BREAST CANCER

Weight Management and Physical Activity for

Breast Cancer Prevention and Control
Jennifer A. Ligibel, MD1; Karen Basen-Engquist, PhD, MPH2; and Jennifer W. Bea, PhD3
overview

Observational evidence has consistently linked excess adiposity and inactivity to increased breast cancer risk
and to poor outcomes in individuals diagnosed with early-stage, potentially curable breast cancer. There is less
information from clinical trials testing the effect of weight management or physical activity interventions on
breast cancer risk or outcomes, but a number of ongoing trials will test the impact of weight loss and other
lifestyle changes after cancer diagnosis on the risk of breast cancer recurrence. Lifestyle changes have
additional benefits beyond their potential to decrease primary or secondary breast cancer risk, including
improvements in metabolic parameters, reduction in the risk of comorbidities such as diabetes and heart
disease, improvement of physical functioning, and mitigation of side effects of cancer therapy. Despite these
myriad benefits, implementation of lifestyle interventions in at-risk and survivor populations has been limited
to date. This article reviews the evidence linking lifestyle factors to breast cancer risk and outcomes, discusses
completed and ongoing randomized trials testing the impact of lifestyle change in primary and secondary
breast cancer prevention, and reviews efforts to implement and disseminate lifestyle interventions in at-risk
and breast cancer survivor populations.

INTRODUCTION disseminate lifestyle interventions in at-risk and breast

Growing evidence suggests a role for weight man-
agement and increased physical activity in breast cancer
prevention and control. Numerous observational studies
demonstrate that postmenopausal women with obesity
are at increased risk of developing breast cancer,1 and
obesity is linked to increased risk of breast cancer re-
currence and mortality in both pre- and postmenopausal
women.2 Similarly, observational evidence suggests that
inactivity, independent of its contribution to excess adi-
posity, is a risk factor for breast cancer incidence3-5 and
mortality.6 Despite the strong and consistent evidence
linking obesity and inactivity to breast cancer risk and
outcomes, less is known about the impact of weight loss
or physical activity interventions in lowering breast cancer
risk or in improving outcomes in individuals diagnosed
with early-stage, potentially curable breast cancer. Ad-
ditionally, despite the evidence linking a healthy lifestyle
Author affiliations to lower breast cancer risk and better breast cancer
and support outcomes, obesity and inactivity are prevalent, both in
information (if women at risk for developing breast cancer and in breast
applicable) appear
at the end of this
cancer survivors.7,8 Strategies are needed to disseminate
article. weight management and physical activity programs to
Accepted on May 17, these populations to optimize breast cancer outcomes.
2019 and published This article reviews the evidence linking lifestyle factors to
at ascopubs.org on breast cancer risk and outcomes, discusses completed
May 17, 2019:
DOI https://doi.org/
and ongoing randomized trials testing the impact of
10.1200/EDBK_ lifestyle change in primary and secondary breast can-
237423 cer prevention, and reviews efforts to implement and
cancer survivor populations.
IMPACT OF OBESITY AND LIFESTYLE ON BREAST
CANCER RISK AND PREVENTION
There is a large body of evidence demonstrating that
overweight and obesity, characterized by body mass
index (BMI), are associated with an increased risk of
postmenopausal breast cancer. In contrast, obesity
has not been associated with increased risk of pre-
menopausal breast cancer.1,4,9,10 In fact, higher BMI
has been associated with a reduced risk of pre-
menopausal breast cancer. Given that breast cancer is
most frequently diagnosed among postmenopausal
women,11 this section will largely focus on primary
prevention of postmenopausal breast cancer. How-
ever, lifestyle strategies that impact adiposity and have
independent effects are also applicable to pre-
menopausal women because healthy body weight,
diet, and physical activity are protective against the
majority of noncommunicable diseases, such as di-
abetes and cardiovascular disease.
Obesity and Breast Cancer Risk
Greater than 70% of Americans are overweight or
obese.12 BMI categories are normal weight (, 25 kg/m2),
overweight (≥ 25 to , 30 kg/m2), and obese (≥ 30
kg/m2). Obesity is associated with breast cancer risk
reduction among premenopausal women,1,4 but over-
weight or obesity is associated with 1.5 to 2 times

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Copyright © 2021 American Society of Clinical Oncology. All rights reserved.
 Weight, Physical Activity, and Breast Cancer Prevention and Control
PRACTICAL APPLICATIONS
• Weight management across the lifespan is
important to reduce the risk of breast cancer
and other chronic conditions that can increase
breast cancer risk and poor outcomes.
• Physical activity is associated with risk of breast
cancer, independent of body mass index, but is
also partially attributed to its favorable effects on
body weight and composition.
• Observational evidence suggests that obesity
and inactivity are linked to an increased risk of
breast cancer recurrence and mortality; ongo-
ing trials will evaluate whether lifestyle change
after breast cancer diagnosis will improve
outcomes.
• Physical activity after breast cancer diagnosis
has been shown to reduce fatigue and other
side effects related to cancer treatment and to
improve quality of life and fitness in survivors of
breast cancer.
• Free resources to encourage a physically active
lifestyle for the prevention of breast cancer and
other chronic conditions may be found online
(https://health.gov/paguidelines/moveyourway/
toolkit/); the updated guide for physical activity
among cancer survivors will be released by the
American College of Sports Medicine in 2019.
increased risk of postmenopausal breast cancer, re-
spectively.1 Estrogen receptor–positive (ER+) and progesterone
receptor–positive (PR+) breast cancers, specifically, as
well as risks of advanced disease and death have been
elevated among postmenopausal women with excess
adiposity.13
Weight change and breast cancer risk Early adult,14-17
midlife, and menopausal weight gain16-19 have all been
associated with increased risk of postmenopausal breast
cancer in longitudinal and case-control analyses, with
minimal disagreement.20 It has been estimated that every
5 kg of weight gain above the lowest adult weight is asso-
ciated with a 4% to 8% increase in postmenopausal breast
cancer risk.21,22 However, this risk appears to be limited to or
stronger among individuals who do not use hormone
therapy (HT).14,15,23-27 Higher risks associated with weight
gain among patients who do not use HT may be particularly
relevant for advanced disease.16 In addition, weight gain has
been more strongly associated with ER+ and PR+ than for
ER− and PR− tumors,28 which may be related to greater
central adiposity among patients who do not use HT.22
Conversely, weight loss has been associated with a reduced
risk of breast cancer in longitudinal studies and case-control
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Copyright © 2021 American Society of Clinical Oncology. All rights reserved.
studies,14,15,17,21,29 although the results of one study limited
to overweight and obese women were nonsignificant.30
However, the timing of weight loss in the life cycle may
be important. For example, weight loss among women
whose highest weight occurred after age 45 was not as-
sociated with breast cancer risk (odds ratio [OR], 1.00;
95% CI, 0.95–1.05) but was associated with a reduced risk
of postmenopausal breast cancer if the highest weight
was before age 45 (OR, 0.90; CI, 0.84–0.98, per 5 kg).21
Weight fluctuations, also termed weight cycling, occur
among overweight and obese women when maintenance of
intentional weight loss cannot be achieved. Although one
small case-control study demonstrated an increased risk of
postmenopausal breast cancer with weight fluctuations,31
the majority of large national longitudinal cohort studies and
case-control studies have not.21,32-34 Based on these ob-
servational data, it appears that weight cycling is not as-
sociated with an increased risk of breast cancer.
Importantly, there may be racial/ethnic differences in the
associations between weight changes and breast cancer
risk. There is some suggestion that increased risk of breast
cancer among Hispanic women with weight gain in early life
may be independent of menopausal status,23 which differs
from non-Hispanic women. Among Asian women, high BMI
combined with recent weight gain (≥ 4.5 kg, approximately)
in midlife poses the greatest risk,19,35 whereas recent weight
loss may be associated with reduced breast cancer risk.19
Further prospective studies are needed to confirm these
racial/ethnic differences.
Body composition considerations BMI is a proxy for body fat
across populations and is not a sensitive measure for adi-
posity or lean mass within individuals. Specific tissue vol-
umes and patterns of deposition are not reflected in BMI,
which relies on total mass and height. Deleterious changes
in body composition compartments (increased fat and
decreased lean mass) and deposition patterns (preferential
abdominal fat deposition) with aging can be masked by
stable BMI. The insufficient precision of BMI for adipose
estimation with aging likely plays a role in the differential pre-
versus postmenopausal relation between breast cancer and
obesity. Furthermore, because metabolic dysfunction, in-
flammation, and production of postmenopausal estrogen
are associated with increased adiposity, particularly visceral
adipose tissue, it is important to consider more direct
measures of body composition such as dual-energy x-ray
absorptiometry.
Chronic low-grade inflammation and metabolic dysfunction
are believed to be intermediate biomarkers linking obesity to
postmenopausal breast cancer. Indeed, metabolic syn-
drome36 and type 2 diabetes accompanied by obesity have
been established as notable risk factors for postmeno-
pausal breast cancer.37,38 However, type 2 diabetes alone is
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 Ligibel, Basen-Engquist, and Bea
associated with increased risk of breast cancer, in-
dependent of BMI.39
Although it is difficult to study weight- or fat-specific loss as
a primary prevention intervention for the reduction of breast
cancer risk because of the length of follow-up required,
reductions in body weight among overweight and obese
individuals have been shown to reduce chronic low-grade
inflammation and to partially or completely resolve meta-
bolic disturbances, which supports reduced risk of other
chronic conditions and potentially breast cancer risks.
Therefore, both adiposity and metabolic dysfunction, which
can be favorably altered by diet and activity with and without
weight change, are relevant targets for breast cancer risk
reduction.36
Obesity and mammographic screening Mammographic
screening is recommended by most leading organizations
for women with average risk, with some variability in age to
initiate/terminate screening.40,41 Importantly, it has been
suggested that obesity may interfere with screening uptake
and effectiveness.42-44 Discomfort discussing weight issues,
appointment cancelations, technical limits regarding body
size and breast tissue mobility, and gown and imaging
window fit have been cited as potential barriers to screening
effectiveness.42 Additionally, high mammographic density is
positively associated with breast cancer. Although BMI is
inversely associated with breast density, adult weight gain
has been associated with the proportion of dense tissue in
the breast.45 Keeping these issues in mind when discussing
weight management and screening recommendations with
patients is prudent.
Physical activity and breast cancer risk Physical activity is
an important component of weight management. Higher
levels of physical activity have also been associated with
a reduced risk of breast cancer.3-5 Achieving the World
Health Organization’s recommendations for leisure time
physical activity (≥ 10 MET-hours/week) is associated with
a significantly lower risk of breast cancer.46 It has been
debated whether the reduction of the risk of breast cancer
with physical activity is attributable, in part, to its positive
effects on weight and body composition.47-49 Some have
shown that the relationship between physical activity
and breast cancer is independent of BMI, ER status, weight
gain, and HT.5,47,49,50 There is also the suggestion that
vigorous activity may be required for risk reduction,50
whereas some have shown risk reductions with walking49
and household activities for both pre- and postmenopausal
breast cancer.51 Most impressively, physical activity is as-
sociated with decreased breast cancer risk independent of
smoking status5 and is associated with a significantly
delayed onset of breast cancer among BRCA carriers.52
Although the exact dose and type of activity required to
reduce breast cancer risk is yet to be determined, it is clear
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Copyright © 2021 American Society of Clinical Oncology. All rights reserved.
that physical activity is associated with a reduced risk of
breast cancer.
Proposed mechanisms of action for physical activity reductions
in breast cancer risk include favorable reductions in estrogen
availability, inflammation, and metabolic dysfunction, in ad-
dition to improved body composition.53 More research is
needed to fully understand the mechanisms by which physical
activity could reduce breast cancer risk. However, imple-
menting a physically active lifestyle has little downside, with
much to gain. Most U.S. adults do not meet the recommended
levels of physical activity.54 Therefore, increasing physical
activity should be considered an important strategy for breast
cancer risk reduction, regardless of weight status and other
lifestyle factors (Table 1). Recently updated Physical Activity
Guidelines for Americans are available (https://health.gov/
paguidelines/second-edition/).55,56
Cancer prevention guidelines and impact on breast cancer
risk Weight management and physical activity are recom-
mended for cancer prevention by leading U.S. and in-
ternational organizations, alongside other preventive
behaviors3,4 to address the multifaceted nature of pre-
vention (Table 2). Women meeting at least five of the World
Cancer Research Fund/American Institute for Cancer Re-
search recommendations had a 60% lower risk of breast
cancer (hazard ratio [HR], 0.40; 95% CI, 0.25–0.65), with
further reduction in breast cancer risk with each additional
recommendation met (HR, 0.89; 95% CI, 0.84–0.95).57 A
recent systematic review demonstrated alignment with
these findings, and adherence to cancer prevention
guidelines was associated with a 13% to 60% reduction in
breast cancer risk.58
WEIGHT, PHYSICAL ACTIVITY, AND DIET IN BREAST
CANCER SURVIVORSHIP
In addition to data linking obesity, inactivity, and, to some
extent, dietary quality to breast cancer risk, observational
studies also suggest that these factors may also impact
outcomes in women diagnosed with early-stage breast
cancer. The relationship between body weight at the time
of breast cancer diagnosis and the risk of breast cancer
recurrence and mortality has been evaluated in more than
100 reports over the last 40 years.2,59,60 A 2014 meta-
analysis including 82 studies and encompassing 213,075
women with early-stage breast cancer reported a 35%
increase in breast cancer–related mortality and a 41%
increase in overall mortality in women who were obese at
the time of breast cancer diagnosis compared with women
who were of normal weight. Interestingly, the relationship
between obesity and increased risk of mortality did not
vary by menopausal status, with obese premenopausal
women having a 75% increased risk of mortality after
breast cancer diagnosis compared with normal-weight
premenopausal women (relative risk [RR], 1.75; 95%
 Weight, Physical Activity, and Breast Cancer Prevention and Control

TABLE 1. Weight Status, Diet, and Physical Activity Influence on Breast Cancer Risk
Menopausal Status

Premenopausal Postmenopausal

Item Risk Level of Evidence Risk Level of Evidence

Vigorous physical activity Decreased Strong Decreased Strong
Total physical activity Decreased Limited Decreased Strong
Overweight/obese (young adulthood, age Decreased Strong Decreased Strong
18–30)
Overweight/obese: before menopause (pre); Decreased Strong Increased Strong
across adulthood (post)
Weight gain in adulthood — — Increased Strong
Alcohol consumption Increased Strong Increased Strong
Nonstarchy vegetable consumptiona,b Decreased Limited Decreased Limited
a
Carotenoid-containing foods Decreased Limited Decreased Limited
Dairy consumption Decreased Limited — —
Calcium-rich diet Decreased Limited Decreased Limited
a
The evidence presented did not specify pre- or postmenopausal breast cancer.
b
Estrogen receptor–negative breast cancer only (adapted from the World Cancer Research Fund/American Institute for Cancer Research4; lactation not
presented).

CI, 1.26–2.41) and obese postmenopausal women having
a 34% increased risk of mortality after cancer diagnosis
compared with obese postmenopausal women (RR, 1.34;
95% CI, 1.18–1.53).2
In addition to the relationship between obesity and in-
creased risk of breast cancer and overall mortality, obesity
has also been shown to be associated with an increased risk
of second primary malignancies in breast cancer survivors.
A review and meta-analysis by the World Cancer Research
Fund of eight studies evaluating the relationship between
BMI and risk of contralateral breast cancer in breast cancer
survivors found that for each 5-kg/m2 increase in BMI, there
was a 13% increase in the risk of contralateral breast cancer
(summary RR, 1.13; 95% CI, 1.06–1.21).61 When com-
paring the highest to lower BMI categories, the summary
RR for contralateral breast cancer was 1.30 (95% CI,
1.14–1.48). Similarly, in four studies that evaluated the
relationship between BMI and risk of endometrial cancer
among breast cancer survivors, survivors with the highest BMI
versus the lowest had a 94% increase in the risk of en-
dometrial cancer (summary RR, 1.94; 95% CI, 1.45–2.59).
Although the literature is more limited, observational studies
have also evaluated the relationship between physical ac-
tivity patterns after breast cancer diagnosis and cancer
recurrence and mortality. A recent meta-analysis of 16
cohort studies, encompassing 42,602 patients, demon-
strated that breast cancer survivors who engaged in the
highest levels of physical activity after cancer diagnosis had
a 29% lower risk of breast cancer–specific mortality (RR,
0.71; 95% CI, 0.58–0.87, p , .01) and a 43% lower risk of
all-cause mortality (RR, 0.57; 95% CI, 0.45–0.72, p , .01)
compared with inactive breast cancer survivors.6
Finally, numerous efforts have been made to evaluate the
relationship between breast cancer outcomes and dietary
patterns and intake of specific nutrients and foods. A thorough
review of this work is beyond the scope of this article, but was
summarized in a recent review by the World Cancer Research
Fund.61 Although individual studies have shown associations
between various dietary elements and mortality in breast
cancer survivors, data have largely been inconsistent.
Impact of Lifestyle Change After Diagnosis on Breast
Cancer Recurrence and Mortality
Despite the consistent evidence linking lifestyle factors to
breast cancer prognosis, there are relatively few studies that
have evaluated the effect of lifestyle change—weight loss,
increased physical activity, or dietary change—after breast
cancer diagnosis on the risk of cancer recurrence or
mortality. Two trials, both initiated almost 3 decades ago,
evaluated the impact of dietary change on breast cancer
recurrence and mortality. Both studies focused on reduction
in dietary fat. The Women’s Intervention Nutrition Study
randomly assigned 2,437 women with stage I to III breast
cancer whose diets included at least 20% of daily calories
from fat to a low-fat dietary intervention, with a target goal of
reducing fat to ≤ 15% of daily calories, or to a usual-care
control group.62 Intervention participants decreased dietary
fat intake and body weight compared with controls. After
a median follow-up of 5.6 years and 227 relapse events,
disease-free survival was significantly better in intervention

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 Ligibel, Basen-Engquist, and Bea
TABLE 2. Lifestyle-Based Cancer Prevention Guidelines for Individuals by Organization
World Cancer Research Fund/American Institute for Cancer Research
(2018)
Be a healthy weight.
Be physically active.
Eat a diet rich in whole grains.
Limit consumption of fast foods.
Limit consumption of red and processed meat.
Limit consumption of sugar-sweetened drinks.
Limit alcohol consumption.
Do not use supplements for cancer prevention.
For mothers: breastfeed your baby, if you can.
After a cancer diagnosis, follow these recommendations, if you can:
• Avoid smoking and other exposure to tobacco.
• Avoid excess sun.
participants compared with controls (HR, 0.76; 95% CI,
0.60–0.98). With further follow-up, these findings lost sta-
tistical significance, but an exploratory subgroup analysis
demonstrated a significant survival benefit of the in-
tervention for patients with ER− breast cancer (HR, 0.41;
p = .003).63 The Women’s Healthy Eating and Living study
had a similar design, randomly assigning 3,088 women with
stage I to III breast cancer to a usual-care control group or to
a dietary intervention focused on increasing intake of fruits,
vegetables, and fiber and lowering fat intake.64 Patients
were eligible regardless of baseline diet. Intervention par-
ticipants significantly increased intake of fruits and vege-
tables and decreased the percentage of dietary calories
from fat, but they did not experience weight loss. After
a median follow-up of 7.3 years and 518 relapse events,
there was no difference in recurrence rates in the diet and
control groups (16.7% vs. 16.9%; p = .63).
More recent randomized trials are evaluating the impact of
interventions including both physical activity and dietary
components on breast cancer recurrence and survival. The
SUCCESS-C trial was a phase III randomized trial with a two-
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American Cancer Society (2012)
Achieve and maintain a healthy weight throughout life.
Be as lean as possible throughout life without being underweight.
Avoid excess weight gain at all ages. For those who are currently overweight
or obese, losing even a small amount of weight has health benefits and is
a good place to start.
Engage in regular physical activity and limit consumption of high-calorie
foods and beverages as key strategies for maintaining a healthy weight.
Adopt a physically active lifestyle.
Adults should engage in at least 150 minutes of moderate intensity or
75 minutes of vigorous intensity activity each week, or an equivalent
combination, preferably spread throughout the week.
Children and adolescents should engage in at least 1 hour of moderate or
vigorous intensity activity each day, with vigorous intensity activity
occurring at least 3 days each week.
Limit sedentary behavior such as sitting, lying down, watching television, or
other forms of screen-based entertainment.
Doing some physical activity above usual activities, no matter what one’s
level of activity, can have many health benefits.
Consume a healthy diet, with an emphasis on plant foods.
Choose foods and beverages in amounts that help achieve and maintain
a healthy weight.
Limit consumption of processed meat and red meat.
Eat at least 2.5 cups of vegetables and fruits each day.
Choose whole grains instead of refined grain products.
If you drink alcoholic beverages, limit consumption.
Drink no more than one drink per day for women or two per day for men.
by-two factorial design, first randomly assigning women with
stage II to III breast cancer to one of two chemotherapy
regimens and subsequently randomly assigning women
with a BMI between 24 and 40 kg/m2 to a telephone-based
weight loss intervention or usual-care control group.65
Preliminary trial results were presented at the San Anto-
nio Breast Cancer Symposium in December 2018.66 A total
of 2,292 participants in the SUCCESS-C trial met the BMI
requirements and were randomly assigned to the weight
loss intervention group versus the control group. The weight
loss intervention was composed of a calorie-restricted, low-
fat diet combined with increased physical activity and was
delivered through 19 phone calls over the duration of the
2-year intervention period. Baseline BMI of study participants
was approximately 28 kg/m2. Over the 2-year intervention
period, patients randomly assigned to the weight loss in-
tervention lost an average of 1 kg versus a 0.95-kg weight
gain in controls (p , .001). More than 50% of the patients in
the weight loss intervention group dropped out of the
program, compared with 20% of controls. There were no
differences in disease-free or overall survival in the weight
 Weight, Physical Activity, and Breast Cancer Prevention and Control
loss intervention versus control groups in intention-to-treat
analyses. Exploratory unplanned analyses suggest that
participants who completed the 2-year intervention period
had better disease-free and overall survival than patients
who dropped out (p , .001). Among individuals who
completed the study, there was a lower rate of cancer re-
currence and mortality in individuals assigned to the weight
loss arm; however, the differential drop-out rates and dif-
ferences in participants who completed the weight-loss
intervention versus those who dropped out make in-
terpretation of these findings difficult.
Two additional ongoing trials will test the effect of diet and
exercise interventions on breast cancer recurrence and
mortality. The DIANA-5 study is a randomized trial testing
the impact of a Mediterranean lifestyle intervention on
breast cancer recurrence among 1,214 Italian women with
stage I to III breast cancer.67 Participants were randomly
assigned to a lifestyle intervention focused on exercise and
consumption of a Mediterranean, macrobiotic diet or to
a usual-care comparison group. Patient recruitment was
completed in 2010 and follow-up is ongoing. The Breast
Cancer Weight Loss (BWEL) study is a National Cancer
Institute–funded phase III randomized trial evaluating the
effect of a weight loss program on cancer recurrence among
3,136 overweight and obese women with stage II to III breast
cancer in the United States and Canada.68 Study partici-
pants are randomly assigned to a 2-year telephone-based
weight loss program or to a control group. All participants
receive a health education program consisting of evidence-
based materials supporting a healthy lifestyle. The study
opened to enrollment in August 2016 and is currently ac-
cruing participants from more than 1,100 oncology prac-
tices across North America. As of March 1, 2019, 1,900
women had been enrolled. Study results are anticipated in
approximately 2024.
FIGURE 1. American Cancer Society Guidelines on Nutrition and Physical
Activity for Cancer Survivors
Adapted from Rock et al.77
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Other benefits of lifestyle interventions in breast cancer
survivors Although relatively few large-scale randomized
trials have tested the effect of lifestyle interventions on breast
cancer recurrence and survival, many smaller interventional
trials have evaluated the impact of exercise and weight
loss interventions on a diverse array of outcomes for breast
cancer survivors. Meta-analyses have demonstrated
consistent evidence that exercise interventions lead to
improvements in cardiorespiratory fitness69 and physical
functioning,70 as well as reductions in fatigue.71 More
limited evidence also suggests that exercise interventions
can reduce anxiety72 and depression73 and lead to im-
provements in quality of life.70 Studies have also shown
that structured exercise interventions can reduce the risk
of lymphedema after axillary surgery and can also reduce
the frequency of exacerbations in women who have al-
ready developed lymphedema.74 Trials have also dem-
onstrated that exercise and weight loss interventions can
lead to reductions in fasting insulin and improvements in
other metabolic and inflammatory biomarkers,75,76 pro-
viding insight into the biologic mechanisms through which
these factors could impact breast cancer risk and out-
comes as well as reduce comorbidities and improve
overall health.
IMPLEMENTING PHYSICAL ACTIVITY AND WEIGHT
MANAGEMENT INTERVENTIONS IN SURVIVORSHIP CARE
Based on the evidence presented above, the American
Cancer Society has developed guidelines for nutrition and
physical activity for cancer survivors (Fig. 1).77 The National
Comprehensive Cancer Network also includes nutrition,
weight management, and physical activity as part of its
survivorship recommendations.78 However, incorporating
these components into survivorship care presents chal-
lenges, and information on research and best practices is
not readily available. Providers report multiple barriers to
addressing these issues in survivorship care, including lack
of knowledge and training in this area, uncertainty about
when in the cancer continuum to introduce it, lack of
support from hospital administration, and issues of time and
patient flow.79,80 Supporting cancer survivors in physical
activity and weight management behavior can take a number
of different forms with varying intensity.
Education
At a minimum, oncology practices should provide evidence-
based information to breast cancer survivors about physical
activity, nutrition, and weight management. Many survivors
will have questions about whether it is appropriate for them
to be physically active. Additionally, survivors often are
concerned that they will lose weight after diagnosis, but
weight gain is common among breast cancer survivors,
and survivors should be taking steps to avoid weight gain. A
lack of education, or worse, misinformation obtained from
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 Ligibel, Basen-Engquist, and Bea
unqualified sources on the internet or within the community
may confuse survivors about the optimal course to take with
regard to physical activity and weight management. Survi-
vorship care providers can serve as a credible and trusted
information source. Provision of educational materials that
are clear and readable, attractive, and available in appro-
priate language by an oncology practice can ensure that
survivors have the basic information about health behavior
recommendations. Practices that have patient education
resources can work with these resources to develop patient
materials, whether they be print materials or digital. For
practices that do not have an in-house patient education
department, resources such as the American Society of
Clinical Oncology booklet Managing Your Weight After
a Cancer Diagnosis: A Guide for Patients and Families
(www.cancer.net/sites/cancer.net/files/weight_after_cancer_
diagnosis.pdf), the American Cancer Society website (www.
cancer.org/treatment/survivorship-during-and-after-treatment/
staying-active.html), or the National Comprehensive Cancer
Network website (www.nccn.org/patients/resources/life_after_
cancer/nutrition.aspx and www.nccn.org/patients/resources/
life_after_cancer/exercise.aspx) may be helpful.
Assessment and counseling Patients with cancer and
survivors express a strong preference to receive in-
formation about physical activity, diet, and weight man-
agement from their oncology providers,81 and studies
indicate that such discussions can be influential82,83 and
are associated with increased physical activity among
cancer survivors.84,85 Providers may not have time to
provide extensive counseling about physical activity, nu-
trition, and weight management but can help by raising the
topic. Doing so establishes the importance of these be-
haviors after cancer diagnosis, and providers can reassure
patients who might be uncertain about the safety or ap-
propriateness of exercise or weight loss after treatment.
Furthermore, providers can identify any precautions that
are necessary or additional testing that might be warranted
for the patients. One model for encouraging provider
counseling borrowed from the smoking cessation field is
the “5As” model (Ask, Advise, Assess, Assist, Arrange),86
which has been shown to be a successful approach to
motivate smokers to quit and connect them with cessation
interventions. With some modification, this model can be
adapted to counseling cancer survivors about weight and
physical activity. Vallis et al87 suggest adding “agree” to the
5As when counseling patients about obesity. To assess
patient readiness and avoid having patients feel stigma-
tized about their weight, it is appropriate to first ask patients
whether they are willing to talk about their weight. This
step should include assessment of current activity, weight
status, physical limitations, and questions about the
patient’s goals and preferred activities/modes of seeking
help.
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Referral/provision of programming and resources Once
a survivor agrees to work toward weight management and/
or a more physically active lifestyle, some assessment of
the survivor’s health status is needed. Survivors’ comorbid
health conditions and cancer sequelae can affect the
medical clearance needed and type of exercise or weight
loss setting that is most appropriate. For example, survivors
who have lymphedema should have this condition eval-
uated and treated by a lymphedema specialist before
starting an exercise program that involves upper body
exercise. In addition, they should be referred initially to
a program supervised by an exercise professional with
expertise in this area, because upper body resistance
training should start with low resistance and proceed
slowly to prevent injury that could exacerbate lymphe-
dema. For patients with chronic disease, the American
College of Sports Medicine (ACSM) recommendations88 for
preparticipation health screening can be followed, with
adaptation as needed for cancer-related conditions. The
ACSM recommends medical clearance for (1) people who are
not currently exercising and have known cardiovascular,
metabolic, or renal disease or any signs and symptoms; or (2)
people who are currently exercising and have signs or
symptoms of cardiovascular, metabolic, or renal disease. For
patients who are currently exercising and have known car-
diovascular, metabolic, or renal disease, the ACSM recom-
mends medical clearance only if the patient wants to begin
vigorous intensity exercise. The clearance/evaluation needed
should also be tailored to the type of exercise or physical activity
the participant is willing to do. The majority of cancer survivors
express that walking is their preferred form of physical activity.89
Walking is a relatively safe form of exercise that can be done by
the majority of survivors and is unlikely to require extensive
medical clearance or a supervised setting.
Physical activity and weight management programs
Programs to help cancer survivors address weight or
physical activity must reflect the diversity of their needs,
interests, goals, preferences, and resources. Programs can
be delivered as supervised, monitored, or unsupervised,
each suggesting different roles for professionals. Although
some survivors may be able to proceed with exercise or
weight management independently, others may experience
barriers that make lifestyle change challenging or even
unsafe in unsupervised settings and thus must be part of
a structured cancer rehabilitation program before pro-
ceeding with home- or community-based programs.90
Survivors also differ in their motivation for pursuing life-
style programming. Some seek health promotion that targets
the prevention of future health problems, whereas others
must remediate impairments and activity limitations through
medical rehabilitation. Mobile health intervention strate-
gies (e.g., mobile apps, wearables) may be useful across
the range of programs, either to provide information and
 Weight, Physical Activity, and Breast Cancer Prevention and Control
self-monitoring support to survivors in supervised programs, or
as free-standing interventions for survivors who are interested
in a self-directed program.91 Optimal design of such inter-
ventions to maximize engagement and effectiveness is a crit-
ical research need.92 Regardless of program type or delivery
characteristics, all programs must be evidence based, with
demonstrated efficacy, effectiveness, and safety.
One notable community-based exercise program tailored to
the needs of cancer survivors is the LIVESTRONG at the
YMCA program. This 12-week lifestyle change program has
been shown to increase physical activity and improve quality
of life and fitness.93 It is currently offered in 735 commu-
nities, making it the most widely available cancer-specific
lifestyle program. Cancer survivors who prefer individual
interventions may want to seek out a personal trainer with
expertise in working with cancer survivors. The ACSM has
a Cancer Exercise Trainer certification program. Certified
trainers can be identified through the “Find a Pro” feature
on the ACSM website (https://certification2.acsm.org/
profinder?_ga=2.139239987.1600007473.1525799292-
1759941655.1523997371).
Are cancer survivor–specific programs needed? The answer
to this question largely depends on the health needs and
functional limitations of the individual survivor, the survivor’s
risk level of the activity, and his or her comfort level. A cancer-
specific program that provides appropriate guidance and
supervision to minimize risk is appropriate for survivors who
experience or are at risk for substantial treatment side effects
(e.g., survivors at risk for lymphedema, undernutrition, or
health problems exacerbated by prevalent comorbidities).
However, some survivors, even those with relatively few cancer
sequelae, may lack self-efficacy for lifestyle behavior change
after cancer.94,95 These individuals may be more comfortable
with a program that can address their specific needs and
concerns, as well as reinforce the survivor-specific benefits of
improved lifestyle factors.96
AFFILIATIONS
1
Dana-Farber Cancer Institute, Boston, MA
2
The University of Texas MD Anderson Cancer Center, Houston, TX
3
University of Arizona Cancer Center, Tucson, AZ
CORRESPONDING AUTHOR
Jennifer A. Ligibel, MD, Dana-Farber Cancer Institute, 450 Brookline Ave.,
Boston, MA 02215; email: jennifer_ligibel@dfci.harvard.edu.
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Copyright © 2021 American Society of Clinical Oncology. All rights reserved.
Clearly, cancer survivors need wider availability of a range of
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AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST
AND DATA AVAILABILITY STATEMENT
Disclosures provided by the authors and data availability statement (if
applicable) are available with this article at DOI https://doi.org/10.1200/
EDBK_237423.
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