Strategies for promoting exercise adherence within a cancer exercise recovery program: a qualitative case study.

Background

Physical activity (PA) meaningfully improves physical health, mental health, and other critical quality of life indicators for cancer survivors [ 1 , 2 ]. Furthermore, studies investigating breast, colorectal, and prostate cancer survivors suggest that PA can lower the risk of cancer recurrence and improve survival [ 2 ]. However, despite the benefits of PA for cancer survivors, adherence to cancer-specific PA guidelines (defined as the degree to which cancer survivors engage in PA in accordance with the recommended cancer specific PA guidelines) is low, with current estimates suggesting that 17% to 47% of cancer survivors meet PA guidelines [ 3 – 8 ].

Diverse factors may influence whether cancer survivors adhere to PA [ 9 ]. At a societal and structural level, low adherence may be due to health policies and health system approaches [ 10 ]. For example, PA resources are least represented of all supportive care services; thus, PA programs developed specifically for the unique needs of cancer survivors can be hard to access [ 11 ]. At a programmatic level, trainers’ knowledge about a survivor’s background, along with the availability of proper cancer PA education, can support cancer survivors’ PA self-efficacy [ 12 ]. At the individual level, previous PA participation, knowledge, and skills, as well as cancer treatment effects can influence adherence [ 13 , 14 ]. Low PA participation may also be due to program quality [ 15 ]. Quantitative measures like attendance, frequency, and duration are commonly used to assess the quality of PA programs, but these metrics have limitations in fully capturing the depth and richness of individual experiences and program effectiveness [ 16 ].

To assist in the development of quality PA programs, researchers developed the Quality Parasport Participation Framework [ 17 ]. The Framework identifies six experiential elements of quality participation: autonomy, belongingness, challenge, engagement, mastery, and meaning [ 17 ]. To foster these experiential elements, there are also programmatic conditions to consider, relating to the physical environment, social environment, and program environment. Initially developed for sport among people with disabilities, this Framework has since demonstrated applicability to diverse programs and communities, including PA for cancer survivors [ 18 , 19 ]. Fong and colleagues identified the quality participation elements of challenge and mastery, as well as social and physical environment conditions as being linked to quality experiences for breast cancer survivors in outdoor exercise programming [ 18 ]. A further study examining community-based exercise program participation for breast cancer survivors identified five quality components for program design: improve cancer literacy, provide opportunities to participate with peers, foster self-efficacy, prioritize program accessibility, and integrate program within a network of supportive cancer care [ 20 ].

The purpose of this study was to understand patient and trainer experiences within a high adherence cancer PA program, with the goal of identifying program delivery strategies that may be related to high program adherence. In contrast to the adherence rates identified in the literature, the program of interest (Cancer Exercise Recovery Program; CERP) has a high adherence rate of over 90% session completion (75% is generally classified as adherent with larger percentages indicating high adherence) [ 21 , 22 ]. The program also has extensive interest with an over 6-month waitlist, which is significant given the low rates of PA participation and interest in this population [ 23 ]. Ultimately, identifying factors that contribute to successful implementation of a high adherence cancer exercise program may support health care providers and exercise physiologists in developing and delivering cancer exercise programs that promote sustained participation so cancer survivors may experience the important benefits of PA.

Methods

The case

The case examined in this study is the Cancer Exercise Rehabilitation Program (CERP), a hospital-based exercise program for cancer survivors delivered in a large medical research hospital in the United States. Consistent with a Stake constructivist case study approach [ 24 , 25 ], the case was defined as the implementation and delivery of CERP within this institutional medical setting. The case was bounded by the program setting (cancer-specialized rehabilitation center at Cedars-Sinai Medical Center), the individuals directly involved in the program (CERP patients and trainers), and the program timeframe corresponding to participation in a 3-month intervention. The unit of analysis was participants’ experiences and perceptions of program delivery and adherence within this program context. The bounded case provided the context through which patient and trainers perspectives were explored.

CERP

CERP is a 3-month program that is part of the Wellness, Resilience, and Survivorship offerings through Cedars-Sinai’s cancer center. Any patient treated for cancer (generally within 1–2 years of completing treatment) is potentially eligible for the program. Once active cancer treatment is completed, the patient is evaluated by a cancer rehabilitation clinician to determine whether skilled interventions are needed to address functional deficits that may impact the ability to participate in CERP. If there are no significant functional deficits but shortfalls in reaching exercise goals (at least 150 min per week of moderate aerobic exercise and two sessions of resistance training per week), then CERP may be offered to the patient to support launching exercise behavior change. CERP is agnostic to cancer type. Hormonal and maintenance regiments are accepted within the program. CERP is an in-person program; however, some patients in the current manuscripts participated virtually as their involvement overlapped with the COVID-19 pandemic (see Table 1 ).

The CERP gym space features approximately 2800 sq. ft. which includes the gym, and conference room space for individual assessments. The space has one wall of windows to allow for natural light and views of the city to look at while engaging in exercise. Equipment includes a treadmill, elliptical machine, upright and recumbent bike, leg/chest press, leg curl extension, cable cross machine, rower, and free weights. The program was designed to be highly individualized for cancer survivors to ensure it is safe for their age, functional status, co-morbidities, and other clinical factors important in this population (e.g., cachexia, chemotherapy-induced peripheral neuropathy, bone metastasis, lymphedema, or negative changes in body composition). To help assure safety, prior to enrollment, patients are evaluated by a physician to determine that CERP will be appropriate both medically and physically. Upon enrollment, the patient undergoes a comprehensive fitness and medical evaluation led by the lead exercise physiologist. During this evaluation, the patient’s personal goals are established to guide the development of their program. The assessment also includes strength testing, functional assessments, and measurement of body composition. The exercise physiologist then creates a customized program that is gradually progressed over three-months. Sessions are tailored to rebuild strength, endurance, and flexibility. The intervention is supervised by a trainer (exercise physiologist or technician with oncology certification through the American College of Sports Medicine). One trainer is assigned to a maximum of two patients per one-hour session, with sessions occurring two to three times per week. At the end of the 3-month program, the assessment is repeated to measure impact and to help plan a home program for maintenance.

Philosophical assumptions

This study was framed in ontological relativism and epistemological constructivism to gain an in-depth understanding of CERP program experiences and mechanisms of program delivery that support strong adherence. Our patient demographics represent significant heterogeneity in gender, cancer type, cancer treatment, physical activity history, and family support. In addition, our data also includes heterogeneity in format of exercise participation. Some patients experienced CERP virtually due to COVID-19. Rather than assuming a single, objective account of CERP, we sought to embrace how patient and trainer unique identities and experiences influence how CERP is experienced and interpreted by patients and trainers within its specific institutional and programmatic context.

Consistent with a Stake constructivist case study approach [ 24 , 25 ], the goal of this study was to develop an understanding of how program delivery features within this bounded case were perceived to support engagement and adherence. Knowledge was understood to be co-constructed through interaction between participants, researchers, and the case itself. As a result, the purpose of this research was not to explain outcomes or establish causal mechanisms but to develop an interpretive understanding of how patients and trainers experienced and made meaning of program delivery within CERP. Meanings were treated as situated and contingent, shaped by participants’ distinct histories and experiences, as well as by structural and relational characteristics of CERP. While findings are grounded in CERP, the analytic focus on shared meanings, practices, and conditions supports naturalistic generalization, enabling readers to assess the relevance insights to similar cancer rehabilitation contexts [ 24 , 26 ].

Positionality

Our research team consisted of researchers and clinicians trained in physical medicine and rehabilitation, as well as behavioral sciences, sport and exercise psychology, and exercise physiology. One member of the team created and leads the CERP program (AA), another member co-leads the program (PC), while a third member of our team is the lead exercise physiologist (NC). To increase patient willingness to be honest and transparent, data collection and analysis was led by the other team members who are not involved in delivery of CERP or any clinical programming (CHS, NH, RR). Regular meetings were held with AA and NC to enhance understanding of program elements discussed in interviews and improve contextual knowledge. Given the closeness of two members of the research team to the program being examined, the research team continuously questioned how their experiences and identity influenced their interpretation of the transcripts and openness to patient responses. NH and CHS held ongoing weekly discussions about their perspectives of PA in survivorship throughout the analysis process. In addition, throughout analysis and preparation of this paper, transcripts were reviewed to ensure that findings were representative of patient experiences. This ongoing interrogation of researcher positionality was particularly important given the interpretive nature of a constructivist case study and the close relationships between some members of the research team and the case.

Participants

Ethics approval was received from the Cedars-Sinai Medical Center Institutional Review Board, which operates in accordance with the Belmont principles (STUDY00000627). Following receipt of this approval, participants were recruited for interviews based on their direct involvement either as patients or trainers of the CERP program, enabling exploration of multiple diverse perspectives within the bounded case. Former and current CERP patients ( n = 18) were recruited through an e-mail with study information sent by AA to a database of CERP patients and alumni. CERP trainers ( n = 2) were current staff involved in CERP. They were invited to participate by email and in-person during their monthly meeting. Two of the three trainers agreed to participate. While sample size for trainers was based on the number of CERP trainers, sample size for patients was based on information power [ 27 , 28 ]. As a result the number of patients recruited was guided by multiple concepts including the scope of the study aim, sample specificity, previous research in this field, the quality of the dialogue, and analytical approach [ 28 ]. The research team had regular discussions regarding these factors to determine when recruitment should end. Prior to engaging in an interview, verbal informed consent was obtained from all participants (trainers and CERP patients). A total of 20 participants engaged in interviews. See Table 1 for demographic information of patients. Demographic information for trainers is not provided as the two trainers who participated would be easily identifiable with this information.

Procedure

Semi-structured one-on-one virtual interviews were conducted by individuals unaffiliated with CERP to enable patients to share their experiences without concern of the impact of their feedback on their future healthcare experiences or employment. Interviews lasted approximately 45 min. Interviews were audio-recorded and subsequently transcribed verbatim by a member of the research team.

The interview guide

Interviews were designed to elicit rich, contextualized accounts. As such, interview guides were tailored based on the individual’s role in the CERP case and developed to support in-depth exploration of experiences rather than test predefined hypotheses. The patient interview guide (see supplementary file A) was divided into three parts: [1] identifying their PA background prior to diagnosis; [2] CERP experience; and [3] program expectations. Patients who had completed CERP were also asked about their post-CERP PA participation. Those patients who had participated in CERP virtually were asked the same questions as those who participated in-person so as to identify strategies relevant across participation formats (virtual/in-person).

The trainer interview guide (see supplementary file B) was informed by the Quality Parasport Participation Framework [ 17 ], and focused on: [1] their background in PA and cancer survivorship; [2] the program environment; [3] their approach to building an optimal social environment; and [4] ideal outcomes for patients.

Data analysis

NVivo software was used as a data management tool to support analysis. All analysis was conducted by the research team with no codes, themes, or interpretation generated by software or AI tools.

Thematic analysis was used to interpret participants’ experiences within the bounded context of the CERP program [ 29 ]. This consisted first of deep immersion in the transcripts. NH read and reread the data, taking notes on questions and thoughts that arose throughout. Throughout this process, NH had weekly meetings with RR and CHS, who had conducted the interviews, to ask questions about the interviews and engage in reflexive consideration of positionality and biases. An inductive coding process was then conducted during which meaningful extracts of data were identified and labeled. These codes were organized into themes representing patterns in how participants described program delivery strategies and their influence on engagement and adherence within CERP. These themes were then examined in relation to the Quality Parasport Participation Framework [ 17 ]. This additional analysis provided deeper consideration on the definitions and expression of the different quality elements that could be indicative of best practices in the context of CERP and resulted in reorganization and relabeling of themes. NH and CHS then presented the refined themes to the rest of the team. During these meetings, the team members acted as critical friends, provoking further discussion and consideration of patient meanings. These meetings were important based on each attendee’s diverse backgrounds, roles in relation to the research project and CERP, and experiences with PA and cancer survivors. These diverse backgrounds allowed for a more thorough review and discussion of the data and findings. Following these meetings, themes were refined again, which was followed by the writing of the manuscript. Throughout the analysis, attention was given to how meanings were shaped by the specific relational, institutional, and programmatic features of CERP. In addition to the quality and methodological rigour practices identified above, the research team were further guided by 20 questions for assessing thematic analysis research quality [ 30 ].

Results and discussion

Findings pointed to the importance of differentiating cancer exercise programs from traditional programs and commercial gyms. Two themes were identified indicative of approaches for achieving this goal. The first theme highlighted the need to consider the creation of the gym culture, while the second noted the requirement to address the burden of cancer and cancer barriers through program and gym logistics. Within the context of the Quality Parasport Participation Framework [ 17 ], these themes correspond to the programmatic conditions (physical environment, social environment, and activity characteristics). Within each theme, corresponding strategies are identified that were linked by CERP patients and trainers to quality participation and outcomes.

Creation of the gym culture

Within this theme, the first consideration was the importance of differentiating gym culture – with a focus on comparison between traditional gyms and gyms supportive for cancer survivors. Patients highlighted these differences and also identified foundational components of a supportive gym culture for cancer survivors. Within this question of how a supportive gym culture for cancer survivors could be created, three additional sub-themes were identified including intentional dyad pairing to foster relationships; trainer education and approach; and tailoring program goals and approach not only to the physical effects of treatment and cancer but to patient goals for life post-treatment.

Differentiating cancer exercise gyms from traditional gym cultures and environments

Consistent with existing research, patients mentioned bodily changes due to cancer treatment, which resulted in both physical and psychological barriers to PA [ 31 , 32 ]. Physical changes decreased self-efficacy because of low perceived ability to perform at the level they did before treatment. Learning how to be active with these changes elicited fear. Patients suggested that commercial gym culture may discourage exercise engagement for cancer survivors. Hazel, a patient with breast cancer, found the commercial gyms conducive to negative comparison, noting it was discouraging to observe someone “lifting 50 pounds [while she was] only on 10 pounds.” The fitness culture fostered in these environments caters specifically to individuals without illnesses and many felt bad seeing others who could lift more or were active in ways they couldn’t achieve following diagnosis and treatment. This perspective was reinforced by trainers, who noted that the physical appearance and fitness of individuals at commercial gyms had the potential to discourage cancer survivors dealing with the physical health and psychological effects of cancer diagnosis and treatment. Patients believed that CERP’s physical location and layout (a private gym designed specifically for cancer survivors) provided a safe venue for them to restart exercise post-active treatment while commercial gyms did not:

It was wanting to do exercise, wanting to do it in a place that was safe. I don’t really care for gyms that much. There’s so much grunting [from] all these showoff guy. They’re like, ‘oh, yeah’ I [don’t] wanna see them give birth you know (laughs)… I find that really distracting and then it kind of pisses me off. So [CERP] was like a safe environment for me. It didn’t matter that I wasn’t this skinny chick. It was just my own body, and I didn’t feel like I had to like tuck in my belly or something. I just was able to be myself. (Caroline, a patient with breast cancer)

Unlike commercial gyms, the CERP facility provides a sense of privacy that allows patients to exercise at their own pace without fear of comparison to non-cancer survivors. As demonstrated in Caroline’s quote, seeing people without cancer demonstrate common gym behaviors, like “grunting” when using heavy weights, was distracting and impeded her PA experience by evoking negative feelings like anger because the distractions caused her to lose focus. CERP’s facility offered an atmosphere where she could “just be.” She felt safe — physically, socially, or emotionally — in this space. She no longer felt pressure to conform to the “skinny chick” persona, signifying a mental distancing from societal beauty standards that no longer served her, especially as a cancer survivor. Moreover, she regained bodily awareness and rejected negative perceptions of body image by realizing that she did not need to tuck in her stomach to appear skinny, accepting her body as is. This personal sense of security fosters an environment where cancer survivors feel comfortable expressing vulnerability and being authentic. In this space, the patient reclaimed bodily acceptance and self-acceptance by reconnecting and taking ownership of her body, which can be an important milestone in survivorship. The statement “I just was able to be myself” underscores emotional healing, implying that other gyms offer limited opportunities for comparable psychological recovery.

Beyond the needs of physical rehabilitation from cancer, cancer survivorship and rehabilitation involve reconstructing a sense of identity because cancer is a disruptive and life-changing experience that alters the lives of patients across many domains [ 33 ]. There are new personal identities (i.e. survivor, patient, person with cancer) and which they choose to adopt and how they choose to identify can be related to psychological functioning and adeptness to cope with their cancer journey [ 34 ]. For cancer survivors, especially those who feel they have been reduced to a cancer diagnosis, finding spaces that foster rediscovery of self through physical movement is rare and deeply meaningful.

CERP’s facility fostered a sense of belonging, rooted in nonjudgmental privacy and shared understanding of diverse recovery experiences with other survivors. This emotional connection and alignment with others offered patients a sense of safety to be present in their exercise and autonomy to set recovery goals. Despite the facility’s small size, patients noted a particular benefit: more interaction. Privacy and intimacy were vital elements that were seen to minimize external distractions and facilitate relationship building with trainers and other patients.

Fostering relationships among patients with a focus on intentional dyad pairing

The social support received post-treatment can be integral for adaptive coping [ 35 – 37 ]. CERP offered an opportunity for patients to interact with individuals who shared their cancer experience. CERP staff reviewed patient files prior to scheduling sessions. When feasible, based on the discretion of the program coordinator and exercise physiologist, patients were paired based on age, gender, or stage of cancer (i.e. advanced, metastatic versus remission, cured). This attention to social pairing had the intended effect. Patients often spent their time discussing treatment or medication experiences and gaining emotional support from a fellow survivor’s perspective. These interactions allowed patients to feel comfortable expressing fears or hardships without judgement and helped to normalize the cancer experience [ 38 ]. Barbara, a patient with breast cancer, discussed how CERP provided the foundation for community-building:

I just was so appreciative. (…) I do think it’s helpful to be there with other patients going through maybe what you went through and maybe you talk about how you’re feeling or who your oncologist is. I think that’s important to have a sense of community (…) we all cheered each other on too. It’s just like, keep going, you can do it – that kind of thing.

This quote demonstrates how group-based, peer-supported exercise environments promote not only physical recovery but also emotional and social well-being. As noted in the first sub-theme, survivors can feel alienated in conventional fitness settings. Being surrounded by peers who have intuitive understanding of your present reality can lower psychological barriers and facilitate the informal exchange of emotional and informational support. Conversations about wellbeing or care experiences validated patient challenges while offering real practical coping strategies that their dyad peer had found successful. Expressions of mutual encouragement—such as cheering one another on—further enhanced their motivation and persistence. For individuals managing fatigue, anxiety, or self-doubt, this peer support was pivotal, transforming exercise from a clinical task into a meaningful and empowering social experience. It is important to note, however, that need for camaraderie between CERP patients was, however, dependent on the existence of available support elsewhere (e.g., other programs, family, friends) and whether patients viewed peer support as important prior to the program.

Peer interactions further provided opportunities for motivation and modeling of exercise participation. One patient, Iris, who was diagnosed with anal cancer, expressed in her interview that having a space to observe peers being positive even when encountering significantly worse outcomes (i.e. cancer recurrence) provided “positive reinforcement” for her to maintain a positive outlook:

There is something about realizing that there are other people who are going through something similar as you and the plans that they’re making going forward. And some of them are in their, like, second round of cancer, which I hope not to see for myself, but you know. And they’re still very positive. I mean, there’s positive reinforcement in more, […] positive reinforcement from the people who are being trained [with you] more than from the trainers.

For many survivors, recovery is not only physical but also deeply psychological [ 39 ]. Being in a group where others model perseverance can help reframe one’s own limitations or fears, reducing isolation and reinforcing a sense of possibility. It also shifts the focus from comparison to connection—rather than feeling discouraged by others’ experiences. Iris drew strength from this dynamic. She reflected on the emotional impact of being surrounded by others who were navigating similar, or sometimes more advanced, cancer journeys yet still maintaining a hopeful and forward-looking mindset. This context fostered a unique kind of positive reinforcement that did not come from medical and exercise experts but from fellow patients who embody resilience in real time. Consistent with the concept of vicarious experience being an important building block of participation and adherence [ 40 ], patients noted that observing other cancer survivors work hard in the gym gave them confidence and motivated them to do the same. This reflects peer-supported programs can promote emotional regulation, meaning-making, and long-term adherence to PA through social learning and emotional resonance in a supportive environment.

Trainer education and approach to cancer-focused rehabilitation

Staff and trainers may serve as pillars of support by fostering autonomous engagement, developing caring connections, instilling trust through expert instruction, managing conflict directly and effectively, and creating a climate where people want to attend a program [ 41 ]. Indeed, patients highlighted the importance of having knowledgeable and compassionate trainers to guide them during the rehabilitation process. Research suggests that cancer survivors prefer to receive instruction from trainers who are knowledgeable about cancer [ 42 ]. Working with trainers who have prior experience with cancer survivors was identified as essential as patients felt these trainers would “[understand] psychologically what’s going on” (Paul) and have more empathy that would avoid “stupid conversations” (Jo). With this understanding, trainers can tailor their approach to each patient, adapting exercises to individual and/or daily needs as the program progresses.

CERP staff receive extensive training in PA and cancer survivorship. For example, CERP exercise physiologists receive American College of Sports Medicine certification in cancer and exercise training. In addition to this formal training, the Director of CERP also leads monthly team meetings to discuss recent scientific advancements on PA promotion and/or cancer survivorship. The CERP trainers’ understanding of the physiological components of post-treatment exercise, as well as psychosocial aspects of the cancer experience provided two benefits: (1) patients felt understood and respected with trainers finding a balance between being empathetic of their cancer diagnosis while still viewing them as capable individuals; and (2) patients felt comfortable openly communicating their concerns because the trainers are knowledgeable and capable of modifying activities as needed. Having trainers capable of recognizing how to adapt to the sometimes daily fluctuations of side effects allow patients to continue to engage in PA. For many patients it was also important that trainers did so without defining them by their diagnosis. This perspective was expressed by Kai, a patient with breast cancer, who said:

I felt like she got me. She got it. Like she didn’t let me off the hook, but she also took into consideration all the little collateral damage that I had from treatment. I’m like, ‘Okay. My shoulder is this, or like this…’ or ‘I have this spasm in my chest.’ I don’t want to explain that to someone who just doesn’t know or doesn’t even get it. And like I could be doing well one day, and I could have a spasm. It’s spontaneous. But I also don’t want to be looked at like, ‘Oh you have cancer.’ I don’t want that; I don’t need that. But I do want an understanding that my body is different and sensitive. And I think that she had the perfect balance at that.

This quote highlights the critical role of cancer exercise specialists in supporting cancer survivors’ PA journey during recovery. Kai’s statement, “she got me,” underscores the importance of being understood beyond the medical diagnosis. As survivors carry unseen burdens such as fatigue, pain, and emotional trauma, a practitioner who acknowledges these without requiring explanation fosters trust and psychological safety. After cancer, survivors often find themselves in environments where they must justify or explain their symptoms—an experience that can feel alienating or even retraumatizing. The value of working with someone who already understands the embodied realities of survivorship cannot be overstated. It relieves the survivor of having to perform emotional labor on top of physical exertion. Additionally, the trainer’s ability to create a “perfect balance” between compassion and motivation is critical since overly aggressive approaches risk harm, while insufficient challenge can feel dismissive. She also articulates a common tension among survivors— wanting to avoid being treated like a patient while still needing accommodations. Professionals who recognize and adapt to this duality empower survivors to re-engage with their bodies more confidently and autonomously.

Healthcare providers build trust by demonstrating competence, care, and communicating effectively [ 43 ]. The previous strategies demonstrated competence and caring; however, effective communication was also employed to support patient goals and bolster confidence. According to trainers, initial sessions are particularly important for acclimating patients to the space, reintroducing exercise, and building self-efficacy for PA post-treatment. Building rapport through methods including casual conversation can ease discomfort during those early stages of rehabilitation. As time went on, trainers provided constructive feedback for guidance and to celebrate improvements. This gave patients a practical assessment of progress, which motivated them to continue PA. Finally, trainers also used non-verbal communication like body language, and encouraging facial expressions and gestures to promote comfort and confidence. For the patient, the above communication techniques are important for reducing tension or fear [ 44 ], and have been demonstrated to help establish trust and promote engagement [ 45 ].

Program goals and approach tailored not only to physical effects of treatment and cancer but to patient goals for life post-treatment

Cancer diagnosis and treatment may affect PA, so activities should be tailored to fit individual preference, age, type and stage of cancer, and other health considerations [ 46 ]. Patients felt it was important for trainers to customize activities to account for individual differences. The nuanced understanding that trainers attain from working with cancer survivors strengthen their ability to tailor activities to daily fluctuations in symptoms with precision and care.

Beyond tailoring to treatment and cancer effects, it was viewed as equally important to tailor participation to individual goals both within and outside CERP. These goals and the subsequent tailoring of activities may not directly target treatment-related symptoms, but the ability to engage in patient-preferred activities. Being receptive to these requests through an autonomy-supportive approach has been demonstrated to promote adherence to PA guidelines [ 47 ]. Beyond autonomy, other quality elements were fostered, particularly an increased sense of mastery. CERP patients gained self-confidence in their abilities after consistently achieving and surpassing activity goals set during each session. As the patient becomes more confident in themself, they begin setting new goals. In addition to promoting goal setting, the program was tailored to enhance emotional wellness. Olivia, who is a patient with ovarian cancer, mentioned how her personalized training improved her mental health:

Going through a program that was tailored toward me in my experience of what I was going through with chemo is really important because I think it would be difficult to find a trainer that knows how to deal with some of the side effects of what I was going through. At the time, I still had a port in my arm as well. And they took that into consideration that it wasn’t bothering that area that was still sore and tender. And work towards just like goals I had around balance and the neuropathy. It was important to me for that reason really improved my mental health as well…As a young person with cancer, it’s hard to not be able to do things that [I] used [to do] easily.

Olivia’s account highlights the value of a tailored exercise program in enhancing both mental health and physical function, specifically one that accommodates the unique physical and medical realities of cancer treatment. Standard fitness programs often overlook the complexities of cancer survivorship, including side effects like fatigue, neuropathy, and the presence of medical devices (i.e. a port) [ 48 ]. As a young patient facing post-chemotherapy limitations, Olivia experienced emotional distress linked to reduced physical capacity. She emphasizes that her trainer understood and adapted exercises to avoid painful areas, enhancing both safety and comfort while supporting her personal goals. By directly targeting issues like neuropathy and balance, the program empowers her to regain functional independence. This approach not only helped rebuild physical function but also improved her emotional wellness by fostering a sense of control and validation. For young survivors like Olivia, such programs can also ease the emotional difficulty of no longer being able to do activities once taken for granted. CERP helped her navigate the emotional complexities of post-treatment PA by challenging her to adjust expectations and re-establishing new routines, underscoring the value of trainers having cancer-specific knowledge of individuals affected by treatment.

Besides tailored programming, certain techniques employed by staff also added to the patients’ overall experience during their time in the program. Exercise physiologists utilized care planning techniques like coordinating with other providers and assigning one trainer per patient for the entirety of their journey through CERP. One patient noted that “the really great thing about CERP is that we were getting individual attention. And I couldn’t wait to get there every day for that.” (Iris) Not only is having one on one time with a trainer important for building rapport, but it also makes patients eager for the next session. In addition, patients believed that it made them more accountable for session attendance. Tailored programs promoted consistent involvement by acknowledging the individual experience of illness and recovery, making participation less intimating, while also making the experience feasible and enjoyable.

Addressing the burden of cancer and cancer barriers through program and gym logistics

Within this theme, two main strategies were identified targeting important programmatic and logistical barriers: [1] ensuring that PA does not add to the burden of financial toxicity post-treatment; and [2] placing the burden of scheduling on the gym and not the cancer survivor. Within traditional PA programs, a patient taking responsibility of scheduling and cost can be seen as important indicators of patient commitment, with lower cost and no-cost programming most likely to be discussed in underserved demographic communities. However, understanding the unique implications of life during and post-cancer treatment means re-evaluating the lens through which program and gym logistics are developed and evaluated. For study patients, that meant understanding what aspects of participation could be considered burdensome on top of an already overwhelming schedule of appointments and long list of expenses.

Ensuring PA does not add to the burden of financial toxicity post-treatment

Patients discussed the poor mental health outcomes of financial toxicity and its larger impact on exercise. Cancer survivors who experience more financial toxicity report higher levels of depression and anxiety symptomology, greater unease, and lower self-efficacy in coping with cancer [ 49 ]. These depressive symptoms can influence a patient’s motivation to seek recovery activities [ 50 ]. The compounded effect of both financial restrictions and the emotional implications of financial restrictions discouraged many patients not only from trying to find programs but from participating in exercise at all. Incorporating exercise after treatment required emotional effort as cancer treatment required substantial financial and physical effort and exercise would have been another responsibility for patients to shoulder. Patients recognized the importance of PA as part of a supportive care plan and as a means, in some cases, to combat cancer recurrences and/or cancer effects. However, many discussed having little to no funds available to pay for programs resulting in a lack of PA participation despite willingness. It isn’t uncommon for cost of PA to deter PA participation [ 51 ]. With the financial burden shouldered by patients and their families due to cancer treatment, a key strategy was the fact that CERP is free for patients. Not having to think about the cost of CERP or find funds to pay for the program decreased some of the mental load, allowing patients the freedom to choose to engage in exercise to support their recovery.

Patients discussed the poor mental health outcomes of financial toxicity and its larger impact on exercise. These depressive symptoms can influence a patient’s motivation to seek recovery activities and hinder their decision to partake in exercise [ 41 ]. Quinn, a patient with skin melanoma, breast, and endometrial cancer, noted:

[CERP is] like a gift. There’s not a lot of joy all the time. I get depressed a lot, but [CERP] helps, and [it] feels good that it’s free and they care. It’s just one less [financial] responsibility and it’ll make you show up. You start financially …. you get depressed and then you start pulling away. Like it might not be that you don’t want to go. There’s too much financial burden, so it makes you get into a bad head space and then the head space makes you not want exercise. It becomes an out-of-control spiral cause we’re there so much for so many visits, for doctors, that we’re paying so much money for so much else.

In Quinn’s case, financial constraints—along with the emotional burden associated with those constraints—significantly hindered her engagement with PA. These challenges not only limited her ability to seek out exercise programs but also discouraged participation altogether. The incorporation of exercise after treatment requires emotional investment [ 52 ], which was difficult given that her cancer experience had already demanded considerable financial and physical effort at every stage. As a result, PA was perceived as another obligation, rather than a source of recovery or empowerment. The program’s cost-free enrollment enabled patients, including Quinn, to reconnect with PA without the added burden of financial considerations. For cancer survivors experiencing significant psychological distress related to their financial circumstances, the removal of program-related expenses reduced cognitive and emotional strain. This reduction in mental load provided both financial and psychological space, facilitating patients’ ability to make an autonomous decision to engage in exercise as part of their recovery process.

The absence of a participation fee facilitated post-treatment exercise, but program characteristics supported patients’ continued engagement and adherence over time. Due to their positive experience, most patients expressed willingness to pay to continue with a reasonable per session or total program fee. When asked if they would pay an initial fee to join the program, many said they would not have paid without knowing if the program would be beneficial. Others preferred the initial program to be free but were willing to pay if the program were to continue. Cost-free programming enabled patients to explore the benefits of participating in a structured PA program without any financial stress—underscoring success in not only patient recruitment but also sustaining interest in PA during and after its conclusion.

A flexible approach that places the burden of scheduling on the gym and not the cancer survivor

One of the barriers to PA consistently identified is time [ 53 ]. For many cancer survivors, life post-treatment means resuming all of life’s responsibilities from work, to family, and/or education [ 54 ]. As such, it is no surprise that within the current study, time and feasibility to integrate exercise heavily influenced post-recovery exercise program engagement. An important strategy used by CERP was placing the burden of scheduling on CERP staff rather than the patient. When patients joined the program, they had an initial call with a program coordinator who took note of their work schedule, commitments, and driving distance. Staff then created a flexible scheduling system to reflect these barriers and would be feasible for integrating CERP into daily life. Freya, a patient with breast cancer, highlights how the program’s approach to patient-centered scheduling supported her in reintegrating PA into her life:

He was also really flexible in terms of scheduling. I mean, I know there’s a certain amount of time and obviously schedules everybody. Someone’s late they throw off everybody else’s schedule and I had to make some changes. I had corporate meetings. I had to be at stuff, and he was just, as long as I emailed him which I always did ahead of time, super flexible with that. So that all made a really big difference. It really felt like a really high end paid personal training program. You know, where it wasn’t like, you know, you miss it, we can’t make it up. We understand you’re not in any trouble, but we have to move on. It was not like that. It was really such a thoughtful program.

Cancer survivors often face unpredictable fatigue, lingering side effects, and disrupted routines after treatment [ 55 , 56 ]. A rigid exercise program can create stress or guilt when survivors can’t meet scheduled sessions. Freya’s appreciation of the trainer’s flexibility reflects how understanding and accommodating support can reduce pressure and make it easier to stay committed. Her account also emphasizes the feeling of safety to request accommodations without feeling judgment. By making it easy to reschedule, the trainer helped the patient remain consistent—a key factor in long-term adherence to PA. Moreover, the comparison to a “high-end personal training program” suggests she felt valued and treated with dignity, not just like another client. Being met with respect and care can assist with rebuilding confidence and motivation to reconnect with their bodies through exercise.

While many praised these scheduling accommodations, limitations were identified based on CERP being a clinical program versus a commercial gym. As a clinical program, CERP is only open Monday to Friday during business hours. Patients who didn’t have regular employment, were on leave, or retired didn’t mind. However, others noted that adding timeslots outside working hours (mornings, evenings, weekends) would make their day smoother and less stressful, particularly as some had to submit special requests to their employers to allow for late arrival or early departures to engage in CERP. Timeslots outside working hours were also an important consideration given the heavy traffic often encountered in the city. More scheduling variety was viewed as creating better accessibility.

Conclusion

This constructivist case study identified delivery strategies linked by CERP patients and trainers to cancer exercise program adherence, building upon previous quality participation research for cancer survivors [ 17 , 19 ]. While some of the identified strategies may not be unique to cancer survivors, when applied through a cancer-focused lens they are linked to an important shift that supports the individual’s transition from patient to life after active treatment. Specifically, programs may benefit from creating an environment that prioritizes emotional and physical safety with a foundation of in-depth cancer knowledge among trainers and staff. We note, however, that emotional and physical safety may differ based on mode of participation. While some of our participants engaged in virtual CERP due to the pandemic, CERP is primarily an in-person program and separating out virtual and in-person approaches was beyond the scope of the current manuscript. Future research needs to consider delivery of virtual programming and whether strategies differ or need to be modified to promote program adherence in virtual settings. Other potential considerations that may limit applicability include the urban clinic-based setting of the program and, as a result, the lack of patient diversity in the sample. In sum, as the benefits of PA programming for cancer survivors continue to be reinforced, it is important that researchers examine methods for program implementation, in particular the delivery strategies and experiential aspects of participation that influence participation and adherence to optimize the benefits of supportive care programming.

Supplementary Information

Supplementary Material 1.

Supplementary Material 2.

Acknowledgements

We would like to thank Cedars-Sinai Cancer Exercise Recovery Program (CERP) and its participants for their involvement in this research.

Abbreviations

Cancer exercise recovery program

Physical activity

Authors’ contributions

All contributed to the study conception and design. Material preparation and data collection were conducted by C.S. and R.R. Analysis was led by N.H. with collaboration from all authors. The first draft of the manuscript was written by NH, and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Funding

This research was funded by Cedars-Sinai Cancer.

Data availability

The interview data generated and analyzed during the current study are available from the corresponding author upon request.

Declarations

Ethics approval and consent to participate

Ethics approval (STUDY00000627) was received from the Cedars-Sinai Medical Center Institutional Review Board, which operates in accordance with the Belmont principles and the Helsinki Declaration. All participants provided informed consent for participation in the study.

Consent for publication

Not applicable.

Competing interests

Three of the authors are affiliated with CERP (AA, PC, and NC). As such, data collection, analysis, and manuscript development were led by CHS, RR, and NH who are not engaged in the development or delivery of CERP and had no prior interactions with the trainers or participants.

Footnotes

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Arash Asher and Celina H. Shirazipour contributed equally to this work.

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Associated Data

Supplementary Materials

Supplementary Material 1.

Supplementary Material 2.

Data Availability Statement

The interview data generated and analyzed during the current study are available from the corresponding author upon request.