Non-commonly prescribed physical exercises, disciplines and sports in breast cancer survivors: a narrative review

Introduction

Physical activity and exercise are increasingly recognized as vital factors in promoting both physical and psychological well-being among cancer survivors, particularly breast cancer survivors (BCS). They contribute to overall health by activating multiple biological pathways (1-4). The significance of exercise lies in its broad-ranging benefits for mental and physical health (4,5), along with its ability to provide primary, tertiary, and quaternary prevention of cancer recurrence and mitigate the negative side effects of treatments (6-8). Since 1944, when the first preclinical study demonstrated that exercise could inhibit tumor growth (9), research has expanded, leading to the development of comprehensive guidelines detailing the type, duration, intensity, frequency, volume, progression, and combinations of physical exercises that are beneficial for cancer patients, especially BCSs, even considering treatment side effects (6-8,10). These guidelines emphasize a “multimodal approach” that incorporates aerobic and resistance exercises, complemented by balance, flexibility, and mind-body practices. Such prescriptions require a multidisciplinary understanding for proper design and supervision. However, despite detailed guidelines and expanding evidence, the field of exercise oncology still faces challenges in implementing exercise prescription principles among healthcare providers. These challenges are largely attributable to limited knowledge, insufficient time during medical appointments, and inadequate human and financial resources, which hinder the formation of a multidisciplinary healthcare team (11-13). Indeed, although most oncology providers express support for recommending exercise to cancer survivors (14), less than one-third of cancer survivors’ report receiving exercise guidance from their oncology providers (15). For example, in the United States, only 37.7% of BCSs meet aerobic exercise guidelines, while a mere 17.6% meet resistance exercise recommendations (16). A similar trend is seen across Europe (11), with low rates of exercise prescription and participation among BCSs, and most programs focus on single-modality exercises like walking or strength training, often lacking the appropriate frequency, intensity, duration, volume, and progression (6-8,11,17-20). Obviously, this is a general overview, as each country has its own best practices in this field. The central role of oncologists in addressing these gaps is well-documented, even though they are not the only players involved. Indeed, studies indicate that oncologists are often the most trusted source of exercise information for patients across cancer types. Around 60–80% of cancer patients in multiple studies preferred receiving physical activity advice directly from their oncologists, while other sources included general practitioners, physiotherapists, nurses, and personal trainers (21-23). Interestingly, Martínez Aguirre-Betolaza et al. (17) found that exercise prescription by oncologists appears to be linked to their age, reflecting differences in education and experience. Specifically, younger oncologists (30–40 years old) were more likely to recommend walking, providing more general guidance. In contrast, middle-aged oncologists (41–50 years old) tended to recommend strength training and stretching/mobility activities. Notably, in the survey conducted by Martínez Aguirre-Betolaza et al. (17), when oncologists were asked, “Do you normally recommend physical activity to your patients? If your answer is affirmative, briefly describe the recommendations you give them”, the most common responses were walking, cycling, swimming, strength training, and stretching/mobility activities, with “other” receiving the lowest percentage. These recommendations align with the exercise preferences and most frequently studied activities among BCSs (6,7,17-20). Indeed, a systematic review from 2012 (24) and a follow-up review in 2019 (19) revealed that despite existing guidelines, exercise interventions for BCSs rarely applied all the principles of exercise training in randomized controlled trials. The earlier review found that no studies published between 1990 and 2010 adhered to all the principles of exercise prescription. Specificity was applied in 64% of cases, progression in 41%, overload in 31%, initial values in 62%, and diminishing returns and reversibility in only 7%. The follow-up review (19), examining studies from 2010 to 2017, found minimal improvements: specificity was applied in 84%, progression in 29%, overload in 38%, and initial values in 67%. Notably, reversibility was reported in just 3% and diminishing returns in 22% of studies. At this point, it is natural to question whether the primary issue lies in the awareness and understanding of the comprehensive guidelines.

To fully understand the current state of exercise practices among BCSs and improve adherence to effective exercise regimens, a broad view and intervention are required. Exercise prescription must address both the multidisciplinary efforts of the health alliance professionals, involved in properly designing and supervising these programs, and the behaviors of patients, who must initiate and maintain lifestyle changes. Unlike taking a pill, exercise adherence involves complex motivational dynamics that differ greatly among individuals. A comprehensive mixed-methods review by Clifford et al. (25) identified numerous barriers and facilitators to exercise among cancer survivors. Some of the top barriers included the lack of facilities, insufficient guidance, lack of enjoyment, low motivation, and the absence of an exercise partner. Conversely, variety in exercise types emerged as a motivating factor, albeit not among the top-ranked reasons for adherence (Table 1).

Reminding the multifaceted nature of exercise adherence, the described landscape makes it conceivable to think that the low participation rates are partially linked to the fact that current prescriptions mainly attract BCSs who already enjoy activities like walking, cycling, swimming, strength training, or stretching, which also experience a dropout (26). Research has identified several reasons for this: (I) “physical discomfort”. Joint pain, neuropathy, and muscle stiffness can deter survivors from continuing exercise, particularly if prescriptions do not align with comprehensive guidelines (27). (II) “Low motivation”. Lack of motivation and visible progress are common reasons for discontinuation, especially when exercise programs are not well-tailored to individual needs (27). (III) “Monotony”. Survivors are more likely to drop out if they find exercise routines monotonous or unenjoyable (28). Given these challenges, it is plausible that current exercise prescriptions may not be sufficiently diverse or appealing to a broader range of BCSs.

Starting from the understanding that when we refer to aerobic, strength, flexibility, and balance exercises, we are addressing broad categories that encompass a wide range of activities, each with its own unique characteristics [e.g., aerobic exercise is not limited to walking, cycling, or swimming but includes any sustained rhythmic activity that primarily relies on aerobic energy pathways, using oxygen to produce energy (29)]; the aim of this narrative review is to encourage a more comprehensive, person-centered approach to exercise prescription, recognizing the effects of less commonly prescribed exercises, disciplines, and sports on BCSs, to better promote exercise practice within the oncology setting. By broadening the range of recommended activities, we aim to enhance adherence and optimize the benefits of exercise for this population. We present this article in accordance with the Narrative Review reporting checklist (available at https://tbcr.amegroups.com/article/view/10.21037/tbcr-24-63/rc).

Methods

A literature search was conducted over the following databases: PubMed, Scopus, Web of Science, and CINAHL. All the search terms and filters were adapted to each database that was searched from the earliest record up to November 10, 2024. Reference lists from all included studies and any thematic reviews on this field were screened to identify further pertinent articles. Titles and abstracts of selected articles were independently evaluated by two authors. Duplicates and records outside the scope of the study were removed at the preliminary stage of the screening. Eligible studies were included based on the information reported in their full texts. The PRISMA flow diagram is shown in Figure 1, while search strategy is summarized in Table 2.

Figure 1 Flow diagram.

Results

Effects of non-commonly prescribed physical exercises and disciplines

At the end of the screening phase, out of the initial 54,872 records, 27 studies were selected for inclusion in this narrative review. These studies examined dance-based exercises, functional training, horseback riding, water-based activities, dragon boating, fencing, rowing, and sailing.

Dance-based exercises and dance/movement therapy

According to the literature, dance-based exercise and dance/movement therapy have positive psychophysical effects on BCSs. Indeed, across the studies, participants consistently reported reductions in anxiety, depression, and fatigue, alongside improvements in all aspects of physical function, body image, and quality of life. They also promote social interaction and emotional expression, which are crucial for coping with cancer-related stress, and provide a greater sense, in BCSs, of control over their health. Literature also underlines that dance-based exercise and dance/movement therapy have minimal adverse effects, including non-functional fatigue, and physical discomfort may occur in those BCSs undergoing treatments (30-32).

Functional training

Considering the selection criteria, excluding those manuscripts referring to classical resistance workouts using machines, elastic bands, dumbbells, and Pilates-based exercises, literature showed interesting results. Winters-Stone et al. (33), investigating the effects of a combined impact and resistance training program on bone health and body composition in BCSs who experienced premature menopause due to treatment, found the increase of bone mineral content of the hip and the reduction of body fat. The used protocol included resistance exercise with weights, using shin guards and weight vests, dumbbells, kettlebells, and barbells, with 8–15× repetition orientation and adjustment of weight based on individual capacity. Due to the proposed protocol, some participants faced difficulties maintaining consistent participation in the exercise program over the year, while a few cases of minor musculoskeletal injuries were reported, likely due to the impact nature of some exercises. Artese et al. (34) showed that 12-week functional training, including alternated strength and high-impact exercises for the first three rounds and core strength in the fourth round, using free-weights and calisthenics exercises, elicited the reduction of fat mass, the increase of lean body mass, together with bone mineral density at the lumbar spine and femoral neck regions, and both lower and upper body strength. No adverse events relating to the training program were reported, and no participants reported lymphedema-related symptoms. In our experience, 12 weeks of myofascial exercise practice are able to elicit the improvement of flexibility, witnessed by the improvement of the results of right and left back scratch and sit and reach tests, strength, witnessed by the improvement of right and left handgrip, total handgrip, right and left single-leg back bridge, and by the improvement of the muscle quality index without adverse events (35).

Horseback riding

Horseback riding or hippotherapy has been shown useful in BCSs both in psychological and physiological fields. Cerulli et al., evaluating the effects of a 16-week horseback riding program on BCSs, found the increase of maximal oxygen uptake (VO2max), whole body muscle strength, and quality of life, together with the reduction of body fat (36). As underlined by Cerulli et al., Douglas et al., in their systematic review of the literature on performance in equestrian athletes, explained that horseback riding is not a workout just for the horse (37). The main research findings were that as a horse progress through the gait (i.e., walk, trot, and canter), the rider’s heart rate and oxygen consumption increase, probably because of higher levels of tonic muscular contraction primarily involving the musculature of the torso and lower limbs, to maintain balance in the saddle, and upper limbs grooming, saddling, unsaddling, mounting, and controlling the horse with the reins (37). This physiological and function improvement pushes the psychological recovery, also benefiting from the healing power of pets (38). Viruega et al. confirmed and enlarged the psychological evidence on the positive effects of hippotherapy. Indeed, after a 6-month program, BCSs experienced an increase in quality of life, positive body image, memory, and attention and the reduction of fatigue, anxiety, and depression (39).

Water-based exercises

Water-based exercises include a big variety of disciplines ranging from rehabilitation to fitness exercises, not considering the swimming-based exercises. Water-based exercises have been shown to reduce fatigue and pain and to improve quality of life, in the short term, together with flexibility, mainly of the shoulders, and whole-body muscle strength, thanks to the use of rubber expanders, noodles, blades, and water dumbbells, in the short and middle terms, and thanks to the proper water temperature management. However, the effects on lymphedema are not conclusive, while the adherence to treatment was high, and none of the considered studies reported serious adverse events during the study period (40).

The considered literature underlined that all the non-commonly prescribed physical exercises and disciplines we considered had accessibility and customization challenges to broader implementation, underscoring the need for more trained practitioners and personalized approaches in BCSs.

Effects of sport practice

Dragon boating

In their systematic review, Herrero-Zapirain et al. (41) examined the effects of dragon boat paddling on the quality of life of BCSs. Quality of life tends to improve in subjects who practice dragon boat; indeed, in nine out of 10 of the studies, it has been shown to increase, and, in some cases, dragon boat improves quality of life more than physical activities like walking, Pilates, yoga, and resistance training (42,43). In other studies, the authors found that dragon boating improves quality of life in a similar way to those who perform other physical activities, such as walking or resistance training (41,44). Boeer et al. (45) found, by the study conducted on BCSs having (21%) and not having lymphoedema at the starting point, a negative effect of the dragon boat on it in just 4% of the participants, while the arm circumferences have been shown to be significantly reduced. Participants often experience increased upper and lower-body strength and endurance, together with myocardial function and aerobic fitness (44,46). Engaging in dragon boating has been linked to lower levels of anxiety and depression, a higher sense of achievement and empowerment by mastering a physically demanding activity, and a supportive environment where survivors share experiences, reducing feelings of isolation, develop lasting friendships, create a network of emotional and practical support (47). Literature reminds the importance of an appropriate physical exercise prescription, as the repetitive nature of paddling may lead to overuse injuries, particularly in the shoulders and wrists, especially if participants are not adequately trained, especially in BCSs having experienced, in addition to other persons, surgeries and radiation therapy having local and systemic negative functional effects (48). At the end, it is important to remember that dragon boating requires access to specific equipment (i.e., boats, paddles) and a suitable water body, making it less accessible compared to other forms of exercise like yoga or walking.

Fencing

Adapted fencing seems to offer several benefits to BCSs. Indeed, adapted fencing involves dynamic arm movements that can enhance shoulder flexibility and correct postural imbalances, often resulting from breast cancer surgery and radiation therapy (49,50). The controlled and progressive upper limb movements in fencing aid lymphatic drainage, potentially lowering the risk of developing or worsening lymphedema if properly practiced (50). The sport’s emphasis on agility, coordination, and cardiovascular endurance contributes to overall physical conditioning, aiding recovery and general health (50,51). Participation in fencing has been associated with reduced fatigue, anxiety, and depression, leading to improved mental well-being and quality of life (50,52). Literature also underlines that the program must be tailored to individual abilities, considering post-surgical limitations and overall fitness levels, and requesting specific modifications, including lighter equipment and shorter bouts to prevent overexertion. This means that proper guidance from instructors familiar with the needs of BCSs is crucial to ensure safety and effectiveness, particularly in avoiding strain or injury: participants should begin with low-intensity exercises and gradually increase complexity and intensity to build endurance and strength without overwhelming their system.

Rowing

According to the literature, engaging in rowing offers several benefits for BCSs, including the increase of quality of life and daily physical activity level (53), aerobic fitness together with whole body muscle strength, flexibility, and body composition (54), and cardiovascular parameters (55) mainly due to the whole body engagement in the practice of a discipline being a closed skill with a regular and symmetrical executive rhythm, combining the development of overall strength and aerobic endurance, and being practicable in indoor and outdoor settings. Literature also underlines the potential negative effects of non-properly tailored rowing workouts in BCSs, including the increased risk of lymphedema in those BCSs having a lymph node dissection in the upper limb due to the intensive upper-body activities and increased risk of musculoskeletal strain due to improper rowing techniques leading to musculoskeletal injuries, particularly in the shoulders and back. Professional guidance is recommended to ensure correct form and prevent injury.

Sailing

Literature concerning sailing and breast cancer provides two interesting studies. One exploring the psychological impact of sailing experiences on women with a history of oncological diseases (56), and another characterizing the psychological traits of women participating in a sailing cruise (57). Sailing experience has been shown to be able to improve the quality of life of BCSs and to reduce their anxiety and distress (56). Even if one study showed the psychological effects of sailing on a sample having the starting values of quality of life lower than that of the general population, together with higher anxiety and distress (56), the other showed that women participating in the sailing cruise exhibited high levels of openness to experience and extraversion, indicating a preference for stimulation and new experiences and a proactive personal settling in managing stress and challenges (57).

As shown for the non-commonly prescribed exercises and disciplines, also the literature concerning the described sports had accessibility and customization challenges to broader implementation, underscoring the need for more trained practitioners and personalized approaches in BCSs.

Discussion

A significant positive outcome of this narrative review is the inclusion of literature focusing on the effects of physical exercises, disciplines, and sports beyond commonly prescribed activities such as walking, jogging, running, Nordic walking, cycling, swimming, strength training, Pilates, yoga, tai chi, qigong, balance, and mobility exercises. While further research is necessary, these finding highlights progress in addressing gaps in exercise prescription for BCSs. It challenges the outdated perception that exercise requires the same simple behavioral processes as taking a pill. Instead, exercise prescription must consider the complex motivational and behavioral dynamics unique to everyone. In the post-acute phase, beyond rehabilitation protocols that address functional thresholds for daily living, it is crucial to consider activities that individuals enjoy or aspire to pursue. Personalizing exercise types is vital for fostering sustained engagement in physical activity. The field of sport science recognizes over 200 sports recognized by national and international federations, expanding to more than 8,000 when indigenous disciplines and sports are included (58). This number grows exponentially when all possible physical exercises are considered, emphasizing the need for tailored approaches to address BCSs’ preferences. Research shows that 60–80% of cancer patients prefer receiving physical activity advice from their oncologists (21-23). However, oncologists should not work in isolation; building a multidisciplinary team is essential. This team should also include physiatrists, physiotherapists, sports medicine specialists, and kinesiologists to ensure holistic prescription and supervision of physical exercise for BCSs throughout the acute and follow-up phases (59). The objective is not to reduce exercise to a narrow set of activities but to prioritize psychological engagement as a core driver of adherence. Existing guidelines for aerobic and resistance exercises, complemented by balance, flexibility, and mind-body practices, should be integrated with BCSs’ individual preferences. For example, Bock et al. (60) found that only 61.48% of 1,067 postmenopausal BCSs continued structured physical activity 1-year post-surgery. Walking participation slightly increased, from 86 to 105 participants, but engagement in less commonly prescribed activities dropped dramatically, from 389 participants before diagnosis to just 137 1-year post-surgery. This significant decline raises questions about the adequacy and appeal of current exercise prescriptions.

Oncologists play a pivotal role in initiating a virtuous cycle of physical activity and exercise prescription. This involves educating patients about the importance of exercise during and after therapy and facilitating multidisciplinary evaluations. Effective exercise prescriptions should be informed by (I) BCSs’ psychophysical health status and behaviors; (II) BCSs’ barriers and motivators to physical activity; (III) physical activity and exercise guidelines; and (IV) BCSs’ individual preferences (Figure 2). Achieving these goals requires targeted training for healthcare professionals and system-wide efforts to promote a patient-centered, multidisciplinary approach. Unfortunately, while oncologists often lack awareness of cancer-specific exercise guidelines (61,62), clinicians frequently cite insufficient numbers of trained exercise specialists and limited availability of tailored programs as major barriers to exercise promotion (63). Similarly, a study on kinesiology students revealed limited knowledge of exercise oncology, with only 44% and 54% correctly identifying the recommended aerobic and strength activities, respectively, as per the American College of Sports Medicine guidelines (64). The same study highlighted a lack of university courses addressing cancer-specific exercise prescriptions, further emphasizing the need for improved educational frameworks.

Figure 2 Exercise prescription algorithm. BCS, breast cancer survivor.

Physical exercise prescription should evolve with the progression of BCSs, transitioning from initial fitness levels to more advanced activities that align with individual preferences and goals. This periodized approach involves tailoring frequency, intensity, time, volume, and type of exercise (29). At the same time, clinicians must recognize that long-term training strategies differ significantly from acute rehabilitation protocols (Figure 3).

Figure 3 Exercise characteristics in oncology.

The strength of this narrative review lies in its unconventional approach, which expands the discussion of low exercise prescription and adherence in BCSs. By presenting alternative perspectives, this review aims to enhance exercise oncology practices and address critical gaps in the field, even if much more literature, based on this approach, is needed to properly push the necessary change. This review can be useful for providing general background and indications, however, further comprehensive form of review may be necessary to mark evidence-based research findings, especially translational and clinical research, to wider explore such mechanisms to refine exercise prescriptions, optimize timing, and establish guidelines for integrating exercises, disciplines and sports into routine cancer care and prevention protocols.

Conclusions

In conclusion, this narrative review shifts the focus from what BCSs should improve to what prescribers can do better within the field of exercise oncology. The highlighted actions emphasize that prescribers must adopt a more proactive and innovative approach, especially considering that the literature already provides the necessary foundational knowledge. Physical exercise prescription involves far more than calculating energy expenditure or assigning a percentage of maximal capacity. It requires a nuanced integration of BCSs’ psychophysical health status, behaviors, barriers, and motivations with evidence-based exercise guidelines and individual preferences to develop comprehensive, personalized prescriptions and supervision plans.

One key objective of exercise prescription for BCSs should be to move beyond a narrow focus on commonly prescribed activities, such as walking, jogging, running, Nordic walking, cycling, swimming, strength training, Pilates, yoga, tai chi, qigong, balance, and stretching exercises. Instead, it is essential to embrace the full spectrum of exercise types, disciplines, and sports. By considering activities that align with individual interests and passions, prescribers can increase adherence, enhance engagement, and ultimately optimize the benefits of exercise for BCSs. This patient-centered approach offers a pathway to greater inclusivity and sustained physical activity practice, ensuring long-term health and well-being.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://tbcr.amegroups.com/article/view/10.21037/tbcr-24-63/rc

Peer Review File: Available at https://tbcr.amegroups.com/article/view/10.21037/tbcr-24-63/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tbcr.amegroups.com/article/view/10.21037/tbcr-24-63/coif). A.D.B. serves as an unpaid editorial board member of Translational Breast Cancer Research from January 2024 to December 2025. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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