JCT  Vol.3 No.2 , April 2012
Group Exercise versus Personal Training for Prostate Cancer Patients: A Pilot Randomized Trial
ABSTRACT
Background: Previous studies have demonstrated psychosocial and physical benefit from exercise for older men treated with androgen deprivation therapy (ADT) for prostate cancer (PCa). To date, different intervention delivery methods have not been assessed. This study compared the effect of group-based exercise (GBE) to personal training (PT) in men undergoing ADT for PCa. Methods: 13 participants (mean age = 68.2, SD = 7.2) were randomly assigned to GBE or PT for 8 weeks. Participants exercised for 60 minutes three times per week at a moderate-vigorous intensity. Results: 10 participants completed the intervention. At post-intervention, the PT group improved: fatigue, systolic BP, waist circumference, body fat percentage, and maximal leg strength; participants in the GBE group improved leg strength. At 8 weeks, maximal upper body strength in the PT group was greater than the GBE group. There were no adverse events associated with moderate-high intensity training in this population of older men. Conclusion: PT may be more efficacious than GBE in improving several physical fitness outcomes and fatigue in men with PCa who are androgen deprived. Due to the small sample size and attrition, these results require cautious interpretation and confirmation from adequately powered trials.

Cite this paper
D. Santa Mina, P. Ritvo, A. G. Matthew, A. Rampersad, H. Stein, A. M. Cheung, J. Trachtenberg and S. M. H. Alibhai, "Group Exercise versus Personal Training for Prostate Cancer Patients: A Pilot Randomized Trial," Journal of Cancer Therapy, Vol. 3 No. 2, 2012, pp. 146-156. doi: 10.4236/jct.2012.32020.
References
[1]   Canadian Cancer Society’s Steering Committee on Cancer Statistics, “Canadian Cancer Statistics 2011,” Canadian Cancer Society, Toronto, 2011.

[2]   A. Bill-Axelson, L. Holmberg, F. Filen, M. Ruutu, H. Garmo, C. Busch, et al., “Radical Prostatectomy versus Watchful Waiting in Localized Prostate Cancer: The Scandinavian Prostate Cancer Group-4 Randomized Trial,” Journal of the National Cancer Institute, Vol. 100, No. 16, 2008, pp. 1144-1154. doi:10.1093/jnci/djn255

[3]   A. L. Potosky, J. Legler, P. C. Albertsen, J. L. Stanford, F. D. Gilliland, A. S. Hamilton, et al., “Health Outcomes after Prostatectomy or Radiotherapy for Prostate Cancer: Results from the Prostate Cancer Outcomes Study,” Journal of the National Cancer Institute, Vol. 92, No. 19, 2000, pp. 1582-1592. doi:10.1093/jnci/92.19.1582

[4]   M. Quinn and P. Babb, “Patterns and Trends in Prostate Cancer Incidence, Survival, Prevalence and Mortality. Part I: International Comparisons,” British Journal of Urology International, Vol. 90, No. 2, 2002, pp. 162-173. doi:10.1046/j.1464-410X.2002.02823.x

[5]   P. J. Saylor, N. L. Keating and M. R. Smith, “Prostate Cancer Survivorship: Prevention and Treatment of the Adverse Effects of Androgen Deprivation Therapy,” J Gen Intern Med, Vol. 24 Suppl. 2, No. 2009, pp. S389-S394.

[6]   M. R. Cooperberg, G. D. Grossfeld, D. P. Lubeck and P. R. Carroll, “National Practice Patterns and Time Trends in Androgen Ablation for Localized Prostate Cancer,” Journal of the National Cancer Institute, Vol. 95, No. 13, 2003, pp. 981-989. doi:10.1093/jnci/95.13.981

[7]   V. B. Shahinian, Y. F. Kuo, J. L. Freeman, E. Orihuela and J. S. Goodwin, “Increasing Use of GonadotropinReleasing Hormone Agonists for the Treatment of Localized Prostate Carcinoma,” Cancer, Vol. 103, No. 8, 2005, pp. 1615-1624. doi:10.1002/cncr.20955

[8]   S. M. Alibhai, S. Gogov and Z. Allibhai, “Long-Term Side Effects of Androgen Deprivation Therapy in Men with Non-Metastatic Prostate Cancer: A Systematic Literature Review,” Critical Reviews in Oncology and Hematology, Vol. 60, No. 3, 2006, pp. 201-215. doi:10.1016/j.critrevonc.2006.06.006

[9]   J. A. Smith, Jr., M. S. Soloway and M. J. Young, “Complications of Advanced Prostate Cancer,” Urology, Vol. 54, Suppl. 6A, 1999, pp. 8-14.

[10]   M. R. Smith, J. S. Finkelstein, F. J. McGovern, A. L. Zietman, M. A. Fallon, D. A. Schoenfeld, et al., “Changes in Body Composition During Androgen Deprivation Therapy for Prostate Cancer,” The Journal of Clinical Endocrinology and Metabolism, Vol. 87, No. 2, 2002, pp. 599-603. doi:10.1210/jc.87.2.599

[11]   D. A. Galvao, N. A. Spry, D. R. Taaffe, R. U. Newton, J. Stanley, T. Shannon, et al., “Changes in Muscle, Fat and Bone Mass after 36 Weeks of Maximal Androgen Blockade for Prostate Cancer,” BJU International, Vol. 102, No. 1, 2008, pp. 44-47. doi:10.1111/j.1464-410X.2008.07539.x

[12]   R. J. Segal, R. D. Reid, K. S. Courneya, S. C. Malone, M. B. Parliament, C. G. Scott, et al., “Resistance Exercise in Men Receiving Androgen Deprivation Therapy for Prostate Cancer,” Journal of Clinical Oncology, Vol. 21, No. 9, 2003, pp. 1653-1659. doi:10.1200/JCO.2003.09.534

[13]   D. A. Galvao, K. Nosaka, D. R. Taaffe, N. Spry, L. J. Kristjanson, M. R. McGuigan, et al., “Resistance Training and Reduction of Treatment Side Effects in Prostate Cancer Patients,” Medicine and Science in Sports and Exercise, Vol. 38, No. 12, 2006, pp. 2045-2052. doi:10.1249/01.mss.0000233803.48691.8b

[14]   D. A. Galvao, N. Spry, D. R. Taaffe, J. Denham, D. Joseph, D. S. Lamb, et al., “A Randomized Controlled Trial of an Exercise Intervention Targeting Cardiovascular and Metabolic Risk Factors for Prostate Cancer Patients from the Radar Trial,” BMC Cancer, Vol. 9, 2009, pp. 419-426.

[15]   C. L. Carmack Taylor, C. Demoor, M. A. Smith, A. L. Dunn, K. Basen-Engquist, I. Nielsen, et al., “Active for Life after Cancer: A Randomized Trial Examining a Lifestyle Physical Activity Program for Prostate Cancer Patients,” Psycho-Oncology, Vol. 15, No. 10, 2006, pp. 847-862. doi:10.1002/pon.1023

[16]   S. N. Culos-Reed, J. L. Robinson, H. Lau, K. O’Connor and M. R. Keats, “Benefits of a Physical Activity Intervention for Men with Prostate Cancer,” Journal of Sport and Exercise Psychology, Vol. 29, No. 1, 2007, pp. 118-127.

[17]   S. N. Culos-Reed, J. Robinson, H. Lau, L. Stephenson, M. Keats, S. Norris, et al., “Physical Activity for Men Receiving Androgen Deprivation Therapy for Prostate Cancer: Benefits from a 16-Week Intervention,” Supportive Care in Cancer, Vol. 18, No. 5, 2010, pp. 591-599. doi:10.1007/s00520-009-0694-3

[18]   J. W. Keogh and R. D. Macleod, “Body Composition, Physical Fitness, Functional Performance, Quality of Life, and Fatigue Benefits of Exercise for Prostate Cancer Patients: A Systematic Review,” Journal of Pain and Symptom Management, Vol. 43, No. 1, 2011, pp. 96-110.

[19]   L. Thorsen, K. S. Courneya, C. Stevinson and S. D. Fossa, “A Systematic Review of Physical Activity in Prostate Cancer Survivors: Outcomes, Prevalence, and Determinants,” Supportive Care in Cancer, Vol. 16, No. 9, 2008, pp. 987-997. doi:10.1007/s00520-008-0411-7

[20]   D. Santa Mina, P. Ritvo, R. Segal, S. N. Culos-Reed and S. M. H. Alibhai. “Exercise after Prostate Cancer Diagnosis,” In: J. Saxton and A. Daley, Eds., Exercise and Cancer Survivorship: Impact on Health Outcomes and Quality of Life, Springer, New York, 2010.

[21]   R. J. Segal, R. D. Reid, K. S. Courneya, S. C. Malone, M. B. Parliament, C. G. Scott, et al., “Resistance Exercise in Men Receiving Androgen Deprivation Therapy for Prostate Cancer,” Journal of Clinical Oncology, Vol. 21, No. 9, 2003, pp. 1653-1659. doi:10.1200/JCO.2003.09.534

[22]   D. A. Galvao, D. R. Taaffe, N. Spry, D. Joseph and R. U. Newton, “Combined Resistance and Aerobic Exercise Program Reverses Muscle Loss in Men Undergoing Androgen Suppression Therapy for Prostate Cancer without Bone Metastases: A Randomized Controlled Trial,” Journal of Clinical Oncology, Vol. 28, No. 2, 2010, pp. 340-347. doi:10.1200/JCO.2009.23.2488

[23]   D. A. Galvao, K. Nosaka, D. R. Taaffe, N. Spry, L. J. Kristjanson, M. R. McGuigan, et al., “Resistance Training and Reduction of Treatment Side Effects in Prostate Cancer Patients,” Medicine and Science in Sports and Exercise, Vol. 38, No. 12, 2006, pp. 2045-2052. doi:10.1249/01.mss.0000233803.48691.8b

[24]   C. L. Carmack Taylor, C. Demoor, M. A. Smith, A. L. Dunn, K. Basen-Engquist, I. Nielsen, et al., “Active for Life after Cancer: A Randomized Trial Examining a Lifestyle Physical Activity Program for Prostate Cancer Patients,” Psycho-Oncology, Vol. 15, No. 10, 2006, pp. 847-862. doi:10.1002/pon.1023

[25]   C. Peeters, A. Stewart, R. Segal, E. Wouterloot, C. G. Scott and T. Aubry, “Evaluation of a Cancer Exercise Program: Patient and Physician Beliefs,” Psycho-Oncology, Vol. 18, No. 8, 2009, pp. 898-902. doi:10.1002/pon.1406

[26]   C. Stevinson and K. R. Fox, “Feasibility of an Exercise Rehabilitation Programme for Cancer Patients,” European journal of cancer care, Vol. 15, No. 4, 2006, pp. 386-396. doi:10.1111/j.1365-2354.2006.00677.x

[27]   M. Craike, P. Livingston and M. Botti, “An Exploratory Study of the Factors That Influence Physical Activity for Prostate Cancer Survivors,” Supportive Care in Cancer, Vol. 19, No. 7, 2011, pp. 1019-1028. doi:10.1007/s00520-010-0929-3

[28]   R. Segal, W. Evans, D. Johnson, J. Smith, S. Colletta, J. Gayton, et al., “Structured Exercise Improves Physical Functioning in Women with Stages I and II Breast Cancer: Results of a Randomized Controlled Trial,” Journal of Clinical Oncology, Vol. 19, No. 3, 2001, pp. 657-665.

[29]   W. Demark-Wahnefried, “Print-to-Practice: Designing Tailored Print Materials to Improve Cancer Survivors’ Dietary and Exercise Practices in the Fresh Start Trial,” Nutrition Today, Vol. 42, No. 3, 2007, pp. 131-138. doi:10.1097/01.NT.0000277790.03666.95

[30]   L. W. Jones and K. S. Courneya, “Exercise Counseling and Programming Preferences of Cancer Survivors,” Cancer Practice, Vol. 10, No. 4, 2002, pp. 208-215. doi:10.1046/j.1523-5394.2002.104003.x

[31]   L. Q. Rogers, S. J. Markwell, K. S. Courneya, E. McAuley and S. Verhulst, “Exercise Preference Patterns, Resources, and Environment among Rural Breast Cancer Survivors,” Journal of Rural Health, Vol. 25, No. 4, 2009, pp. 388-391. doi:10.1111/j.1748-0361.2009.00249.x

[32]   L. Q. Rogers, S. J. Markwell, S. Verhulst, E. McAuley and K. S. Courneya, “Rural Breast Cancer Survivors: Exercise Preferences and Their Determinants,” PsychoOncology, Vol. 18, No. 4, 2009, pp. 412-421. doi:10.1002/pon.1497

[33]   D. Cella, “The Functional Assessment of Cancer Therapy-Anemia (Fact-an) Scale: A New Tool for the Assessmente of Outcomes in Cancer Anemia and Fatigue,” Seminars in Hematology, Vol. 34, No. 3, 1997, pp. 13-19.

[34]   S. B. Yellen, D. F. Cella, K. A. Webster, C. Blendowski and E. Kaplan, “Measuring Fatigue and Other Anemia-Related Symptoms with the Functional Assessment of Cancer Therapy (Fact) Measurement System,” Journal of Pain and Symptom Management, Vol. 13, 1997, pp. 63-74.

[35]   R. J. Segal, R. D. Reid, K. S. Courneya, R. J. Sigal, G. P. Kenny, D. G. Prud’Homme, et al., “Randomized Controlled Trial of Resistance or Aerobic Exercise in Men Receiving Radiation Therapy for Prostate Cancer,” Journal of Clinical Oncology,” Vol. 27, No. 3, 2009, pp. 344-351. doi:10.1200/JCO.2007.15.4963

[36]   P. Esper, F. Mo, G. Chodak, M. Sinner, D. Cella and K. J. Pienta, “Measuring Quality of Life in Men with Prostate Cancer Using the Functional Assessment of TherapyProstate Instrument,” Urology, Vol. 50, No. 6, 1997, pp. 920-928. doi:10.1016/S0090-4295(97)00459-7

[37]   M. Krahn, P. Ritvo, J. Irvine, G. Tomlinson, A. Bezjak, J. Trachtenberg, et al., “Construction of the Patient-Oriented Prostate Utility Scale (PORPUS): A Multiattribute Health State Classification System for Prostate Cancer,” Journal of Clinical Epidemiology, Vol. 53, No. 9, 2000, pp. 920-930. doi:10.1016/S0895-4356(00)00211-0

[38]   P. S. Brucker, K. Yost, J. Cashy, K. Webster and D. Cella, “General Population and Cancer Patient Norms for the Functional Assessment of Cancer Therapy-General (FACT-G),” Evaluations And The Health Professions, Vol. 28, No. 2, 2005, pp. 192-211. doi:10.1177/0163278705275341

[39]   D. Cella, L. Hernandez, A. E. Bonomi, M. Corona, M. Vaquero, G. Shiomoto, et al., “Spanish Language Translation and Initial Validation of the Functional Assessment of Cancer Therapy Quality-of-Life Instrument,” Medical Care, Vol. 36, No. 9, 1998, pp. 1407-1418. doi:10.1097/00005650-199809000-00012

[40]   H. Fumimoto, K. Kobayashi, C. H. Chang, S. Eremenco, Y. Fujiki, S. Uemura, et al., “Cross-Cultural Validation of an International Questionnaire, the General Measure of the Functional Assessment of Cancer Therapy Scale (FACT-G), for Japanese,” Quality of Life Research, Vol. 10, No. 8, 2001, pp. 701-709. doi:10.1023/A:1013851216181

[41]   J. Overcash, M. Extermann, J. Parr, J. Perry and L. Balducci, “Validity and Reliability of the Fact-G Scale for Use in the Older Person with Cancer,” American Journal of Clinical Oncology, Vol. 24, No. 6, 2001, pp. 591-596. doi:10.1097/00000421-200112000-00013

[42]   P. Winstead-Fry and A. Schultz, “Psychometric Analysis of the Functional Assessment of Cancer Therapy-General (Fact-G) Scale in a Rural Sample,” Cancer, Vol. 79, No. 12, 1997, pp. 2446-2452. doi:10.1002/(SICI)1097-0142(19970615)79:12<2446::AID-CNCR23>3.0.CO;2-Q

[43]   U. Monga, S. L. Garber, J. Thornby, C. Vallbona, A. Kerrigan, T. N. Monga, et al., “Exercise Prevents Fatigue and Improves Quality of Life in Prostate Cancer Patients Undergoing Radiotherapy,” Archives of Physical Medicine and Rehabilitation, Vol. 88, No. 11, 2007, pp. 1416-1422. doi:10.1016/j.apmr.2007.08.110

[44]   P. Ritvo, J. Irvine, G. Naglie, G. Tomlinson, A. Bezjak, A. Matthew, et al., “Reliability and Validity of the Porpus, a Combined Psychometric and Utility-Based Quality-of-Life Instrument for Prostate Cancer,” Journal of Clinical Epidemiology, Vol. 58, No. 2005, pp. 466-474.

[45]   M. D. Krahn, K. E. Bremner, G. Tomlinson and G. Naglie, “Utility and Health-Related Quality of Life in Prostate Cancer Patients 12 Months after Radical Prostatectomy or Radiation Therapy,” Prostate Cancer and Prostatic Diseases, Vol. 12, No. 4, 2009, pp. 361-368. doi:10.1038/pcan.2009.32

[46]   P. Toren, S. M. H. Alibhai, A. Matthew, M. Nesbitt, R. Kalnin, N. Fleshner, et al., “The Effect of Nerve-Sparing Surgery on Patient-Reported Continence Post-Radical Prostatectomy,” Canadian Urology Association Journal, Vol. 3, No. 6, 2009, pp. 465-470.

[47]   J. Trachtenberg, A. Bogaards, R. A. Weersink, M. A. Haider, A. Evans, S. A. McCluskey, et al., “Vascular Targeted Photodynamic Therapy with Palladium-Bacteriopheophorbide Photosensitizer for Recurrent Prostate Cancer Following Definitive Radiation Therapy: Assessment of Safety and Treatment Response,” Journal of Urology, Vol. 178, No. 5, 2007, pp. 1974-1979. doi:10.1016/j.juro.2007.07.036

[48]   J. Trachtenberg, R. A. Weersink, S. R. Davidson, M. A. Haider, A. Bogaards, M. R. Gertner, et al., “VascularTargeted Photodynamic Therapy (Padoporfin, Wst09) for Recurrent Prostate Cancer after Failure of External Beam Radiotherapy: A Study of Escalating Light Doses,” BJU International, Vol. 102, No. 5, 2008, pp. 556-562. doi:10.1111/j.1464-410X.2008.07753.x

[49]   D. Santa Mina, A. Matthew, J. Trachtenberg, G. Tomlinson, C. L. Guglietti, S. M. H. Alibhai, et al., “Physical Activity and Quality of Life after Radical Prostatectomy,” Canadian Urology Association Journal, Vol. 4, No. 3, 2010, pp. 180-186.

[50]   V. H. Heyward, “Advanced Fitness Assessment and Exercise Prescription,” Human Kinetics, Windsor, 2002.

[51]   J. Lerman, R. A. Bruce, E. Sivarajan, G. M. Pettet and S. Trimble, “Low Level Dynamic Exercises for Earlier Cardiac Rehabilitation: Aerobic and Hemodynamic Responses,” Archives of Physical Medicine and Rehabilitation, Vol. 57, No. 1976, pp. 355-360.

[52]   Canadian Society for Exercise Physiology, Fitness Assessment and Interpretation, “The Canadian Physical Activity Fitness and Lifestyle Approach,” Ottawa, 2004. pp. 7.1-7.57.

[53]   M. Brzycki, “Strength Testing-Predicting One-Repetition Max from Reps-to-Fatigue,” Journal of Physical Education, Recreation & Dance, Vol. 64, No. 1, 1993, pp. 8890.

[54]   I. C. Backer, E. Van Breda, A. Vreugdenhil, M. R. Nijziel, A. D. Kester and G. Schep, “High-Intensity Strength Training Improves Quality of Life in Cancer Survivors,” Acta Oncologica, Vol. No. 2007, pp. 1143-1151.

[55]   L. Adamsen, M. Quist, J. Midtgaard, C. Andersen, T. Moller, L. Knutsen, et al., “The Effect of a Multidimensional Exercise Intervention on Physical Capacity, WellBeing and Quality of Life in Cancer Patients Undergoing Chemotherapy,” Supportive Care in Cancer, Vol. 14, No. 2, 2006, pp. 116-127. doi:10.1007/s00520-005-0864-x

[56]   P. W. Duncan, D. K. Weiner, J. Chandler and S. Studenski, “Functional Reach: A New Clinical Measure of Balance,” Journal of Gerontology, Vol. 45, No. 6, 1990, pp. M192-M197.

[57]   D. K. Weiner, P. W. Duncan, J. Chandler and S. A. Studenski, “Functional Reach: A Marker of Physical Frailty,” Journal of the American Geriatric Society, Vol. 40, No. 3, 1992, pp. 203-207.

[58]   A. S. Jackson and M. L. Pollock, “Generalized Equations for Predicting Body Density of Men,” British Journal of Nutrition, Vol. 40, No. 3, 1978, pp. 497-504. doi:10.1079/BJN19780152

[59]   G. Guglielmi, G. Scalzo, F. de Terlizzi and W. C. Peh, “Quantitative Ultrasound in Osteoporosis and Bone Metabolism Pathologies,” Radiologic Clinics of North America, Vol. 48, No. 3, 2010, pp. 577-588. doi:10.1016/j.rcl.2010.02.013

[60]   M. A. Krieg, R. Barkmann, S. Gonnelli, A. Stewart, D. C. Bauer, L. Del Rio Barquero, et al., “Quantitative Ultrasound in the Management of Osteoporosis: The 2007 Iscd Official Positions,” Journal of Clinical Densitometry, Vol. 11, No. 1, 2008, pp. 163-187. doi:10.1016/j.jocd.2007.12.011

[61]   E. M. Lewiecki, B. Richmond and P. D. Miller, “Uses and Misuses of Quantitative Ultrasonography in Managing Osteoporosis,” Cleveland Clinic Journal of Medicine, Vol. 73, No. 8, 2006, pp. 742-746. doi:10.3949/ccjm.73.8.742

[62]   A. Moayyeri, S. Kaptoge, N. Dalzell, S. Bingham, R. N. Luben, N. J. Wareham, et al., “Is Qus or Dxa Better for Predicting the 10-Year Absolute Risk of Fracture?” Journal of Bone Mineral Research, Vol. 24, No. 7, 2009, pp. 1319-1325. doi:10.1359/jbmr.090212

[63]   S. N. Culos-Reed, J. W. Robinson, H. Lau, L. Stephenson, M. Keats, S. Norris, et al., “Physical Activity for Men Receiving Androgen Deprivation Therapy for Prostate Cancer: Benefits from a 16-Week Intervention,” Supportive Care in Cancer, Vol. 18, No. 5, 2009, pp. 591-599.

[64]   P. M. Windsor, K. F. Nicol and J. Potter, “A Randomized, Controlled Trial of Aerobic Exercise for Treatment-Related Fatigue in Men Receiving Radical External Beam Radiotherapy for Localized Prostate Carcinoma,” Cancer, Vol. 101, No. 3, 2004, pp. 550-557. doi:10.1002/cncr.20378

[65]   C. Stevinson, V. Capstick, A. Schepansky, K. Tonkin, J. K. Vallance, A. B. Ladha, et al., “Physical Activity Preferences of Ovarian Cancer Survivors,” Psycho-Oncology, Vol. 18, No. 4, 2009, pp. 422-428. doi:10.1002/pon.1396

[66]   L. Q. Rogers, K. S. Courneya, S. Verhulst, S. J. Markwell and E. McAuley, “Factors Associated with Exercise Counseling and Program Preferences among Breast Cancer Survivors,” Journal of Physical Activity and Health, Vol. 5, No. 5, 2008, pp. 688-705.

[67]   L. W. Jones, B. Guill, S. T. Keir, K. Carter, H. S. Friedman, D. D. Bigner, et al., “Exercise Interest and Preferences among Patients Diagnosed with Primary Brain Cancer,” Supportive Care in Cancer, Vol. 15, No. 1, 2007, pp. 47-55. doi:10.1007/s00520-006-0096-8

[68]   J. K. Vallance, K. S. Courneya, L. W. Jones and T. Reiman, “Exercise Preferences among a Population-Based Sample of Non-Hodgkin’s Lymphoma Survivors,” European Journal of Cancer Care (England), Vol. 15, No. 1, 2006, pp. 34-43. doi:10.1111/j.1365-2354.2005.00617.x

[69]   K. S. Courneya, C. M. Friedenreich, H. A. Quinney, A. L. Fields, L. W. Jones and A. S. Fairey, “A Randomized Trial of Exercise and Quality of Life in Colorectal Cancer Survivors,” European Journal of Cancer Care, Vol. 12, No. 4, 2003, pp. 347-357. doi:10.1046/j.1365-2354.2003.00437.x

[70]   W. Demark-Wahnefried, N. M. Aziz, J. H. Rowland and B. M. Pinto, “Riding the Crest of the Teachable Moment: Promoting Long-Term Health after the Diagnosis of Cancer,” Journal of Clinical Oncology, Vol. 23, No. 24, 2005, pp. 5814-5830. doi:10.1200/JCO.2005.01.230

 
 
Top