeah, I got a sports injury!' They were so proud to have a sports injury. That's the truth."

The men's wives also noted that their husbands "had a spring in their step" when they went off to the trial's training sessions, said Campbell, citing the qualitative research again.

Using sports to engage and activate men with cancer is a compelling strategy, said Daniel Santa Mina, PhD, assistant professor, Exercise and Cancer, University of Toronto, Ontario, Canada.

"We just completed a pilot study of men with testicular cancer participating in sports training with varsity basketball players, coaches, and strength and conditioning staff," he told Medscape Medical News in an email.

There is "definitely growing interest" in using sports as a medium for delivering health and fitness interventions, he added.

But as a cancer intervention, sport has limitations.

In the current trial, the primary outcome was mean change difference in prostate cancer-specific quality of life at 12 weeks. The football group and usual care control group had similar scores, as reported earlier this year.

"We can't give them back their urinary continence," investigator Bjerre summarized.

However, exercise may extend overall survival for men and women living with cancer, according to epidemiological, observational data, said Campbell.

Such benefit has never been shown in a randomized controlled trial, she added. That may change in the coming years as major exercise trials in prostate, colorectal, and breast cancer are underway.

TrygFonden sponsored the trial and the Danish Cancer Society supplied funding for DXA bone scans. Gupta and Mina have reported no relevant financial relationships. Campbell is the founder and owner of CanRehab, which provides exercise training for patients with cancer in the UK.

PLOS Medicine. Published online October 1, 2019. Abstract

Follow Medscape's Nick Mulcahy on Twitter. For more from Medscape Oncology, join us on Twitter and Facebook.

Comments

Commenting is limited to medical professionals. To comment please Log-in.

Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.