Risk-Adaptive Cardio-Oncology Rehabilitation: A Narrative Review of Exercise Prescription, Multimodal Monitoring, and Implementation Pathways

Background/Objectives: Cardiovascular toxicity and pre-existing cardiovascular disease can affect cancer-treatment tolerance, functional recovery, and survivorship. This narrative review aimed to summarize current evidence and propose an author-derived risk-adaptive clinical framework for adult cardio-oncology rehabilitation (CORE), organized around exercise prescription, multimodal monitoring, and implementation. Methods: PubMed/MEDLINE and the Web of Science Core Collection were searched from database inception through 27 July 2026. Guidelines, systematic reviews, randomized and non-randomized clinical studies, feasibility studies, and selected mechanistic sources were prioritized according to their relevance to the three review domains. Evidence was classified as direct clinical, guidance/synthesis, feasibility/implementation, or mechanistic/conceptual; no PRISMA protocol, formal risk-of-bias assessment, or meta-analysis was undertaken. Results: Clinical trials support improvements in cardiorespiratory fitness, selected cardiovascular risk factors, and functional outcomes in some settings, but effects on cancer therapy-related cardiac dysfunction, cardiovascular events, and mortality remain uncertain. Direct evidence is dominated by breast-cancer cohorts and women, although mixed-cancer, lymphoma, and lung-cancer studies broaden the functional evidence base. An evidence-informed approach is to individualize aerobic and resistance exercise to treatment context, symptoms, functional capacity, and clinical stability, with reassessment linked to actionable findings; the proposed pathway remains conceptual and non-validated. Artificial intelligence, digital twins, omics, and monitoring-guided exercise-dose adjustment remain investigational. Conclusions: CORE is best regarded as exercise-centered care linked to guideline-based risk assessment and clinically indicated reassessment. Prospective studies should test therapy-specific timing, risk-stratified delivery, monitoring-guided dose adjustment, clinical endpoints, equity, and cost-effectiveness.