Body image issues and attitudes towards exercise amongst men undergoing androgen deprivation therapy (ADT) following diagnosis of prostate cancer

Androgen deprivation therapy (ADT) is an established treatment for prostate cancer (PCa), but its side‐effects can affect body appearance and functioning. However, research into the impact of ADT on body image is limited. Exercise can help patients to counterbalance some side‐effects, potentially improving body image too. However, adherence to exercise recommendations is low. Therefore, we explored body image after ADT and attitudes towards exercise.


| BACKGROUND
Prostate cancer (PCa) is the second most prevalent cancer amongst men worldwide and the third most prevalent cancer in Europe, with an estimate of 450 000 new cases in 2018. 1 Although PCa treatment options are improving outcomes for survival, each therapy is associated with side-effects. In this regard, androgen deprivation therapy (ADT) is of particular interest because of its potential impact on body composition and psychological well-being. 2 ADT is recommended by the National Institute for Health and Care in the UK (NICE guidelines). 3 ADT increases prostate cancer specific survival 4 and is received by almost 50% of PCa patients at some point during treatment in the United States, both as a stand-alone therapy or in combination with other treatments. 5 ADT reduces androgens levels with a gonadotropin releasing hormone (GnRH) agonist, interrupting testosterone supplies to prostate cancer cells. However, many patients experience side-effects including weight gain (reported by 70%), breast enlargement (28.6%), penile shrinkage (93%), lack of libido (58%-91%), impotence (73.3%-95%), incontinence (25%-69%), hot flushes (44%-80%), and fatigue (33%-46.8%). 6,7 The bodily changes provoked by ADT can negatively impact the relationship patients have with their body, different both in its appearance and functioning, and potentially eliciting negative body image (defined as the negative subjective evaluation of one's body appearance and functioning). 8 A large amount of literature has shown that negative body image represents a threat to one's psychological wellbeing. 9 However, to the best of our knowledge, only nine studies to date have investigated directly or indirectly body image concerns in PCa patients, representing a preliminary contribution to the field. Qualitative studies by Ervik and Asplund and Navon and Morag highlighted how the bodily changes induced by ADT can prompt feelings of loss of masculine identity and shame for a feminized appearance. 10,11 Similarly, Kelly found that patients felt their body was deeply different from how it had been before cancer. 12 In quantitative research, Fowler et al and Harrington et al found that PCa patients undergoing ADT have significantly higher body image concerns when compared with ADT-naïve patients, 13 and that body image issues were negatively correlated to quality of life (QoL). 14,15 In line with these results, a longitudinal study by Taylor-Ford et al found that change in body image over time was a significant predictor of change in QOL amongst PCa patients on ADT. 16 These results highlight how ADT can have a negative impact on patients' relationships with their bodies. However, there is a lack of research investigating PCa patients' needs for support around body image issues. In general, previous studies found that PCa patients are often reluctant to seek psychological help. 17 This reluctance might be related to stereotypical views of masculinity where seeking help is considered inappropriate. 18 These results suggest that PCa patients might be reluctant to seek psychological help for body image issues as well. Therefore, patients might benefit from practical activities with a positive impact on psychological outcomes. Specifically, exercise could be an acceptable and effective way to reduce body image concerns in patients undergoing ADT, in addition to improving cancerspecific health outcomes. 19,20 Indeed, some studies have supported this preliminary evidence. For example, a correlational study by Langelier et al found that higher levels of aerobic exercise were associated with higher levels of masculinity, improved body image, and QOL in PCa patients. [21][22][23] Yet, although exercise could have a positive impact on both physical and psychological health, 3,20 adherence to exercise recommendations amongst PCa patients is very low. 24 19,25 and only 14% engaged in one session of weekly resistance training. 26 Research into perceived barriers to exercise in PCa patients has identified not only time management, fatigue, and incontinence, but also limited resources, lack of expertise, and poor awareness of benefits. 21,22,27 Within the general population, body image concerns have also been cited as an exercise barrier, 28 but research has yet to investigate whether they might contribute to lack of exercise in patients following ADT.

| Aims
This study explored the impact of ADT side-effects on PCa patients' body image and sense of masculinity. Moreover, we investigated patients' attitudes towards exercise and potential exercise barriers in relation to ADT side-effects. While body image and exercise have been considered in other cancers, 29 there has been a lack of research in this area with regards to PCa.

| METHODS
The study received ethical approval from the Faculty Ethics Committee. The research was conducted qualitatively since this method is ideal for capturing an insight into the impact of cancer at the individual level. 12 Moreover, qualitative methodology has been largely implemented in similar research. 30,31

| Participants
The study was advertised as "My body after Prostate Cancer," consisting of an interview focusing on ADT-induced body image changes and attitudes towards exercise. Participants were recruited through charities, social media, and press release. Men were eligible if they have had a diagnosis of prostate cancer, have followed ADT at some point in their life, and did not have any major condition preventing them from exercising.

| Data collection
The interview topic guide was developed by the first author on the basis of previous literature and after discussing potential topics with PCa patients and fellow researchers (for full access to the topic guide, please access Data S1). Thirteen participants were interviewed over the phone, while nine, face-to-face (Table 1). Participants gave informed consent, including permission to audio-record the session. Pseudonyms were used to protect participants' identity.

| Data analyses
The transcripts were analysed using NVivo, applying thematic analysis and constant comparative method. This approach is not guided by any pre-existing theoretical framework 32 and is therefore ideal for relatively unexplored fields. The first author coded the interview transcripts following an iterative process of analysis, developing themes while collecting the data, and then revising the themes once all the interviews were completed. The themes produced by the first author were discussed by the research team to ensure trustworthiness.

| Results
Twenty-two patients were interviewed, two of which were excluded from the analyses because of poor audio recording quality. Participants' ages ranged from 43 to 85 years (M age = 67.9 y, SD = 9.99), they were all white British, self-identified as heterosexual, and time since diagnosis ranged between 3 months and 15 years (Table 1).

| Body image issues as body feminization issues
Patients experienced several ADT-induced bodily changes, some of which had a distressing impact on their masculine identity. These changes often led participants to experience their body as inherently Fat-increase was also concerning for many participants, who defined weight gain as undesirable aesthetically and functionally, and The ADT-provoked bodily changes induced feelings of loss for the body as it was prior to diagnosis and, for some participants, a loss of their identity as male. Some described frustration towards their current body, changed in its appearance and functioning. Some men expressed regret for not appreciating their bodies more when they were cancer-free. However, during the interviews younger patients did not explicitly referred to their young age as an aggravating factor.

| Compromising exercise and side-effects: Between compensation and barriers
Most participants reported to regularly engage in light exercise, often walking and cycling, but also Pilates and light weight-lifting. Exercise was identified as an effective strategy to compensate ADT sideeffects, weight gain in particular, and helped patients enhance resilience against cancer.  In conclusion, exercise seemed to enhance patients' body confidence and reduce health-related worry. However, fear of negative evaluation for body appearance and functioning seemed to prevent some patients from accessing the positive psychological effects of exercise.

| DISCUSSION
This qualitative study explored the impact of ADT-related side-effects on PCa patients' body image and their attitudes towards exercise. Our results supported and expanded previous findings.
In line with previous literature, most of the patients referred to ADT-induced bodily changes as distressing because they were feminizing. 10,11 The combination of weight gain, breast enlargement, functionality loss, and sexual issues left patients with a body that was perceived as profoundly different from the one they had prior to diagnosis, both for its appearance and functioning, representing a threat to patients' masculine identity. Being strong, muscular, and sexually active are key features of a masculine ideal, 23 which can be referred to as a hegemonic model centred around competitiveness, sexual and athletic power, control, and stoicism. 33

| Clinical implications
PCa patients currently refer a lack of information from health care professionals about the impact of ADT-side effects. 11 These findings suggest that patients might benefit at the beginning of their treatment from specific information from health care professionals and support groups around ADT-induced bodily changes and their psychological impact. However, given the reluctance of men to talk about the aforementioned issues, further research should explore the most effective and acceptable ways to provide support around body image issues and exercise. Another factor to take into consideration is the gender and age gap between the interviewer and the participants. While the first author was a woman in her late 20s at the time of the data collection, all the interviewees were males between their 40s and 80s.

| Limitations
This gap may have influenced the quantity and quality of information patients shared. Some might have found it difficult to open up and relate to a young female. However, other patients mentioned feeling more comfortable talking with women (eg, wives, friends, and often nurses), considered more empathetic compared with males. In support of this, in a previous study by Chapple and Ziebland, PCa patients were given the choice to be interviewed either by a male or a female researcher and all the participantswith the exception of one-preferred to talk to the female researcher. 40

| CONCLUSION
In line with previous literature, our results suggest that ADT sideeffects can be detrimental for men's appearance and functionality satisfaction, impacting negatively on the relationship they have with their body and on their sense of masculinity. Exercise seems to be an effective strategy to compensate ADT side-effects, increasing patients' sense of control and physical self-efficacy. Our study expands previous literature by suggesting that fear of negative evaluation might prevent some patients from exercising and therefore from experiencing its positive psychological effects.