Making exercise part of routine cancer care seems like a no-brainer. Study after study supports it. Guidelines call for it. Surveys show that many patients want their oncologists to discuss it.

And now, with the publication of the CHALLENGE trial last year, the field has moved beyond evidence that exercise helps with brain fog, fatigue, and surgery recovery — all important outcomes on their own. The CHALLENGE trial proves that a structured exercise program can reduce the long-term risk for recurrence and even extend survival.

The trial “puts exercise in a whole new evidentiary category,” according to Kathryn H. Schmitz, PhD, MPH, professor at the University of Pittsburgh and deputy director of the Hillman Cancer Center, both in Pittsburgh.

“This is now saving your life,” Schmitz said.

But the reality is, there are barriers to translating a clinical trial intervention to everyday practice. The CHALLENGE trial randomly assigned patients with colon cancer to either a 3-year exercise program that included 50-70 hours of structured support or a control group that received educational materials encouraging exercise.

And most oncology practices look a lot more like that control group.

Clinic time is tight, and discussions about physical activity can fall by the wayside. Most practices lack an onsite, philanthropy-funded exercise program just steps or a click away. Third-party payers, meanwhile, aren’t lining up to contribute.

Then there’s the patient perspective. Research suggests many patients want their oncologist to discuss exercise. But few (27% in this survey) actually feel capable of ramping up their activity levels — highlighting their need for support.

So obstacles do exist. At the same time, the evidence of benefit from exercise is too strong to ignore.

“The question is no longer, should patients exercise? [It’s] how do we consistently incorporate exercise into routine oncology care?” said Jessica Scott, PhD, director of the exercise oncology program at Memorial Sloan Kettering Cancer Center in New York City.

While community oncology practices may lack the resources to offer CHALLENGE-like support, they can make a meaningful difference. Scott recommends a framework of “assess, advise, and refer.”

Make Exercise an Ongoing Discussion

Given the complexity and variation of each patient’s situation, clinicians need to read the room when it comes to the timing of exercise talks. However, evidence suggests that recommending exercise can be beneficial throughout the cancer care continuum, ranging from pre- and post-surgery to the period after active treatment.

“We routinely ask about pain, weight loss, and treatment toxicities,” Scott said, “but we often don’t ask whether a patient is physically active. Simply asking, ‘How many days per week are you active?’ creates an opportunity for intervention.”

If patients say they aren’t active, share some of the potential benefits of exercise for people with cancer.

Readiness exists on a continuum, and “the way people get ready is they hear about the value,” said Jennifer Ligibel, MD, professor at Harvard Medical School and director of the Leonard P. Zakim Center for Integrative Therapies and Healthy Living at Dana-Farber Cancer Center in Boston.

Sometimes the topic of exercise will arise naturally, such as at the beginning of care when patients worry about how a treatment plan may disrupt their life, Ligibel said. Other potential windows are when side effects such as brain fog and fatigue arise. When treatment toxicities begin to wear off, aftercare visits are another time to revisit the topic, and a readiness opening usually arises, since patients usually have some “what’s next?” questions.

Trust That Your Advice Matters

You do not have to be an exercise specialist or behavioralist to have these discussions. Scott said that one of the strongest predictors of exercise participation is a recommendation from a trusted clinician.

That point was echoed by Ligibel, who is the lead author of the current guideline on exercise and diet during cancer treatment from the American Society of Clinical Oncology (ASCO).

After a cancer diagnosis, Ligibel said, many people are interested in making lifestyle changes, and the oncologist “has an incredible role” in helping them direct their focus on changes that will best serve them.

In some cases, she noted, discussing exercise can redirect a patient’s passionate interest in unproven supplements or less beneficial dietary changes. (Per the ASCO guideline, there’s very limited evidence on the value of dietary interventions during cancer treatment).

The big caveat is, clinicians need to do more than just tell patients to get moving.

“We would never tell somebody, ‘Go get some chemotherapy,’ and I’ll leave it up to them to figure out how to do that,” Ligibel pointed out.

But that doesn’t mean oncologists should prescribe exercise plans. In fact, both Ligibel and Scott advised against that and suggested a collaborative approach instead.

Rather than mentioning an exercise goal of 150 weekly minutes — the standard advice for adults in general — Scott often asks, “What kinds of physical activity do you enjoy?” or “What amount of exercise feels realistic right now?”

Given that many patients may feel wiped out, let them know — as counterintuitive as it may sound — that getting up and moving every day can give them more energy, Ligibel said. And on days when they are just too tired for conventional exercise such as walking, options such as a virtual seated yoga class can be a good alternative.

If you do any motivational interviewing, ask permission before offering advice, explore barriers without judgment, and ask patients their own reasons for change.

Do Your Referral Homework

Although some people can make significant physical activity changes on their own, structured programs generally have better results. A major obstacle, Ligibel noted, is the lack of third-party payment. But there are community programs, some free or low-cost, that offer physical activity tailored to people with cancer.

The American College of Sports Medicine (ACSM) maintains the Moving Through Cancer directory of about 2300 exercise programs nationwide. The Young Men’s Christian Association network also offers a free exercise program for people with cancer.

As for virtual options, Scott recommended two. Moving For Life is free and includes programming for all people dealing with cancer — including caregivers — as well as focused offerings for older patients (the site specifically mentions people in their 90s) and for young adults and children with cancer. For those who can afford a monthly fee of $30 or $60, Greatly Health was developed by Sloan Kettering experts for patients undergoing active treatment and those in the aftercare period.

As the evidence for exercise in cancer care continues to build, there is growing momentum to put it into practice now. Along with the ASCO guidelines (which are currently being updated), the ACSM strongly backs exercise as part of routine care. The American College of Surgeons is also throwing its weight behind physical activity: Its 2027 breast care standards call for accredited breast-care programs to perform functional screenings and recommend exercise or refer patients to physical therapy when appropriate, and the group’s Commission on Cancer has proposed exercise oncology standards that, Schmitz said, could be finalized by January 2028.

Schmitz, who has dedicated her career to exercise oncology clinical trials and implementation, is confident that exercise will soon be an integral part of cancer care.

“It’s coming,” she said.

Ligibel, Schmitz, and Scott reported having no relevant financial disclosures.