Prescribing Exercise in Oncology: Moving Beyond “Good Luck”

In a dialogue with CancerNetwork®, Nathan Goodyear, MD, highlighted a lifestyle intervention that moves beyond conventional perspective on oncology care, advocating for the integration of exercise as a precise, prescribable biological therapy rather than a passive lifestyle recommendation.

Goodyear addressed a prevailing misconception in oncology: the idea that exercise lacks therapeutic efficacy. Citing clinical evidence like the OPTIMUS trial (NCT02950324) and phase 3 CHALLENGE trial (NCT00819208), he emphasized that exercise yields distinct, reproducible immunologic and metabolic benefits.^1,2 Crucially, these effects depend on a deliberate, structured prescription. Just as oncology relies on tailored chemotherapy regimens, exercise must be meticulously dosed, differentiating between the unique physiological impacts of cardiovascular and resistance training.

Furthermore, Goodyear highlighted how exercise acts as an interventional tool to combat immunosenescence and accelerated aging; frequent adverse effects of traditional treatments like surgery and chemotherapy. By shifting from a standard, one-size-fits-all regimen to a model of precision medicine, clinicians can utilize exercise to modulate inflammatory responses and optimize recovery phases. Ultimately, Goodyear asserted that fusing conventional treatments with structured lifestyle interventions could transform the internal biological ecosystem, pivoting patient care away from the mere management of disease and toward comprehensive, lifelong healing.

CancerNetwork: What are some common misconceptions about exercise that clinicians or patients might have?

Goodyear: One of the greatest misconceptions is that exercise doesn’t work. [These] 2 studies alone––the OPTIMIST and the CHALLENGE [studies]––show that they stand on their own feet, but they also stand in support. That’s what happens a lot in oncology. That’s why I say following integrative oncology and integrative medicine is simply looking at where the science is going. If people are in conventional medicine and people are in natural, holistic care, they tend to lock themselves into a certain thought. Integrative medicine says “Let’s look at the whole”—and that’s what the word means, the whole.

Here, it’s saying, “Okay, you know what we need to do?” We need to understand that it does have science to support it, there is research that shows how to implement it, and now let’s put it into practice. If doctors say it doesn’t work, then the patient’s not going to think it works. Doctors must be in the science to know that it’s there, that there’s evidence to support that it’s working, and then don’t just live a more active lifestyle, because the CHALLENGE study showed that you have to be deliberate in the design. You can’t just say, “Here’s some exercise, good luck to you, I hope it works.” That would be like, “Hey, here’s a bunch of chemotherapies. Good luck, I hope it works for you.” Everybody would say that’s preposterous, and rightly so. How is that any different from what we’re now seeing with exercise?

It’s also important to understand that cardio exercise and resistance training are different. Their impacts are different; their immunologic impacts are different. Then the patient’s capacity to do those 2 treatments is different. Again, we may be able to just start with cardio with a patient, but it may be more just walking down to the mailbox to get your mail. “All right, I want you to do that 3 times a day.” “Yeah, but I already picked up the mail.” “I [still] want you to do it twice [more] a day.” The fact that cardio and resistance have different impacts immunologically, that’s next level.

It’s diving into the fact that exercise is a prescribable therapy. From a doctor’s perspective, we need to start thinking about that. When we prescribe medications, we need to prescribe exercise just as we would prescribe everything else. All those strategies that go into a prescription that, if you don’t fill them in, a pharmacy will reject because they say, “This is confusing, the patient doesn’t know what to do.” We’ve got to take that same deliberate approach to prescribing exercise to appropriately apply it and administer it to achieve proper success.

Looking at acute vs chronic, it’s like, “I could modulate the immune system and the inflammatory response simply through exercise if I properly time it.” Okay, now they’re scheduled for a segment of surgery. How do I do exercise before? That’s going to be different. That’s the OPTIMIST study. We’re going to do exercise leading up to it. We’re going to have more necrosis and more immune infiltration into the tumor.

What is the importance of prescribing exercise?

What about in recovery? Exercise changes. Why? Well, you had major surgery; you’re not going to go right back to the same thing. Now we need to change the program of exercise there, because our structure and our intent is different. Now, let’s help you recover. That’s the whole process. We need to approach it like we approach all therapies that we prescribe, but the problem is we don’t, and when we don’t, I don’t know that it’s intended, but we delegitimize it.

There’s just an uncomfortable feeling in that space with doctors stepping into those areas because they’re like, “I’m not prescribing a [medication], I’m not cutting, I’m not doing this, I’m not doing that.” Well, then prescribe it the same way because the science says it’s going to help those other therapies. If the science says the “what” and the “how,” and we’ve got human studies that are randomized and double-blinded, that must get in there.

These major medical institutions, ASCO and others, are stepping into that space and they’re starting to say, “Hey, here’s something,” but we need to do more. We need to say, “Hey, here’s what you need to do.” We need to encourage doctors to think openly and think freely, because with that comes the ability to meet that exercise program, that nutritional program, that chemotherapy program, that immunotherapy program, and that surgery program for the patient that’s sitting right in front of you.

A patient that is wheelchair-bound, if I have a standardized exercise program that I submit to all of them, it will not work. Likewise, a patient that’s wheelchair-bound, their quality-of-life scores are ECOG 4, their immune system––their neutrophils are less than 500 ––if you come in with full-dose chemotherapy, it’s not going to go well. We’ve got to look at the person in front of us: precision medicine. We have to look at exercise through the same prism as we do other therapies. When we do that, we will see the outcomes that the studies show, because they’re [quite] structured, and that’s a problem––doctors have not translated that to clinical practice. We need to embody it ourselves. We need to take control of it ourselves, meaning we need to be the ones [directing and incentivizing] it, and then do it in a structured way, like what we do [for] the rest of our practice. That’s when we’re going to see the outcomes that are seen in these studies.

What else should clinicians consider when thinking of exercise regimens for patients with cancer?

When we look at the process of cancer and what it’s doing, the accelerated aging process, in part, is why cancer is there, but cancer accelerates aging as well. That in turn accelerates the process of immunologic aging: immunosenescence, senescent-associated secretory phenotypes, and chronic inflammation. We get in this feed-forward cycle. We come in with an accelerated aging process, and we say our intent here is to get into remission and to help patients live a long life. How do we break that?

The challenge over the last 75 years is we come in with surgery, chemotherapy, and radiation, and these are therapies that have efficacy; there’s no question about that. They then themselves also promote senescence and accelerated aging. What if we’re able to bring in these therapies that can work to break those cycles, like exercise? Yes, they may not be as “sexy” as cutting somebody open and removing an organ. I get that, but at the same time, if it improves the outcome, if it helps the patient heal better, if it empowers their immune system in intended, direct ways that are reproducible in the research, and if it helps to block that accelerated aging, we reengage the immune system, countering the immunosenescence that is accelerating that process called inflammation.

We can work on the process… where aging and cancer are simultaneous objectives, where we can not only help people work towards that goal of remission (3 years, 5 years, that’s great), but how about the rest of their life? Because now you put the body in a position to not just go into remission but to heal. Instead of farming with the pH of disease, we’re now pivoting into farming health and wellness.

Exercise and nutrition––these things, again, are not seen as sexy, not seen as standard therapies in the conventional space. They now help the conventional therapies work better, so they’re not just lifestyle interventions for prevention; they’re interventional biological therapies that enable the body to perform better: the immune system, metabolically, endocrinologically, and the gut microbiome.

Now we have the chance to pivot. Not from, “Okay, doc, I’m in remission now. What now?” “Well, now we’re going to continue more of the same,” because those therapies that we’ve mixed and matched together... Yes, the chemotherapy goes away. Yes, the selective estrogen receptor modulators go away. The radiation goes away. Now we’re going to take those other therapies that we were using as adjuncts. We’re going to continue those, and those are going to continue the process of healing and wellness, hopefully, so that the patient in front of us who is 28, 32, or 38 doesn’t just live 5 years, but they live 25 or 50 years.

That’s the success that these new ideas, new thinking built on the science will enable us to achieve. It will transform the ecosystem from one within the body that is leading to ecological collapse to one that leads to ecological healing and wellness. It’s interesting that the word “wellness” just means health; it means whole: let’s keep the body whole.

The therapeutic approach, guess what, equally must be whole: exercise, nutrition, and all the other conventional standards brought together to make the treatment whole and the strategy whole. That is going to change the ecological system within the body, and that will change not just a 3-to-5-year strategy, but a lifetime strategy. That’s what the patients want.

References

1. Courneya KS, Vardy JL, O’Callaghan CJ, et al. Structured exercise after adjuvant chemotherapy for colon cancer. N Engl J Med. 2025;393(1):13-25. doi:10.1056/NEJMoa2502760
2. Rayner CJ, Bartlett DB, Allen SK, et al. Prehabilitation during neoadjuvant chemotherapy results in an enhanced immune response in esophageal adenocarcinoma tumors: A randomized controlled trial. J Sport Health Sci. 2025;14:101063. doi:10.1016/j.jshs.2025.101063