The update reflects survival benefits of post-diagnosis exercise in stage II–III colon cancer as recently reported in the CHALLENGE study
Once considered only healthy lifestyle advice for people with cancer, physical activity, when personalised and delivered as a structured programme, is now recommended by ESMO for patients with resected stage III or high-risk stage II colon cancer.
The Express Update of the ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up of localised colon cancer, released this week on ESMO Open, was developed based on high-level evidence reported in the CO.21 Colon Health and Lifelong Exercise Change (CHALLENGE) study, which demonstrated for the first time a causal relationship between post-diagnosis exercise and colorectal cancer recurrence (N Engl J Med. 2025 Jul 3;393(1):13-25 ).
Over a three-year intervention, in the randomised phase III trial, 889 patients with resected stage III or high-risk stage II colon cancer who had completed adjuvant chemotherapy within the previous 2-6 months, received either standard-practice health education materials promoting physical activity or healthy nutrition, or health education materials plus a structured exercise programme. Patients in the exercise group achieved statistically significant improvements in disease-free survival (DFS) compared with those who received health education materials and standard surveillance alone (5-year DFS of 80.3% versus 73.9%, respectively).
While acknowledging that the study established a new standard of care for selected patients in specific clinical and socioeconomic contexts, ESMO’s updated recommendations provide guidance on how to address key aspects for the implementation of exercise programmes in clinical practice. Attention is also given to patient’s preferences and the need for adequate infrastructure.
“In CHALLENGE, the structured exercise programme was individualised with a prescription developed by a physical activity consultant: it consisted of aerobic physical activity at moderate-to-vigorous intensity, and patients choose the type, frequency and duration of activity,” noted Anna Campbell, Professor in Clinical Exercise Science at Edinburgh Napier University, UK, commenting on the study findings at the ESMO Virtual Journal Club last December. “Behaviour change theory was key to the success of the study and was embedded into all aspects of intervention.” However, simply informing patients that exercise is beneficial to them will not change behaviour or outcomes, she added, and “there should be much more investments by healthcare systems in physical-activity behaviour-support programmes.”
One of the most compelling issues now, in fact, is how to integrate regular exercise not only throughout the patient journey, but also within oncology departments and services. “Who could work with patients to get them more active? What kind of programme is right for each of them? And where it should take place?,” asked Campbell, highlighting the complexity of building an internationally standardised workforce and developing appropriate programme (J Natl Cancer Inst Monogr. 2025 Sep 1;2025(71):334-343), which is of primary relevance to ensure that physical activity can truly be placed on a par with other medical interventions.
