Abstract
Background
We proposed the Physical Activity and Cancer Control (PACC) framework in 2007 to help organise, focus, and stimulate research on physical activity in eight cancer control categories: prevention, detection, treatment preparation/co**, treatment co**/effectiveness, recovery/rehabilitation, disease prevention/health promotion, palliation, and survival.
Methods
This perspective paper provides a high-level overview of the scientific advances in physical activity research across cancer control categories, summarises current guidelines, updates the PACC framework, identifies remaining and emerging knowledge gaps, and provides future research directions.
Results
Many scientific advances have been made that are reflected in updated physical activity guidelines for six of the cancer control categories apart from detection and palliation. Nevertheless, the minimal and optimal type, dose, and timing of physical activity across cancer control categories remain unknown, especially for the understudied population subgroups defined by cancer type, age, race/ethnicity, and resource level of regions/countries.
Conclusion
To achieve the full benefit of physical activity in cancer control, future research should use innovative study designs that include diverse at-risk populations and understudied cancer sites. Additionally, effective behaviour change strategies are needed to increase physical activity levels across populations that use implementation science to accelerate the translation from evidence generation into practical, real-world interventions.
Similar content being viewed by others
Introduction
The cancer care continuum is a multi-phase, sometimes cyclic process that may include multiple treatment modalities, cancer progression, recurrence and new primary cancers and that necessitates a range of cancer control categories depending on various factors including the patient and setting [1]. While the major focus in cancer treatment and care has been on clinical interventions, only in the past few decades has the role of lifestyle factors, including dietary intake and physical activity, been considered in cancer control. The first research studies that examined how physical activity could be involved in cancer etiology were published in early 1980s with limited research until the 1990s. Given that this field was relatively new and unstructured, we were motivated to publish an organizational framework for research on physical activity across the cancer experience (PEACE) to help provide structure to this emerging research area [2]. In 2007, we updated that framework with the Physical Activity and Cancer Control (PACC) framework [3] to organize, focus, and stimulate further research on physical activity and cancer control (Fig. 1). Eight cancer control categories (eight populations at risk) on the cancer care continuum were specified in the PACC framework in six cancer-related time periods including two pre-diagnosis (prevention, detection) and four post-diagnosis (pre-treatment, treatment, survivorship and end of life). This framework has been seminal in structuring and focusing research on physical activity in cancer control to specific time points.
aThis article was published in Seminars Oncology Nursing journal, Copyright Elsevier (2007).
The purpose of this review paper was to assess the current state of scientific evidence on physical activity across the entire cancer continuum from prevention to survival to identify: 1) existing knowledge gaps; 2) opportunities for future research and 3) needs for further physical activity/exercise guideline development. We conducted a narrative review to assess the updated current evidence of the role of physical activity in cancer control in accordance with the PACC framework (Supplementary Materials). We searched for published systematic reviews in physical activity/exercise and cancer control in the past five years in MEDLINE by March 19, 2023, and updated the search on April 27, 2024. When systematic reviews were not available for a component of the PACC framework, we included the most current literature based on our literature search to identify and assess the emerging evidence and to identify future research directions.
Throughout this review paper, we use the term “physical activity” which includes all forms of movement done in occupational, recreational, household and transportation settings. For post-diagnosis components of the PACC framework (e.g., before, during and after treatment) where research studies frequently investigated exercise interventions, the focus of the evidence review is mainly on “exercise” which is a subset of physical activity that is planned, structured, and done repeatedly to improve or maintain physical fitness. Herein we describe the current state of evidence on physical activity by cancer control category followed by a summary of the current physical activity guidelines. We then identify the gaps in knowledge and identify priority areas for future research.
Evidence review
Physical activity and cancer prevention
The body of evidence on the etiologic role of physical activity in cancer prevention has markedly increased since 2007, when colon, breast, endometrial, prostate and lung were the main cancer sites that had been investigated [3]. The evidence on risk reduction for cancer of the gallbladder, liver, kidney, small intestine, myeloid leukemia, myeloma, and non-Hodgkin lymphoma is now accumulating [4]. Highest vs. lowest leisure-time physical activity was associated with a relative cancer risk reduction ranging between 8 to 25%, with the level of evidence deemed strong for bladder, breast, colon, endometrium, esophagus, gastric and renal, moderate for lung, and limited for hematologic, head and neck, ovary, pancreas, prostate, brain, thyroid and rectal cancer [5]. Recent review articles have also begun to synthesize evidence for understudied cancer types and different dimensions of physical activity, reporting inconsistent associations between physical activity and risk of testicular cancer [6], lower risk in colon (26%) but higher risk (115%) in lung cancer associated with occupational physical activity [7, 8], lower risk in endometrial, colon and breast cancers associated with transport-related physical activity (1–9%) [9] and lifetime physical activity (18–25%) [10], lower risk in colon and breast cancers associated with physical activity at young age (19–33%) [10]; and have examined potential risk stratifications by menopausal status [11] and by family history for breast [12] and colorectal cancer [13], and potential biological mechanisms involved for breast cancer [14, 15].
It is worth noting that nearly all research evidence on physical activity for cancer prevention is from observational epidemiologic studies given the cost, feasibility and time requirements that would be required for randomized controlled trials. To the best of our knowledge, no randomized controlled exercise trials reported cancer incidence as the primary endpoint. Consequently, the focus has been on exercise intervention trials that have examined hypothesized biological pathways [16, 17] that could explain how physical activity reduces the risk of develo** cancer. Observational studies have suggested the relationship between physical activity and specific cancer risk differs by the magnitude of the relative risk reduction as well as the shape of the dose-response [18]. Leisure-time physical activity within the recommended level (7.5–15 MET hours/week) was associated with 6–29% risk reduction among several cancers, including colon, breast, endometrial, kidney, myeloma, liver and non-Hodgkin lymphoma (in women). Beyond the recommended level, physical activity continued to further reduce risk in some but not all cancers, likely suggesting fundamental differences in the underlying biological mechanisms for different cancer types [18]. However, the number of trials testing the minimal and optimal dose (type, frequency, intensity, and duration) of exercise for cancer prevention remains small [19,20,21,22,23]. Additionally, these trials have focused primarily on aerobic exercise with only a limited emphasis on resistance (i.e., muscle strengthening activity) as well.
Muscle-strengthening activities are not well captured by self-reported questionnaire or accelerometer-based devices that are commonly used in large cohort studies. A small body of evidence from observational studies found muscle-strengthening activity was associated with inconsistent findings for the risk of colon and bladder cancer [24,25,26,27], reduced risks for kidney cancer [24,25,26], and limited evidence regarding the risks for cancers of the lung, pancreas, prostate and rectal [26]. Muscle-strengthening activities involving major muscle groups could influence metabolic function [28], inflammation [29], and sex hormones [30,31,32], which are biological mechanisms associated with develo** cancer [33]. Currently, it is unknown whether muscle-strengthening activity alone, or combined with aerobic activity, contributes to cancer risk reduction.
Sedentary behavior, independent of physical activity, has been associated with an increased risk of colon, endometrial and lung cancer [34]. Sedentary behavior is hypothesized to operate through the metabolic function pathway to influence cancer risk [33]. Given the methodologic limitations in measuring the bouts and duration of sedentary behavior at the population level and the lack of available intervention tools to interrupt or reduce sedentary behavior, generating observational or interventional data to examine and elucidate the potential relationship between sedentary behavior and cancer risk remains limited.
Physical activity and cancer detection
Limited research has examined the role of physical activity on cancer detection. Physical activity has at least two ways to influence cancer detection: 1) indirectly by influencing cancer screening behavior (i.e., higher uptake of cancer screening which could result in an early stage at diagnosis), and 2) directly by influencing the sensitivity and/or specificity of cancer screening tests [3]. Several studies indicated that physical activity, among other lifestyle behaviors, was associated with higher uptake of colorectal screening [35, 36]. Observational studies that examined cancer stage at diagnosis found physical activity was associated with higher odds of late-stage lung cancer diagnosis [37] and no association with stage at breast cancer diagnosis [38]. With respect to cancer screening tests, observational and intervention studies have found no association between physical activity and mammographic density [39,40,41,42]. Meanwhile, physical activity, especially acute exercise may increase serum prostate-specific antigen (PSA) concentration [43, 44] leading to false PSA levels, but habitual physical activity may be associated with lower PSA concentration [45]. More recently, a case study reported that the supervision of exercise may be a cancer detection test for metastatic disease by uncovering symptoms that suggest recurrence or metastatic spread such as pain, neurological issues, or functional issues [46]. These “exercise-detected” symptoms may allow for earlier detection of recurrence or metastatic spread.
Physical activity and treatment preparation/co**
Using physical activity as preparation to increase readiness prior to cancer treatment, or cancer prehabilitation, has gained significant clinical interest [47]. The concept of “prehabilitationc” was first scientifically documented in 1946, in a non-clinical setting, as a total body exercise training program that the British Army developed to increase the physical health of young recruits, i.e., to qualify for conscription [48]. In the oncology setting, physical activity for cancer prehabilitation has the potential to: 1) improve physical health to endure or become eligible for cancer treatment, 2) improve psychological health to cope with the diagnosis and impending cancer treatment, 3) prevent treatment-induced toxicities and improve treatment completion and recovery, and 4) influence the tumor biology and microenvironment directly to improve treatment efficacy or delay the need for treatment. Over 30 review articles have been published on the topic of physical activity for cancer prehabilitation. Existing systematic reviews were mostly focused on: selective cancer sites (majority in lung cancer surgery) [49,50,51,52,53,54,55,56,57,58,59,60], cancer site-specific treatment side-effects [61,62,63], or selective exercise intervention modalities (HIIT or combined aerobic and resistance training) [64,65,66,67]. Importantly, many prehabilitation studies included cancer patients undergoing neoadjuvant therapy [49, 51,52,53, 67,68,69,70,71,72] or undergoing other systematic therapies (chemotherapy and radiation therapy) [73, 74], which overlaps with the cancer control category of physical activity and treatment effectiveness/co**. While the combination of patients before and during treatment does not allow for investigation into physical activity and cancer control category-specific outcomes, both cancer control categories are situated in the clinical setting, i.e., likely using similar or overlap** intervention delivery strategies/pathways.
Given the relatively small volume of primary research in treatment preparation/co**, it is not surprising that findings from previous systematic reviews were inconclusive. Our recent sco** review reports that the number of primary studies on physical activity for cancer prehabilitation consists of 32 interventions and 12 observational studies using heterogeneous intervention designs and physical activity assessments [75]. All previous studies on physical activity and cancer prehabilitation enrolled patients waiting for planned cancer treatment, therefore it is unknown whether physical activity may influence treatment decision especially in settings where multiple treatment options exist. Prehabilitation exercise appears to improve health-related fitness but the evidence to improve clinical outcomes is lacking [75]. Notably, nearly all studies conducted in the oncology setting to investigate the role of physical activity for prehabilitation have focused on surgical treatment, presenting a major knowledge gap and opportunities to increase evidence generation and translation to realize the full potential benefits of physical activity to prepare cancer patients facing non-surgical treatment modalities.
Physical activity and treatment effectiveness/co**
Many randomized controlled trials have been conducted in this cancer control category testing exercise dose in accordance with the generic physical activity guidelines. For example, for cancer patients undergoing curative treatment, there is evidence from over 70 systematic reviews of exercise interventions. Notably, the endpoints of these interventions were largely patient-oriented instead of oncologic outcomes, i.e., improved fatigue, cardiorespiratory fitness, muscle strength, physical function, body composition, quality of life, depression and anxiety, sleep, and cognitive function. Physical activity may influence treatment effectiveness/co** through: 1) a direct effect on tumor growth and metastasis, 2) improved treatment completion rate, 3) improved treatment efficacy, 4) managing treatment-induced toxicities, and 5) improved physical, psychosocial outcomes and quality of life. However, most of these hypothesized effects have not been fully investigated.
In this cancer control category, exercise interventions remain exploring feasibility measures in different treatment settings [76, 77], understanding the potential to prevent cardiotoxicity [78,79,80], and accumulating data on physical, psychosocial outcomes and quality of life [81, 82]. Limited data are available on the impact of exercise intervention on “treatment effectiveness”, such as chemotherapy completion or dose intensity, cancer treatment response, or cancer progression, recurrence and survival [83]. Furthermore, there is significant heterogeneity across exercise intervention studies in their study designs, interventions, and study populations making it difficult to recommend the minimal and optimal type and dose of physical activity during cancer treatment. Nevertheless, interest is growing to investigate exercise as a cancer treatment; considerations related to observational and experimental study designs for specific clinical oncology settings have been detailed elsewhere [84, 85].
Another important consideration in, but not limited to, this cancer control category is the potential harm of exercise. A recent systematic review and meta-analysis included 129 published and unpublished controlled trials comparing exercise interventions versus usual care in adults with cancer scheduled to undergo systemic treatment to synthesize evidence on adverse events, health-care utilization, and treatment tolerability and response [86]. This meta-analysis reported higher risks of serious adverse events, thromboses, and fracture, lower risk of fever, and higher relative dose intensity of systemic treatment in intervention versus control. Their findings indicated uncertainty regarding the harms of exercise in cancer patients undergoing systemic treatment, and concluded that insufficient data existed on the harms to make evidence-based risk-benefit assessments of the application of structured exercise in this population.
Physical activity and cancer survivorship (recovery/rehabilitation and disease prevention/health promotion)
Many systematic reviews have been published on the topic of physical activity and cancer survivorship which includes the two cancer control categories of “recovery/rehabilitation” and “disease prevention/health promotion”. Separating research conducted in these two cancer control categories is difficult because of the lack of clear definitions for patient characteristics and outcome assessment. “Recover” defined by the US National Cancer Institute is “to become well and healthy again” [87], and “rehabilitation” is defined as “a process to restore mental and/or physical abilities lost due to injury or disease, in order to function in a normal or near-normal way” [88]. Hence, the recovery/rehabilitation category is the acute phase (within six months) after treatment completion [3] with the goal for cancer patients to regain function and reach normalcy. Therefore, the goals of physical activity after cancer treatment completion for recovery/rehabilitation are to: 1) reduce acute treatment toxicities, 2) improve physical function, 3) improve psychosocial outcomes, to 4) improve quality of life and regain normalcy. With respect to “health promotion”, defined by WHO as “the process of enabling people to increase control over, and to improve, their health”, and “disease prevention”, the focus is on specific efforts aimed at reducing the development and severity of chronic disease and other morbidities [89, 90]. Therefore, the goals of physical activity after cancer treatment completion for disease prevention/health promotion are to: 1) manage long-term and late effects of cancer and cancer treatment, 2) improve psychosocial outcomes and quality of life, 3) reduce the risks of chronic diseases, and 4) reduce the risk of cancer recurrence, and a second primary cancer. Accordingly, we updated the PACC framework to include specific outcomes and intervention settings for each cancer control category (Fig. 2).
Updated physical activity and cancer control framework.
Over 1000 exercise trials have been conducted to examine the effect of exercise on outcomes during the post-treatment survivorship period. Nevertheless, common cancers such as breast [91, 92], prostate [93,94,95], colorectal [96, 97], and lung cancers [98, 99] are heavily investigated, some studies on childhood cancers [100, 101], while there is a paucity of data on less common cancers [102] including survivors of adolescent and young adult cancer [103]. Admittedly, the potential feasibility of this type of trial is low in less common cancers, especially when randomized controlled trials tend to be designed and powered to generate evidence on a single primary outcome [104, 105]. Even for cancer types/sites that are more frequently investigated, few data are available on the effect of physical activity on chronic disease risks among cancer survivors. A few reviews summarized the positive effect of exercise on the cardiovascular system [106], C-reactive protein as an inflammatory biomarker [107], blood lipid profile [108], fasting insulin levels [109], and metabolic function [110] among breast cancer survivors as biologic pathways involved in physical activity and breast cancer outcomes. These biologic pathways also operate on the development of chronic disease among cancer survivors. Cancer treatment can exacerbate the existing comorbidities and increase the risk of new comorbidities in cancer survivors [111, 112], many of which can be potentially prevented and managed by physical activity. Currently, the natural history of comorbidities in relation to physical activity is largely unknown in cancer survivors, representing a clear gap of future studies to inform the timing, type, frequency, intensity, and duration of physical activity that should be considered in exercise interventions aiming at disease prevention.
Although most identified systematic reviews remain focused on synthesizing the effect of exercise on acute, long-term, and late effect of cancer, several reviews have begun to explore how to design physical activity behavior change interventions among cancer survivors [113,114,115,116,117,118,119,120,121,122,123] including digital approach [124]. These intervention designs include both clinical [125, 126] and community [127,128,129,130,131] settings, but have mostly used individual-based approaches. Typical strategies of health promotion and disease prevention are population-based interventions that aim to address social determinants and health inequity simultaneously [90]. However, how to design population-based interventions with evidence-based risk stratification strategies that target cancer-specific outcomes remains unknown.
Physical activity and palliation
Palliative care aims to improve quality of life and help reduce pain in people who have a serious or life-threatening disease [132]. The body of literature on physical activity in the cancer palliation setting is increasing yet remains limited. The largest most recently published systematic review identified 22 exercise interventions explicitly in the cancer palliative care setting that improved quality of life, health-related fitness and fatigue [133,134,135]. Other reviews reported similar benefits of exercise interventions among patients with advanced cancer [136,137,138,139,140,141,142,143,144,145] or with cancer metastasis [146,147,148,149] on physical and psychological health and quality of life outcomes. The 2007 PACC framework proposed that in the palliative care setting, physical activity may help cancer survivors manage symptoms, improve mobility, slow functional decline, and maintain quality of life at the end of life [3]. Importantly, the survival of certain advanced cancers has improved to the point where a diagnosis of advanced cancer is no longer an acute “end of life” phase [150]. In addition, early palliative care may even prolong cancer survival [151]. While exercise appears feasible in this setting, more evidence is needed to understand the potential benefits and harms of physical activity in patients diagnosed with advanced cancer, especially those with bone metastases [152]. More importantly, given the potential of palliative care to prolong cancer survival, further research in physical activity and cancer palliation should consider clinical outcomes such as disease progression and metastasis [84]. Given the severe symptoms associated with advanced cancer and its treatment, such as fatigue, pain and muscle wasting, exercise trials in this population are more challenging and should consider the physical and psychological capability of cancer survivors to avoid exacerbating any symptoms and mental distress.
Physical activity and survival
There is limited to moderate evidence for physical activity to reduce cancer-specific and all-cause mortality for breast, colorectal and prostate cancer [5]. Notably, the mortality risk reduction associated with physical activity is estimated to range between 30% for cancer-specific mortality and 32% reduced risk of all-cause mortality [153]. A few ongoing randomized controlled trials are examining the effect of exercise intervention on survival outcomes among colorectal [154] and prostate [155] cancer survivors. Given the challenges in cost, recruitment and time requirements in such trials, the minimal and optimal type and dose of exercise to improve cancer survival remains unknown. One large scale, on-going observational study in breast cancer is assessing physical activity, sedentary behavior and health-related fitness using both direct measurements as well as self-report to examine the association with survival outcomes with greater precision [156, 157]. In addition, the effect of exercise on inflammatory, insulin, and metabolic pathways involved in physical activity and cancer survival is hypothesized [110], however, current evidence is limited to select high risk populations, or to monitor the biologic response to exercise among cancer survivors. This topic area is being assessed in some of the on-going trials and observational studies [154,155,156, 158].
Physical activity guidelines
As the evidence base on physical activity in cancer control has accumulated, national and international agencies have developed and updated their physical activity guidelines. With more targeted research, it has also been possible to begin develo** more specific guidelines for the cancer control categories with some developed for all but cancer detection and palliation. We have included examples of current guidelines that provided recommendations on quantified physical activity/exercise and cancer in each of the cancer control categories (Table 1).
Cancer prevention
For physical activity and cancer prevention, the World Cancer Research Fund (WCRF) [159] in 2018 recommended that adults be active daily and do at last 150 min of moderate physical activity or at least 75 min of vigorous physical a week which aligned with the 2008 Physical Activity Guidelines for Americans [160] and the 2010 World Health Organization’s (WHO) guidelines on physical activity [161]. The 2018 Physical Activity Guidelines for Americans updated their recommendation to 150 to 300 min of moderate-intensity aerobic activity, 75–150 min of vigorous aerobic activity, or an equivalent combination of each intensity each week for cancer prevention, which were adopted by the 2020 American Cancer Society (ACS) guidelines for reducing the risk of develo** cancer [162] and the 2020 World Health Organization’s (WHO) recommendation [163]. These updated guidelines have recognized that more physical activity (i.e., up to 300 min/week) confers additional benefits whilst emphasizing that benefits are also attained at 150–300 min of weekly activity. Generic physical activity guidelines, e.g., those of the WHO [163], or USA [164], recommend twice-weekly muscle-strengthening activity in addition to aerobic activity for health promotion and the prevention of other chronic disease such as cardiovascular disease and Type 2 diabetes [163]. Muscle-strengthening activity, however, is currently not included in cancer prevention guidelines because of the lack of evidence. Another physical activity related recommendation in generic physical activity guidelines [163] is to limit sedentary behavior, which is not currently included in guidelines specific to cancer prevention.
Cancer treatment
The American College of Sports Medicine (ACSM) published updated exercise guidelines for cancer survivors during and after treatment in 2019 [102]. In 2022, the American Society of Clinical Oncology (ASCO) developed guidelines stating that oncology providers should recommend regular aerobic and resistance (muscle-strengthening) exercise for patients during active treatment with curative intent and preoperative exercise for patients undergoing surgery for lung cancer [165]. Similar guidelines have been developed for activity during and after treatment in several other countries worldwide (e.g. Australia, UK) [166, 167].
The 2019 ACSM updated exercise guidelines for cancer survivors stated that exercise training was generally safe and well tolerated during and after cancer treatment, and recommended 150 min/week aerobic exercise and twice weekly strength training to manage the acute, long-term and late effects of cancer [102]. More specific guidelines were provided for particular symptoms and side effects including fatigue, anxiety, depression, and sleep quality [102].
The 2022 American Cancer Society (ACS) nutrition and physical activity guidelines [168] for cancer survivors agreed with the WHO 2020 guidelines for populations with chronic disease. Both organizations currently recommend 150–300 min/week of moderate-intensity activity or 75–150 min/week vigorous-intensity activity or a combination of the two intensities, and muscle-strengthening two or more days per week. These recommendations are aimed at improving quality of life during cancer treatment and long-term survivorship for survivors who are disease-free or have stable disease [168].
Cancer survivorship
The ACSM 2019 guidelines were developed based on evidence generated from randomized controlled trials that examined the effect of exercise on a list of cancer-related health outcomes with a high degree of clinical relevance [102]. It is important to note that these outcomes of acute, long-term and late effects of cancer have variable trajectories [169].
Consequently, the randomized controlled trials in the evidence syntheses included cancer survivors at both recovery/rehabilitation and disease prevention/health promotion categories.
For cancer survivors who are disease-free or living with stable disease, the 2022 ACS guidelines recommend physical activity to reduce cancer-specific and all-cause mortality for specific cancer types (breast, upper aerodigestive and digestive system, genitourinary, gynecologic, lung, hematological, and childhood cancer survivors) [168]. Besides evidence on survival, the ACS guidelines attempted to synthesize evidence on physical activity and the risk of cancer recurrence and a second cancer [168]. Currently, there is preliminary evidence synthesized from two randomized controlled trials on physical activity to reduce the risk of breast cancer recurrence [170], but in general there is no data on other cancer sites/types or the risk of a second primary cancer.
Future research
This review of the current state of evidence on the role of physical activity in cancer control has revealed that evidence has accumulated unevenly across the cancer continuum with most evidence on cancer prevention, during cancer treatment, and rehabilitation; moderate research on cancer survival; and only limited evidence in cancer detection and palliation. Furthermore, across all cancer control categories in the PACC framework, it remains unknown which populations may benefit the most from physical activity to improve cancer-related outcomes and the minimal and optimal type, frequency, intensity, and duration of physical activity to achieve such benefits (Table 2). Substantial biological and behavioral heterogeneities exist within populations in terms of how they respond to physical activity. Some initial research has been conducted demonstrating the potential effect of physical activity on colorectal cancer risk reduction irrespective of cancer genetic predisposition [171]. Much more observational and intervention epidemiologic research is required to understand the biologic mechanisms whereby physical activity may reduce cancer risk and to identify biologic markers that could be used to identify, monitor, and evaluate individuals who could benefit from physical activity. Thus far, most of the existing evidence and guidelines have been derived from and pertain to high-income countries. While the level of physical activity remains higher in low- and middle-income countries than in high income countries [172], there is a global trend of declining physical activity that was exacerbated by the COVID-19 pandemic [173]. Future research is needed in low- and middle-income countries to refine the evidence of cancer prevention and control in relation to physical activity and to reverse this declining trend. In addition, programs and policies that are targeted, relevant, and feasible in these low- and middle-income countries are needed that will encourage physical activity and reverse the declining levels of activity that accompany industrialization.
Observational research
Observational studies are the cornerstone to generate evidence that can inform exercise dose in interventional studies [174, 175]. It is important to understand the minimal and optimal dose of exercise that can benefit targeted outcomes for individuals diagnosed with cancer, who face multi-faceted demands and time constraints. Many exercise interventions for cancer survivors follow the generic physical activity guidelines. There is a paucity of data generated from observational studies that is specific to cancer survivors. The effect of physical activity on the range of cancer, health-related, and healthcare utilization outcomes, is particularly unexplored in the three most clinically relevant cancer control categories: treatment preparation/co**, treatment co**/effectiveness, and palliation. Thus, generating this evidence is critical to inform the optimal design of clinical exercise programs.
Intervention research
Clinical exercise trials that use experimental designs can serve a range of purposes to test the effect of physical activity on a specific outcome, to investigate the underlying biological mechanisms, to determine the optimal dose of exercise intervention, or to compare different exercise modalities to address causality in physical activity and cancer control. Given the accumulating evidence supporting the benefits of exercise on patient-centered outcomes and the current knowledge gaps, more intervention studies after diagnosis are needed in under-studied patient populations that are adequately powered to examine clinically important outcomes (such as treatment efficacy, recurrence, and survival) and to explore the heterogeneity in patient behavioral and biological responses to exercise. This research is needed before more definitive and targeted guidelines can be developed for health care providers to prescribe exercise to cancer patients and survivors.
Sustaining physical activity is challenging, which makes the investigation into long-term physical activity interventions and cancer outcomes extremely challenging. Effective intervention design should consider two domains of precision: 1) the intervention content (i.e., type and dose of physical activity specific to cancer-related outcomes) and the intervention delivery (i.e., individuals interacting with the complex social system). Hence, behavior change research is required to understand the behavioral mechanisms involved in exercise intervention delivery for cancer survivors. Behavior change techniques targeting individual and structural barriers to increase physical activity, ideally, should be fully integrated into clinical exercise trials in the oncology setting to enhance the intervention fidelity.
Future intervention studies should also consider adequate adverse event reporting for risk-benefit assessments, particularly among patients with high symptom burdens. Currently, adverse event tracking tools exist in the oncology setting, such as the European Organisation for Research and Treatment of Cancer (EORTC) Item Library for patient-reported outcomes and the Common Terminology Criteria for Adverse Events (CTCAE) for clinician reporting [176]; however their application in exercise trials is yet to be standardized.
Meanwhile, modern societies continue to become increasingly sedentary [177]. One important factor contributing to this sedentary trend was the sole focus on increasing structured, moderate-to-vigorous intensity physical activity in previous interventions [178]. Such interventions were indeed useful for socially advantaged populations but likely widened the equity gap between high resource populations and those facing barriers related to social and environmental constraints created by limited time, affordability, access to facilities, and low neighborhood walkability [179]. Novel approaches such as home-based interventions addressing the social and environment determinants of physical activity are needed to narrow the equity gap between high and low resource populations. From a behavior change perspective, interventions to increase physical activity could target sedentary behavior to interrupt prolonged sitting to increase physical activity. Develo** tools and methods to assess domain-specific physical activity (including both aerobic and muscle-strengthening activities) and sedentary behavior at the population level, as well as intervention tools to interrupt and reduce sedentary behavior, are necessary to begin generating efficacy evidence on the cancer prevention potential of targeting sedentary behavior.
Biologic mechanisms research
Whilst some observational [180] and experimental research [19,20,21,22,23] has examined the underlying biologic mechanisms that are operative between physical activity and cancer control outcomes, there remains a dearth of evidence regarding these putative mechanisms. A key recommendation for future research is to embed assessments of biologic mechanisms into future observational and exercise intervention trials.
Translational research
Primary prevention is arguably the most challenging timepoint in the cancer care continuum for translating from evidence to implementation because of the inherent difficulties in evaluating effective interventions aimed at reducing cancer incidence in the population [181]. Cancer prevention requires a sufficient evidence base, political will to fund programs to address the prevention potential, and a social strategy or plan by which we apply our knowledge to initiate or improve programs [182]. Current efficacy evidence on the role of physical activity in cancer etiology, although not yet fully elucidated, is sufficient to inform policy changes and to develop strategies for population health interventions to increase physical activity for primary cancer prevention. Nevertheless, evidence is lacking on how to best design interventions to increase physical activity at the population level [183]. Whilst programs for physical activity exist, chronic conditions and low resources pose physical, financial and environmental barriers to participation [184]. These barriers are remarkably common among individuals at disadvantaged socioeconomic positions who are also at higher risks of cancer and, therefore, the highest needs for behavior change. Hence, future research should consider evaluating physical activity as the endpoint in effectiveness trials that take into consideration equity parameters to fully understand the context of behavior change.
Several guidelines exist on physical activity during cancer treatment and cancer survivorship. While there remains a dearth of evidence for specific components across the cancer continuum, sufficient evidence has been accumulated for several time points across this cancer continuum. More research is needed to understand the heterogeneity in patient behavioral and biological responses to exercise in order to have individualized exercise or activity prescriptions that are tailored to the patient/survivor that take into consideration their physical abilities, tolerance to exercise, their cancer stage, status and treatment, their comorbidities, and their likelihood of responding to an exercise regimen. Whilst this objective would be the ideal endpoint, it is unlikely that such level of specificity in the evidence will be achieved in the short term. However, efforts to begin disseminating physical activity guidelines remains paramount given the clear benefits that have already been documented for physical activity after a cancer diagnosis.
In such settings, health professionals play a pivotal role in recommending physical activity to cancer patients and survivors [185]. Nevertheless, safety concerns, time constraints, and the lack of screening tools and referral resources remain barriers for exercise counseling and referral in cancer care [186]. Educational and infrastructure support with brief risk assessment and stratification tools of exercise readiness are needed to accelerate the implementation of existing guidelines. Future studies in these settings should incorporate implementation science methods to optimize the effectiveness and sustainability of the exercise program within complex treatment pathways and health system. Beyond a focus on patient-centered data, implementation process measures with healthcare providers should also be carefully considered using a mixed-methods evaluation approach to understand fully the implementation of exercise programs in the real-world condition. In addition, while exercise programs with professionals specialized in exercise in cancer care exist, this type of resource is often limited. Home-based exercise interventions and other digital exercise options with low resource demands should be developed to meet the needs of the majority of the cancer survivor population [187].
Natural experiment
While knowledge gaps remain in each of the cancer control categories, there is a strong and growing interest to develop and implement exercise programs in clinical practise [185, 188, 189]. The development of this type of intervention delivery infrastructure can also lead to the creation of natural experiments to generate further evidence on changes in cancer outcomes in response to exposure variations [190]. The traditional approach of translation of evidence into practice takes a linear path that typically starts from proof of concept and feasibility/pilot research, through efficacy and effectiveness studies, to dissemination and implementation trials to generate “evidence-based medicine” [191, 192]. Natural experiments, on the other hand, create the opportunity to evaluate an exercise program rigorously using existing environments, settings, infrastructure to generate “practice-based evidence” that includes all aspects of the research continuum from feasibility to implementation [191]. Such infrastructure will continue to refine the intervention content and offer efficient strategies to gather data on survivors of different types of cancer (e.g., rare cancers) and at various time points in the continuum (e.g., at treatment preparation, treatment effectiveness) that are logistically challenging to study.
Conclusion
Substantial scientific progress has been achieved in physical activity and cancer control since the publication of the updated PACC framework in 2007. The growing quantity and quality of research has informed the development and refinement of guidelines on physical activity and cancer control for prevention and survival, as well as before, during and after cancer treatment. Nonetheless, significant knowledge gaps remain, particularly in discerning the minimal and optimal dose of physical activity required for each cancer control category and in devising population-based interventions with evidence-based risk stratification strategies tailored to cancer-specific outcomes. This level of evidence is crucial to harness the potential benefit of physical activity fully in reducing the cancer burden. We provided future research directions that incorporate comprehensive monitoring of adverse events, innovative study design, and the application of implementation science to accelerate the translation from evidence generation into practical, real-world interventions.
References
Taplin SH, Anhang Price R, Edwards HM, Foster MK, Breslau ES, Chollette V, et al. Introduction: Understanding and influencing multilevel factors across the cancer care continuum. J Natl Cancer Inst Monogr. 2012;2012:2–10.
Courneya KS, Friedenreich CM. Framework PEACE: an organizational model for examining physical exercise across the cancer experience. Ann Behav Med. 2001;23:263–72.
Courneya KS, Friedenreich CM. Physical activity and cancer control. Semin Oncol Nurs. 2007;23:242–52.
Moore SC, Lee IM, Weiderpass E, Campbell PT, Sampson JN, Kitahara CM, et al. Association of Leisure-Time Physical Activity With Risk of 26 Types of Cancer in 1.44 Million Adults. JAMA Intern Med. 2016;176:816–25.
McTiernan A, Friedenreich CM, Katzmarzyk PT, Powell KE, Macko R, Buchner D, et al. Physical Activity in Cancer Prevention and Survival: A Systematic Review. Med Sci Sports Exerc. 2019;51:1252–61.
Huang S, Signal V, Sarfati D, Shaw C, Stanley J, McGlynn K, et al. Physical activity and risk of testicular cancer: a systematic review. BMC Cancer. 2018;18:189.
Mahmood S, MacInnis RJ, English DR, Karahalios A, Lynch BM. Domain-specific physical activity and sedentary behaviour in relation to colon and rectal cancer risk: a systematic review and meta-analysis. Int J Epidemiol. 2017;46:1797–813.
Rana B, Hu L, Harper A, Cao C, Peters C, Brenner D, et al. Occupational Physical Activity and Lung Cancer Risk: A Systematic Review and Meta-Analysis. Sports Med. 2020;50:1637–51.
Thu W, Woodward A, Cavadino A, Tin Tin S. Associations between transport modes and site-specific cancers: a systematic review and meta-analysis. Environ Health. 2024;23:39.
Hidayat K, Zhou H-J, Shi B-M. Influence of physical activity at a young age and lifetime physical activity on the risks of 3 obesity-related cancers: systematic review and meta-analysis of observational studies. Nutr Rev. 2020;78:1–18.
Neilson HK, Farris MS, Stone CR, Vaska MM, Brenner DR, Friedenreich CM. Moderate-vigorous recreational physical activity and breast cancer risk, stratified by menopause status: a systematic review and meta-analysis. Menopause. 2017;24:322–44.
Cohen SY, Stoll CR, Anandarajah A, Doering M, Colditz GA. Modifiable risk factors in women at high risk of breast cancer: a systematic review. Breast Cancer Res. 2023;25:45.
Shaw E, Farris MS, Stone CR, Derksen JWG, Johnson R, Hilsden RJ, et al. Effects of physical activity on colorectal cancer risk among family history and body mass index subgroups: a systematic review and meta-analysis. BMC Cancer. 2018;18:71.
Boyne DJ, O’Sullivan DE, Olij BF, King WD, Friedenreich CM, Brenner DR. Physical Activity, Global DNA Methylation, and Breast Cancer Risk: A Systematic Literature Review and Meta-analysis. Cancer epidemiology, biomarkers & prevention : a publication of the American Association for Cancer Research, cosponsored by the American. Soc Prev Oncol. 2018;27:1320–31.
Hong BS, Lee KP. A systematic review of the biological mechanisms linking physical activity and breast cancer. Phys Act Nutr. 2020;24:25–31.
Hojman P, Gehl J, Christensen JF, Pedersen BK. Molecular Mechanisms Linking Exercise to Cancer Prevention and Treatment. Cell Metab. 2018;27:10–21.
Jurdana M. Physical activity and cancer risk. Actual knowledge and possible biological mechanisms. Radio Oncol. 2021;55:7–17.
Matthews CE, Moore SC, Arem H, Cook MB, Trabert B, Håkansson N, et al. Amount and Intensity of Leisure-Time Physical Activity and Lower Cancer Risk. J Clin Oncol. 2020;38:686–97.
Friedenreich CM, Woolcott CG, McTiernan A, Ballard-Barbash R, Brant RF, Stanczyk FZ, et al. Alberta physical activity and breast cancer prevention trial: sex hormone changes in a year-long exercise intervention among postmenopausal women. J Clin Oncol. 2010;28:1458–66.
Friedenreich CM, Neilson HK, O’Reilly R, Duha A, Yasui Y, Morielli AR, et al. Effects of a High vs Moderate Volume of Aerobic Exercise on Adiposity Outcomes in Postmenopausal Women: A Randomized Clinical Trial. JAMA Oncol. 2015;1:766–76.
Monninkhof EM, Velthuis MJ, Peeters PH, Twisk JW, Schuit AJ. Effect of exercise on postmenopausal sex hormone levels and role of body fat: a randomized controlled trial. J Clin Oncol. 2009;27:4492–9.
Irwin ML, Yasui Y, Ulrich CM, Bowen D, Rudolph RE, Schwartz RS, et al. Effect of Exercise on Total and Intra-abdominal Body Fat in Postmenopausal Women: A Randomized Controlled Trial. JAMA. 2003;289:323–30.
McTiernan A, Tworoger SS, Ulrich CM, Yasui Y, Irwin ML, Rajan KB, et al. Effect of Exercise on Serum Estrogens in Postmenopausal Women: A 12-Month Randomized Clinical Trial. Cancer Res. 2004;64:2923–8.
Mazzilli KM, Matthews CE, Salerno EA, Moore SC. Weight Training and Risk of 10 Common Types of Cancer. Med Sci Sports Exerc. 2019;51:1845–51.
Rezende LFM, Lee DH, Keum N, Wu K, Eluf-Neto J, Tabung FK, et al. Resistance training and total and site-specific cancer risk: a prospective cohort study of 33,787 US men. Br J Cancer. 2020;123:666–72.
Nascimento W, Ferrari G, Martins CB, Rey-Lopez JP, Izquierdo M, Lee DH, et al. Muscle-strengthening activities and cancer incidence and mortality: a systematic review and meta-analysis of observational studies. Int J Behav Nutr Phys Act. 2021;18:69.
Boyle T, Bull F, Fritschi L, Heyworth J. Resistance training and the risk of colon and rectal cancers. Cancer Causes Control. 2012;23:1091–7.
Pesta DH, Goncalves RLS, Madiraju AK, Strasser B, Sparks LM. Resistance training to improve type 2 diabetes: working toward a prescription for the future. Nutr Metab. 2017;14:24.
Calle MC, Fernandez ML. Effects of resistance training on the inflammatory response. Nutr Res Pract. 2010;4:259–69.
Kraemer WJ, Häkkinen K, Newton RU, Nindl BC, Volek JS, McCormick M, et al. Effects of heavy-resistance training on hormonal response patterns in younger vs. older men. J Appl Physiol. 1999;87:982–92.
Roberts CK, Croymans DM, Aziz N, Butch AW, Lee CC. Resistance training increases SHBG in overweight/obese, young men. Metabolism. 2013;62:725–33.
Westcott WL. Resistance training is medicine: effects of strength training on health. Curr Sports Med Rep. 2012;11:209–16.
Friedenreich CM, Ryder-Burbidge C, McNeil J. Physical activity, obesity and sedentary behavior in cancer etiology: epidemiologic evidence and biologic mechanisms. Mol Oncol. 2021;15:790–800.
Schmid D, Leitzmann MF. Television viewing and time spent sedentary in relation to cancer risk: a meta-analysis. J Natl Cancer Inst. 2014;106:dju098.
Weber MF, Banks E, Ward R, Sitas F. Population characteristics related to colorectal cancer testing in New South Wales, Australia: results from the 45 and Up Study cohort. J Med Screen. 2008;15:137–42.
Unanue-Arza S, Solís-Ibinagagoitia M, Díaz-Seoane M, Mosquera-Metcalfe I, Idigoras I, Bilbao I, et al. Inequalities and risk factors related to non-participation in colorectal cancer screening programmes: a systematic review. Eur J Public Health. 2021;31:346–55.
Aktary ML, Ghebrial M, Wang Q, Shack L, Robson PJ, Kopciuk KA. Health-Related and Behavioral Factors Associated With Lung Cancer Stage at Diagnosis: Observations From Alberta’s Tomorrow Project. Cancer Control. 2022;29:10732748221091678.
Wang Q, Aktary ML, Spinelli JJ, Shack L, Robson PJ, Kopciuk KA. Pre-diagnosis lifestyle, health history and psychosocial factors associated with stage at breast cancer diagnosis – Potential targets to shift stage earlier. Cancer Epidemiol. 2022;78:102152.
Azam S, Kemp Jacobsen K, Aro AR, von Euler-Chelpin M, Tjønneland A, Vejborg I, et al. Regular physical activity and mammographic density: a cohort study. Cancer Causes Control. 2018;29:1015–25.
Siozon CC, Ma H, Hilsen M, Bernstein L, Ursin G. The association between recreational physical activity and mammographic density. Int J Cancer. 2006;119:1695–701.
Soh WH, Rajaram N, Mariapun S, Eriksson M, Fadzli F, Ho WK, et al. Physical activity and mammographic density in an Asian multi-ethnic cohort. Cancer Causes Control. 2018;29:883–94.
Woolcott CG, Courneya KS, Boyd NF, Yaffe MJ, Terry T, McTiernan A, et al. Mammographic Density Change with 1 Year of Aerobic Exercise among Postmenopausal Women: A Randomized Controlled Trial. Cancer Epidemiol Biomark Prev. 2010;19:1112–21.
Oremek GM, Seiffert UB. Physical activity releases prostate-specific antigen (PSA) from the prostate gland into blood and increases serum PSA concentrations. Clin Chem. 1996;42:691–5.
Kindermann W, Lehmann V, Herrmann M, Loch T. [Influencing of the PSA concentration in serum by physical exercise (especially bicycle riding)]. Urol A. 2011;50:188–96.
Loprinzi PD, Kohli M. Effect of physical activity and sedentary behavior on serum prostate-specific antigen concentrations: results from the National Health and Nutrition Examination Survey (NHANES), 2003–2006. Mayo Clin Proc. 2013;88:11–21.
Pelaez M, Stuiver MM, Broekman M, Schmitz KH, Zopf EM, Clauss D, et al. Early Detection of Brain Metastases in a Supervised Exercise Program for Patients with Advanced Breast Cancer: A Case Report. Med Sci Sports Exerc. 2023;55:1745–9.
Principles and guidance for prehabilitation within the management and support of people with cancer. Available at : https://www.macmillan.org.uk/assets/prehabilitation-guidance-for-people-with-cancer.pdf, Accessed March 09, 2020
“Prehabilitation, rehabilitation, and revocation in the Army” SUPPLEMENT 2170. Brit Med J. 1946;1:S187-S204
Himbert C, Klossner N, Coletta AM, Barnes CA, Wiskemann J, LaStayo PC, et al. Exercise and lung cancer surgery: A systematic review of randomized-controlled trials. Crit Rev Oncol Hematol. 2020;156:103086.
Piraux E, Reychler G, de Noordhout LM, Forget P, Deswysen Y, Caty G. What are the impact and the optimal design of a physical prehabilitation program in patients with esophagogastric cancer awaiting surgery? A systematic review. BMC Sports Sci Med Rehabil. 2021;13:33.
Falz R, Bischoff C, Thieme R, Lässing J, Mehdorn M, Stelzner S, et al. Effects and duration of exercise-based prehabilitation in surgical therapy of colon and rectal cancer: a systematic review and meta-analysis. J Cancer Res Clin Oncol. 2022;148:2187–213.
Cuijpers ACM, Linskens FG, Bongers BC, Stassen LPS, Lubbers T, van Meeteren NLU. Quality and clinical generalizability of feasibility outcomes in exercise prehabilitation before colorectal cancer surgery - A systematic review. Eur J Surgical Oncol. 2022;48:1483–97.
Vermillion SA, James A, Dorrell RD, Brubaker P, Mihalko SL, Hill AR, et al. Preoperative exercise therapy for gastrointestinal cancer patients: a systematic review. Syst Rev. 2018;7:103.
Li X, Li S, Yan S, Wang Y, Wang X, Sihoe ADL, et al. Impact of preoperative exercise therapy on surgical outcomes in lung cancer patients with or without COPD: a systematic review and meta-analysis. Cancer Manag Res. 2019;11:1765–77.
Rosero ID, Ramírez-Vélez R, Lucia A, Martínez-Velilla N, Santos-Lozano A, Valenzuela PL, et al. Systematic Review and Meta-Analysis of Randomized, Controlled Trials on Preoperative Physical Exercise Interventions in Patients with Non-Small-Cell Lung Cancer. Cancers. 2019;11:944
Briggs LG, Reitblat C, Bain PA, Parke S, Lam NY, Wright J, et al. Prehabilitation Exercise Before Urologic Cancer Surgery: A Systematic and Interdisciplinary Review. Eur Urol. 2022;81:157–67.
Wade-Mcbane K, King A, Urch C, Jeyasingh-Jacob J, Milne A, Boutillier CL. Prehabilitation in the lung cancer pathway: a sco** review. BMC Cancer. 2023;23:747.
Raz DJ, Kim JY, Erhunwmunesee L, Hite S, Varatkar G, Sun V. The value of perioperative physical activity in older patients undergoing surgery for lung cancer. Expert Rev Respiratory Med. 2023;17:691–700.
Kichena S, Kamani A, Fricke B. Potential of prehabilitation in hepatocellular carcinoma: a narrative review of available evidence. Ann Palliat Med. 2024;13:101–11.
Dovey Z, Horowitz A, Waingankar N. The influence of lifestyle changes (diet, exercise and stress reduction) on prostate cancer tumour biology and patient outcomes: A systematic review. BJUI Compass. 2023;4:385–416.
Yang A, Sokolof J, Gulati A. The effect of preoperative exercise on upper extremity recovery following breast cancer surgery: a systematic review. Int J Rehabilit Res. 2018;41:189–96.
Geng E, Yin S, Yang Y, Ke C, Fang K, Liu J, et al. The effect of perioperative pelvic floor muscle exercise on urinary incontinence after radical prostatectomy: a meta-analysis. Int Braz J Urol. 2023;49:441–51.
Zhou L, Chen Y, Yuan X, Zeng L, Zhu J, Zheng J. Preoperative pelvic floor muscle exercise for continence after radical prostatectomy: a systematic review and meta-analysis. Front Public Health. 2023;11:1186067.
Smyth E, O’Connor L, Mockler D, Reynolds JV, Hussey J, Guinan E. Preoperative high intensity interval training for oncological resections: A systematic review and meta-analysis. Surgical Oncol. 2021;38:101620.
Franssen RFW, Janssen-Heijnen MLG, Barberan-Garcia A, Vogelaar FJ, Van Meeteren NLU, Bongers BC. Moderate-intensity exercise training or high-intensity interval training to improve aerobic fitness during exercise prehabilitation in patients planned for elective abdominal cancer surgery? Eur J Surgical Oncol. 2022;48:3–13.
Piraux E, Caty G, Reychler G. Effects of preoperative combined aerobic and resistance exercise training in cancer patients undergoing tumour resection surgery: A systematic review of randomised trials. Surgical Oncol. 2018;27:584–94.
Palma S, Hasenoehrl T, Jordakieva G, Ramazanova D, Crevenna R. High-intensity interval training in the prehabilitation of cancer patients—a systematic review and meta-analysis. Supportive Care Cancer. 2021;29:1781–94.
** S, Li S, Zhang Q, Pang D. Preoperative physical exercise strategies for patients undergoing major abdominal cancer surgery: a sco** review. Support Care Cancer. 2021;29:7057–71.
Lee K, Zhou J, Norris MK, Chow C, Dieli-Conwright CM. Prehabilitative Exercise for the Enhancement of Physical, Psychosocial, and Biological Outcomes Among Patients Diagnosed with Cancer. Curr Oncol Rep. 2020;22:71.
Boereboom C, Doleman B, Lund JN, Williams JP. Systematic review of pre-operative exercise in colorectal cancer patients. Tech Coloproctol. 2016;20:81–9.
Lau CSM, Chamberlain RS. Prehabilitation Programs Improve Exercise Capacity Before and After Surgery in Gastrointestinal Cancer Surgery Patients: A Meta-Analysis. J Gastrointest Surg. 2020;24:2829–37.
Sebio Garcia R, Yáñez Brage MI, Giménez Moolhuyzen E, Granger CL, Denehy L. Functional and postoperative outcomes after preoperative exercise training in patients with lung cancer: a systematic review and meta-analysis. Interact Cardiovasc Thorac Surg. 2016;23:486–97.
Brownson-Smith R, Orange ST, Cresti N, Hunt K, Saxton J, Temesi J. Effect of exercise before and/or during taxane-containing chemotherapy treatment on chemotherapy-induced peripheral neuropathy symptoms in women with breast cancer: systematic review and meta-analysis. J Cancer Surviv. 2023. https://doi.org/10.1007/s11764-023-01450-w Online ahead of print.
Flores LE, Westmark D, Katz NB, Hunter TL, Silver EM, Bryan KM, et al. Prehabilitation in radiation therapy: a sco** review. Support Care Cancer. 2024;32:83.
Yang L, Azam A, Friedenreich CM. Physical activity for cancer prehabilitation: a sco** review. Critical Rev Oncol Hematol. 2024;196:104319.
Kearney N, Connolly D, Begic S, Mockler D, Guinan E. Feasibility metrics of exercise interventions during chemotherapy: A systematic review. Crit Rev Oncol Hematol. 2024;195:104272.
Grosek A, Grosek K, Bloch W. Safety and feasibility of exercise interventions in patients with hematological cancer undergoing chemotherapy: a systematic review. Support Care Cancer. 2023;31:335.
Zoth N, Tomanek A, Seuthe K, Pfister R, Baumann FT. Exercise as medicine could be a chance for early detection and prevention of Cardiotoxicity in cancer treatments - a narrative review. Oncol Res Treatment. 2023;46:131–9.
Ma Z-Y, Yao S-S, Shi Y-Y, Lu N-N, Cheng F. Effect of aerobic exercise on cardiotoxic outcomes in women with breast cancer undergoing anthracycline or trastuzumab treatment: a systematic review and meta-analysis. Suppor Care Cancer. 2022;30:10323–34.
Kendall SJ, Langley JE, Aghdam M, Crooks BN, Giacomantonio N, Heinze-Milne S, et al. The Impact of Exercise on Cardiotoxicity in Pediatric and Adolescent Cancer Survivors: A Sco** Review. Curr Oncol. 2022;29:6350–63.
Correia IR, Cardoso V, Cargaleiro C, Magalhaes JP, Hetherington-Rauth M, Rosa GB, et al. Effects of home-based exercise programs on physical fitness in cancer patients undergoing active treatment: A systematic review and meta-analysis of randomized controlled trials. J Sci Med sport. 2023;26:222–31.
Malveiro C, Correia IR, Cargaleiro C, Magalhaes JP, de Matos LV, Hilario S, et al. Effects of exercise training on cancer patients undergoing neoadjuvant treatment: A systematic review. J Sci Med Sport. 2023;26:586–92.
Yang L, Morielli AR, Heer E, Kirkham AA, Cheung WY, Usmani N, et al. Effects of Exercise on Cancer Treatment Efficacy: A Systematic Review of Preclinical and Clinical Studies. Cancer Res. 2021;81:4889–95.
Courneya KS, Booth CM. Exercise as cancer treatment: A clinical oncology framework for exercise oncology research. Front Oncol. 2022;12:957135.
Courneya KS, Friedenreich CM. Designing, analyzing, and interpreting observational studies of physical activity and cancer outcomes from a clinical oncology perspective. Front Oncol. 2023;13:1098278.
Thomsen SN, Lahart IM, Thomsen LM, Fridh MK, Larsen A, Mau-Sørensen M, et al. Harms of exercise training in patients with cancer undergoing systemic treatment: a systematic review and meta-analysis of published and unpublished controlled trials. EClinicalMedicine. 2023;59:101937.
National Cancer Insititue. NCI Dictionaries. Rehabilitation. Available at: https://www.cancer.gov/publications/dictionaries/cancer-terms/def/rehabilitation. Accessed July 05, 2023.
National Cancer Insititue. NCI Dictionaries. Recover. Available at: https://www.cancer.gov/publications/dictionaries/cancer-terms/def/recover, Accessed July 05, 2023.
World Health Organization. Health Promotion. Available at: https://www.who.int/westernpacific/about/how-we-work/programmes/health-promotion. Accessed July 05, 2023.
World Health Organization. Health promotion and disease prevention through population-based interventions, including action to address social determinants and health inequity. Available at:https://www.emro.who.int/about-who/public-health-functions/health-promotion-disease-prevention.html. Accessed July 05, 2023.
Goldschmidt S, Schmidt ME, Steindorf K. Long-term effects of exercise interventions on physical activity in breast cancer patients: a systematic review and meta-analysis of randomized controlled trials. Support Care Cancer. 2023;31:130.
Cariolou M, Abar L, Aune D, Balducci K, Becerra-Tomas N, Greenwood DC, et al. Postdiagnosis recreational physical activity and breast cancer prognosis: Global Cancer Update Programme (CUP Global) systematic literature review and meta-analysis. Int J Cancer. 2023;152:600–15.
Rendeiro JA, Rodrigues CAMP, de Barros Rocha L, Rocha RSB, da Silva ML, da Costa Cunha K. Physical exercise and quality of life in patients with prostate cancer: systematic review and meta-analysis. Support Care Cancer. 2021;29:4911–9.
Reimer N, Zopf EM, Bowe R, Baumann FT. Effects of Exercise on Sexual Dysfunction in Patients With Prostate Cancer - A Systematic Review. J Sex Med. 2021;18:1899–914.
Neil-Sztramko SE, Medysky ME, Campbell KL, Bland KA, Winters-Stone KM. Attention to the principles of exercise training in exercise studies on prostate cancer survivors: a systematic review. BMC Cancer. 2019;19:321.
Machado P, Morgado M, Raposo J, Mendes M, Silva CG, Morais N. Effectiveness of exercise training on cancer-related fatigue in colorectal cancer survivors: a systematic review and meta-analysis of randomized controlled trials. Support Care Cancer. 2022;30:5601–13.
Mbous YP, Patel J, Kelly KM. A systematic review and meta-analysis of physical activity interventions among colorectal cancer survivors. Transl Behav Med. 2020;10:1134–43.
Teba P-P, Esther M-G, Raquel S-G. Association between physical activity and patient-reported outcome measures in patients with lung cancer: a systematic review and meta-analysis. Qual Life Res. 2022;31:1963–76.
Medysky ME, Bland KA, Neil-Sztramko SE, Campbell KL, Sullivan DR, Winters-Stone KM. Attention to the Principles of Exercise Training in Exercise Studies of Persons With Lung Cancer: A Systematic Review. J Aging Phys Act. 2021;29:1042–52.
Wogksch MD, Goodenough CG, Finch ER, Partin RE, Ness KK. Physical activity and fitness in childhood cancer survivors: a sco** review. Aging Cancer. 2021;2:112–28.
Moberg L, Fritch J, Westmark D, Mina DS, Krause C, Bilek L, et al. Effect of physical activity on fatigue in childhood cancer survivors: a systematic review. Support Care Cancer. 2022;30:6441–9.
Campbell KL, Winters-Stone KM, Wiskemann J, May AM, Schwartz AL, Courneya KS, et al. Exercise Guidelines for Cancer Survivors: Consensus Statement from International Multidisciplinary Roundtable. Med Sci Sports Exerc. 2019;51:2375–90.
Caru M, Levesque A, Rao P, Dandekar S, Terry C, Brown V, et al. A sco** review to map the evidence of physical activity interventions in post-treatment adolescent and young adult cancer survivors. Crit Rev Oncol Hematol. 2022;171:103620.
Boutron I, Dutton S, Ravaud P, Altman DG. Reporting and Interpretation of Randomized Controlled Trials With Statistically Nonsignificant Results for Primary Outcomes. JAMA. 2010;303:2058–64.
Chen T, Li C, Qin R, Wang Y, Yu D, Dodd J, et al. Comparison of Clinical Trial Changes in Primary Outcome and Reported Intervention Effect Size Between Trial Registration and Publication. JAMA Netw. 2019;2:e197242-e.
Wang S, Yang T, Qiang W, Shen A, Zhao Z, Chen X, et al. Effectiveness of physical exercise on the cardiovascular system in breast cancer patients: a systematic review and meta-analysis of randomized controlled trials. Complementary Therapies Clin Pr. 2021;44:101426.
Abbasi F, Pourjalali H, do Nascimento IJB, Zargarzadeh N, Mousavi SM, Eslami R, et al. The effects of exercise training on inflammatory biomarkers in patients with breast cancer: A systematic review and meta-analysis. Cytokine. 2022;149:155712.
Kong L, Gao R. Aerobic exercise combined with resistance exercise training improves cardiopulmonary function and blood lipid of patients with breast cancer: A systematic review and meta-analysis. Medicine. 2022;101:e32391.
Kang D-W, Lee J, Suh S-H, Ligibel J, Courneya KS, Jeon JY. Effects of Exercise on Insulin, IGF Axis, Adipocytokines, and Inflammatory Markers in Breast Cancer Survivors: A Systematic Review and Meta-analysis. Cancer epidemiology, biomarkers & prevention : a publication of the American Association for Cancer Research, cosponsored by the American. Soc Preventive Oncol. 2017;26:355–65.
Friedenreich CM, Morielli AR, Lategan I, Ryder-Burbidge C, Yang L. Physical Activity and Breast Cancer Survival-Epidemiologic Evidence and Potential Biologic Mechanisms. Curr Nutr Rep. 2022;11:717–41.
Sarfati D, Koczwara B, Jackson C. The impact of comorbidity on cancer and its treatment. CA Cancer J Clin. 2016;66:337–50.
Spratt DE, Shore N, Sartor O, Rathkopf D, Olivier K. Treating the patient and not just the cancer: therapeutic burden in prostate cancer. Prostate Cancer Prostatic Dis. 2021;24:647–61.
Cooper KB, Lapierre S, Carrera Seoane M, Lindstrom K, Pritschmann R, Donahue M, et al. Behavior change techniques in digital physical activity interventions for breast cancer survivors: a systematic review. Transl Behav Med. 2023;13:268–80.
Rossi A, Friel C, Carter L, Garber CE. Effects of Theory-Based Behavioral Interventions on Physical Activity Among Overweight and Obese Female Cancer Survivors: A Systematic Review of Randomized Controlled Trials. Integr cancer Therapies. 2018;17:226–36.
Finne E, Glausch M, Exner A-K, Sauzet O, Stolzel F, Seidel N. Behavior change techniques for increasing physical activity in cancer survivors: a systematic review and meta-analysis of randomized controlled trials. Cancer Manag Res. 2018;10:5125–43.
Amireault S, Fong AJ, Sabiston CM. Promoting Healthy Eating and Physical Activity Behaviors: A Systematic Review of Multiple Health Behavior Change Interventions Among Cancer Survivors. Am J Lifestyle Med. 2018;12:184–99.
Liu MG, Davis GM, Kilbreath SL, Yee J. Physical activity interventions using behaviour change theories for women with breast cancer: a systematic review and meta-analysis. J Cancer Surviv. 2022;16:1127–48.
Hailey V, Rojas-Garcia A, Kassianos AP. A systematic review of behaviour change techniques used in interventions to increase physical activity among breast cancer survivors. Breast Cancer. 2022;29:193–208.
Hallward L, Patel N, Duncan LR. Behaviour change techniques in physical activity interventions for men with prostate cancer: A systematic review. J Health Psychol. 2020;25:105–22.
Finlay A, Wittert G, Short CE. A systematic review of physical activity-based behaviour change interventions reaching men with prostate cancer. J Cancer Surviv. 2018;12:571–91.
Roberts AL, Fisher A, Smith L, Heinrich M, Potts HWW. Digital health behaviour change interventions targeting physical activity and diet in cancer survivors: a systematic review and meta-analysis. J Cancer Surviv. 2017;11:704–19.
Werts SJ, Robles-Morales R, Bea JW, Thomson CA. Characterization and efficacy of lifestyle behavior change interventions among adult rural cancer survivors: a systematic review. J Cancer Survivor. 2023.
de Vries-Ten Have J, Winkels RM, Kampman E, Winkens LHH. Behaviour change techniques used in lifestyle interventions that aim to reduce cancer-related fatigue in cancer survivors: a systematic review. Int J Behav Nutr Phys Act. 2023;20:126.
Rogers LQ, Pekmezi D, Schoenberger-Godwin Y-M, Fontaine KR, Ivankova NV, Kinsey AW, et al. Using the TIDieR checklist to describe development and integration of a web-based intervention promoting healthy eating and regular exercise among older cancer survivors. Digital Health. 2023;9:20552076231182805.
Brunet J, Wurz A, Nader PA, Belanger M. A systematic review summarizing the effect of health care provider-delivered physical activity interventions on physical activity behaviour in cancer survivors. Patient Educ Counsel. 2020;103:1287–301.
Meyer-Schwickerath C, Morawietz C, Baumann FT, Huber G, Wiskemann J. Efficacy of face-to-face behavior change counseling interventions on physical activity behavior in cancer survivors - a systematic review and meta-analysis. Disabil Rehabilit. 2022;44:5386–401.
Swartz MC, Lewis ZH, Lyons EJ, Jennings K, Middleton A, Deer RR, et al. Effect of Home- and Community-Based Physical Activity Interventions on Physical Function Among Cancer Survivors: A Systematic Review and Meta-Analysis. Arch Phys Med Rehabilit. 2017;98:1652–65.
Covington KR, Hidde MC, Pergolotti M, Leach HJ. Community-based exercise programs for cancer survivors: a sco** review of practice-based evidence. Support Care Cancer. 2019;27:4435–50.
Wagoner CW, Lee JT, Battaglini CL. Community-based exercise programs and cancer-related fatigue: a systematic review and meta-analysis. Support Care Cancer. 2021;29:4921–9.
Neil-Sztramko SE, Smith-Turchyn J, Fong A, Kauffeldt K, Tomasone JR. Community-Based Exercise Programs for Cancer Survivors: A Sco** Review of Program Characteristics Using the Consolidated Framework for Implementation Research. Arch Phys Med Rehabilit. 2022;103:542–58.e10.
Groen WG, van Harten WH, Vallance JK. Systematic review and meta-analysis of distance-based physical activity interventions for cancer survivors (2013–2018): We still haven’t found what we’re looking for. Cancer Treat Rev. 2018;69:188–203.
National Cancer Insititue. NCI Dictionaries. Palliative care. Available at https://www.cancer.gov/publications/dictionaries/cancer-terms/def/palliative-care: Accessed July 05, 2023.
Toohey K, Chapman M, Rushby A-M, Urban K, Ingham G, Singh B. The effects of physical exercise in the palliative care phase for people with advanced cancer: a systematic review with meta-analysis. J Cancer Surviv. 2023;17:399–415.
Tanriverdi A, Ozcan Kahraman B, Ergin G, Karadibak D, Savci S. Effect of exercise interventions in adults with cancer receiving palliative care: a systematic review and meta-analysis. Support Care Cancer. 2023;31:205.
Rogers-Shepp I, Bhattacharya S, Mennillo HA, Kumar R, Hsieh B, Anandarajah G. Exercise interventions for advanced cancer palliative care patients: A systematic literature review and descriptive evidence synthesis of randomized controlled trials. Palliat Med. 2023;37:677–91.
Besseling J, van Velzen M, Wierdsma N, Alonso-Duin KS, Weijs P, May AM, et al. Exercise and Nutritional Interventions in Patients with Advanced Gastroesophageal Cancer: A Systematic Review. J Gastrointestinal Cancer. 2022:54:1006–9.
Barnes O, Wilson RL, Gonzalo-Encabo P, Kang D-W, Christopher CN, Bentley T, et al. The Effect of Exercise and Nutritional Interventions on Body Composition in Patients with Advanced or Metastatic Cancer: A Systematic Review. Nutrients. 2022;14:2110.
Shallwani SM, Ranger M-C, Thomas R, Brosseau L, Poitras S, Sikora L, et al. A sco** review of studies exploring leisure-time physical activity in adults diagnosed with advanced cancer. Palliat Support Care 2021;19:615–30.
Geng Z, Wang J, Zhang Y, Wu F, Yuan C. Physical activity in the context of advanced breast cancer: An integrative review. J Adv Nurs. 2021;77:2119–43.
De Lazzari N, Niels T, Tewes M, Gotte M. A Systematic Review of the Safety, Feasibility and Benefits of Exercise for Patients with Advanced Cancer. Cancers. 2021;13:4478.
Chen Y-J, Li X-X, Ma H-K, Zhang X, Wang B-W, Guo T-T, et al. Exercise Training for Improving Patient-Reported Outcomes in Patients With Advanced-Stage Cancer: A Systematic Review and Meta-Analysis. J Pain Symptom Manag. 2020;59:734–49.e10.
Sheill G, Guinan E, Brady L, Hevey D, Hussey J. Exercise interventions for patients with advanced cancer: A systematic review of recruitment, attrition, and exercise adherence rates. Palliat Support Care 2019;17:686–96.
Heywood R, McCarthy AL, Skinner TL. Efficacy of Exercise Interventions in Patients With Advanced Cancer: A Systematic Review. Arch Phys Med Rehabilit. 2018;99:2595–620.
Heywood R, McCarthy AL, Skinner TL. Safety and feasibility of exercise interventions in patients with advanced cancer: a systematic review. Support Care Cancer. 2017;25:3031–50.
Dittus KL, Gramling RE, Ades PA. Exercise interventions for individuals with advanced cancer: A systematic review. Prevent Med. 2017;104:124–32.
Wilk M, Kepski J, Kepska J, Casselli S, Szmit S. Exercise interventions in metastatic cancer disease: a literature review and a brief discussion on current and future perspectives. BMJ Support Palliat Care. 2020;10:404–10.
van Doorslaer de Ten Ryen S, Deldicque L. The Regulation of the Metastatic Cascade by Physical Activity: A Narrative Review. Cancers. 2020;12:153.
Rincon-Castanedo C, Morales JS, Martin-Ruiz A, Valenzuela PL, Ramirez M, Santos-Lozano A, et al. Physical exercise effects on metastasis: a systematic review and meta-analysis in animal cancer models. Cancer Metastasis Rev. 2020;39:91–114.
Duong H, Walker M, Maugham-Macan M. Exercise Intervention for Bone Metastasis: Safety, Efficacy and Method of Delivery. Cancers. 2023;15:1796.
Langbaum T, Smith TJ. Time to Study Metastatic-Cancer Survivorship. N Engl J Med. 2019;380:1300–2.
Temel JS, Greer JA, Muzikansky A, Gallagher ER, Admane S, Jackson VA, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med. 2010;363:733–42.
Campbell KL, Cormie P, Weller S, Alibhai SMH, Bolam KA, Campbell A, et al. Exercise Recommendation for People With Bone Metastases: Expert Consensus for Health Care Providers and Exercise Professionals. JCO Oncol Pr. 2022;18:e697–e709.
Cao C, Friedenreich CM, Yang L. Association of Daily Sitting Time and Leisure-Time Physical Activity With Survival Among US Cancer Survivors. JAMA Oncol. 2022;8:395–403.
Courneya KS, Booth CM, Gill S, O’Brien P, Vardy J, Friedenreich CM, et al. The Colon Health and Life-Long Exercise Change trial: a randomized trial of the National Cancer Institute of Canada Clinical Trials Group. Curr Oncol. 2008;15:279–85.
Newton RU, Kenfield SA, Hart NH, Chan JM, Courneya KS, Catto J, et al. Intense Exercise for Survival among Men with Metastatic Castrate-Resistant Prostate Cancer (INTERVAL-GAP4): a multicentre, randomised, controlled phase III study protocol. BMJ Open. 2018;8:e022899.
Courneya KS, Vallance JK, Culos-Reed SN, McNeely ML, Bell GJ, Mackey JR, et al. The Alberta moving beyond breast cancer (AMBER) cohort study: a prospective study of physical activity and health-related fitness in breast cancer survivors. BMC Cancer. 2012;12:525.
Friedenreich CM, Vallance JK, McNeely ML, Culos-Reed SN, Matthews CE, Bell GJ, et al. The Alberta moving beyond breast cancer (AMBER) cohort study: baseline description of the full cohort. Cancer Causes Control. 2022;33:441–53.
Courneya KS, Vardy JL, O’Callaghan CJ, Friedenreich CM, Campbell KL, Prapavessis H, et al. Effects of a Structured Exercise Program on Physical Activity and Fitness in Colon Cancer Survivors: One Year Feasibility Results from the CHALLENGE Trial. Cancer epidemiology, biomarkers & prevention : a publication of the American Association for Cancer Research, cosponsored by the American. Soc Preventive Oncol. 2016;25:969–77.
World Cancer Research Fund/American Institute for Cancer Research. Continuous Update Project Expert Report 2018. Physical Activity and the Risk of Cancer. Available at https://www.wcrf.org/diet-activity-and-cancer/accessed Dec 19, 2023.
U.S. Department of Health and Human Services. Physical Activity Guidelines for Americans. 2008. Available at: http://www.health.gov/paguidelines.
Global Recommendations on Physical Activity for Health. Geneva: World Health Organization; 2010.
Rock CL, Thomson C, Gansler T, Gapstur SM, McCullough ML, Patel AV, et al. American Cancer Society guideline for diet and physical activity for cancer prevention. CA Cancer J Clin. 2020;70:245–71.
Bull FC, Al-Ansari SS, Biddle S, Borodulin K, Buman MP, Cardon G, et al. World Health Organization 2020 guidelines on physical activity and sedentary behaviour. Br J Sports Med. 2020;54:1451–62.
U.S. Department of Health and Human Services. Physical Activity Guidelines for Americans. 2nd edition. Washington DC: U.S. Department of Health and Human Services; 2018.
Ligibel JA, Bohlke K, May AM, Clinton SK, Demark-Wahnefried W, Gilchrist SC, et al. Exercise, Diet, and Weight Management During Cancer Treatment: ASCO Guideline. J Clin Oncol. 2022;40:2491–507.
Cormie P, Atkinson M, Bucci L, Cust A, Eakin E, Hayes S, et al. Clinical Oncology Society of Australia position statement on exercise in cancer care. Med J Aust. 2018;209:184–7.
Cancer Research UK. Exercise guidelines for cancer patients. https://www.cancerresearchuk.org/about-cancer/co**/physically/exercise-guidelinesAccessed. March 8, 2024.
Rock CL, Thomson CA, Sullivan KR, Howe CL, Kushi LH, Caan BJ, et al. American Cancer Society nutrition and physical activity guideline for cancer survivors. CA Cancer J Clin. 2022;72:230–62.
Stein KD, Syrjala KL, Andrykowski MA. Physical and psychological long-term and late effects of cancer. Cancer. 2008;112:2577–92.
Morishita S, Hamaue Y, Fukushima T, Tanaka T, Fu JB, Nakano J. Effect of Exercise on Mortality and Recurrence in Patients With Cancer: A Systematic Review and Meta-Analysis. Integr Cancer Therapies. 2020;19:1534735420917462.
Byrne S, Boyle T, Ahmed M, Lee SH, Benyamin B, Hyppönen E. Lifestyle, genetic risk and incidence of cancer: a prospective cohort study of 13 cancer types. Int J Epidemiol. 2023;52:817–26.
Sfm C, Van Cauwenberg J, Maenhout L, Cardon G, Lambert EV, Van Dyck D. Inequality in physical activity, global trends by income inequality and gender in adults. Int J Behav Nutr Phys Act. 2020;17:142.
Tison GH, Barrios J, Avram R, Kuhar P, Bostjancic B, Marcus GM, et al. Worldwide physical activity trends since COVID-19 onset. Lancet Glob Health. 2022;10:e1381–e2.
Thomas G, Tahir MR, Bongers BC, Kallen VL, Slooter GD, van Meeteren NL. Prehabilitation before major intra-abdominal cancer surgery: A systematic review of randomised controlled trials. Eur J Anaesthesiol. 2019;36:933–45.
Michael CM, Lehrer EJ, Schmitz KH, Zaorsky NG. Prehabilitation exercise therapy for cancer: A systematic review and meta-analysis. Cancer Med. 2021;10:4195–205.
Gilbert A, Piccinin C, Velikova G, Groenvold M, Kuliś D, Blazeby JM, et al. Linking the European Organisation for Research and Treatment of Cancer Item Library to the Common Terminology Criteria for Adverse Events. J Clin Oncol. 2022;40:3770–80.
Yang L, Cao C, Kantor ED, Nguyen LH, Zheng X, Park Y, et al. Trends in Sedentary Behavior Among the US Population, 2001–2016. JAMA. 2019;321:1587–97.
Lane C, McCrabb S, Nathan N, Naylor P-J, Bauman A, Milat A, et al. How effective are physical activity interventions when they are scaled-up: a systematic review. Int J Behav Nutr Phys Act. 2021;18:16.
Czwikla G, Boen F, Cook DG, de Jong J, Harris T, Hilz LK, et al. Equity-specific effects of interventions to promote physical activity among middle-aged and older adults: results from applying a novel equity-specific re-analysis strategy. Int J Behav Nutr Phys Act. 2021;18:65.
Irwin ML, McTiernan A, Bernstein L, Gilliland FD, Baumgartner R, Baumgartner K, et al. Relationship of Obesity and Physical Activity with C-Peptide, Leptin, and Insulin-Like Growth Factors in Breast Cancer Survivors. Cancer Epidemiol Biomark Prev. 2005;14:2881–8.
Meyskens FL, Jr., Mukhtar H, Rock CL, Cuzick J, Kensler TW, Yang CS, et al. Cancer Prevention: Obstacles, Challenges and the Road Ahead. J National Cancer Inst. 2016;108:djv309.
Atwood K, Colditz GA, Kawachi I. From public health science to prevention policy: placing science in its social and political contexts. Am J Public health. 1997;87:1603–6.
Nau T, Bauman A, Smith BJ, Bellew W. A sco** review of systems approaches for increasing physical activity in populations. Health Res Policy Syst. 2022;20:104.
Sallis JF, Owen N, Fisher EB. Ecological models of health behavior. Health behavior and health education: Theory, research, and practice, 4th ed. San Francisco, CA, US: Jossey-Bass; 2008. p. 465–85.
Schmitz KH, Campbell AM, Stuiver MM, Pinto BM, Schwartz AL, Morris GS, et al. Exercise is medicine in oncology: Engaging clinicians to help patients move through cancer. CA Cancer J Clin. 2019;69:468–84.
Ramsey I, Chan A, Charalambous A, Cheung YT, Darling HS, Eng L, et al. Exercise counselling and referral in cancer care: an international sco** survey of health care practitioners’ knowledge, practices, barriers, and facilitators. Support Care Cancer. 2022;30:9379–91.
Shaffer KM, Turner KL, Siwik C, Gonzalez BD, Upasani R, Glazer JV, et al. Digital health and telehealth in cancer care: a sco** review of reviews. Lancet Digital Health. 2023;5:e316–27.
Molenaar CJL, Minnella EM, Coca-Martinez M, ten Cate DWG, Regis M, Awasthi R, et al. Effect of Multimodal Prehabilitation on Reducing Postoperative Complications and Enhancing Functional Capacity Following Colorectal Cancer Surgery: The PREHAB Randomized Clinical Trial. JAMA Surg. 2023;158:572–81.
Segal R, Zwaal C, Green E, Tomasone JR, Loblaw A, Petrella T. Exercise for people with cancer: a clinical practice guideline. Curr Oncol. 2017;24:40–6.
Craig P, Cooper C, Gunnell D, Haw S, Lawson K, Macintyre S, et al. Using natural experiments to evaluate population health interventions: new Medical Research Council guidance. J Epidemiol Community Health. 2012;66:1182–6.
Ogilvie D, Adams J, Bauman A, Gregg EW, Panter J, Siegel KR, et al. Using natural experimental studies to guide public health action: turning the evidence-based medicine paradigm on its head. J Epidemiol Community Health. 2020;74:203–8.
Eldridge SM, Chan CL, Campbell MJ, Bond CM, Hopewell S, Thabane L, et al. CONSORT 2010 statement: extension to randomised pilot and feasibility trials. BMJ. 2016;355:i5239.
Author information
Authors and Affiliations
Contributions
LY, KSC, and CMF contributed to the conceptualization. LY reviewed the literature and drafted the manuscript. LY, KSC and CMF reviewed, revised and approved the final manuscript.
Corresponding author
Ethics declarations
Competing interests
The authors declare no competing interests.
Additional information
Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Supplementary information
Rights and permissions
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
About this article
Cite this article
Yang, L., Courneya, K.S. & Friedenreich, C.M. The Physical Activity and Cancer Control (PACC) framework: update on the evidence, guidelines, and future research priorities. Br J Cancer (2024). https://doi.org/10.1038/s41416-024-02748-x
Received:
Revised:
Accepted:
Published:
DOI: https://doi.org/10.1038/s41416-024-02748-x
- Springer Nature Limited