A cancer diagnosis used to mean rest, wait and recover. For a long time the standard advice was to take it easy, conserve energy and let the treatment do its work. That advice is starting to change. There is now a serious and growing body of research showing that structured exercise, started after a diagnosis and continued through treatment, can improve a patient’s fitness, protect their physical function and help them tolerate surgery and chemotherapy better.
A big part of this new treatment regime is prehabilitation, or prehab. The idea is quite simple. Instead of waiting until after surgery to begin rehabilitation, you use the weeks between diagnosis and treatment to build the patient up. You raise their fitness, their strength and their resilience so they go into a major operation or a course of chemotherapy from a stronger starting point. The patient is going to face a serious physiological stress. Prehab gives them more in reserve to draw on.
This is a sensitive area and it should always be handled with care. None of what follows suggests a personal trainer should be managing a cancer patient on their own, or that exercise replaces medical treatment. It does not. What the evidence does support is that a suitably qualified PT, working alongside the clinical team and within a clear referral pathway, can have a real influence on how a patient comes through their treatment. Knowing where you fit, and where you do not, is the whole job here.
What Prehabilitation Actually Means
Prehabilitation is the practice of optimising a patient’s health in the window between diagnosis and the start of active treatment. In the UK it has been shaped by a set of principles published jointly by Macmillan Cancer Support, the Royal College of Anaesthetists and the National Institute for Health and Care Research (NIHR). Those principles describe prehab as multimodal, meaning it usually combines three strands: physical activity, nutrition and psychological support. Exercise is the strand a PT is most likely to be involved with, but it sits inside a wider package of care.
The clearest UK example is Prehab4Cancer, a programme run across Greater Manchester for people facing surgery for colorectal, lung and oesophago-gastric cancers. Patients are referred into a community-based exercise and wellbeing service after diagnosis, supported by exercise professionals working hand in hand with the surgical and oncology teams. It is a useful model for any PT thinking about this space, because it shows what good looks like: structured, supervised, individualised and fully integrated with the clinical pathway.
The concept is not new in principle. The American College of Sports Medicine roundtable that produced the (Schmitz et al., 2019) “Exercise is Medicine in Oncology” guidance set out the case for engaging clinicians to help patients move through cancer, rather than rest through it. What has changed in the last two years is the strength of the trial evidence behind it.
What the 2024 Prehab Evidence Shows
The most useful recent summary is a 2024 systematic review and meta-analysis of randomised controlled trials by (Gennuso et al., 2024), published in BMC Cancer. It pulled together 42 studies, with 13 going into the quantitative analysis, all looking at prehabilitation delivered after diagnosis and before surgery or chemotherapy.
The findings: Patients who went through a prehab programme showed reduced postoperative hospital stays, better endurance, greater muscle strength and improved respiratory function. The walking test results were a standout. The six-minute walk test, a simple and widely used measure of functional capacity, improved by an average of around 38 metres compared with usual care. That is the kind of change that has a real influence on whether someone can manage stairs, carry shopping or stay independent in the weeks after an operation.
Just as noteworthy were the mental health results. Anxiety and depression scores both fell in the prehab groups. For a patient sitting in the gap between a diagnosis and an operation, often one of the most frightening periods of the whole experience, having something active and purposeful to do is valuable in its own right. The authors were honest about the limitations, flagging that the quality of the underlying trials varied and the risk of bias was a concern, so the effects should be read as encouraging rather than definitive. That is exactly the tone a responsible PT should take with clients too.
Exercise and Survival
Beyond the surgical window, there is the bigger question of whether being active is linked to living longer after a cancer diagnosis. A 2025 meta-analysis by (Ungvari et al., 2025), published in GeroScience, brought together the cohort evidence across breast, lung, prostate, colorectal and skin cancers.
They found that patients who were physically active after their diagnosis had a lower risk of dying from their cancer, with reductions in cancer-specific mortality of roughly a quarter reported for several of the cancer types looked at. Keep in mind, this is observational data, which shows a strong and repeated association, not a guarantee of cause and effect. People who are able to stay active may differ in other ways from those who cannot. But the size and consistency of the link, across multiple cancers and large numbers of patients, is hard to dismiss and lines up with what the trial evidence on fitness and function is showing.
The World Cancer Research Fund has long made the case that regular physical activity is associated with better outcomes both before and after a cancer diagnosis, and this kind of analysis adds weight to that position. For a PT, the practical message is not to overclaim. You are not promising anyone they will live longer. You are helping them stay as fit, strong and functional as possible, which is a goal worth having on its own, and which the evidence links to better long-term outcomes.
Aerobic and Resistance Training Together
On the practical side of programming prehab, the most relevant recent work looks at concurrent training, meaning aerobic and resistance exercise delivered together. A 2025 systematic review and meta-analysis by (Maroto-Izquierdo et al., 2025), published in Healthcare, focused on colorectal cancer patients waiting for surgery.
Across six trials and 379 patients, combining aerobic and resistance work during the prehab window produced a real improvement in functional capacity, again measured by the six-minute walk test. The effect was larger in patients under 70 than in older patients, which is a useful reminder that the same programme will not land the same way for everyone and that age, fitness history and the specifics of the diagnosis all shape what is realistic. The principle that comes through is that concurrent training, rather than cardio alone or strength alone, gives patients the broadest functional benefit before they go under the knife.
There is also good evidence for higher-intensity work where it is appropriate and supervised. A 2025 meta-analysis by (Cuomo et al., 2025), also in Healthcare, looked specifically at high-intensity interval training (HIIT, short bursts of harder effort with recovery in between) during cancer prehab. Across seven studies and 352 patients, HIIT produced a small but reliable improvement in cardiorespiratory fitness, measured as VO2 peak, which is the body’s peak rate of oxygen use during hard exercise and a strong predictor of how well someone copes with surgery. HIIT is not the right starting point for every patient, but for the right person, under the right supervision, it offers a time-efficient way to build fitness in a short window.
A Sensible Prescription Framework
Pulling the evidence together, a workable prehab framework for the patients a PT might see (always under referral and supervision) looks roughly like the matrix below. The numbers are a starting point, not a prescription, and every element is adjusted to the individual and signed off by the clinical team.
| Component | Typical Prescription | Purpose |
|---|---|---|
| Aerobic training | 3 to 5 sessions per week, moderate intensity, building duration over the window | Raises cardiorespiratory fitness ahead of surgery |
| Resistance training | 2 to 3 sessions per week, major muscle groups, progressive but conservative loading | Protects muscle mass and strength against treatment-related loss |
| Higher-intensity intervals | Where appropriate and supervised, short bursts with recovery | Time-efficient gains in VO2 peak when the window is short |
| Breathing and mobility | Daily, light, especially before chest or abdominal surgery | Supports respiratory function and recovery |
The thread running through all of it is that prehab is concurrent and individualised. Aerobic and resistance work together, scaled to the person in front of you, progressed carefully and never pushed past what the clinical team is comfortable with.
Screening and Safety Come First
A cancer patient is not a healthy general client. Treatment and disease can bring complications that change what is safe: low blood counts that raise infection or bleeding risk, bone metastases that make certain loading dangerous, fatigue that fluctuates day to day, lymphoedema, cardiac effects from some chemotherapy drugs, and surgical wounds or stomas that need protecting. Some of these are absolute reasons to pause or modify, and a PT will not always be able to spot them.
That is exactly why a qualified PT does not take a cancer patient on independently. The patient should come through a referral pathway, with clear medical clearance and a shared understanding of what is and is not safe for that individual. The PT’s job is to deliver the exercise safely within those boundaries, to watch closely for warning signs such as unusual breathlessness, dizziness, new pain or swelling, and to stop and refer back the moment something does not look right. When in doubt, you stop and you ask. That instinct is more valuable than any single exercise prescription.
Working With the Clinical Team
Cancer care is run by a multidisciplinary team (the MDT), which brings together oncologists, surgeons, specialist nurses, physiotherapists, dietitians and others. A PT is not a member of that team in the clinical sense, but can be a genuinely useful partner to it when communication is good. That means knowing who to report to, sharing progress and concerns clearly, respecting the boundaries of your role and never giving advice that strays into clinical territory such as commenting on treatment, prognosis or medication.
Good communication also protects the patient. If a PT notices that a client is unusually fatigued, has lost weight quickly or has a new symptom, flagging it promptly to the right person can make a real difference. The model to aim for is the one Prehab4Cancer uses: the exercise professional is a trusted, well-briefed part of the wider pathway, clear on their lane and clear on when to hand back.
Where a PT Genuinely Adds Value
It is worth being clear about what a PT brings that the clinical team often cannot. Time, for one. A PT sees a client regularly, builds a relationship and notices changes week to week in a way a busy clinic appointment cannot. Coaching skill, for another. Helping someone who is frightened and deconditioned to move again, to rebuild confidence and to stick with a programme through a hard period is exactly the skill set a good PT has spent years developing.
Many of us find our clients are dealing with far more than a fitness goal, and a cancer diagnosis is the sharpest version of that. The PTs who do this well are not trying to be clinicians. They are doing the thing they are best at, helping people move, supporting them and keeping them engaged, inside a safe and properly supervised pathway. That is a serious and worthwhile role, and the demand for professionals who can fill it responsibly is only going to grow.
Why Fitness Going In Changes the Outcome
It helps to understand why prehab works, because it makes the prescription easier to explain to a nervous client. Major surgery is a large physiological stress. The body has to cope with the trauma of the operation itself, a period of enforced inactivity afterwards and, in many cancer cases, a course of chemotherapy or radiotherapy that takes its own toll. How well a patient copes with all of that depends heavily on the reserve they had to begin with.
Think of it like a savings account. A patient with a higher level of cardiorespiratory fitness, more muscle mass and better functional strength has more in the account to draw down when the bill arrives. They are more likely to get up and moving sooner after surgery, less likely to develop complications such as chest infections, and more likely to leave hospital earlier. That is the mechanism behind the shorter hospital stays seen in the trial data. Prehab does not change the operation. It changes the patient who walks into it.
The same logic applies to muscle. Cancer and its treatment can drive a rapid loss of muscle mass and strength, sometimes called cancer-related muscle wasting. Resistance training during the prehab window helps defend against that loss, so the patient comes out the other side with more of their physical function intact. For an older patient in particular, the difference between keeping and losing the ability to climb stairs or get out of a chair unaided is enormous, and it often comes down to how much muscle they protected through treatment.
The UK Has Led on Putting This Into Practice
The UK has been one of the leading places for putting prehab into practice rather than just studying it. The joint principles from Macmillan Cancer Support, the Royal College of Anaesthetists and the NIHR gave the country a shared framework for what good prehab looks like, built around the three strands of physical activity, nutrition and psychological support. The National Institute for Health and Care Excellence (NICE) has increasingly recognised the role of physical activity in cancer care, and the World Cancer Research Fund continues to make the case that staying active is associated with better outcomes both before and after a diagnosis.
Prehab4Cancer in Greater Manchester remains the clearest working example. It takes patients referred after diagnosis for colorectal, lung and oesophago-gastric cancers and puts them through a community-based programme delivered by exercise professionals who are fully briefed and connected to the surgical and oncology teams. The reason it is worth studying as a PT is that it shows the model done properly. The exercise professional is not freelancing at the edge of their competence. They are a trusted, integrated part of a pathway, with clear lines of communication and a clear remit. That is the standard to aim for, whether you are working with an NHS programme or supporting a private client who is also under clinical care.
Reading the Walking Test Results Properly
The six-minute walk test keeps coming up in this evidence, so it is worth knowing what it actually tells you. The patient walks as far as they comfortably can in six minutes along a flat course, and the distance is recorded. It is cheap, quick and reflects real-world function far better than a lab measure does. A change of around 30 metres or more is generally considered the point at which a patient would actually notice a difference in daily life.
That is why the roughly 38-metre improvement in the Gennuso analysis, and the gains in the Maroto-Izquierdo colorectal work, are worth taking seriously rather than treating as dry statistics. These are not marginal numbers on a spreadsheet. They represent patients who can walk further, manage more of their own care and recover their independence faster. When you are explaining prehab to a client, framing it in those terms, more ability to do the things they care about most, will be listened to far better than quoting effect sizes.
Building a Session in Practice
So what does a prehab session actually look like for a PT working within a referral pathway? The shape is recognisable to any trainer, but the priorities shift. You start with a careful check-in, not just the usual how-are-you-feeling but a genuine read on fatigue, any new symptoms, how the last round of treatment went and whether anything has changed since you last spoke. With this population, that conversation is part of the safety screen, not small talk.
The aerobic component is built up gradually, starting wherever the patient is and progressing only as tolerated. For many patients that means brisk walking, cycling on a stationary bike or similar low-impact work, with intensity guided by how they feel rather than chasing a number. The resistance component focuses on the major muscle groups and movement patterns that protect daily function, the legs, the trunk and the pushing and pulling of everyday life, kept progressive but conservative. Where the clinical team is comfortable and the patient is suitable, short higher-intensity intervals can be woven in to make the most of a short window, but that is a refinement, not a starting point.
Throughout, the watchwords are individualise and adjust. A patient mid-chemotherapy may need a much lighter session, or a rest day, and being willing to scale right back is a sign of good judgement, not a failure of the programme. The aim is consistency across the window, not heroics in any one session.
Getting Into This Work Responsibly
If this is a direction you want to take your career, the route in is through the right qualifications and the right relationships, not through advertising yourself as a cancer specialist off the back of a general PT certificate. An Exercise Referral qualification is the recognised foundation, because it is built specifically around taking clients referred from healthcare, screening them safely and communicating with clinical teams. From there, working with cancer patients specifically usually means linking up with an established programme or a clinical team who can refer appropriately and provide oversight.
It is also worth being honest with yourself about the emotional side. This is rewarding work, but it brings you close to people at a frightening time, and some clients you support will not have the outcome everyone hoped for. Going in with realistic expectations, clear boundaries and a good support network around you is part of doing the job sustainably. The PTs who last in this space are the ones who know it is a privilege and a responsibility in equal measure.
Bringing It Into Your Practice
Structured exercise after a cancer diagnosis, and prehab in the window before surgery or chemotherapy, improves fitness, protects function, shortens hospital stays and supports mental health, and being active is consistently linked to better survival. Concurrent aerobic and resistance training is the backbone of a good programme, with higher-intensity work added carefully where it suits the individual.
For PTs, the opportunity is real but it comes with a clear condition. This work is done alongside the clinical team, never instead of it, through proper referral pathways, with careful screening and a firm grasp of where your role ends. Get that balance right and a qualified PT can have a genuine, positive influence on how a patient comes through one of the hardest experiences of their life. That is about as worthwhile as this job gets.
References
Gennuso, D., Baldelli, A., Gigli, L., Ruotolo, I., Galeoto, G., Gaburri, D. and Sellitto, G. (2024). Efficacy of prehabilitation in cancer patients: an RCTs systematic review with meta-analysis. BMC Cancer, 24(1), 1302. Click here to review the full research article.
Ungvari, Z., Fekete, M., Varga, P. and others (2025). Exercise and survival benefit in cancer patients: evidence from a comprehensive meta-analysis. GeroScience, 47(3), pp.5235-5255. Click here to review the full research article.
Maroto-Izquierdo, S., Bautista, I.J., Pérez-Guerrero, A. and others (2025). Effects of prehabilitation concurrent exercise on functional capacity in colorectal cancer patients: a systematic review and meta-analysis. Healthcare, 13(10), 1119. Click here to review the full research article.
Cuomo, S., Brustio, P.R., Mulasso, A., Beratto, L. and others (2025). High-intensity interval training during cancer prehabilitation may improve cardiorespiratory fitness: a meta-analysis. Healthcare, 13(23), 3030. Click here to review the full research article.
Schmitz, K.H., Campbell, A.M., Stuiver, M.M. and others (2019). Exercise is medicine in oncology: engaging clinicians to help patients move through cancer. CA: A Cancer Journal for Clinicians, 69(6), pp.468-484. Click here to review the full research article.
Train to Work With Clinical Populations
If this article has made you think about working with patients referred from healthcare, the natural next step is the Exercise Referral qualification. It is the recognised route into taking clients referred by a GP or clinical team for conditions including cancer recovery, cardiovascular disease, diabetes and more. It teaches you how to screen safely, design appropriate programmes and communicate with healthcare professionals, which is exactly the skill set the prehab evidence calls for.
Exercise Referral Course – Distance Study
