Structured Exercise after Adjuvant Chemotherapy for Colon Cancer 2025 Courneya et al

[Andy]

Abstract

Background
Preclinical and observational studies suggest that exercise may improve cancer outcomes. However, definitive level 1 evidence is lacking.

Methods
In this phase 3, randomized trial conducted at 55 centers, we assigned patients with resected colon cancer who had completed adjuvant chemotherapy to participate in a structured exercise program (exercise group) or to receive health-education materials alone (health-education group) over a 3-year period. The primary end point was disease-free survival.

Results
From 2009 through 2024, a total of 889 patients underwent randomization to the exercise group (445 patients) or the health-education group (444 patients). At a median follow-up of 7.9 years, disease-free survival was significantly longer in the exercise group than in the health-education group (hazard ratio for disease recurrence, new primary cancer, or death, 0.72; 95% confidence interval [CI], 0.55 to 0.94; P=0.02). The 5-year disease-free survival was 80.3% in the exercise group and 73.9% in the health-education group (difference, 6.4 percentage points; 95% CI, 0.6 to 12.2). Results support longer overall survival in the exercise group than in the health-education group (hazard ratio for death, 0.63; 95% CI, 0.43 to 0.94). The 8-year overall survival was 90.3% in the exercise group and 83.2% in the health-education group (difference, 7.1 percentage points; 95% CI, 1.8 to 12.3). Musculoskeletal adverse events occurred more often in the exercise group than in the health-education group (in 18.5% vs. 11.5% of patients).

Conclusions
A 3-year structured exercise program initiated soon after adjuvant chemotherapy for colon cancer resulted in significantly longer disease-free survival and findings consistent with longer overall survival. (Funded by the Canadian Cancer Society and others; CHALLENGE ClinicalTrials.gov number, NCT00819208.)

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[Andy]

A 7% difference between groups is reported as....

Major study shows exercise improves cancer survival

"An exercise programme for colon cancer patients can cut the risk of dying by a third, a major international trial shows.

The researchers said it was "not a large amount" of exercise and any type of workout from swimming to salsa classes counted.

The results could change the way colon cancer is treated around the world.

Scientists are already investigating whether similar exercise regimes could improve survival for people with other diseases, such as breast cancer.

"It's a bit of a mind-shift, thinking of treatment as something you do, not just something you take," says researcher Prof Vicky Coyle from Queen's University Belfast."

https://www.bbc.co.uk/news/articles/c8xgyw7k7veo

 

[Andy]

Ah, the SMC is in on the hype, https://www.sciencemediacentre.org/...d-reduced-risk-of-recurrence-of-colon-cancer/

 

[Utsikt]

Adherence was really low.

 

[Utsikt]

Improvement in disease-free survival from exercise was primarily driven by reductions in liver recurrence (3.6% vs. 6.5%) and new primary cancers (5.2% vs. 9.7%), particularly breast (0.4% vs. 2.7%), prostate (1.1% vs. 2.0%), and colorectal (0% vs. 1.1%) cancers.

No significant differences in deaths without recurrence or without a second primary cancer (1.3% versus 1.8%) were noted, which suggests that the benefit of exercise came from improved cancer outcomes.

Our trial has some limitations. The recruitment of patients was slow and spanned a 15-year period. However, during that time, the only change in standard treatment was from 6 months to 3 months of FOLFOX or CAPOX therapy.

A total of 92.4% of our planned sample (889 of 962 patients) underwent randomization, but we observed only 58.9% of our targeted number of events (224 of 380 events).

The 3-year disease-free survival was higher than expected, probably because of a selection bias toward higher-functioning patients but also because of the timing of our intervention.

We enrolled patients 2 to 6 months after they had undergone chemotherapy, so we excluded patients with recurrences during the first year after diagnosis who were likely to have had more biologically aggressive disease.

Whether initiating an exercise intervention earlier in the treatment trajectory (e.g., before surgery or during chemotherapy) would further improve cancer outcomes remains to be determined.

Have they accounted for the lower recruitment, and especially the lower amount of events detected?

What about multiple testing?

And they forgot to mention in the abstract that they only recruited the less severe patients.

Moreover, we did not track the number of patients with Lynch syndrome who would have been at higher risk for second primary cancers; however, randomization would be expected to balance groups with respect to such deleterious genetic mutations.

Finally, we relied on patients’ retrospective recall of moderate-to-vigorous physical activity over the past month, a procedure that has known limitations. However, we confirmed the self-reported increases in physical activity with improvements in objective cardiorespiratory fitness and physical functioning.

 

[forestglip]

A 7% difference between groups is reported as....

Major study shows exercise improves cancer survival

"An exercise programme for colon cancer patients can cut the risk of dying by a third, a major international trial shows.

That seems accurate. 7% reduction in absolute risk, but that's influenced by how rare or common the event of dying in that timeframe is in general.

But if ~17% of people died in the control group and ~10% died with exercise, that's more than a third less that died over the 8 years. And the hazard ratio of .63 indicates a 37% lower mortality rate in the exercise group.

 

[ME/CFS Skeptic]

Only read the abstract but sounds like an impressie difference.

 

[Eleanor]

So the treatment group got not only exercise training but lots of personal contact with HCPs (and "behavioural support"); did the control group get anything to match that?

 

[Utsikt]

So the treatment group got not only exercise training but lots of personal contact with HCPs (and "behavioural support"); did the control group get anything to match that?

No, I don’t think so. But they do mention that other studies found no survival benefit from contact alone.

The patients in the exercise group also received more social contacts with physical activity consultants than those in the health-education group, so we cannot completely rule out benefits related to social interaction. Nevertheless, previous oncology trials involving group psychosocial support37 and nutrition interventions38-40 have also provided substantially more contacts to intervention patients but did not report a survival benefit.

 

[Yann04]

The Guardian headline for this is criminal:
Exercise ‘better than drugs’ to stop cancer returning after treatment, trial finds

https://www.theguardian.com/society...er-cancer-treatment-international-trial-finds

I’m of the opinion these sorts of headlines can cause excess deaths by convincing people they don’t need medical care and can just solve the cancer themselves with healthy living

 

[Jonathan Edwards]

I’m of the opinion these sorts of headlines can cause excess deaths by convincing people they don’t need medical care and can just solve the cancer themselves with healthy living

Very much so, a dreadful headline.

I find it quite hard to believe that there isn't a flaw here somewhere relating to greater supervision in the exercise group. Multicentre studies are very open to abuse because decisions are delegated to all sorts of people who may not understand the need for rigour. Whenever there is some outcome which isn't quite clear it will get biased if the trial is open like this.

What the abstract does not say specifically is the difference in recurrence of the original tumour. That is the only thing I would take note of. If anything the bias would be likely to be the other way if there was more supervision.

 

[Kitty]

That seems accurate. 7% reduction in absolute risk, but that's influenced by how rare or common the event of dying in that timeframe is in general.

But if ~17% of people died in the control group and ~10% died with exercise, that's more than a third less that died over the 8 years. And the hazard ratio of .63 indicates a 37% lower mortality rate in the exercise group.

It does look good, but I wonder if they controlled for factors such as existing health conditions and disability that might mean some of the non-survivors were potentially more unwell to start with?

Or that people who're less likely to engage (or be able to engage) might have other major risks that add to mortality regardless of whether or not they have cancer? The effects of poverty and the complex web of issues associated with it are far from trivial.

 

[Jonathan Edwards]

Presumably, if recruitment was slow, it is likely/possible that the cohort recruited were a rather special group of people who were very motivated to have an exercise training programme - 'Ooh, yes please, I'll do that trial'. In which case the result might imply that telling people that they didn't get the personal training option worsens their chances of survival more than telling people they cannot have more chemo!!

Maybe what they should have done is randomise all patients who fit inclusion criteria and only offer exercise to the ones that drew that option. If only 5% said yes please that would mean you would get a more realistic picture of what offering exercise does.

Trouble is that trials like that are usually unethical. You cannot enrol people in trials and not tell them they were enrolled but drew blank (I think).

If recruitment was very slow you can probably divide the apparent benefit by five or ten for the real world.

 

[Utsikt]

What the abstract does not say specifically is the difference in recurrence of the original tumour. That is the only thing I would take note of. If anything the bias would be likely to be the other way if there was more supervision.

There were 12 cases of recurrence in the «local colon» in both groups.

 

[Utsikt]

If recruitment was very slow you can probably divide the apparent benefit by five or ten for the real world.

It was. They spent 15 years and didn’t meat their quota, and had far fewer events than what they powered the study for.

Our trial has some limitations. The recruitment of patients was slow and spanned a 15-year period. However, during that time, the only change in standard treatment was from 6 months to 3 months of FOLFOX or CAPOX therapy.

A total of 92.4% of our planned sample (889 of 962 patients) underwent randomization, but we observed only 58.9% of our targeted number of events (224 of 380 events).

 

[Jonathan Edwards]

The biggest difference is for new breast cancer. Breast cancer is associated with BMI I think but the difference is striking

For recurrence I think the overall figure is relevant - which shows just slight overlap in confidence limits but is not trivial

 

[rvallee]

The Guardian headline for this is criminal:
Exercise ‘better than drugs’ to stop cancer returning after treatment, trial finds

https://www.theguardian.com/society...er-cancer-treatment-international-trial-finds

I’m of the opinion these sorts of headlines can cause excess deaths by convincing people they don’t need medical care and can just solve the cancer themselves with healthy living

Steve Jobs is, uh, yeah, probably not recommending this framing. As you say, this headline is frankly criminal. It will lead to some literally choosing to try exercise over treatment. If quacks like RFK Jr see this you can bet they will hype it to the max.

I may be too cynical, but I don't believe it. Studies like this are always too poor to be reliable, and always end up being too good to be true. I'll wait for more, assuming that this amazing stupendous groundbreaking number will drop by a lot with more rigorous investigation.

Because, really, if it was that simple and effective, how in the hell would this have not been obvious for decades? There is literally nothing in this study that couldn't have been done a century ago, or at any point since.

 

[NelliePledge]

The Guardian headline for this is criminal:
Exercise ‘better than drugs’ to stop cancer returning after treatment, trial finds

https://www.theguardian.com/society...er-cancer-treatment-international-trial-finds

I’m of the opinion these sorts of headlines can cause excess deaths by convincing people they don’t need medical care and can just solve the cancer themselves with healthy living

Ironically today in the Guardian emphasis on misinformation about cancer
https://www.theguardian.com/society...rmation-online-coffee-enemas-raw-juice-diets-

 

[rvallee]

“I would urge people to be sceptical of any ‘miracle cures’ you may see on social media around cancer and use trusted, credible sources like the NHS website or your care team to verify anything you are unsure of – because these fairytales aren’t just misleading, they can be harmful.”

The Guardian headline for this study:
Exercise ‘better than drugs’ to stop cancer returning after treatment, trial finds

While most people trusted doctors, the paper found, more than half of those surveyed said experts seemed to contradict one another. One in 20 had no trust in scientists to provide cancer information. “We’re losing the battle for communication. We need to regain that battlefield,”

Yes you are. And when you are losing a battle, the first step is to stop digging yourselves further. This would involve not giving ammunition and free gifts to your opponents. Which, for all intents and purposes, appears to be the future of medicine, with magical mind-body healing powers, or whatever bullshit framing they are on about these days.

Meanwhile I was just browsing reddit and saw a post about some UK-based guru pushing water fasting for CFS. What would most physicians think of this? They'd tut-tut about how the real cure is exercise and psychotherapy, which is just as false as water-fasting. Quacks and trolls on the Internet are saying essentially the same thing as official sources, with just a tiny distinction that makes no difference.

The conspiracy fantasy communities can mostly simply sit back and let their opponents make all the mistakes. They keep getting tips and intelligence delivered for free, and have been handed out several nuclear-powered devices in the giant blundering of the COVID pandemic, which has supercharged antivaccine beliefs.

“There is a huge amount of cancer misinformation online. Every day I get messages from scared women who want to know if they need to stop eating dairy, soy, flaxseeds. Do they need to stop wearing underwired bras, using deodorants? Is it true that juicing can cure cancer? What about miracle supplement cures like mushrooms and CBD?”

CBD? No. CBT? Yes. Somehow, that makes sense to people who tut-tut about misinformation. Even though the entire psychobehavioral ideology is as textbook version of pseudoscience and miracle cures as it gets, and not much different.

Good grief humans are terrible at politics. It's all the dishonesty, all the lying with good intent, the ends justifying the means. Which they never do, because the means always become the ends. When you lie your way into a goal, you end up with lies and no goals achieved.