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Exercise Recommendations

This page outlines where evidence is available for healthcare professionals on the implementation of and considerations for exercise interventions for prostate cancer patients.

However, practitioners should be conscious of safety considerations such as contraindications to exercise and tailor sessions to personal factors such as goals, limitations, baseline fitness level, response to exercise, age, treatment modality, treatment stage and exercise preferences. 

Exercise as Medicine: recommendations for implementation

This document sets out some of the evidence and recommendations for implementing exercise interventions for prostate cancer patients.

As lasting benefits depend on sustained behaviour change, the review also explores exercise engagement through behaviour change models such as the COM-B framework (1), considering common barriers and motivations and acknowledging important inequalities, particularly for Black men, who face twice the risk of prostate cancer compared to other men but remain under-represented in research (2).

1. Screening and testing

There's ongoing debate regarding the need for medical clearance before exercise testing and prescription.

Requiring clearance for all patients may create unnecessary barriers, particularly given the known harms of inactivity, and that targeted exercise is rarely contraindicated. However, medical clearance can facilitate valuable communication between the exercise practitioner, treating clinician, and the patient.  

The Physical Activity Readiness Questionnaire for Everyone (PAR-Q+) is a useful screening tool to identify if individuals should seek further advice from a healthcare professional before becoming more physically active. 

Ideally, men should be assessed in all components of health-related physical fitness (i.e., cardiorespiratory fitness, bone density, muscle strength and endurance, body composition, and flexibility) before, during, and after intervention. However, as with the issue of medical clearance, mandatory exercise testing may create an unnecessary barrier to starting activity and isn’t necessary to start low-intensity aerobic training (i.e., walking or cycling), resistance training with gradual progression, or a flexibility program in most cases. (3)

2. Pre- and post- intervention measurements

Measuring health outcomes before, during, and after an exercise intervention helps determine whether the program is effective, highlights when adjustments to activity are needed, and may motivate men as they see their progress.

Assessments and interventions should be tailored to each individual’s symptoms, goals, and exercise capacity. Below are some suggested measures.  

Physical function and mobility:   

Short Physical Performance Battery (SPPB) - predictor of major mobility disability in older adults.

6-minute walk test - assesses submaximal level of functional capacity and reflects the functional exercise level needed for daily physical activities.

Balance and fall risk:   

Berg balance scale - high-validity test used to determine someone’s capacity to balance safely during various tasks and in different settings (home, hospital etc.)

Chair stand test (a.k.a. 5-times sit to stand test) - predicts fall risk.

 Fatigue and QoL:   

Functional Assessment of Cancer Therapy – Prostate (FACT-P)- subjective measure of prostate cancer symptoms, pain-related symptoms, and overall HRQoL for men with prostate cancer.

EORTC QLQ-C30- cancer specific quality of life questionnaire.

 Muscle strength:   

1 Repetition Max (1RM) or 5 Repetition Max (5RM) strength test - 1RM involves high loading to assess maximal strength, while the 5RM is a submaximal and potentially safer alternative.

Handgrip strength - Although handgrip strength correlates to overall muscle strength when used as a screening tool, it's not responsive to resistance training of the lower limbs, which is a key component of functional training in mobile adults. Therefore, handgrip strength should be used for screening only and not as an indicator of progress following exercise interventions (4).

 Muscle mass 

Calf circumference - This is a simple, accessible way to estimate muscle mass that closely reflects results from more complex measurement methods.

 Cardiovascular fitness:   

VO2max - gold standard to measure cardiovascular fitness. It's a calculation of how efficiently the body’s cells use oxygen for energy.

Rating of Perceived Exertion (RPE) on the Modified Borg Scale - measures perceived exertion or exercise intensity without the need to rely on physiological parameters such as peak O2 uptake, heart rate and lactate levels.

 Body composition:   

DXA scan / CT scan / MRI- DXA imaging is considered the gold standard for body composition measurement; however, all these modalities require specialised equipment and can be costly, meaning they're not always feasible in clinical or community settings.

Skin fold thickness - a simple, reliable, low-cost, and non-invasive method that can be adjusted for factors such as race and age; however, it's less accurate in individuals with severe obesity and requires adequate training to perform accurately.

Waist to hip ratio (WHR) - linked to cardiovascular and metabolic health outcomes, including diabetes. However, it's subject to measurement error and requires adequate training to assess accurately. WHR does not account for age, sex, or ethnicity, and results may be confounded by large hip circumference.

Body Mass Index (BMI) - easy to calculate but limited accuracy as health measurement.

3. Exercise preferences

Exercise medicine may be particularly appealing to men, as it aligns with traditional male values and action-oriented coping strategies, and offers sustained support within a peer group setting (5). Walking is the most consistently preferred activity across cancer types and treatment stages (6).  

A systematic review of cancer survivors found that they prefer moderate-intensity physical activity (6); however, moderate to vigorous exercise has been found to be most effective in improving physical and psychological outcomes (3,7). Therefore, exercise programmes may benefit from starting at a moderate intensity and progressing gradually to higher intensities to support adherence while maximising health benefits.  

Supervised exercise programmes are generally more effective than unsupervised interventions (3) and group sessions have the added benefit of facilitating peer support and social engagement, which are commonly identified facilitators of adherence (8). However, given the popularity of home-based training (8), NICE suggests a hybrid approach, such as initial in-person supervision followed by ongoing remote support (e.g. telephone check-ins), which may help balance effectiveness with accessibility and reduce barriers such as transport or discomfort with group exercise (9).  

4. Adherence to Exercise and Behaviour Change 

Men should be actively involved in programme design and delivery to promote a sense of ownership and engagement in their own care. This includes setting clear, personalised goals, developing practical action plans, monitoring progress over time, and incorporating social support to encourage adherence.

For this approach to be effective, healthcare practitioners must work collaboratively with men to understand their individual barriers to exercise and identify factors that motivate them. 

Behaviour Change

The COM-B behaviour change framework explains behaviour as the result of interactions between capability, motivation and opportunity and provides a useful lens for understanding men’s willingness to engage in exercise (1). In the context of cancer patients, a fourth ‘clinician-related barriers’ domain should be considered.  

Capability refers to the physical and mental skills, knowledge, and strength to exercise (1,10). This includes understanding that exercise is safe and beneficial for people with cancer, having the skills and confidence to engage in exercise, and being physically able to do so. Cancer and treatment-related symptoms, such as fatigue, pain, breathlessness, incontinence following prostatectomy or radiotherapy, and reduced motivation from ADT, as well as lack of clinical support, could limit this capacity. 

Motivation comes from the brain processes that initiate, guide and sustain behaviour (i.e. goals, impulses and reflexive patterns) (1). In men with prostate cancer, motivation could be reduced by competing priorities such as work, childcare, or family responsibilities, and negative emotions including fear, embarrassment, guilt, anxiety, or low self-esteem.  

Opportunity (or structural) barriers are physical and social factors external to the individual such as time, location, resources, and support (1). Social barriers may be intensified by previous negative healthcare experiences, cultural norms, or experiences of racism.  

Deprivation is a key determinant of prostate cancer outcomes, with Black men disproportionately represented in more deprived neighbourhoods and therefore at increased risk of poorer outcomes (2). 

Depenbusch J. et al. found that people from lower socioeconomic groups are generally less physically active and perceive greater structural barriers to exercise. Even after accounting for factors such as age, health, and treatment type, higher perceived structural barriers were associated with significantly lower activity levels following a cancer diagnosis. (11) 

Clinician-related barriers are factors related to healthcare professionals that limit the discussion, recommendation, or support of exercise in clinical care. These may include fear of causing injury, time constraints, uncertainty about exercise safety or referral pathways and the belief that it's not the oncologist’s role to prescribe exercise. Without clear guidance from clinicians, exercise may feel daunting or even counterintuitive, contributing to a cycle in which inactivity further worsens symptoms and functional decline. 

Suggestions to overcome barriers to exercise in prostate cancer patients:  

Provide education and training for both patients and clinicians to support exercise engagement.

Use community focus groups to inform programme design, ensuring interventions meet local needs and address financial constraints.

Develop programmes specifically targeting Black communities through collaboration with community and religious leaders.

Ensure information and interventions are culturally sensitive and tailored to specific populations, such as Black men.
Create tailored and flexible interventions, e.g. adaptable to fluctuating symptoms or weekly fatigue pattern during treatment.

Adapt exercise programmes to accommodate the working patterns of people in low-paid or insecure employment.

Offer both in-person, at-home or combined options for structured exercise programmes.

Carry out exercise testing before and after interventions and use pedometers during sessions to track progress, help men see improvements and inform programme progression.

Aim to establish a routine or habit of exercising, reinforced through ongoing contact with healthcare practitioners, such as regular check-ins or telephone monitoring.

Additional considerations for Black men 

Communication is most effective when it's informal and community- or family-centred. Some studies suggest Black men prefer to receive information from trusted sources such as family, partners, community, or religious leaders, rather than print materials. (12)

Faith can both facilitate and hinder engagement, as some men rely on prayer instead of consulting clinicians, while others view God as supporting medical care (12).

Interventions that emphasise independence, regaining physical fitness, and post-treatment recovery are particularly appealing among African Caribbean men with prostate cancer (13) .

A prostate cancer diagnosis often leads to financial strain, disproportionately affecting men who are Black, as often those men can be younger at diagnosis and socioeconomically disadvantaged (14,15).

References

1. Michie S, van Stralen MM, West R. The behaviour change wheel: A new method for characterising and designing behaviour change interventions. Implementation Science. 2011 Apr 23;6(1). doi:10.1186/1748-5908-6-42 PubMed PMID: 21513547.

2. Inequalities in prostate cancer mortality in England | Prostate Cancer UK [Internet]. [cited 2026 Jan 23]. Available from: https://prostatecanceruk.org/for-health-professionals/data-and-evidence/inequalities-in-prostate-cancer-mortality-in-england

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4. Abdalla PP, Carvalho ADS, Dos Santos AP, Venturini ACR, Alves TC, Mota J, et al. One-repetition submaximal protocol to measure knee extensor muscle strength among older adults with and without sarcopenia: A validation study. BMC Sports Sci Med Rehabil. 2020 May 6;12(1). doi:10.1186/s13102-020-00178-9 PubMed PMID: 32391159.

5. Galvão DA, Taaffe DR, Spry N, Gardiner RA, Taylor R, Risbridger GP, et al. Enhancing active surveillance of prostate cancer: The potential of exercise medicine. Nature Reviews Urology. Nature Publishing Group; 2016. p. 258–65. doi:10.1038/nrurol.2016.46 PubMed PMID: 26954333.

6. Wong JN, McAuley E, Trinh L. Physical activity programming and counseling preferences among cancer survivors: A systematic review. International Journal of Behavioral Nutrition and Physical Activity. BioMed Central Ltd.; 2018. doi:10.1186/s12966-018-0680-6 PubMed PMID: 29879993.

7. Edmunds K, Tuffaha H, Scuffham P, Galvão DA, Newton RU. The role of exercise in the management of adverse effects of androgen deprivation therapy for prostate cancer: a rapid review. Supportive Care in Cancer. 2020;28:5661–71. doi:10.1007/s00520-020-05637-0/Published

8. Finch A, Benham A. Patient attitudes and experiences towards exercise during oncological treatment. A qualitative systematic review. Supportive Care in Cancer. Springer Science and Business Media Deutschland GmbH; 2024. doi:10.1007/s00520-024-08649-2 PubMed PMID: 38992238.

9. Falls: assessment and prevention in older people and in people 50 and over at higher risk NICE guideline [Internet]. 2025. Report. Available from: www.nice.org.uk/guidance/ng249

10. Rana B, Okere UC, Imm KR, Yang L, Housten AJ. Physical activity behaviour change in black prostate cancer survivors: a qualitative study using the Behaviour Change Wheel. Supportive Care in Cancer. 2024 Mar 1;32(3). doi:10.1007/s00520-024-08334-4 PubMed PMID: 38340207.

11. Depenbusch J, Wiskemann J, Haussmann A, Tsiouris A, Schmidt L, Ungar N, et al. Impact and Determinants of Structural Barriers on Physical Activity in People with Cancer. Int J Behav Med. 2022 Jun 1;29(3):308–20. doi:10.1007/s12529-021-10014-0 PubMed PMID: 34550527.

12. Christie-de Jong F, Oyeniyi OS, Nnyanzi LA, Ling J, Murphy MK, Eberhardt J, et al. Barriers and facilitators to accessing healthcare for early diagnosis of prostate cancer for black men—a qualitative exploration in North-East England and Scotland. BMC Public Health. 2025 Dec 1;25(1). doi:10.1186/s12889-025-23650-y PubMed PMID: 40660194.

13. Er V, Lane JA, Martin RM, Persad R, Chinegwundoh F, Njoku V, et al. Barriers and facilitators to healthy lifestyle and acceptability of a dietary and physical activity intervention among African Caribbean prostate cancer survivors in the UK: A qualitative study. BMJ Open. 2017 Oct 1;7(10). doi:10.1136/bmjopen-2017-017217 PubMed PMID: 29038181.

14. Black men and prostate cancer | Prostate Cancer UK [Internet]. [cited 2026 Jan 23]. Available from: https://prostatecanceruk.org/prostate-information-and-support/risk-and-symptoms/black-men-and-prostate-cancer

15. EAU Guidelines. Edn. presented at the EAU Annual Congress Madrid 2025. ISBN 978-94-92671-29-5.