Older Adults and Cancer Survivors

Introduction

Older Adults and Cancer Survivors

This chapter highlights the unique considerations and guidelines for designing exercise programs for two distinct and growing populations: older adults and cancer survivors. Despite their differences, both groups share the potential to achieve substantial improvements in physical health, resilience, and overall quality of life through carefully structured and progressive exercise interventions.

The first section focuses on older adults, addressing ageism and the pervasive underdosing of exercise prescriptions for this population. It emphasizes the remarkable capacity of older adults to build strength, improve mobility, and maintain independence when provided with appropriately tailored programs. Drawing on the universal algorithm for exercise programming, this section provides evidence-based strategies to counteract age-related physical decline and enhance overall well-being.

The second section shifts to cancer survivors, detailing the challenges posed by the disease and its treatments, such as fatigue, neuropathy, and cardiovascular changes. It underscores the vital role of exercise in recovery and long-term health, offering specific guidelines to safely and effectively design programs that meet the individual needs of this population. By fostering collaboration between fitness professionals and healthcare teams, this section aims to empower survivors to reclaim their physical and emotional health.

Together, these sections provide comprehensive insights into how fitness professionals can support these populations, helping them navigate barriers and unlock their full potential through exercise.

Section 1: Older Adults

Introduction

Older adults represent a highly diverse population with immense potential for physical improvement and resilience. Despite this, ageism—an often unspoken bias against aging populations—has led to the pervasive underdosing of exercise prescriptions. Underdosing, driven by assumptions that older adults are inherently fragile or incapable of handling moderate to high-intensity exercise, perpetuates ageism and limits the potential of this population. The American Physical Therapy Association (APTA) has recognized this as a significant issue, citing underdosing as a barrier to optimal health outcomes across all special populations, including older adults. This chapter challenges these misconceptions, emphasizing that older adults can significantly enhance their strength, aerobic capacity, and quality of life through appropriately prescribed, progressive exercise programs. As seen in master’s athletes—individuals in their 60s and beyond who maintain over 70% of the fitness they had in their 20s and 30s—age alone is not a limitation. Rather, a lack of proper training opportunities and guidance is often the true barrier.

Defining Aging and "Older Adults"

Aging is a gradual and multifaceted process beginning around age 30, characterized by declines in physiological functions such as strength, power, mobility, endurance, and cognition. These declines accelerate after age 50 and significantly after age 70. Importantly, regular exercise—especially resistance training—along with a healthy diet, sleep, and stress management, can mitigate these declines, enhancing both lifespan and healthspan.

The term "older adults" typically encompasses individuals aged ≥65 years, as well as those aged 50-64 years with clinically significant conditions that limit physical activity or fitness. According to the Centers for Disease Control and Prevention (CDC), older adults represent a rapidly growing demographic, yet only 23% meet the recommended guidelines for aerobic and resistance training. Addressing this gap requires tailored, progressive exercise interventions that consider both physiological and psychological barriers to participation.

Prevalence and Significance

Older adults account for an increasing share of the population. The rapid growth of this group underscores the urgency of addressing the physical, cognitive, and social barriers that prevent engagement in exercise. Age-related physical decline is not inevitable and can be substantially slowed or even reversed with structured, progressive exercise programs. In addition, exercise has been shown to improve cognitive function, reduce depression, and enhance overall quality of life. Programs designed with these broader outcomes in mind can have profound societal and individual benefits.

Effects of Aging

Aging impacts multiple body systems, but the extent of decline varies based on lifestyle, genetics, and physical activity levels. Below are key effects of aging and their implications:

These declines emphasize the need for targeted interventions that improve physical and cognitive resilience. Strategies such as resistance training and balance exercises can directly counteract many of these age-related changes.

Screening and Assessment: Individualized Capacity over Assumptions

Referencing earlier chapters, the universal algorithm—screen, assess, initiate, progress, reflect, feedback, improve—is critical for older adults. This population benefits greatly from the familiarization phase, where fitness professionals determine the correct entry point for each individual. This could range from a bodyweight squat to a barbell squat with 50% of their body weight or more. The emphasis on individualized capacity avoids the trap of one-size-fits-all programming and dispels myths of frailty.

Popular programs like Silver Sneakers often prioritize low-intensity activity, inadvertently reinforcing underdosing and limiting progress. While these programs may serve as an entry point for sedentary individuals, they should not represent the ceiling of potential for older adults. Evidence from resistance training interventions in nursing homes shows that even short-term high-intensity programs can lead to three- to four-fold increases in strength, significant improvements in functional outcomes, and enhanced quality of life.

The Potential for High-Intensity Training

As stated previously, scientific research supports that lifelong athletes maintain substantial fitness levels, with endurance and strength athletes retaining up to 70% of their peak fitness into their 70s. Furthermore, studies demonstrate that older adults with chronic conditions such as Parkinson’s disease, multiple sclerosis, type II diabetes, cancer, and cardiovascular diseases experience significant benefits from high-intensity resistance training. These improvements include better strength, mobility, metabolic health, and reduced fall risk.

Qualitative studies highlight another key insight: older adults find unprogressive, low-intensity programs boring and are motivated to adhere when they see tangible strength and conditioning gains. This aligns with the universal algorithm’s philosophy: start low, progress slow, but always progress.

Sarcopenia, Frailty, and Quality of Life

Sarcopenia (age-related muscle loss and associated loss of function) and frailty are not inevitable consequences of aging. They are often the result of insufficient physical activity and a lack of resistance training. Resistance training can not only halt but reverse these conditions, increasing lean muscle mass, improving strength, and enhancing overall function. For older adults, this translates into greater independence, reduced risk of nursing home admission, and increased longevity.

Progressive resistance training also combats the chronic diseases commonly associated with aging. Conditions such as osteopenia, osteoporosis, and type II diabetes improve markedly with programs that incorporate sufficient intensity and volume. For example, older adults should aim for an 8RM squat equivalent to ~60-70% of their body weight at a minimum—a goal that can be achieved through consistent, progressive programming.

Initial Exercise Assessments

• Flexibility and trigger point assessment. The fitness professional or exerciser should incorporate the flexibility and trigger point assessments as described in Chapter 7 along with the additional considerations described in Chapter 11.
• Cardiovascular assessment. The fitness professional or exerciser can follow the guidelines in Chapter 5 along with the additional considerations in Chapter 11.
• Strength assessment. The fitness professional or exerciser should incorporate the strength assessment as part of the Familiarization Phase, as described in Chapter 6.

Program Design Considerations

• Cardiovascular program design. Older adults should engage in aerobic exercise three to five days per week, 20 to 60 minutes per session, at an RPE of 4 to 6 (on a 1 to 10 scale). The goal is to accrue 150 to 300 minutes of moderate to vigorous intensity aerobic exercise each week (Garber, 2011).

High-intensity interval training (or modified interval training, such as interval walking) can be implemented within training sessions once the person can maintain 20 minutes or greater of continuous aerobic exercise at an RPE of 5 to 6 (Ribeiro, 2017). If high-intensity exercise is implemented within the program:

• Overall volume/duration should be low (i.e. cycle through the recovery:work period no more than three times and progress from there).
• The work portion should begin relatively short (e.g., 30 to 60 seconds).
• The recovery portion should begin at a 3:1 to 5:1 rest to work ratio (e.g., 120 seconds of rest for every 30 seconds of work).
• The intensity should primarily be guided via the use of the RPE-Talk Test method.
• The program should begin with modified high-intensity interval training (i.e., interval walking program) for more deconditioned individuals, whereby the work portion remains in the moderate to high end of the aerobic training zone for a short period as opposed to the anaerobic training zone.

• Including a modified high-intensity interval training session is at the fitness professional or exerciser’s mutual discretion. It should be based on fitness level, absence of symptoms, well-controlled resting blood pressure, and having a positive response to exercise progression. The recovery portion should be at an RPE of 2 to 3 and work portion at an RPE of 6 to 7.
• For example, recovery to work ratio may begin at 5:1 or 6:1, cycling through each ratio 3 to 5 times (e.g., 2.5 minutes at an RPE of 2 to 3 followed by 30 seconds at an RPE of 6 to 7); see RPE-Talk Test method in Chapter 6 for more detail).
• It is the fitness professional or exerciser’s responsibility to determine frequency, duration, intensity, and progression on a case by case and session by session basis.
• Resistance training program design. The exerciser can follow the resistance training guidelines covered in Chapters 4 and 6 with the following additional considerations:
• Always ensure “readiness to train” questions are asked prior to every session. Based on the answers to each question, the volume and intensity of the session should be adjusted accordingly.
• If the person begins to develop any of the following symptoms: light-headedness, dizziness, nausea, pale or clammy skin, excessive sweating, headache, chest pain, chest tightness, heart palpitations, unusual fatigue, blurred vision, or feels anything “other than the norm,” terminate the session and seek medical advice.
• Following the low volume, low intensity Familiarization Phase, use The RPE Method as the primary guide for intensity adjustments. Working sets should be terminated when the RPE reaches a 6 to 8 on a 1 to 10 scale.

Note: It is the fitness professional or exerciser’s responsibility to determine repetition ranges, phase lengths, and session intensities on a case by case, session by session basis.

Precautions and Considerations

• Chronic Conditions: Modify exercises to avoid aggravating conditions (e.g., osteoarthritis, hypertension). For instance, use partial range of motion for individuals with severe joint pain.
• Contraindications: Avoid exercises with high fall risk or excessive joint stress. Use supportive equipment or modify exercises as needed.
• Medication Effects: Monitor responses closely, particularly for medications affecting heart rate or balance. Ensure readiness to train is assessed prior to every session.
• Psychological Barriers: Build confidence through gradual exposure, positive reinforcement, and visible progress. Address fears of injury by demonstrating safety measures.

Lifestyle Integration

Encourage older adults to integrate exercise with other healthy behaviors. Nutritional guidance, adequate hydration, and sleep hygiene significantly enhance the benefits of physical activity. Social engagement through group classes or partner exercises can further improve adherence and overall well-being.

Adequate protein intake is critical for mitigating muscle loss and enhancing the effects of resistance training. Older adults should aim for 1.2 to 2.2 grams of protein per kilogram of body weight per day, distributed across meals. Examples of protein sources include:

Progress as Tolerated

Older adults can progress similarly to younger populations, albeit with more conservative increments. Training intensity, volume, and complexity should be adjusted based on individual adaptation and readiness to ensure sustainable improvements.

Summary

Older adults possess extraordinary potential to improve physical capacity, manage chronic conditions, and enhance quality of life through structured, progressive exercise programs. By addressing the underdosing epidemic and leveraging the universal algorithm, fitness professionals can empower this population to achieve outcomes that defy conventional expectations, extend healthspan, and redefine aging.

Section 2: Cancer Survivors

Introduction

Cancer presents unique challenges to physical health, stemming from the disease itself and the effects of treatments such as surgery, chemotherapy, and radiation therapy. This section explores the role of exercise as a cornerstone of recovery and long-term health for cancer survivors. It provides comprehensive guidelines for designing exercise programs that address the physiological and psychological challenges faced by this population.

The section begins with an overview of cancer staging, treatment modalities, and their common side effects, such as fatigue, neuropathy, cardiovascular changes, and reduced physical function. It then transitions into specific exercise programming strategies, emphasizing the safety and adaptability of aerobic, resistance, and flexibility training. Special attention is given to the importance of gradual progression, symptom monitoring, and collaboration with healthcare teams to tailor programs effectively.

By integrating evidence-based practices with individualized care, this section equips fitness professionals to support cancer survivors in regaining strength, improving quality of life, and reducing the risk of cancer recurrence. Exercise is presented not only as a tool for recovery but also as a means to empower individuals to take an active role in their long-term health.

What is Cancer?

Cancer is a group of diseases characterized by the uncontrolled growth and spread of abnormal cells. If the growth and spread are not controlled, it can result in death. Although the exact causes of cancer remain largely unknown, there are many factors known to increase risk. Some of these are modifiable, such as tobacco use and excess body fat, while others are generally unmodifiable, such as inherited genetic mutations, hormones, and immune conditions. Cancer causes about 1 in every 6 deaths worldwide, more than AIDS, tuberculosis, and malaria combined. Today, it is the second-leading cause of death (following cardiovascular diseases) worldwide.

According to estimates from the International Agency for Research on Cancer (IARC), in 2018 there were 18.0 million new cancer cases and 9.5 million cancer deaths worldwide. By 2040, the global burden is expected to grow to 27.5 million new cancer cases and 16.3 million cancer deaths simply due to the growth and aging of the population. The future burden will probably be even larger due to the increasing prevalence of factors that increase risk, such as smoking, unhealthy diet, and physical inactivity (Cancer Today, 2019).

Cancer Staging

A cancer staging system is a standardized way to describe the extent to which a cancer has spread. For most cancers, stage is based on the size or extent of the primary tumor and whether it has spread to nearby lymph nodes or other areas of the body at the time of diagnosis. A number of different staging systems are used to classify cancer. A system of summary staging is used for descriptive and statistical analysis of tumor registry data and is particularly useful for tracking.

According to this system, if cancer cells are present only in the layer of cells where they developed, the stage is in situ. If cancer cells have penetrated beyond the original layer of tissue, the cancer has become invasive and is categorized as local, regional, or distant based on the extent of spread.

Clinicians mainly use a different staging system. The TNM staging system is the most used categorization. It assesses the spread and growth of cancer in 3 ways:

• Extent of the primary tumor (T).
• Absence or presence of regional lymph node involvement (N).
• Absence or presence of distant metastases (M).

Once the T, N, and M categories are determined, a stage of 0, I, II, III, or IV is assigned, with stage 0 being in situ (localized), stage I being early, and stage IV being the most advanced disease. Some cancers (e.g., lymphoma) have alternative staging systems (Irwin, 2012).

Cancer Treatment

Treatments for cancer include surgery, radiation therapy, chemotherapy, and hormonal therapy. Treatment varies based on the type, size, and stage of cancer. Most cancer patients undergo surgery, and most receive chemotherapy. The treatments used for cancer come with side-effects including but not limited to:

• Pain (may range from sharp, burning, or stabbing, to vague, dull, or crampy)
• Fatigue (which people may describe as a distressing, persistent sense of tiredness or exhaustion)
• Sleep disturbance
• Cardiovascular changes and damage (e.g., rhythm disturbances, decreased ejection fraction, inflammation, fibrosis)
• Pulmonary changes and damage (e.g., shortness of breath, decreased exercise tolerance)
• Neurological changes and damage (e.g., burning, tingling, numbness, or phantom pain)
• Endocrine (hormonal) changes (e.g., hypothyroidism)
• Reduced immune function
• Gastrointestinal issues
• Decreased organ function
• Liver, renal, skin, and hair damage

It is recommended that the person completes a New Client Treatment Form (Figure 15.6), to gain further insight into the cancer type, treatment, medications, and any related signs or symptoms. This information should be added to the information obtained from the initial consultation and assessment to assist in the design of the exercise program. It is critical that the fitness professional connects with the individual’s oncologist and other members of their healthcare team (if applicable), either before the consultation or immediately afterward, to discuss any potential restrictions, contraindications, or areas of emphasis within the program design, or that the individual diagnosed with cancer learn this information from their healthcare team.

An important example to consider would be bone cancer survivors. It is critical that prior to establishing a resistance training program, the fitness professional or individual learns where bone lesions exist(ed) and if there remains any risk of fracture in those areas. Caution should be taken with exercise selection, volume, intensity, and progression, and the fitness professional should adhere closely to the advice of the healthcare provider(s).

While age, sex, and genetics are unavoidable risk factors for the development of cancer, approximately one third of cancer deaths may be avoidable and are attributable to lifestyle factors such as smoking, obesity, an unhealthy diet, excessive exposure to UV rays, and inactivity. Like many other diseases, cancer is associated with chronic, low-grade, systemic inflammation, which may be at least partially a function of inactivity (Deng, 2016).

With a properly designed program, the benefits of exercise for cancer patients mirror the benefits of exercise for everyone – increased aerobic capacity, stamina, strength, and flexibility, improved body composition and quality of life, and decreased fatigue and pain.

In November 2019 a consensus statement from an international multidisciplinary roundtable of experts developed exercise guidelines for cancer survivors (Campbell, 2019). They concluded that every cancer survivor should avoid inactivity and that both exercise training and testing are generally safe for them. They also found that there exists enough evidence to conclude that aerobic, resistance, or aerobic combined with resistance training improve health outcomes. In most cases, supervised exercise training was found to be superior to unsupervised training.

Across cancer types, the experts recommended that cardiovascular training be done within the individual’s aerobic training zone most days of the week for 20 to 60 minutes. They also recommended resistance training be performed two to three days per week within the 8 to 15 repetition range, and that RPE scales be used to guide to intensity. These expert recommendations and the considerations listed below should serve as guidelines for program design but should ultimately be tailored to the individual on a case-by-case basis.

Initial Exercise Assessments

• Flexibility and trigger point assessment. The fitness professional or exerciser should incorporate the flexibility and trigger point assessments as described in Chapter 7 along with the additional considerations described in Chapter 11.
• Cardiovascular assessment. The fitness professional can follow the guidelines in Chapter 5 with the additional considerations in Chapter 11 and the following considerations:
• Pay special attention to signs of breathlessness, discomfort, and fatigue, and if applicable, adjust the session as needed.
• Receive regular feedback from the exerciser regarding how they feel and if they feel comfortable increasing intensity during the graded assessment.
• The fitness professional should consider beginning the assessment at an RPE of 2 to 3 (i.e., very light) before progressing in intensity.
• It may be prudent to terminate the assessment when an RPE of 4 to 5 has been achieved and use this as the baseline intensity for initial program design.
• If the exerciser wishes to terminate the assessment prior to achieving an RPE of 4 on a 1 to 10 scale, it is recommended that medical advice is sought before engaging in structured exercise, as this is a sign of severe deconditioning which may need more specialized, clinical care.
• Strength assessment: The fitness professional should incorporate the strength assessment as part of the Familiarization Phase, as described in Chapter 6. It may be prudent to choose initial loads that equate to approximately a “4” (on a 1 to 10 scale) before progressing (review Figure 6.2). Err significantly on the side of caution.

Program Design Considerations

• Cardiovascular program design. The fitness professional or exerciser is reminded to “start low and progress slow” with the design and pace of the program. Rates of progression will vary widely, and some people may need to remain in the low end of their aerobic training zone. The fitness professional should be empathetic about the client’s situation and have working knowledge of the RPE-Talk Test method as the primary guide to intensity. Cancer survivors may not be able to sustain continuous aerobic exercise for a significant time (e.g., 10 to 15 minutes), at least initially. Allow individual autonomy when choosing mode of exercise.

When the exerciser can sustain 20 minutes of continuous, low-intensity exercise, they may be placed on a modified interval training program, whereby they move from below or in the low end of their training zone during the rest portion (e.g., 40 to 60% of predicted maximum heart rate), to a moderate level of intensity for short intervals (e.g., 5 to 10 seconds). It is the fitness professional or exerciser’s responsibility to determine the efficacy of this type of program based on client fitness, feedback, and ability to tolerate an RPE of approximately 5 (on a 1 to 10 scale). It is also helpful for the fitness professional to elicit feedback from the client’s primary care provider, oncologist, or allied health practitioner and provide updates regarding the client’s progression.

• Including a modified high-intensity interval training session is at the fitness professional or exerciser’s mutual discretion. It is based on fitness level, absence of symptoms, well-controlled resting blood pressure, and positive response to exercise. Recovery portion should be at an RPE of 2 to 3 and work portion at an RPE of 6 to 7.
• For example, recovery to work ratio may begin at 5:1 or 6:1, cycling through each ratio 3 to 5 times (e.g., 2.5 minutes at an RPE of 2 to 3 followed by 30 seconds at an RPE of 6 to 7). See RPE-Talk Test method in Chapter 6 for more detail.
• It is the fitness professional or exerciser’s responsibility to determine frequency, duration, intensity, and progression on a case by case and session by session basis.
• Strength program design. The fitness professional or exerciser can follow the resistance training guidelines covered in Chapters 4 and 6 with the following additional considerations:
• Always ensure “readiness to train” questions are asked prior to every session. Based on the answers to each question, the volume and intensity of the session should be adjusted accordingly.
• If the exerciser begins to develop any of the following symptoms: light-headedness, dizziness, nausea, pale or clammy skin, excessive sweating, headache, chest pain, chest tightness, heart palpitations, unusual fatigue, blurred vision, or feels anything “other than the norm,” terminate the session and seek medical advice.
• Start low, go slow.
• During the Familiarization Phase, use The RPE Method to choose loads for every exercise, whereby the initial RPE is approximately 3 (on a 1 to 10 scale).
• During the Familiarization Phase keep volume low—only one to two exercises are performed for each major muscle group.
• Extend rest periods between sets as needed. Successive sets or exercises should only be performed when the exerciser’s heart and breathing rate have returned to a resting level, and they feel physically and mentally ready and capable of performing the next set or exercise.
• Avoid the Valsalva maneuver.
• Allow autonomy with exercise selection and consider beginning with less complex exercises before progressing.

Examples include:

• Legs (leg press, bodyweight bridge, knee extension, knee curl, bilateral calf raise)
• Back (straight arm pulldown, light single arm cable or dumbbell row)
• Chest (chest fly, light dumbbell press, or machine press)
• Shoulders (light lateral raise, light reverse fly)
• With bone cancer survivors, learn from a healthcare provider (e.g., oncologist) where any lesion(s) exist(s) or existed, and if there is still a risk of fracture. Obtain guidance regarding exercise selection, volume, intensity, and rate of progression. Fitness professionals should refer out if not qualified to train this population.

• Following the first or second cycle of the above three suggested phases (following the Familiarization Phase) loading zones may be shifted to 12 to 15 reps/set, 10 to 12 reps/set, 8 to 10 reps/set, and 6 to 8 reps/set at the discretion of the fitness professional, the exerciser, and their healthcare provider (if appropriate). This should be based on fitness level, absence of symptoms, positive response and natural progression to exercise.
• It is the fitness professional or exerciser’s responsibility to determine repetition ranges, phase lengths, and session intensities on a case by case, session by session basis.

Practical Application

• Collaboration with Healthcare Providers: Fitness professionals should maintain open communication with the client's oncologist or healthcare team to understand contraindications and ensure the exercise program aligns with medical advice.
• Initial Assessments: Conduct comprehensive evaluations, including flexibility, cardiovascular, and strength assessments, to establish a safe baseline for program design.
• Tailored Program Design: Use the provided cardiovascular and resistance training frameworks to design individualized programs. Begin with low-intensity exercises and progress cautiously based on the client's feedback and physical response.
• Monitoring and Feedback: Regularly monitor the client for adverse symptoms such as fatigue, pain, or dizziness, and adjust the program accordingly. Utilize readiness-to-train questions to guide session intensity and duration.
• Empowerment and Autonomy: Allow clients to choose exercises they feel comfortable with and incorporate their preferences into program design to foster trust, adherence and enjoyment.
• Education and Resources: Provide clients with access to educational resources, such as videos and handouts, to enhance their understanding of the benefits of exercise and encourage long-term engagement.

Summary

This chapter explored the critical role of exercise in enhancing health and quality of life for older adults and cancer survivors. For older adults, it underscored the importance of overcoming ageism and underdosing by providing appropriately progressive exercise programs that counteract physical decline, improve functional independence, and extend healthspan.

For cancer survivors, the chapter detailed strategies to address treatment-related challenges and promote recovery through individualized and adaptive exercise programs. It emphasized collaboration between fitness professionals and healthcare teams to ensure safe and effective programming tailored to each survivor’s unique needs.

By integrating these evidence-based approaches, fitness professionals can help these populations unlock their potential, demonstrating that age or medical history need not be barriers to achieving significant physical and emotional health benefits.