Exercise is now embedded in survivorship guidelines, yet the prescription itself has barely changed in two decades. Most survivors are offered the same aerobic and resistance targets regardless of their cancer, their treatment exposure, or the physiological reason they are limited. Cardiovascular outcomes from this one-size-fits-all approach have been inconsistent, and in some groups the response to training is blunted.
This presentation will make the case that the problem is not exercise, but how we prescribe it. Exercise intolerance after cancer therapy is rarely explained by the heart alone. Non-invasive oxygen-pathway phenotyping shows that limitation may sit anywhere along the cascade, from cardiac output and haemoglobin mass to coronary microvascular function and skeletal muscle oxygen extraction, and that survivors with identical peak VO₂ can have entirely different reasons for it. A precision approach would match the intervention to the limitation and deliver it at the point in the treatment trajectory where it can still modify risk. Precision must not mean exclusivity: the survivors at highest cardiovascular risk are often those least able to attend a hospital-based program, and digital and remote-monitoring platforms offer a realistic route to scaling individualised prescription into rural and under-served communities. I will outline what is already achievable in Australian practice, what remains aspirational, and the trial designs needed to close that gap.