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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


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 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 268,490 new cases of prostate cancer and 34,500 deaths from prostate cancer in 2022.3 The estimated risk for developing prostate cancer in males 70 and older is 1 in 11. In the last decade the percentage of patients diagnosed at later stages has increased from 3.9% to 8.2%.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 prostate cancer prevention trial showed a reduced risk of biopsy diagnosed prostate cancer with the use of 5-α-reductase inhibitors but the significance of these results is debated.5 The United States Preventative Services Task Force for Prostate Cancer Screening recommends men aged 55 to 69 decide individually if they should be screened and that men aged 70 and older not be screened.6


Most prostate cancers are adenocarcinomas with less than 10% coming from pure ductal origin.1 Prostate cancers are universally graded based on the Gleason grading system. It is a classification of the architectural and cellular features of prostate tissues examined at low magnification. A Gleason score is made by determining the most prevalent glandular differentiation pattern and the second most prevalent pattern. A grade group from 1-5 is then assigned based off the Gleason score with higher grades correlating with worse prognoses.7

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.8 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.9 Prostate cancers follow a predictable pattern of progression from localized androgen dependent disease to metastatic castration resistant disease. Prostatic intraepithelial neoplasia and proliferative inflammatory atrophy are two types of potentially premalignant lesions that could predispose to prostate cancer. Fortunately, prostate cancer often follows a long natural history, and most patients will die with prostate cancer as opposed to from it. In cases of metastasis, prostate cancer 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 as these can severely impact a patient’s 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 fibrosis of musculature and ligaments causing weakness, pain, incontinence, and lumbosacral plexus damage.       

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, and decreased bone mineral density which may all contribute to deconditioning, debility and decreased quality of life. Hot flashes are also frequently encountered. 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 a sensory and motor polyneuropathy causing discomfort, impairing proprioception, and increasing fall risk. Additional side effects include fluid retention, fatigue, weakness, infection, and nail changes.10

Essentials of Assessment


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 the treatment dates. Review of systems including but not limited to fevers, weight loss, muscle weakness, fatigue, paresthesias, back pain, joints pains, urinary symptoms (slow or weak urinary stream, nocturia, frequency), hematuria, hematospermia, erectile dysfunction, ejaculatory dysfunction, perineal pain, and bowel/bladder incontinence can be asked to explore progression of disease or adverse effects of therapies. 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 examination should focus on areas of concern brought up during the history.

In addition to vitals and general examination of the cardiac, respiratory and gastrointestinal systems, special attention should be given to the genitourinary, rectal and neuromuscular systems as indicated.

Areas of pain including the genitalia should be visualized to assess for possible lesions from radiation therapy. Digital rectal exam may be performed in cases of bowel incontinence to assess rectal tone.

Neurologic exam to assess cognition, mental status, strength, sensation, reflexes, and coordination is crucial. Manual muscle testing can determine localized or generalized weakness. 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.

Patients with areas of bony metastases should have areas of lesions inspected to ensure adequate range of motion without pain. The presence of functional pain may be an indication for prophylactic fixation depending on other factors per Mirels’ Criteria (see below). Care should be taken during strength and functional testing to avoid possible pathologic fracture.

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 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 only 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 states 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.11 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. 6 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.


Advances in imaging technology have improved the diagnostic tools for prostate cancer. Multiparametic Magnetic Resonance Imaging has demonstrated a pooled sensitivity of 89% and specificity of 73% in the detection of prostate cancer lesions.12 MRI-directed biopsies also have improved sensitivity and specific over transrectal ultrasound directed biopsies alone. In metastatic disease, CT scan of the abdomen and pelvis is performed to assess for soft tissue disease in the liver, lung, and lymph nodes. PET scans can detect areas of actively metabolizing disease but is only FDA-approved to assess clinical response in patients receiving chemotherapy in the setting of clinical trials.12 Patients receiving androgen deprivation therapy should undergo baseline dual-energy x-ray absorptiometry (DXA) scan and 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 concern for spinal cord injury. Additionally, plain films in areas of known appendicular skeletal metastasis (most often hips and shoulders) can help to guide activity restrictions and 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.13 For long bone metastases, Mirels’ Criteria can be used to determine stability and need for prophylactic fixation.14

SINS ComponentScore
Junctional Occiput-C2, C7-T2, T11-L1, L5-S13
Mobile spine (C3-C6, L2-L4)2
Semirigid (T3-T10) 11
Rigid (S2-S5)0
Occasional pain but not mechanical1
Pain-free lesion0
Bone Lesion 
Mixed (lytic/blastic)1
Radiographic Spinal alignment 
Subluxation/translation present4
De novo deformity (kyphosis/scoliosis)2
Normal alignment0
Vertebral body collapse 
> 50% collapse3
< 50% collapse2
No collapse with > 50% body involved1
 None of the above0
Posterolateral involvement of spinal elements 
None of the above0
-0-6: Stable
-7-12: Potentially unstable
-13-18: Unstable
Mirels’ Scoring System 
ScoreSite of LesionSize of LesionNature of lesionPain
1Upper limb<1/3 of cortexBlasticMild
2Lower Limb1/3-2/3 of cortexMixedModerate
3Trochanteric Region>2/3 of cortexLyticFunctional
-A score greater than 8 suggests need for prophylactic fixation

Early prediction of outcomes

The stage of prostate cancer ranges from I to IVB is based on Gleason score, Grade Group, TMN categories, and PSA. The higher the stage, the more the cancer has spread with distant metastasis correlating with decreased survival. According to statistics from the Surveillance, Epidemiology, and End Results Program, 5-year relative survival rates are 100% when disease is localized or regional and 30.6% when cancer has metastasized.15


Studies have indicated a role of high fat diet and obesity in the development and progression of prostate cancer. 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

Although the survival rates of prostate cancer have improved over the years, the trends in survival and quality of life vary across 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 rehabilitation of prostate cancer at all stages making all efforts to ensure equitable care.

Patients undergo a variety of emotional challenges when diagnosed with prostate cancer and adjustment disorder with depressed or anxious mood is not uncommon. Patients should be screened for comorbid psychological disorders using tools such as the Patient Health Questionnaire-2 and offered treatment when warranted.16 Patients should be encouraged to seek support from friends and family and referred to community and online support groups. Referral to specialty services such as clinical social work and psychiatry may also be beneficial.

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 patient quality due to side effects. Limited time and resources with physicians a potential barrier for delivering ethical, cost effective, patient centered care.17

Rehabilitation Management and Treatments

Available or current treatment guidelines

Patients with low-risk prostate cancer can be offered active surveillance or watchful waiting. The goal of surveillance is to perform prostate cancer testing at regularly scheduled intervals to track progression to higher risk tumor stages. 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 then 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 myriad 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 vigilant 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.


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.18 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 guidelines.19

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.20 Radiation can also incur long term sequala 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. Some patients may also benefit from referral to a pelvic floor rehabilitation specialist as The American Cancer Society Prostate Survivorship guidelines recommend that patients with pelvic floor dysfunction be referred to physical therapist for pelvic floor rehabilitation.21

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.22

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.23,24 The American Cancer Society Prostate Survivorship guidelines recommend for patient 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.20 For patients being planned for chemotherapy, physiatrists should actively be monitoring for distal symmetric polyneuropathy. Pretreatment electromyography may be considered to assess for pretreatment neuropathy which may be exacerbated by chemotherapy.10 For patient who develop functional impairment or intolerable neuropathy, clinicians should discuss with oncologists about delaying, reducing, substituting or stopping chemotherapy. The only pharmacologic treatment option to date that is strongly recommended in management of chemotherapy induced peripheral neuropathy is duloxetine.25 There is limited evidence showing benefits of exercise, acupuncture, scrambler therapy, gabapentinoids, tricyclic antidepressants, and oral cannabinoids.25 In addition to symptom management, patients should be screened for functional impairments, most often with gait and balance, from chemotherapy induced neuropathy. Patients often present with impaired proprioception and can improve their balance and gait with a course of physical therapy. Less often, patients may require an ankle foot orthotic or assistive device such as a cane or walker.

Palliative Care

In patients with metastatic disease resistant to multiple treatments, therapies should be focused on palliative measures to decrease pain and improve quality of life at the end stages of prostate cancer. Referral should be made to palliative care professionals who specialize in pharmacologic pain management. Areas of refractory bone pain may be considered for palliative radiation therapy. Severe back pain related to bony metastasis can sometimes be alleviated by thoracic lumbosacral orthotics.

Coordination of care

Given the sequelae of prostate cancer and the myriad adverse effects that can occur an interdisciplinary approach is required. It is critical that physiatrists work and communicate closely with medical and radiation oncology to manage symptoms and monitor for complications. There may be times where a patient is seeing the physiatrist more frequently and they may catch focal neurologic deficits that may warrant new imaging. Discussing the use of antioxidants during radiation therapy or steroid injections in the setting of immunotherapy are also decisions that should be made jointly. 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.26

Patient & 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 include education on maintaining healthy age-appropriate weight by limiting consumption of high calorie foods and beverages. Alcohol consumption should be limited to no more than 2 drinks per day. Regular physical activity should be promoted per the American College of Sports Medicine and the National Comprehensive Cancer Network. Tobacco use should be ascertained and patients should be offered tobacco cessation counseling and resources.20 Patients beginning on radiation therapy and ADT should also be counseled about likely effects including generalized weakness, deconditioning, and fatigue and how to pre-emptively mitigate such effects.

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.

There are numerous questionnaires that assess overall quality of life in patients with cancer. Commonly used assessments include the European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire (EORTC-QLQ), Functional Assessment of Cancer Therapy – General, and measures from the Patient Reported Outcomes Measurement Information System (PROMIS). A recently validated assessment tool specific to cancer rehabilitation practices is the PROMIS Cancer Function 3D Profile which assesses domains of physical function, fatigue, and social participation.

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.

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 National Comprehensive Cancer Network 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 using the SINS system and Mirels’ criteria 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

Cutting edge concepts and practice

  • The use of molecular imaging using PET-CT has gained traction over the last few years in the detection of prostate cancer. Radiotracers approved by the US Food and drug administration include C-choline PET-CT, 18F-fluciclovine PET-CT, 18F-sodium fluoride PET-CT. Studies so far have shown that PET-CT and PET MRI have comparable sensitivity and specificity to current standard of care modalities. 12
  • There are several minimally invasive, organ-sparing ablative therapies for localized prostate cancer, such as cryotherapy, high-intensity focused ultrasound, vascular targeted photodynamic therapy, interstitial laser thermos-therapy, electroporation, brachytherapy, and stereotactic radiotherapy which currently lack long-term term prospective comparative data.2
  • Precision medicine in prostate cancer is a continually evolving field. The impact of various genes such as CDK12ATMCHEK1/2 on prostate cancer phenotype and treatment are under active investigation.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

There continues to be controversy regarding optimal screening recommendations for prostate cancer and further research informing future guidelines is needed. Finding effective strategies to mitigate the detrimental effects of ADT including fatigue and muscle atrophy should also take priority and there should be further research on nutritional and exercise interventions. We also need better interventions in preventing bone loss and osteoporosis. Whole body vibration therapy has showed some initial promise and may be a potential strategy for reversing bone demineralization.27


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  2. Prostate cancer – The Lancet. Accessed March 26, 2022. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)00950-8/fulltext
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  15. Cancer of the Prostate – Cancer Stat Facts. SEER. Accessed April 1, 2022. https://seer.cancer.gov/statfacts/html/prost.html
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Author Disclosure

Marc Ramos Emos, MD
Nothing to Disclose

Arpit Arora, MD
Nothing to Disclose

Philip Chang, DO
Nothing to Disclose