The research team used a qualitative design grounded in interpretive description, a methodology suited to generating practical insights for clinical settings. They invited members of the clinical team involved in the referral to and delivery of ACE-Neuro to participate in semi-structured interviews, conducted either in person or remotely. Ten clinical team members ultimately took part, with interviews averaging just under thirty-six minutes. The analysis was carried out by a transdisciplinary team that included collaboration with a neuro-oncology clinical partner, ensuring that the interpretation of the data remained anchored in the realities of patient care. From those interviews, three major themes emerged, each pointing to a different layer of the implementation challenge: the mechanics of referral, the design of the exercise programming itself, and the policy and funding environment that ultimately determines whether such programs survive.

The first theme, described by the researchers as the Gateway, centered on optimizing exercise referral in neuro-oncology. Clinicians involved in the study perceived an electronic medical record referral pathway as feasible, a finding with significant practical implications. In many cancer centers, exercise programs exist but patients never reach them because there is no systematic mechanism to connect a clinical encounter with a community or hospital-based exercise service. Referrals often depend on individual clinicians remembering to raise the topic, on paper-based processes, or on patients advocating for themselves. An embedded electronic referral pathway would formalize the connection, making exercise a routine part of the care plan rather than an optional add-on. The clinical team’s assessment that such a pathway is workable suggests that the technical and workflow barriers are surmountable, provided institutions commit to building them.

The second theme, the Building Blocks, addressed the delivery model itself. Here the message from clinicians was unambiguous: tailored exercise is non-negotiable for neuro-oncology patients. Unlike many other cancer populations, people with primary brain tumors face a distinctive constellation of challenges, including seizures, cognitive and perceptual changes, motor deficits, fatigue, and the effects of medications such as anticonvulsants and corticosteroids. A generic cancer exercise class is not equipped to manage these complexities. The ACE-Neuro program was designed as a multi-site, clinic-supported, and tailored exercise oncology program specifically for this population, and the clinicians interviewed for the study championed this individualized approach as essential. Their perspective reinforces a growing consensus in exercise oncology that the principle of exercise as medicine only holds when the prescription is adapted to the patient’s clinical status, functional abilities, and personal goals.

The third theme reached beyond the clinic walls entirely: neuro-oncology, the researchers concluded, needs a stronger voice in funding and policy. Clinicians and administrators identified funding and policy as major barriers to sustainable exercise programming. This is the step backward in the study’s framing of one step forward, two steps back. Even when a program demonstrates feasibility and effectiveness, it often exists on short-term grant funding, leaving patients and providers in a cycle of launching, evaluating, and then losing services. Without administrative and policy support, access to supportive care resources for people living with brain cancer remains precarious. The study’s authors argue that bridging policy and system-level strategies is key to long-term program sustainability, and that the field must advocate for exercise services to be embedded within funded cancer care structures rather than depending on the goodwill of researchers and volunteers.

The context for this work is sobering. Brain tumors carry a substantial burden of physical and psychological morbidity, and research has documented inequalities in access to neuro-oncology supportive care and rehabilitation. Survival for some brain tumor types remains poor, which has historically contributed to a therapeutic nihilism in which supportive care services like exercise were deprioritized. Yet for the growing population of longer-term survivors, and for patients at every stage of the disease trajectory, quality of life matters. Studies have linked health-related quality of life and psychological functioning to clinical and demographic factors in patients with primary malignant brain tumors, and the broader exercise oncology literature has established that physical activity can improve fitness, function, and well-being across cancer types. What has been missing in neuro-oncology is the translation of that evidence into accessible, tailored services.

The ACE-Neuro study itself was implemented and evaluated for feasibility and effectiveness precisely to address the lack of an exercise referral pathway and tailored programming in neuro-oncology care. The program is registered as a clinical trial, and earlier publications from the team have reported on its feasibility across multiple sites and on an oncology rehabilitation triage clinic that assessed rehabilitation and exercise need within the study. A companion qualitative study captured the patient and caregiver experience of the program, while the present study completes the picture by documenting the clinical perspective. Together, this body of work illustrates a central tenet of implementation science: a program’s success depends not only on whether it helps participants, but on whether the systems around it, from referral workflows to funding streams, can support its delivery at scale.

The implications for cancer survivors are direct. From the perspective of clinicians, integrating exercise into routine neuro-oncology care requires methodical referral pathways and tailored exercise program delivery. Patients should not have to discover exercise programs on their own or rely on a single motivated physician to connect them. When referral is built into the electronic medical record and the programming is genuinely individualized, access to evidence-based and personalized neuro-oncology exercise resources can expand. At the same time, the study is a reminder that individual programs, however well designed, cannot substitute for structural change. The clinicians in this study were strong champions of exercise within neuro-oncology supportive care, but champions burn out when the systems around them do not evolve.

The study also highlights the value of qualitative research in health care implementation. While randomized trials can establish whether an intervention works under controlled conditions, qualitative studies reveal why implementation succeeds or stalls in the real world. By using interpretive description and involving a transdisciplinary team with clinical collaboration, the researchers were able to surface practical, actionable insights: that electronic referral is perceived as feasible, that tailoring is viewed as essential rather than optional, and that funding and policy are the decisive barriers. These findings align with broader implementation frameworks that emphasize the need to intervene at multiple levels, from individual clinician behavior to organizational structures and policy environments, rather than expecting a single-point solution to transform care.

For the neuro-oncology community, the path forward suggested by this research involves three coordinated efforts. First, health systems should optimize referral pathways, leveraging electronic medical records to make exercise referral as routine as any other clinical order. Second, programs must champion tailored delivery models that account for the unique neurological, cognitive, and medication-related considerations of brain tumor patients, supported by trained exercise specialists working alongside clinical teams. Third, and perhaps most critically, the field must build a stronger voice in funding and policy conversations, securing the administrative and governmental support needed to keep programs running beyond the lifespan of a research grant. One step forward has been taken: clinicians believe in exercise for brain cancer patients and have shown that tailored programs can work. The next steps, embedding referral into routine practice and locking in sustainable funding, will determine whether that progress endures or slips back into the status quo.

Subject of Research: Clinical perspectives on implementing tailored exercise programs and referral pathways in neuro-oncology care

Article Title: One step forward, two steps back: a qualitative study of clinical perspectives on implementing exercise in neuro-oncology care

Article References: Daun, J. T., Roldan Urgoiti, G., Bansal, M., McDonough, M. H., Capozzi, L. C., Easaw, J. C., McNeely, M. L., Francis, G. J., & Culos-Reed, S. N. (2026). One step forward, two steps back: a qualitative study of clinical perspectives on implementing exercise in neuro-oncology care. Journal of Cancer Survivorship. https://doi.org/10.1007/s11764-026-02113-2

Image Credits: AI Generated

DOI: 10.1007/s11764-026-02113-2

Keywords: neuro-oncology, exercise oncology, brain tumors, cancer survivorship, referral pathways, qualitative research, implementation science, supportive care, ACE-Neuro, health policy, funding sustainability, rehabilitation