Structured Exercise Program Is Cost-Saving After Adjuvant Chemo in CRC

At the 2026 American Society of Clinical Oncology (ASCO) Annual Meeting, Kelvin KW Chan, MD, PhD, associate professor at the Sunnybrook Odette Cancer Centre of the University of Toronto, presented a cost-utility analysis of the phase 3 CHALLENGE trial (NCT00819208) evaluating the economic value of a structured exercise program (SEP) following adjuvant chemotherapy for colon cancer.¹

The CHALLENGE trial randomly assigned patients with colon cancer who had completed adjuvant chemotherapy to a 3-year SEP (n = 445) or a health education materials (HEM) control arm (n = 444). The SEP was a behavior change program delivered by qualified personal trainers; sessions occurred every 2 weeks in year 1, then monthly through years 2 and 3. As previously reported in The New England Journal of Medicine, the SEP significantly improved disease-free survival (DFS; HR, 0.72; 95% CI, 0.55-0.94; P = .017) and overall survival (OS; HR, 0.63; 95% CI, 0.43-0.94; P = .022), with absolute benefits of 6.4% and 7.1% at 5 years, respectively.^1,2

The cost-utility analysis assessed the incremental cost, incremental quality-adjusted life years (QALYs), and incremental cost-utility ratio (ICUR) of the SEP from the perspective of a public healthcare payer. Direct medical costs –– including the exercise program itself, costs of cancer recurrence or new primary cancer, anticancer therapies, and hospitalizations –– were collected prospectively within the CHALLENGE trial and expressed in 2024 Canadian dollars. Health utilities were assessed using the 36-Item Short Form Survey mapped to the Short-Form 6-Dimension (SF-6D), with a 5-year time horizon and a 1.5% discount rate.¹

Despite the upfront per-patient program cost of $2917 in Canadian dollars, the SEP generated meaningful downstream savings. Costs of cancer recurrence ($12,732 vs $15,772), anticancer therapy ($12,660 vs $14,582), and end-of-life care ($54 vs $100) were all lower in the SEP arm than in the HEM arm. These savings more than offset the program investment, yielding total per-patient costs of $31,957 in the SEP group vs $33,546 in the HEM group, a net cost savings of $1589.¹

Patients in the SEP arm also accrued more life years (4.72 vs 4.66) and more QALYs (3.84 vs 3.75), yielding an incremental QALY gain of 0.10. The ICER was classified as dominant, meaning the SEP was simultaneously cost-saving and more effective than HEM. On the cost-effectiveness acceptability curve, the SEP was dominant in 53% of all probabilistic iterations and had an 80% probability of being cost-effective at a willingness-to-pay threshold of $50,000 per QALY. For perspective, Canada's Drug Agency reported a mean ICER for cancer drugs recommended for reimbursement in 2025 of $435,729 per QALY (median, $242,571 per QALY). Recently, investgators have explored the emerging clinical and institutional landscape for exercise oncology as evidence for its role as a prescribable therapeutic intervention continues to build.^1,3

The SEP remained dominant across all sensitivity and scenario analyses with 1 exception: inclusion of overhead costs, which yielded an ICUR of $4405 per QALY — still well within accepted cost-effectiveness thresholds. When accounting for indirect costs of lost productivity, the SEP generated $1067 in additional cost savings; extending the analysis to a 10-year time horizon further increased savings to $3938 per patient.¹

Chan concluded that these findings provided economic evidence to support the integration of SEPs into routine clinical care following adjuvant chemotherapy for colon cancer. The ESMO Clinical Practice Guideline Express Update on Localised Colon Cancer now includes concomitant participation in a structured exercise programme as a follow-up recommendation for patients with stage III disease, further underscoring the readiness of the evidence base to support clinical implementation.¹

References

1. Chan KK, Chu RW, Cheung MC, et al. Structured exercise program following adjuvant chemotherapy for colon cancer: a cost-utility analysis of the CHALLENGE trial. J Clin Oncol. 2026;44(suppl 16):3507. doi:10.1200/JCO.2026.44.16_suppl.3507
2. Courneya KS, Vardy JL, Friedenreich CM, et al. Structured exercise after adjuvant chemotherapy for colon cancer. N Engl J Med. 2025;393(1):13-25. doi:10.1056/NEJMoa2502760
3. Booth CM, Vardy JL, O’Callaghan CJ, et al. A randomized phase III trial of the impact of a structured exercise program on disease-free survival (DFS) in stage 3 or high-risk stage 2 colon cancer: Canadian Cancer Trials Group (CCTG) CO.21 (CHALLENGE). J Clin Oncol. 2025;43(suppl 17):LBA3510. doi:10.1200/JCO.2025.43.17_suppl.LBA3510