# CHALLENGE: a structured exercise programme after chemotherapy improves survival in colon cancer

Source: https://onco.cc/key-papers/paper-challenge-exercise-nejm-2025/  
OnCo record `paper-challenge-exercise-nejm-2025` (Key paper). Data CC BY-NC 4.0, attribute "Data from OnCo (onco.cc)"; commercial use needs a licence.

## TL;DR

In CHALLENGE, three years of supervised, goal-based exercise after adjuvant chemotherapy for colon cancer reduced recurrence or death by 28% and deaths by 37%, the first randomised proof that exercise itself improves cancer survival.

## Summary

CHALLENGE (CCTG CO.21) randomised 889 patients with resected stage III or high-risk stage II colon cancer who had completed adjuvant chemotherapy to a 3-year structured exercise programme (behavioural support and supervised sessions, targeting an increase of at least 10 MET-hours per week) or to health-education materials alone. The primary endpoint was disease-free survival.

After a median follow-up of nearly 8 years, 5-year DFS was 80.3% with exercise versus 73.9% with education (HR 0.72). Eight-year overall survival was 90.3% versus 83.2% (HR 0.63). Physical functioning improved and musculoskeletal adverse events were more common in the exercise arm.

This is the first phase 3 trial to show that an exercise intervention, rather than exercise as a correlate, lengthens survival in cancer.

## Fields

- Kind: Key paper
- Last checked: 2026-09-08
- Journal: New England Journal of Medicine
- Year: 2025
- DOI: 10.1056/NEJMoa2502760
- Authors: Courneya KS, Vardy JL, O'Callaghan CJ, et al. (Canadian Cancer Trials Group CO.21)
- Findings: Five-year disease-free survival 80.3% vs 73.9% (HR 0.72, 95% CI 0.55-0.94); Eight-year overall survival 90.3% vs 83.2% (HR 0.63, 95% CI 0.43-0.94); Median follow-up 7.9 years across 55 centres in Canada, Australia, the UK, France, Israel and the US; Musculoskeletal adverse events 18.5% vs 11.5%; the programme was delivered by physical activity consultants over 3 years
- What it means: For colon cancer survivors, a prescribed, supported exercise programme is now an evidence-based treatment with a survival benefit comparable to many drugs. Health systems will need to fund exercise consultants as they fund chemotherapy. The trial does not tell us whether unsupervised advice achieves the same.
- Caveats: The intervention was intensive (behavioural support for 3 years); uptake and cost in routine care are untested; Participants were fit enough to enrol and motivated; benefit in frail or sedentary populations is unproven; Open-label; DFS assessment could be influenced by differential surveillance; Recruitment took 15 years, so adjuvant regimens evolved during the trial

## Sources

- DOI: https://doi.org/10.1056/NEJMoa2502760
- ClinicalTrials.gov NCT00819208: https://clinicaltrials.gov/study/NCT00819208
- PubMed: https://pubmed.ncbi.nlm.nih.gov/40450658/

## Connected records

- ideas: [Combine the new anti-wasting antibody with exercise and protein](https://onco.cc/ideas/idea-bio2-gdf15-plus-exercise/), [Fund structured exercise after colon cancer surgery as a treatment, because a randomised trial says it works as well as a drug](https://onco.cc/ideas/idea-crc-exercise-as-a-funded-treatment/), [Pay for supervised exercise the way we pay for drugs](https://onco.cc/ideas/idea-bio2-exercise-reimbursement/), [Structured exercise prescribed like a drug in all curative-intent cancer care](https://onco.cc/ideas/idea-exercise-as-adjuvant/)
- roadmaps: [Supportive care and survivorship roadmap: making treatment bearable → proving it extends life → caring for tens of millions afterwards](https://onco.cc/roadmaps/survivorship-roadmap/)
- key papers: [Duration of adjuvant chemotherapy for stage III colon cancer (the IDEA collaboration)](https://onco.cc/key-papers/paper-idea-duration-adjuvant-stage-iii-colon-nejm-2018/)
- cancers: [Colon cancer (adenocarcinoma of the colon)](https://onco.cc/cancers/colon-cancer/), [Colorectal cancer](https://onco.cc/cancers/colorectal/)
- fronts: [Diet, Exercise & Lifestyle](https://onco.cc/fronts/nutrition-lifestyle/), [Supportive Care & Survivorship](https://onco.cc/fronts/supportive-care/)
- technologies: [Exercise & lifestyle oncology](https://onco.cc/technologies/exercise-oncology/), [What actually works after treatment](https://onco.cc/technologies/rejuv-frontier-what-works/)
- companies: [Canadian Cancer Trials Group (CCTG)](https://onco.cc/companies/cctg/)
- people: [Christopher M. Booth](https://onco.cc/people/christopher-booth/), [Janet Dancey](https://onco.cc/people/dancey-janet/), [Kerry S. Courneya](https://onco.cc/people/kerry-courneya/)
- bottlenecks: [Funding follows fashion, not burden](https://onco.cc/bottlenecks/b-funding-allocation/), [No incentive to repurpose cheap drugs](https://onco.cc/bottlenecks/b-generic-repurposing/), [Prevention we already have is not deployed](https://onco.cc/bottlenecks/b-prevention-adoption/), [Survivorship and late effects are neglected](https://onco.cc/bottlenecks/b-survivorship/)
- journals: [New England Journal of Medicine](https://onco.cc/journals/nejm/)
- trials: [CHALLENGE (CCTG CO.21)](https://onco.cc/trials/challenge/)

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