How can regular exercise be integrated into the patient journey?

A few months ago, a large phase III trial made headline news when it reported clear evidence that physical activity has a significant impact on patient survival, prompting new questions on how a structured exercise programme should be integrated into usual clinical care. In the CO.21 Colon Health and Lifelong Exercise Change (CHALLENGE) study, patients with stage II–III colon cancer who received a structured exercise programme with regular supervised sessions and a set of agreed exercise goals achieved statistically significant improvements in disease-free survival (DFS) compared with those who received health education materials and standard surveillance over a 3-year period after completing adjuvant chemotherapy (5-year DFS of 80.3% versus 73.9%, respectively) (N Engl J Med. 2025;393:13‒25).

Differences of this magnitude are not often seen with new adjuvant therapies for colon cancer, and the benefits are not off-set by the toxicities so frequently associated with chemotherapy or targeted therapies. This is why the results of the CHALLENGE study are considered groundbreaking. But a crucial question remains: how can these findings be translated into routine clinical practice, given that adherence to exercise programmes is generally low, and patients struggle to integrate exercise into their daily activities?

A recent systematic review of more than 300 studies reported patients’ psychological fear of making symptoms or disease worse, losing weight and side-effects of anticancer treatment, especially fatigue, as significant barriers to participation in physical activity (Support Care Cancer. 2024;32:509).

The medical oncologist can play a pivotal role in explaining the importance of physical activity to the patient, and a lack of support, education and awareness typically has a negative impact on patients’ adherence to regular exercise. However, the reality is that support from oncologists and other healthcare professionals (HCPs) is often limited. An online survey of HCPs treating patients with head and neck cancer reported that only ~40% discussed physical activity with their patients and the majority of HCPs (76%) acknowledged the need for further training in the promotion of physical activity to be routine practice along the patient journey (Support Care Cancer. 2024;32:848).

Additional insights are provided by new data from the CHALLENGE study presented at the ESMO Congress 2025 (Berlin, 17–21 October), focusing on predictors of adherence to a structured exercise programme (LBA28). Rates of adherence to structured exercise sessions declined over time, ranging from 77% at 1–6 months to 53% at 13–36 months. Adherence to the first 6 months of the programme was a consistent predictor of subsequent adherence and achieving physical activity targets. Country of residence also affected adherence (higher in patients from Canada than others), while a lower body mass index (<30 kg/m2) and an oxaliplatin adjuvant regimen were associated with a higher likelihood of achieving physical activity targets.

Other aspects need to be carefully considered to integrate regular exercise into cancer care. The first is which assessment tools and endpoints can be used to accurately evaluate the impact of physical activity in patients with cancer, as findings from another study presented in Berlin suggest. The phase II/III QUALIOR study explored a potential approach to help patients undertake exercise through home-based supervised physical activity (Abstract 2802O). At 3 months, no major impact on fatigue or health-related quality of life (QoL) was observed between supervised physical activity and a control arm in which patients received a booklet outlining recommended physical activity.

Suboptimal QoL assessment tools, a more advanced cancer patient population and a shorter time with physical activity could possibly explain the different outcomes observed between the two trials. QoL tools may not completely capture how a patient feels, so may not be the best endpoint on which to evaluate the impact of physical activity. Even where a drug is known to be relatively toxic, a QoL difference is not always significantly demonstrated (J Clin Oncol. 2021;39(Suppl 15):e15593).

Discrepancies in the way in which different countries and cultures view physical activity may also impact the successful integration of a structured exercise programme. The importance of providing culturally relevant context to the meaning of physical activity to better engage individuals and communities has been well documented (Front Public Health. 2023;11:1223919).

Identifying the predictors of adherence to exercise programmes, using appropriate assessment tools and outcome measures and human factors such as physician education and cultural differences will be crucial to establishing physical activity as a treatment on a par with other medical interventions.