Exercise Plus Behavioral Support Significantly Increases Overall Survival in Patients With Colorectal Cancer

Following definitive therapy for stage 2 or 3 colorectal cancer, does a structured exercise program plus behavioral support increase the likelihood of disease-free survival?

A structured exercise program that added approximately 10 metabolic equivalent (MET) hours per week (equivalent to briskly walking 45–60 minutes three to four times per week) significantly improved overall and disease-free survival in patients who had been treated for mostly stage 3 colorectal cancer. Patients also received behavioral support. (Level of Evidence = 1b)

The Canadian study identified 889 patients who had completed surgery and chemotherapy for high-risk stage 2 or 3 colorectal cancer. They were randomized to receive general health information (control) or a structured exercise program consisting of 12 mandatory behavioral support sessions alternating with 12 exercise sessions delivered over 24 weeks. For the next 24 weeks, the exercise group had behavioral support and exercise sessions every 2 weeks, which could be delivered remotely. During years 2 and 3 of the study, those participants had 24 mandatory behavioral support sessions that could be combined with an exercise session if the patient attended in person. Because the authors stratified the patients prior to randomization, the groups were closely balanced by age (median 61 years), performance status, and cancer stage (90% stage 3). The median time from diagnosis to enrollment in the study was 1 year.

Adherence to supervised exercise and behavioral support sessions declined gradually over time. Measures of physical fitness improved significantly more in the structured exercise group. Most important, overall survival improved (hazard ratio = 0.63; 95% CI, 0.43–0.94; annual incidence, 1.4% vs 2.3%) and disease-free survival improved (hazard ratio for death, recurrence, or new primary disease = 0.72; 95% CI, 0.55–0.94; annual incidence, 3.7% vs 5.4%; P = .02). The number needed to treat was approximately 16 to prevent one all-cause death over 5 years. Participants in the exercise group added approximately 10 METs of task hours per week compared with patients in the control group, equivalent to briskly walking for 45 to 60 minutes three to four times per week. Musculoskeletal adverse events were more common in the exercise group than in the control group (18.5% vs 11.5% or 15.4% vs 9.1% for stage 3 or higher events).

Study design: Randomized controlled trial (nonblinded)

Funding source: Foundation

Allocation: Concealed

Setting: Outpatient (specialty)

Reference: Courneya KS, Vardy JL, O'Callaghan CJ, et al.; CHALLENGE Investigators. Structured exercise after adjuvant chemotherapy for colon cancer. N Engl J Med. 2025;393(1):13-25.

Editor’s Note: Dr. Ebell is deputy editor for evidence-based medicine for AFP.