Introduction
The number of cancer survivors in the USA is increasing. As of 2014, there were over 14.5 million estimated individuals with a history of cancer, who are considered survivors [
1]. Racial disparities are increasingly evident in prostate cancer survival, with African-American men exhibiting notable disadvantages [
1‐
3]. African-American men are nearly 1.6 times more likely to be diagnosed with prostate cancer than white men and almost 2.5 times more likely to die from the disease [
2], exhibiting the highest rates of prostate cancer incidence and mortality in the USA [
1,
2]. Radical prostatectomy (RP) provides effective control for prostate cancer resulting in high survival rates subsequently increasing the number of survivors across races [
4]. Long-term complications like urinary incontinence and sexual dysfunction are a burden for many men after surgery, and African-American men have reported higher rates of urinary, bowel, and physical issues than Caucasian men [
3,
5,
6]. Cancer survivorship is a unique and crucial phase, and there is a pressing need for standardized models of care for survivors [
3]. To ensure effective continuity of care for survivors, in 2005, the Institute of Medicine (IOM) Survivorship Committee in their report
From Cancer Patient to Cancer Survivor:
Lost in Transition acknowledged the vital role of communication in the management and coordination of care between healthcare providers and patients [
7].
Many cancer survivorship investigations have reported that most patients prefer receiving cancer information from their healthcare provider [
6,
8,
9]. Specifically, African-American men are more likely to adhere to medications and treatment plans when they trust their provider [
10]. Potential benefits of effective patient-provider communication include the following: better understanding of treatment information and adherence to providers’ recommendations, shorter hospital stays, fewer complications, appreciation of care, increased patient satisfaction, decreased anxiety, and improvement in overall health-related quality of life [
8,
9,
11,
12]. Nonetheless, studies addressing prostate cancer patients’ experiences with physician “prescribed” physical activity are lacking.
Sustaining a physically active lifestyle routine is essential to maintaining healthy conditions and overall quality of life. Physical activity (PA) is recognized as a complementary therapy to improve physical and physiological functions among prostate cancer survivors [
5,
13‐
15]. Epidemiologic data has linked physical activity with better survival outcomes in prostate cancer patients [
16,
17]. Meta-analytic data from randomized controlled trails have demonstrated the benefits of engaging in physical activity for improved quality of life, fatigue, fitness, and function for men with prostate cancer [
18]. The American Cancer Society recommends that all prostate cancer survivors engage in both aerobic exercise and resistance training for cancer management [
19]. Given the documented low PA and poor outcomes on urinary and sexual functions post-RP among African-American men, they are at increased risk of complications from the RP surgical procedure [
20,
21]. Nevertheless, little is known about regular PA communication between providers (physicians/urologists) and African-American prostate cancer patients, a high risk population, about the health benefits of regular PA on their prognosis and recovery.
According to the transtheoretical model (TTM), behavioral change occurs in stages rather than one major change [
22]. For example, Woods et al. [
23] used TTM as an intervention to encourage young adults to become more active. Consequently, the current study is based on theory of the TTM. This model was considered appropriate, given the evidence of low PA among African-American, and especially poor urinary and sexual functions post-RP among African-American men. Using TTM model and phenomenological approach, the primary aim of this study was to explore African-American prostate cancer survivors’ experiences with physical activity prescription from their physicians.
Method
Approach
The study employed a qualitative research design using focus groups to encourage participants to share their personal experiences and facilitate deeper discussion. A focus group qualitative interview method is well suited to exploring respondents’ beliefs and experiences which could not be feasible using other research methods like questionnaire surveys and observations [
23]. For this unique population, this method was considered appropriate to elucidate discussion and interaction among this group of individuals to identify factors inductively rather than deductively. This approach also allowed the participants to name and define their own thoughts about this health behavior.
Selection and recruitment of participants
Participants were recruited from a larger observational cohort of prostate cancer patients titled “Energy Balance and Post-Radical Prostatectomy Urinary and Sexual Function (IRB #201011787).” This parent study enrolled a total of 440 men diagnosed with localized prostate cancer undergoing radical prostatectomy between September 2011 and January 2014 through Washington University School of Medicine, Alvin J. Cancer Center, in St. Louis, as well as Brigham and Women’s Hospital/Dana Farber Cancer Institute. All men undergoing radical prostatectomy for clinically diagnosed prostate cancer were eligible. Further exclusion criteria included previous primary prostate cancer treatment, past radiation treatment to the pelvis (including bladder, rectum, or prostate), major pelvic surgery (including penile implant or urinary sphincter), and having a known urethral stricture, colostomy, or an inability to urinate requiring chronic urinary catheter.
All African-American participants from the larger cohort were eligible to participate in the focus groups. Of the 40 African-American men enrolled in the larger cohort, only 31 were still residing in the immediate area (Missouri). All 31 men were invited to participate in a focus group to discuss their prostate cancer experiences with regard to PA prescription. Those who agreed to participate in this subsample qualitative study were grouped into sessions based on their availability over four-week period in May 2014 in St. Louis, Missouri. The number of participants and focus group sessions were not preset, but determined by data saturation. The final sample consisted of 12 African-American males, all living in St. Louis, Missouri, with all three focus group interviews taking place in community settings.
Data collection
The interview questions were open ended, and comprised descriptive, probing, as well as opinion questions [
24‐
27]. The questions addressed experiences with improving urinary and sexual function through increasing physical activity including patient-physician communication during clinic visit, physical activity participation, and barriers to physical activity. As interviews progressed, participant statements also provoked further questions and clarifications.
Each focus group was held in a conference room on the Washington University School of Medicine campus and lasted about 90 minutes. Groups were facilitated by a well experienced moderator and an observer. The moderator assisted in the development of the question guide and was trained to probe for further information. Attendance for each focus group varied, and group size ranged from 3 to 5. The total number of participants was 12, which reflected a 39% recruitment success rate from the pool of eligible participants. The study was approved on April 11, 2014 by the Institutional Review Board at the Washington University School of Medicine, as a continuation of the parent study (IRB #201011787). At the beginning of each focus group section, participants were informed about rights and principles of protection of human subjects, and each approved their participation with a written informed consent under the principle of full disclosure and received a copy of the consent form. Each person received a $30.00 gift card for participation.
Data analysis
Focus groups were audio-recorded and transcribed verbatim. Data were analyzed using standard inductive text analysis [
27]. Initially, two coders, FW and KI, reviewed the transcripts to familiarize themselves with the data expressions of survivors’ in regard to their experience with physician physical activity prescription. In the next level of the analysis, a line-by-line analysis of the data was conducted separately by each coder, and identified statements and phrases that described survivors experience were labeled accordingly. Next, common codes were identified and categorized into concepts. From these concepts, meanings were created bearing in mind not to disrupt the original meaning of what participants said. All meaningful units were assigned codes, which were reviewed again to identify core categories, develop themes, and further cluster the themes. Although this study sought to look at only quotes related to this specific topic, codes were inductively derived from the transcribed tapes. Through this analysis, no new participants were recruited since thematic saturation was reached as no new codes emerged through coding and verification of the transcripts. Two additional coders, LY and AH, conducted independent review, and the few discrepancies noted were resolved through verification of data.
Discussion
Cancer diagnosis and treatment is usually considered a traumatic experience with an intense impact on all aspects of life. In addition, the recovery period following surgical treatment can involve a series of adjustments and changes to effectively deal with the physical symptoms and treatment side effects. Maintaining regular physical activity is recognized as an important public health concern [3]. Given the established benefits of participation in regular physical activity and the current high prevalence of obesity and sedentary lifestyle, the current study used a qualitative approach to shed light on the importance of healthcare providers’ prescription of exercise and physical activity for African-American prostate cancer survivors. This study adds to the growing literature around African-American men’s physical activity [
28‐
30]. Specifically, by broadcasting patients’ desires for physician-prescribed PA and suggesting physicians place more importance on PA during recovery and survivorship for better adherence. This has clear and important implications for clinical practice as the number of survivors is growing and survivors are living longer.
Previous research revealed that healthcare providers have a great influence on patients’ attitudes towards disease management, regimen, beliefs, and general behavioral lifestyle changes [8, 9]. In spite of the proven advantages associated with physical activity for cancer patients, it was apparent from the findings that only a few physicians engaged in some discussion regarding physical activity and prostate cancer care and survival. Physicians engaging in communication in this context refers to discussion or exchange of information between healthcare providers and patients on the importance of engaging in physical activity and recommendations on the type of exercise deemed to be appropriate for each prostate cancer survivor. Most participants reported that their physicians did not communicate/share this information. Additionally, participants shared that they valued information about physical activity from physicians. Participants also described the benefit of specific physical activity recommendation to address specific symptoms. These results further support the importance of physicians discussing PA with patients going through RP. These findings reinforce the need for every care provider to include physical activity prescription in their discussion during oncological visit with their patients.
This study highlights some of the consequential complications of undergoing RP. Conditions like uncontrollable urinary and sexual dysfunction appeared to be barriers to engaging in physical activity. Participants described anxiety, distress, and frustration concerning “embarrassment” they had to endure in public which prevented them from engaging in physicial activity despite the perceived benefits. This may provide a partial explanation for why these men were seeking conversations with physicians and others who had undergone similar health experiences since these were sensitive and “embarrassing” topics to discuss. Also, even though some men were convinced that physical activity is an important factor in preventing and treating illness, many revealed that family and work commitments often were major challenges limiting them from being physically active. This finding is consistent with previous results which revealed that time constraints prevented many prostate cancer survivors from engaging in regular physical activity [
31‐
33].
Similarly, survey of 452 recently diagnosed breast and prostate cancer survivors to evaluate their concerns with physical activity reported that the biggest barriers for survivors were “being too busy” and/or “having no willpower” to engage in physical activity [
33]. The time constraints as a barrier also suggest that physical activity interventions should, ideally, be best designed and implemented to be conveniently incorporated into their daily life [
31‐
33]. For instance, strategies such as enabling walking by promoting walkable neighborhoods, improving infrastructures to provide free or low-cost recreational facilities, and designing cancer survivor-specific wellness programs that support comprehensive care to improve their survival. Additionally, educational efforts are needed to shift the social norm on lifestyle towards being active among African-American prostate cancer survivors. Finally, recommendations for specific exercises to address specific post-RP symptoms are important to men as they are transitioning back into their regular routines. In the future, studies looking into priorities and motivation may support the design of physician led interventions to support physical activity following RP.
Limitations
The main limitation of this study is that the experiences associated with these men may not reflect the experiences of all African-American prostate cancer survivors; hence, these findings may not be generalizable to all. In addition, the study included the small sample size. One of the challenges as a researcher is to reach the study participants who are difficult to access, especially due to mistrust and history of documented research abuses of African-Americans. Nevertheless, the small sample size is consistent with previously reported difficulties associated with minority participant recruitment [
34]. Further, using a focus group design generated rich and thorough discussion for data analysis, enabling thematic saturation. Given the paucity of study on this topic, the present findings provide a foundation for further understanding of the importance of healthcare professionals’ prescription of physical activity for African-American prostate cancer patients, a high risk population, and emphasize the need for additional inquiry into this area.
Conclusion
Understanding cancer diagnosis and treatment options is a very stressful journey for cancer patients and survivors, complicated by fear, anxiety, grief, and many emotional issues. This study enhances understanding of health communication between healthcare providers and African-American prostate cancer patients regarding physical activity prescription and its impact on recovery and survival. It is clear from these findings that transitioning from post-RP treatment to “normal life” was an important concern to survivors. Routine participation in physical activity has been reported to improve survival among cancer patients. Given the established evidence that provider-patient communication enhances adherence to care plans, it should be recommended that physicians and other healthcare providers discuss and prescribe exercise/physical activity. Results may aid in the future design of larger-scale interventions to better facilitate physician patient PA communication and thereby increase patients’ PA awareness, adherence, and overall quality of life.
Compliance with ethical standards
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