Livingston, P.M., Craike, M.J., Salmon, J., Courneya, K.S., Gaskin, C.J., Fraser, S.F., . . . ENGAGE Uro-Oncology Clinicians' Group. (2015). Effects of a clinician referral and exercise program for men who have completed active treatment for prostate cancer: A multicenter cluster randomized controlled trial (ENGAGE). Cancer, 121, 2646–2654. 

To determine the effectiveness of referrals from nurses or medical providers to a 12-week exercise program compared to usual care for the outcome of self-reported physical activity among men after completion of active prostate cancer treatment.

Participants were randomly assigned to the intervention or to the control: The intervention was a 12-week exercise program that included two gym sessions and one home-based session per week beginning 3–12 months after active treatment for prostate cancer was completed. Intervention participants were given a referral slip stating that the clinician recommended participation in the exercise program. The 12-week exercise program was at a local community gym, supervised by exercise physiologists, and followed exercise guidelines for cancer survivor exercises by the American College of Sports Medicine and the Exercise and Sport Science Australia. The exercise intervention also used social cognitive theory. The control group had usual care, which included a recommendation to exercise.

• N = 131  
• MEAN AGE: 65 years (range = 39-84)
• MALES: 100%  
• KEY DISEASE CHARACTERISTICS: 3-12 months after completion of treatment with curative intent for prostate cancer 
• OTHER KEY SAMPLE CHARACTERISTICS: A majority of participants had stage I (15%) or stage II (16.5%) prostate cancer, and there were no significant between-group differences except for the disease stage (p < 0.01) and treatment (p < 0.05) between groups. English language ability to read and complete surveys

• SITE: Single site     
• SETTING TYPE: Outpatient        
• LOCATION: Melbourne, Australia

• PHASE OF CARE: Late effects and survivorship

• Prospective, multicenter, cluster, randomized controlled trial with two arms

• Godin-Shepherd Leisure Time Exercise Questionnaire: A monthly self-report of number of minutes of moderate-to-vigorous physical activity in a typical week in the past month. Measures were zero minutes, light intensity, moderate intensity, vigorous intensity, and minutes greater than 150 per week, with definitions of each level.
• ActiGraph for T1 (7 days at the baseline) and T2 (immediately after the 12-week exercise program) with the same time period of measures in the control group. Freedson adult cut points for light-intensity and average daily activity: used in the activity calculations but not reported. 
• Quality of life: Measured by the European Organization for Research and Treatment of Cancer Quality-of-Life Core-30 questionnaire (QLQ-C30, which has a cognitive functioning subscale) and prostate tumor–specific module (QLQ-PR25). 
• Prostate cancer–related anxiety: Memorial Anxiety Scale for Prostate Cancer (MAX-PC).
• Depressive symptoms: 20-item Center for Epidemiological Studies-Depression Inventory, with mean and total scores calculated.
• Satisfaction: Measured in the intervention group using a survey to assess the acceptability, convenience, and feasibility of the clinician referral and exercise program. 

Intervention participants indicated positive reports about clinician referral influencing participation in the exercise program.  Prostate cancer-related anxiety declined more in the control group (d = 0.42, p = 0.02).  Effects on depression were not significant, but there was greater decline in the intervention group (d = -0.35, p = 0.06). There was no significant change in the cognitive subscale of the QOL measure. A higher percentage of those in the intervention group reported achievement of aerobic exercise guidelines.

Clinician referral from doctor or nurse care provider influences decision to participate in a tailored exercise program among men who have completed prostate cancer treatment. Exercise program supervision helps to ensure that exercise is tailored to each individual, risk of injury is reduced, and potential for adherence is improved.

• Risk of bias (no blinding)
• Risk of bias (no appropriate attentional control condition)
• Other limitations/explanation: Activity level may have been higher at baseline due to time after completion of treatment; activity measures may not have been as accurate as desired or may have been worn at different times than desired.

Nurse clinicians may influence participation in an exercise program for men who have completed radiation, chemotherapy, or surgery for prostate cancer, touting benefits of improved physical activity, cognition, QOL, and other health outcomes, including significant reduction of anxiety self-report and moderate reduction of depression symptoms. A specific referral or prescription for exercise may enhance exercise participation and activity that meets current national recommendations.