International Research Conference

on Food, Nutrition & Cancer

Physical Activity and Cancer Prevention:

Etiologic Evidence and Biological Mechanisms1,2
Christine M. Friedenreich3 and Marla R. Orenstein
Division of Epidemiology, Prevention and Screening, Alberta Cancer Board, Calgary, Alberta, Canada, T2N 1N3

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ABSTRACT Scientific evidence is accumulating on physical activity as a means for the primary prevention of
cancer. Nearly 170 observational epidemiologic studies of physical activity and cancer risk at a number of specific
cancer sites have been conducted. The evidence for decreased risk with increased physical activity is classified as
convincing for breast and colon cancers, probable for prostate cancer, possible for lung and endometrial cancers
and insufficient for cancers at all other sites. Despite the large number of studies conducted on physical activity
and cancer, most have been hampered by incomplete assessment of physical activity and a lack of full examination
of effect modification and confounding. Several plausible hypothesized biological mechanisms exist for the
association between physical activity and cancer, including changes in endogenous sexual and metabolic hormone
levels and growth factors, decreased obesity and central adiposity and possibly changes in immune function.
Weight control may play a particularly important role because links between excess weight and increased cancer
risk have been established for several sites, and central adiposity has been particularly implicated in promoting
metabolic conditions amenable to carcinogenesis. Based on existing evidence, some public health organizations
have issued physical activity guidelines for cancer prevention, generally recommending at least 30 min of
moderate-to-vigorous intensity physical activity on ⱖ5 d/wk. Although most research has focused on the efficacy
of physical activity in cancer prevention, evidence is increasing that exercise also influences other aspects of the
cancer experience, including cancer detection, coping, rehabilitation and survival after diagnosis. J. Nutr. 132:
3456S–3464S, 2002.

KEY WORDS: ● cancer ● etiology ● prevention ● physical activity ● biological mechanisms

● exercise guidelines

Interest in physical activity as a means for the primary
prevention of cancer is increasing as the evidence for a pro-
tective effect is rapidly accumulating. Along with dietary
intake and tobacco use, physical activity may be one of the
main risk factors for cancer that can be modified through
lifestyle/behavior change. Clear public health recommenda-
tions and health promotion campaigns have been established
for diet (1) and tobacco (2) that would, if adopted, result in a
clear decreased incidence of cancer worldwide. A similar focus
is now being directed to the role of physical activity as a means
for reducing risk for some of the major cancer sites. This report
provides an updated review of the literature on physical ac-
tivity and cancer for each of the main cancer sites, an over-
view of the hypothesized biological mechanisms that may be
operative in the association between physical activity and
cancer risk at these sites, a summary of the public health
guidelines for physical activity for cancer prevention devel-
oped by health agencies worldwide and a brief description of
how physical activity can influence all aspects of the cancer
experience from prevention to palliation.
Review of evidence on physical activity and cancer
prevention

Nearly 170 observational epidemiologic studies have exam-

1
Presented as part of a symposium, “International Research Conference on ined the relation between physical activity and cancer preven-
Food, Nutrition & Cancer,” given by the American Institute for Cancer Research
and the World Cancer Research Fund International in Washington, D.C., July
tion at specific cancer sites. Assessments of the evidence for
11–12, 2002. This conference was sponsored by BASF Aktiengesellschaft; Cali- reduced risk with increased physical activity at each site are
fornia Dried Plum Board; The Campbell Soup Company; Danisco Cultor; Galileo examined here and are summarized in Table 1. The scientific
Laboratories, Inc.; Mead Johnson Nutritionals; Roche Vitamins, Inc.; and Yama- evidence for the association between physical activity and
nouchi/Shaklee/INOBYS. Guest editors for this symposium were Helen Norman
and Ritva Butrum, American Institute for Cancer Research, Washington, D.C. cancer is categorized according to the definitions developed
20009.
2
and used in the World Cancer Research Fund and American
Dr. Friedenreich was supported by a New Investigator career award from the Institute for Cancer Research report on diet and cancer pre-
Canadian Institutes of Health Research.
3
To whom correspondence should be addressed. vention (1). The categories used are “convincing,” “probable,”
E-mail: chrisf@cancerboard.ab.ca. “possible” and “insufficient.”

0022-3166/02 $3.00 © 2002 American Society for Nutritional Sciences.

3456S
 PHYSICAL ACTIVITY AND CANCER PREVENTION 3457S

TABLE 1
Summary of observational epidemiologic evidence on the association between physical activity and cancer

Strength of risk association

Consistency of Overall level
evidence for Range of risk Average risk Dose- of scientific
Cancer site decreased risk1 estimates reduction response2 evidence3

Colon 43 of 51 0.3–1.0 40–50% 25 of 29 Convincing

Breast 32 of 44 0.3–1.6 30–40% 20 of 23 Convincing
Prostate 17 of 30 0.5–2.2 10–30% 9 of 13 Probable
Endometrium 9 of 13 0.1–1.0 30–40% 5 of 6 Possible
Lung 8 of 11 0.4–1.3 30–40% 4 of 5 Possible
Testis 3 of 9 0.5–3.3 10–30% 3 of 3 Insufficient

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Ovary 3 of 7 0.3–2.5 20–30% 2 of 2 Insufficient
Kidney 2 of 6 NA4 NA 1 of 1 Insufficient
Pancreas 3 of 3 NA NA 2 of 2 Insufficient
Thyroid 2 of 2 NA NA NE5 Insufficient
Melanoma 2 of 2 NA NA 1 of 1 Insufficient

1 Of the total studies, number of studies demonstrating a reduction in risk of cancer with increased levels of physical activity.
2 Of the total studies examining trend, number of studies demonstrating a dose-response for decreased risk.
3 Definitions adapted from the World Cancer Research Fund and American Institute for Cancer Research (1). Convincing evidence is defined as
evidence that is conclusive; probable evidence indicates evidence is strong enough to conclude that a causal relation is likely; possible evidence
indicates a causal relation may exist; insufficient evidence indicates evidence is suggestive but too sparse to make a more definitive judgment.
4 NA, not applicable. Too few studies conducted to estimate a range in risk estimates.
5 NE, not examined.

Colon cancer. The most definitive epidemiologic evi-
dence for an association between physical activity and cancer
exists for colon cancer. Of the 51 studies conducted to date on
colon and colorectal cancer (3–53), 43 (3,6 – 47) demon-
strated a reduction in cancer risk among the most physically
active male and female participants. The risk reduction aver-
aged 40 –50%, and up to 70% reductions were found in some
studies when the highest and lowest activity levels were com-
pared within each study. Increasing levels of activity were
associated with a trend in decreasing risks of cancer in 25
(3,6 –29) of 29 (3,5–33,48 –50) studies that examined whether
a dose-response effect could be found. Despite varied and often
crude physical activity assessment methods used in these stud-
ies, a very consistent risk reduction was found with the differ-
ent designs and study populations. The effect was observed for
both occupational and recreational activity and does not ap-
pear to be confounded by other risk factors for colon cancer,
such as dietary intake or body mass index. Despite the strong
association found for colon cancer, there is agreement across
studies on the lack of an association between physical activity
and rectal cancer.
Breast cancer. The evidence for an association between
physical activity and breast cancer is neither as strong nor as
consistent as that found for colon cancer but can nonetheless
be classified as convincing, because ⬎20 studies conducted
worldwide have shown an association, and the risk reductions
are considerable. Of 44 studies conducted thus far, 32 (35,54 –
84) observed a reduction in breast cancer risk in women who
were most physically active. Increased breast cancer risk was
found with increased physical activity in only two studies
(85,86) and the remaining studies found no association (3,87–
95). Of the 32 studies that observed a decreased breast cancer
risk, the reduction in risk was on average 30 – 40%. Evidence
for a dose-response relation between increasing activity levels,
however defined, and decreased breast cancer risk was found in
20 (54, 56 –74) of 23 (54 –76) studies that examined the trend.
The inconsistent outcomes observed among studies can be
attributed in part to methodological differences in assessing
physical activity across these studies and in part to the fact
that the relation between physical activity and breast cancer
risk probably differs among subgroups of women, which has
not been fully examined in previous research. In addition, the
biological mechanisms for breast cancer are likely to be more
complex than those for colon cancer, which may complicate
the association and make it somewhat less clear to examine.
Prostate cancer. The evidence for an association between
physical activity and prostate cancer is less consistent than
that for either colon or breast cancer and can be classified only
as probable. To date, 15 (5,26,35,51,52,96 –105) of 30 studies
have found a reduction in prostate cancer risk in men who
were most physically active, with risk reductions averaging
10 –30%. Two other studies found decreased risk only in
subgroups of the population (106,107). No associations were
found in nine (3,4,30,108 –113) studies, and increased risk was
found in four (114 –117) studies. Some particular methodolog-
ical issues have uniquely influenced prostate cancer studies and
may in part explain the inconsistencies found across these
studies. For prostate cancer, high levels of activity may be
needed to influence hormone levels that are potentially im-
plicated in the etiology of this cancer (118). The majority of
these studies did not have a sufficient number of study subjects
who attained very high levels of activity. If a threshold effect
exists, few of the studies conducted thus far would have been
able to detect an association. Furthermore, most studies ex-
amined activity done later in life, closer to the time of the
cancer diagnosis. However, physical activity performed early
in life may be the most etiologically relevant for prostate
carcinogenesis (118). A lack of understanding remains about
the natural history of prostate cancer and hence the etiologic
role of physical activity, including the biological mechanisms
and relevant time periods in prostate carcinogenesis, are still
unknown.
Endometrial cancer. There have been 13 (3,83,85,119–
128) studies of endometrial cancer, of which 9 (83,119–126)
have found evidence for decreased risk with increased levels of
physical activity. The risk reductions have ranged quite widely in
these studies from 0 to 90%, with an average reduction around
30 – 40%. Some evidence exists for a dose-response effect; six
3458S SUPPLEMENT
(3,121–127) studies examined this trend, and of those, five (121–
125) have found decreasing risks with increasing levels of activity.
Given the strength of the association of endometrial cancer with
breast cancer and the comparable etiologies, the possibility that
physical activity might influence endometrial cancer etiology is
considered fairly high. More research is needed to solidify the
evidence; hence this site can be listed only as being possibly
associated with physical activity.
Lung cancer. Physical activity as a risk factor has been
examined in 11 studies of lung cancer (3,5,26,30,51,52,129 –
132), of which 8 (4,5,30,51,52,129 –131) found a risk reduc-
tion. Because the reductions in risk have been around 30 –
40%, the evidence for this site can also be classified as being
possibly associated with physical activity. The most important
confounder for this site is smoking status, and appropriate
control for this confounder was made in these studies.
Other cancer sites. Fewer studies have been conducted on
the role of physical activity in reducing risk of cancer at other
sites. Physical activity as a risk factor was examined in nine
studies of testicular cancer (3,4,26,133–137), seven studies of
ovarian cancer (3,83,85,138 –141), six studies of renal cell
(kidney) cancer (4,52,142–145), three studies of pancreatic
cancer (4,146,147) and two studies each of thyroid cancer
(4,148) and melanoma (4,149). These studies have provided
some preliminary indications of the role of physical activity;
however, the level of evidence is still too limited to make any
statements regarding causal associations and must be classified
as insufficient. Preliminary evidence suggests that physical
activity may influence cancer risk at several of these sites,
particularly the pancreas and thyroid, but results need to be
corroborated before any conclusions can be made.
Methodological considerations
Assessment of physical activity. To assess accurately the
relation between physical activity and cancer risk, reliable,
valid and comprehensive measures of physical activity must be
used. To date, there has been little standardization in the
methods used for assessing physical activity in epidemiologic
studies, and few methods have been appropriately tested for
reliability and validity. The use of crude measures of physical
activity has led to a large possibility of measurement error and
difficulty in determining the true nature of the relation be-
tween physical activity and breast cancer risk.
For a complete analysis, all components of physical activity
need to be assessed. These include type (physical activity is
often thought of as recreational activity or exercise but mod-
erate-to-high intensity occupational and household activities
have also been implicated in reducing cancer risk and impor-
tant differences may exist between resistance and endurance/
aerobic activity), frequency (e.g., number of days per week),
duration (e.g., number of hours per day), intensity [e.g., num-
ber of metabolic equivalents (150) or energy expended] and
activity levels throughout the participant’s entire lifetime—
information crucial for assessing the relevant times in life
when physical activity influences the risk of developing
cancer.
These parameters of physical activity have not been mea-
sured consistently in epidemiologic studies. Most studies have
relied on recall surveys, with time frames ranging from 1 week
to a lifetime. Many have focused on only one type of physical
activity, such as recreational exercise, or have classified activ-
ity level by occupation. The level of detail captured on phys-
ical activity has ranged from quantitative histories that assess
all types of activity—the frequency, duration and intensity of
activity— over entire lifetimes (151) to a single global ques-
tion that assesses, for example, only the frequency of current
recreational activity (e.g., How often do you exercise?). These
latter types of questions miss information on the full dose of
the activity and all other types of activity, leading to substan-
tial misclassification of exposure and possibly to a decreased
ability to detect an inverse association.
Subgroup effects. Cancer risk differs across subsets of the
population. This difference in risk is demonstrated clearly in
the established relation between obesity and breast cancer, in
which obesity increases the risk of breast cancer in postmeno-
pausal women but not in premenopausal women (152). Phys-
ical activity also may have different associations within
population subgroups. Some of the subgroups that may be
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expected to respond differently to physical activity can be
partitioned along the lines of sex, age, race, energy intake,
weight or body mass index or level of athletic fitness. Each of
these factors may modify the effects of physical activity on
cancer outcome. Studies that fail to examine effects by sub-
groups may be difficult to interpret; information on the sub-
group being assessed is important when comparing studies.
Relatively few studies on physical activity and cancer risk
reduction have been conducted with study samples with het-
erogeneous racial and ethnic backgrounds. The majority of
studies examining the relation between physical activity and
cancer risk have been conducted in Western countries, pri-
marily with whites. Results from these studies therefore may
not be applicable to populations with different lifestyle habits
and levels of energy intake.
Confounding Because the etiology of all of these cancer
sites is multifactorial, the observed relation between physical
activity and cancer risk may be attributable partly to a lack of
consideration of other confounding risk factors. Physical ac-
tivity may be associated with other generally healthy behaviors
in the areas of dietary intake, smoking, alcohol intake, weight
maintenance or regular medical screening, all of which have a
known association with cancer risk. More recently published
studies have generally evaluated more completely the influ-
ence of possible confounding factors, whereas several of the
earlier studies adjusted only for age.
Types of studies. A last methodological consideration is
that the existing epidemiologic evidence on the association
between increased physical activity and decreased cancer risk
has been based entirely on observational studies. Observa-
tional studies have provided important preliminary infor-
mation regarding etiologic associations but not any direct
evidence regarding the underlying biological mechanisms
whereby physical activity influences cancer risk. Hence, there
is a need to conduct controlled, clinical trials that examine the
effects of exercise on specific biological mechanisms (153).
Possible biological mechanisms
An understanding of the biological mechanisms operative
in the association between physical activity and cancer risk is
needed to understand more completely how changes in phys-
ical activity can influence cancer risk. Specifically, this under-
standing would allow more appropriate public health recom-
mendations to be developed that would maximize the
effectiveness of physical activity for cancer risk reduction
because the exact type, dose and time periods in life when
activity influences cancer risk at a physiological level would be
understood.
The underlying mechanisms operative in the association
between physical activity and cancer have not been estab-
lished; however, several plausible biological mechanisms have
been proposed (Table 2). These hypothesized mechanisms
 PHYSICAL ACTIVITY AND CANCER PREVENTION
TABLE 2
Biological mechanisms that may be involved in the association between physical activity and cancer1
Cancer site Possible mechanisms involved
Colon Decreased gastrointestinal transit time
Decreased ratio of prostaglandins
Lowered bile acid secretion or enhanced acid
metabolism
Breast Decreased lifetime exposure to estrogen
Prostate Reduced exposure to testosterone
All cancers, especially Decreased percent body fat
breast, endometrial and
ovarian
All cancers Genetic predisposition of habitually active people
Exercise-induced increase in antitumor immune
defenses
Improved antioxidant defense systems
Decreased circulating insulin and glucose
Decreased insulin and insulin-like growth factors
(IGFs)
1 Adapted from Friedenreich (154) with permission.
include changes in endogenous sexual and metabolic hormone
levels (155,156) and growth factors (157), decreased obesity
and central adiposity (152) and possibly changes in immune
function (158).
Physical activity appears to lower levels of biologically
available sex hormones, which could lead to decreased risk of
hormone-related cancers, including cancers of the breast, en-
dometrium, ovaries, prostate and testes. Increased lifetime
exposure to endogenous estrogens through natural reproduc-
tive events (e.g., early menarche, late age at menopause, late
age at first birth, lack of lactation or increased number of
ovulatory cycles) or through individual variation in estrogen
levels is known to increase the risk of breast cancer in both
premenopausal and postmenopausal women. Prostate cancer
has been linked with increased levels of biologically available
testosterone in men. Physical activity may affect risk of these
hormone-related cancers not only by decreasing the endoge-
nous production of estrogens and androgens but also by in-
creasing amounts of circulating sex-hormone binding globulin,
which binds to these sex hormones and reduces their ability to
influence target tissues.
Other metabolic hormones and growth factors may also be
reduced with increasing physical activity. Regular physical
exercise significantly lowers insulin levels, which may be as-
sociated with decreased cancer risk (159). Exercise may also
affect cancer risk through its effects on insulin-like growth
3459S
Rationale
Physical activity increases gut motility and reduces
mucosal exposure time to carcinogens.
Strenuous exercise may increase prostaglandin (PG) F,
which inhibits colonic cell proliferation and increases gut
motility while not increasing PGE2, which affects colonic
cell proliferation, opposite to the effect of PGF.
Bile acid concentrations may be decreased in physically
active (confounding by diet?) persons.
Physical activity delays menarche, reduces the number of
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ovulatory cycles, and reduces ovarian estrogen
production. It also reduces body fat and could reduce
fat-produced estrogens. It increases the production of
sex hormone–binding globulin, resulting in less
biologically available estrogen.
Physical activity increases production of sex
hormone–binding globulin, resulting in lower levels of
free testosterone.
Obese women have increased infertility, which may
increase breast cancer risk. Fat storage of carcinogens
can occur in visceral fat, which can be released in
overweight individuals.
Constitutional factors influence athletic selection or interest
in physical activity and susceptibility to cancer.
Exercise may increase number and activity of
macrophages, lymphokine-activated killer cells and their
regulating cytokines; it may increase mitogen-induced
lymphocyte proliferation.
Strenuous exercise increases the production of free
radicals, whereas chronic exercise improves free radical
defenses by up-regulating both the activities of free
scavenger enzymes and antioxidant levels.
The extent of exercise-induced changes in oxidant
defenses is unknown.
Increased exercise may decrease levels of insulin and
bioavailable IGF-I, both of which enhance division of
normal cells and inhibit cell death.
factors (IGFs)4 (157), because high levels of circulating IGF-I
have been associated with increased risk of colorectal, breast,
prostate and lung cancers (160 –163). There is mixed evidence
from studies on the influence of exercise on IGF-I levels
(164,165), although this effect may vary by population and
type of activity. The evidence is more consistent that physical
activity, decreased energy intake and decreased body weight
have all been shown to increase levels of IGF binding pro-
tein-3, which binds to IGF in the blood and decreases its
ability to affect potential cancer sites (157).
Weight control
Of the possible biological mechanisms mediating an asso-
ciation between physical activity and cancer prevention,
weight control may be particularly important. Weight control
and physical activity are very strongly associated through the
concept of energy balance—whether an individual consumes
and expends the same amount of energy. A positive energy
balance results in increased weight and increased fat mass, or
adiposity; a negative balance results in weight loss; and a
balance results in the maintenance of a stable body weight.
Energy intake comes solely through food consumption but
4
Abbreviation used: IGF, insulin-like growth factor.
3460S SUPPLEMENT
TABLE 3
Public health recommendations on physical activity
and cancer risk reduction1
• Physical activity recommendations should be included in primary
prevention interventions for cancer prevention.
• All messages for physical activity should be in the context of
reducing the risk of cancer rather than of preventing cancer.
• To reduce cancer risk, physical activity should compose at least
30 to 45 minutes of moderate-to-vigorous activity on most days of
the week.
• Examples of moderate and vigorous physical activities should be
provided as part of messaging; these should include activities
appropriate to various age, sex and culture groups.
• Messaging should recognize the variation in maximal
cardiorespiratory capacity within the population. For example,
because maximal capacity declines, on average, with increasing
age, the upper end of the recommended activity level (i.e., 45
minutes of vigorous exercise) is in general more appropriate for
youth, and the lower end (i.e., 30 minutes of moderate exercise) is
more appropriate for the elderly. Recommended activity levels for
those who have been sedentary should initially be less than for
those who are already active.
• Physical activity messages can be linked to other risk reduction
messages, such as maintaining a healthy body weight.
• Physical activity should be encouraged at all ages.
• Advocacy is required for policies and environmental supports for
physical activity.
• A surveillance and measurement system should be implemented
for tracking population levels of physical activity.
1 Reprinted from Marrett et al. (171) with permission.
energy is expended in one of three ways: through the basal/
resting metabolic rate, physical activity and the thermic effect
of digesting food (166). The basal metabolic rate represents
the energy expended to maintain normal body functions,
including respiration, circulation, endocrine secretion, kidney
filtration, etc. Physical activity refers to voluntary physical
activities, such as walking, jogging or climbing stairs, in which
energy is mainly expended through muscle action. The diges-
tion, absorption and metabolism of food also represent signif-
icant energy expenditures. The amount of energy that is re-
quired depends in part on the composition of the food; dietary
fats, for example, are more readily converted to body fat and
require less energy to do so than do carbohydrates. Although
the amount of energy expended through physical activity can
be adjusted voluntarily, the energy expended through metab-
olism and through digestion of food is governed by a number
of endogenous and exogenous factors, including metabolism,
genetics and endocrine responses (167). Energy balance has
become an important concept in exploring the etiology of a
number of chronic diseases, including cancer, because of its
close association with weight gain and overweight, conditions
known to increase the risk of many chronic diseases.
Epidemiologic studies have shown positive associations be-
tween various measures of overweight and adiposity and a
variety of cancers. There is moderate-to-strong evidence for
greater body weight being associated with increased risk of
colon, kidney, esophagus, endometrium, thyroid and post-
menopausal breast cancer (168). However, greater weight ap-
pears to protect against premenopausal breast cancer and lung
cancer, although the latter association may be confounded by
cigarette use. Abdominal fat (as opposed to fat accumulated on
other parts of the body, such as the hips or buttocks) is
particularly metabolically active (169) and may confer greater
disease risk than fat deposited elsewhere (170).
One mechanism whereby physical activity may prevent
cancer development is through a reduction in abdominal fat
mass. Although both decrease in dietary intake and increase
in physical activity are effective in decreasing body weight,
physical activity appears in some studies to preferentially
reduce intra-abdominal fat (170) and is more strongly as-
sociated with weight maintenance after a weight loss inter-
vention. Another possible link among excess body weight,
physical inactivity and cancer risk is through hormone
metabolism. Both obesity and physical inactivity cause
problems with insulin metabolism, which in turn leads to
disease-inducing alterations in blood glucose, IGF-I, IGF-
binding proteins, sex hormones and sex hormone– binding
globulin.
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Both physical activity and weight reduction are impor-
tant risk factors for cancer, and although they are strongly
linked, each appears to confer an independent benefit to
reduce cancer risk. The International Agency for Research
on Cancer has estimated that between one fourth and one
third of cancer cases may be attributable to the combined
effects of elevated body weight and inadequate physical
activity (168).
Summary of biological mechanisms
Other biological mechanisms for the association between
physical activity and cancer risk have been proposed, and it is
likely that multiple, interrelated actions are involved. How-
ever, the level of scientific evidence for any of these possible
mechanisms is still minimal, and much further research is
needed to determine which mechanisms are operative for each
type of cancer.
Public health recommendations for cancer prevention
On the basis of the existing evidence, public health orga-
nizations have issued physical activity guidelines for individ-
uals, with the intention of reducing cancer rates in the general
population. These organizations (including the American
Cancer Society, U.S. Department of Health and Human Ser-
vices, International Union against Cancer, World Cancer
Research Fund and American Institute for Cancer Research,
Harvard Center for Cancer Prevention, Canadian Cancer
Society and Health Canada) have generally recommended a
minimum of 30 min/d of moderate-to-vigorous intensity ac-
tivity on 5 d/wk or more. Moderate-to-vigorous intensity ac-
tivity is any physical activity that raises the heart rate or causes
the individual to sweat. Examples include brisk walking, rec-
reational sports and heavy housework or yard work.
The Workshop on Physical Activity and Cancer Preven-
tion convened in March 2000 by Cancer Care Ontario (171)
developed recommendations for practitioners and health pro-
fessionals on appropriate ways and contexts in which to con-
vey these physical activity guidelines to the general public.
These recommendations are summarized in Table 3.
Physical activity in other aspects of cancer
Although most attention has been focused on the efficacy
of physical activity in cancer prevention, it must be empha-
sized that physical exercise may also be useful in improving
other aspects of the cancer experience. Figure 1 provides a
conceptual model for organizing research into the antecedents
and consequences of physical exercise for cancer control.
Framework PEACE (Physical Exercise Across the Cancer Ex-
perience) (172) (Fig. 1) highlights the need to examine phys-
ical exercise across each of six discrete time periods that
 PHYSICAL ACTIVITY AND CANCER PREVENTION
FIGURE 1 Framework PEACE: an organizational model for examining when and how physical exercise may affect the cancer experience.
demarcate the cancer experience and for each of eight general
cancer control outcomes that may be amenable to physical
exercise interventions. As shown at the bottom of the figure,
research is already under way for several time periods and
outcomes.
Conclusion
The evidence for a beneficial effect of physical activity on
cancer incidence is accumulating rapidly and can be classified
as “convincing” for colon and breast and “probable” for pros-
tate. To increase our understanding of the possible etiologic
role of physical activity in cancer etiology, it will be necessary
to conduct more well-designed studies that include detailed,
quantitative lifetime histories of physical activity and examine
the effects across varied populations and subgroups of popula-
tions. More consideration of the underlying biological mech-
anisms that are operative is also necessary both to refine the
scientific understanding of the causal pathways between activ-
ity and cancer incidence and to provide public health recom-
mendations regarding physical activity and weight control as
means for the primary prevention of cancer. Based on the
current level of knowledge, general recommendations can be
made for the public that are aligned with those developed for
other major chronic diseases. When each cancer site has
accumulated more specific dose information, more detailed
recommendations for physical activity and cancer prevention
can be formulated. Until then, sufficient evidence already
exists to recommend that the general population try to achieve
at least moderate intensity activity of a minimum of 30 min/d
on 5 d/wk or more. For some cancer sites, the level of activity
required may be vigorous and the duration of the activity may
be at least 45– 60 min. At this time, these public health
guidelines on physical activity for cancer prevention are pre-
3461S
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liminary. However, given the clear health benefits for physical
activity for many other chronic diseases, adoption of these
guidelines for cancer prevention can be considered sound
public health practice without harmful consequences. In fact,
given the high level of obesity and inactivity in the population
and the clear economic and health burdens on society because
of these two major modifiable lifestyle risk factors, urgency
exists to ensure that the general population becomes more
active.
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