The study, published in the journal Supportive Care in Cancer, analyzed data from the International Registry for Men with Advanced Prostate Cancer, known as IRONMAN, a multinational registry launched in 2017 across 15 countries spanning high-, middle-, and low-income settings. Of 4,538 men enrolled in the registry, 2,485 completed at least one leisure-time physical activity questionnaire at six, 18, or 30 months after joining. These men had either metastatic hormone-sensitive prostate cancer, meaning their disease had already spread to bone or other organs at diagnosis, or castration-resistant prostate cancer, the stage at which the cancer progresses despite testosterone suppression and which accounts for most prostate cancer deaths.

The biological backdrop makes the exercise question urgent. Because most prostate tumors are driven by the androgen receptor pathway, the cornerstone of treatment is androgen deprivation therapy, which suppresses testosterone to castration levels and is often combined with androgen receptor pathway inhibitors or chemotherapy. While effective at slowing the disease, this therapy carries a heavy toll: fatigue, psychological distress, increased fat mass, loss of lean body mass, and declining physical function. Resistance training is considered particularly important for counteracting the muscle-wasting effects of hormone therapy, and emerging evidence links both aerobic fitness and muscle strength to reduced mortality among cancer patients. Exercise is also considered safe and feasible even for patients with bone metastases, provided appropriate precautions are taken.

To measure activity, the researchers used a modified Paffenbarger questionnaire administered at each follow-up, capturing time and intensity spent walking, jogging, cycling, swimming, and performing resistance exercise with arm and leg weights. Activities were classified as moderate or vigorous using established metabolic equivalent thresholds of 3.0 and 6.0 respectively. The two primary outcomes followed the 2019 American College of Sports Medicine exercise guidelines for cancer patients: at least 150 minutes of moderate or 75 minutes of vigorous aerobic activity per week, and at least two resistance training sessions weekly. Because the questionnaire recorded duration rather than frequency for strength work, the team conservatively converted every 15 minutes of resistance exercise into one session.

The headline numbers were encouraging on one front and sobering on another. Between 58 and 63 percent of participants met the aerobic activity guidelines across the three timepoints, with median weekly moderate-to-vigorous activity ranging from 190 to 210 minutes, mostly at moderate intensity. But only 19 to 23 percent met the resistance training guideline, and the median weekly duration of strength training across the entire sample was zero minutes. Just one-third of participants reported any resistance training at all. The researchers suggest that this gap may reflect the practical demands of strength work, which typically requires access to facilities, equipment, or supervision, unlike walking, which is freely available to most people.

The disparities by race and geography were the study’s most striking finding. At six months, 69 percent of White participants met the aerobic guideline compared with just 25 percent of Black participants, and the regional contrast was similarly stark: 70 percent in Europe and Australia and 63 percent in North America versus only 20 percent in Africa. In mixed-effects logistic regression models that pooled all follow-up data and accounted for repeated measures and clustering by treatment site, participants who self-identified as Black had 77 percent lower crude odds of meeting the aerobic guideline than White participants, an odds ratio of 0.23. Participants from African regions had 92 percent lower crude odds than those from Europe, with an odds ratio of 0.08. The aerobic activity disparity persisted after statistical adjustment for age, education, performance status, disease state, and treatment regimen, and it remained robust in sensitivity analyses that excluded Black participants from African sites, suggesting that geography alone does not explain the gap.

Resistance training showed an even more extreme pattern. Crude odds of meeting the strength guideline were 70 percent lower among Black participants, and in African regions participation was nearly nonexistent, ranging from zero to three percent, compared with 19 to 32 percent in Europe, Australia, and North America. The researchers caution that some of this may reflect measurement rather than behavior: the questionnaire’s strength items capture free weights and machines, which may not reflect locally available or culturally typical strength activities in low- and middle-income countries, potentially leading to under-reporting. Moreover, the instrument measured only leisure-time activity, excluding the occupational, transport, and household domains that contribute substantially to total physical activity in many African countries, which may partly explain why the regional pattern contrasts with global data showing high overall activity levels in some African nations.

The authors emphasize that the racial disparities likely reflect social and health-system factors, including socioeconomic status, health literacy, and access to supportive care, rather than biological differences or individual motivation. They also note that patients with hormone-sensitive disease and those on more intensive treatment combinations tended to be more active, while those on androgen deprivation monotherapy reported the lowest guideline adherence, possibly reflecting poorer functional status. The study has limitations worth weighing: respondents to the activity questionnaire were slightly younger and healthier than non-respondents, so overall prevalence may be overestimated, and self-reported activity over long recall periods is vulnerable to recall and social desirability bias. Still, sensitivity analyses suggested the core findings were robust to missing data.

What emerges is a clear roadmap for clinicians and policymakers. Aerobic activity levels among men with advanced prostate cancer appear higher than earlier small studies suggested, which is genuinely good news for a population often assumed to be too ill to exercise. But the near-total absence of strength training, particularly in Africa and among Black patients, points to structural and cultural barriers that simple advice cannot overcome. The researchers call for strategies that integrate physical activity support into routine cancer care and that are explicitly designed to be accessible and culturally appropriate for the high-risk subgroups identified. Given that resistance training is linked to preserving muscle mass, physical function, and potentially survival, closing this gap could be one of the most consequential supportive care interventions available to men facing advanced prostate cancer.

Subject of Research: Physical activity guideline adherence and racial and regional disparities among men with advanced prostate cancer

Article Title: Prevalence of meeting aerobic physical activity and resistance training guidelines in advanced prostate cancer: a descriptive study of racial and regional disparities in the IRONMAN registry

Article References: Solberg, A., Grydeland, M., Nilsen, T. S., Storås, A. H., Davis, I. D., Greaves, N., Anderson, S., Fay, A. P., Chi, K. N., Enting, D., McDermott, R., Badal, S., Waihenya, C. G., Popoola, A., Lazarus, J. M., Mateo, J., Bjartell, A., Omlin, A., Odedina, F., … the IRONMAN investigators (2026). Prevalence of meeting aerobic physical activity and resistance training guidelines in advanced prostate cancer: a descriptive study of racial and regional disparities in the IRONMAN registry. Supportive Care in Cancer, 34(10), Article 998. https://doi.org/10.1007/s00520-026-11251-3

Image Credits: AI Generated

DOI: 10.1007/s00520-026-11251-3

Keywords: advanced prostate cancer, physical activity, resistance training, exercise guidelines, health disparities, IRONMAN registry, androgen deprivation therapy, racial disparities, regional disparities, supportive care, exercise oncology, global health