Really, Men With Prostate Cancer Do Yoga

Nick Mulcahy

April 18, 2017

A groundbreaking trial of yoga as an intervention to relieve the side effects of prostate cancer treatment had a lot of initial doubters, said senior author, Neha Vapiwala, MD, a radiation oncologist at the University of Pennsylvania in Philadelphia.

Feasibility was the big unknown and caused the investigators to wonder: "Will men even sign up?" she recounted to Medscape Medical News.

Yoga's been studied as a tool to mitigate treatment side effects in patients with breast cancer, but never in prostate cancer. Dr Vapiwala said there are "myths" that men don't practice yoga and that "men with prostate cancer aren't interested in that kind of stuff."

She heard other criticisms as well because, after all, guys with prostate cancer are typically older than retirement age: "Everyone said they wouldn’t do it."

Worse yet, even she and her colleagues were doubters of a kind, harboring a fear of rejection: that they would seek to enroll men, who, in turn, "would laugh."

Instead, they got a "staggering" response, but many of the men could not ultimately participate because of scheduling conflicts, she told Medscape Medical News. "They're not the men who you would think. They're not all fitness buffs. We got everyone."

Male intuition might have been at work.

It turned out that, in the new randomized clinical trial, yoga relieved the side effects of radiotherapy and hormone therapy. That is, the men who practiced the ancient modality reported less fatigue and better sexual and urinary function compared with men who did not do yoga.

The results were published April 6 in the International Journal of Radiation Oncology • Biology • Physics.

In the phase 2 study, the yoga guys (n = 22) attended two 75-minute classes a week for 6 to 9 weeks (depending on the length of their radiotherapy) at Penn's Abramson Cancer Center, before or after a treatment session, between October 2014 and January 2016. The control group (n = 28) did whatever they were doing at baseline, in terms of activity. (The study started with 68 men, but 18 dropped out — again, mainly because of scheduling.)

The median age of men in the study was 67.3 years. Most were white and married, had an annual income of greater than $80,000, and lived within an hour of the facility. Importantly, none of the study participants had ever practiced yoga before.

For the primary endpoint of fatigue (measured by the Brief Fatigue Inventory), the yoga guys reported less fatigue than patients in the control group, with global fatigue, impact of fatigue, and severity of fatigue subscales showing significant interactions ( P < .0001).

Overall, the men in the control group had a worsening of fatigue scores. "The controls did exactly what we expected them to do," said Dr Vapiwala about their results.

The opposite was true for the yoga guys. "The men in the yoga arm not only didn’t get worse, they improved," said Dr Vapiwala.

This was unexpected, she said. "We hypothesized that yoga would help men maintain their energy. We did not expect that men in the yoga arm would have improvements from baseline."

In a secondary outcome, sexual health scores (Sexual Health Inventory for Men), which include erectile function, showed a significant interaction (P = .0333). "The yoga group remained unchanged over time," said Dr Vapiwala.

"We are not saying it made them [the yoga guys] into a whole new breed of man, but the control group reported worsening erectile dysfunction over the same time period," she observed.

We are not saying it made them into a whole new breed of man. Dr Neha Vapiwala

The yoga guys reported "moderately favorable" erectile dysfunction scores throughout the study period, said the authors.

However, the differences between treatment groups were significant only at 4 weeks (P = .047) and not, ultimately, at the final readings at 6 to 9 weeks  (P = .314).

Still, the sexual health results are impressive because a higher percentage of yoga guys received androgen deprivation therapy during the study period than controls (60% vs 53%, respectively). "Hormone therapy completely takes away the libido," said Dr Vapiwala.

The study results also showed that the yoga guys had some superior quality-of-life and urinary symptom scores compared with controls.

The new study is notable in a number of ways, said Alyson Moadel-Robblee, PhD, an epidemiologist at the Albert Einstein College of Medicine in New York City, who was not involved in the new study.

First, it demonstrates "relatively high interest and participation in yoga among men, which is not often seen in other studies of mind-body therapies and cancer," she said in an email to Medscape Medical News.  

Second, it is an example of "integrative oncology" wherein a complementary therapy is woven into the cancer treatment regimen, said Dr Moadel-Robblee, who was the lead author of a randomized trial of yoga as an intervention for women with breast cancer, including those in the midst of treatment.

Third, it showed that yoga can improve fatigue and reduce sexual impairment, two "common and distressing" side effects of prostate cancer treatment.  

However, the study results may be due, at least in part, to effects other than yoga, such as socializing or attention, commented Dr Moadel-Robblee, echoing some of the authors' own stated limitations.

Both the authors and Dr Moadel-Robblee say that it is uncertain how exactly the intervention may have worked. Furthermore, both hope to see an extension of the study to determine whether the effects are durable and to see whether any subset of patients continue with the practice and receive further benefit. Dr Vapiwala said they would also like to do another randomized trial that compares yoga to general exercise.

How Did a Group of Seniors Do Yoga?

The type of yoga used in the study was Eischens, which is an offshoot of the more well-known Iyengar yoga. Eischens focuses more on energy — and getting it moving through the body — than on the complexity of the body positioning. Like Iyengar yoga, this type of yoga relies on props, including chairs and belts, to perform yoga postures. These modifications allow older, less flexible individuals and people with different body types to effectively participate in yoga.

However, the truth is that older men are rarely yoga students. As the authors stated in another paper, men older than age 44 years make up less than 7% of the adult yoga practitioner population in the United States.

But the guys at Penn did it. They had to attend at least 80% of classes to count as study participants. In class, they performed a mix of positions, including seated (in a folding chair), standing, and reclining.

Other men at the center, who wanted to join the study but could not, would stop by on the way to treatment and ask Dr Vapiwala: "How's the study going?" They "lamented" not participating, she said.

"No one should be telling prostate cancer patients what they can and can't do," said Dr Vapiwala.

"We should not buy into stereotypes about men, especially older men, and yoga," she emphasized.

This study was partially funded through an American Cancer Society Institutional Grant and a Prostate Cancer Foundation Young Investigator Award. Dr Vapiwala and Dr Moadel-Robblee have disclosed no relevant financial relationships.

Int J Radiat Oncol Biol Physics. Published online April 6, 2017. Abstract

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