For citation purposes: Laszlo R, Hartveg P, Laszlo S, Otto S, Prokopchuk D, Steinacker JM. Physical activity and cancer. OA Sports Medicine 2014 Jan 18;2(1):1.


Training, Performance & Rehabilitation

Physical activity and cancer

R Laszlo*, P Hartveg, S Laszlo, S Otto, D Prokopchuk, JM Steinacker

Division of Sports and Rehabilitation Medicine, University of UIm, Leimgrubenweg 14, 89070 Ulm, Germany

* Corresponding author Email:



Literature indicates that physical activity has significant primary-preventive effects concerning various cancer entities. An entity-specific approach is needed to study the mechanisms for these effects. Numerous studies showed that physical activity during tumour therapy can result in a reduction in fatigue, increase in quality of life and exercise capacity and a reduction in treatment-associated disorders such as fatigue, nausea, insomnia and pain. Therefore, physical activity during ongoing cancer treatment is considered to be an effective support therapy without any negative effects, if relevant contraindications are considered. Prognosis of some malignant diseases may be modulated by physical activity during follow-up care. Furthermore, due to its other multi-dimensional effects, physical activity plays an increasing role in follow-up care even independent of the influence on prognosis. Significance of physical activity in all phases of cancer disease is delineated in this review.


Physical activity can be recommended during all stages of cancer disease if contraindications are followed.


Physical activity (PA) is defined by a motion-caused increase in metabolic rate above the basal rate. Competition, muscular effort and enjoyment of motion are basic principles of sports[1]. In contrast, humans are classified as inactive if they are precisely not or at best a little physically active in all areas of everyday life[1].

PA can be objectified by load-dependent oxygen uptake of the organism. The ratio between oxygen uptake during exercise and during rest is called ‘metabolic equivalent’ (MET). For example, taking a walk is up to 3 MET, bicycling 6 MET or jogging (11 km/h) 11 MET[2].

There is a close relationship between PA and, respectively, exercise capacity and all-cause mortality. For example, in a large study with 15,000 male subjects (60 ± 11 years old), ergometry-determined exercise capacity at baseline was the strongest predictor of all-cause mortality during follow-up: adjusted risk was reduced by 13% for every 1-MET increase in exercise capacity[3].

Not only due to positive influence of PA on mortality, but also due to manifold positive effects on physical and mental health, at least 150 min of moderate- (3–6 MET) or, respectively, 75 min of high- (>6 MET) intensity PA are recommended by world health organization (WHO). However, these recommendations are insufficiently implemented by a large portion of human population of many countries[4,5]. There is a negative correlation between physical activity and obesity[6]. In parallel, obese people are not as physically active as people who are of a normal weight[7]. Therefore, insufficient PA of large parts of the population of many countries is probably responsible for increasing prevalence of overweight and obesity in these countries[8].

During the past years, as a consequence of the generally positive effects of PA[9] and of the benefits in primary and secondary prevention of cardiovascular diseases[10], PA of cancer patients attracted more clinical and scientific interest. Significance of PA in all phases of cancer disease is delineated in this review.


Physical activity and primary prevention of malignant diseases

Based on the close relationship between PA, bodyweight and all-cause mortality, one can wonder whether the risk of affection of a malignant disease also depends on body weight or, respectively, PA. As shown in a meta-analysis of 282, 317 cancer cases, increased body mass index (BMI) is associated with an increased risk of cancer. For example, compared with people of normal body weight, there is a 1.5-fold increase in risk for oesophagus-carcinoma with every 5 kg/m²-increment of BMI[11].

A weak point of many studies concerning the issue ‘PA and cancer’ is due to methodical reasons – it may be difficult to acquire PA in proper style during everyday life[12]. However, there is epidemiological evidence that cancer-protective effects of PA are rather under, than overestimated by common methods of acquisition of PA (questionnaire, accelerometer)[13].

An inverse association between PA and cancer incidence was found in a large cohort study of 40,700 men[14]. Currently, largest evidence for primary-preventive effects of PA on cancer risk can be found for colon carcinoma[15]. In summary, between 9% and 19% of the most common tumours seems to be attributed to deficit PA[16]. As especially the risk for the most common tumours (e.g. cancer of breast and colon) seems to be reduced, increase in PA in terms of behaviour-oriented prevention offers an enormous potential for general population health care.

Compared with cardiovascular diseases[17], there is equivocality concerning the mechanisms of primary-preventive effects of PA on risk of cancer. On the one hand, this may be due to the fact that ‘cancer’ summarises many heterogeneous diseases of different aetiology, and on the other hand, ‘PA’ is also only a superordinate concept of a complex behaviour which elicits various physical and psychic reactions of the organism. As a multiplicity of biological modes of action can be taken into account, an entity-specific approach is needed. Generally[18,19,20,21], increase in muscle mass and, accordingly, reduction in body fat as a consequence of PA result in positive endocrinological alterations (sex/ steroid hormones, growth factors, insulin/insulin resistance) which finally inhibit carcinogenesis. Positive influence of PA on ‘oxidative stress’, inflammation and DNA repair mechanisms as well as its induction of specific gene expression patterns and, respectively, extensive effects of PA on the immune system are discussed as further possible unspecific mechanisms (Figure 1). Accelerated gastro-intestinal transition time and – as a consequence – reduced contact time of carcinogen substances with the mucosa also seems to be responsible that of all things, primary-preventive effects of PA on risk of colon carcinoma are especially high[22].

Potential mechanisms of primary-preventive effects of physical activity on risk of cancer.

Physical activity as cancer-support therapy

As a residue of former therapeutic standards, the thought that cancer patients should rest and do not bear or are even marred by PA still haunts some people’s mind[23]. Typical consequence of cancer disease and therapy such as surgery-induced limitation of flexibility or even immobility, side-effects of drugs (anaemia, cardiotoxicity, pulmonary toxicity), sarcopaenia, myopathy, susceptibility to infection, pain, anxiety, mental stress, depression, insomnia, nutritional disturbance (malnutrition, cachexia) may result in breathlessness, tachycardia and fatigue[24]. Therefore, at first glance it may be traceable that PA in terms of a cancer-support therapy is considered to be an unreasonable demand for cancer patients. However, physical protection/inactivity may end up in a vicious circle (Figure 2): muscle mass is reduced as well as cardiac and, respectively, pulmonary exercise capacity and – as consequence – endurance capacity and muscular strength. Former activities of daily living are getting more and more difficult for the patients and are thus avoided whereupon inactivity and physical protection are further increased.

Vicious circle of physical protection and inactivity.

Thus, breakthrough of this vicious circle is an important aim of PA within the scope of tumour therapy. For that matter, numerous studies showed that PA during tumour therapy results in a reduction in fatigue[24,25], an increase in quality of life and exercise capacity[26] and a reduction in treatment-associated disorders such as nausea, fatigue, insomnia and pain[27]. Therefore, PA during ongoing cancer treatment is considered to be an effective cancer-support therapy without any negative effects if relevant contraindications are considered. Contraindications for participation are similar to those of healthy people and, respectively, patients with chronic diseases[28]. Specific characteristics of cancer- or therapy-related alterations of the patient have to be considered. Table 1 gives an overview of general contraindications of sport participation, whereupon attention of the specific situation of a patient is always a necessity[28,29].

Table 1

Contraindications of sport participation of cancer patients

Preliminary assessment of cancer patients includes clinical status, laboratory parameters and exclusion of skeletal instability. Cardiological examination is essential for older patients, patients at risk for coronary heart disease and after high-dose chemotherapy or treatment with cytostatic drugs with cardiotoxicity or pulmonary toxicity. Examination should include resting- and stress-ECG, echocardiography and pulmonary function test for assessment of exercise capacity, additional (e.g. invasive) diagnostics may be necessary in certain clinical situations[28,30].

Training programme[29,30,31,32,33,34,35] should respect the patient’s affinity for certain sports. Very often, cancer patients exhibit a severely reduced exercise capacity. Therefore, a frequent and individual monitoring is important. A combination of resistance and endurance training, for example, jogging, walking, bicycling, gymnastics or (under consideration of general state of health and immune state) rowing and swimming is recommended for cancer patients. Ball games or contact sports may be dangerous for patients with impaired blood coagulation. Endurance training (30–45 min/day) should be performed with 70%–80% of maximal exercise capacity, a modulation of intensity due to concomitant disease (coronary heart disease, arterial occlusive disease, diabetes, osteoarthritis) may be needed but with possibly consecutive reduction in effectiveness of training. Reduction in intensity due to a generally reduced state of health of the patient to offer sports participation results in a disproportional increase in training time and is therefore not generally recommended. However, training with reduced intensity may be focused on muscle coordination to improve motor deficits in some of these patients. If hygiene factors for immunosuppressed patients are considered, sports participation is also possible for patients with leukopaenia/neutropaenia.

Physical activity in follow-up care

Negative influence of overweight/obesity and, respectively, positive effects of PA concerning risk of cancer disease have been already discussed. Hence, the question comes up whether factors such as bodyweight and PA are able to modulate prognosis of malign diseases. The correlation between BMI at baseline and risk of cancer-related death during follow-up was examined in a large cohort study with 900,000 subjects who did not have cancer diagnosis at baseline[36]. During follow-up (16 years), there was a 52% (♂) and accordingly 62% (♀) increase in risk of cancer-related death of the most obese (BMI > 40 kg/m2) compared with subjects with normal body weight. An association between BMI and increased mortality was also found for cancer of the colon and rectum, oesophagus, liver, gallbladder, pancreas and kidney and for death due to non-Hodgkin’s lymphoma and multiple myeloma. Significant trends were observed for death from stomach cancer and prostate in men and for death from breast, uterus, cervix and ovary cancers in women. Based on these associations, it was calculated that overweight and obesity in the United States could account for 14%–20% of all deaths from cancer.

Concerning positive effects of PA on prognosis, there is good evidence for colon carcinoma. For example, in a prospective study by Meyerhardt et al.[37] with 573 patients suffering from colon carcinoma (I–III), dependency of cancer-related and accordingly all-cause mortality on PA before and after diagnosis and, respectively, changing of PA after diagnosis was examined. Cancer-related and all-cause mortality was not influenced by degree of PA before diagnosis but was modulated – the more, the better – by magnitude of PA after diagnosis, whereupon it did not play a role whether the patients were physically active at a defined level already before or as recently as after diagnosis. Similar results became apparent at patients with breast cancer wherein exact entity (e.g. receptors) plays an important role[38]. At other cancer entities, there is no or at most minor evidence for a prognosis-modulation effect of PA[39].

However, due to its multi-dimensional effects, PA plays an important role in follow-up care of cancer patients even independent of the influence on prognosis. PA is effective concerning improvement of exercise capacity, acts as antidepressant and enhances mental health and body functioning[40]. At the moment, there is no acceptably data if these effects can be observed also in a palliative situation[41]. Finally, PA promotes social re-integration and results in a better quality of life[12,42].


Positive effects of PA concerning primary prevention of certain cancer entities are assured or are at least highly probable. Under consideration of important contraindications, PA acts as an effective cancer support therapy and does not harm patients. Positive influence of PA on prognosis of certain cancer entities can be assumed. In addition, further multi-dimensional effects on physiological (exercise capacity), psychological (depression) and social (re-integration) levels and concomitant increase in quality of life underline the importance of sports/PA in follow-up care of cancer patients. Summarised, PA can be recommended during all stages of cancer disease if contraindications are followed.

Abbreviations list

BMI, body mass index; MET, metabolic equivalent; PA, physical activity; WHO, World Health Organization.

Authors contribution

All authors contributed to the conception, design, and preparation of the manuscript, as well as read and approved the final manuscript.

Competing interests

None declared.

Conflict of interests

None declared.


All authors abide by the Association for Medical Ethics (AME) ethical rules of disclosure.


  • 1. Ezzati M, Hoorn SV, Lopez AD, Danaei G, Rodgers A, Mathers CD. Comparative quantification of mortality and burden of disease attributable to selected risk factors. In: Lopez AD, Mathers CD, Ezzati M, Jamison DT, Murray CJL, editors. Global burden of disease and risk factors. Washington DC: The International Bank for Reconstruction and Development/The World Bank Group 2006.
  • 2. Ainsworth BE, Haskell WL, Leon AS, Jacobs DR Jr, Montoye HJ, Sallis JF. Compendium of physical activities: classification of energy costs of human physical activities. Med Sci Sports Exerc 1993 Jan;25(1):71-80.
  • 3. Kokkinos P, Myers J, Kokkinos JP, Pittaras A, Narayan P, Manolis A. Exercise capacity and mortality in black and white men. Circulation 2008 Feb;117(5):614-22.
  • 4. Sjöström M, Oja P, Hagströmer M, Smith B, Bauman A. Health-enhancing physical activity across European Union countries: the Eurobarometer study. J Public Health 2006;14(5):291-300.
  • 5. Institut RK . Gesundheit in Deutschland aktuell. Robert Koch Institut 2009.
  • 6. Fogelholm M, Kukkonen-Harjula K. Does physical activity prevent weight gain–a systematic review. Obes Rev.: Off J Int Assoc Study Obes 2000 Oct;1(2):95-111.
  • 7. Hauner H, Berg A. Körperliche Bewegung zur Prävention und Behandlung der Adipositas. Dtsch Arztebl Int 2000 Mar;97(12):768.
  • 8. . Anonym. European cardiovascular disease statistics, 4th ed. 2012: EuroHeart II. Eur Heart J 2013 Oct;34(39):3007-13.
  • 9. . WHO. Global recommendations on physical activity for health 2010.
  • 10. Perez-Terzic CM . Exercise in cardiovascular diseases. PM & R: J Injury, Funct Rehab 2012 Nov;4(11):867-73.
  • 11. Renehan AG, Tyson M, Egger M, Heller RF, Zwahlen M. Body-mass index and incidence of cancer: a systematic review and meta-analysis of prospective observational studies. Lancet 2008 Feb;371(9612):569-78.
  • 12. Bourke L, Homer KE, Thaha MA, Steed L, Rosario DJ, Robb KA. Interventions for promoting habitual exercise in people living with and beyond cancer. Cochrane Database Syst Rev 2013 Sep;9CD010192.
  • 13. Kipnis V, Freedman LS. Impact of exposure measurement error in nutritional epidemiology. J Natl Cancer Inst 2008 Dec;100(23):1658-9.
  • 14. Orsini N, Mantzoros CS, Wolk A. Association of physical activity with cancer incidence, mortality, and survival: a population-based study of men. Br J Cancer 2008 Jun;98(11):1864-9.
  • 15. Wolin KY, Yan Y, Colditz GA, Lee IM. Physical activity and colon cancer prevention: a meta-analysis. Br J Cancer 2009 Feb;100(4):611-6.
  • 16. Friedenreich CM, Neilson HK, Lynch BM. State of the epidemiological evidence on physical activity and cancer prevention. Eur J Cancer (Oxford, England: 1990) 2010 Sep;46(14):2593-604.
  • 17. Gielen S, Schuler G, Adams V. Cardiovascular effects of exercise training: molecular mechanisms. Circulation 2010 Sep;122(12):1221-38.
  • 18. Rogers CJ, Colbert LH, Greiner JW, Perkins SN, Hursting SD. Physical activity and cancer prevention : pathways and targets for intervention. Sports Med 2008 Apr;38(4):271-96.
  • 19. Tsugane S, Inoue M. Insulin resistance and cancer: epidemiological evidence. Cancer Sci 2010 May;101(5):1073-9.
  • 20. Davies NJ, Batehup L, Thomas R. The role of diet and physical activity in breast, colorectal, and prostate cancer survivorship: a review of the literature. Br J Cancer 2011 Nov;105(Suppl 1):S52-73.
  • 21. Kruijsen-Jaarsma M, Revesz D, Bierings MB, Buffart LM, Takken T. Effects of exercise on immune function in patients with cancer: a systematic review. Exerc Immunol Rev 2013;19120-43.
  • 22. Boyle T, Keegel T, Bull F, Heyworth J, Fritschi L. Physical activity and risks of proximal and distal colon cancers: a systematic review and meta-analysis. J Natl Cancer Inst 2012 Oct;104(20):1548-61.
  • 23. Berger AM, Abernethy AP, Atkinson A, Barsevick AM, Breitbart WS, Cella D. Cancer-related fatigue. J. Natl Compr Canc Netw 2010 Aug;8(8):904-31.
  • 24. Cramp F, Byron-Daniel J. Exercise for the management of cancer-related fatigue in adults. Cochrane Database Syst Rev 2012 Nov;11CD006145.
  • 25. Brown JC, Huedo-Medina TB, Pescatello LS, Pescatello SM, Ferrer RA, Johnson BT. Efficacy of exercise interventions in modulating cancer-related fatigue among adult cancer survivors: a meta-analysis. Cancer Epidemiol Biomarkers Prev.: Publ Am Assoc Cancer Res, cosponsored by the Am Soc Prev Oncol 2011 Jan;20(1):123-33.
  • 26. Mishra SI, Scherer RW, Snyder C, Geigle PM, Berlanstein DR, Topaloglu O. Exercise interventions on health-related quality of life for people with cancer during active treatment. Cochrane Database Syst Rev 2012 Aug;8CD008465.
  • 27. Focht BC, Clinton SK, Devor ST, Garver MJ, Lucas AR, Thomas-Ahner JM. Resistance exercise interventions during and following cancer treatment: a systematic review. J Support Oncol 2013 Jun;11(2):45-60.
  • 28. Garber CE, Blissmer B, Deschenes MR, Franklin BA, Lamonte MJ, Lee IM. American College of Sports Medicine position stand. Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise. Med Sci Sports Exerc 2011 Jul;43(7):1334-59.
  • 29. Dimeo FC . Körperliche Aktivität bei Patienten mit neoplastischen Erkrankungen. Deutsche Zeitschrift für Sportmedizin 2004 Apr;55(4):106-7.
  • 30. Schmitz KH, Courneya KS, Matthews C, Demark-Wahnefried W, Galvao DA, Pinto BM. American College of Sports Medicine roundtable on exercise guidelines for cancer survivors. Med Sci Sports Exerc 2010 Jul;42(7):1409-26.
  • 31. Wolin KY, Schwartz AL, Matthews CE, Courneya KS, Schmitz KH. Implementing the exercise guidelines for cancer survivors. J Support Oncol 2012 Sep–Oct;10(5):171-7.
  • 32. Lakoski SG, Eves ND, Douglas PS, Jones LW. Exercise rehabilitation in patients with cancer. Nat Rev Clin Oncol 2012 Mar;9(5):288-96.
  • 33. Clague J, Bernstein L. Physical activity and cancer. Curr Oncol Rep 2012 Dec;14(6):550-8.
  • 34. Newton RU, Galvao DA. Exercise in prevention and management of cancer. Curr Treat Options Oncol 2008 Jun;9(2–3):135-46.
  • 35. Otto S, Berend M, Küchler T, Kremer B, Hartmann JT. Anspruch und Wirklichkeit der Sporttherapie in der Onkologie – Beobachtungen aus der Praxis. B & G 2011 Apr;27(04):156-62.
  • 36. Calle EE, Rodriguez C, Walker-Thurmond K, Thun MJ. Overweight, obesity, and mortality from cancer in a prospectively studied cohort of U.S. adults. N Engl J Med 2003 Apr;348(17):1625-38.
  • 37. Meyerhardt JA, Giovannucci EL, Holmes MD, Chan AT, Chan JA, Colditz GA. Physical activity and survival after colorectal cancer diagnosis. J Clin Oncol 2006 Aug;24(22):3527-34.
  • 38. Holmes MD, Chen WY, Feskanich D, Kroenke CH, Colditz GA. Physical activity and survival after breast cancer diagnosis. JAMA 2005 May;293(20):2479-86.
  • 39. Ballard-Barbash R, Friedenreich CM, Courneya KS, Siddiqi SM, McTiernan A, Alfano CM. Physical activity, biomarkers, and disease outcomes in cancer survivors: a systematic review. J Natl Cancer Inst 2012 Jun;104(11):815-40.
  • 40. Fong DY, Ho JW, Hui BP, Lee AM, Macfarlane DJ, Leung SS. Physical activity for cancer survivors: meta-analysis of randomised controlled trials. BMJ 2012 Jan;344e70.
  • 41. Lowe SS . Physical activity and palliative cancer care. Recent results in cancer research Fortschritte der Krebsforschung Progres dans les Recherches sur le Cancer 2011 Jan;186349-65.
  • 42. Mishra SI, Scherer RW, Geigle PM, Berlanstein DR, Topaloglu O, Gotay CC. Exercise interventions on health-related quality of life for cancer survivors. Cochrane Database Syst Rev 2012 Aug;8CD007566.
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Contraindications of sport participation of cancer patients

Absolute contraindication Relative contraindications
Acute disease Thrombopaenia < 50,000/μL
Decompensation of disease Bone metastasis
Acute episode of chronic disease Anaemia
Fever Chronic pain
New-onset pain
Thrombopaenia < 10,000/μL
Pronounced cachexia