The Oncology Podcast

Getting Exercise to Improve Cancer Survival? Challenge Accepted!

• Professor Bogda Koczwara AM • Season 2 • Episode 3

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Welcome to the latest Series of Supportive Care Matters, a podcast hosted by Medical Oncologist and International Cancer Survivorship Expert, Professor Bogda Koczwara AM.

"If it were a pill, we would all want it." This powerful opening statement captures the essence of ground-breaking research that's transforming our understanding of cancer survivorship care. The CHALLENGE Study has delivered what many considered impossible: definitive evidence that structured exercise significantly extends the lives of colorectal cancer survivors.

The results are nothing short of remarkable. Colorectal cancer patients who participated in a structured exercise program for three years after completing surgery and chemotherapy showed an 80% disease-free survival rate at five years, compared to 74% in those who received only health education materials. The results showed that structured exercise provides a significantly longer disease-free survival. Even more impressive, overall survival improved from 83% to 90% - a 37% decrease in risk. To put this in perspective, for every 14 patients who followed the exercise program, one additional life was saved.

What makes this intervention unique is its sophisticated approach to behaviour change. Participants received individualised exercise prescriptions targeting 150 minutes of moderate aerobic activity weekly, combined with regular supervision and motivational support. Exercise physiologists conducted environmental scans to identify accessible opportunities, established accountability through regular check-ins and helped participants overcome barriers to physical activity. This wasn't simply about telling people to exercise - it was about teaching them how to make sustainable lifestyle changes.

The implications for clinical practice are profound. To discuss this ground-breaking paper in detail, Professor Bogda Koczwara is joined by the Australian Principal Investigators - Professor Haryana Dhillon and Professor Janette Vardy.

Visit www.oncologynews.com.au for show notes and more information about Supportive Care Matters.

This conversation is proudly produced by the Podcast Team at The Oncology Podcast, part of the Oncology Media Group Australia.

Speaker 1:

If it were a pill, we would all want it. But since exercise is not a pill, getting cancer survivors to exercise can be a bit of an uphill battle, but now there is new evidence that may change all that. I'm Bogda Kozlara, and this is Supportive Care Matters. My guests today are two researchers who have made their mark in many areas of cancer survivorship in Australia and internationally. Professor Jeanette Vardy is a medical oncologist working as a clinician researcher at the Concord Cancer Centre and the University of Sydney. She is the director of the Sydney Cancer Survivorship Centre at the Concord Cancer Centre. Professor Haryana Dhillon is a behavioural scientist and psycho-oncologist at the University of Sydney and the chair of the Scientific Advisory Committee at Psycho-Oncology Cooperative Research Group. Together they co-lead the Survivorship Research Group at the University of Sydney. They are also best of friends and full disclosure good friends of mine. Jeanette and Harry. Welcome to the show. Thank you, bogda. Thanks Bogda. All right, so you both have a long track record of many achievements in cancer survivorship, in psychosocial care, cognitive function, lifestyle interventions and many others.

Speaker 1:

But today we're diving into one topic, and the topic is one study that you were both involved in, a challenge study published recently in New England Journal of Medicine. We're going to have links to the paper in our show notes. The results of the study were initially presented at the American Society of Clinical Oncology meeting, which normally takes place at the beginning of June, and, as I understand it, the presentation resulted in a standing ovation in a meeting of thousands of attendees from all over the world. So clearly this is something worth talking about and we are devoting an entire podcast well, almost an entire podcast to this one study, to learn about its findings and, more importantly, to learn how to take these findings into clinical practice. So let's set the scene. Can you tell me a little bit about the study, maybe just a brief sort of summary of the aims and the design?

Speaker 2:

So the aim of the study was to see whether a structured exercise program could improve survival as well as quality of life fitness, and the study design was a phase three randomized controlled trial and this was in patients with colon cancer who had had their surgery and had then completed adjuvant chemotherapy. So they were stage three or high risk stage two colorectal cancer patients and it was two to six months after finishing their adjuvant treatment. So they were randomized to one of two groups. All the patients got health education material saying exercise, eat healthy, and then the intervention group also had a structured exercise program and one of the really important things to emphasize is that as well as exercise and this was a three-year intervention it included a behavioral change component to the exercise program.

Speaker 1:

So, in a nutshell, everybody was told exercise is good for you, but the intervention arm had more than just information. What was the intervention? You mentioned behavioural components, so can you take us through the components, both the behavioural and exercise, and whatever else might be included?

Speaker 3:

So it was an overall three-year exercise program. It was much more intensive at the beginning so we had, in the first six months all of the participants had a fortnightly mandatory supervised exercise session and a mandatory behavior change session. Those were often combined where the accredited exercise physiologist or the physical activity consultant worked with them, supervised their exercise and talked to them about what's happening, how they were going about incorporating physical activity into their daily lives and helped them overcome barriers to get them able to exercise more and to really try and meet those exercise goals that they agreed on. We encourage people in the off fortnight to come back and have a supervised session face-to-face. Then at the six-month mark it was monthly exercise sessions and behaviour change sessions and then at the years one to three they had monthly contact with the exercise consultant. But that could be face-to-face if they needed it, or it could have been by telephone if things were going well, or by video conference once we all became familiar with Zoom during COVID.

Speaker 1:

So, just to be exactly clear, the intensity of the contact with the researchers had diminished over time, because initially you started with face-to-face contact every two weeks and then it became less frequent, but that does not mean that the intensity of exercise would have been expected to be any different. Is that correct?

Speaker 3:

Yeah, that's absolutely right, Bobda. So the first six months were intensive to really try and kickstart people's change in behavior and to get them exercising more and to continue to do that so that they were able to continue exercising over the three-year period and hopefully beyond the end of the study as well. That we were really wanting to change people's behaviour from being fairly sedentary to meeting the current guidelines or exceeding those guidelines, so achieving that 150 minutes of moderate physical activity aerobic physical activity every week, so equivalent to maybe 40 to 45 minutes of brisk walking or cycling or swimming or any of those things that get your heart rate up.

Speaker 1:

So the focus was on aerobic activity as a main aspect of exercise. Were other aspects of exercise, like strength or balance or something else, was that included? Optional? How? How was the recommendation or the exercise prescription built in?

Speaker 2:

so it was deliberately individualized depending on what the patient's strengths and preferences were, but the focus was very much on aerobic because when this design study was designed, that was where we really felt the benefit was likely to come from. However, many of the exercise consultants would have added in some strength or resistance training. If balance was an issue, balance would have been included as well. So the whole point was that it needed to be personalised to that person's abilities, disabilities and preferences.

Speaker 1:

And you mentioned that the duration of the intervention was three years. What that means is that each participant who was randomised, randomly assigned to the intervention arm, would have been expected to participate in the intervention for three years.

Speaker 2:

Correct. The first six months obviously was about building up. The aim was to try and aim for an improvement of about 10 med hours per week and then after that, depending on the person's ability, if possible you'd push even more, but otherwise to maintain that or to maintain what their ability was.

Speaker 3:

Yeah, and I think the really important part of that was the accountability back to the exercise consultants. So the participants in the study knew that somebody was going to be contacting them, checking in on them and asking what they were going to be, what they'd been up to. The other thing that they could do is if something happened, they'd been unwell or they had to have another surgery or something along those lines. They were able to talk to their exercise physiologist and come back for additional booster sessions if they needed it. So if they kind of fell off the exercise wagon, we were helping them get back on that. So it was really that sustained connection with the exercise consultants that helped them do that.

Speaker 2:

And the other thing just worth highlighting, bogda, was that one of the eligibility criterias were people at the start could not be meeting the recommended exercise guidelines. So this wasn't just all your sort of people that were already doing all this exercise to start with, so many of them had never been in a gym in their life they weren't. There were some, clearly, that had done quite a bit of exercise before their cancer but then had dropped off and at this stage, which was two to six months after chemo, they still weren't meeting the recommended guidelines for exercise.

Speaker 1:

So this is a really important point, because that means that the study was designed to improve exercise activity as opposed to maintaining something that is already good. So, harry, you are a behavioural researcher and clearly the behavioural influence is really important here. Can you just kind of give us some examples of what sort of behavioural strategies were employed? You already mentioned that accountability is one, but any other things that would be effective in motivating people to increase their physical activity and maintain it?

Speaker 3:

So I think it was really having people who working with patients or the participants, who understood how to see where someone was at in terms of their level of motivation and help to try and move them forward. So to move from the idea that maybe exercise was good but actually to enacting the exercise behavior. So using techniques like motivational interviewing to help embed that behavior change, really understanding what people's preferences were, so what they did and didn't like about exercise, what they were probably scared of there's a lot of people that have fears about what their body's capable of after they've had a cancer experience and really trying to help them address and overcome those fears in a stepwise approach. I think the other thing that was really critical as part of this was the environmental scans that people were done as part of this program, where the exercise consultants would talk to the patients about the environment they lived in, what kind of physical activity or outdoor resources that they had available to them, and try and really work out what was where they could do their walking safely and confidently or if they needed to go to, you know, a more kind of structured facility to feel safe about doing that. Then finding gyms in the local area or walking groups and those kinds of things really made the big difference.

Speaker 3:

But I think it's really it's. It's a combination of all of those things, so motivating people through motivational interviewing techniques, understanding them and then holding them accountable for well, actually, the other thing I didn't mention was really the goal setting. So we didn't start by saying everybody had to make their 10-minute hours right from the get-go. It was about what are you doing now? How much do you think you can? How much more do you think you can do? Much do you think you can? How much more do you think you can do? And let's keep working towards that and then reassessing the goals on a regular basis so that we can continue to increase this, to get to up to at least meeting the guidelines, if not exceeding them a bit.

Speaker 1:

So I know that this is relevant to kind of the application of results later, but I want to throw it in now because I might forget. Does that mean that you had to train your exercise physiologists who were undertaking the supervision and behavioral support of people exercising? Or can you take it for granted that an exercise physiologist would do an environmental scan and will be skilled in motivational interviewing? Because it sounds to me that this is not just putting people on an exercise bike, it's much more than that.

Speaker 3:

Yeah, and I think it varies. I would say that probably over the time that this study had been running, that exercise science and exercise physiology degrees have probably changed a bit and that that emphasis on behaviour change is more common now. But I think everybody can always upskill further in terms of how good they are and how capable they are at achieving that kind of behavioural counselling and support. But it is a big difference in the accredited exercise physiologists compared to other people Not everybody so personal trainers may not be trained in behaviour change in that same way. So I think it's probably important to understand the people that you're referring patients to and patients when they're looking for someone to guide them, that you actually want to know what your exercise physiologist or the person you're talking to understands about behaviour change.

Speaker 2:

And we also had written a workbook that helped both the participant and probably the physical activity consultant. There was slight differences for the Australians compared to the Canadians because, as you can imagine, their barriers were more about what do you do when it's, you know, minus 20 or minus this side. Now it was more about how do you cope when it's plus 30 or 40 outside. So, yeah, that also helped.

Speaker 3:

We took out the snowshoeing bit.

Speaker 1:

This is positioning everything in context, isn't it?

Speaker 3:

Well. But it's an interesting point then, when you sort of think about adaptations for these kinds of behavioral interventions, that it is important that it's context specific, and so we couldn't have just taken the Canadian book and said, here you go, australian patients, take that and for it to resonate with them. So that adaptation was actually an important part of the development of the study as well.

Speaker 1:

Okay, well, I'm not going to hold people in suspense any longer. Can you take us through the findings? How many people were involved in the study? What did?

Speaker 2:

you find. So there were 889 that were randomized from six countries and 55 centers. Our primary endpoint was disease-free survival. Our primary endpoint was disease-free survival and we were very pleased to show a big difference in five-year survival disease-free survival. So the exercise group was 80% compared to 74% in the health education material alone. So that equates to a 28% risk reduction. We also had as a secondary endpoint overall survival and this was based on about eight years and it was from 90% in the exercise group to 83% in the health education material. So that equates to a 37% decrease in risk reduction. So if you want to talk about numbers needed to treat, for every 14 patients you had exercising, then you had extra survival in one of those patients.

Speaker 1:

So, for those of you who do not dabble in oncology, that's huge. Yeah, that's absolutely huge, isn't it? It is Explain the standing ovation.

Speaker 2:

Yes, on the front page of the Guardian. Yeah, yeah.

Speaker 3:

So I mean, I guess that one of the things to sort of think, to talk about, really is thinking about what that means in context of other onc to chemotherapy which had a 5% improvement in overall survival at five years. So you know, it's adding the same kind of level of benefit as having chemotherapy.

Speaker 2:

And we're not for a moment suggesting that people don't have chemotherapy, but this is an adjunct, something in addition that they can do after, although the next question is when you should start it, but that's another question.

Speaker 1:

And the thing is, in oncology, the sceptics would always say well, you know, you may not be confident in your finding if your study is very small, whereas this was a really large study. It was a study that was undertaken in a number of research centers, so it's not like one place where it might have done something, let's say, a little bit creative of the results. Not that I claim that anybody would, but I think that these are really solid findings where it's really quite compelling evidence that says if you were to add exercise on top of standard treatment, which includes surgery and chemotherapy, then people live longer and people stay cancer free for longer. And that obviously is a significant, significant finding. Now, of course, if you were to add chemotherapy to make people live longer, the obvious question would be can chemotherapy give you toxicity? What is the trade of? How much toxicity do you get as a result of treatment? What sort of toxicities do you get with exercise? Did anybody fall over the exercise bike or something like that, or something like that?

Speaker 2:

We did look at adverse events between the two groups. It was, I think, 15% in the exercise group compared to 10% in the non-exercise group and if you look at overall, the main difference was with musculoskeletal. So it was, I think, 19% in the exercise group compared to 12% in the non-exercise group. So, yes, there might have been the odd twisted ankle, but you know, and bear in mind that exercise helped with many of the toxicities they still have from the cancer or from more so, from their chemotherapy. So it's a pretty low price to pay.

Speaker 1:

And I think to emphasize that people who are not randomized to the intervention had adverse events of some sorts anyway. So this is where the value of randomization comes into it, and you're right that exercise is well documented to assist with other things, whether this is fatigue or other symptoms. So there are potentially other fringe benefits to exercise that might be relevant as well. But the results that you're looking at really pertain to what happens to cancer, which again is quite important, because historically, as oncologists, we tend to say to patients well, you should exercise because you'll feel better, but we don't usually. You should exercise because you'll feel better, but we don't usually say you should exercise because you could live longer. So this, to me, is a significant game changer. How does it sit in the context of evidence for exercise and survival from other studies or from other cancers, for example?

Speaker 2:

The problem with other cancers is that most of the studies up until challenge it's all been observational data, with all the inherent biases that observational data has. One of the big problems is that you need such a large study if you're looking at survival. It would be very hard to do in many cancers. So, for example, with breast cancer, where the cancers tend to recur much later, you would have to have such long follow-up. It would be very, very difficult to do this study in a really large breast cancer population and to follow them for long enough.

Speaker 1:

So let's pick on that. Do you expect that anybody else will do a study like this?

Speaker 2:

I suspect they would have incredible difficulty getting the funding to do a study like this. It'd be nice. You could easily design it. We could easily move challenge to a breast cancer population. You wouldn't have to change very much at all, but you'd need to follow them for a bit longer. But the issue is funding it.

Speaker 3:

But I guess the other thing is I mean, within the challenge study we did look at other new primary cancers and we saw fewer new breast cancers, new prostate cancers and new colon cancers in the exercise group compared to the control. So that kind of does give you some indication, even though the numbers are small, some suggestion that maybe we should just take the evidence for what it is and it's not going to do any harm and it possibly could do quite a lot of good. And we'll be really interested to see what the cost-effectiveness results tell us, because that, I think, really is going to be another additional piece in the story that helps us to really think about, well, what's the value proposition of funding and supporting people to do exercise. Post-cancer diagnosis.

Speaker 1:

So what other results are yet to come, obviously to cancer diagnosis? So what other results are yet to come? Obviously cost-effectiveness, health economic analysis is planned. Any other findings? Biomarkers, predictors of response Did you notice anything in the results that would sort of generate any new hypotheses? So all the above are still to come.

Speaker 2:

There is, and also quality of life, the mechanisms. You know we collected blood samples at each assessment up until the three years and so we have bloods where we were looking particularly at cytokines, at inflammatory markers in particular and the insulin-like growth factors, looking at those. So that's all yet to come. Health effectiveness is on its way. I don't know the results, but with that amount of survival you'd be surprised if it's not cost effective. We also will be looking at adherence and predictors for adherence to the study. So yeah, there's still a number of papers and sub-studies still to come.

Speaker 1:

So I just want to pick up on two things that are kind of hinted on in the paper, just to sort of emphasize it. One is that I don't believe that your intervention group really demonstrated significant change in weight, so weight change is not likely to be the driving mechanism. But I'm not sure whether I got it right. And the second thing that I wanted to explore is did you notice significant change in the level of fitness, like I don't know, vo2 max or something else? What were the differences in, let's say, indirect indicators of fitness?

Speaker 2:

Yep. So we did look at fitness. We looked at VO2 max. There was improvement across each time point in the exercise group. We also looked at a six-minute walk test, so how many metres people can walk in the six minutes and there was improvement between the two groups on that. When we were first designing the study, we had some discussion do we include diet or not? We decided not to because we really wanted to know how much of this was exercise. So we didn't apart from the healthy education materials which said eat a healthy diet, it didn't include diet. So we didn't expect people to be losing weight and they didn't. If anything, they're probably building up muscle mass. The other thing that we have that hasn't been reported on yet in Australia only we added in an accelerometer sub-study. So that's also yet to come, where we can, because there's always issues with self-report for exercise. So we will also be able to compare with the accelerometer data.

Speaker 1:

So there is much more information to come that will provide more opportunities for exploration of the mechanisms and better identification of individuals who are more likely to benefit. But at the moment, what I take from this is exercise is good for you, it's pretty safe and it has a number of potential benefits, as documented in this live study, in addition to other benefits that we already knew about. So now the challenge is how to put it into clinical practice, and before we kind of explore how to do that, I just want to reflect on the fact that this was the study that took a long time to recruit, and I recall that we were recruiting to this study at Flinders Medical Center, where I worked, and it wasn't an easy study to recruit into. Looking back, what sort of lessons can you take from the process of recruitment and what implications does it have of how we apply this very intervention into clinical practice in real life? It?

Speaker 2:

was difficult to recruit to. It was difficult on a number of levels. One was actually getting the buy-in to get funding in the first place, getting the buy-in to get funding in the first place. And we had comments like you know, just tell people to go and exercise, or why would you do a study in exercise, etc. So there was at that level. However, we then did get NHMRC funding twice. Then there was convincing oncologists. There was convincing oncologists. Most of them are more pro-exercise now than what they were back then.

Speaker 2:

But there was also the difficulty with this study was that it was more expensive to do as a study in some respects and more difficult to do because we had to set in place the whole exercise intervention. So most places did not have a gym, they did not have exercise physiologists, so all that had to be put into place. Most exercise consultants or physiologists were not used to working with cancer patients, so there was training from that point of view. And then, if you think that what most of our colleagues were used to doing was a drug trial, and most commonly on a drug trial you get provided, often free of charge, with the drug and probably with the placebo. So there was also this. Well, why are we paying for an intervention? In this case, the exercise intervention and there was also a little bit of this isn't a real study like a drug study is a real study. Now you've seen the results, which speak for themselves, but that took a little bit of convincing when we were setting this up and doing the groundwork back in 2008, 2009.

Speaker 3:

I think the other thing is in relation to that that a lot of people would say to us when we started I can't do your study because I can't randomise people to an exercise program or no exercise program, because I tell all of my patients to exercise, to which we said that's great. You, I tell all of my patients to exercise, to which we said that's great. You keep telling all of your patients to exercise because we want you to do that. But we're pretty sure that that's not enough and that's why we need to do your study.

Speaker 1:

So you've described a number of system issues that were the barrier to the trial lack of infrastructure, lack of funding, complexity of the patient, lack of equipoise from the perspective of healthcare providers. What about patients recognising that those who get to you to be recruited into the study presumably got there because they wanted to? But once they got on the study, was your retention good? Did people drop out? For those who did, what were the barriers to sustaining three years of structured, supervised exercise?

Speaker 2:

The retention was quite good. Once they got onto the study, people could see that there was a benefit to it. So we had the occasional patient that, like one of our patients, went on to run has since run marathons. She'd never, ever done anything like that before. We had another patient that went on to do the Tough Mudder. She'd never done that.

Speaker 2:

Now, that wasn't the aim of it, but it was a nice outcome for those people, but for many. So we had some patients that would. They'd met in the gym on the study and so they would meet up and do walking together during the week and, you know, they'd go off and have a cup of coffee or whatever. So for most they could really see the benefit and they became more enthusiastic as they went along. Now, both groups and not surprising when you're trying to recruit to an exercise group you did have people that were probably doing a bit more than the average colorectal cancer patient, which at that stage was actually very little. They were still, as I said, doing less than the guidelines. But exercise did increase in both groups, but nowhere to the extent as it did in the structured exercise group, which just highlights that telling people to go and exercise is not enough.

Speaker 3:

I think the other thing that I'd add to that is that we did do an interim analysis relatively early on in the study when we had about 250 people who'd been recruited and finished the program had done a year on the program which showed that we were seeing the kind of level of difference in physical activity levels in the people in the structured exercise program compared to the control as we had predicted. So that was really heartening to see that we could actually see that difference in the level of activity that they were engaging in.

Speaker 1:

So let's fast forward to 2025. We've got the results of the study, You've got more staff coming forward, so that's good. But for now, what does it mean in terms of clinical practice? Of course we can continue recommending to patients to exercise, perhaps with a little bit more enthusiasm than before, but that is their control arm. So what does it take to change practice? Does it just take change? Does it take a behavioral intervention? Because clearly that works.

Speaker 2:

Or perhaps something else. I think there's no doubt that when I see patients in the survivorship clinic before, where I was saying you really need to exercise, we think exercise can decrease the risk of the cancer coming back, we can now say that much more emphatically. It's really important to encourage patients to. You know, we need to give an exercise prescription and we, as oncologists aren't the best people to be doing that. I think exercise physiologists are extremely well placed to do that. For patients that are able to go out and get themselves an exercise physiologist, that's the ideal, but clearly it's not going to happen in 2025. But if this was a drug study and we had found drug X had this incredible survival difference, we would all be definitely pushing to have this drug provided on the PBS and for the Australian government to be funding it. Well, I think in the same way, particularly once, if the cost analysis data is positive, then we need to be looking to provide exercise intervention for our patients.

Speaker 3:

It needs to be embedded right from the beginning. So, in the same way that when someone's diagnosed with colon cancer, we talk about needing surgery and the potential to have to have chemotherapy, we need to be starting to talk to them at that point about exercise being part of their treatment plan, whether that's during treatment, which we know will help reduce their side effects from chemotherapy and help them recover from surgery faster, or whether it's more in the post-chemotherapy setting. And I do think that we need a behaviour change intervention for the healthcare professionals who talk to patients about this. We need to be better at understanding where patients are in their thinking about exercise and helping to kind of move them forward so that they will be more likely to take up that recommendation or referral to an exercise physiologist, and there are people working on those sorts of interventions at the moment.

Speaker 1:

As I think about it, it occurs to me that the difficulty in terms of translating this into clinical practice is that it takes a lot of exercise physiologists time to deliver interventions, sort of one-on-one for three years, one-on-one for three years. And thus I wonder are there alternative ways of achieving the engagement with the exercise, perhaps with prioritizing behavioral intervention, where not just exercise physiologists but other health professionals could contribute? Do you think that that is a way of trying to make the implementation more feasible, or can you think of any other ways of building capacity to achieve that behavioural intervention?

Speaker 2:

So just to clarify, it doesn't need to be one-to-one. Many were done in group classes, but they're still individualised within the group session. So our ones that we have in our survivorship gym, there might be 10 people in the gym usually much less than that but where they're doing their own individualized program and the exercise physiologist is going between the different people. You're correct. The motivational or the behaviour change does not need to be done by an exercise physiologist, but it needs to be done by somebody with good training in motivational behaviour. I think the exercise physiologist it works out really well to be the same person doing the two things, but that's something that could certainly be looked into further. We started off face-to-face, but a number of the sessions could be done by telehealth, for example, which again would increase the capacity to be able to reach out to a lot more people. The other thing there's more exercise physiologists around than what you may realise, or other exercise people, but it needs to be trained exercise consultants.

Speaker 1:

If I may just put a plug here and that's not directly derived from the paper but our capacity to monitor how people exercise is also improving, partly due to technology, so remote activity monitoring is potentially an option as well. There are opportunities for online exercise coaching. So I think that there are alternative ways of getting people to exercise in such a way that we can build the broader capacity, and I'm sure that that can also be tailored to different individual needs. Some people require more support, others might require a little bit less, so hopefully we can improve our ability to getting patients to exercise.

Speaker 3:

One thing that's really important to factor into this is the ability for those kinds of group-based exercise programs, whether it's virtual or in-person, to address some of the loneliness experiences that people have post a cancer diagnosis. And we didn't really look at that in our study. In other work that we have done subsequently that's very much coming out as part of the benefit to people that they're not feeling so alone through their cancer experience and recovery if they're engaged with a group-based exercise program.

Speaker 1:

And that assists with motivation as well. I've promised you that we're not going to cover just the challenge study, although overwhelming majority of the time is dedicated to the challenge study, because it's awesome. You both should really be congratulated on the results of it, together with the rest of the international team. But the last few minutes of our discussion I would like to really dedicate to your personal reflection on the labor of love of delivering such a study 15 years of recruitment, convincing clinicians to do something that they don't want to do, getting exercise physiologists into clinical settings. What have you learned from the process of undertaking a study of such mammoth proportions? Any reflections now, any tips for courageous individuals who are following in your path?

Speaker 2:

It very much was a labour of love. For me, it has been a career highlight, but what will be the big highlight is when this gets implemented so that patients around Australia and around the world will be able to do an exercise intervention. That's what will sort of make the difference. It was difficult to do. Harry and I were chatting about this this morning in a meeting and I were chatting about this this morning in a meeting, and it certainly took quite a bit of resilience on our behalf to pull it off. It was difficult, as I said, to get the funding, but it was also difficult to get support, and yet there were others that just saw the big picture very quickly and were very supportive. It was a great team that we worked with, with the Canadians and our Australian team. I just think that it's something that will hopefully make a big difference to cancer survivors, and not just colorectal cancer survivors.

Speaker 3:

For me it was very much. It could be summed up in terms of relationships and resilience. It was very much it could be summed up in terms of relationships and resilience. So we really had to have solid relationships within our own team and then being able to build those relationships with sites and exercise providers and having the resilience to kind of pick yourself up after you didn't get that grant application or you know someone that you thought would be really interested in being involved in the study just went no, not interested, all of those kinds of things.

Speaker 3:

I guess the other thing that I would reflect on is how much things have changed in that 17 years since we started working on the protocol. When we first raised this with AGITG I think at the time, maybe around 2007, 2008, agitg hadn't had a clinical trial that had been solely led by a female chief investigator. So there had been, you know, co-investigators, but you know, and so this is really a big shift in what we've seen in how clinical trials are done, who does them and, I guess, the diversity of the people that are involved.

Speaker 1:

So for me that's another highlight that actually things have changed. In the morning and try again, and try again. It's the people. It's always the people, it's the relationships, the patients that you support, it's the colleagues you work with, it's the people who sort of buy you coffee when everything fails. And at the end of the day, it's with people and it's for people. So to the two of you, the most amazing people I know, thank you. You've done an awesome job and let's hope that we see translation of these research findings into practice very, very soon. So thank you for joining me tonight. Absolute pleasure.

Speaker 1:

Thanks, bogda. It was a pleasure Over and out. That is all for Supportive Care Matters, a podcast created by me, bogda Kozluara, for researchers, clinicians, policymakers and patients passionate about improving the lives of people affected by cancer. Thanks to Mark Tai, who composed the original music, and the Oncology Network, our producers. For show notes, go to wwwoncologynewscomau. Subscribe to this podcast at your favorite podcast provider and rate us. It will help others find us.