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EXERCISE ONCOLOGY

 

Exercise oncology is now recognised as a core component of comprehensive cancer care rather than simply supportive therapy. Physical activity is safe and feasible throughout the cancer continuum, including before treatment (prehabilitation), during active treatment, and after treatment. International organisations including the American College of Sports Medicine (ACSM), American Cancer Society (ACS), National Comprehensive Cancer Network (NCCN), and Clinical Oncology Society of Australia (COSA) recommend routine exercise counselling and prescription as part of standard oncology care. Exercise improves treatment tolerance, functional capacity, quality of life, and symptom burden, while emerging evidence suggests it may also improve cancer-specific outcomes and survival.

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Benefits of Exercise

Exercise produces numerous physiological adaptations that contribute to improved outcomes in patients with cancer. Regular physical activity has been shown to:

  • Improve cardiorespiratory fitness and muscular strength

  • Improve body composition and reduce treatment-related deconditioning

  • Enhance immune function and reduce systemic inflammation

  • Improve insulin sensitivity and metabolic health

  • Reduce fatigue, anxiety and depression

  • Improve treatment tolerance, functional independence and recovery

 

Emerging evidence also suggests exercise may influence tumour biology through improved tumour perfusion, enhanced immune-cell infiltration, and reduced metastatic potential.

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Exercise Across the Cancer Continuum

Exercise should be considered at every stage of cancer management.

Prehabilitation involves initiating exercise before treatment to optimise functional reserve and improve tolerance to surgery, chemotherapy or radiotherapy. Patients who participate in prehabilitation experience improved treatment tolerance, fewer complications, faster recovery and better preservation of physical function.

Prior to commencing an exercise programme, patients should undergo a structured assessment that includes:

  • Baseline functional status

  • Cancer type and treatment phase

  • Comorbidities

  • Symptom burden

  • Musculoskeletal or cardiovascular limitations

  • Potential contraindications to exercise

 

Exercise prescriptions should then be individualised according to patient capacity and goals.

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Exercise and Cancer Outcomes

Beyond symptom management, physical activity is associated with meaningful improvements in cancer outcomes.

Compared with inactive individuals, physically active people have:

  • 10–20% lower overall cancer risk

  • Approximately 20% lower cancer mortality

Additional evidence suggests:

  • High-intensity aerobic exercise is associated with approximately 72% lower risk of metastatic cancer

  • Every additional 10 MET-hours/week of physical activity in breast cancer survivors is associated with an estimated 14% reduction in breast cancer mortality

 

Effects on Symptoms and Physical Function

Exercise consistently improves outcomes that directly influence treatment tolerance and quality of life. Improvements have been demonstrated in:

  • Cancer-related fatigue

  • Physical function

  • Cardiorespiratory fitness

  • Muscle strength

  • Body composition

  • Health-related quality of life

  • Anxiety and depression

Cancer-related fatigue has the strongest evidence supporting exercise as an intervention. Regular moderate-intensity aerobic exercise significantly reduces fatigue, with additional benefits observed when resistance training is incorporated.

 

Evidence-Based Exercise Prescription

Current guidelines generally recommend approximately 150 minutes of moderate-intensity aerobic exercise per week, combined with resistance training at least twice weekly. Exercise should always be individualised according to treatment stage, symptom burden and patient capacity.

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Cancer-related fatigue

  • Aerobic: 3 sessions/week, 30 minutes, moderate intensity

  • Resistance: 2 sessions/week, 2 sets of 12–15 repetitions

  • Combined aerobic and resistance training provides the greatest benefit

Health-related quality of life

  • Aerobic: 2–3 sessions/week, 30–60 minutes (moderate-vigorous)

  • Resistance: 2 sessions/week, 2 sets of 8–15 repetitions

Physical function

  • Aerobic: 3 sessions/week, 30–60 minutes

  • Resistance: 2–3 sessions/week, 2 sets of 8–12 repetitions

Anxiety and depression

  • Aerobic exercise: 3 sessions/week, 30–60 minutes

  • Combined aerobic and resistance training is also beneficial

  • There is insufficient evidence for resistance training alone

Lymphedema

  • Progressive supervised resistance training 2–3 times/week

  • Resistance training does not worsen symptoms and is effective for both prevention and management

Bone health

  • Moderate-to-vigorous resistance training 2–3 times/week

  • High-impact loading (approximately 3–4 × body weight) for ≥12 months

Sleep

  • Moderate-intensity aerobic exercise 3–4 times/week for 30–40 minutes

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CHALLENGE Trial

The landmark phase III CHALLENGE trial (NCT00819208) provides the strongest evidence that exercise improves long-term oncological outcomes. The trial randomised 889 patients with resected colon cancer across 55 centres to either a structured 3-year exercise programme or health education following adjuvant chemotherapy.

After a median follow-up of 7.9 years, structured exercise resulted in:

  • 28% lower risk of recurrence, new primary cancer or death (HR 0.72; 95% CI 0.55–0.94; P=0.02)

  • Improvement in 5-year disease-free survival from 73.9% to 80.3%

  • Improvement in 8-year overall survival from 83.2% to 90.3%

  • 37% reduction in mortality risk

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These findings provide strong level I evidence that structured exercise can improve long-term outcomes in colon cancer survivors.

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Clinical Considerations

  • Despite a robust evidence base, implementation remains inconsistent. Common barriers include limited clinician knowledge, lack of referral pathways, restricted access to exercise programmes, and patient concerns regarding fatigue or symptom exacerbation.

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  • Exercise should therefore be incorporated into routine oncology practice through early assessment, individualised prescription, and referral to physiotherapists or accredited exercise professionals when appropriate. Combined aerobic and resistance exercise should be considered the preferred approach for most patients, with programmes tailored according to treatment phase, comorbidities and functional capacity.

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