Role of physical activity in cancer prevention: An update.

Core Tip: Physical activity and cancer are inversely related. Prehabilitation involving of cancer patients is beneficial in improving their health-related quality of life and patient symptoms. There is a need for structured physical activity guidelines for cancer prevention focusing on the entire continuum of cancer. The current literature focusses only on improved patient outcomes and not oncologic outcomes like reduction in cancer incidence. There is a dearth in literature of the role of resistance and balance exercises in cancer prevention. Tailor made protocols involving integrative approach (Yoga, Tai chi) need to be established for different stages of various cancers.

INTRODUCTION

Globally, cancer is a public health concern. The Global Cancer Observatory reports estimate for overall cancer incidence, prevalence and mortality for the World Health Organization-South-East Asia Region as about 2.3 million, 5.4 million and 1.5 million[ 1 ]. The prime modalities in conventional treatment for cancer remain anti-cancer drugs, surgery and radiotherapy either utilized solo or in conjunction with each other, on a case-to-case basis[ 2 ]. In cancer treatment as well as prevention, the role of traditional and complimentary medicine (TCM) along with physical activity is gaining traction worldwide[ 3 ]. Physical activity is an essential lifestyle measure for maintaining optimum health. The World Health Organization (WHO) has defined physical activity as any bodily movement produced by muscles requiring energy expenditure. WHO recommends adults to do at least 150-300 minutes of moderate-intensity aerobic activity, or an equivalent mix of moderate and vigorous intensity activity throughout the week[ 4 ]. Regular exercise if incorporated in daily routine can provide the necessary boost to immunity, maintain optimum weight and regulate the hormonal balance in the body. Oncogenesis can be mitigated by choosing a healthy lifestyle that incorporates regular exercise, a balanced diet, avoiding smoking and alcohol consumption. Cancer prevention via regular physical activity has been studied across the world. Exercise downregulates inflammation in the body[ 5 ]. This reduces the reactive oxidative stress produced due to various processes like alcohol consumption, stress levels and pollutants. Also aiding in peristalsis, clearing the bowels more frequently thus removing harmful toxins from the body. This minireview aims to present the latest updates in research in the context of the role of physical activity in the cancer prevention.

MECHANISMS

The various mechanisms describe how physical activity preventing cancer (Figure 1 ).

Hormonal balance

It has been studied that prolonged hormonal stimulation of target organs contributes to neoplasia. Joshi et al [ 6 ] highlighted the normal growth and function of this organ is controlled by one or more polypeptide or steroid hormones. This includes cancers of the endometrium, breast, prostrate, thyroid, ovary, bone and testis. Estrogen and progesterone are crucial in maintaining the hormonal balance in the female reproductive cycle. Raised levels of these hormones increase the risk of breast cancer[ 7 ]. A study from United Kingdom demonstrated that the risk of breast cancer reduced significantly by 9% ( P < 0.001) with physical activity[ 8 ]. A meta-analysis of prospective cohort studies demonstrated raised levels of these hormones are associated with increased risk of endometrial cancer[ 9 ]. Studies have revealed significant reduction in prostate cancer risk associated with vigorous physical activity[ 10 ].

Weight reduction

Physical activity is a medium for weight reduction. Obesity is linked to many comorbidities like diabetes, hypertension and cancer risk[ 11 ]. According to global predictions, by 2030 about 20% of the world’s population will be obese with a remarkable increase in the developing nations[ 12 ]. The International Agency for Research on Cancer[ 13 ] has found ample evidence to indicate a relation between excess adiposity and cancer in the following anatomical sites: (1) Esophageal; (2) Gastric cardia; (3) Colorectal; (4) Pancreas; (5) Liver; (6) Gallbladder; (7) Endometrium; (8) Breast (in post-menopausal patients); (9) Thyroid; (10) Ovaries; (11) Kidneys; (12) Meningioma; and (13) The bone marrow (multiple myeloma). There is additional data showing the relationship between advanced prostate cancer and adiposity[ 14 ]. One of the hormones, leptin is known to foster breast cancer via advancing angiogenesis and cell proliferation, indirectly via hormones like estrogen and insulin signalling pathways. Hence the link between leptin, adiposity and higher risk of breast and ovarian cancers[ 15 ]. Another hormone, adiponectin is inversely correlated with adiposity and breast cancer risk, apparently as a result of their anti-inflammatory properties[ 16 ].

Adiposity and inflammation

The adipose tissue releases adipokines that regulate energy homeostasis and inflammation. Elevated leptin and visfatin levels, coupled with low adiponectin, are implicated in carcinogenesis[ 17 ]. For instance, in case of colorectal cancer, leptin induces the growth of neoplastic colorectal cancer cells. Ahechu et al [ 18 ] reported chronic inflammation is another mechanism of cancer development. In case of reproductive organs, leptin stimulates endometrial, breast, and ovarian cancer cell growth and impairs apoptosis through activation of multiple signalling pathways. In addition, it induces hyperestrogenism via increasing the expression of aromatase[ 19 ].

Immunity

Tumor cells evade immune destruction through mechanisms such as elevated lactate levels, impairing cytotoxic T-cell function. This mechanism promotes tumor growth. They accomplish this task via various methods. elevation of lactate levels within cancer cells is one such method[ 20 ]. This affects the functioning of cytotoxic T cells thus escaping elimination. Muscles secrete muscle cytokines or myokines on physical activity. These mediate beneficial functions on the immune system. The notable myokines are interleukins, namely interleukin (IL)-4, IL-6, IL-7, IL-8 and IL-15. IL-6 has both prominent proinflammatory and anti-inflammatory properties. In the context of exercise, IL-7 and IL-15 play a crucial role in the promotion of cell survival through upregulating antiapoptotic mechanisms and telomerase activity to preserve telomere length. IL-15 is vital in the proliferation and differentiation of natural killer (NK) cells, which then recognise and kill cancer cells[ 21 ]. Subsequent to dynamic exercise (rowing, cycling, swimming), there is an acute mobilization of leucocytes to the blood compartment. These include the NK cells, gamma delta (γδ) T-cells, CD8+ T cells, CD4+ T cells and B-cells. These then identify cancer cells and are capable of terminating them[ 22 ].

Sunlight exposure and vitamin D levels

Exercising in open air has the benefit of increasing vitamin D levels via increased sunlight exposure[ 23 ]. Vitamin D has a role in the modulation of cell differentiation, proliferation, and apoptosis of neoplastic cells, as well as the antineoplastic action of the immune system[ 24 ]. The beneficial effects of physical activity in the sun in preventing cancer are indirect. Chakraborty et al [ 25 ] reports a deficiency of serum vitamin D increasing the risk of breast cancer. Vitamin D has an effect on cell differentiation, proliferation and apoptosis. Yet not direct causal link has been established between the same. These maybe via beneficial effects of sunlight on the immune system and circadian rhythm[ 26 ].

Insulin resistance

Regular physical exercise reduces insulin resistance[ 27 ]. It has been noted that insulin resistance leads to hyperglycemia and hyperinsulinemia further associated with an increased risk of neoplasia, poorer prognosis and greater risk of relapse after initial treatment[ 28 ]. Insulin resistance may lead to altered metabolic (MET) states leading to obesity and type 2 diabetes.

Yoga as a form of prevention

Yoga, an ancient practice originating in India, is now studied for its health benefits, including cancer prevention[ 29 ]. One of the mechanisms is reduction in pro tumorigenic cytokines. A study in Texas examined how a 16 weeks therapeutic Yoga program modulated the cytokine levels in cancer survivors. Cytokines are released as a response to chronic inflammation in the body[ 30 ]. These are remarkably raised as a response to cancer therapies leading to chronic non-resolving inflammation. In a metanalysis performed to determine the effect of exercise training on pro and anti-inflammation markers, a decrease in pro inflammatory biomarkers were was noted ( P < 0.001)[ 31 ]. Structured exercise interventions (aerobic, resistance or combined training or Tai chi/Yoga) were compared to usual care control group. Further it was found that that prostate ( P = 0.004) and breast cancer populations were most responsive ( P = 0.001), combined aerobic and resistance training had the greatest effect ( P < 0.001), and that C-reactive protein ( P = 0.025) and tumour necrosis factor ( P = 0.004) were the most sensitive to change. Yoga has been incorporated into primary health care in India and is being implemented from the village level[ 32 ]. Health and wellness centres in villages have a designated Yoga room and teacher for Yoga classes. This helps improve lifestyle and reduce the overall burden of all non-communicable diseases including cancer[ 24 ]. Glaser et al [ 33 ] in an integrative approach to cancer care in Buffalo reported, cancer survivors, their caregivers and hospital staff were included in an adaptive Yoga program at the comprehensive cancer centre. In patients of breast cancer, much research has been conducted to find the effect of Yoga on the health-related quality of life. This has a positive effect as noted by preventing and/or managing chemotherapy-related adverse effects and increasing the quality of life among breast cancer patients[ 34 ].

EXERCISE DOSE RESPONSE ON THE PREVENTION OF CANCER

A significant negative relationship between total physical activity and the risk of gastric, liver, colon, breast and lung cancers has been demonstrated by the Global Burden of Disease Study[ 35 ]. Compared to individuals with insufficient activity, measured as MET equivalents, (total activity level < 600 MET-minutes/week), individuals with high levels of activity (≥ 8000 MET-minutes/week) experienced a 10.3% risk reduction for breast cancer; 5.9% for lung cancer; 7.1% for colon cancer; 5.1% for gastric cancer; 17.1% for liver cancer. A systematic review was conducted to assess the associations between physical activity and risk for cancer, and mortality in cancer patients[ 36 ]. This review found out that there is strong overall evidence linking physical activity and the risk of developing breast, colon, endometrium, esophageal (adenocarcinoma), renal, bladder and gastric cancer. Lung cancer has moderate overall evidence whereas there is limited evidence for hematologic, ovarian, pancreas, prostate, brain, thyroid, head and neck and rectal cancer. Table 1 summarizes the evidence linking physical activity and cancer risk reduction[ 6 , 7 , 9 , 11 , 18 , 35 , 36 ].

Physical activity as a form of prehabilitation

Prehabilitation, as stated by Stout et al [ 37 ], is a program that prepares individuals for cancer treatment by focusing on physical and mental well-being before treatment begins, aiming to improve outcomes and recovery. Cancer drugs related cardiovascular fitness, neurotoxicity and fatigue have shown improvement with exercise[ 38 ]. Improvement in cancer related psychological wellbeing and quality of life has been associated with exercise as a prehabilitation therapy, as reported by Michael et al [ 39 ].

Physical activity and mortality reduction in cancer

Evidence suggests an improved survival outcome for cancer with pre and post diagnosis physical activity. In case of breast and colorectal cancers, greater reduction was noted for post diagnosis physical activity [hazard ratio (HR) = 0.58-0.63] compared with prediagnosis physical activity (HR = 0.80-0.86) for all-cause and cancer-specific mortality[ 40 ]. In a meta-analysis of prospective cohort studies, the inverse association between prediagnosis physical activity and cancer mortality was more definite for colon cancer than that for rectal cancer ( P = 0.08). A meta-analysis of prospective cohort studies for breast cancer inverse dose-response relationships between physical activity and breast cancer-specific and all-cause mortality were observed, with significant decrease in hazards to 10-15 MET equivalent hours per week[ 40 ].

ROLE OF TCM ALONG WITH PHYSICAL ACTIVITY IN CANCER PREVENTION

TCM has been in wide usage across the world in cancer prevention and treatment[ 3 ]. Natural herbs combined with movement practices like Tai chi and Yoga have gained traction[ 41 ]. These practices involve controlled breathing and gentle movements emphasizing the connection between the mind, body, and spirit. Specific protocols for various cancers in its entire continuum are required to be established. There is limited evidence in this regard yet. Literature synthesis can be done with high political will and strong scientific vigour backing age old practices into cancer prevention. Randomized controlled trials involving holistic exercise regimens are essential in establishing scientific credibility of these practices in preventing cancer. Combining these physical activities with complimentary and alternative medicine along with the current modern medicine protocols is crucial in establishing integrative oncology as a remedy. This is in line with the current WHO Traditional Medicine Strategy 2014-2023, integrative oncology is an upcoming field in this regard exploring the role of TCM practices in cancer prevention[ 42 ].

RECOMMENDATIONS

Future research should explore the optimal duration and intensity of physical activity for specific cancer types, as well as the mechanisms underlying Yoga's benefits. Integrative oncology needs extensive research with both conventional and TCM exploring the role of physical activity in cancer prevention. Tailor made protocols involving integrative approach need to be established for different stages of various cancers.

For primary prevention, study subjects need to be followed over long durations and systematically monitored for any development of new cases (incidence). This is time consuming, cost intensive and resource intensive. This is why most researchers have conducted observational study designs. Due to limited interventional research availability, the current evidence is restricted in a sense that it focusses on secondary and tertiary prevention but not primary prevention. Hence there is a need for high-quality prospective cohorts or mechanistic trials as more feasible alternatives.

CONCLUSION

Strong evidence supports an inverse relationship between physical activity and cancer risk, particularly for breast, liver, lung and colorectal cancers. There is limited evidence for hematologic, head and neck, ovarian, pancreas, prostate, brain, thyroid and rectal cancer. Dose response for exercise and cancer demonstrates a relation of greater risk reduction with higher MET equivalents per time period. Physical activity has a demonstrated role under prehabilitation or tertiary prevention of cancer. Along with regular cancer treatments, physical activity improves the overall wellbeing of the patient. The minireview highlights the need for interventional trials involving holistic methods combing modern and traditional medicine/therapies in cancer prevention. These can be applied at any stage of cancer continuum. Physical activities rooted in tradition like Yoga and Tai chi are slow, controlled movements that improve balance and coordination. There is also a need for structured physical activity guidelines for cancer prevention focusing on the entire continuum of cancer. The current literature focusses only on improved patient outcomes and not oncologic outcomes like reduction in cancer incidence. The current minireview brings forth the dearth in literature of resistance and balance exercises. The systematic reviews and trials mainly focus on aerobic exercise with minimal focus on the latter.

ACKNOWLEDGEMENTS

We would like to thank Department of Community Medicine, ABVIMS and Dr. Ram Manohar Lohia Hospital, New Delhi for their support.

Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.

Provenance and peer review: Invited article; Externally peer reviewed.

Peer-review model: Single blind

Specialty type: Oncology

Country of origin: India

Peer-review report’s classification

Scientific Quality: Grade A, Grade C

Novelty: Grade A, Grade C

Creativity or Innovation: Grade A, Grade C

Scientific Significance: Grade A, Grade C

P-Reviewer: Yu MK; Zheng HJ S-Editor: Luo ML L-Editor: A P-Editor: Zhao YQ

1 Ferlay J Ervik M Lam F Laversanne M Colombet M Mery L Piñeros M Znaor A Soerjomataram I Bray F Global Cancer Observatory: Cancer Today. Lyon, France: International Agency for Research on Cancer. 2024. [cited 4 April 2025]. Available from: https://gco.iarc.who.int/today

2 Sonkin D Thomas A Teicher BA Cancer treatments: Past, present, and future Cancer Genet 2024 286-287 18 24 38909530 10.1016/j.cancergen.2024.06.002 PMC11338712

3 Mao JJ Pillai GG Andrade CJ Ligibel JA Basu P Cohen L Khan IA Mustian KM Puthiyedath R Dhiman KS Lao L Ghelman R Cáceres Guido P Lopez G Gallego-Perez DF Salicrup LA Integrative oncology: Addressing the global challenges of cancer prevention and treatment CA Cancer J Clin 2022 72 144 164 34751943 10.3322/caac.21706 PMC13183357

4 World Health Organization WHO guidelines on physical activity and sedentary behaviour. Geneva: World Health Organization, 2020 33369898

5 Yang L Courneya KS Friedenreich CM The Physical Activity and Cancer Control (PACC) framework: update on the evidence, guidelines, and future research priorities Br J Cancer 2024 131 957 969 38926526 10.1038/s41416-024-02748-x PMC11405831

6 Joshi D Patel J Munshi M Mistry Z Prajapati A Mukherjee A Ramachandran AV Parashar NC Parashar G Haque S Tuli HS Hormones as a double-edged sword: the role of hormones in cancer progression and the potential of targeted hormone therapies Med Oncol 2024 41 283 39400627 10.1007/s12032-024-02517-z

7 Drummond AE Swain CTV Milne RL English DR Brown KA Skinner TL Lay J van Roekel EH Moore MM Gaunt TR Martin RM Lewis SJ Lynch BM Linking Physical Activity to Breast Cancer Risk via the Insulin/Insulin-like Growth Factor Signaling System, Part 2: The Effect of Insulin/Insulin-like Growth Factor Signaling on Breast Cancer Risk Cancer Epidemiol Biomarkers Prev 2022 31 2116 2125 36464995 10.1158/1055-9965.EPI-22-0505 PMC7613928

8 Tin Tin S Reeves GK Key TJ Endogenous hormones and risk of invasive breast cancer in pre- and post-menopausal women: findings from the UK Biobank Br J Cancer 2021 125 126 134 33864017 10.1038/s41416-021-01392-z PMC8257641

9 Poorolajal J Heidarimoghis F Karami M Cheraghi Z Gohari-Ensaf F Shahbazi F Zareie B Ameri P Sahraee F Factors for the Primary Prevention of Breast Cancer: A Meta-Analysis of Prospective Cohort Studies J Res Health Sci 2021 21 e00520 34698654 10.34172/jrhs.2021.57 PMC8957681

10 Shephard RJ Physical Activity and Prostate Cancer: An Updated Review Sports Med 2017 47 1055 1073 27844337 10.1007/s40279-016-0648-0

11 Friedenreich CM Ryder-Burbidge C McNeil J Physical activity, obesity and sedentary behavior in cancer etiology: epidemiologic evidence and biologic mechanisms Mol Oncol 2021 15 790 800 32741068 10.1002/1878-0261.12772 PMC7931121

12 Kelly T Yang W Chen CS Reynolds K He J Global burden of obesity in 2005 and projections to 2030 Int J Obes (Lond) 2008 32 1431 1437 18607383 10.1038/ijo.2008.102

13 Lauby-Secretan B Scoccianti C Loomis D Grosse Y Bianchini F Straif K International Agency for Research on Cancer Handbook Working Group Body Fatness and Cancer--Viewpoint of the IARC Working Group N Engl J Med 2016 375 794 798 27557308 10.1056/NEJMsr1606602 PMC6754861

14 Clinton SK Giovannucci EL Hursting SD The World Cancer Research Fund/American Institute for Cancer Research Third Expert Report on Diet, Nutrition, Physical Activity, and Cancer: Impact and Future Directions J Nutr 2020 150 663 671 31758189 10.1093/jn/nxz268 PMC7317613

15 Argolo DF Hudis CA Iyengar NM The Impact of Obesity on Breast Cancer Curr Oncol Rep 2018 20 47 29644507 10.1007/s11912-018-0688-8

16 Pham DV Park PH Adiponectin triggers breast cancer cell death via fatty acid metabolic reprogramming J Exp Clin Cancer Res 2022 41 9 34986886 10.1186/s13046-021-02223-y PMC8729140

17 Anazco D Acosta A Cathcart-Rake EJ D'Andre SD Hurtado MD Weight-centric prevention of cancer Obes Pillars 2024 10 100106 38495815 10.1016/j.obpill.2024.100106 PMC10943063

18 Ahechu P Zozaya G Martí P Hernández-Lizoáin JL Baixauli J Unamuno X Frühbeck G Catalán V NLRP3 Inflammasome: A Possible Link Between Obesity-Associated Low-Grade Chronic Inflammation and Colorectal Cancer Development Front Immunol 2018 9 2918 30619282 10.3389/fimmu.2018.02918 PMC6297839

19 Sánchez-Jiménez F Pérez-Pérez A de la Cruz-Merino L Sánchez-Margalet V Obesity and Breast Cancer: Role of Leptin Front Oncol 2019 9 596 31380268 10.3389/fonc.2019.00596 PMC6657346

20 Angelin A Gil-de-Gómez L Dahiya S Jiao J Guo L Levine MH Wang Z Quinn WJ 3rd Kopinski PK Wang L Akimova T Liu Y Bhatti TR Han R Laskin BL Baur JA Blair IA Wallace DC Hancock WW Beier UH Foxp3 Reprograms T Cell Metabolism to Function in Low-Glucose, High-Lactate Environments Cell Metab 2017 25 1282 1293.e7 28416194 10.1016/j.cmet.2016.12.018 PMC5462872

21 Pedersen BK Febbraio MA Muscles, exercise and obesity: skeletal muscle as a secretory organ Nat Rev Endocrinol 2012 8 457 465 22473333 10.1038/nrendo.2012.49

22 Gustafson MP DiCostanzo AC Wheatley CM Kim CH Bornschlegl S Gastineau DA Johnson BD Dietz AB A systems biology approach to investigating the influence of exercise and fitness on the composition of leukocytes in peripheral blood J Immunother Cancer 2017 5 30 28428879 10.1186/s40425-017-0231-8 PMC5394617

23 Raymond-Lezman JR Riskin SI Benefits and Risks of Sun Exposure to Maintain Adequate Vitamin D Levels Cureus 2023 15 e38578 37284402 10.7759/cureus.38578 PMC10239563

24 Henn M Martin-Gorgojo V Martin-Moreno JM Vitamin D in Cancer Prevention: Gaps in Current Knowledge and Room for Hope Nutrients 2022 14 4512 36364774 10.3390/nu14214512 PMC9657468

25 Chakraborty M Arora M Ramteke A Yadav V Naaz H Muntakhab M Tripathi P K NC FokI polymorphism of Vitamin D receptor gene and deficiency of serum Vitamin D increases the risk of breast cancer in North Indian women Endocrine 2023 81 168 174 36854857 10.1007/s12020-023-03334-6

26 Seraphin G Rieger S Hewison M Capobianco E Lisse TS The impact of vitamin D on cancer: A mini review J Steroid Biochem Mol Biol 2023 231 106308 37054849 10.1016/j.jsbmb.2023.106308 PMC10330295

27 Amaravadi SK Maiya GA K V Shastry BA Effectiveness of structured exercise program on insulin resistance and quality of life in type 2 diabetes mellitus-A randomized controlled trial PLoS One 2024 19 e0302831 38771888 10.1371/journal.pone.0302831 PMC11108169

28 Szablewski L Insulin Resistance: The Increased Risk of Cancers Curr Oncol 2024 31 998 1027 38392069 10.3390/curroncol31020075 PMC10888119

29 Nagendra HR Cancer: Prevention and Rehabilitation through Yoga Int J Yoga 2018 11 1 2 29343926 10.4103/ijoy.IJOY_71_17 PMC5769194

30 Patel DI Almeida GJ Darby NT Serra MC Calderon T Lapetoda A Gutierrez B Ramirez AG Hughes DC Therapeutic yoga reduces pro-tumorigenic cytokines in cancer survivors Support Care Cancer 2022 31 33 36517621 10.1007/s00520-022-07536-y PMC9750838

31 Khosravi N Stoner L Farajivafa V Hanson ED Exercise training, circulating cytokine levels and immune function in cancer survivors: A meta-analysis Brain Behav Immun 2019 81 92 104 31454519 10.1016/j.bbi.2019.08.187

32 Gupta P Yoga at Primary Health Centers - A Pathway to Holistic Health: Narrative Review Int J Yoga 2024 17 93 100 39444671 10.4103/ijoy.ijoy_106_24 PMC11495301

33 Glaser KM Crabtree-Ide CR Flores TF Reid ME Integrating Yoga into Comprehensive Cancer Care: Starting Somewhere Eur J Integr Med 2024 67 102348 39372426 10.1016/j.eujim.2024.102348 PMC11449015

34 Inbaraj G Sathyaprabha TN Udupa K Ram A Patil S Rajeswaran J Nandakumar KK Belur S Singh AD Prathyusha PV Bayari SK Raghavendra RM Impact of integrated yoga therapy on cognitive impairment and cardiac dysfunction in relation to quality of life in breast cancer patients undergoing chemotherapy: Study protocol for a two-arm randomized controlled trial Front Oncol 2022 12 955184 36185291 10.3389/fonc.2022.955184 PMC9524232

35 Diao X Ling Y Zeng Y Wu Y Guo C Jin Y Chen X Feng S Guo J Ding C Diao F Du Z Li S Qiu H Physical activity and cancer risk: a dose-response analysis for the Global Burden of Disease Study 2019 Cancer Commun (Lond) 2023 43 1229 1243 37743572 10.1002/cac2.12488 PMC10631483

36 McTiernan A Friedenreich CM Katzmarzyk PT Powell KE Macko R Buchner D Pescatello LS Bloodgood B Tennant B Vaux-Bjerke A George SM Troiano RP Piercy KL 2018 Physical Activity Guidelines Advisory Committee* Physical Activity in Cancer Prevention and Survival: A Systematic Review Med Sci Sports Exerc 2019 51 1252 1261 31095082 10.1249/MSS.0000000000001937 PMC6527123

37 Stout NL Fu JB Silver JK Prehabilitation is the Gateway to Better Functional Outcomes for Individuals with Cancer J Cancer Rehabil 2021 4 283 286 35048084 PMC8765744

38 Yang L Alice A Friedenreich CM Physical activity for cancer prehabilitation: A scoping review Crit Rev Oncol Hematol 2024 196 104319 38460927 10.1016/j.critrevonc.2024.104319

39 Michael CM Lehrer EJ Schmitz KH Zaorsky NG Prehabilitation exercise therapy for cancer: A systematic review and meta-analysis Cancer Med 2021 10 4195 4205 34110101 10.1002/cam4.4021 PMC8267161

40 Friedenreich CM Stone CR Cheung WY Hayes SC Physical Activity and Mortality in Cancer Survivors: A Systematic Review and Meta-Analysis JNCI Cancer Spectr 2020 4 pkz080 32337494 10.1093/jncics/pkz080 PMC7050161

41 Casuso-Holgado MJ Heredia-Rizo AM Gonzalez-Garcia P Muñoz-Fernández MJ Martinez-Calderon J Mind-body practices for cancer-related symptoms management: an overview of systematic reviews including one hundred twenty-nine meta-analyses Support Care Cancer 2022 30 10335 10357 36322248 10.1007/s00520-022-07426-3

42 World Health Organization WHO traditional medicine strategy: 2014-2023. 2013. [cited 4 April 2025]. Available from: https://apps.who.int/gb/ebwha/pdf_files/EB152/B152_37-en.pdf