A Guide to Exercising Through Cancer Care

In 2021, Angela Runyon had finally finished 18 months of treatment for stage IV kidney disease, brought on by a rare postpartum blood disorder, when she got the news: A routine mammogram and subsequent biopsy revealed that Runyon had stage IIB, triple-positive breast cancer.

The mom of three was devastated. “It’s an incredibly aggressive cancer. Within a week, I got a port. The day after, I was doing chemotherapy.”

Prior to the birth of her third child, Runyon, who lives in Tucson, had been regularly doing yoga, running 5Ks, and hiking. But with all the health issues she’d been navigating since then, she felt deconditioned going into cancer treatment.

“It really did impact my mental health and my anxiety,” she recalls. “I wanted to try and build up some stamina and do some exercising, but I wasn’t quite sure what I was going to be able to do.”

A friend invited Runyon to join the Tucson Cancer Conquerors (TCC), a group of nearly 200 women who meet for exercise classes, walks, and other physical activities.

“The thing about TCC is you don’t just sit around in a circle, tell your story, and cry. This group is really active. They’re not going to let you just sit there and wallow in misfortune. They’re going to help you literally move through it,” says Runyon.

Before she knew it, Runyon was taking TCC’s chair fitness classes and meeting new friends for walks, which she continued to do throughout treatment. She eventually worked her way up to TCC’s most advanced strength training class (she is now cancer-free and still attending).

Exercise not only helped Runyon regain strength and return to the physical activities she loves: It was key to maintaining her mental health. “I always feel better when I’m exercising. I’m less anxious and more able to stay in the present moment instead of ruminating about recurrence,” she says.

Exercise is a powerful way cancer patients and survivors can support their bodies and minds amid a multitude of passive treatments.

“Many of the benefits of exercise, whether you have cancer or not, are the same,” says Colin Champ, MD, CSCS, a radiation oncologist, integrative- and holistic-medicine physician, and strength and conditioning coach who runs the Allegheny Health Network Cancer Institute Exercise Oncology and Resiliency Center.

“You feel better, you look better, you build muscle mass, you increase mobility. Exercise helps your mood, and it helps you sleep better at night. All those [benefits] happen when you have cancer; the difference is that all those things are a lot more important when you have cancer.”

Our body needs movement, says Champ — and yet, for many cancer patients, movement is an untapped resource for coping and healing.

A survey led by Memorial Sloan Kettering researchers, published in 2018, showed that 75 percent of people reported reducing their physical activity for a year or more following their cancer diagnosis — and for understandable reasons. Fatigue, pain, lack of motivation and discipline, as well as treatment side effects, were all cited as barriers to exercise. If you’re a cancer survivor or have ever supported a loved one through a cancer diagnosis, you know that the fatigue alone is enough to slow someone down.

Even healthcare practitioners have been slow to acknowledge the importance of integrating exercise into treatment protocols. A study published in 2016 found that only 35 percent of oncology providers communicated with patients about the benefits of physical activity. However, a 2018 survey indicated that 79 percent of oncology clinicians agreed that they should recommend physical activity to their patients.

Understanding both the why and the how can help you or your loved ones develop a healthy movement practice despite the many challenges of cancer treatment.

 

Physical Benefits of Exercise During Cancer Care

A study published in 2023 in the Journal of Clinical Oncology found that people diagnosed with cancer who regularly exercise reduce their risk of dying from all causes by 25 percent compared with cancer patients who do not exercise. The study analyzed 11,480 people with different types of cancer who provided complete data about their exercise. Researchers followed some people for up to 25 years.

“I’m a big proponent of the soil and seed mindset, where if your soil is healthy, the weeds are going to die,” says Champ. “The healthier the terrain overall, the less chance we’re going to have cancer coming back.” (Learn more about the terrain theory: “What Is the Terrain Theory of Cancer?”)

We know that exercise reduces inflammation, increases muscle mass, improves metabolism, boosts immune response, and lowers blood glucose — all things that lead to improved overall health, he explains. On the other hand, having excess adipose tissue and inflammation increases the risk of cancer returning.

One reason cancer patients report not exercising is treatment side effects, but regular exercise can actually offset the side effects of cancer treatment, he adds.

For instance, most women with breast cancer undergo antiestrogen treatment, which leads to bone weakness. Some women also go through chemotherapy, which causes neuropathy and muscle loss, says Champ.

“You give someone imbalance, poor nerve function, and weak bones, it’s a recipe for disaster. It’s a huge fall risk and it’s a hip-fracture risk.” Resistance training, however, helps maintain or even build muscle mass and bone density to reduce both risks.

In some cases, exercise may help cancer patients better tolerate chemotherapy, preventing delays in treatment, says Jenny Spencer, RN, BSN, an oncology nurse at the Dana-Farber Cancer Institute and a cancer exercise specialist. “The goal for patients undergoing chemotherapy is to get as close to relative-dose intensity [RDI] — the ratio of chemotherapy delivered to prescribed  — as possible. Evolving studies show those doing exercise programming have better RDIs.”

 

Mental Health Benefits of Exercise During Cancer Care

Beyond its many physical benefits, exercise can be a powerful tool for supporting mental health throughout cancer treatment. Aerobic exercise has been shown to be an effective intervention for cancer-related fatigue, sleep disruption, anxiety, and quality of life. Exercise, coupled with a social support network, such as a group fitness class or walking group, has the additional benefit of improving accountability and helping cancer patients feel like they’re not alone.

Elizabeth Almli, MD, is an anesthesiologist, ACSM-certified personal trainer, certified cancer exercise specialist, and founding member and president of the TCC. Almli was inspired to head the group through her own personal journey of navigating the challenges of a cancer diagnosis and treatment. Like Runyon, she was diagnosed with an aggressive form of breast cancer in her 40s. Though she was supported by family, after a year of enduring chemotherapy and multiple surgeries, Almli felt isolated.

“Throughout the entire treatment year, the thing that kept me sane was exercise,” she recalls. “Not just the physical part of making my body stronger, but the mental part of socially being out with people and not feeling so fatigued.”

“So, when you say, ‘I’m so tired I can’t exercise,’ the truth is, you’re so tired you need to exercise. Exercising actually stimulates our natural endorphins, which improves our mood and helps us with our sleep.”

“The literature tells us that exercise is beneficial in improving sleep, and reducing stress, anxiety, and depression,” Almli continues. “Often, cancer patients are receiving high-dose steroids with their chemotherapy, making it nearly impossible to sleep. Not sleeping makes you tired, which makes you reluctant to exercise. Ongoing fatigue increases our anxiety, our perception of pain, and adversely affects our mental health.

“So, when you say, ‘I’m so tired I can’t exercise,’ the truth is, you’re so tired you need to exercise. Exercising actually stimulates our natural endorphins, which improves our mood and helps us with our sleep.”

“We can again look at benefits exercise has for the general long-term health for the general public and amplify that effect for those who have dealt with cancer,” says Mark Schneider, NASM-CPT, a Twin Cities–based personal trainer who coaches clients through cancer care and owns the Retreat Strength Gym. “There is evidence of reduced recurrence of many cancers when an exercise lifestyle is maintained. Increased quality of life, sustained autonomy post-treatment, healthier immune and hormone function . . . the whole deck of health is stacked toward a better health outcome for the cancer survivor.”

Guidelines for Exercising During Cancer Treatment

The recommendations for exercising during cancer treatment are not much different from those geared toward the general public, experts say. The American College of Sports Medicine (ACSM) recommends healthy adults should get a minimum 150 minutes of moderate-intensity aerobic exercise per week at least two days of which should include some resistance training.

1) Get started now.

The sooner you start moving, the better, says Spencer. “A lot of people think, I don’t need to work on this now, and so they wait until treatment is done. At that point, they may be tired and deconditioned, and side effects possibly could have been mitigated if they had started moving sooner.

It’s just about meeting [yourself] where you’re at.

“For the most part everyone can be moving more: It’s just about meeting [yourself] where you’re at. If you haven’t been active your entire life and now you’re going through treatment, you might be doing five minutes a day and building up from there,” she says.

 

2) Make a plan with your care team.

“Besides getting the initial clearance to work out, it’s important to find out if there are any issues you should be particularly concerned about,” says Champ. “Ask, ‘Based on the surgery I had, is there a decreased range of motion? Are there concerns because of chemo? Are there concerns because of [my] immune system?’ All those things come into play.”

Experts recommend working with an exercise professional who can communicate and collaborate with your care team. This helps ensure safety while also increasing the effectiveness of workouts. “Much like medical treatment, this should all be done in person, under expert personnel. But also it has to be dose-escalated,” says Champ. “If I give you a low dose of radiation, it’s not going to cause any side effects, but also it’s not going to work.”

Some of the most prominent cancer organizations, such as the Mayo Clinic and Memorial Sloan Kettering, promote exercise as an integral part of treatment plans. There are also trainers, physical therapists, and other movement professionals who have experience with cancer and may be a resource for clients.

“While there are certifications out there in the field, there isn’t a generally accepted approach saying [this] is ‘the right way,’” says Schneider. “The best option would be for the fitness professional to stay in contact with the oncology team to make sure they are clear on treatment and potential side effects, and the team is aware of exercise and recovery the patient is going through.”

 

3) Take it one day at a time.

Cancer treatment has a cyclical nature, explains Spencer. “The first one to five days after chemo, a patient may be feeling badly, but the closer they get to the next cycle, the more energy they’ll have. It’s important to reassure them it’s normal not to feel their best after treatment. Doing something at a lesser intensity is OK, as long as they’re still moving.” (Try this gentle, somatic workout designed to support you well-being.)

That said, not every day has to be an easy day. When a patient is feeling good, Spencer advises, the approach to exercise should look much the same as it does for someone without a cancer diagnosis: Progressively increase the load, intensity, and/or volume of their workouts to match their energy and fitness level.

Champ uses a red-, yellow-, and green-light system so that patients can let him and other trainers know how they’re feeling. Red indicates a light and easy day; yellow means they can push a little harder; and green shows they’re ready for a regular workout.

 

4) To maximize your benefits, maximize your efforts.

“Too often, people say, ‘This person has cancer; we’re not going to push them hard.’ But data shows that the more muscle mass and the less fat you have, the better the outcome [of overall treatment],” says Champ.

When patients come to Champ’s facility, they get a quick lesson in the principle of progressive overload: This means that to see results, you need to continue to put your body under additional stress.

“Whether you’re on nasty chemo or you’re not on chemo at all, we’re going to overload you. It’s just figuring out personally where you are and what that level of overload is,” says Champ. This approach helps ensure that patients aren’t just going through the motions — that the work they’re putting in is actually effective.

“If we think we’re going to put on muscle with exercise, it has to be exercise that’s going to cause you to put muscle mass on.”

Similarly, Almli urges cancer patients to challenge themselves with their cardio workouts. “A lot of people think, Well, I’m just going to walk. But you need to walk fast enough to get your heart rate up. If it took you 25 minutes to walk a mile on the treadmill, that’s probably not an effective cardio exercise. We’re human beings, we’re supposed to walk,” she says. “I love the idea of some sort of wearable technology so you can see what your heart rate is doing.”

 

5) Be aware of red flags that indicate you’re doing too much.

“I tell people it’s OK to be tired; it’s not OK to be hurting. If you want to stop because you’re tired, challenge yourself to do a little bit more,” says Almli.

“If you want to stop because you’re tired, challenge yourself to do a little bit more.”

To see if a client has pushed too far — or not enough — Schneider watches for changes in mental clarity or brain fogginess, windedness, strength gain or loss, pain, range of motion, and emotional states.

“The biggest tell will be if they can recover quickly,” he says. “The metric I use is: Work as hard as you can while being able to do it again tomorrow. Not necessarily the same routine but being able to maintain a similar intensity level.”

 

6) Find an accountability partner.

“It’s really hard to exercise on your own, especially if you don’t feel well,” says Almli. “But if you get a buddy and start slow, you have someone to hold you accountable.” You can make regular plans with a friend to meet for walks, join a group fitness class that you’re expected to attend, or work with a personal trainer.

She recommends scheduling exercise like you would an appointment. “When you’re going through cancer treatment, your calendar is so full of things you don’t want to do — labs, scans, doctor appointments, chemotherapy, radiation, etc. Add some exercise with a friend, so when you look at your calendar, it gives you something to look forward to.”

Regaining Some Control Over Your Health

When professional runner Gabrielle Grunewald was diagnosed with a rare terminal cancer, running became her coping strategy while going through rounds of treatments. Grunewald not only continued to run, but she took her career to a higher level, powering through treatment to place second in the 1,500-meter Division I 2010 NCAA Championships.

Before her death in 2019, Grunewald created the Brave Like Gabe foundation to advocate and raise money for treatment of rare cancers — and to inspire those undergoing cancer treatment to pursue their fitness goals and share their stories of bravery.

“From the very first day I was told I had cancer in 2009, I knew running would be a big part of my journey back to health,” she wrote. “Physical activity is a critical part of cancer prevention and is also a way for patients and survivors to ease treatment side effects, tolerate new therapies, and improve their mental health. … It has truly been my refuge; when everything else seems to be going wrong and the outcomes are far beyond my control, I can find perspective and hope on the run. … You could say I run on hope.”

Most people don’t take a cancer diagnosis and channel it toward athletic success, but Grunewald’s words resonate with many cancer patients and survivors. Exercise is key to supporting mental health. The challenge lies in building a movement practice that feels empowering and supportive. What this looks like will vary from one individual to another.

“The hardest thing to maintain while going through a potentially traumatic experience is a sense of curiosity and wonder. You will have harder days and easier days — days that feel like you can’t handle things anymore and other days that feel like your normal,” says Schneider. “Through that entire rollercoaster of feelings and experience, if you can continually ask yourself I wonder if I can … or I want to try …, it will act as a current that pulls you through tough parts, makes the easy parts feel more adventurous, and may shine a light on unknown possibilities.”

Ultimately, exercising should be a practice of gratitude — whether you’re feeling grateful for the ability to move your arms while sitting in a chair, or grateful to keep running when nothing else is in your control.

“Encourage yourself the way you would encourage a friend. Be thankful for what your body can do, instead of focusing on what it can’t,” says Almli. “Any gains that we have, we need to give ourselves credit. Cancer treatment is the most challenging thing I’ve ever done. But you can really feel empowered by regaining control over your health and just showing up.”

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