To our knowledge, this is the first study that assesses sociodemographic and contextual determinants of receiving exercise advice from healthcare providers solely among breast cancer survivors. Breast cancer survivors have unique needs relating to exercise; for instance, due to adverse effects of treatment, preexisting conditions, and lower exercise participation following diagnosis, women with breast cancer may have a higher risk of cardiovascular disease-related mortality than the general population [38, 39]. Additionally, breast cancer survivors may face reduced muscular strength and mobility due to treatment-related side effects [40, 41]. Therefore, it is important that clinicians discuss the benefits and potential risks of exercise with these women.

Our results show that only about half of the older breast cancer survivors (52.3%) had received exercise advice from their healthcare providers. This is consistent with a previous study [29] using the SEER-MHOS dataset (2008–2014), which found that only about half (53.4%) of older breast, colorectal, and prostate cancer survivors reported discussing exercise with their healthcare providers. Previous studies not specific to the cancer survivor population have also shown that, among adult patients, only about half (50.2%) of healthcare providers counsel their patients on either diet, exercise, or weight control [34, 42,43,44]. Healthcare providers cite numerous reasons for limited engagement in discussions about exercise in clinical practice, including the lack of time and clinical tools to support personalized discussions [22,23,24, 45]. Providers, especially those in primary care, report feeling time pressure during their visits with patients [46], and often there is not enough time for them to discuss exercise. Providers also report feeling like they have a lack of expertise and knowledge about exercise [47, 48]. Survey studies have shown that clinicians may not be aware of the current exercise guidelines, as it remains absent from the formal education of many healthcare professions [47, 48]. Additionally, providers may not be aware of the different types, frequency, and duration of exercise that a patient may need based on the patient’s risk of cardiovascular disease and other comorbidities [49, 50]. Healthcare providers who offer advice to cancer survivors may focus on discussing the benefits of exercise for physical and functional health gains rather than discussing the full range of benefits that exercise may offer breast cancer survivors, including improvements in quality of life during treatment [19]. Thus, it is important that clinicians are provided training and education about exercise, information on referral programs, and training on how to discuss exercise effectively in different patient populations.

We found that sociodemographic and contextual factors in this population are associated with the likelihood of receiving advice about exercise from a healthcare provider. Overall, lower levels of education were associated with a lower likelihood of receiving advice about exercise from a healthcare provider. A similar relationship was observed in non-Hispanic White and Hispanic women; however, these subgroup analyses were considered exploratory due to limited sample size. While we observed a strong relationship between lower levels of education and lower likelihood of being advised about exercise, potential reasons for this are unclear. Educational attainment has been shown to be a significant predictor of pre-existing exercise levels, with lower levels of education associated with less exercise [51]. This relationship could be driven by lower exercise self-efficacy, low income stability, and limited social support associated with lower levels of education [52]. It is possible that patients may have prompted this discussion among providers. It may be important to develop targeted interventions to increase discussions and exercise participation among these individuals since lower levels of education are associated with other concurrent, intersecting challenges to survivorship, including obesity, morbidity, and mortality [51]. Additionally, providers should consider a patients’ level of health literacy when delivering exercise advice; information should be given to patients at a level that they can understand in order to increase their self-efficacy, enabling them to feel confident about exercising [53, 54].

We also observed that survivors who had never been married were significantly less likely to report receiving exercise advice than those who had been married. However, studies show that married women report higher levels of exercise and leisure time activity compared to their single counterparts [13]. This may be explained by the marriage protection theory, which suggests that marriage provides health benefits due to increased social and financial support [55]. It is essential for providers to consider encouraging survivors who have never been married to also pursue exercise, especially among those who may not have access to other avenues of social support, given the potential benefits of marriage.

Among clinical factors, BMI had the strongest association with receiving exercise advice among breast cancer survivors. Older breast cancer survivors who had overweight or obesity showed a higher likelihood of receiving exercise advice. While there may certainly be additional benefits to exercise relevant to these populations, this can also potentially feed into pre-existing biases by providers that alienate patients of greater weight and worsen health outcomes if advice is not delivered effectively, while not adequately serving patients of normal weight who may benefit from greater muscle mass/functional status. Additionally, compared to normal weight, underweight survivors had a lower likelihood of receiving exercise advice. Underweight older survivors may be nearing death, so it might be inappropriate for clinicians to recommend exercise to these individuals [56].

With advancing age, breast cancer survivors were less likely to receive exercise advice from their healthcare providers, even when considering comorbidities. This is particularly concerning given that older women participate in the least exercise [57]. There could be inadvertent bias against older patients, where providers may have negative ageist stereotypes that may lead to poorer quality of care [58]. Providers need to encourage older breast cancer survivors to exercise, and future interventions are needed to ensure that providers deliver advice effectively to this patient population. Providers may consider offering exercise advice while considering different modalities, such as home-based exercise, that may increase exercise among this patient population [59].

Diabetes, cardiovascular, and musculoskeletal diseases were also associated with a higher likelihood of receiving exercise advice from a healthcare provider. However, in our study, pulmonary disease and hypertension were not associated with the receipt of exercise advice. Interestingly, prior studies have shown that exercise significantly reduces morbidity and mortality related to all of these conditions [60,61,62,63,64], encouraging the possibility of providers to expand the patients with comorbidities whom they encourage to exercise.

The intersection of cultural factors with the factors that we measured may influence breast cancer survivors’ ability to exercise, and these factors should be considered when providers engage in discussions about exercise with their patients. For example, in our study, we found that non-Hispanic American Indian/Alaska Native/Asian or Pacific Islander breast cancer survivors had a greater likelihood of receiving exercise advice. These findings are encouraging considering the lower levels of exercise [65,66,67,68] and higher rates of obesity and comorbidities reported in these groups [69]. Previous studies have shown that American Indian and Alaska Native women were more likely to exercise if they had higher levels of social support [70, 71]. However, most existing exercise interventions have failed to incorporate community-based strategies to help these women rely on their social environments [71]. Similarly, Asian American women report cultural reasons, lack of time due to keeping their traditions, and feeling like exercise was not appropriate for women as reasons for not exercising [72]. Community-based and culturally relevant exercise interventions that incorporate social and cultural norms, values, and beliefs may help engage these women in discussions about exercise. Interventions that are designed with community members, aligned with their values, delivered at a relevant health literacy level, and address specific barriers relevant to the community are more effective and can help increase the efficacy of exercise programs [73,74,75].

Our study presents several limitations. Due to the small sample size, while we could analyze single factors, we were unable to run subgroup analyses stratified by multiple factors (e.g., race and education; BMI and comorbidities). Additionally, the sample sizes for non-Hispanic Asian, Pacific Islander, American Indian, and Alaska Native breast cancer survivors were small. As a result, we were unable to conduct separate analyses for these women. There is a critical need to increase the inclusion of these underrepresented groups in registry data. As we focused on women aged over 65 years who may be clinically underserved with regard to exercise advice, our findings may not be generalizable to younger women. Our sample also only included women with Medicare Advantage plans, and patients who are on other types of health insurance may demonstrate different rates of receiving exercise advice from providers based on alternative factors (such as income). For instance, we were not able to evaluate the impact of the potential differences in physician services and payment structures in Medicare Advantage and fee-for-service Medicare plans that may influence exercise discussions [76, 77]. The SEER-MHOS dataset does not collect follow-up data on the uptake of exercise; therefore, we were unable to assess whether exercise discussions/advice with a healthcare provider resulted in a behavioral change or maintenance. Additionally, the SEER-MHOS dataset provided a single binary variable for receiving exercise advice from a clinician. Future research may include variables that describe the characteristics of exercise advice including ‘what’, ‘when’, ‘how’, and ‘why’ exercise advice was provided to the patient. Additionally, we were not able to include chemotherapy in our analyses due to the lack of completeness of the chemotherapy variable reported in SEER [78]. Also, we only used data from 2008 to 2015; as a result we were unable to evaluate the impact of the COVID-19 pandemic on the receipt of exercise advice from healthcare providers. As the data becomes available, future research may consider evaluating the impact of the COVID-19 pandemic on the receipt of exercise advice among older adults. Finally, given the nature of the SEER-MHOS questionnaire, our results may have been influenced by recall bias, where women who were already engaging in exercise were more likely to report that their clinicians recommended exercise. However, the intersection of older age and exercise patterns among breast cancer survivors remains a space with limited data.

In summary, our study provides important data to help healthcare providers identify, engage, and provide advice about exercise to older breast cancer survivors. Our findings also indicate that exercise prescriptions may require consideration of both individual clinical and sociodemographic factors. A clinical decision tool or a conversation aid specific to breast cancer survivors, extending the capabilities and level of individualization offered by existing tools such as ‘The Exercise and Screening for You’ tool [79], could potentially help address barriers to communicating the benefits of exercise in diverse breast cancer settings and could potentially help improve the overall quality of breast cancer survivorship care.