Implementing Lifestyle Medicine in Cancer Survivorship: A Narrative Review of Global Models

Abstract

Cardiovascular disease and cancer are the leading causes of mortality in developed countries. Advances in screening and treatment have led to a growing population of cancer survivors who require long-term supportive care. Many experience persistent health challenges, including fatigue, functional decline, and cardiometabolic comorbidities. Lifestyle medicine, which includes nutrition, physical activity, stress management, sleep, social connections, and risk reduction, provides a structured approach to optimizing survivorship outcomes.This narrative review examines the role of Lifestyle Medicine in oncology and highlights global implementation models. Programs analyzed include the Mass General Cancer Center’s Lifestyle Medicine Clinic, the Clinical Oncology Society of Australia’s exercise oncology framework, the Cleveland Clinic Abu Dhabi’s Lifestyle Medicine Oncology Program, and Kansas City’s community-based Cancer Wellness for Life initiative. Across diverse clinical settings, structured lifestyle interventions have been associated with improved treatment tolerance, quality of life, and the potential to reduce cardiometabolic risk factors. Hospital-based programs integrate multidisciplinary support, while community-driven initiatives expand access to lifestyle interventions. Despite strong evidence supporting these approaches, barriers to widespread adoption include gaps in clinician training, limited institutional support, and disparities in patient access. Global models show the feasibility and advantages of integrating Lifestyle Medicine into survivorship care. Increasing access, overcoming implementation challenges, and using technology can improve survivorship outcomes. Including Lifestyle Medicine in standard oncology care can improve long-term health and encourage survivors to manage their well-being actively.

“Patients, primary care physicians, and oncologists face challenges transitioning from active treatment to ongoing survivorship care.”

Background

Cardiovascular disease and cancer are the two leading causes of death in developed countries. In 2023, approximately 1.96 million new cancer diagnoses were made in the United States.^1,2 Advancements in screening and treatment have significantly improved survival rates, with the number of cancer survivors projected to increase to 22.5 million by 2032. More than 75% of patients live 5 years or longer after a cancer diagnosis, emphasizing the need for long-term management beyond active treatment. However, as patients transition from active treatment to survivorship, they often face long-term adverse side effects, including fatigue, functional decline, and an increased risk of secondary cancers. ³ Comprehensive survivorship care is needed to reduce morbidity and mortality and improve the quality of life for cancer survivors.

There is a close interplay between cancer and cardiometabolic disease, highlighting the need for integrated approaches to cancer care. Cardiometabolic diseases such as obesity, hypertension, diabetes, and dyslipidemia are risk factors for cancer development and can influence treatment choices and exacerbate adverse effects.^4,5 Furthermore, chemotherapy, radiation, and hormonal therapies can exacerbate cardiometabolic comorbidities. Lifestyle interventions targeting both cancer and cardiometabolic risk factors can lead to significantly improved patient outcomes. ⁶

Lifestyle medicine is an evidence-based field using therapeutic interventions to prevent, manage, and reverse chronic diseases. Approximately 42% of newly diagnosed cancer cases are attributed to modifiable lifestyle factors, such as tobacco use, poor diet, lack of physical activity, and alcohol consumption. ⁷ Lifestyle medicine is based on six pillars: nutrition, physical activity, stress management, sleep, avoiding risky substances, and fostering positive social connections. ⁸ Early integration of these interventions can benefit patients with or without pre-existing cardiometabolic conditions, reduce complications, and enhance treatment efficacy. ⁶

Lifestyle interventions improve treatment tolerance, enhance quality of life, and reduce cancer recurrence and comorbidities, including diabetes and cardiovascular disease.^3,8-12 National organizations, including the American Society of Cancer Oncology (ASCO), the American Cancer Society (ACS), the World Cancer Research Fund, and the American Institute for Cancer Research, recommend integrating healthy lifestyles into cancer care.^7,13 However, these interventions are underutilized in clinical practice despite the strong evidence. A 2021 ASCO survey demonstrated that 79% of healthcare providers agreed that the treating physician should recommend weight loss, physical activity, and nutrition. ¹⁴ Yet, 84% of respondents indicated that interventions should be managed by clinical staff with relevant expertise, reflecting a lack of training among clinicians. ¹⁴

Modifying lifestyle factors can improve health outcomes in cancer survivorship care. The RENEW program revealed that lifestyle interventions could effectively improve health outcomes for sedentary, overweight, or obese cancer survivors aged 65 and older by offering personalized telephone counseling and tailored materials to encourage exercise and dietary changes.^12,17 Participants increased their physical activity by 36.3 minutes per week, improved their diet quality with an additional 1.24 servings of fruits and vegetables, and reduced their saturated fat intake by 3.06 grams daily. ¹⁷ The Survivor SHINE program adapted this approach to an online platform, resulting in improved lifestyle knowledge and a self-reported physical activity increase of 11.8 minutes per week among 41 cancer survivors, with reductions in red meat and alcohol consumption. ¹⁵ However, weight loss outcomes varied, with RENEW participants achieving an average weight reduction of 2.06 kg over 12 months, while a similar intervention by Lynch et al reported a higher average weight loss of 4.8 kg.^17,18 These findings highlight the importance of conducting further research to improve the design and implementation of the program.

Given the increased prevalence of obesity-related cancers and the rising misinformation on social media, lifestyle medicine’s evidence-based and patient-centered approach plays a vital role in promoting informed health decisions and the development of sustainable, healthy behaviors.^13,19 Incorporating lifestyle medicine into oncology care can empower patients to actively manage their health and provide comprehensive support throughout their cancer care. Collaboration between primary care physicians, oncologists, and allied health professionals is essential for comprehensive survivorship care. ¹⁹

This review investigates the complementary role of lifestyle medicine in oncology, highlighting its potential to enhance treatment outcomes and support long-term survivorship. By examining successful intervention models and discussing barriers to implementation, this paper aims to provide a framework for integrating lifestyle medicine as a core component in comprehensive cancer care. Lifestyle medicine aligns with conventional medical treatments to optimize health, well-being, and, in many cases, outcomes for individuals diagnosed with cancer.^6,8,13,19 We will review the core pillars of lifestyle medicine in the context of cancer survivorship, focusing on their role in improving health outcomes, reducing treatment-related side effects, and supporting overall well-being.

Cancer survivorship and lifestyle medicine

Cancer survivorship begins at diagnosis and continues through end-of-life care.^16,20 It encompasses surveillance for cancer recurrence, screening for secondary cancers, and managing the long-term and late physical and psychological effects of cancer and treatment.^21,22 Survivorship also includes managing comorbid medical conditions and providing preventive primary care. Integrating therapeutic lifestyle interventions can bridge the gap in survivorship care by addressing modifiable risk factors such as diet, physical activity, body composition, sleep, stress, and substance use. ¹

Nutrition is a fundamental component of lifestyle medicine and plays a significant role in cancer development and prognosis. Malnutrition and unintentional weight loss are linked to poorer prognosis and increased treatment-related complications.^9,10,17 Conversely, weight gain and obesity can exacerbate comorbid medical conditions and may promote cancer progression. Addressing this dual challenge requires personalized dietary recommendations that align with each patient’s unique needs and clinical context.^9,10,17,23

Nutrition

The Diet Patterns Methods Project examined dietary patterns, including the Mediterranean diet, the Dietary Approaches to Stop Hypertension (DASH), the U.S. Department of Agriculture Healthy Eating Index, and the Harvard Alternate Healthy Eating Index, and demonstrated strong associations between high dietary quality and reduced cancer incidence, cancer-specific mortality, and chronic disease risk.^7,24,25 ACS guidelines recommend nutrient-dense and minimally processed foods such as colorful vegetables, fruits, legumes, and whole grains, which support gut health, reduce carcinogenic exposure, and support weight maintenance.^7,25 Although restrictive diets, such as ketogenic diet, low-fat, low-carbohydrate, and fasting regimens, have been studied in preclinical and small-scale clinical trials, the evidence remains insufficient to recommend specific nutritional interventions.^6,25 Therefore, the current evidence supports the consumption of minimally processed and plant-predominant foods to reduce cancer risk, improve long-term health outcomes, and decrease adverse metabolic effects associated with cancer progression and recurrence.^1,9,19,25,26

Physical Activity

Physical activity is another pillar of lifestyle medicine supported by organizations like the World Health Organization (WHO), ASCO, ACS, and the American College of Sports Medicine (ACSM). ²⁷ During and after cancer treatment, exercise significantly improves fatigue, cardiorespiratory fitness, muscle strength, physical function, and quality of life.^6,28,29 Resistance training is beneficial for preserving muscle mass, as low muscle mass correlates with increased morbidity and mortality, while aerobic exercise is beneficial for maintaining cardiovascular and respiratory fitness. Adverse events related to exercise are rare, and current evidence supports the recommendation to include aerobic and resistance training. To optimize benefits within the constraints of an individual’s disease stage, treatment, and personal and behavioral characteristics, individualized exercise prescriptions should be prioritized alongside behavior change support, a strategy integral to multiple pillars of lifestyle medicine.^.14,29,30 Further research is needed to refine these strategies to align with specific cancer types and treatment stages. ³¹

Social Connections

Beyond exercise, strong social support networks are associated with reduced risks of cardiovascular disease, type 2 diabetes, and lower cancer-specific mortality rates. ²⁷ Social isolation and loneliness have been associated with increased hospitalization rates, higher healthcare costs, and lower overall survival. ²⁶ Incorporating social support strategies into survivorship care, such as support groups, family involvement, and community resources, can improve emotional resilience and health outcomes. ²⁶

Avoiding Risky Substances

Avoiding risky substances such as tobacco and excessive alcohol is another fundamental component of lifestyle medicine. ²⁷ Alcohol and nicotine are the most common substances in the United States. Tobacco is associated with several cancers, including lung, bladder, colon, and kidney. Smoking cessation is associated with increased overall survival, reduction in disease-specific mortality, and development of secondary cancers.^32,33 Similarly, alcohol use is associated with increased recurrence risk and the development of primary cancers such as breast, colorectal, and liver cancer and can negatively affect treatment outcomes. ³³ ACS recommends that survivors should avoid alcohol or, if unable to do so, limit consumption to one drink per day for women and two drinks per day for men. ³³ Counseling for tobacco and alcohol cessation is a critical aspect of comprehensive survivorship care that can significantly enhance long-term health outcomes.^25,33

Stress Management

Stress management, another pillar of lifestyle medicine, plays a key role in survivorship. ¹ Chronic stress is associated with persistent activation of the hypothalamic-pituitary-adrenal axis and the autonomic nervous system. This has been associated with immune dysfunction and increased inflammation, negatively impacting quality of life and health outcomes.^1,34,35 Evidence-based interventions like mindfulness, meditation, acupuncture, and exercise reduce anxiety, improve mental resilience, and lower cortisol levels. ³⁴ Tailored stress management strategies can ensure long-term adherence and improved outcomes for cancer survivors and their quality of life. ²⁷

Restorative Sleep

Sleep health, including duration, efficiency, quality, and regularity, is critical to overall well-being and cancer outcomes.^35,36 Poor sleep can impair immune function, increase stress response, promote inflammation, decrease DNA repair, and disrupt metabolic and hormonal regulation.^35,36 Among cancer survivors, inadequate sleep is associated with reduced treatment efficacy, adverse health outcomes, and increased mortality. Sleep also influences modifiable risk factors such as physical activity, diet, alcohol consumption, and tobacco use. Both short (<7 hours per night) and long (>9 hours per night) sleep durations are associated with increased cancer mortality risk, although findings on cancer incidence remain inconsistent. ³⁶ Current guidelines suggest 7-9 hours per night for adults aged 18-60. ³⁶

Lifestyle Medicine Models in Cancer Care

Integrating lifestyle medicine into oncology care has demonstrated the potential to improve patient outcomes, enhance quality of life, and promote long-term survivorship. ² Lifestyle interventions have been effectively integrated into standard oncology practice at several institutions, including Mass General Cancer Center in the United States, Cleveland Clinic Abu Dhabi, a community-based oncology program in Kansas City, and national initiatives in Australia. These models demonstrate the feasibility and potential of lifestyle medicine in survivorship, establishing a framework for incorporating comprehensive approaches in cancer care.^{8,17,19,28,29} These diverse models illustrate that integrating lifestyle medicine into oncology care is feasible and can be effectively implemented across various healthcare settings when supported by structured referral systems, interdisciplinary collaboration, and institutional commitment.

Australia: A Global Leader in Translating Exercise Oncology into Standard Cancer Care

Australians serve as pioneers in implementing exercise oncology into standard practice. In 2009, the Association of Exercise and Sports Science Australia (ESSA) published the first exercise prescription guidelines for cancer patients. Initially, the guidelines were broad, recommending participation in regular (3-5 times/week), low- to moderate-intensity, mixed-mode (aerobic and resistance) exercise. Over the subsequent decade, the quality and quantity of published studies contributing to the exercise oncology evidence base exponentially increased.^37,38 Positive physical, psychosocial, emotional, quality of life and potential survival benefits were consistently observed through participation in exercise following diagnosis of common cancers (e.g., breast, colorectal, prostate) through to more rare cancers (e.g., hematological, head and neck, gynecological). Consequently, the Clinical Oncology Society of Australia, Australia’s peak national body representing oncology health professionals from all disciplines, endorsed guidelines recommending exercise therapy in routine cancer care.^36,37 While somewhat controversial at the time, additional oncology organizations have now gone on to replicate the endorsement of exercise as necessary cancer therapy. Furthermore, the original ESSA exercise prescription recommendations have been updated, setting the scene for developing additional national and international guidelines.^37,38 Collectively, these guidelines promote participation in regular physical activity during and following cancer treatment, with individualized exercise prescription that incorporates mixed mode, moderate- to vigorous-intensity exercise.

As consumer and clinician understanding of the benefits of exercise has increased over the years, so has the availability of cancer-specific exercise programs within hospital settings and the community. These programs typically involve 8-12 weeks of 2+ supervised, one-on-one or group-based exercise sessions per week, whereby access for people residing in more rural/regional areas of Australia is limited. Costs associated with participating in these programs vary—some are free and supported by cancer organizations.^37,38 In contrast, for other programs, private health insurers, the government, and participants may share costs. Federally funded exercise therapy is available via Australia’s Chronic Disease Management Plan. This program allows up to 5 sessions per year with an allied health professional (including exercise physiologists or physiotherapists) for people with a chronic condition, including cancer. However, the availability of allied health professionals with expertise in exercise oncology varies widely across Australia. As such, while all Australians can access one-on-one or group-based exercise therapy following a diagnosis of cancer, in practice, the uptake of exercise therapy as part of routine cancer care is limited to those who are more likely living in metro areas and are of higher socioeconomic status.^37-39 Access to a range of other lifestyle medicine services, such as nutrition and psychology services are also supported by the Chronic Disease Management Plan. However, when more than one service is required, the allocated 5 sessions per year need to be shared among allied health professionals providing the therapy.

United States: Mass General Cancer Center’s Comprehensive Lifestyle Medicine Approach

The Lifestyle Medicine Program at Mass General Cancer Center provides personalized consultations and group visits for any patient with cancer or a history of cancer who is interested in improving their physical fitness, nutrition, quality of life, or adopting healthy lifestyle habits. The lifestyle medicine program was designed to help patients with cancer adopt evidence-based lifestyle behaviors to improve health and well-being and, in many cases, the outcomes of their disease.

The current multidisciplinary clinic is conducted within the cancer center, and clinic visits are held via telemedicine, virtually via HIPAA-compliant Zoom. The structure of the lifestyle medicine clinic has evolved since its initial launch in 2020, from a single-day in-person consult clinic to an insurance-billed, electronic medical record-integrated longitudinal clinic. ⁴⁰ Patients are referred to the lifestyle medicine clinic by a member of their oncology care team or primary care provider, or they may be self-referred. Patients can be anywhere in their cancer trajectory, and individuals with all types of cancer diagnoses may be seen.

The first appointment is with an ACLM-certified physician or nurse practitioner. During this visit, a comprehensive medical history is taken, and patients are screened for limitations on physical activity using the Physical Activity Readiness Questionnaires.^41,42 The six pillars of lifestyle medicine are a foundational structure for the initial visits. Patients are encouraged to identify the topics within lifestyle medicine that are most important to them as a focus of the consultation. Following the initial consultation, patients can then be referred to other members of the lifestyle medicine team or to various programs or specialists in the hospital system, as appropriate. Patients are often referred to an oncology-registered dietitian for a comprehensive nutrition assessment and personalized recommendations. A follow-up with an oncology-registered dietitian can be further scheduled if the patient has specific nutrition-related goals.

If a patient has specific psychosocial concerns, stressors, or challenges with enacting behavior change, a referral is placed to the clinical psychologist who sees patients for short-term cognitive/behavioral therapy. Additional referrals to obesity medicine, stress management groups, psychiatry, physiatry, and physical therapy are made as needed based on the needs and goals identified in the visit. A six-session virtual group visit program based on the six pillars of lifestyle medicine was developed by members of the lifestyle medicine team to offer ongoing education and skills for lifestyle education and behavior change. The virtual group visits provide a structured, longitudinal lifestyle medicine model to increase access for patients seeking more general lifestyle medicine support and education. The curriculum for the group visits is based on the established PAVING The Path to Wellness curriculum,^43-45 a 12-week lifestyle medicine-based survivorship program for which patients with breast cancer can also be referred. The virtual group visits are offered on a rolling basis, and participants are encouraged to attend all 6 visits.

The lifestyle medicine program enhances care for cancer survivors by providing education about the role of lifestyle interventions as a key component of survivorship care. The patients derive great benefit from an initial individualized assessment and the opportunity to be referred to other programs and specialists within our hospital system/cancer center. The development of the lifestyle medicine clinic model has great potential to enhance cancer survivors’ care and quality of life.

Abu Dhabi: Cleveland Clinic Abu Dhabi’s Lifestyle Medicine Oncology Program

The lifestyle medicine Oncology Program at Cleveland Clinic Abu Dhabi (CCAD), part of the Fatima Bint Mubarak Center, provides a comprehensive, multidisciplinary approach to cancer care by incorporating evidence-based lifestyle interventions. The program supports patients throughout their cancer journey, focusing on personalized nutrition plans, exercise regimens, mental health support, sleep optimization, and stress management to improve quality of life and treatment outcomes. The uniqueness of this program lies in its focus on cultural sensitivity and personalized care, which are essential for addressing the needs of Abu Dhabi patients. ⁸

Personalized dietary plans consist of nutrient-dense, whole foods to support treatment efficacy and reduce inflammation.^3,39 Individualized exercise programs, consisting of aerobic and resistance training, aim to maintain muscle mass, reduce fatigue, and improve cardiovascular health. Mental health services, including counseling, cognitive-behavioral therapy, and mindfulness techniques such as mindfulness-based stress reduction (MBSR) and breathing exercises, address the psychological challenges of cancer and aim to improve sleep hygiene and overall well-being. Educational workshops, yoga, reiki sessions, and a Survivorship Sponsorship Program are available for additional patient support. Patient portals and telehealth consultations ensure continuous patient support and engagement.^46,47

A recent evaluation of 50 breast cancer patients within the program revealed that 70% had elevated Hemoglobin A1c (HbA1c) levels, indicating poor glycemic control. Lifestyle interventions improved glycemic control in 35% of patients after one year, demonstrating the impact of dietary modifications, physical activity, and stress management on metabolic health. ⁴⁰

Future plans for this program include integrating wearable devices and AI-driven analytics, aiming to personalize further and enhance care.^46,47 The plan is to expand the program, but the main obstacles are resources, financial constraints, and trained professionals. Strategies will utilize telemedicine, shared medical appointments, and collaborations with local health organizations to address these challenges.

United States: Kansas City’s Community-Based Oncology Program

Cancer Wellness for Life (CW4L) is a hospital-based consultative exercise program established in Lenexa, Kansas, designed to integrate structured physical activity into cancer care. The program operates outside the traditional healthcare system but is embedded within oncology care through referral pathways and patient navigation. ⁴⁸ It was established in 2017 and has since expanded to include a clinical exercise physiologist and a cancer-specific physical therapist. The program provides exercise interventions tailored to patient performance, clinical measures, and health system disease priorities, ensuring access to evidence-based physical activity. Patients typically participate in 3 to 5 sessions, with individualized plans developed based on functional assessments.

CW4L utilizes a structured referral system, initially driven by a breast oncology physician champion. Over time, standard referrals were incorporated for specific cancer populations, including breast, pancreatic, esophageal, glioblastoma, and bone marrow transplant patients. Additionally, oncology clinician scan refers patients based on changes in mobility or strength, and self-referrals are also permitted. A key component of the program is its integration with EMR, allowing exercise oncology professionals to document patient assessments, recommendations, and progress within the medical record. This integration ensures direct communication between the exercise team and oncology providers, aligning exercise interventions with broader treatment goals. ⁴⁸

Strategic leadership engagement and collaboration with nurse navigators, oncologists, and hospital administrators drove the program’s growth. A strong physician champion in breast oncology was crucial in securing institutional support, advocating for the program within hospital operations, and integrating it into oncology workflows. ⁴⁸ CW4L leadership-maintained program visibility by participating in hospital credentialing processes and tumor board meetings, facilitating institutional buy-in. However, staff turnover and leadership transitions posed barriers to continuity and growth. Limited access to key decision-makers also hindered expansion efforts.

Despite these challenges, several factors contributed to CW4L’s success. Physician champions facilitated early referrals and expanded awareness among oncology teams. Engagement with tumor conferences and hospital credentialing meetings further strengthened institutional support. Most importantly, the program’s emphasis on outcome tracking and data sharing with leadership demonstrated its value in improving patient function, mobility, and quality of life. By leveraging physician advocacy, EMR integration, and strategic communication, CW4L has successfully embedded exercise into cancer care, reinforcing the role of physical activity as a key component of survivorship and enhancing the overall well-being of patients undergoing cancer treatment.^49,50

Discussion

Integrating lifestyle medicine into oncology care provides a comprehensive approach to enhancing cancer treatment and survivorship care by addressing the challenges of cancer and cardiometabolic disease. While conventional medical treatment, including surgery, chemotherapy, and radiation, is essential for cancer treatment, lifestyle medicine provides a framework by focusing on critical survivorship care recommended by NCCN and guidelines from ASCO, AICR, WHO, ACS, and the Clinical Oncology Society of Australia. The key pillars of lifestyle medicine include nutrition, physical activity, stress management, sleep optimization, avoidance of risky behavior, and social support. Evidence-based interventions improve treatment efficacy, quality of life, and, in many cases, reduce the risk of cancer recurrence.^6,7,19,29,51

Patients, primary care physicians, and oncologists face challenges transitioning from active treatment to ongoing survivorship care. Programs like RENEW and Survivor SHINE highlight the efficacy of structured interventions in improving dietary quality, physical activity, and metabolic health among cancer survivors. ¹⁵ Additionally, case studies from Mass General Cancer Center, CCAD, Australia, and Kansas City’s community-based oncology program show the scalability and adaptability of these interventions across diverse healthcare settings. These programs highlight the importance of multidisciplinary collaboration, patient education, and personalized care to address the complex needs of cancer patients.

Despite supportive evidence from national and international societies, significant gaps in implementation persist. In a cross-sectional study using data from the Behavioral Risk Factor Surveillance System, which included 10,020 cancer survivors, only 4% of cancer survivors adhered to all 4 ACS guidelines. ⁵¹ These gaps require policy reforms, institutional support, multidisciplinary collaboration, enhanced clinical education,^52,53 and technology integration.^6,44,45

Cancer-related misinformation is widespread on social media and often promotes unproven lifestyle interventions in place of evidence-based care.^3,54 For example, some YouTube videos and social media posts recommend unproven treatments such as high-dose vitamin C, special diets, or herbal remedies as cancer cures, despite a lack of scientific support. ⁵⁴ As the prevalence of lifestyle-related cancers and misinformation about lifestyle practices continues to rise, integrating lifestyle medicine into oncology care is becoming increasingly important. Future priorities should include expanding access to interventions, tailoring programs to diverse populations, and conducting research to refine and optimize these strategies. Establishing lifestyle medicine as a core component of cancer care can empower patients to actively manage their health, improve survivorship outcomes, and foster sustainable, evidence-based practices in oncology.

ORCID iDs

Jasmin Hundal https://orcid.org/0000-0002-1358-1209

Supriya Peshin https://orcid.org/0000-0002-3895-9474