Leisure-Time Physical Activity and Cancer Mortality Among Cancer Survivors

Erika Rees-Punia; Lauren R Teras; Christina C Newton; Steven C Moore; I-Min Lee; Lauren Bates-Fraser; Kathryn E Chiang; Den E Bloodworth; A Heather Eliassen; Lorelei Mucci; Brigid M Lynch; Meir Stampfer; Mingyang Song; Kristen D Brantley; Konrad H Stopsack; Charles E Matthews; Alpa V Patel

doi:10.1001/jamanetworkopen.2025.56971

. 2026 Feb 17;9(2):e2556971. doi: 10.1001/jamanetworkopen.2025.56971

Leisure-Time Physical Activity and Cancer Mortality Among Cancer Survivors

Erika Rees-Punia ^1,^✉, Lauren R Teras ¹, Christina C Newton ¹, Steven C Moore ², I-Min Lee ^3,⁴, Lauren Bates-Fraser ¹, Kathryn E Chiang ¹, Den E Bloodworth ¹, A Heather Eliassen ^4,^5,⁶, Lorelei Mucci ^4,⁷, Brigid M Lynch ^8,⁹, Meir Stampfer ^4,⁵, Mingyang Song ^4,^5,^10,¹¹, Kristen D Brantley ^4,¹², Konrad H Stopsack ^4,¹³, Charles E Matthews ², Alpa V Patel ¹

¹Department of Population Science, American Cancer Society, Atlanta, Georgia

²Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland

³Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts

⁴Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts

⁵Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts

⁶Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts

⁷Discovery Science, American Cancer Society, Atlanta, Georgia

⁸Cancer Epidemiology Division, Cancer Council Victoria, Melbourne, Victoria, Australia

⁹Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia

¹⁰Division of Gastroenterology, Harvard Medical School, Boston, Massachusetts

¹¹Clinical and Translational Epidemiology Unit, Massachusetts General Hospital, Boston

¹²Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts

¹³Department of Epidemiologic Methods and Etiologic Research, Leibniz Institute for Prevention Research and Epidemiology–BIPS and Faculty of Human and Health Sciences, University of Bremen, Bremen, Germany

Accepted for Publication: December 4, 2025.

Published: February 17, 2026. doi:10.1001/jamanetworkopen.2025.56971

^✉

Corresponding Author: Erika Rees-Punia, PhD, Department of Population Science, American Cancer Society, 270 Peachtree Rd, Atlanta, GA 30303 (erika.rees-punia@cancer.org).

Author Contributions: Dr Rees-Punia had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Rees-Punia, Moore, Lynch, Patel.

Acquisition, analysis, or interpretation of data: Rees-Punia, Teras, Newton, Moore, Lee, Bates-Fraser, Chiang, Bloodworth, Eliassen, Mucci, Stampfer, Song, Brantley, Stopsack, Matthews, Patel.

Drafting of the manuscript: Rees-Punia.

Critical review of the manuscript for important intellectual content: All authors.

Statistical analysis: Rees-Punia, Bates-Fraser.

Obtained funding: Lee, Eliassen.

Administrative, technical, or material support: Rees-Punia, Moore, Lee, Bloodworth, Eliassen, Lynch, Stampfer, Song, Matthews.

Supervision: Teras, Stampfer, Patel.

Conflict of Interest Disclosures: Drs Lee, Eliassen, and Stampfer reported receiving grants from the National Institutes of Health (NIH) during the conduct of the study. Dr Mucci reported receiving grants from the National Cancer Institute during the conduct of the study; and receiving grants from Astra Zeneca and having an equity interest in Convergent Therapeutics outside the submitted work. Dr Lynch reported receiving personal fees from Elsevier outside the submitted work. No other disclosures were reported.

Funding/Support: The data harmonization and analysis for this project was funded by the American Cancer Society.

Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH. The views expressed here are those of the authors and do not necessarily represent the American Cancer Society or the American Cancer Society–Cancer Action Network.

Data Sharing Statement: See Supplement 2.

Additional Contributions: The American Cancer Society funds the creation, maintenance, and updating of the Cancer Prevention Study-II cohort. The Nurses’ Health Study was supported by NIH research grants UM1 CA186107 and P01 CA87969. The Nurses’ Health Study II was supported by NIH research grant U01 CA176726. The Health Professionals Follow-up Study was supported by NIH research grants U01 CA167552, R01 CA50385. The Women’s Health Study was supported by NIH research grants CA047988, CA182913, HL043851, HL080467, and HL099355. The NIH-AARP Diet and Health Study was supported by the Intramural Research Program of the National Cancer Institute, NIH. The authors express sincere appreciation to all Cancer Prevention Study-II participants, and to each member of the study and biospecimen management group. The authors acknowledge the contributions of data to this study from central cancer registries supported through the Centers for Disease Control and Prevention’s National Program of Cancer Registries and cancer registries supported by the National Cancer Institute’s Surveillance Epidemiology and End Results Program.

^✉

Corresponding author.

PMCID: PMC12914486 PMID: 41701497

This pooled analysis of 6 cohort studies evaluates whether participating in moderate to vigorous physical activity after a cancer diagnosis is associated with longer survival among individuals with a history of bladder, endometrial, kidney, lung, oral, ovarian, or rectal cancer.

Key Points

Question

Is engagement in physical activity after a cancer diagnosis associated with longer survival among individuals with a history of bladder, endometrial, kidney, lung, oral, ovarian, or rectal cancer?

Findings

This pooled analysis of 6 cohort studies involving 17 141 participants found that higher levels of moderate to vigorous physical activity after diagnosis were associated with lower risk of cancer mortality among survivors of bladder, endometrial, lung, and ovarian cancers. Lung and rectal cancer survivors who were inactive before diagnosis but became active after diagnosis had lower risk of cancer mortality.

Meaning

Findings suggest that physical activity may benefit survivors of cancer, even if they were inactive prior to diagnosis.

Abstract

Importance

There is insufficient evidence to determine whether physical activity lengthens survival among people with a history of cancers less commonly studied for such benefit.

Objective

To examine the associations between physical activity assessed after a cancer diagnosis with cancer mortality and, secondarily, changes in physical activity before vs after diagnosis with cancer mortality among people previously diagnosed with 1 of 7 cancers.

Design, Setting, and Participants

This study used a pooled dataset of 6 cohorts (Cancer Prevention Study-II Nutrition Cohort, Health Professionals Follow-Up Study, National Institutes of Health–AARP Diet and Health Study, Nurses’ Health Study, Nurses’ Health Study II, and Women’s Health Study). Participants were survivors of bladder, endometrial, kidney, lung, oral cavity, ovarian, or rectal cancer who had completed surveys and had repeated measures of leisure-time physical activity. Baseline data were collected from 1976 through 1997. The mean (SD) follow-up was 10.9 (7.0) years. Data were analyzed from June 2023 to March 2024.

Exposures

Leisure-time moderate to vigorous physical activity (MVPA) before and after cancer diagnosis.

Main Outcomes and Measures

Association of MVPA in categories of metabolic equivalents of task hours per week (MET-h/wk) measured before and a mean (SD) of 2.8 (1.5) years after cancer diagnosis with cancer mortality.

Results

This pooled analysis included 17 141 cancer survivors (mean [SD] age, 67 [8] years; 60% female). Engagement in low amounts of MVPA (>0 to <7.5 vs 0 MET-h/wk) was associated with lower risk of cancer mortality among survivors who had been diagnosed with bladder (hazard ratio [HR], 0.67 [95% CI, 0.50-0.91]), endometrial (HR, 0.62 [95% CI, 0.45-0.87]), and lung cancer (HR, 0.56 [95% CI, 0.43-0.75]). Doubling the recommended MVPA guideline or more (eg, >15 vs 0 MET-h/wk) was associated with lower risk of cancer mortality among oral (HR, 0.39 [95% CI, 0.15-0.99] for >22.5 to 30.0 MET-h/wk) and rectal (HR, 0.57 [95% CI, 0.33-0.97] for >15.0 to 22.5 MET-h/wk) cancer survivors. Point estimates were less than 1 for cancer mortality among kidney cancer survivors (HR, 0.51 [95% CI, 0.22-1.18] for >15.0 to 22.5 MET-h/wk), although the confidence interval included the null. Compared with survivors who did not meet the MVPA guidelines before or after diagnosis, lung (HR, 0.58 [95% CI, 0.47-0.71]) and rectal (HR, 0.51 [95% CI, 0.32-0.83]) cancer survivors who met guidelines after diagnosis had a lower risk of cancer mortality, even if they were inactive before their diagnosis.

Conclusions and Relevance

In this analysis of 6 pooled cohorts, higher levels of MVPA after a cancer diagnosis were associated with lower risk of cancer mortality among people previously diagnosed with 1 of 7 cancers not commonly studied for their association with MVPA. Findings suggest that it is important for health care professionals to promote physical activity for longevity and overall health among people living with and beyond cancer.

Introduction

The role of physical activity (PA) in mitigating cancer risk is well recognized,^1,2,3,4,5 and the understanding of this association has led to clear PA recommendations for cancer prevention.⁶ Similarly, people with a history of cancer are recommended to accumulate 150 to 300 minutes of moderate intensity or 75 to 150 minutes of vigorous intensity aerobic PA per week (eg, 7.5-15.0 metabolic equivalent of task hours per week [MET-h/wk]).⁷ However, these recommendations are largely based on research of mortality outcomes within breast,^8,9,10,11,12 prostate,^13,14,15 or colon^16,17,18 cancer survivors. Indeed, at the time of the United States Physical Activity Guidelines Report on physical activity and cancer (2019),³ systematic reviews, meta-analyses, and pooled analyses on the association between physical activity and mortality among cancer survivors were available only for survivors of these 3 cancer types. Thus, there is insufficient evidence to support appropriate PA recommendations for cancer survival among people with a history of cancers whose associations with PA and mortality have been less commonly studied. This is particularly problematic because roughly 50% of cancer cases are types other than breast, colon, and prostate. In fact, survivors of bladder, endometrial, kidney, lung, oral, ovarian, and rectal cancers together will account for over 30% of the 2 million new cancer cases in the US in 2025.^19,20

The few recent studies of PA and mortality that include people with a history of cancers beyond breast, colon, and prostate^21,22 provide promising evidence but are limited by a modest number of survivors of specific cancer types (eg, <12 000 survivors of all cancer types combined, including breast, colon, and prostate). These studies either combine survivors of less common cancers into a single category²¹ or explore cancer type–specific associations of PA and mortality in broad categories of PA, such as meeting vs not meeting PA guidelines.²² Highlighting gaps in earlier work, a 2019 meta-analysis of the association between postdiagnostic PA and cancer mortality only included 1 study among kidney cancer survivors, and no studies among bladder, ovarian, endometrial, lung, or oral cancer survivors.²³ Taken together, it is clear that more research regarding the benefits of PA is needed among survivors of cancers other than breast, colon, and prostate. The aims of the present study were to examine the associations between PA assessed after a cancer diagnosis and before vs after diagnosis changes in PA with cancer mortality using a pooled dataset from bladder, endometrial, kidney, lung, oral, ovarian, or rectal cancer survivors.

Methods

Study Population

Cohorts participating in the National Cancer Institute Cohort Consortium Physical Activity and Cancer work group were considered for inclusion in this pooled analysis. Data from 6 cohorts that had repeated measures of leisure-time PA, confounding variables that were previously harmonized,^1,2 and clinical data (including cancer treatment and stage) were pooled for the current analyses: the Cancer Prevention Study-II Nutrition Cohort (CPS-II NC),²⁴ Health Professionals Follow-Up Study (HPFS),²⁵ National Institutes of Health–AARP Diet and Health Study (NIH-AARP), Nurses’ Health Study (NHS),²⁶ Nurses’ Health Study II (NHSII), and Women’s Health Study (WHS) (eTable 1 in Supplement 1).²⁷ This study was conducted in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline, and each cohort received ethical approval from its respective institutional review boards. The CPS-II NC protocol was approved by the institutional review boards of Emory University and of participating registries as required. The HPFS, NHS, WHS, and NHSII were conducted in accordance with the Declaration of Helsinki²⁸ and approved by the institutional review board of Brigham and Women’s Hospital and Harvard T.H. Chan School of Public Health. The NIH-AARP study was approved by the Special Studies Institutional Review Board of the US National Cancer Institute, and all participants provided informed consent by completing and returning the baseline questionnaire. All participants provided written or oral informed consent. Baseline data were collected from 1976 through 1997.

Cancer site, stage, timing, and first-course treatment (chemotherapy and radiation therapy) were identified or confirmed by linking respective cohorts to cancer registries (CPS-II NC, NIH-AARP) or through medical record verification (CPS-II NC, NHS, NHSII, HPFS, and WHS). Given the focus on cancers less commonly studied for the association of PA with survival, survivors of cancers with at least 25 cancer deaths per cohort other than breast, colon, or prostate were included: bladder, endometrial (CPS-II NC, NIH-AARP, NHS, NHSII, and WHS only), kidney, lung, oral cavity, ovarian (CPS-II NC, NIH-AARP, NHS, NHSII, and WHS only), or rectal cancer (eTables 2-4 in Supplement 1).

Physical Activity Exposures

All 6 cohorts assessed PA every 2 to 8 years over mean (SD) of 10.9 (7.0) years of follow-up. Estimated leisure-time moderate to vigorous PA (MVPA) from each cohort’s baseline survey (eTable 1 in Supplement 1) was used as the prediagnostic MVPA measure, and estimates from the first survey completed at least 1 year following the date of cancer diagnosis represented postdiagnostic MVPA. Assessments from this time frame were chosen to avoid estimates from surveys that may have been completed while undergoing active treatment, as treatment could impact the ability to achieve normal activity levels. Participants completed their MVPA survey a mean (SD) of 2.8 (1.5) years after their cancer diagnosis. Secondary and supplemental analyses also include a prediagnostic measure of MVPA, which was assessed on each cohort’s baseline survey (eTable 1 in Supplement 1).

MVPA surveys asked participants to report the average or approximate time spent per week on different recreational physical activities within the last year. Leisure-time activities classified as moderate (3.0-5.9 METs) or vigorous (≥6.0 METs) intensity were used to calculate the volume of MVPA in metabolic equivalent task hours per week (MET-h/wk). MVPA volume was classified according to current PA recommendations^7,29 in the primary analyses: none (referent), more than 0 to less than 7.5 MET-h/wk (less than guideline or inactive), 7.5 to less than 15.0 MET-h/wk (meeting guideline), 15.0 to less than 22.5 MET-h/wk (doubling guideline), 22.5 to less than 30.0 MET-h/wk (tripling guideline), and ≥30.0 MET-h/wk (more than tripling guideline). In secondary analyses of prediagnosis to postdiagnosis change in MVPA, categories were combined to align with adherence to guidelines at each time point (ie, did not meet guideline prediagnosis or did not meet guideline postdiagnosis [referent], met guideline prediagnosis or did not meet guideline postdiagnosis).

Mortality Outcomes

Vital status and cause of death were collected by individual cohorts via medical record review, death certificate, linkage to the US National Death Index, or reports from next of kin. The outcome was mortality with the primary cause of death being any type of cancer.

Statistical Analysis

Cohort- and cancer site–specific hazard ratios (HRs) and 95% CIs for leisure-time MVPA and cancer mortality were estimated using Cox proportional hazards models and then pooled using DerSimonian and Laird random-effects models, consistent with 2-stage pooling methods.^30,31 Delayed-entry Cox models, in which the time axis was time since diagnosis and follow-up time was calculated from postdiagnostic questionnaire return to death or the end of cohort follow-up, were used to account for differences in time between cancer diagnosis and postdiagnostic survey completion. A stratified Cox procedure was used to adjust for age within 1-year strata.

Model covariates were harmonized across cohorts and included self-reported sex, race and ethnicity (categorized by the research team as non-Latino White, all other races and ethnicities), smoking (never, former, current, and missing), and alcohol use (current user, nonuser, and missing) abstracted from the same survey as the MVPA exposure. Race and ethnicity were assessed on the baseline survey of each cohort for use as appropriate (eg, confounding variables, strata) in future analyses. Models also included stage at diagnosis (Surveillance, Epidemiology, and End Results General Summary Stage collapsed into in situ, localized, regional, distant, and missing [collapsed into distant, not distant, and missing for lung, oral, and bladder cancer survivors]; harmonized under the guidance of a certified oncology data specialist, D.E.B.) and first-course cancer treatment (chemotherapy: yes, no, or missing; and radiation: yes, no, or missing). Participants missing both cancer stage and treatment were excluded from analyses (n = 624). Prior work using this harmonized dataset compared results from models adjusting for cancer stage only, treatment only, and both stage and treatment, and there were only minor differences in model results.³² As cancer stage and treatment are potential mediators on a causal pathway from prediagnostic MVPA to survival, these variables were not included in supplemental models in which the main exposure was measured prior to diagnosis.³³ Finally, models with or without adjustment for prediagnostic body mass index (BMI, calculated as weight in kilograms divided by height in meters squared) were compared, as BMI may be both a confounder and mediator of the association between MVPA and survival.

Because individuals with overt illness and impending death may reduce their activity levels, we conducted a sensitivity analysis excluding participants who died within 2 years of follow-up. Analyses restricted to participants diagnosed with in situ, local, or regional stage cancer were also conducted. Additionally, to reduce concerns around the association of residual confounding with smoking, analyses were repeated restricted to never smokers, although this analysis was only possible among bladder and endometrial cancer survivors because of the small number of cancer deaths among never smokers diagnosed with the other cancer types. The proportional hazards assumption was tested by assessing the interaction term between postdiagnostic MVPA and follow-up time within each cohort (eTable 5 in Supplement 1). All statistical analyses were conducted from June 2023 to March 2024 using SAS, version 9.4 (SAS Institute Inc). Statistical significance was defined as a 95% CI excluding 1.0.

Results

The pooled analysis included 17 141 bladder, endometrial, kidney, lung, oral cavity, ovarian, or rectal cancer survivors with a postdiagnostic measure of MVPA (Table 1). Participants were a mean (SD) age of 67 (8) years at diagnosis. Overall, 49% of survivors were diagnosed with local or regional stage disease, and survivors of bladder (24%), endometrial (22%), and lung (18%) cancers accounted for over half of the cohort. Overall, 60% of participants in the pooled cohort were female (40% male). During a mean (SD) of 10.9 (7.0) years of follow-up, 4872 participants died of cancer.

Table 1. Cancer Survivor Characteristics by Postdiagnostic Leisure-Time Physical Activity.

Characteristic	Survivor postdiagnostic MVPA, MET-h/wk
Characteristic	0 (n = 1705)	>0 to <7.5 (n = 4964)	7.5 to <15.0 (n = 2234)	15.0 to <22.5 (n = 2010)	22.5 to <30.0 (n = 1248)	≥30.0 (n = 4980)
Age at diagnosis, mean (SD), y	71.6 (9.4)	67.7 (9.5)	66.5 (8.4)	67.3 (8.9)	66.8 (8.5)	66.7 (7.1)
Sex, No. (%)
Female	1165 (68)	3582 (72)	1375 (62)	1205 (60)	702 (56)	2202 (44)
Male	540 (32)	1382 (28)	859 (38)	805 (40)	546 (44)	2778 (56)
Race and ethnicity
Non-Latino White, No. (%)	1649 (97)	4739 (96)	2106 (94)	1935 (96)	1187 (95)	4712 (95)
All other	56 (3)	225 (4)	128 (6)	75 (4)	61 (5)	268 (5)
Time from diagnosis to survey, mean (SD), mo	26.1 (12.5)	27.8 (14.1)	31.6 (19.2)	32.3 (18.9)	36.4 (23.4)	44.3 (25.9)
Prediagnostic BMI, mean (SD)^a	27.6 (5.5)	26.7 (5.2)	26.4 (5.0)	26.1 (4.7)	26.2 (5.0)	26.3 (4.9)
Postdiagnostic smoking status, No. (%)
Never	583 (34)	1855 (37)	839 (38)	725 (36)	441 (35)	1556 (31)
Former	663 (39)	2072 (42)	974 (44)	935 (46)	597 (48)	2541 (51)
Current	450 (26)	996 (20)	387 (17)	322 (16)	190 (15)	738 (15)
Missing	9 (0)	41 (1)	34 (2)	28 (1)	20 (2)	145 (3)
Postdiagnostic alcohol use, No. (%)
User	633 (37)	1752 (35)	653 (29)	575 (29)	357 (29)	1100 (22)
Nonuser	948 (56)	2938 (59)	1473 (66)	1336 (66)	842 (68)	3771 (76)
Missing	124 (7)	274 (6)	108 (5)	99 (5)	49 (4)	109 (2)
First-course treatment, No. (%)
Chemotherapy plus radiation	151 (9)	336 (7)	99 (4)	64 (3)	47 (4)	299 (6)
Chemotherapy only	60 (4)	253 (5.	106 (5)	62 (3)	38 (3)	258 (5)
Radiation only	72 (4)	112 (2)	58 (3)	38 (2)	23 (2)	272 (6)
No chemotherapy or radiation	300 (18)	1004 (20)	421 (19)	306 (15)	292 (23)	2139 (43)
Missing	1122 (66)	3259 (66)	1550 (69)	1540 (77)	848 (68)	2012 (40)
SEER General Summary Stage, No. (%)
In situ	203 (12)	592 (12)	299 (13)	317 (16)	178 (14)	644 (13)
Localized	538 (32)	1659 (33)	786 (35)	708 (35)	400 (32)	1551 (31)
Regional	217 (13)	518 (10)	239 (11)	210 (10)	115 (9)	520 (10)
Local or regional^b	114 (7)	417 (8)	158 (7)	107 (5)	75 (6)	102 (2)
Distant	177 (10)	468 (9)	149 (7)	131 (6)	67 (5)	196 (4)
Missing	456 (27)	1310 (26)	603 (27)	537 (27)	413 (33)	1967 (40)
Cancer type, No. (%)
Bladder	365 (21)	952 (19)	520 (23)	529 (26)	338 (27)	1487 (30)
Endometrial	331 (19)	1277 (26)	561 (25)	456 (23)	251 (20)	810 (16)
Kidney	151 (8.8)	500 (10)	221 (10)	215 (11)	135 (11)	566 (11)
Lung	447 (26.2)	958 (19)	355 (16)	297 (15)	195 (16)	745 (15)
Oral	99 (6)	284 (6)	153 (7)	133 (7)	80 (6)	381 (8)
Ovarian	146 (9)	519 (10)	176 (8)	148 (8)	89 (7)	256 (5)
Rectal	166 (9.7)	474 (10)	248 (11)	232 (12)	160 (13)	735 (15)

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Abbreviations: BMI, body mass index; MET-h/wk, metabolic equivalent of task hours per week; MVPA, moderate to vigorous intensity physical activity; SEER, Surveillance, Epidemiology, and End Results.

^{^a}

BMI calculated as weight in kilograms divided by height in meters squared.

^{^b}

SEER General Summary Stage could not be discerned between local or regional for certain bladder and lung cancer cases.

Postdiagnostic Physical Activity and Cancer Mortality

Higher levels of postdiagnostic MVPA were associated with lower risk of cancer mortality among survivors of bladder, endometrial, lung, and ovarian cancers (Figure 1). Compared with survivors reporting no PA, any amount of PA, including an amount below recommendations (ie, >0 to <7.5 MET-h/wk), was associated with lower risk of cancer mortality among survivors of bladder (HR, 0.67 [95% CI, 0.50-0.91]), endometrial (HR, 0.62 [95% CI, 0.45-0.87]), and lung (HR, 0.56 [95% CI, 0.43-0.75]) cancer. Similarly, meeting MVPA guidelines (7.5 MET-h/wk to <15.0 MET-h/wk) was associated with further reduction in risk for endometrial (HR, 0.40 [95% CI, 0.21-0.78]) and lung (HR, 0.38 [95% CI, 0.24-0.60]) cancer survivors (Figure 1). Doubling the recommended MVPA guideline or more (eg, >15 vs 0 MET-h/wk) was associated with lower risk of cancer mortality among oral (HR, 0.39 [95% CI, 0.15-0.99] for >22.5 to 30.0 MET-h/wk) and rectal (HR, 0.57 [95% CI, 0.33-0.97] for >15.0 to 22.5 MET-h/wk) cancer survivors.

Figure 1. — The reference category was no MVPA. Overall P value for bladder cancer, P = .003; for endometrial cancer, P = .02; for kidney cancer, P = .53; for lung cancer, P < .001; for oral cancer, P = .06; for ovarian cancer, P = .007; and for rectal cancer, P = .30. HR indicates hazard ratio; MET-h/wk, metabolic equivalent of task hours per week.

Although postdiagnostic MVPA was not associated with lower risk of cancer mortality overall for survivors of kidney, oral, or rectal cancer, the direction of each estimate was consistent with lower risk. For example, point estimates for meeting MVPA guidelines ranged from 0.61 to 0.82 for those 3 groups (eg, HR, 0.61 [95% CI, 0.36-1.03] for risk among kidney cancer survivors meeting guidelines). Results were largely similar when further adjusting for prediagnostic BMI among survivors of most cancer types (eTable 6 in Supplement 1). In an analysis exploring the influence of each cohort’s effect estimate on the overall pooled estimate, excluding 1 cohort in turn only modestly affected HRs (eTable 7 in Supplement 1).

Prediagnostic to Postdiagnostic Changes in Physical Activity and Cancer Mortality

Given the limited clinical utility of potential findings, models using prediagnostic MVPA as the primary exposure are presented in eTable 8 and the eFigure in Supplement 1 (n = 55 709 cancer survivors). Compared with cancer survivors who did not meet the PA guidelines both before and after diagnosis, lung (HR, 0.58 [95% CI, 0.47-0.71]) and rectal (HR, 0.51 [95% CI, 0.32-0.83]) cancer survivors who met guidelines after diagnosis had lower risk of cancer mortality, even if they were inactive before the diagnosis (Figure 2). For ovarian and bladder cancer survivors, meeting guidelines postdiagnosis was associated with lower risk of cancer mortality among those who also met guidelines before diagnosis (HR, 0.66 [95% CI, 0.52-0.82] for bladder cancer; HR, 0.74 [95% CI, 0.55-0.99] for ovarian cancer). No associations were found among survivors who did not meet guidelines before diagnosis for bladder (HR, 0.84 [95% CI, 0.62-1.13) and ovarian (HR, 0.79 [95% CI, 0.55-1.12]) cancer. Although the confidence intervals included the null, point estimates suggested that endometrial cancer survivors who met guidelines after diagnosis, regardless of MVPA levels prior to diagnosis, may be at lower risk of cancer mortality compared with those who were inactive at both time points (HR, 0.76 [95% CI, 0.57-1.02] for those not meeting guidelines before diagnosis but meeting guidelines after diagnosis; HR, 0.72, [95% CI, 0.44-1.17] for those meeting both prediagnosis and postdiagnosis guidelines). There were no clear differences in risk of total cancer mortality by prediagnostic to postdiagnostic change in MVPA among survivors of kidney or oral cancer.

Figure 2. — The reference category was not meeting PA guideline adherence prediagnosis and postdiagnosis. HR indicates hazard ratio.

Stratified and Sensitivity Analyses of Postdiagnostic Physical Activity and Cancer Mortality

Compared with main analyses, restricting to never smokers resulted in an attenuation of point estimates among endometrial cancer survivors, and there was no longer an association (Table 2). For bladder cancer survivors, restricting to never smokers strengthened point estimates, although confidence intervals widened (and included the null for those meeting and more than tripling guidelines). When excluding deaths that occurred in the first 2 years of follow-up (eg, death within 2 years of the postdiagnostic MVPA survey), HRs were attenuated, although associations remained for survivors of endometrial, lung, ovarian, and rectal cancer (Table 2). Similarly, HRs were attenuated but associations remained for survivors of kidney, lung, and rectal cancer when excluding those missing stage information and those diagnosed with distant stage disease (eTable 9 in Supplement 1) or for survivors of bladder, endometrial, lung, and ovarian cancer when accounting for competing risks (eTable 10 in Supplement 1).

Table 2. Stratified and Sensitivity Analyses of Postdiagnostic Physical Activity.

Postdiagnostic MVPA, MET-h/wk	Hazard ratio (95% CI)
Postdiagnostic MVPA, MET-h/wk	Excluding deaths in 2 y	Among never smokers
Bladder cancer
No. of cancer deaths	769	229
0	1 [Reference]	1 [Reference]
>0 to <7.5	0.69 (0.38-1.25)	0.39 (0.17-0.88)
7.5 to <15.0	0.76 (0.41-1.42)	0.54 (0.24-1.24)
15.0 to <22.5	0.62 (0.33-1.14)	0.33 (0.14-0.80)
22.5 to <30.0	0.65 (0.32-1.34)	0.26 (0.08-0.91)
≥30.0	0.68 (0.46-1.03)	0.52 (0.21-1.29)
Endometrial cancer
No. of cancer deaths	360	272
0	1 [Reference]	1 [Reference]
>0 to <7.5	0.60 (0.40-0.92)	0.80 (0.49-1.30)
7.5 to <15.0	0.56 (0.35-0.91)	0.54 (0.30-0.99)
15.0 to <22.5	0.54 (0.32-0.92)	0.73 (0.38-1.38)
22.5 to <30.0	0.82 (0.46-1.47)	0.84 (0.39-1.81)
≥30.0	0.50 (0.28-0.88)	0.52 (0.13-2.04)
Kidney cancer
No. of cancer deaths	348	121
0	1 [Reference]	NA^a
>0 to <7.5	0.57 (0.23-1.38)	NA^a
7.5 to <15.0	0.53 (0.28-1.00)	NA^a
15.0 to <22.5	0.53 (0.28-0.99)	NA^a
22.5 to <30.0	0.63 (0.29-1.35)	NA^a
≥30.0	0.54 (0.23-1.28)	NA^a
Lung cancer
No. of cancer deaths	763	114
0	1 [Reference]	NA^a
>0 to <7.5	0.62 (0.46-0.84)	NA^a
7.5 to <15.0	0.68 (0.47-0.99)	NA^a
15.0 to <22.5	0.48 (0.31-0.72)	NA^a
22.5 to <30.0	0.65 (0.41-1.04)	NA^a
≥30.0	0.49 (0.33-0.74)	NA^a
Ovarian cancer
No. of cancer deaths	391	111
0	1 [Reference]	NA^a
>0 to <7.5	0.61 (0.26-1.42)	NA^a
7.5 to <15.0	0.62 (0.22-1.80)	NA^a
15.0 to <22.5	0.55 (0.20-1.52)	NA^a
22.5 to <30.0	0.48 (0.17-1.35)	NA^a
≥30.0	0.35 (0.17-0.74)	NA^a
Rectal cancer
No. of cancer deaths	393	149
0	1 [Reference]	NA^a
>0 to <7.5	0.84 (0.35-1.99)	NA^a
7.5 to <15.0	0.52 (0.25-1.06)	NA^a
15.0 to <22.5	0.47 (0.24-0.91)	NA^a
22.5 to <30.0	0.67 (0.28-1.63)	NA^a
≥30.0	0.55 (0.29-1.05)	NA^a

Open in a new tab

Abbreviations: MET-h/wk, metabolic equivalent of task hours per week; NA, not available.

^{^a}

Selected stratified or sensitivity analyses are not shown because of small numbers of cancer deaths; too few cancer deaths among oral cancer survivors remained after making additional exclusions or stratifying to consider any of these analyses.

Discussion

In this pooled analysis of 6 cohorts including 17 141 survivors of bladder, endometrial, kidney, lung, oral, ovarian, or rectal cancer, more MVPA after a diagnosis was associated with lower risk of cancer mortality among survivors of bladder, endometrial, lung, and ovarian cancer during a mean follow-up of 10.9 years. Additionally, MVPA equivalent to, double, or triple the recommended amount was associated with lower cancer mortality among oral cancer survivors. Even among participants who did not meet the MVPA guideline prior to diagnosis, meeting the guideline after diagnosis was associated with lower risk of cancer mortality for survivors of lung, and rectal cancer. These findings build on prior work by members of our team assessing associations between postdiagnostic MVPA with all-cause mortality among all cancer survivors.³²

Findings from the current study confirm and extend with results from the small number of prior studies on postdiagnostic MVPA and cancer mortality by cancer type.^34,35,36,37 In 1 study of 667 kidney cancer survivors, accumulating at least 7 h/wk of MVPA postdiagnosis was not associated with lower risk of cancer mortality (compared with <1 h/wk; HR, 0.59 [95% CI, 0.25-1.38]).³⁴ Although our sample of kidney cancer survivors was larger, all confidence intervals similarly included the null. One study of MVPA and cancer-specific mortality among ovarian cancer survivors³⁵ also reported results similar to the current study, although this is to be expected as the prior study used NHS and NHSII data, which are included in the harmonized cohort in the current study. For survivors of endometrial cancer, studies have assessed only postdiagnostic MVPA and overall survival.^36,37 Importantly, several of these prior studies were limited in their ability to assess the association of reverse causality and residual confounding by smoking through sensitivity and stratified analyses because of a relatively low number of cancer deaths. In the current study, although we excluded deaths within the first 2 years of follow-up and restricted analyses to never smokers among bladder and endometrial cancer survivors, wide confidence intervals made it difficult to infer the impact of these 2 important biases.

Several prior cancer survival studies focused on associations with prediagnostic measures of MVPA.²³ However, the clinical relevance of these studies may be minimal—perhaps only useful for identifying patients with cancer at the highest risk of poor prognosis—as prediagnostic behavior cannot be intervened on at the time of diagnosis.³⁸ Further, survival models including prediagnostic exposures may be subject to immortal time or selection bias.^33,39 As implications of findings around prediagnostic PA are limited, we presented associations as prediagnostic to postdiagnostic changes in PA, and presented associations with prediagnostic PA only in Supplement 1.

Lung and kidney cancer survivors who met the PA guidelines after diagnosis, but not prior to diagnosis, had a lower risk of cancer mortality compared with survivors not meeting guidelines at either time point. These findings outline an actionable and translatable public health message that may motivate cancer survivors to become as active as they are able after a diagnosis, even if they were not active before. On the other hand, meeting PA guidelines only before diagnosis (ie, not meeting guidelines after diagnosis) was not associated with a reduced likelihood of cancer mortality for survivors of any cancer type. These findings reflect results from other studies that report an inverse association between postdiagnostic MVPA and mortality but not between prediagnostic MVPA and mortality.^35,36

Strengths and Limitations

The primary strength of this study is the large sample of survivors of cancers less commonly studied in the context of PA and mortality, including bladder, endometrial, kidney, lung, oral, ovarian, and rectal cancer. Additionally, all included cohort studies had more than a mean decade of follow-up and had similar processes for collecting MVPA exposure, cancer outcome, and covariate data. All survivors also had cancer stage or treatment data; although treatment is an obvious estimator of mortality, these data are not always available in large cohorts and thus have historically been difficult to include in studies of MVPA and cancer mortality.

The results of this study should be interpreted with its limitations in mind. Perhaps the most substantial limitation is the likelihood for reverse causality, in which inactivity may be a marker of poor general health or impending death, resulting in spurious associations between low or no PA and cancer mortality. In the current study, follow-up time began at the postdiagnostic survey return (which occurred a mean of 2.8 years after diagnosis), but to further reduce the association with reverse causality, a sensitivity analysis excluding participants dying within 2 years of the postdiagnostic MVPA measure was examined. Results from this sensitivity analysis were indeed attenuated compared with the main results, although associations remained for survivors of most cancers besides bladder cancer. While the lag from diagnosis to postdiagnostic measures may reduce the impact of reverse causality, it may also be associated with selection bias, as patients with cancer needed to be healthy enough to complete a postdiagnostic survey. Stratified analyses also suggested that results of the main analysis may have been associated with residual confounding by smoking. Importantly, the number of cancer deaths among never smokers was too small to perform this analysis among survivors of 2 types of cancer that are highly associated with smoking: lung and oral cancer. In addition, interpretation of the current study may be limited by the reliance on a single time point of self-reported PA data, which is susceptible to recall and social desirability bias. However, validation studies of the MVPA measures used in these cohorts have shown acceptable agreement with doubly labeled water and accelerometry.^{40,41,42,43,44,45,46} Further, there is evidence to suggest that use of self-reported measures, compared with device-based measures, may result in an attenuation toward the null for certain health outcomes.⁴⁷

Conclusions

Findings from this pooled analysis of 6 cohort studies suggest that any amount of postdiagnostic MVPA was associated with lower risk of cancer mortality among survivors of less commonly studied cancers, including bladder, endometrial, lung, and ovarian cancers. A higher amount of postdiagnostic MVPA consistent with doubling or tripling MVPA guidelines may also be associated with lower risk of cancer mortality among survivors of oral and rectal cancer. Further research is needed to pinpoint the optimal dose of MVPA for survival among people with a history of cancer. Furthermore, there were no clear indications that postdiagnostic MVPA may be more beneficial for survivors of certain cancers over others, in part due to wide and overlapping confidence intervals. Additional research is warranted to clarify whether associations may vary by specific cancer site. Findings suggest the importance of promoting PA for longevity and overall health among people living with and beyond cancer.

Supplement 1.

eTable 1. Cohort and physical activity measure information

eTable 2. International Classification of Diseases for Oncology, 3rd Ed. Codes by cancer site

eTable 3. Cancer case numbers for models of prediagnostic physical activity by cohort

eTable 4. Cancer case numbers for models of postdiagnostic physical activity by cohort

eTable 5. Results from tests of the proportional hazards assumption

eTable 6. Summary hazard ratios (HR) and 95% confidence intervals of cancer mortality for postdiagnostic moderate-to-vigorous intensity aerobic physical activity (MVPA) by cancer type, adjusting for body mass index

eTable 7. Impact of omitting each cohort in turn from the analysis: summary hazard ratios (HR) and 95% confidence intervals of cancer mortality for postdiagnostic moderate-to-vigorous intensity aerobic physical activity (MVPA)

eTable 8. Cancer survivor characteristics by prediagnostic leisure-time physical activity

eFigure. Summary hazard ratios (HR) and 95% confidence intervals of cancer mortality for prediagnostic moderate-to-vigorous intensity aerobic physical activity (MVPA) by cancer type

eTable 9. Summary hazard ratios (HR) and 95% confidence intervals of cancer mortality for postdiagnostic moderate-to-vigorous intensity aerobic physical activity (MVPA) among participants diagnosed with in situ, local, or regional stage cancer

eTable 10. Summary hazard ratios (HR) and 95% confidence intervals of cancer mortality for postdiagnostic moderate-to-vigorous intensity aerobic physical activity (MVPA), Fine and Gray models of competing risk

jamanetwopen-e2556971-s001.pdf^{(558.8KB, pdf)}

Supplement 2.

Data Sharing Statement

jamanetwopen-e2556971-s002.pdf^{(14.6KB, pdf)}

References

1.Matthews CE, Moore SC, Arem H, et al. Amount and intensity of leisure-time physical activity and lower cancer risk. J Clin Oncol. 2020;38(7):686-697. doi: 10.1200/JCO.19.02407 [DOI] [PMC free article] [PubMed] [Google Scholar]
2.Moore SC, Lee IM, Weiderpass E, et al. Association of leisure-time physical activity with risk of 26 types of cancer in 1.44 million adults. JAMA Intern Med. 2016;176(6):816-825. doi: 10.1001/jamainternmed.2016.1548 [DOI] [PMC free article] [PubMed] [Google Scholar]
3.McTiernan A, Friedenreich CM, Katzmarzyk PT, et al. ; 2018 Physical Activity Guidelines Advisory Committee . Physical activity in cancer prevention and survival: a systematic review. Med Sci Sports Exerc. 2019;51(6):1252-1261. doi: 10.1249/MSS.0000000000001937 [DOI] [PMC free article] [PubMed] [Google Scholar]
4.Physical activity and the risk of cancer: expert report 2018. World Cancer Research Fund/American Institute for Cancer Research: Continuous Update Project. Accessed December 17, 2025. https://www.wcrf.org/wp-content/uploads/2024/10/Physical-activity.pdf
5.Lynch BM, Bassett JK, Milne RL, et al. Estimating cancer incidence attributable to physical inactivity in the United States. Cancer. 2025;131(4):e35725. doi: 10.1002/cncr.35725 [DOI] [PMC free article] [PubMed] [Google Scholar]
6.Rock CL, Thomson C, Gansler T, et al. American Cancer Society guideline for diet and physical activity for cancer prevention. CA Cancer J Clin. 2020;70(4):245-271. doi: 10.3322/caac.21591 [DOI] [PubMed] [Google Scholar]
7.Rock CL, Thomson CA, Sullivan KR, et al. American Cancer Society nutrition and physical activity guideline for cancer survivors. CA Cancer J Clin. 2022;72(3):230-262. doi: 10.3322/caac.21719 [DOI] [PubMed] [Google Scholar]
8.Cannioto RA, Hutson A, Dighe S, et al. Physical activity before, during, and after chemotherapy for high-risk breast cancer: relationships with survival. J Natl Cancer Inst. 2021;113(1):54-63. doi: 10.1093/jnci/djaa046 [DOI] [PMC free article] [PubMed] [Google Scholar]
9.Chen LH, Irwin MR, Olmstead R, Haque R. Association of physical activity with risk of mortality among breast cancer survivors. JAMA Netw Open. 2022;5(11):e2242660. doi: 10.1001/jamanetworkopen.2022.42660 [DOI] [PMC free article] [PubMed] [Google Scholar]
10.Fortner RT, Brantley KD, Tworoger SS, et al. Physical activity and breast cancer survival: results from the Nurses’ Health Studies. J Natl Cancer Inst Cancer Spectr. 2023;7(1):7. doi: 10.1093/jncics/pkac085 [DOI] [PMC free article] [PubMed] [Google Scholar]
11.Johnsson A, Broberg P, Krüger U, Johnsson A, Tornberg ÅB, Olsson H. Physical activity and survival following breast cancer. Eur J Cancer Care (Engl). 2019;28(4):e13037. doi: 10.1111/ecc.13037 [DOI] [PubMed] [Google Scholar]
12.Jung AY, Behrens S, Schmidt M, et al. Pre- to postdiagnosis leisure-time physical activity and prognosis in postmenopausal breast cancer survivors. Breast Cancer Res. 2019;21(1):117. doi: 10.1186/s13058-019-1206-0 [DOI] [PMC free article] [PubMed] [Google Scholar]
13.Dickerman BA, Giovannucci E, Pernar CH, Mucci LA, Hernán MA. Guideline-based physical activity and survival among US men with nonmetastatic prostate cancer. Am J Epidemiol. 2019;188(3):579-586. doi: 10.1093/aje/kwy261 [DOI] [PMC free article] [PubMed] [Google Scholar]
14.Friedenreich CM, Wang Q, Neilson HK, Kopciuk KA, McGregor SE, Courneya KS. Physical activity and survival after prostate cancer. Eur Urol. 2016;70(4):576-585. doi: 10.1016/j.eururo.2015.12.032 [DOI] [PubMed] [Google Scholar]
15.Bonn SE, Sjölander A, Lagerros YT, et al. Physical activity and survival among men diagnosed with prostate cancer. Cancer Epidemiol Biomarkers Prev. 2015;24(1):57-64. doi: 10.1158/1055-9965.EPI-14-0707 [DOI] [PubMed] [Google Scholar]
16.Arem H, Pfeiffer RM, Engels EA, et al. Pre- and postdiagnosis physical activity, television viewing, and mortality among patients with colorectal cancer in the National Institutes of Health-AARP Diet and Health Study. J Clin Oncol. 2015;33(2):180-188. doi: 10.1200/JCO.2014.58.1355 [DOI] [PMC free article] [PubMed] [Google Scholar]
17.Campbell PT, Patel AV, Newton CC, Jacobs EJ, Gapstur SM. Associations of recreational physical activity and leisure time spent sitting with colorectal cancer survival. J Clin Oncol. 2013;31(7):876-885. doi: 10.1200/JCO.2012.45.9735 [DOI] [PubMed] [Google Scholar]
18.Qiu S, Jiang C, Zhou L. Physical activity and mortality in patients with colorectal cancer: a meta-analysis of prospective cohort studies. Eur J Cancer Prev. 2020;29(1):15-26. doi: 10.1097/CEJ.0000000000000511 [DOI] [PubMed] [Google Scholar]
19.Wagle NS, Nogueira L, Devasia TP, et al. Cancer treatment and survivorship statistics, 2025. CA Cancer J Clin. 2025;75(4):308-340. doi: 10.3322/caac.70011 [DOI] [PMC free article] [PubMed] [Google Scholar]
20.Siegel RL, Kratzer TB, Giaquinto AN, Sung H, Jemal A. Cancer statistics, 2025. CA Cancer J Clin. 2025;75(1):10-45. [DOI] [PMC free article] [PubMed] [Google Scholar]
21.Cao C, Friedenreich CM, Yang L. Association of daily sitting time and leisure-time physical activity with survival among us cancer survivors. JAMA Oncol. 2022;8(3):395-403. doi: 10.1001/jamaoncol.2021.6590 [DOI] [PMC free article] [PubMed] [Google Scholar]
22.Lavery JA, Boutros PC, Scott JM, Tammela T, Moskowitz CS, Jones LW. Pan-cancer analysis of postdiagnosis exercise and mortality. J Clin Oncol. 2023;41(32):4982-4992. doi: 10.1200/JCO.23.00058 [DOI] [PMC free article] [PubMed] [Google Scholar]
23.Friedenreich CM, Stone CR, Cheung WY, Hayes SC. Physical activity and mortality in cancer survivors: a systematic review and meta-analysis. JNCI Cancer Spectr. 2019;4(1):pkz080. doi: 10.1093/jncics/pkz080 [DOI] [PMC free article] [PubMed] [Google Scholar]
24.Calle EE, Rodriguez C, Jacobs EJ, et al. The American Cancer Society Cancer Prevention Study II Nutrition Cohort: rationale, study design, and baseline characteristics. Cancer. 2002;94(2):500-511. doi: 10.1002/cncr.10197 [DOI] [PubMed] [Google Scholar]
25.Rimm EB, Stampfer MJ, Colditz GA, Giovannucci E, Willett WC. Effectiveness of various mailing strategies among nonrespondents in a prospective cohort study. Am J Epidemiol. 1990;131(6):1068-1071. doi: 10.1093/oxfordjournals.aje.a115598 [DOI] [PubMed] [Google Scholar]
26.Belanger CF, Hennekens CH, Rosner B, Speizer FE. The Nurses’ Health Study. Am J Nurs. 1978;78(6):1039-1040. [PubMed] [Google Scholar]
27.Rexrode KM, Lee IM, Cook NR, Hennekens CH, Buring JE. Baseline characteristics of participants in the Women’s Health Study. J Womens Health Gend Based Med. 2000;9(1):19-27. doi: 10.1089/152460900318911 [DOI] [PubMed] [Google Scholar]
28.World Medical Association . World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. JAMA. 2013;310(20):2191-2194. doi: 10.1001/jama.2013.281053 [DOI] [PubMed] [Google Scholar]
29.2018. Physical Activity Guidelines Advisory Committee Scientific Report. US Department of Health and Human Services. Accessed December 17, 2025. https://odphp.health.gov/sites/default/files/2019-09/PAG_Advisory_Committee_Report.pdf
30.DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials. 1986;7(3):177-188. doi: 10.1016/0197-2456(86)90046-2 [DOI] [PubMed] [Google Scholar]
31.Smith-Warner SA, Spiegelman D, Ritz J, et al. Methods for pooling results of epidemiologic studies: the Pooling Project of Prospective Studies of Diet and Cancer. Am J Epidemiol. 2006;163(11):1053-1064. doi: 10.1093/aje/kwj127 [DOI] [PubMed] [Google Scholar]
32.Rees-Punia E, Teras LR, Newton CC, et al. Leisure-time physical activity after diagnosis and survival by cancer type: a pooled analysis. J Natl Cancer Inst. 2025;117(8):1689-1698. doi: 10.1093/jnci/djaf112 [DOI] [PMC free article] [PubMed] [Google Scholar]
33.Wang Z, Albers FE, Wang SE, English DR, Lynch BM. Biased effects of pre-diagnostic physical activity on breast cancer survival: systematic review and meta-analysis. Cancer Epidemiol. 2024;89:102544. doi: 10.1016/j.canep.2024.102544 [DOI] [PubMed] [Google Scholar]
34.Schmid D, Matthews CE, Leitzmann MF. Physical activity and sedentary behavior in relation to mortality among renal cell cancer survivors. PLoS One. 2018;13(6):e0198995. doi: 10.1371/journal.pone.0198995 [DOI] [PMC free article] [PubMed] [Google Scholar]
35.Wang T, Townsend MK, Eliassen AH, et al. Prediagnosis and postdiagnosis leisure time physical activity and survival following diagnosis with ovarian cancer. Int J Cancer. 2021;149(5):1067-1075. doi: 10.1002/ijc.33676 [DOI] [PMC free article] [PubMed] [Google Scholar]
36.Friedenreich CM, Cook LS, Wang Q, et al. Prospective cohort study of pre- and postdiagnosis physical activity and endometrial cancer survival. J Clin Oncol. 2020;38(34):4107-4117. doi: 10.1200/JCO.20.01336 [DOI] [PMC free article] [PubMed] [Google Scholar]
37.Arem H, Pfeiffer RM, Moore SC, Brinton LA, Matthews CE. Body mass index, physical activity, and television time in relation to mortality risk among endometrial cancer survivors in the NIH-AARP Diet and Health Study cohort. Cancer Causes Control. 2016;27(11):1403-1409. doi: 10.1007/s10552-016-0813-7 [DOI] [PMC free article] [PubMed] [Google Scholar]
38.Courneya KS, Friedenreich CM. Designing, analyzing, and interpreting observational studies of physical activity and cancer outcomes from a clinical oncology perspective. Front Oncol. 2023;13:1098278. doi: 10.3389/fonc.2023.1098278 [DOI] [PMC free article] [PubMed] [Google Scholar]
39.Albers FE, Moreno-Betancur M, Milne RL, et al. Prediagnostic exposures and cancer survival: can a meaningful causal estimand be specified? Epidemiology. 2025;36(3):408-412. doi: 10.1097/EDE.0000000000001844 [DOI] [PubMed] [Google Scholar]
40.Al-Shaar L, Pernar CH, Chomistek AK, et al. Reproducibility, validity, and relative validity of self-report methods for assessing physical activity in epidemiologic studies: findings from the Women’s Lifestyle Validation Study. Am J Epidemiol. 2022;191(4):696-710. doi: 10.1093/aje/kwab294 [DOI] [PMC free article] [PubMed] [Google Scholar]
41.Bonnefoy M, Normand S, Pachiaudi C, Lacour JR, Laville M, Kostka T. Simultaneous validation of ten physical activity questionnaires in older men: a doubly labeled water study. J Am Geriatr Soc. 2001;49(1):28-35. doi: 10.1046/j.1532-5415.2001.49006.x [DOI] [PubMed] [Google Scholar]
42.Chasan-Taber S, Rimm EB, Stampfer MJ, et al. Reproducibility and validity of a self-administered physical activity questionnaire for male health professionals. Epidemiology. 1996;7(1):81-86. doi: 10.1097/00001648-199601000-00014 [DOI] [PubMed] [Google Scholar]
43.Milton K, Clemes S, Bull F. Can a single question provide an accurate measure of physical activity? Br J Sports Med. 2013;47(1):44-48. doi: 10.1136/bjsports-2011-090899 [DOI] [PubMed] [Google Scholar]
44.Pernar CH, Chomistek AK, Barnett JB, et al. Validity and relative validity of alternative methods of assessing physical activity in epidemiologic studies: findings from the Men’s Lifestyle Validation Study. Am J Epidemiol. 2022;191(7):1307-1322. doi: 10.1093/aje/kwac051 [DOI] [PMC free article] [PubMed] [Google Scholar]
45.Shiroma EJ, Cook NR, Manson JE, Buring JE, Rimm EB, Lee IM. Comparison of self-reported and accelerometer-assessed physical activity in older women. PLoS One. 2015;10(12):e0145950. doi: 10.1371/journal.pone.0145950 [DOI] [PMC free article] [PubMed] [Google Scholar]
46.Wolf AM, Hunter DJ, Colditz GA, et al. Reproducibility and validity of a self-administered physical activity questionnaire. Int J Epidemiol. 1994;23(5):991-999. doi: 10.1093/ije/23.5.991 [DOI] [PubMed] [Google Scholar]
47.Wasfy MM, Lee I-M: Examining the dose–response relationship between physical activity and health outcomes. NEJM Evid. 2022;1(12):EVIDra2200190. doi: 10.1056/EVIDra2200190 [DOI] [PubMed] [Google Scholar]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplement 1.

eTable 1. Cohort and physical activity measure information

eTable 2. International Classification of Diseases for Oncology, 3rd Ed. Codes by cancer site

eTable 3. Cancer case numbers for models of prediagnostic physical activity by cohort

eTable 4. Cancer case numbers for models of postdiagnostic physical activity by cohort

eTable 5. Results from tests of the proportional hazards assumption

eTable 8. Cancer survivor characteristics by prediagnostic leisure-time physical activity

eFigure. Summary hazard ratios (HR) and 95% confidence intervals of cancer mortality for prediagnostic moderate-to-vigorous intensity aerobic physical activity (MVPA) by cancer type

jamanetwopen-e2556971-s001.pdf^{(558.8KB, pdf)}

Supplement 2.

Data Sharing Statement

jamanetwopen-e2556971-s002.pdf^{(14.6KB, pdf)}

[zoi251519r1] 1.Matthews CE, Moore SC, Arem H, et al. Amount and intensity of leisure-time physical activity and lower cancer risk. J Clin Oncol. 2020;38(7):686-697. doi: 10.1200/JCO.19.02407 [DOI] [PMC free article] [PubMed] [Google Scholar]

[zoi251519r2] 2.Moore SC, Lee IM, Weiderpass E, et al. Association of leisure-time physical activity with risk of 26 types of cancer in 1.44 million adults. JAMA Intern Med. 2016;176(6):816-825. doi: 10.1001/jamainternmed.2016.1548 [DOI] [PMC free article] [PubMed] [Google Scholar]

[zoi251519r3] 3.McTiernan A, Friedenreich CM, Katzmarzyk PT, et al. ; 2018 Physical Activity Guidelines Advisory Committee . Physical activity in cancer prevention and survival: a systematic review. Med Sci Sports Exerc. 2019;51(6):1252-1261. doi: 10.1249/MSS.0000000000001937 [DOI] [PMC free article] [PubMed] [Google Scholar]

[zoi251519r4] 4.Physical activity and the risk of cancer: expert report 2018. World Cancer Research Fund/American Institute for Cancer Research: Continuous Update Project. Accessed December 17, 2025. https://www.wcrf.org/wp-content/uploads/2024/10/Physical-activity.pdf

[zoi251519r5] 5.Lynch BM, Bassett JK, Milne RL, et al. Estimating cancer incidence attributable to physical inactivity in the United States. Cancer. 2025;131(4):e35725. doi: 10.1002/cncr.35725 [DOI] [PMC free article] [PubMed] [Google Scholar]

[zoi251519r6] 6.Rock CL, Thomson C, Gansler T, et al. American Cancer Society guideline for diet and physical activity for cancer prevention. CA Cancer J Clin. 2020;70(4):245-271. doi: 10.3322/caac.21591 [DOI] [PubMed] [Google Scholar]

[zoi251519r7] 7.Rock CL, Thomson CA, Sullivan KR, et al. American Cancer Society nutrition and physical activity guideline for cancer survivors. CA Cancer J Clin. 2022;72(3):230-262. doi: 10.3322/caac.21719 [DOI] [PubMed] [Google Scholar]

[zoi251519r8] 8.Cannioto RA, Hutson A, Dighe S, et al. Physical activity before, during, and after chemotherapy for high-risk breast cancer: relationships with survival. J Natl Cancer Inst. 2021;113(1):54-63. doi: 10.1093/jnci/djaa046 [DOI] [PMC free article] [PubMed] [Google Scholar]

[zoi251519r9] 9.Chen LH, Irwin MR, Olmstead R, Haque R. Association of physical activity with risk of mortality among breast cancer survivors. JAMA Netw Open. 2022;5(11):e2242660. doi: 10.1001/jamanetworkopen.2022.42660 [DOI] [PMC free article] [PubMed] [Google Scholar]

[zoi251519r10] 10.Fortner RT, Brantley KD, Tworoger SS, et al. Physical activity and breast cancer survival: results from the Nurses’ Health Studies. J Natl Cancer Inst Cancer Spectr. 2023;7(1):7. doi: 10.1093/jncics/pkac085 [DOI] [PMC free article] [PubMed] [Google Scholar]

[zoi251519r11] 11.Johnsson A, Broberg P, Krüger U, Johnsson A, Tornberg ÅB, Olsson H. Physical activity and survival following breast cancer. Eur J Cancer Care (Engl). 2019;28(4):e13037. doi: 10.1111/ecc.13037 [DOI] [PubMed] [Google Scholar]

[zoi251519r12] 12.Jung AY, Behrens S, Schmidt M, et al. Pre- to postdiagnosis leisure-time physical activity and prognosis in postmenopausal breast cancer survivors. Breast Cancer Res. 2019;21(1):117. doi: 10.1186/s13058-019-1206-0 [DOI] [PMC free article] [PubMed] [Google Scholar]

[zoi251519r13] 13.Dickerman BA, Giovannucci E, Pernar CH, Mucci LA, Hernán MA. Guideline-based physical activity and survival among US men with nonmetastatic prostate cancer. Am J Epidemiol. 2019;188(3):579-586. doi: 10.1093/aje/kwy261 [DOI] [PMC free article] [PubMed] [Google Scholar]

[zoi251519r14] 14.Friedenreich CM, Wang Q, Neilson HK, Kopciuk KA, McGregor SE, Courneya KS. Physical activity and survival after prostate cancer. Eur Urol. 2016;70(4):576-585. doi: 10.1016/j.eururo.2015.12.032 [DOI] [PubMed] [Google Scholar]

[zoi251519r15] 15.Bonn SE, Sjölander A, Lagerros YT, et al. Physical activity and survival among men diagnosed with prostate cancer. Cancer Epidemiol Biomarkers Prev. 2015;24(1):57-64. doi: 10.1158/1055-9965.EPI-14-0707 [DOI] [PubMed] [Google Scholar]

[zoi251519r16] 16.Arem H, Pfeiffer RM, Engels EA, et al. Pre- and postdiagnosis physical activity, television viewing, and mortality among patients with colorectal cancer in the National Institutes of Health-AARP Diet and Health Study. J Clin Oncol. 2015;33(2):180-188. doi: 10.1200/JCO.2014.58.1355 [DOI] [PMC free article] [PubMed] [Google Scholar]

[zoi251519r17] 17.Campbell PT, Patel AV, Newton CC, Jacobs EJ, Gapstur SM. Associations of recreational physical activity and leisure time spent sitting with colorectal cancer survival. J Clin Oncol. 2013;31(7):876-885. doi: 10.1200/JCO.2012.45.9735 [DOI] [PubMed] [Google Scholar]

[zoi251519r18] 18.Qiu S, Jiang C, Zhou L. Physical activity and mortality in patients with colorectal cancer: a meta-analysis of prospective cohort studies. Eur J Cancer Prev. 2020;29(1):15-26. doi: 10.1097/CEJ.0000000000000511 [DOI] [PubMed] [Google Scholar]

[zoi251519r19] 19.Wagle NS, Nogueira L, Devasia TP, et al. Cancer treatment and survivorship statistics, 2025. CA Cancer J Clin. 2025;75(4):308-340. doi: 10.3322/caac.70011 [DOI] [PMC free article] [PubMed] [Google Scholar]

[zoi251519r20] 20.Siegel RL, Kratzer TB, Giaquinto AN, Sung H, Jemal A. Cancer statistics, 2025. CA Cancer J Clin. 2025;75(1):10-45. [DOI] [PMC free article] [PubMed] [Google Scholar]

[zoi251519r21] 21.Cao C, Friedenreich CM, Yang L. Association of daily sitting time and leisure-time physical activity with survival among us cancer survivors. JAMA Oncol. 2022;8(3):395-403. doi: 10.1001/jamaoncol.2021.6590 [DOI] [PMC free article] [PubMed] [Google Scholar]

[zoi251519r22] 22.Lavery JA, Boutros PC, Scott JM, Tammela T, Moskowitz CS, Jones LW. Pan-cancer analysis of postdiagnosis exercise and mortality. J Clin Oncol. 2023;41(32):4982-4992. doi: 10.1200/JCO.23.00058 [DOI] [PMC free article] [PubMed] [Google Scholar]

[zoi251519r23] 23.Friedenreich CM, Stone CR, Cheung WY, Hayes SC. Physical activity and mortality in cancer survivors: a systematic review and meta-analysis. JNCI Cancer Spectr. 2019;4(1):pkz080. doi: 10.1093/jncics/pkz080 [DOI] [PMC free article] [PubMed] [Google Scholar]

[zoi251519r24] 24.Calle EE, Rodriguez C, Jacobs EJ, et al. The American Cancer Society Cancer Prevention Study II Nutrition Cohort: rationale, study design, and baseline characteristics. Cancer. 2002;94(2):500-511. doi: 10.1002/cncr.10197 [DOI] [PubMed] [Google Scholar]

[zoi251519r25] 25.Rimm EB, Stampfer MJ, Colditz GA, Giovannucci E, Willett WC. Effectiveness of various mailing strategies among nonrespondents in a prospective cohort study. Am J Epidemiol. 1990;131(6):1068-1071. doi: 10.1093/oxfordjournals.aje.a115598 [DOI] [PubMed] [Google Scholar]

[zoi251519r26] 26.Belanger CF, Hennekens CH, Rosner B, Speizer FE. The Nurses’ Health Study. Am J Nurs. 1978;78(6):1039-1040. [PubMed] [Google Scholar]

[zoi251519r27] 27.Rexrode KM, Lee IM, Cook NR, Hennekens CH, Buring JE. Baseline characteristics of participants in the Women’s Health Study. J Womens Health Gend Based Med. 2000;9(1):19-27. doi: 10.1089/152460900318911 [DOI] [PubMed] [Google Scholar]

[zoi251519r28] 28.World Medical Association . World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. JAMA. 2013;310(20):2191-2194. doi: 10.1001/jama.2013.281053 [DOI] [PubMed] [Google Scholar]

[zoi251519r29] 29.2018. Physical Activity Guidelines Advisory Committee Scientific Report. US Department of Health and Human Services. Accessed December 17, 2025. https://odphp.health.gov/sites/default/files/2019-09/PAG_Advisory_Committee_Report.pdf

[zoi251519r30] 30.DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials. 1986;7(3):177-188. doi: 10.1016/0197-2456(86)90046-2 [DOI] [PubMed] [Google Scholar]

[zoi251519r31] 31.Smith-Warner SA, Spiegelman D, Ritz J, et al. Methods for pooling results of epidemiologic studies: the Pooling Project of Prospective Studies of Diet and Cancer. Am J Epidemiol. 2006;163(11):1053-1064. doi: 10.1093/aje/kwj127 [DOI] [PubMed] [Google Scholar]

[zoi251519r32] 32.Rees-Punia E, Teras LR, Newton CC, et al. Leisure-time physical activity after diagnosis and survival by cancer type: a pooled analysis. J Natl Cancer Inst. 2025;117(8):1689-1698. doi: 10.1093/jnci/djaf112 [DOI] [PMC free article] [PubMed] [Google Scholar]

[zoi251519r33] 33.Wang Z, Albers FE, Wang SE, English DR, Lynch BM. Biased effects of pre-diagnostic physical activity on breast cancer survival: systematic review and meta-analysis. Cancer Epidemiol. 2024;89:102544. doi: 10.1016/j.canep.2024.102544 [DOI] [PubMed] [Google Scholar]

[zoi251519r34] 34.Schmid D, Matthews CE, Leitzmann MF. Physical activity and sedentary behavior in relation to mortality among renal cell cancer survivors. PLoS One. 2018;13(6):e0198995. doi: 10.1371/journal.pone.0198995 [DOI] [PMC free article] [PubMed] [Google Scholar]

[zoi251519r35] 35.Wang T, Townsend MK, Eliassen AH, et al. Prediagnosis and postdiagnosis leisure time physical activity and survival following diagnosis with ovarian cancer. Int J Cancer. 2021;149(5):1067-1075. doi: 10.1002/ijc.33676 [DOI] [PMC free article] [PubMed] [Google Scholar]

[zoi251519r36] 36.Friedenreich CM, Cook LS, Wang Q, et al. Prospective cohort study of pre- and postdiagnosis physical activity and endometrial cancer survival. J Clin Oncol. 2020;38(34):4107-4117. doi: 10.1200/JCO.20.01336 [DOI] [PMC free article] [PubMed] [Google Scholar]

[zoi251519r37] 37.Arem H, Pfeiffer RM, Moore SC, Brinton LA, Matthews CE. Body mass index, physical activity, and television time in relation to mortality risk among endometrial cancer survivors in the NIH-AARP Diet and Health Study cohort. Cancer Causes Control. 2016;27(11):1403-1409. doi: 10.1007/s10552-016-0813-7 [DOI] [PMC free article] [PubMed] [Google Scholar]

[zoi251519r38] 38.Courneya KS, Friedenreich CM. Designing, analyzing, and interpreting observational studies of physical activity and cancer outcomes from a clinical oncology perspective. Front Oncol. 2023;13:1098278. doi: 10.3389/fonc.2023.1098278 [DOI] [PMC free article] [PubMed] [Google Scholar]

[zoi251519r39] 39.Albers FE, Moreno-Betancur M, Milne RL, et al. Prediagnostic exposures and cancer survival: can a meaningful causal estimand be specified? Epidemiology. 2025;36(3):408-412. doi: 10.1097/EDE.0000000000001844 [DOI] [PubMed] [Google Scholar]

[zoi251519r40] 40.Al-Shaar L, Pernar CH, Chomistek AK, et al. Reproducibility, validity, and relative validity of self-report methods for assessing physical activity in epidemiologic studies: findings from the Women’s Lifestyle Validation Study. Am J Epidemiol. 2022;191(4):696-710. doi: 10.1093/aje/kwab294 [DOI] [PMC free article] [PubMed] [Google Scholar]

[zoi251519r41] 41.Bonnefoy M, Normand S, Pachiaudi C, Lacour JR, Laville M, Kostka T. Simultaneous validation of ten physical activity questionnaires in older men: a doubly labeled water study. J Am Geriatr Soc. 2001;49(1):28-35. doi: 10.1046/j.1532-5415.2001.49006.x [DOI] [PubMed] [Google Scholar]

[zoi251519r42] 42.Chasan-Taber S, Rimm EB, Stampfer MJ, et al. Reproducibility and validity of a self-administered physical activity questionnaire for male health professionals. Epidemiology. 1996;7(1):81-86. doi: 10.1097/00001648-199601000-00014 [DOI] [PubMed] [Google Scholar]

[zoi251519r43] 43.Milton K, Clemes S, Bull F. Can a single question provide an accurate measure of physical activity? Br J Sports Med. 2013;47(1):44-48. doi: 10.1136/bjsports-2011-090899 [DOI] [PubMed] [Google Scholar]

[zoi251519r44] 44.Pernar CH, Chomistek AK, Barnett JB, et al. Validity and relative validity of alternative methods of assessing physical activity in epidemiologic studies: findings from the Men’s Lifestyle Validation Study. Am J Epidemiol. 2022;191(7):1307-1322. doi: 10.1093/aje/kwac051 [DOI] [PMC free article] [PubMed] [Google Scholar]

[zoi251519r45] 45.Shiroma EJ, Cook NR, Manson JE, Buring JE, Rimm EB, Lee IM. Comparison of self-reported and accelerometer-assessed physical activity in older women. PLoS One. 2015;10(12):e0145950. doi: 10.1371/journal.pone.0145950 [DOI] [PMC free article] [PubMed] [Google Scholar]

[zoi251519r46] 46.Wolf AM, Hunter DJ, Colditz GA, et al. Reproducibility and validity of a self-administered physical activity questionnaire. Int J Epidemiol. 1994;23(5):991-999. doi: 10.1093/ije/23.5.991 [DOI] [PubMed] [Google Scholar]

[zoi251519r47] 47.Wasfy MM, Lee I-M: Examining the dose–response relationship between physical activity and health outcomes. NEJM Evid. 2022;1(12):EVIDra2200190. doi: 10.1056/EVIDra2200190 [DOI] [PubMed] [Google Scholar]

PERMALINK

Leisure-Time Physical Activity and Cancer Mortality Among Cancer Survivors

Erika Rees-Punia, PhD

Lauren R Teras, PhD

Christina C Newton, MSPH

Steven C Moore, PhD

I-Min Lee, ScD

Lauren Bates-Fraser, PhD

Kathryn E Chiang, PhD

Den E Bloodworth, BS

A Heather Eliassen, ScD

Lorelei Mucci, ScD

Brigid M Lynch, PhD

Meir Stampfer, DrPH

Mingyang Song, ScD

Kristen D Brantley, PhD

Konrad H Stopsack, MD

Charles E Matthews, PhD

Alpa V Patel, PhD

Key Points

Question

Findings

Meaning

Abstract

Importance

Objective

Design, Setting, and Participants

Exposures

Main Outcomes and Measures

Results

Conclusions and Relevance

Introduction

Methods

Study Population

Physical Activity Exposures

Mortality Outcomes

Statistical Analysis

Results

Table 1. Cancer Survivor Characteristics by Postdiagnostic Leisure-Time Physical Activity.

Postdiagnostic Physical Activity and Cancer Mortality

Figure 1. Forest Plot of Postdiagnosis Leisure-Time Moderate to Vigorous Intensity Physical Activity (MVPA) and Total Cancer Mortality Among Survivors of Bladder, Endometrial, Kidney, Lung, Oral Cavity, Ovarian, or Rectal Cancer.

Prediagnostic to Postdiagnostic Changes in Physical Activity and Cancer Mortality

Figure 2. Forest Plot of Physical Activity (PA) Guideline Adherence Before (Pre) and After (Post) Diagnosis and Total Cancer Mortality Among Survivors of Bladder, Endometrial, Kidney, Lung, Oral Cavity, Ovarian, or Rectal Cancer.

Stratified and Sensitivity Analyses of Postdiagnostic Physical Activity and Cancer Mortality

Table 2. Stratified and Sensitivity Analyses of Postdiagnostic Physical Activity.

Discussion

Strengths and Limitations

Conclusions

References

Associated Data

Supplementary Materials

ACTIONS

PERMALINK

RESOURCES

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