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Physical activity at baseline and risk of prostate cancer grade reclassification on active surveillance: results from a prospective cohort study

Prostate Cancer and Prostatic Diseases (2026)Cite this article

Subjects

Abstract

Background

For men with low-risk prostate cancer (PCa) on active surveillance (AS), there remain limited and conflicting data regarding whether physical activity may influence disease progression evidenced by grade reclassification (GR). Furthermore, it is unclear whether physical activity affects the risk independently of other lifestyle factors such as diet and smoking.

Methods

This is a prospective cohort study of men diagnosed with Grade Group (GG) 1 PCa undergoing AS. Patients completed diet and physical activity questionnaires upon AS enrollment. Physical activity level was evaluated as metabolic equivalent of task hours per week (MET-h/wk), and diet quality as energy-adjusted Healthy Eating Index (E-HEI) score. Multivariable competing risk regressions were utilized to examine the association of baseline physical activity level with GR to ≥GG2 and to ≥GG3, adjusting for established clinicopathological risk factors, diet quality, and smoking history.

Results

We included 828 men with a median follow up of 6.4 years (quartiles: 4.0–9.1). In multivariable regression models adjusted for covariates, increased baseline physical activity levels (3 to <9 MET-h/wk versus <3: subdistribution hazard ratio [SHR] 0.18, 95% confidence interval [CI] 0.05–0.61; 9 to <18 MET-h/wk versus <3: SHR 0.26, 95% CI 0.10–0.68; ≥18 MET-h/wk versus <3: SHR 0.31, 95% CI 0.12–0.80) were associated with significantly decreased risks of GR to ≥GG3. Increased physical activity levels were associated with non-significant decreases in GR to ≥GG2. An increased E-HEI score was also significantly associated with decreased GR to ≥GG3, and non-significant reduction in GR to ≥GG2. Smoking history was not associated with either GR outcome.

Conclusions

In a large prospective cohort with longitudinal follow-up of men pursuing AS for GG1 PCa, increased baseline physical activity levels, compared to a sedentary lifestyle defined as <3 MET-h/wk, was independently associated with a lower risk of progression to ≥GG3 disease.

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Fig. 1: Cumulative incidence of prostate cancer grade reclassification (GR) during active surveillance.
Fig. 2: Cumulative incidence of prostate cancer grade reclassifi cation during active surveillance stratifi ed by activity level.

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Data availability

The data that support the findings of this study are available from the corresponding author upon reasonable request. The data are not publicly available due to institutional policies and the need to protect participant privacy.

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Acknowledgements

We thank constructive comments and helpful suggestions from anonymous reviewers for Prostate Cancer and Prostatic Diseases, which significantly improved the design and interpretations of our study.

Funding

This study was supported by the Patrick C. Walsh Prostate Cancer Research Fund (BJT) and Persky Scholarship (ZTS), a Johns Hopkins intramural scholarship.

Author information

Author notes

  1. These authors contributed equally: Michelle I. Higgins, Zhuo Tony Su.

Authors and Affiliations

  1. The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA

    Michelle I. Higgins, Zhuo Tony Su, Mufaddal Mamawala, Yuezhou Jing, Patricia K. Landis, Mark N. Alshak, Aurora J. Grutman, Carlos A. Rivera Lopez, Christian P. Pavlovich & Bruce J. Trock

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  1. Michelle I. Higgins
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  2. Zhuo Tony Su
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Contributions

MIH and ZTS contributed equally to this work. MIH and ZTS conceived and designed the study, interpreted the data, and drafted the manuscript. MM and YJ performed the statistical analyses and contributed to data interpretation. PKL coordinated data collection and database management. MNA, AJG, and CARL contributed to data acquisition and critical revision of the manuscript. CPP contributed to study design, clinical interpretation, and manuscript revision. BJT supervised the study, contributed to study conception and design, provided statistical and methodological oversight, and critically revised the manuscript. All authors reviewed and approved the final manuscript.

Corresponding author

Correspondence to Michelle I. Higgins.

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Competing interests

BJT reported receiving personal fees for consulting from Emmes Inc and Myriad Genetics and grants from MDxHealth outside the submitted work. No other disclosures to report.

Ethics approval and consent to participate

Institutional Review Board approval was obtained from the Johns Hopkins IRB (number NA_00045103). Informed consent was obtained from all participants at the time of active surveillance enrollment. The study was performed in accordance with the Declaration of Helsinki.

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Higgins, M.I., Su, Z.T., Mamawala, M. et al. Physical activity at baseline and risk of prostate cancer grade reclassification on active surveillance: results from a prospective cohort study. Prostate Cancer Prostatic Dis (2026). https://doi.org/10.1038/s41391-026-01085-9

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