Sport Medicine in the Prevention and Management of Cancer

Abstract

Physical inactivity is a major concern in cancer patients despite the established preventative and therapeutic effects of regular physical exercise for this patient group. Sport not only plays an important role in supporting the development and maintenance of a physically active lifestyle but also is increasingly used as a health promotion activity in various populations. Nevertheless, the potential of sport as an effective strategy in the prevention and management of cancer has gained little attention. Based on the scant evidence to date, participation of cancer patients in supervised, well-tailored sport programs appears to be safe and feasible and is associated with an array of physical and psychological benefits. We propose that sport participation may serve as an alternative strategy in the prevention of cancer and sport medicine in the management of cancer. As with the traditional exercise modes, benefits derived from sport participation will be dependent on the sport undertaken and the physical/physiological, motor, and cognitive demands required. To this end, further work is required to develop a solid evidence base in this field so that targeted sport participation can be recommended for cancer patients.

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https://doi.org/10.1177/1534735419894063
Integrative Cancer Therapies
Volume 18: 1 –14
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Review Article
Introduction
Cancer is a worldwide problem and imposes a tremendous
disease burden. In 2018, the expected number of new cancer
cases globally was 18.1 million.1 For most cancer patients,
the disease and related treatments will have a severe adverse
effect on physical, mental, and social health with the most
common symptoms being fatigue,2,3 pain,4,5 nausea,6,7
reduced functional capacity,8,9 depression,10,11 anxiety,3,12
and social disconnectedness.13,14 In addition, cancer patients
are also more vulnerable to other chronic comorbidities such
as cardiovascular disease, diabetes, osteoporosis, and sarco-
penia.15-17 Therefore, strategies that can reduce the risk of
cancer and mitigate a wide range of health sequelae related
to the disease and its treatments are of clinical importance.
Regular physical exercise is associated with a reduced
risk of many types of cancers18,19 and cancer recurrence20 as
well as attenuated treatment-related symptoms in cancer
patients.15,21,22 However, physical inactivity or an insuffi-
cient level of physical activity, irrespective of a cancer diag-
nosis, remains a major concern. According to data recently
published,23 worldwide 27.5% of adults in 2016 (rising
from 23.3% in 2010) did not meet the World Health
Organization recommendations on minimum physical
activity for health, that is, at least 150 minutes of moderate-
intensity, or 75 minutes of vigorous-intensity physical
activity per week, or equivalent combinations. With regard
to cancer patients in developed countries, the prevalence of
a sedentary lifestyle is much higher. The National Cancer
Institute recently reported24 that 34.8% of adult cancer
patients engaged in no physical activity in 2016. In addi-
tion, an estimated 88% of prostate cancer patients in
Australia do not meet the recommended physical activity
level, of which 47.5% are totally inactive25; while in
894063ICTXXX10.1177/1534735419894063Integrative Cancer TherapiesLuo et al
research-article20192019
1Guangdong Vocational Institute of Sport, Guangzhou, Guangdong, China
2Edith Cowan University, Joondalup, Western Australia, Australia
3University of Queensland, Brisbane, Queensland, Australia
4The University of Hong Kong, Hong Kong
Corresponding Author:
Dennis R. Taaffe, Exercise Medicine Research Institute, Edith Cowan
University, 270 Joondalup Drive, Joondalup, Western Australia 6027,
Australia.
Email: d.taaffe@ecu.edu.au
Sport Medicine in the Prevention and
Management of Cancer
Hao Luo, MEd1,2 , Daniel A. Galvão, PhD2,
Robert U. Newton, PhD2,3,4 , Ciaran M. Fairman, PhD2,
and Dennis R. Taaffe, PhD, DSc, MPH2,3
Abstract
Physical inactivity is a major concern in cancer patients despite the established preventative and therapeutic effects of
regular physical exercise for this patient group. Sport not only plays an important role in supporting the development and
maintenance of a physically active lifestyle but also is increasingly used as a health promotion activity in various populations.
Nevertheless, the potential of sport as an effective strategy in the prevention and management of cancer has gained little
attention. Based on the scant evidence to date, participation of cancer patients in supervised, well-tailored sport programs
appears to be safe and feasible and is associated with an array of physical and psychological benefits. We propose that sport
participation may serve as an alternative strategy in the prevention of cancer and sport medicine in the management of
cancer. As with the traditional exercise modes, benefits derived from sport participation will be dependent on the sport
undertaken and the physical/physiological, motor, and cognitive demands required. To this end, further work is required
to develop a solid evidence base in this field so that targeted sport participation can be recommended for cancer patients.
Keywords
sport medicine, prevention, management, cancer, exercise
Submitted May 21, 2019; revised November 7, 2019; accepted November 19, 2019

2 Integrative Cancer Therapies
Canada, only 21% of cancer patients were considered active
in 2005,26 with similar results also reported in the 2009-
2010 National Health Survey round.27
Sport participation is commonly advocated by policy
makers to facilitate the development and maintenance of an
active lifestyle in the general public. As suggested by Khan
and colleagues,28 sport contributes to a healthier nation
through improved physical activity level of the population.
Individuals who play sports are more likely to meet the rec-
ommended physical activity level for health than those who
are not active in sport.29 Sport, through varied forms of
interactive (such as partnered-based and group-based activ-
ity) and match/contest play, may have the potential to
increase participation rate and maintain exercise continu-
ance in various populations.30,31
In recent years, a range of sports as a health promotion
activity has been examined in the noncancer populations. A
period of participation in organized sport activities were
reported to result in a broad spectrum of cardiometabolic
and musculoskeletal benefits in both the apparently healthy
population and patients with common chronic diseases such
as diabetes, hypertension, and osteoporosis.32,33 In addition,
sport participation is often associated with a wide array of
psychological benefits including enhanced self-esteem and
self-efficacy and a general feeling of well-being.34 However,
the potential of sport as an effective intervention in the man-
agement of cancer has gained little attention. This may be
partially related to a prevailing dogma that vigorous exer-
cise, which would include a wide range of sport activities,
may increase the risk of immunosuppression thereby com-
promising the immune system against tumor cells. However,
a recent review by Campbell and Turner35 dispelled such a
misconception and concluded that acute vigorous exercise
may actually enhance immunological health.
To date, there is no definitive evidence that would pre-
clude sport participation in cancer patients. On the contrary,
a recent review by Ruiz-Casado et al36 synthesizing numer-
ous preclinical and human mechanistic studies concluded
that an active lifestyle (and this could be achieved through
exercise and sport) through multiple biological mechanisms
(such as vascular normalization, myokine secretion, etc)
may potentially exert an antitumorigenic effect. In addition,
emerging clinical trials37,38 have showed preliminary effi-
cacy of prescribed sport activities (such as soccer, triathlon,
wall climbing, and dragon boat racing) in patients with
common types of cancers (predominantly prostate and
breast cancers) on a variety of supportive care outcomes.
Therefore, we propose that participating in structured sport
programs may serve as an alternative strategy to conven-
tional clinic-based and community-based physical exercise
programs and could be implemented more widely in the
prevention and management of cancer. In this review, we
discuss the positive association between sport participation
and the risk of cancer and cancer-specific and overall
mortality, present studies reporting sport activities in the
management of cancer, provide initial recommendations on
sport participation for cancer patients, and finally discuss
future opportunities for research in this emerging field of
oncology.
In order to facilitate discussion on this topic, in this article
sport is defined as an activity requiring physical effort and
skills with predetermined rules and objectives, which typi-
cally requires multifaceted physical and physiological
demands depending on various factors such as movement
components and forms of play.39,40 Evidence regarding sport
participation for cancer management in this review was
obtained through a systematic literature search. Briefly, elec-
tronic searching was undertaken in PubMed, Web of Science,
SPORTDiscus, PsycINFO, and Google Scholar databases
using keywords for population (cancer OR tumor OR malig-
nancy) AND keywords for intervention (sport OR individual
sports OR team sports OR specific sport disciplines based on
the current list of Summer and Winter Olympics), with data-
bases searched up until May 2019. In addition, the reference
lists of relevant primary and secondary studies (review arti-
cles, commentaries, and editorials) were also checked to
identify potential eligible studies. Due to the limited evi-
dence on sports for cancer management, studies on exercise
programs primarily composed of sport-related activities
(including sport skills practice and targeted physical training
preparation for a specific sport such as triathlon) in cancer
patients were also included in this review.
Sport, Cancer Risk, and Cancer
Mortality
It is well established that sport participation reduces the risk
of all-cause mortality and improves life expectancy in vari-
ous populations.41-44 In the cancer context, individuals
repeatedly exposed to sports (including the general public,
amateur/collegiate athletes, and professional/elite athletes)
also have decreased risk of cancer and cancer-related death,
although disparity exists in their training levels and physi-
cal condition. An early observational study45 suggested that
regular sport participation led to a lower rate of cancer inci-
dence in middle-aged and older men. In a similar fashion,
life-time sport-active adult women have a reduced inci-
dence of breast cancer (>50% reduction) compared with
age-matched nonactive women with stronger protective
effects observed in those with earlier sport engagement and
higher activity level.46 In amateur/collegiate athletes with
higher training volume and intensity, a lower rate of cancer
risk has also been observed. An early large-scale survey47 in
5398 female former collegiate athletes and nonathletes indi-
cated that long-term participation in organized sport activi-
ties was associated with a reduced risk of not only breast
cancer but also gynecologic cancers; while a 15-year fol-
low-up48 of these subjects also indicated that previous

Luo et al 3
college sports experience conferred a life-time prophylactic
effect against breast cancer. Recently, a retrospective study49
in French athletes demonstrated that the longer life expec-
tancy in elite athletes of numerous sports was primarily
attributed to the lower risk of cancer.
Regarding cancer mortality, several cohort studies50-52
and a meta-analysis53 have demonstrated that, in comparison
with the general population, elite professional athletes and
Olympians (mostly men) have fewer cancer-specific deaths.
As reported in the meta-analysis,53 the pooled standard mor-
tality ratio for cancer was 0.60 (95% confidence interval =
0.38-0.94) in professional or Olympic-level athletes.
Therefore, encouraging evidence suggests that engagement
in sports may be conducive in reducing cancer incidence and
cancer-specific and overall mortality in adult men and
women with varied sport training backgrounds, which may
be attributable to a healthier lifestyle including less smoking
and more physical activity in sport active people.50
Sport and Cancer Management
Work to date indicates that sport participation as a health
promotion activity has a broad spectrum of physical and
psychological benefits in not only healthy/asymptomatic
individuals but also clinical populations with common car-
diometabolic comorbidities including hypertension, diabe-
tes, and obesity regardless of age, sex, and socioeconomic
background. A summary of beneficial effects resulting from
a period of participation in individual and team-based sport
activities including golf,42 rugby,54,55 soccer,56-60 basket-
ball,61 handball,62 and floorball63,64 in untrained, healthy/
asymptomatic individuals and noncancer patients is pre-
sented in Table 1. Likewise, a small but growing number of
studies65-79 have shown that regular participation in individ-
ual and team-based sports (including triathlon, wall climb-
ing, dragon boat racing, and soccer) is also effective as an
exercise therapy for persons previously diagnosed with can-
cer (mostly breast and prostate cancer) in alleviating disease-
related and treatment-related adverse effects on physical,
physiological, and psychological function (Tables 2 and 3).
Physical and Physiological Benefits
Positive adaptations in physical performance, functional
ability, cardiovascular fitness, and body composition have
been observed in cancer patients following short-term to
long-term participation in structured soccer and dragon boat
(team paddling in a heavy, dragon-shaped boat) programs
with some of the changes more notable than those engaging
in other fitness activities (Table 2). For example, a short-
term (8-week) program of dragon boating resulted in sig-
nificant improvement in muscular strength and aerobic
capacity in adult cancer patients.71 In middle-aged and older
breast cancer (BCa) patients,75 cardiac diastolic function
substantially improved following long-term (48 months)
participation in dragon boating compared with healthy
women undertaking predominantly traditional cardiorespi-
ratory activities including running, cycling, and swimming.
In addition, BCa patients engaged in a twice-weekly dragon
boat program for over 6 months had lower lymphedema
incidence than a comparison group undertaking other forms
of aerobic exercise including Pilates, yoga, tai-chi, jogging,
and walking.77 A randomized controlled trial (RCT) demon-
strated that recreational soccer training up to 32 weeks in
duration induced marked improvement in lean body mass,73
bone mineral density,76 and lower limb muscle strength and
function76 in men with locally advanced or metastatic pros-
tate cancer (PCa) undergoing androgen deprivation therapy.
In a subsequent 5-year follow-up,78 the beneficial effects on
the skeleton were maintained through regular participation
in self-organized recreational soccer games with significant
improvement observed in femoral neck bone mineral den-
sity compared with those undergoing resistance training,
aerobic exercise, and yoga.
Beyond soccer and dragon boat racing, other sports
including triathlon and wall climbing (adapted indoor rock
climbing), albeit less examined in cancer patients, have also
shown initial efficacy in improving physical functioning
(Table 2). For instance, a 14-week program culminating
with participation in a sprint distant triathlon (800-m swim-
ming, 20-km cycling, and 5-km running), which comprised
Table 1. Summary of Benefits of Sport Participation in Untrained, Healthy/Asymptomatic Individuals and Noncancer Patients.
Increased Decreased
Muscle mass54,60-62 Body fat54,56,58,60-63
Bone mineral density59,61,62,64 Heart rate55,56,61-63
Cardiorespiratory fitness42,54-58,60-62,64 Blood pressure55-58,60,61
Muscular strength42,63 Blood glucose42,58,60
Functional capacity42,63 Insulin resistance58,63
Physical performance61,62 Plasma triglycerides58,60,61,63
Mental wellness42,62 Low-density lipoprotein cholesterol60,63
Proinflammatory cytokines54,58
Stress and anxiety42

4
Table 2. Physical and Physiological Benefits of Sport Participation in Cancer Patients.
Author (Year) Study Design
Participants (Number, Cancer Type/Health
Status, Gender, Mean Age) Activity
Training Program (Duration,
Frequency, Session Duration)
Changes for Intervention/
Sport Participation Group
Carter etal71 (2012) NRCT INT = 68, adult cancers, 53.8 years Dragon boat paddling 3 rounds, 8 weeks/round, 2/week,
60 min/session
Upper-limb strength a,b
Aerobic capacity a
COMP = 52, adult cancers, 58.2 years Group-based walking NR Lower-limb strength a
Uth etal73 (2014)cRCT INT = 29, PCa, male, 67.1 years Recreational soccer 12 weeks, 2-3/week, 45-60 min/
session
LBM b
CON = 28, PCa, male, 66.5 years No activity prescribed
Stefani etal75 (2015) Intervention study
comparison with
healthy controls
INT = 55, BCa, female, 57 years Dragon boat 48 months, 2/week, 120 min/session A peak a,b
IVRT a,b
Ea a
COMP = 36, healthy, female Running (21), cycling (2), tennis (5),
canoeing (1), riding (1), scuba diving (1),
swimming (3), and fitness (2)
48 months, 3/week, ≥120 min/
session
Uth etal76 (2016)cRCT As above (see Uth etal, 2014) As above (see Uth etal, 2014) 32 weeks, 2-3/week, 45-60 min/
session
(R) Total hip BMD b
Stair climbing a,b
1RM a
Sit-to-stand a
Ng etal80 (2017) SAT 21, BCa, female, 48 years Team triathlon training with additional
home-based program
Triathlon training: 14 weeks, 2/
week, 90 min/session; home-based
program: 14 weeks, 3-4 (3-7
hours)/week
6-minute walk test a
VO2max†a
Crawford etal81 (2017) RCT INT = 24, GCa, female, 52.5 years Wall climbing 8 weeks, 2/week, 120 min/session 6-minute walk test a,b
CON = 11, GCa, female, 54.1 years No activity prescribed Hand-grip strength a,b
30-second arm curls a,b
30-second chair stands a,b
Sit-and-reach a,b
8-foot up-and-go a,b
Iacorossi etal77 (2019) OS Group A = 50, BCa, female Dragon boat >6 months, 2/week Lymphedema a
Group B = 50, BCa, female Compression therapy, lymphatic drainage,
Pilates/yoga/tai-chi, jogging/walking
>6 months, 2/week
Uth etal78 (2018)cNRCT INT = 11, PCa, male, 71.3 years Self-organized recreational soccer 5 years of follow-up with no specific
prescription
(R) Femoral neck BMD b
Resting HR a
CON = 11, PCa, male, 71.3 years Resistance training, aerobic exercises and
yoga
5 years of follow-up with no specific
prescription
Abbreviations: , increase; , decrease; A peak, peak mitral annular velocity during late diastole; BCa, breast cancer; BMD, bone mineral density; CON, control group; COMP, comparison group; Ea,
the time to onset of early diastolic velocity of the mitral annulus; F, female; GCa, gynecologic cancer; HR, heart rate; INT, intervention group; IVRT, isovolumic relaxation time; LBM, lean body mass;
min, minute; NR, not reported; NRCT, nonrandomized controlled trial; OS, observational study; PCa, prostate cancer; R, right; RCT, randomized controlled trial; RM, repetition maximum; SAT,
single-arm trial; VO2max, maximum oxygen uptake.
aStatistically significant from baseline.
bStatistically significant from control/comparison group.
cSame trial with different intervention duration and outcomes reported.

5
Table 3. Psychological Benefits of Sport Participation in Cancer Patients.
Author (Year) Study Design Qualitative Data Collection
Participants (Number, Cancer Type,
Gender, Mean Age/Age Range) Activity Conclusion/Changes
Mitchell etal65 (2002) ROS Open-ended interviews 6, BCa, female, 43-75 years Dragon boating Enhancement of well-being for BCa patients through
participating in dragon boating.
Unruh etal66 (2004) ROS Semistructured interviews 3, BCa, female, early 50s Dragon boating Dragon boating was associated with improved emotional
well-being and energy for BCa patients.
Culos-Reed etal67
(2005)
POS — 109, BCa, female, 52.9 years Dragon boating BCa patients participating in dragon boating experienced
comparable improvement in team cohesion and health-
related QoL with subclinical population and healthy
women, respectively.
Sabiston etal68 (2007) ROS Semistructured interviews 20, BCa, female, 58.7 years Dragon boating Dragon boating was psychologically beneficial for BCa
patients in facilitating social support and regaining
personal control.
Mitchell etal69 (2007) POS Semistructured and open-
ended interviews
10, BCa, female, 35-70 years Dragon boating BCa patients experienced improved wellness and
posttreatment QoL.
McDonough etal70
(2011)
POS Semistructured interviews 17, BCa, female, 51.2 years Dragon boating Participating in dragon boating is effective in developing
social relationships and support for BCa patients.
Carter etal71 (2012) NRCT — INT = 68, adult cancers, 53.8 years Dragon boating Team cohesion a
COMP = 52, adult cancers, 58.2 years Group-based walking QoL b
Ray etal72 (2013) Mixed-methods
sequential explanatory
study
Semistructured interviews Quantitative analysis = 100, BCa,
female
Qualitative analysis = 15, BCa, female
Dragon boating Emotional well-being b
Social well-being b
Spiritual well-being b
Health-related QoL b
Bruun etal74 (2014) POS Focus group interviews 26, PCa, male, 67.1 years Recreational soccer Recreational football may facilitate physical exercise
participation and adherence in PCa patients.
Participants observation
Robinson etal86 (2016)cSAT Focus group interviews
Individual phone interviews
11, BCa, female, 50.9 years Team triathlon training
with additional home-
based program
Team participation in a supportive environment was
crucial in exercise initiation and maintenance in BCa
patients.
Ng etal80 (2017)cSAT — 21, BCa, female, 48 years Team triathlon training
with additional home-
based program
QoL b
Barriers to physical activity b
Iacorossi etal77 (2018) ROS — Group A = 50, BCa, female Dragon boating QoL a,b
Group B = 50, BCa, female Compression therapy,
lymphatic drainage,
Pilates/yoga/tai-chi,
jogging/walking
Bjerre etal79 (2019) pRCT — INT = 109, PCa, male, 67.8 years Recreational soccer Mental health a
CON = 105, PCa, male, 69 years Physical activity advice
and rehabilitation
Abbreviations: , increase; , decrease; BCa, breast cancer; COMP, comparison group; CON, control group; INT, interventional group; NRCT, nonrandomized controlled trial; PCa, prostate cancer;
POS, prospective observational study; pRCT, pragmatic randomized controlled trial; QoL, quality of life; ROS, retrospective observational study; SAT, single-arm trial.
aStatistically significant from control/comparison group.
bStatistically significant from baseline.
cSame trial with different data collection and outcomes reported.

6 Integrative Cancer Therapies
twice-weekly team triathlon training and 3 to 7 hours per
week home-based exercise, significantly increased maxi-
mal oxygen uptake in BCa patients.80 In addition, in under-
taking an 8-week wall climbing program (including various
specific skills practice and climbing strategy drills) in gyne-
cologic cancer patients, significant improvement was
observed in aerobic capacity, muscular strength, agility,
dynamic balance, and flexibility.81
The improvements observed in cancer patients are pos-
sibly related to the physical and physiological demands of
the respective sport activity. Soccer is a lower limb–driven
intermittent locomotor activity with various vigorous, high-
impact movements,82 which predominantly results in adap-
tations in cardiorespiratory and lower body musculoskeletal
systems. Dragon boat racing, like most paddle sports (such
as canoeing and rowing), is a non–weight-bearing, upper
limb–driven endurance activity, which predominantly may
result in changes in the cardiovascular system and upper
body muscle endurance.83 Triathlon is a multisport endur-
ance event consisting of 3 continuous and sequentially per-
formed races including swimming, road cycling, and
distance running.84 Wall climbing, which is adapted from an
outdoor sport—rock climbing, primarily requires muscular
strength/power, aerobic endurance, flexibility, and balance
in climbers.85
Psychological and Social Benefits
In addition to physical and physiological endpoints, partici-
pation in sports are accompanied by psychological and
social benefits in cancer patients with the most frequently
reported positive findings being enhanced psychological
well-being and quality of life (QoL; Table 3). For instance,
various dimensions of psychological well-being (such as
emotional, social, and spiritual well-being) in adult BCa
patients were enhanced through participating in dragon boat
racing.65,66,72 In addition, health-related QoL was also
improved in BCa patients67,69,72,80 and other unspecified
adult cancer patients71 after a period of dragon boating or
triathlon training; and the improvement in BCa patients was
comparable with age-matched healthy women.67 A recent
retrospective study77 indicated that BCa patients who par-
ticipated in a short-term low-frequency dragon boat pro-
gram had better QoL compared with a group undertaking
commonly used therapies (such as compression therapy and
lymphatic drainage) and aerobic exercise including Pilates,
yoga, tai-chi, jogging, and walking. Regaining of social
support and personal control was also observed in middle-
aged BCa patients following long periods (19 months to 8
years) of engagement in dragon boat programs.68,70
Moreover, both observational67 and intervention-based71
studies indicate that adult cancer patients (mainly BCa)
within a team format developed strong cohesiveness after a
period of dragon boating, which was at a higher
level compared with those undertaking other group-based
activity (eg, walking)71 and comparable with those in female
sport teams,67 and was crucial to exercise initiation and
maintenance.86 Last, it has been reported that participation
in small-sided soccer games by men with PCa is accompa-
nied by improved mental health.79
Aside from the studies dedicated to a specific sport pro-
gram mentioned above, cross-sectional studies87,88 also
indicate that participation in a range of sports (such as golf,
swimming, hockey, tennis, etc) after a cancer diagnosis is
associated with improved psychosocial outcomes in
patients. The mechanisms underlying the improvements in
psychosocial functioning in cancer patients participating in
sports are possibly related to the social/interactive, support-
ive, and enjoyable/challenging environment featured in
sports and in particular team sports.34,89,90 In team-based
sports, participants are required to work closely toward a
common goal, which tends to generate greater bonding
among team peers compared with undertaking other exer-
cise modalities. In addition, there is also evidence that can-
cer patients consider peer support and shared experience
with co-participants as motivational factors in their sport
participation.86,91,92
Safety and Feasibility
In undertaking sport activities, the cancer patient’s safety
needs to be ensured. With regard to exercise in general, the
Exercise and Sports Science Australia (ESSA) position
stand93 and the American College of Sports Medicine
(ACSM) roundtable statement on exercise for cancer
patients22 concluded that exercise training is well tolerated
during and after cancer treatment and is safe in patients of
common cancers. In addition, numerous systematic reviews
and meta-analyses94-105 published within the past decade
further support this conclusion, adding that resistance-based
and aerobic-based exercises, irrespective of mode, inten-
sity, duration, frequency, and supervision, are safe in com-
mon adult and pediatric cancer patients at different stages or
having received different therapies, with either no adverse
events or only minor exercise-related injuries (such as mus-
cle soreness, sprains, and strains) and discomforts observed.
Similar findings were also reported in patients with
breast, gynecologic, and prostate cancers undertaking var-
ied sport programs, although the incidence and frequency of
adverse events or injuries were not always explicitly
reported by the investigators (Table 4). For example, in
nonmetastatic BCa patients following intensive treatments,
no adverse events and only one case of a non-training–
related injury were reported in a 4-year supervised dragon
boat program75 and a 14-week team triathlon training pro-
gram,80 respectively. Similarly, in an 8-week wall climbing
program in 24 gynecologic cancer survivors,81 only one
participant suffered a leg scratch during training. Even in

7
Table 4. Safety and Feasibility Outcomes of Sport Participation in Cancer Patients.
Author (Year)
Sport Participants (Number, Sex, Mean Age/Age Range,
Cancer Type, Mean Diagnosed Years, Ongoing/Received
Treatments)
Training Period, Frequency,
Session Duration Adverse Events (Incidence, Severity/Nature)
Feasibility Outcomes
(Recruitment, Retention,
Attendance Rate)
Carter etal71 (2012) Dragon boating = 68, male and female, 53.8 years,
mostly (~85%) stage I-IV adult cancers (BCa, PCa,
and other unspecified types), 4.4 years after diagnosis,
mostly (75%) after cancer treatments.
3 rounds, 8 weeks/round, 2/
week, 60 min/session
NR Higher average attendance
than the controls
undertaking group-based
walking (12.7 vs 10.8, P =
.002).
Uth etal73 (2014)aSoccer = 29, male, 67.1 years, advanced or locally
advanced PCa (including those with bone metastasis),
over 1 year after diagnosis, ADT >1 year.
12 weeks, 2-3/week, 45-60
min/session
Five participants (~17%) had musculoskeletal
injuries including fibular fracture (n = 2),
partial Achilles tendon rupture (n = 1), ankle
sprain (n = 1), quadriceps muscle strain (n
= 1), but most recovered after conservative
treatment and resumed training
Attendance rate = 76.5%;
~85% HRmax.
Stefani etal75 (2015) Dragon boating = 55, female, 57 years, nonmetastatic
BCa, 1 year after diagnosis and treatments (total
mastectomy, quadrantectomy, chemotherapy, and
radiotherapy).
48 months, 2/week, 120 min/
session
No adverse events NR
Uth etal76 (2016)aAs above (see Uth etal, 2014). 32 weeks, 2-3/week, 45-60
min/session
As above (see Uth etal, 2014). Attendance rate = 46.2%
Ng etal80 (2017) Triathlon = 21, female, 48 years, stage 0-III BCa, 4 years
post treatments (surgery, chemotherapy, radiotherapy,
and hormonal therapy).
14 weeks, 2/week, 90 min/
session
Unspecified non-training–related injury (n = 1) Retention rate = 84%
Crawford etal81 (2017) Wall climbing = 24, female, 52.5 years, localized or
metastatic GCa (cured or in remission), mostly (67%)
less than 2 years of diagnosis, intensive treatments
completed (including surgery, radiotherapy, and
chemotherapy).
8 weeks, 2/week, 120 min/
session
Leg scratch (n = 1, no medical care and training
discontinuation required)
Attendance rate = 84%
Uth etal78 (2018)aSoccer = 11 (only 9 reported their attendance and
injury incidence), male, 71.3 years, advanced or locally
advanced PCa, over 1 year after diagnosis, 45% of the
participants with ADT.
5 years of self-organized,
unsupervised soccer
training
Unspecified sport-related injury (n = 2) Average weekly attendance
= 1.7 times; mostly
>80% HRmax (based on
monitoring in 3 selected
sessions)
Bjerre etal79 (2019) Soccer = 109, male, 67.8 years, early-stage and
advanced PCa (including bone metastasis), 3 year after
diagnosis, intensive treatments completed (including
prostatectomy, chemotherapy, and radiotherapy) and
56% on ADT.
6 months, 2/week, 60 min/
session
Equivalent or even less adverse events observed
in the soccer training compared with in
the controls (in total, soccer vs controls =
23:30), including falls (soccer vs controls =
10:6), fracture (soccer vs controls = 1:1),
hospitalization (soccer vs controls = 11:22),
and cancer-specific death (soccer vs controls
= 1:1); soccer-related injuries (n = 60, minor
injuries such as muscle strain and sprains
accounting for 97% of the total injuries).
Recruitment rate = 90%;
retention rate = 98%
(12 weeks) and 95% (6
months); attendance rate
= 64% (12 weeks) and
59% (6 months)
Abbreviations: ADT, androgen deprivation therapy; BCa, breast cancer; GCa, gynecologic cancer; HRmax, maximum heart rate; NR, not reported; PCa, prostate cancer.
aSame trial with different intervention duration and outcomes reported.

8 Integrative Cancer Therapies
more advanced (≥T3n) PCa patients (including those with
bone metastases) undergoing androgen deprivation therapy,
the incidence of adverse events was not severe with only 5
of the 29 participants experiencing a musculoskeletal injury
in a 32-week supervised trial73,76 and 2 of 11 soccer partici-
pants suffering an injury in 5 years of unsupervised soccer
training.78 Moreover, in a recent large-scale RCT in men
with early-stage and advanced PCa79 participating in 6
months of twice-weekly supervised soccer, the injury rate in
the soccer players was equivalent to that in the control
group receiving exercise instruction by telephone and reha-
bilitative therapy, with the vast majority of injuries minor
including muscle strain or sprains. Although participating
in soccer games appears to be associated with a risk of
injury, men with PCa might instead perceive the risk a posi-
tive reinforcement of their masculinity.106
In addition to the safety profile, the feasibility outcomes
observed in various cancer patients undertaking sport-based
programs also appears promising (Table 4). For instance, in
the wall climbing program in women diagnosed with gyne-
cologic cancer, on average 13.5 out of 16 sessions were
attended.81 Similarly, in the 14-week, twice-weekly team
triathlon program for BCa patients, 21 out of 25 participants
completed the training program and assessments.80 Carter
et al reported that adult cancer patients undertaking dragon
boating on average attended more sessions than controls
performing group-based walking over an 8-week period.71
However, attendance may alter with program duration as
evidenced in the soccer program by Uth and colleagues,
with attendance of ~77% at 12 weeks73 but only 46% at 32
weeks.76 Last, in a 6-month soccer trial with early-stage and
advanced PCa patients,79 214 out of 238 eligible partici-
pants were recruited with a retention rate of 95% and atten-
dance of 59% at 6 months.
Therefore, the preliminary evidence suggests that partici-
pation in supervised, well-tailored sport programs by cancer
patients is feasible and is of low risk, and may only result in
mild sport injuries that are common for people engaging in
any form of physical exercise. Nevertheless, additional stud-
ies are necessary to develop this evidence base.
Opportunities and Recommendations for Sport
Programs in Cancer
Classification of sports based on the principle of specificity
is an essential prerequisite underpinning the effectiveness
of a sport program for cancer management, as sport activi-
ties with homogeneous physical and physiological profiles
will result in similar responses and adaptations for the par-
ticipants. Almost all sports require a combination of coordi-
nation, strength/power, speed, and aerobic and anaerobic
fitness. In accordance with the predominant characteristics
involved in a particular sport and the potential physiologi-
cal loads imposed by motor activity and movement
demands,107-109 sport disciplines can be divided into 4 cate-
gories, that is, skill-dominant/precision sports, strength/
power-dominant sports, endurance-dominant sports, and
mixed sports. However, it should be noted that there are
multiple ways to categorize sports.110 Although sport activi-
ties within a category share a similar profile, variability in
the demands of different energy systems and movement
components may still exist across the different sports within
a category due to intrinsic patient-centered characteristics,
such as skill level and motivation, and extrinsic factors such
as skills/competitiveness of the opponent/competitors or
fellow team members and environmental factors.
 Skill-dominant/precision sports. We define skill-
dominant/precision sports as activities requiring a
higher level of bodily coordination and skills to
achieve a precise execution of movement (eg, golf,
table tennis, gymnastics, diving, and archery). In
general, skill-dominant sports include only a short
bout of action that predominantly requires cognitive
function, body control, quick reaction, and physical
strength with only modest stress to the cardiorespira-
tory system.
 Strength/power-dominant sports are activities requir-
ing a higher level of physical strength and power out-
put (eg, weightlifting, speed skating, shotput,
sprinting, and triple jump). In general, strength/
power-dominant sports include rapid forceful motion
against body weight and/or an external resistance,
which predominantly requires a higher rate of force
development.
 Endurance-dominant sports are activities requiring
both cardiorespiratory and muscle endurance (eg,
canoeing, road cycling, swimming, rowing, and ori-
enteering). In general, endurance-dominant sports
basically involve cyclic motion that requires sus-
tained, repeated contraction of large muscle groups
and maximum involvement of the cardiorespiratory
system with comparatively lower demands on mus-
cle strength and power.
 Mixed sports. We define mixed sports as activities
requiring involvement of a wide range of systems
with nearly equal demands in technical skills,
strength/power, speed, aerobic, and anaerobic fitness
(eg, soccer, basketball, ice/field hockey, rugby, and
boxing). In general, mixed sports include an assort-
ment of repetitive dynamic movement components
such as jogging, sprinting, acceleration, deceleration,
stopping and cutting, jumping, and so on.
Evidence indicates that people participating in different
types of sport demonstrate different physical and physio-
logical adaptations. For example, a cross-sectional study111
in frail older women indicated that participating in table

Luo et al 9
tennis resulted in better cognitive function than nonpartici-
pants. In addition, older golfers showed better balance con-
trol than age-match nongolfers.112 Male and female athletes
in higher resistance and impact-loading sports consisting
mainly of strength/power-dominant (such as judo and
karate) and mixed sports (such as soccer) show greater mus-
cle mass and bone density compared with non–weight-bear-
ing or low-impact sports (such as swimming and water
polo) with more increases observed in athletes of longer
participation and at sites of more intensive stress.113-116 In a
similar fashion, sport activities with higher aerobic compo-
nents (such as swimming) elicit more improvement in car-
diopulmonary function.117
Accordingly, along with the aforementioned positive
changes in cancer patients undertaking various sport-based
programs,71,73,75-78,80,81 we propose that sport activities with
similar profiles and comparable exercise load stimulus
would also result in similar beneficial effects in cancer
patients. Specifically, cancer patients participating in endur-
ance-dominant sports would predominantly improve car-
diovascular fitness, and cancer patients participating in
strength/power-dominant sports would predominantly gain
lean mass, muscular strength, endurance, and bone density.
For mixed sports, positive adaptations in circulatory and
respiratory systems as well as in body composition and
functional ability would be elicited. In addition, cancer
patients with treatment-related cognitive deficit would ben-
efit from undertaking skill-dominant/precision sports.
However, as variability of demands in the body systems
exist across sports within a category, substantial secondary
adaptions would also be possible in cancer patients through
regular participation.
Given the paucity of evidence with regard to sport par-
ticipation for cancer management as well as the diversified
characteristics across sports, specific recommendations on
dosage for a particular sport in cancer patients still remains
impractical. However, the general guidelines for physical
exercises proposed by ACSM22 and ESSA93 could be con-
sidered as a basis for dosage prescription (ie, weekly 60-150
minutes of exercise at a moderate to vigorous intensity).
Additional Considerations
Several other factors should be taken into account when
planning and implementing a sport program for cancer
patients. First, a sport program should always be practical
for cancer patients. To this end, it is vital to simplify techni-
cal skills, reduce exercise load, and avoid high-risk activity
components (such as body contact) of a sport activity
according to participant’s physical capacity at different
phases of treatment.118 For example, in mixed sport events
(such as soccer and basketball), playing rules, field-of-play,
number of players per side, and game duration can be
adjusted to manage the training load and avoid risk factors.
Second, a selected sport activity should appeal to potential
participants. In this regard, the participant’s personal prefer-
ence and previous experience in sport participation should
be taken into consideration when prescribing sport pro-
grams.118-121 Third, a separate familiarization period before
regular sport participation may be required for participants
to learn and acquire the necessary skills related to the sub-
sequent sport program, which should also be regarded as an
indispensable part of a sport program to further ensure
safety and maintain the participant’s playing interest and
enjoyment as well as facilitate exercise continuance. Finally,
in order to increase the participation rate of cancer patients
in a sport program, the prevalence of different sport events
within a region and availability of facilities should be con-
sidered.122 For example, rugby is one of the most played and
widely watched sports in Australia among men and women
across all age groups, while basketball is one of the most
popular sports in the United States. However, apart from
referring to sport popularity and facility availability, provi-
sion of a list of sport program options for cancer patients
may assist in contributing to a higher sport uptake and
adherence rate.123
Despite all these considerations, a cautious attitude
should still be taken when implementing sport programs in
cancer patients. Overall, for health and fitness, it is highly
recommended for practitioners who are interested in con-
ducting sport medicine programs in cancer patients to fol-
low the general contraindications and reasons for starting
and stopping exercise proposed in the ACSM roundtable
statement.22 In addition, special attention needs to be
attached to patients undergoing active treatments and when
implementing sport programs outdoors.
Perspectives and Future Directions
Although the benefits of physical exercise for cancer man-
agement has been well established, insufficient engagement
and low adherence rate in cancer patients often compromise
the beneficial effects of regular exercise training. Evidence
to date indicates that in cancer patients the lack of ability
and motivation, as well as the tedious and repetitive nature
of exercise, are among the frequently reported barriers to
regular exercise participation.124-128 Conversely, a support-
ive environment during exercise is a facilitator to regular
engagement in physical exercise.124,128,129 Sport participa-
tion is recognized as an enjoyable experience and intrinsi-
cally involves many motivational aspects such as personal
challenge, competitive climate, and goal orientation, and
may facilitate exercise participation and adherence in can-
cer patients.
Sport participation is associated with lower risk of can-
cer and cancer-related death. Based on preliminary evi-
dence, participating in sport activities is feasible and can be
well tolerated by cancer patients. In addition, sport

10 Integrative Cancer Therapies
participation can play a vital role in countering a range of
physical and psychological adverse effects related to the
cancer and its treatments. Therefore, sport participation
could be considered as an alternative strategy to frequently
used fitness exercises in the prevention and management of
cancer. We believe that sport participation as adjunct ther-
apy for cancer management would especially appeal to
those with previous and current experiences in sport includ-
ing sports fans as well as retired professional/recreational
athletes. In general, cancer patients are encouraged to par-
ticipate in different types of sports according to their per-
sonal circumstance and preference.
Although there is a developing body of evidence that
sport participation can enhance physical and psychosocial
functioning in cancer patients, it needs to be recognized that
the evidence base contains few RCTs with only a few sports
investigated and is dominated by pilot studies with only
small sample sizes. Therefore, at this stage, the efficacy of
sport participation in cancer management should be inter-
preted with caution, and further work in this field is required
to develop the evidence base. Robust RCTs are required to
investigate the effectiveness of different sport activities in
cancer patients at different stages of the cancer continuum
and while receiving different treatments. In addition, sport-
specific guidelines and practical strategies in planning sport
programs are warranted. At present, only a handful of sports
have been examined in cancer management with the major-
ity being team-based. Therefore, comparative studies on the
beneficial effects between individual, partner-based, and
team-based sports are also required.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
ORCID iDs
Hao Luo https://orcid.org/0000-0001-5181-7529
Robert U. Newton https://orcid.org/0000-0003-0302-6129
Ciaran M. Fairman https://orcid.org/0000-0001-8834-9669
Dennis R. Taaffe https://orcid.org/0000-0001-6381-1597
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