Exercise as Medicine: evidence review

The evidence on the impact of obesity on overall prostate cancer risk is inconclusive, but some research suggests that being overweight or obese has been associated with a higher risk of aggressive prostate cancer (6).  

In the UK, it's estimated that reducing the body mass index (BMI) of men aged 55-64 to the healthy range (18.5-24.0) could prevent approximately 1,300 prostate cancer deaths annually (7). It should be noted however, that a major limitation of BMI is that it does not distinguish between lean muscle mass and fat mass, nor does it account for sex, age or other aspects of body composition. It may not be accurate for athletes, people with oedema and across racial groups, particularly in Black men, who tend to have higher muscle mass. (8)

In radical prostatectomy, higher BMI is associated with increased risk of recurrence, poorer prognosis, and a higher risk of wound complications (9). In a small presurgical weight loss study, greater reductions in body fat were associated with a significantly lower incidence of postoperative complications (28.6% vs 73.3%), although the sample size was small and findings require confirmation in larger trials (10).

Increasing physical activity in combination with caloric restriction are key factors in reducing fat mass. To mitigate the loss of muscle and bone mass brought about by this energy imbalance, resistance training should be incorporated into any weight-loss programme, especially in prostate cancer populations (11).

2.1 Exercise and Treatment Viability

Research suggests that exercise may lead to better cancer-related outcomes and a review by Galvao et al suggests exercise interventions may have therapeutic potential. For example, one prospective study found that patients who had adopted lifestyle changes, such as dietary modifications and physical activity, experienced a reduction in PSA levels (4% decrease in intervention group versus 6% increase in the non-intervention group) and none progressed to active treatment, compared with 6 men in the non-intervention group. (12). This narrative review examined the potential role of exercise in men with low-risk, localised prostate cancer undergoing active surveillance. Conclusions are limited by small study sizes and a lack of large randomized controlled trials.

According to the NPCA State of the Nation 2025 report, radiotherapy was used to treat approximately 30% of tumours diagnosed in England and Wales between 2019 and 2024 (National Prostate Cancer Audit (NPCA) State of the Nation Report October 2025. London: National Cancer Audit Collaborating Centre, Royal College of Surgeons of England, 2025, n.d.). Preliminary research has found exercise may help improve radiotherapy treatment effectiveness by enhancing blood flow and oxygen delivery to tumours, which could increase radiosensitivity (3).

2.2 The impact of exercise on tumour and biochemical markers

Excess fat can create an environment that supports tumour growth, potentially contributing to cancer progression and recurrence. Although evidence in prostate cancer is limited, research in other cancer types suggests that physical activity can slow tumour growth and progression across different stages of disease, while reducing the proliferation of metastatic cells. Exercise also limits systemic inflammation, a known promoter of tumour progression. In prostate cancer, physical activity has been shown to improve biochemical markers, including reducing PSA levels. (3,12).

2.3 The impact of exercise on treatment side-effects

2.3.1 Fatigue

Cancer-related fatigue (CRF) is one of the most common and debilitating symptoms experienced by patients as a result of cancer or its treatment (14).

Although the EAU reports that regular exercise appears to be the best protective measure against fatigue (15), the evidence is inconclusive. A meta-analysis by Andersen et al. reported no statistically significant improvements in fatigue in men with prostate cancer following exercise (16).

Sleep

A 2013 review reported sleep disruption in 30–50% of cancer patients, making poor sleep quality several times more prevalent in this population than in the general population (14). Whilst aerobic exercise has been shown to improve sleep quality in the general population, studies in cancer patients are not consistent throughout the literature and should be interpreted with caution (Campbell et al., 2019).

2.3.2 Psychological factors and Quality of Life

The literature on the effect of exercise on psychological factors and QoL in prostate cancer patients is mixed and may be impacted by the side effects of various treatments. The EAU recommend moderate intensity exercise training improves cancer-specific QoL and that supervised exercise interventions delivered over twelve months are effective in reducing psychological distress; particularly in those men with highest levels of baseline anxiety and depression (15). In a small study by Langelier et al., men who met activity level guidelines reported better quality of life, improved body image and higher masculinity scores (18). However, Andersen et al. found that the impact of exercise on QoL was small and didn’t reach statistical significance (SMD=0.10, CI 95% −0.01–0.22) (16).

2.3.3 Body composition and metabolic function

Cancer treatments, particularly ADT, often cause rapid loss of lean muscle accompanied by an increase in body fat (15), a condition known as sarcopenic obesity. This may lead to reduced physical function, increased metabolic and cardiovascular risk, poorer quality of life, and worse overall health outcomes. ADT was also associated with a 25% increased risk for diabetes (15).

Despite testosterone suppression limiting the capacity to build muscle (17), exercise interventions during ADT have demonstrated increases in lean body mass and reductions in body fat mass and body fat percentage (15). Interventions have been shown to be particularly effective when initiated at the onset of treatment, as this helps prevent treatment-related declines in muscle strength and physical function (19).

2.3.4 Cardiovascular

According to the European Association of Urology (EAU), cardiovascular mortality is a common cause of death in prostate cancer patients (15). In men on active surveillance, one study found that nearly half of non-prostate cancer deaths were from cardiovascular disease and could occur up to seven times more often than prostate cancer deaths in some populations (20). Additionally, some forms of ADT have been associated with an accelerated cardiovascular risk, with a 57% higher risk of myocardial infarction (15).

Exercise may improve cardiovascular fitness and suppress PSA progression (15), with benefits maintained up to 12 months (21). Andersen et al. found that all exercise modalities were effective in improving cardiovascular fitness (16). In non-cancer populations, exercise has been shown to reduce cardiovascular deaths, myocardial infarctions and hospital admission (22). Additionally, longer-term exercise interventions can reduce systemic inflammation, a key mechanism linked to cardiometabolic health, disease progression, and survival (3).

2.3.5 Bone health

Bone health is another major concern during ADT as it accelerates bone resorption and reduces bone mineral density, therefore increasing the risk of fracture. Severe fractures in men are associated with a significant risk of death (15). Bone mineral density declines by 5-10% in the first 6-12 months of ADT and continues to decrease throughout treatment. In addition, bone is the most common metastatic site, with bone metastases present in approximately 80% of patients presenting with metastatic prostate cancer. (23).

The UK National Guidelines of Bone Health Management recommends combined exercise intervention including resistance training, aerobic exercises and impact exercises, totalling at least three hours per week, for patients with a high risk of falls who are initiating ADT (23).

Age, prostate cancer and exercise

Prostate cancer is a disease associated with older age (24), and its treatment-related side effects are particularly burdensome in older adults, who are already at increased risk of functional decline. An analysis of a US-based randomised controlled trial found that men aged over 70 with a history of cancer were 53% more likely to develop major mobility disability compared to people the same age without cancer (HR=1.53; 95% CI=1.18 to 1.99; P=.001). However, this risk decreased with structured exercise intervention (25).

2.3.6 Incontinence  

According to the NPCA State of the Nation Report 2025, approximately 7% of men diagnosed with low-risk localised prostate cancer in England and Wales underwent radical treatment. Among men with high risk or locally advanced cancer, 69% in England and 68% in Wales received radical treatment (National Prostate Cancer Audit (NPCA) State of the Nation Report October 2025. London: National Cancer Audit Collaborating Centre, Royal College of Surgeons of England, 2025, n.d.). These treatments can damage the voluntary urethral sphincter and cause incontinence (26). According to the EAU, men who undergo radical prostatectomy have nearly 4 times the risk of developing urinary incontinence than men who are on watchful waiting (15). 

Both the EAU and the American Urological Association recommend pelvic floor muscle training as first-line therapy (15,26).

2.3.7 Sexual function

The EAU found that up to 93% of men undergoing ADT experience a cessation of sexual activity due to reduced libido or impaired ability to gain and maintain erections. As a result, over 80% of couples stop sexual activity completely, affecting both patients and their partners. (15)

In some clinical trials exercise maintained or improved sexual health following treatment, but not in others (17). Prostate Cancer UK recommends pelvic floor exercises as part of pre- and post- treatment management.

2.3.8 Neurological disorders

ADT may negatively affect cognitive function and overall brain health through the suppression or blocking of testosterone (27). Patients treated by ADT reported a significant decline in spatial reasoning and working memory, as well as an increased risk of cognitive conditions such as Alzheimer’s. Additionally, some forms of ADT have been associated with up to a 51% increased risk of stroke. (15)

While evidence that exercise mitigates this risk in men with prostate cancer is currently limited, there is increasing research interest and a growing body of evidence in this field. Studies in the general population show that regular moderate-intensity physical activity improves cognitive function and reduces the risk of stroke and dementia in adults over 50 (28,29).

2.3.9 Pain

An American study reported that cancer-related pain is experienced by 45–59% of patients and survivors and can significantly disrupt daily life. Regular physical activity has been associated with reductions in pain intensity (14), however, evidence regarding the specific types and doses of exercise that are most effective remains limited (17).