Greater physical activity—particularly walking—may reduce fatigue and improve quality of life in patients with colorectal cancer, with stronger associations observed in nonmetastatic disease. These findings were demonstrated in a longitudinal analysis of the ColoCare Study population presented by Louisa Liu, MD, of Cedars-Sinai Medical Center, Los Angeles, at the 2026 ASCO Gastrointestinal (GI) Cancers Symposium.1
Colorectal cancer survivors represent the second largest group of cancer survivors in the United States. Yet, as Dr. Liu noted, “many continue to face persistent unmet needs, particularly in physical and psychosocial support.” She emphasized that improving survivorship outcomes requires high-quality longitudinal data—an opportunity made possible through the international ColoCare Study, which follows newly diagnosed patients with colorectal cancer across all disease stages.
The results highlight the potential of simple, scalable strategies like walking as accessible low-risk tools to enhance long-term outcomes….— LOUISA LIU, MD
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“Fatigue is one of the most common and debilitating symptoms experienced by patients with cancer,” Dr. Liu remarked. Nearly 40% of long-term colorectal cancer survivors continue to experience moderate-to-severe fatigue years after treatment, impairing functional recovery, daily activity, and overall quality of life.
Despite its prevalence, Dr. Liu stated that “our toolbox of effective interventions remains relatively limited.” However, a growing body of evidence supports physical activity as a nonpharmacologic strategy. While clinical guidelines already encourage physical activity in survivorship care, important questions remain regarding the optimal timing, type, and real-world implementation—gaps this study aimed to address.
Study Details
The study included 1,718 patients (1,405 nonmetastatic, 313 metastatic) from the ColoCare cohort, with a balanced distribution of colon and rectal cancer subgroups. Patients with metastatic disease diagnosis were, on average, younger than those with nonmetastatic disease.
Physical activity was assessed at baseline and 6, 12, and 24 months using the International Physical Activity Questionnaire (IPAQ). Participants reported the frequency and duration of walking, moderate, and vigorous activities performed over the past week. Energy expenditure was quantified using Metabolic Equivalent of Task (MET) minutes per week, with activity levels categorized as low (< 600 MET minutes/week), moderate (600–3,000 MET minutes/week), or high (> 3,000 MET minutes/week).
Cancer-related fatigue and quality of life were measured using the European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire Core 30 (QLQ-C30). Longitudinal associations were analyzed using mixed-effects models. Random-effects lagged fluctuation models assessed whether physical activity at one time predicted outcomes at a subsequent time point. Analyses were stratified by metastatic status and adjusted for key covariates.
Impact of Physical Activity
Baseline physical activity levels did not appear to significantly differ by disease stage (all P > .8). However, Dr. Liu reported significantly worse fatigue among patients with metastatic vs nonmetastatic disease (mean fatigue score = 40.7 vs 32.5; P < .001), which she said, “is not unexpected given the biologic and functional limitations in this group.”
“Patients who were more physically active consistently reported better outcomes—less fatigue and higher quality of life—especially as they progressed through recovery,” Dr. Liu said. Walking demonstrated the most consistent and durable associations. “Even two years out from diagnosis, patients who walked more continued to report better outcomes.”
Among patients with nonmetastatic disease, walking was found to be associated with approximately 25% lower odds of worse fatigue at 6 (odds ratio [OR] = 0.74, P = .018) and 12 (OR = 0.75, P = .032) months after diagnosis, with a comparable trend observed at 24 months (OR = 0.71, P = .069); vigorous activity showed a similar pattern (6 months: OR = 0.75, P = .021; 12 months: OR = 0.76, P = .036; 24 months: OR = 0.69, P = .061), Dr. Liu added.
“Notably, the strongest and most consistent effects were observed during the first year after diagnosis,” she stated, “suggesting that the early survivorship phase may represent an important window for physical activity interventions to reduce fatigue.”
Additionally, according to Dr. Liu, all forms of physical activity were associated with higher odds of improved quality of life at all follow-up time points among patients with nonmetastatic disease: walking (ORs = 1.71–1.83, all P ≤ .001), moderate exercise (ORs = 1.45–1.85, all P = .002), and vigorous exercise (ORs = 1.33–1.61, P = .006–.019).
“In contrast, among the patients with metastatic disease, we did not see the same long-term associations between physical activity and outcomes,” Dr. Liu commented. “At baseline, higher levels of walking, vigorous, and total activity were all associated with lower odds of fatigue; however, none of these associations held up over time.” She noted that, similarly, none of the physical activity domains were significantly associated with quality of life at any time point in this subgroup.
Long-Term Effects
Using lagged models to examine the timing and consistency of physical activity, Dr. Liu reported that patients who maintained higher levels of vigorous activity over time had a lower risk of future fatigue, an effect that was primarily observed in the nonmetastatic subgroup. Specifically, the between-person effect showed a significant reduction in fatigue risk: for all patients and those with nonmetastatic disease, the ORs were −1.65 and −2.01 (both P < .001), respectively.
“Interestingly, we did not see meaningful benefits from short-term increases in activity,” she noted. “Rather, it appears that consistent, sustained engagement in physical activity is what drives long-term improvements.”
Conclusions and Clinical Implications
Dr. Liu concluded that “for patients with nonmetastatic colorectal cancer, being physically active was consistently linked to lower fatigue and better quality of life throughout recovery. Walking, in particular, stood out as a simple yet highly effect strategy, especially during the first year after diagnosis.” Lastly, “the greatest benefits were seen in patients who remained consistently active over time, which means we need to think beyond just getting patients started and help support them in building habits that last well beyond treatment.”
From a clinical perspective, these findings support integrating stage-specific and recovery phase–specific physical activity recommendations into routine colorectal cancer survivorship care, according to Dr. Liu. The results also complement prior evidence, including the phase III CHALLENGE trial,2 by demonstrating similar benefits in a real-world longitudinal setting, while also moving beyond aggregate physical activity measures to characterize the distinct associations of walking, moderate activity, and vigorous activity across different stages of recovery. “Taken together, the results highlight the potential of simple, scalable strategies like walking as accessible low-risk tools to enhance long-term outcomes and improve how our patients feel long after treatment,” Dr. Liu said.
The study had limitations, including reliance on self-reported physical activity and fatigue, introducing potential recall bias; an observational design with possible residual confounding from unmeasured factors; limited statistical power in the metastatic cohort because of a small sample size and shorter follow-up; and potential bidirectionality between fatigue and physical activity.
Future work will elucidate biologic and behavioral mechanisms linking physical activity to cancer-related fatigue and quality of life by integrating wearable device–derived data, metabolic measures of muscle function and recovery, and assessments of physical activity barriers across diverse populations to inform personalized survivorship interventions.
DISCLOSURE: The study was funded by the National Institute of Nursing Research at the National Institutes of Health. Dr. Liu reported no conflicts of interest.
REFERENCES
1. Liu L, Kazemian E, Lorona N, et al: Longitudinal study on the influence of physical activity in managing cancer-related fatigue in patients with colorectal cancer. 2026 ASCO GI Cancers Symposium. Abstract 16. Presented January 10, 2026.
2. Courneya KS, Vardy JL, O’Callaghan CJ, et al: Structured exercise after adjuvant chemotherapy for colon cancer. N Engl J Med 393:13-25, 2025.
EXPERT POINT OF VIEW
Jonathan B. Greer, MD, Attending Surgeon, Mass General Brigham Cancer Institute, Boston, commented on the findings from a longitudinal analysis of the ColoCare Study population on the influence of physical activity in managing colorectal cancer–related fatigue, congratulating the authors on their research that “adds to a growing body of literature suggesting the benefit of exercise in these patients.”1
“Physical activity as being good for patients with colorectal cancer is not controversial in 2026,” he said. The current National Comprehensive Cancer Network (NCCN) Guidelines for Colon and Rectal Cancer recommend that patients “adopt a physically active lifestyle (at least 30 minutes of moderate-intensity activity on most days of the week)….”2,3
Existing Evidence
In the CHALLENGE trial of patients with high-risk stage II to III colorectal cancer who received adjuvant chemotherapy, those in the intervention arm participated in a structured exercise program for 3 years.4 “Interestingly enough, even when they had this well-structured exercise regimen, the participation rate of the patients was down to about 60% by the end of the study,” Dr. Greer pointed out. Yet, despite the dropouts, the intention-to-treat analysis showed a 7.1% absolute risk reduction in death at 8 years—“a better result than many drug trials, suggesting that exercise really does have an important effect on the biology of the disease.” He noted, however, that this study included only patients with nonmetastatic disease.
Jonathan B. Greer, MD
Other studies, such as the secondary analysis of CALGB/SWOG 80405, found a nonsignificant trend toward better outcomes with increased activity in patients with metastatic colorectal cancer.5 “There have been no randomized trials that have had a targeted intervention [in this setting], so it remains a bit of an unknown question,” Dr. Greer added.
The present study appeared to add to the evidence base, with Dr. Greer noting that greater physical activity was associated with reduced fatigue and improved quality of life across all time points, and that walking produced the strongest effects. “But certainly, vigorous activity does seem to have a role as well,” he said.
Insights and Opportunities
Dr. Greer noted the study’s strengths: It is a large, multi-institutional prospective study that validated findings from smaller analyses; yielded results that can be applied immediately in clinical practice; provided recommendations that are accessible and low-cost—walking, for example, is free; and offered “tangible, relatively immediate” benefits in reducing cancer-related fatigue and improving quality of life. He also raised a clinical consideration, stating, “I wonder if these results could be applied to patients with an ECOG [Eastern Cooperative Oncology Group] of 2 or higher,” noting that “most randomized trials excluded patients in this category.”
He also acknowledged limitations of the study, highlighting the “chicken-and-egg” argument, in that “patients who feel better can do more. [Additionally,] this was not an intervention study; it was an observational study. And the patients with metastatic disease had a less clear relationship.” Despite these caveats, he emphasized opportunities for future research: “I think the future direction is understanding how we can help patients with metastatic disease improve their quality of life…. It would [also] be nice to drill down on why exercise helps….”
DISCLOSURE: Dr. Greer reported no conflicts of interest.
REFERENCES
1. Liu L, Kazemian E, Lorona N, et al: Longitudinal study on the influence of physical activity in managing cancer-related fatigue in patients with colorectal cancer. 2026 ASCO GI Cancers Symposium. Abstract 16. Presented January 10, 2026.
2. Benson AB, Venook AP, Adam M, et al: NCCN Clinical Practice Guidelines in Oncology: Colon Cancer. Version 5.2025. Available at www.nccn.org. Accessed January 15, 2026.
3. Benson AB, Venook AP, Adam M, et al: NCCN Clinical Practice Guidelines in Oncology: Rectal Cancer. Version 4.2025. Available at www.nccn.org. Accessed January 15, 2026.
4. Courneya KS, Vardy JL, O’Callaghan CJ, et al: Structured exercise after adjuvant chemotherapy for colon cancer. N Engl J Med 393:13-25, 2025.
5. Guercio BJ, Zhang S, Ou F-S, et al: Associations of physical activity with survival and progression in metastatic colorectal cancer: Results from Cancer and Leukemia Group B (Alliance)/SWOG 80405. J Clin Oncol 37:2620-2631, 2019.
