Ep. 130 – How to SAFELY dose exercise for patients with cancer (part 1)

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A 1-rep max causes a vertebral fracture in a breast cancer survivor.

This is a loaded statement that we MUST unpack: A fabulous case report just came out discussing a vertebral fracture in 1 repetition maximum testing for a postmenopausal female after breast cancer treatment. The question is now: how do we safely assess & then prescribe exercise for our patients with a history (or currently experiencing) of cancer?

We know exercise is good. But how can we ensure safety?

Step 1: screen appropriately. Here’s some common risk factors for bone integrity issues.

  • Premenopausal women: chemotherapy with resultant ovarian failure, GnRH agonists, Tamoxifen
  • Postmenopausal women: aromatase inhibitors
  • Prolonged bisphosphonate therapy can increase risk of femoral insufficiency fractures
  • Androgen deprivation therapy is associated with significant bone loss & increase in fracture risk
  • Osteoporosis risk factors: general population: sex, age, race, family history, body frame size, hormone imbalances, diet patterns, steroids/other medications, medical conditions like cancer, sedentary lifestyle

Step 2: then screen some more:

  • “First, it shall be addressed whether and how the fracture during 1-RM testing could have been avoided. Here, the most relevant point is the previously unknown osteoporosis. The International Multidisciplinary Roundtable’s exercise guidelines for cancer survivors states that “among patients with bony metastases or known or suspected osteoporosis routine assessments of muscle strength and/or endurance involving musculature that attaches to and/or acts on a skeletal site that contains bone lesions should be avoided”.[3] In this case, osteoporosis was neither known nor suspected by the study team. The participant was a relatively old postmenopausal woman but she did not have a history of fractures and did not receive anti-cancer hormone therapy or other medication known to increase the risk of osteoporosis.” – Rosenberger article below

General recommendation: consider doing a multi-rep max test, such as 8-rep max, 10-rep max, or 12 rep-max.

We just scratched the surface, so stay tuned for next week’s part 2 on how to dose exercise for a patient with non-metastatic cancer.


  • Maltser S, Cristian A, Silver JK, Morris GS, Stout NL. A Focused Review of Safety Considerations in Cancer Rehabilitation. PM R. 2017 Sep;9(9S2):S415-S428. doi: 10.1016/j.pmrj.2017.08.403. PMID: 28942913; PMCID: PMC5627359.
  • Rosenberger F, Schneider J, Schlueter K, Paratte JL, Wiskemann J. Vertebral fracture during one repetition maximum testing in a breast cancer survivor: A case report. Medicine (Baltimore). 2021 May 21;100(20):e25705. doi: 10.1097/MD.0000000000025705. PMID: 34011028; PMCID: PMC8137013.
  • Ding H, Field TS. Bone health in postmenopausal women with early breast cancer: How protective is tamoxifen? Cancer Treat Rev. Jun 14 2007
  • Schwartz AL, Winters-Stone K, Gallucci B. Exercise effects on bone mineral density in women with breast cancer receiving adjuvant chemotherapy. Oncol Nurs Forum. May 2007;34(3): 627-633
  • Winters-Stone KM, Dobek JC, Bennett JA, Maddalozzo GF, Ryan CW, Beer TM. Skeletal response to resistance and impact training in prostate cancer survivors. Medicine and science in sports and exercise. 2014;46(8):1482-1488

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