None of the participants involved in the trial were provided with information on how lifestyle changes might be beneficial to men with prostate cancer during the course of their standard medical treatment. This analysis of post-intervention focus groups supports current evidence that lifestyle changes in men with advanced prostate cancer are beneficial
[11, 20, 21]. Further, we present novel evidence that this intervention ameliorated anxiety around treatment and fear of disease progression. We also report men with prostate cancer have a preference for exercise rehabilitation over conventional discussion groups.
Our analysis should be interpreted in the context of relevant limitations. These views are from 12 men who were willing to be randomized in a clinical trial and as such might not be representative of all men with prostate cancer. Further research is needed to explore the preferences of men who potentially have more severe functional limitations: however, it should be noted that our recruited sample included men with metastatic disease. Also, we were unable to include all 21 men who finished the 12 week lifestyle intervention, due to limitations in their availability, although our sample of 12 was more than 50% of the cohort. The intervention was only short in duration (for example, 12 weeks); ideally cancer rehabilitation programs should be designed to provide sustained support for healthy lifestyles and investigate barriers and facilitators to sustained behavior change during implementation of longer-term (12 month) interventions. However, to the authors’ knowledge this is the first qualitative analysis of how men with prostate cancer evaluate the experience of lifestyle changes and as such represents a novel contribution to the knowledge base.
The potential for disease progression is a frequently reported concern for cancer survivors
 and this can persist for more than five years after diagnosis
. Indeed, PSA levels were a persistent concern for these men. Fear of recurrence/progression has been theorized to be variable in its intensity and potentially exacerbated by imminent treatment follow-up appointments or medical check-ups
. Men in the focus groups reported that being involved in the rehabilitation program helped take the focus away from fear of cancer recurrence and also the unpleasant feelings associated with Zoladex injections. This finding could support the implementation of the lifestyle interventions outside of a hospital setting, possibly in the community or at a dedicated rehabilitation facility where contact with exercise specialists can be facilitated. Indeed, the supervision of exercise sessions enabled the negotiation of individually tailored goal setting between the exercise physiologist and the participants, with appropriate continuous re-evaluation. Such strategies used in conjunction with feedback to guide training progression are well recognized as important strategies to help program adherence and also promote fitness gains
[25, 26]. Evidence from the focus groups indicates that the men felt this process of setting and achieving goals meant they were able to exert or ‘push’ themselves further than expected. This qualitative data reported in the focus groups provides a useful context from understanding some of the quantitative findings of the trial
. Indeed, we reported significant improvements in aerobic exercise tolerance, muscular strength and functional capacity as a result of the lifestyle intervention and clinically relevant improvements in fatigue perception
Advice regarding the benefits of lifestyle changes in men with prostate cancer, was not provided as part of standard Urology follow-up care. As the results of this analysis have demonstrated, supportive evidence in favor of healthy lifestyle changes (in parallel with similar findings elsewhere)
[20, 21], should be passed on during routine clinical practice. These men were strongly supportive of an exercise or lifestyle-based rehabilitation program rather than a discussion and support group. Although previous reports from a meta-analysis have indicated that psychosocial interventions (including guided support groups) are effective at improving overall quality of life in cancer survivors,
 our findings are similar to previous qualitative research in other cancer cohorts indicating that rehabilitation programs are often the patient’s preference
[29, 30]. It is appropriate to draw parallels with the intervention format and the group cohesion often associated with self-help or support groups
[31, 32]. Men reported a sense of equality, confidence and peer support and this was not necessarily an anticipated component of the intervention design. As such, any discussion about disease processes or treatment adverse effects was developed without coercion, and hence at a socially acceptable and comfortable pace during the group sessions
. Furthermore, it should be noted that in contrast to other evidence in cancer cohorts
 these men expressed that they preferred not to have spousal support during the rehabilitation program and that a group demographic consisting exclusively of men with prostate cancer was also a preference.
Accruing observational evidence suggests that habitual exercise could reduce disease progression and mortality in men with prostate cancer.
[34, 35] If this is to be tested through interventions in clinical trials, future research should consider that although men found this short-term experience beneficial, the mechanisms for provision of rehabilitation facilities need to be considered. Commercially available gym memberships were judged too expensive by these men, many of whom subsist from a pension. Long-term rehabilitation programs might have to be delivered using existing health care resources. Alternatively, community exercise facilities with subsidized membership schemes would be appealing. A behavior change support structure will also likely be required to facilitate long-term lifestyle change adherence, which could potentially be delivered at monthly intervals through existing consultations with cancer nurse specialists. Such consultations should include evaluation of progress and re-assessment of lifestyle goals as appropriate.