Rehabilitation Management of Prostate Cancer

Disease/Disorder

Definition

Prostate cancer is an abnormal proliferation of cells within prostatic tissue. The cells of origin can be basal or luminal prostatic epithelial cells. Adenocarcinoma is the most common histologic type though small cell prostate cancers have also been noted.¹

Etiology

The human prostate is divided into the central, transition, and peripheral zones. Most prostate cancers arise from the peripheral zone. Accumulation of genomic aberrations can predispose one to prostatic neoplasia and eventually malignant transformation. Chronic inflammation and infection are theorized to drive prostate carcinogenesis due to oxidative stress.²

Epidemiology including risk factors and primary prevention

Prostate cancer is the second leading cause of cancer related mortality in males for all age groups. The American Cancer Society projects 313,780 new cases of prostate cancer and 35,770deaths from prostate cancer in 2025³ The estimated risk for developing prostate cancer in males between 65 and 84 years is 1 in 9.³

Risk factors include age, race/ethnicity, family history, diet, obesity, mutations in BRCA 1 and 2, exposure to agent orange, and Lynch syndrome.⁴

Currently, there are no FDA approved therapies for the primary prevention of prostate cancer. The United States Preventative Services Task Force for Prostate Cancer Screening recommends men aged 55 to 69 decide individually with their primary care provider if they should be screened and that men aged 70 and older not be screened.⁵

Patho-anatomy/physiology

Most prostate cancers are adenocarcinomas, with fewer than 10% of ductal origin. They are graded using the Gleason system, which assesses architectural and cellular features. The score reflects the predominant and second most prevalent glandular patterns, assigning a grade group (1–5), where higher grades indicate worse prognoses.⁶ Scores range from 6 or less (low grade) to 10 (high grade).

Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)

Prostate cancer is staged utilizing the American Joint Committee on Cancer TNM System.⁷ This is based on the extent of primary tumor (T category), spread of cancer to neighboring lymph nodes (N category), areas of metastasis (M category), prostate specific antigen (PSA) level at time of diagnosis, and the grade group.⁸ Prostate cancers follow a predictable pattern of progression from localized androgen dependent disease to metastatic castration resistant disease. Fortunately, prostate cancer often has a long natural history, with most patients dying with, not from, the disease. When metastatic, it commonly spreads to bones, lymph nodes, lungs, and liver.¹

Specific secondary or associated conditions and complications

Physiatrists should be aware of the adverse effects of various prostate cancer treatments including radiation, surgery, and systemic therapies which can severely impact quality of life.

Radiation therapy, commonly delivered as external beam radiation therapy or brachytherapy, may cause acute, early delayed (within 3 months of finishing treatment) and late delayed (after 3 months of finishing treatment) effects. Acute effects include pain, swelling, proctitis, fatigue, and skin breakdown of irradiated areas. Delayed effects may include bladder or bowel incontinence, lumbosacral plexus damage and fibrosis of musculature and ligaments causing weakness, tightness, and pain.

Surgical management includes varying degrees of partial or complete resection of the prostate. Potential complications from surgery in order of increasing prevalence include bowel incontinence, urinary incontinence, and erectile dysfunction.

Androgen deprivation therapy, typically with a gonadotropin releasing hormone with or without an antiandrogen, is often the cornerstone of treatment for castrate sensitive prostate cancer. Side effects include weight gain, muscle atrophy, metabolic syndrome, fatigue, mood changes, hot flashes, decreased libido, and decreased bone mineral density. In cases of advanced disease or metastasis, alternative antiandrogens including abiraterone or enzalutamide in conjunction with a taxane such as docetaxel may be indicated. Docetaxel commonly causes sensorimotor polyneuropathy leading to discomfort, impaired proprioception, and increased fall risk. Additional side effects include fluid retention, fatigue, weakness, infection, and nail changes.⁹

Essentials of Assessment

History

A comprehensive history should be obtained for patients with prostate cancer. An oncologic history should include date of diagnosis, stage of cancer, and prior treatments (including surgery, radiation therapy, and systemic therapies) along with treatment dates. Review of systems including but not limited to fevers, weight loss, muscle weakness, fatigue, paresthesias, back pain, joint pain, urinary symptoms (slow or weak urinary stream, nocturia, frequency), hematuria, hematospermia, erectile dysfunction, ejaculatory dysfunction, perineal pain, and bowel/bladder incontinence should be explored. Additional history should include family history, social history, vocational history, social support, home environment, and both baseline and current levels of function.

Physical examination

A comprehensive physical exam should focus on concerns raised during history-taking. Special attention should be given to the genitourinary, rectal, and neuromuscular systems. Painful areas, including genitalia, should be examined for radiation-related lesions. A digital rectal exam may assess rectal tone in cases of bowel incontinence. Neuromuscular evaluation should assess cognition, mental status, strength, sensation, reflexes, and coordination. Manual muscle testing may reveal distal weakness consistent with chemotherapy induced neuropathy or proximal weakness consistent with deconditioning. Sensory exam including light touch, vibration, proprioception, pain, and temperature can reveal signs of peripheral neuropathy or central nervous system pathology. Functional assessment of general and focused range of motion, balance, transfer ability, and gait assessment should also be performed.

For patients with bony metastases, lesion sites should be examined to ensure pain-free mobility. Functional pain may warrant prophylactic fixation per Mirels’ Criteria or SINS (see below). Closed fist percussion testing along the spine may indicate a vertebral compression fracture. Strength and functional testing should be performed cautiously to prevent pathologic fractures.

Clinical functional assessment: mobility, self-care cognition/behavior/affective state

Clinicians should ascertain functional status before, during, and after treatment. Impairments in strength, mobility, and self-care should be documented to determine appropriate rehabilitative therapies. Functional tests that can be performed in the office setting include timed up and go, functional reach test, Tinetti balance and gait evaluation, and the Short Performance Physical Battery. Special considerations should be taken for individual living situations, home environment, support systems, and availability of caregivers.

Laboratory studies

PSA is a protein made by the prostate making it the most valuable and commonly used test for the detection of prostate cancer. There has been much debate over the use of PSA as a screening tool for prostate cancer.

The American Cancer Society guidelines currently state that men with at least a 10-year life expectancy should be offered the opportunity to make an informed decision with a health care provider about screening for prostate cancer.¹⁰ Screening should include PSA with or without concomitant digital rectal exam after a thorough discussion of risks, alternatives, and benefits. Men with an average risk should have this discussion at 50 years of age. However, men who are at higher risk such as African Americans with a family history of prostate cancers before the age of 65 should be counseled starting at age 45 years. The US Preventative Task Force currently recommends against PSA screening in men 70 years and older.⁵ In men with equivocal PSA results, clinicians can obtain a PSA density and free PSA level to better estimate the likelihood of prostate cancer. Patients undergoing radiation therapy or receiving systemic therapies should have complete blood counts and comprehensive metabolic panels taken at regular intervals to assess for cytopenias and/or metabolic derangements.

Patients presenting with clinically significant fatigue may undergo additional testing with complete blood count, metabolic panel, vitamin D, vitamin B12, thyroid studies and cortisol levels as indicated.

Imaging

Advances in imaging have enhanced prostate cancer diagnosis. Multiparametric MRI has 89% sensitivity and 73% specificity for detecting lesions, with MRI-directed biopsies outperforming transrectal ultrasound-guided biopsies.¹¹ In metastatic disease, CT assesses soft tissue involvement in the liver, lungs, and lymph nodes, while PET scans detect active disease but are FDA-approved only for clinical trials.¹¹ Patients receiving androgen deprivation therapy should undergo baseline dual-energy x-ray absorptiometry (DXA) scan at 12-24 month intervals following treatment initiation to assess bone mineral density. There should be low threshold to obtain spinal MRI (or CT if MRI is contraindicated) in cases of vertebral metastasis and with suspected spinal cord injury. Plain films in areas of known appendicular skeletal metastasis (most often hips and shoulders) can help to guide activity restrictions and the need for orthopedic referral.

Supplemental assessment tools

In patients with spinal metastasis, the Spine Instability Neoplastic Score (SINS) can be utilized to determine stability of spinal metastases.¹² For long bone metastases, Mirels’ Criteria can be used to determine stability and need for prophylactic fixation.¹³

Scoring:
-0-6: Stable
-7-12: Potentially unstable
-13-18: Unstable

Scoring:
-A score greater than 8 suggests need for prophylactic fixation

Early prediction of outcomes

Prostate cancer staging (I–IVB) is determined by the Gleason score, Grade Group, TNM classification, and PSA levels. Higher stages indicate greater spread, with distant metastases correlating with decreased survival. According to statistics from the Surveillance, Epidemiology, and End Results Program, the 5-year relative survival rate is 100% for localized or regional disease and 30.6% with metastatic disease.¹⁴

Environmental

Studies suggest that a high fat diet and obesity contribute to prostate cancer development and progression. Patients should be educated on the optimization of their modifiable risk factors to decrease the likelihood of developing prostate cancer.^1,4

Social role and social support system

While prostate cancer survival rates have improved over the years, outcomes vary by socioeconomic, racial, and ethnic backgrounds. It has been shown that African Americans have a higher risk of prostate cancer occurring at an earlier age compared to other ethnic groups. Physiatrists should pay special attention to the role of social inequalities during all stages of rehabilitation to strive for equitable care.

 A prostate cancer diagnosis often brings significant emotional challenges, with adjustment disorder, anxiety, and depression being common. Screening for psychological comorbidities using tools like the Patient Health Questionnaire-2 is essential, ensuring timely intervention when needed.¹⁵ Patients should be encouraged to seek support from family, friends, and community or online groups. Referral to clinical social work, psychiatry, spiritual care or other specialty services can further enhance emotional well-being and coping strategies.

Professional issues

Informed consent regarding decision making for PSA testing and digital rectal exam for prostate cancer detection is paramount for ethical care. Although there is level 1 evidence that prostate cancer screening decreases cancer specific mortality, it can potentially lead to overdiagnosis and overtreatment of clinically insignificant cancer. Overtreatment can consequently affect quality of life due to side effects. Limited time and resources with physicians may also be a potential barrier for delivering ethical, cost effective, patient centered care.¹⁶

Rehabilitation Management and Treatments

Available or current treatment guidelines

Patients with low-risk prostate cancer can be offered active surveillance or watchful waiting. Definitive treatment would be offered at the time of disease progression. This allows educated patients with low-risk disease to safely avoid or defer curative treatment thus preserving urinary, sexual and bowel function. In patients with short life expectancies or significant comorbidities, watchful waiting would be the preferred option.²

In patients with locally advanced prostate cancers, they can be offered radical prostatectomy or radiation therapy. Both options have good 10-year disease free survival rates. High risk disease may also be treated with neoadjuvant, concomitant, or adjuvant hormonal therapy. A cohort of patients may present with recurrent disease manifesting as rising PSA after definitive therapy. In locally recurrent, node negative, non-metastatic prostate cancer, patients may be offered salvage prostatectomy.^1,2

Metastatic castrate sensitive prostate cancers are treated with androgen deprivation therapy (ADT). Several forms of ADT are highly effective at slowing disease progression. Common regimens used are a gonadotropin releasing hormone alone or in combination with an antiandrogen. In the last decade, studies have shown the benefit of combining ADT with docetaxel. Patients who progress to metastatic castrate resistant prostate cancer may need to be treated with a combination of antiandrogens, immunotherapy, radium-223, and chemotherapy.¹

Physiatrists should be aware of the adverse effects of prostate cancer treatments as rehabilitation interventions will depend on the impairments present. While deficits ranging from myofascial pain to spinal cord injury may occur, the focus is most often on fatigue and generalized weakness secondary to ADT. Throughout treatment, the rehabilitation professional should be screening for any impairments that do occur and working to maximize function and quality of life.

At different disease stages

Physical impairments from prostate cancer can arise at any stage of the disease. Accurate assessment of functional disorders, pain, urinary disorders, bowel dysfunction, sexual dysfunction, and comorbidities is essential in creating a safe and effective rehabilitation program. Therapy programs should be tailored to the type of cancer treatment received, current disease state, and goals of patients.

Prehabilitation

Rehabilitation interventions should begin early in the continuum of prostate cancer care to maximize and maintain function. A growing body of evidence shows the benefit for prehabilitation in several cancers, including prostate cancer.¹⁷ Prehabilitation traditionally occurs between the time of cancer diagnosis and before the start of definitive treatment although in some circumstances it may occur concurrently with neoadjuvant therapy. Patients who are cleared for physical activity should be encouraged to complete 150 minutes of moderate intensity physical activity per week with 2-3 days per week of strength training targeting major muscle groups per the American College of Sports Medicine (ACSM) guidelines.¹⁸

Complications from radiation therapy

Radiation therapy can acutely cause bowel dysfunction leading to bowel irregularity, diarrhea, and cramps. Short term effects may be managed with stool softeners, topical steroids, suppositories, enemas, or anti-inflammatories such as mesalamine. Late effects of bowel dysfunction can include rectal ulceration, rectal pain, and anal sphincter dysfunction which may necessitate the involvement of gastrointestinal specialist.¹⁹ Radiation can also incur long term sequelae on urinary function including urinary stricture, urinary incontinence, overactive bladder, fistula, and hematuria. Treatment options for urinary dysfunction include anticholinergic medications, alpha blockers, urethral slings, or artificial urinary sphincters. The American Cancer Society Prostate Survivorship guidelines recommend that patients with pelvic floor dysfunction be referred to physical therapist for pelvic floor rehabilitation.²⁰

Complications from surgery

Surgical management and radiation therapy can both have detrimental effects on sexual function. Sexual rehabilitation programs can be useful in minimizing these side effects. Although medical therapy should be offered sooner rather than later for patients experiencing erectile dysfunction, studies suggest maximal recovery may not occur until 18 months following surgery. Medical management most often includes oral phosphodiesterase type 5 inhibitors which can be given with intracavernosal injections of vasodilatory agents. Mechanical therapies including vacuum erectile devices and penile prostheses. Relationship and intimacy issues can be addressed with sexual counseling and couples counseling. Sexual dysfunction is often multifactorial therefore other factors such as depression, anxiety, grief, mourning, partner sexual dysfunction, and comorbidities should be addressed.²¹

Urinary dysfunction can result from surgical intervention of prostate cancer. Urinary function tends to improve gradually after surgery and remains stable after one year. For patients whose urinary function does not improve, treatment options can be similar to the management of urinary dysfunction from radiation therapy as discussed above.

Complications from systemic treatments

ADT is associated with increased risk for cardiovascular disease, metabolic derangements, and osteoporosis. Multiple studies have shown the beneficial effects of resistance and aerobic exercise for patients undergoing ADT.^22,23 The American Cancer Society Prostate Survivorship guidelines recommend that patients starting ADT be offered supervised resistance and aerobic exercise at least twice a week for 12 weeks to reduce fatigue and improve quality of life.¹⁹ Physiatrists should monitor patients for chemotherapy induced polyneuropathy (CIPN). Pretreatment electromyography may assess for preexisting neuropathy, which chemotherapy can worsen.⁹ If functional impairment or intolerable neuropathy develops, clinicians should discuss with oncologists about modifying or stopping chemotherapy. Duloxetine is the only strongly recommended pharmacologic option for CIPN, though limited evidence supports exercise, acupuncture, scrambler therapy, gabapentinoids, tricyclic antidepressants, and cannabinoids.²⁴ In addition to symptom management, patients should be screened for functional impairments. Patients often present with impaired, gait, balance, and proprioception due to CIPN which can be improved with directed physical therapy. Less often, patients may require an ankle foot orthotic or assistive device such as a cane or walker.

Palliative care

Rehabilitation should also focus on palliation to reduce pain and improve quality of life. Referral to palliative care specialists for pain and symptom management is essential. Refractory bone pain may warrant palliative radiation, while severe back pain from metastases may benefit from thoracic lumbosacral orthotics.

Coordination of care

Managing sequelae from prostate cancer requires an interdisciplinary approach. Physiatrists must collaborate with medical and radiation oncologists to monitor symptoms and complications. There may be times when a patient sees the physiatrist more frequently and they may catch focal neurologic deficits that may warrant new imaging.

Certain treatment decisions require joint management. A common example is patients using supplements and antioxidants during chemotherapy and radiation therapy. Antioxidants have the potential to protect not only normal tissue but also tumor cells from oxidative damage, possibly diminishing the efficacy of radiation. As such, these decisions should be made in close collaboration with radiation oncologists to weigh the potential risks and benefits in the context of the patient’s cancer stage and treatment goals. Similarly, steroid injections for musculoskeletal pain should be carefully evaluated in patients receiving immunotherapy. Corticosteroids may blunt the immune response and reduce the effectiveness of immune checkpoint inhibitors. When injections are recommended for function or quality of life, the decision should be made in discussion with the oncology team to minimize any potential negative impact on cancer treatments.

Coordination of care with allied health professionals is also essential. Skilled therapists may uncover findings of new complications or spread of disease and are critical in designing optimal treatment plans. Psychologists may assist patients in mitigating the emotional impact of their cancer. Clinical dieticians can educate patients on healthy food options to decrease risk for prostate cancer. Social workers and case managers are vital for patients with socioeconomic challenges to ensure they have safe and equitable access to their treatments.²⁵

Patient and family education

Patients should be educated on risks and benefits of PSA testing. They should also be educated on the advantages, disadvantages, and contraindications of treatments for prostate cancer. Counseling should emphasize maintaining a healthy age-appropriate weight, limiting high-calorie foods, and restricting alcohol to two drinks daily. Regular physical activity should follow ACSM and National Comprehensive Cancer Network (NCCN) guidelines. Tobacco use should be assessed and cessation support offered. Patients starting radiation therapy or ADT should be counseled on potential effects like weakness, deconditioning, and fatigue, along with strategies to mitigate them.

Measurement of treatment outcomes including those that are impairment-based, activity participation-based and environmentally based.

Several physical tests and questionnaires can be utilized to assess a patient’s function and track physical performance and quality of life throughout the continuum of prostate cancer care. The Expanded Prostate Cancer Index Composite for clinical practice questionnaire is a one-page clinical tool that ascertains a patient’s urinary, bowel, sexual, and hormonal health. This tool can be useful in starting discussions regarding symptoms patients may be reluctant to report. A validated assessment tool specific to cancer rehabilitation practices is the Patient Reported Outcomes Measurement Information System Cancer Function 3D Profile which assesses domains of physical function, fatigue, and social participation. Tests that can be performed in the office to assess patient functional status includes but is not limited to the timed up and go, the short performance physical battery, and gait evaluation.

Translation into practice: practice “pearls”/performance improvement in practice (PIPs)/changes in clinical practice behaviors and skills

As the cornerstone of treatment is often ADT, having as high a level of baseline conditioning as possible prior to treatment and maintaining physical activity throughout treatment is paramount. Patients fit for physical activity according to risk stratification from the NCCN should be encouraged to participate in regular aerobic exercise, resistance training, and stretching as tolerated.

Patients with significant areas of skeletal metastasis particularly in areas of the spine should be counseled on physical activity precautions. Assessments and risk stratification for instability or pathologic fracture should be performed. Patients with significant spinal metastasis should be instructed to avoid movements of the spine in multiple planes such as bending and twisting simultaneously as well as exercises that place increased pressure on the spine such as sit-ups, crunches, and corkscrews. Rather, exercises that maintain a spine neutral position such as planks should be encouraged. In general, patients should avoid any exercises that cause pain.

Cutting Edge/Emerging and Unique Concepts and Practice

• PET-CT molecular imaging has gained traction in prostate cancer detection. FDA-approved radiotracers include C-choline, 18F-fluciclovine, and 18F-sodium fluoride PET-CT. Studies show PET-CT and PET-MRI have comparable sensitivity and specificity to standard modalities.¹¹
• Minimally invasive, organ-sparing ablative therapies for localized prostate cancer include cryotherapy, HIFU, photodynamic therapy, interstitial laser thermotherapy, electroporation, brachytherapy, and stereotactic radiotherapy, though long-term comparative data are lacking.²
• Precision medicine in prostate cancer is evolving, with genes like CDK12, ATM, and CHEK1/2 under investigation for their impact on disease phenotype and treatment.¹
• There is increasing study in the role of immunotherapy and targeted radioisotopes which show promise in treatment of prostate cancer.

Gaps in the Evidence-Based Knowledge

Optimal prostate cancer screening remains controversial, requiring further research. Priorities include mitigating ADT-related fatigue and muscle loss, along with exploring nutritional and exercise interventions. Improved strategies for preventing bone loss and osteoporosis are needed. Whole-body vibration therapy shows promise as a potential method for reversing bone demineralization.²⁶

References

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Original Version of the Topic

Marc Ramos Emos, MD, Arpit Arora, MD, Philip Chang, DO. Rehabilitation Management of Prostate Cancer. 4/20/2022

Author Disclosure

Marc Ramos Emos, MD
Nothing to Disclose

Arpit Arora, MD
Nothing to Disclose

Philip Chang, DO
Nothing to Disclose