Across rural America, patients with cancer face more than just the burden of disease. They battle isolation, long travel distances, fragmented services, and limited access to rehabilitative care. At Self Regional Healthcare in Greenwood, South Carolina, we saw an opportunity to transform survivorship by integrating exercise into the cancer journey. Our Exercise Oncology Rehabilitation Program began as a fellowship project and has evolved into a scalable model of patient-centered, data-driven care that supports healing, strength, and dignity.
Begin With the Patient: A Story That Sparked a Movement
In 2015, a woman in her mid-60s was diagnosed with HER2-positive breast cancer. After completing chemotherapy and treatment with trastuzumab (Herceptin), she experienced profound fatigue. “I beat cancer,” she often said. “But I never got my life back.” Her cancer returned in 2019 with brain metastases, and during treatment, she became one of the first participants in our newly launched exercise oncology pilot.
Over the course of 3 months, she progressed from walking laps to using battle ropes. Her voice echoed through our clinic halls. “I feel like myself again.” She ultimately passed away 2 years later, but not before dancing at her granddaughter’s wedding and urging others to embrace movement. “I did more in those 2 years than I did after my first cancer treatment. Exercise gave me my life back.”
Why It Matters: Beyond Survival, Toward Strength and Dignity
Older patients with cancer are more likely to experience frailty, functional decline, and sarcopenia (loss of muscle tissue). In rural communities, these challenges are amplified by logistical and financial constraints. While the oncology field has made progress in survival, survivorship alone is no longer enough. Exercise interventions improve treatment tolerance, reduce toxicity, enhance mental health, and restore independence. These interventions represent a critical, underutilized pillar of cancer care, particularly in medically underserved settings.
Specifically, these studies offer strong data to support the integration of exercise in oncology:
The Innovation: From Fellowship Project to Institutional Program
We launched the program as part of a 2019 International Society of Geriatric Oncology training in Treviso, Italy, which focused on comprehensive education in the care of older adults with cancer. During that training, significant emphasis was placed on sarcopenia—its impact on patients’ QOL, treatment tolerability, and clinical outcomes—and on strategies to improve these, including early screening, nutritional support, and structured exercise interventions.
What began with just 2 patients quickly demonstrated promise: the model integrated strength, balance, and cardiovascular training alongside oncology treatment. Even in this early phase, patients reported meaningful improvements in mobility, flexibility, energy levels, and confidence—pushing us to make these services a part of cancer care at our institution.
Encouraged by this finding, the pilot program expanded to include patients across the cancer care continuum—from prehabilitation before surgery to patients in active treatment and to those in recovery. Referrals to these services more than doubled in 1 year, from 91 referrals in 2023 to 194 referrals in 2024, and 65 patients with cancer participating in “exercise prescriptions.” The model of care is now an integrated part of Self Regional’s cancer care service line and infrastructure.
How It Works: Program Design and Implementation
Patients are referred early, ideally at the time of diagnosis or first oncology appointment. In 2025, we incorporated a touchpoint within our multidisciplinary breast clinic, allowing patients to meet a trainer during their initial visit—reducing dropout and increasing trust. We also changed the name of our program at the end of 2024 from transitional rehab to exercise oncology, which met with much higher interest from patients. We are collecting data on why patients do not finish the program and what prevents them from participating in it. We also collect QOL data based on the EORTC QLG Core Questionnaire (EORTC QLQ-C30), a 30-item instrument designed to measure QOL in all patients with cancer.
Physical therapists assess patients in 3 domains: hand grip strength,4-7 range of motion, and the Timed Up and Go test, which evaluates a person’s gait, balance, and overall physical function. Patients are then stratified into 1 of 3 regimens:
The program consists of 36 1-hour sessions over 12 weeks, coordinated with treatment schedules to avoid chemotherapy weeks. Sessions occur at our community-based partner facility, Optimum Life.
Functional metrics are recorded before, during, and after the program. Patient-reported outcomes are gathered through standardized surveys.
COVID-19 and Rural Recovery
The COVID-19 pandemic disrupted referrals and delivery of these critical services. Yet 2024 marked a resurgence in interest and patient engagement. With support from the Self Regional Foundation, we expanded subsidies, improved workflows, and recommitted to accessibility. Despite these efforts, over 50% of referred patients do not complete the 12-week course. Common reasons include:
Clinical and Functional Outcomes
Among patients with complete data, range of motion and mobility improved across all cohorts. We saw a 7.3% improvement in handgrip strength; scores increased by 3.7 pounds. Patients have reported less fatigue and breathlessness, improved balance and confidence, and resumption of meaningful activities like gardening, attending church, and participating in social outings. Patients have shared these comments:
Dissemination and Validation
In 2025, we submitted a poster to the Rural Oncology Conference in Kansas, highlighting our pilot study on structured exercise for patients with cancer in a rural setting.8 Coincidentally, that same week, the CHALLENGE trial results were published in the New England Journal of Medicine, reinforcing the impact of exercise on disease-free survival in patients with colon cancer.3 This phase 3 randomized study demonstrated that a 3-year structured exercise program initiated shortly after adjuvant chemotherapy significantly improved disease-free survival in patients with resected colon cancer. While presenting our work, an attendee reflected, “I used to see patients struggling with fatigue and weight gain during treatment, and I would tell them, ‘Just finish treatment—exercise if you can.’ But now, after seeing these data, I realize it’s no longer optional. It’s our duty to help patients achieve this as part of their care.” This comment captured a paradigm shift: exercise is not an add-on, it’s a standard of care—one that must be accessible, actionable, and equitable, especially in rural communities.
Equity in Action: Rural Impact and Sustainability
Our Exercise Oncology Rehabilitation Program brings high-value supportive care to a population that is often left behind. The majority of our patients live in medically underserved zip codes. Many face food insecurity, low health literacy, and limited access to physical therapy or fitness services. Through partnerships with the Self Regional Foundation, we have reduced the financial burden. In 2024, twenty patients received care at no cost. However, long-term sustainability requires broader systemic support and payer recognition of the critical needs for these services.
Our workforce model is also built around a train-here-stay-here approach. Our Exercise Oncology Rehabilitation Program trains and retains local students through mentorship and hands-on experience. This initiative fosters a rural oncology rehabilitation workforce rooted in empathy and community ties. And we have plans to expand through:
A Model for Rural Replication
Our Exercise Oncology Rehabilitation Program is not just a service—it’s a reimagining of what survivorship looks like in rural communities. Through personalized care, data collection, and community partnerships, we empower patients to regain strength, reduce recurrence risk, and live with purpose. Our vision is simple but bold: No patient with cancer should be too far, too frail, or too forgotten to benefit from movement. We hope our model can help benefit patients across the country.
Joanna Metzner-Sadurski, MD, is director of Medical Oncology, Cancer Center and Director, Medical Oncology Laboratory at Self Regional Healthcare in Greenwood, South Carolina. She is also an assistant professor in the Department of Medicine at the Medical University of South Carolina; assistant professor, Department of Internal Medicine at the Edward Via College of Osteopathic Medicine – Carolinas Campus; and preceptor, Physician Assistant Program at Presbyterian College. Dr. Metzner-Sadurski is the principal investigator of the Self Regional NCORP Site. She is also a board member of the Self Regional Healthcare Foundation Board of Trustees and a board member of the South Carolina Oncology Society. Ruiling Yuan, MD, MSc, is dyad director of cancer services at Self Regional Healthcare in Greenwood, South Carolina. She is also an assistant professor in the Department of Medicine at the Medical University of South Carolina; an assistant professor of Internal Medicine at the Edward Via College of Osteopathic Medicine; and a clinical preceptor of the Physician Assistant Program at Presbyterian College. Dr. Yuan is a board member of the South Carolina Oncology Society.
Special thanks to Stephen Shenal, CPT, whose vision and dedication helped launch the Exercise Oncology Program at Self Regional Healthcare, and who continues to play a pivotal role in its ongoing success and patient impact.
References
Understanding both the benefits to be had from offering BsAb therapy to its community and the scope of this undertaking, Vanderbilt-Ingram Cancer Center took a novel approach with its APP-led BsAb step-up dosing clinic, which won the program a 2026 ACCC Innovator Award.
