How we’re revolutionising our understanding of exercise in cancer care

In conversation with Professor Anna Campbell MBE, Professor at Edinburgh Napier University and Director at CanRehab, and Stephen Price, SATCC Advisory Board member and Founder of SP&Co.

Professor Anna Campbell MBE is a Professor in Clinical Exercise Science at Edinburgh Napier University and Director of CanRehab, an award-winning provider of evidence based, specialist training in cancer and exercise for health and fitness professionals. She is an immunologist, biochemist, the author of more than 70 peer reviewed research papers and three educational book chapters on cancer and exercise. Stephen Price is an SATCC Advisory Board member and Founder of SP&Co Group, a collection of globally acclaimed, award-winning, health, fitness, and wellness concepts. His experience spans 20 years in the health sector in which he has been dedicated to championing evidence-based messages around physical activity in the cancer journey. In an interview with the SATCC, they took the time to explain how the approach to exercise and cancer has changed exponentially since 2000.  

Can cancer patients be active during treatment?

Since 2000, Anna has been instrumental in changing the game when it comes to our understanding of exercise and cancer. At the time, she had just completed her Masters in Sport and Exercise Science, when a breast cancer nurse asked if she was right to tell her patients to stay in bed and rest during chemotherapy. 

She says: “When I looked at the literature, there were only one or two studies around exercise and being active after a cancer diagnosis, so I couldn’t give her a good answer. We managed to get  funding from Macmillan Cancer Support to look into the question of whether it’s feasible for women going through chemotherapy for breast cancer to go to an exercise class. The answer was ultimately ‘yes’, and the main incentive was to help with fatigue. However, the trial was small and what we noticed was that only 23 patients out of 1200 were referred onto it. It turned out that nurses were only picking patients who were young, sporty, and determined to be active already. So, we got a large grant from Cancer Research UK – enough to do a whole trial with the help of clinical recruiters.”

Should cancer patients be active during treatment?

Anna then went on to do her next study, where someone working in each recruiting radiotherapy or chemotherapy unit was allocated to ask every person if they would be willing to take part in the exercise during trial. Out of 1000 individuals, 200 said yes and were also eligible, while another 300 said they would be willing but logistical reasons, mainly travel, prevented them from saying yes. That was the first finding.

The second finding came from the randomised trial where 100 out of the 200 people were given a 12-week exercise programme which was group exercise sessions twice a week. Another 100 people were simply told that it was good to be active. The results showed that typically you could be active while on cancer treatment, and the benefits if you were active ranged from increased cardio and respiratory fitness, to improved quality of life, and decreased fatigue. The study followed those women for five years. Five years on, those who had been in the 12-week programme were still more physically active, had a more positive mood and were less depressed than the ones who were in the control group.

By now it was 2010, and Anna and her colleagues realised that this research needed to be explored on an international scale. She says:

“Most studies were very general until that point, but from 2010 onwards a couple of guidelines were set. A landmark moment came when The American College of Sports Medicine (ACSM) recommended that exercise needed to be part of cancer treatment.  People were beginning to explore what happens if you exercise during treatment and whether there were long-term benefits to cardiorespiratory fitness, muscular strength and bone density, and lymphoedema for example. There was also much more specific data emerging about the impact of exercise on the side effects and toxicities of cancer treatments. They found that people who were active during treatment showed far less functional decline in heart and lung function than the people who did nothing. That message that ‘rest is best’ was now proven to be totally wrong. Women who did nothing during cancer treatment showed a decline in cardiorespiratory fitness that was the equivalent of ageing 10 years. Meanwhile, the loss of muscular strength was the equivalent of being in space for eight months, if they did nothing. The research showed that if you stay active during cancer treatment it reduces your functional decline and you can get back to ‘normal’ much quicker after treatment ends as well.”

Lots of studies into exercise during chemotherapy, using randomised control groups, also show that patients who are active tolerate the exact dose and number of chemotherapy treatments better than those who did no exercise. The practical benefit is that they are therefore more likely to complete the recommended course of treatment, at the recommended dose, which means it has a higher likelihood of reducing the chances of the cancer coming back. 

Breast Cancer UK writes: “Physical activity reduces breast cancer recurrence by 20-30% and the mortality risk in diagnosed patients by over 40%. One review that compared women diagnosed with breast cancer doing the least physical activity to those doing the most found that physically active women had a 40% lower risk of breast cancer mortality and a 42% lower risk of mortality from any cause.”

Now the research was showing that being active during cancer treatment was beneficial. Therefore, more sophisticated guidelines began to emerge to prescribe exercise for specific issues during cancer treatment, such as trouble with fatigue, anxiety, depression, bone health, lymphoedema, and sleep. It was being prescribed in the same way that medication might be, using the FITT principle – an acronym whereby exercise could be recommended with specifics for Frequency, Intensity, Time, and Type. 

Getting fit for treatment and living with cancer

By 2020, Anna and her team realised that while exercise during cancer treatment was being addressed, two groups were not. The attention began to turn towards getting people fit for treatment (prehab) and those who were living with advanced stages of cancer or metastatic cancer.

Getting fit for treatment

Anna says: “A lot of surgeons and anaesthetists came to us saying they had issues with patients who needed very complex, long surgeries, or intense cancer treatment, but their fitness levels were such that they were worried about complications. They asked if we could design programmes to get those patients fit for surgery and treatment. That’s now been developed dramatically for the NHS, which proactively tries to get patients more active from the point of diagnosis.”

Anna also discusses how the approach to cancer treatment is shifting from surgery first to chemotherapy first in many instances, in what’s called ‘neo-adjuvant chemotherapy’. She says:

“The idea is that if we shrink the tumour first, then we can cut out less. More people have that approach now, but it’s a double whammy for the body. The more we can reduce the body’s decline through chemotherapy the better someone’s health as they go into surgery.”

Stephen adds: “I remember when I first started, a surgeon told me that if a patient was 55 they might be presenting like a 65 year old in health terms because they’re not well. After cancer treatment they would typically have aged the equivalent of 15 years, putting them at around 80. However, if you can use the weeks before surgery to get that person closer to feeling like they’re 55, then their survivorship will be better. Those 28-day protocols pre-surgery can make a huge difference. It’s also empowering – it’s the one thing people feel they can control when their life has been turned upside down.”

Living with cancer

The other area that needed to be developed was for metastatic or advanced cancer. With more treatments now available and people are living with treatable but not curable cancer for longer. There therefore needed to be greater opportunities to optimise their quality of life as much as possible. 

Anna says: “Sir Chris Hoy is a great example of this.  He is doing a lot of weight lifting, despite having metastatic bone cancer. Even towards the end of life, we are seeing that if you do activities then you can still bend down or lift things out of a cupboard rather than being ‘chair shaped’. We often go into hospices and get people up out of their chairs – it’s about that functionality as much as anything, and there are more guidelines emerging to support that through being active.”

Looking to the future of exercise and cancer care

With all of this research having already transformed our understanding around exercise and cancer care, as well as our approach, things are not stopping there. Anna and Stephen are both excited about ongoing research into the impact of exercise on ‘tumorigenesis’ – or the development of the tumour and its environment. 

Anna says: “We know exercise boosts the immune system and anti-inflammatory responses, which are anti-cancer, it’s good for hormones etc. Now, there’s evidence that it might help to destroy tumours rather than just protect their hosts. It’s really exciting – in studies in mice we can actually see that the tumour stops growing.”

For example, a 2024 paper titled the ‘Impact of exercise on cancer: mechanistic perspectives and new insights‘, says: “Regular, long-term exercise has been shown to reduce the levels of these growth factors in the bloodstream, improve overall metabolic rates, and decrease the stimulation of cancerous tissues by these growth factors.”

Finding what’s right for the individual

Both Anna and Stephen are keen to point out that the message isn’t to go and run a marathon when you’re unwell and feeling washed out, but that it’s ok to lean into exercise when you feel up to it. Lots of people report having days when they feel good, then they overdo it and they crash the next day. 

Anna says: “Learning to pace yourself is important. When I teach a class to cancer patients, I want them to finish it and feel energised, not exhausted. Finding that level is different for everyone – I’ve seen people on the exact same treatment have totally different responses.” 

Stephen adds: “I think tracking is a really good way to find what works for you. I also think it’s important to remember that it’s not just about the physical benefits of exercise, but the social and psychological benefits, because cancer can be very isolating.”

How wellbeing practitioners can support cancer patients through exercise

With so much ‘snake oil’ out there, the knowledge that patients are doing something that’s proven to be beneficial is extremely powerful. Anna says: “I am not saying that exercise is the answer to everything, but there is very strong evidence, which we can grade, to say it’s convincing, moderate, or there is no evidence at all that it may stop or help with a specific side effect of cancer and cancer treatment. For example, we have moderate/good evidence that exercise helps improve sleep quality, and very strong evidence that it helps with depression.”

Looking ahead, Stephen and Anna are both aligned in their thinking, and when looking forward they agree that what we need is a joined-up pathway from diagnosis to community. As things stand however, we don’t have enough exercise specialists to triage patients into a hospital programme. 

We need people like exercise physiologists and CanRehab fitness instructors in leisure centres and spas to have a little knowledge to signpost people to the right programme. So, the work now is not just into research but implementation and development of the workforce. That’s where Anna and her team at CanRehab offer help. They have an online Cancer Confidence course, for example, to help gym staff to become ‘cancer friendly’, giving staff the basics in what questions to ask and how to safely say whether or not that person can go into your gym or if they need a cancer exercise specialist first.