Active Surveillance- Systematic Review of Interventions

I can’t prove what their findings show, I can just show what my results are.

For cardio, I walk a mile twice a day on the track as fast as I can go and I go to the gym three days a week and exercise the whole time I’m there, with weights.

I eat very carefully, Lots of fruit, vegetables, nuts, brown rice, chicken or fish very seldom do I have red meat.

Even though I have BRCA2 and I’ve had prostate cancer for 16 years I’ve been undetectable for the last 30 months. Is my exercise and eating making a difference I don’t know, I do know the cancer is not progressing, yet.

That’s inspiring, you’ve made me want to up my game with the protocol I’ve developed.

So in other words other than HIIT exercise, the evidence to support dietary changes and the use of supplements (although they might improve overall health) to keep PSA scores stable/low and prevent cancer progression is inconclusive?

@ezupcic Great question, and I think the systematic review is really valuable — but I'd read it slightly differently.

You're right that exercise has the strongest evidence. The ERASE trial showed HIIT decreased PSA, PSA velocity, and inhibited cancer cell growth in men on active surveillance. If you only do one thing, make it exercise.

Diet is a step behind but moving in the right direction. The CAPFISH-3 trial (high omega-3, low omega-6 with fish oil) just showed a significant reduction in Ki-67 — a cancer proliferation marker — in AS patients. Published in the Journal of Clinical Oncology. That's not conclusive proof it prevents progression, but it's more than a hunch.

Supplements are the most mixed bag, and the review is right to be cautious about the category overall. But there are some results worth knowing about. Professor Robert Thomas's research group in the UK has now run two double-blind, placebo-controlled RCTs. The original Pomi-T trial (2014, 199 men) showed a polyphenol blend of pomegranate, green tea, broccoli, and turmeric reduced PSA rise by 63.8% compared to placebo. His latest trial, published in European Urology Oncology in 2025, went further — an upgraded phytochemical supplement (YourPhyto) combined with a probiotic (YourGutPlus) slowed PSA progression by 44%, and MRI disease stabilised or shrunk in 91% of patients. It also improved urinary symptoms, erectile function, and grip strength. That's published in one of the top journals in the field and was presented at ASCO GU.

The Belgian PRAEMUNE trial also showed fermented soy with equol modulated PSA in 61% of AS patients and led to fewer biopsies.

So I think the key takeaway isn't that diet and supplements don't work — it's that we don't yet have the very large, long-term trials to say definitively that they prevent progression. That's a different statement. And given that most of these interventions are low-cost, low-risk, and likely to improve overall health regardless, the question for most of us on AS isn't really "is the evidence conclusive?" — it's "is there enough evidence to justify doing this while we wait for bigger trials?" For exercise, clearly yes. For an omega-3 rich diet, I'd say yes. For specific tested supplements like YourPhyto, the evidence is now quite compelling.

I've been pulling together all of this research at evidence.zone — every intervention rated by the quality of the published evidence, with full study citations and limitations. It's free to use. Might be useful if you want to dig into any of these individual findings.

Paul

@paulsweeney, I appreciate the response and the evidence zone site. It is really helpful and I'm trying many of the things that are recommended there. There is a great deal of uncertainty with prostate cancer but I would agree that changes to exercise, diet and supplements are worth trying even if large evidence based studies to support their efficacy do not yet exist.

@ezupcic so glad you found it helpful. And I completely agree on things that are worth trying, many of them are good for general health also.

@paulsweeney

Your analysis of the evidence discussed in this review is spot on!

However, I think the review's conclusion comes across as overly negative and somewhat unwarranted:

"...With moderate certainty, exercise programs improve cardiorespiratory fitness and some patient-reported outcomes (quality of life, fatigue, cancer-related worry), supporting lifestyle change as structured supportive care during surveillance. With low to very low certainty, evidence does not show a consistent, reproducible reduction in key oncologic outcomes such as biopsy upgrading, MRI progression or durable deferral of definitive treatment....For men undergoing active surveillance, lifestyle interventions may be beneficial as supportive measures to improve physical well-being, selected patient-reported outcomes, and cardiometabolic health. However, current evidence remains insufficient to demonstrate a consistent effect on biopsy upgrading, MRI progression, or durable deferral of definitive treatment."

IMHO if I was just diagnosed with low or favorable risk PCa, this review's conclusion is probably going to dampen my resolve to implement any of the cited evidence based interventions. Why am I not surprised?

I think it's important to put these evidence based interventions alongside the alternative...active treatment.

For example, if one goes with the "gold standard" RALP treatment there's an 8 year biochemical reoccurrence (BCR) risk of 21% for Low Risk, 25% for Favorable Intermediate Risk, 41% for Unfavorable Intermediate Risk and 60% for High Risk PCa, in the post-2010 era.
https://www.sciencedirect.com/science/article/abs/pii/S1078143924003442
That doesn't sound anything like "certainty". It sounds more like RALP is quite likely to put my PCa into a "durable deferral of (additional) definitive treatment(s)"....not to mention the absolute certainty of short term, high likelihood of intermediate term and possibility of long term side effects.

In my case, I considered my FIR diagnosis a "draft card" into evidence based intervention "boot camp" and, in my opinion, it needs to be considered as such.

I fully understand why many looking at the ERASE protocol have a million reasons why they can't or won't participate...maybe even receiving medical advise not to even try...but at the end of the day these folks shouldn't kid themselves that going the active treatment route is going to definitively resolve anything...the evidence indicates they are simply trading off to a different set of likely issues.

I am not against active treatment; but the evidence is clear that this also provides "low to very low certainty" (using the conclusion criteria of this review’s authors) that it will be the last time one has to deal with the aftermath of their PCa.

@paulsweeney

Paul, I wanted to ask you this.

I used to exercise a lot, testosterone levels were constantly rising. Everything was leading up to my doctor saying that if my testosterone kept rising, I'd have to have my balls amputated.

I decided to take a rather unusual approach. I actually stopped moving a lot and reduced my exercise to almost nothing. After that, my testosterone levels dropped again.

What do you think about what I wrote about the connection between testosterone levels and exercise?

I read about IGF on your website. Is it scientifically proven that it reduces the progression of prostate cancer?

Thank you, I await your reply!

@handera Alan, this is really well put — and I think you've identified something important that the review itself doesn't address.

The review holds lifestyle interventions to the standard of "durable deferral of definitive treatment" and finds the evidence insufficient. Fair enough. But as you say, the same standard applied to RALP yields 21-60% biochemical recurrence at 8 years. That's not a cure — it's a deferral with side effects.

What strikes me is the asymmetry in how we evaluate the two approaches. Lifestyle interventions are expected to prove they prevent progression before they're taken seriously. Surgery is assumed to be definitive and the burden of proof falls on anyone who questions it. But the data you've cited shows that assumption doesn't hold — a significant proportion of men who undergo surgery will face further treatment down the line, plus the near-certainty of short-term side effects and the real probability of lasting ones.

I agree with the review's finding that exercise has the strongest evidence — the ERASE trial data on PSA, cancer cell growth, and quality of life is hard to argue with. And I think the review is right to be cautious about supplements as a category. But the conclusion that lifestyle interventions provide only "supportive" benefit while treatment provides "definitive" benefit doesn't survive contact with the recurrence data you've shared.

Your "boot camp" framing is exactly right. A diagnosis isn't a death sentence — it's a signal to get serious about everything within your control. And for low-to-favourable intermediate risk, the evidence increasingly supports that an active, engaged approach to surveillance is a legitimate strategy, not just a holding pattern.

Really glad you're in this conversation.

Paul

Thank you for the question — it's a really important one and I want to be careful with my answer because I'm not a doctor.

On the testosterone and exercise connection: it's true that intense exercise can cause temporary spikes in testosterone. But the relationship between testosterone and prostate cancer is more complicated than "higher testosterone = worse cancer." The evidence on this has actually shifted significantly in recent years. The ERASE trial — a randomised controlled trial specifically in men on active surveillance — showed that HIIT exercise decreased PSA, decreased PSA velocity, and inhibited prostate cancer cell growth. Those men were exercising intensely three times a week. If exercise-induced testosterone was driving their cancer, you'd expect the opposite result.

The concern your doctor raised about testosterone may be specific to your clinical situation — particularly if you're being considered for androgen deprivation therapy (ADT). In that context, the goal is to suppress testosterone as low as possible, and your doctor may have been concerned about anything that works against that suppression. That's a very different situation from a man on active surveillance where the goal is to monitor, not suppress.

Stopping exercise to control testosterone worries me, because the overall evidence strongly favours exercise for men with prostate cancer — not just for cancer-specific outcomes, but for cardiovascular health, mental health, bone density (especially important if you're on ADT, which causes bone loss), and overall survival. I'd really encourage you to discuss this with your oncologist and ask specifically whether the exercise benefits outweigh the testosterone concern in your case. I suspect they will.

On IGF — you're right that evidence.zone mentions it. Insulin-like growth factor (IGF-1) is associated with prostate cancer progression in observational studies, and it's one of the reasons obesity and high-insulin diets are flagged as risk factors. But "associated with" is not the same as "proven to cause." The evidence that lowering IGF-1 through diet or lifestyle slows prostate cancer progression in humans is not yet proven in clinical trials — it's biologically plausible and supported by population-level data, but we don't have an RCT showing "lower your IGF-1 and your cancer progresses more slowly." What we do know is that the things that lower IGF-1 — plant-rich diets, healthy weight, moderate exercise, reduced dairy — are the same things that show up across the evidence base as beneficial for men with prostate cancer.

Paul