Health-related fitness in very long-term survivors of childhood cancer: A cross-sectional study

Clinical Assessment of Late Health Outcomes in Survivors of Wilms Tumor

OBJECTIVES

We aimed to clinically characterize the health, neurocognitive, and physical function outcomes of curative treatment of Wilms tumor.

METHODS

Survivors of Wilms tumor (n = 280) participating in the St. Jude Lifetime Cohort, a retrospective study with prospective follow-up of individuals treated for childhood cancer at St. Jude Children's Research Hospital, were clinically evaluated and compared to age and sex-matched controls (n = 625). Health conditions were graded per a modified version of the National Cancer Institute's Common Terminology Criteria for Adverse Events. Standardized neurocognitive testing was graded by using age-adjusted z-scores. Impaired physical function was defined by age- and sex-matched z-scores >1.5 SD below controls. Modified Poisson regression was used to compare the prevalence of conditions and multivariable logistic regression to examine treatment associations.

RESULTS

Median age at evaluation was similar between survivors and controls (30.5 years [9.0-58.0] and 31.0 [12.0-70.0]). Therapies included nephrectomy (100%), vincristine (99.3%), dactinomycin (97.9%), doxorubicin (66.8%), and abdominal (59.3%) and/or chest radiation (25.0%). By age 40 years, survivors averaged 12.7 (95% confidence interval [CI] 11.7-13.8) grade 1-4 and 7.5 (CI: 6.7-8.2) grade 2 to 4 health conditions, compared to 4.2 (CI: 3.9-4.6) and 2.3 (CI: 2.1-2.5), respectively, among controls. Grade 2 to 4 endocrine (53.9%), cardiovascular (26.4%), pulmonary (18.2%), neurologic (8.6%), neoplastic (7.9%), and kidney (7.2%) conditions were most prevalent. Survivors exhibited neurocognitive and physical performance impairments.

CONCLUSIONS

Wilms tumor survivors experience a threefold higher burden of chronic health conditions compared to controls and late neurocognitive and physical function deficits. Individualized clinical management, counseling, and surveillance may improve long-term health maintenance.

Physical and functional performance assessment in pediatric oncology: a systematic review

BACKGROUND

Research indicates reduced physical performance from diagnosis into survivorship of pediatric cancer patients. However, there is no systematic information or guideline available on the methods to assess physical performance and function in this population. The purpose was to systematically compile and describe assessments of physical performance and function in patients and survivors of pediatric cancer, including cardiorespiratory fitness, muscle strength, speed, balance, flexibility, functional mobility, gait and motor performance test batteries.

METHODS

We searched the databases PubMed, SPORTDiscus, and Cochrane Database and performed abstract and full-text selection of 2619 articles according to the Cochrane Handbook of Systematic Reviews. Information on patients characteristics, assessments, information on validity and reliability, and relevant references was extracted.

RESULTS

In summary, 63 different assessments were found in 149 studies including 11639 participants. Most studies evaluated cardiorespiratory fitness and muscle strength with the majority conducted off treatment. Some outcomes (e.g. speed) and diagnoses (e.g. neuroblastoma) were severely underrepresented. With the exception of gait, leukemia patients represented the largest group of individuals tested.

CONCLUSIONS

Insufficient data and patient heterogeneity complicate uniform recommendations for assessments. Our results support researchers and practitioners in selecting appropriate assessment to meet their specific research questions or individual daily practice needs.

IMPACT

This systematic review includes 149 studies and provides a comprehensive summary of 63 assessments to evaluate cardiorespiratory fitness, muscle strength, speed, balance, flexibility, functional mobility, gait or motor performance test batteries in patients and survivors of pediatric cancer. We present the most studied fields within the pediatric cancer population, which are cardiorespiratory fitness and muscle strength, off treatment phase, and leukemia patients. We propose research priorities by identification of subgroups in terms of cancer type, phase of treatment, and outcome of interest that are underrepresented in studies currently available.

Physical activity and fitness in childhood cancer survivors: a scoping review

BACKGROUND

Estimates indicate that nearly eight percent of the over 500,000 survivors of childhood cancer living in the United States are frail in their fourth and fifth decades of life, a phenotype typically seen in geriatric populations. Participation in regular physical activity to improve physical fitness in healthy and diseased populations reduces risk for frail health by increasing physiologic reserve. However, physical activity may not have the same effects on fitness in childhood cancer survivors as it does among their peers with no cancer history.

AIMS

This scoping review seeks to describe associations between physical activity, physical fitness, chronic disease, and mortality in childhood cancer survivors.

METHODS

Relevant literature was identified through a comprehensive search in the PubMed, Web of Science, CINAHL, and Cochrane databases. A narrative synthesis was performed on observational studies that had physical activity or physical fitness clearly defined and compared with chronic disease outcomes.

RESULTS

A total of 595 studies were screened, and results from 11 studies are presented. Childhood cancer survivors who participate in regular physical activity have improved markers of cardiovascular health, decreased risk of overt cardiovascular disease, and decreased risk of all-cause mortality compared to survivors who are not physically active. Childhood cancer survivors who are physically fit have increased neurocognition, and decreased risk of all-cause mortality compared to survivor's who are not fit. The differential effects of physical activity on fitness and health among childhood cancer survivors when compared to peers is potentially related to treatment exposures that damage cardiovascular tissue and impact regenerative potential.

CONCLUSION

Research is needed to determine the optimal timing, frequency, intensity, and duration of physical activity necessary to optimize fitness in childhood cancer survivors.

Motor ability, physical self-concept and health-related quality of life in pediatric cancer survivors

Background

Cancer survivorship is frequently associated with severe late effects. However, research into pediatric cancer survivors on late effects in motor ability, physical self‐concept and their relationship to quality of life is limited.

Methods

Using multiple regression analyses, 78 pediatric cancer survivors and 56 typically developing children were compared in motor ability, physical self‐concept and health‐related quality of life. In addition, mediational multi‐group analyses between motor ability (independent variable), physical self‐concept (mediator) and quality of life (dependent variable) were calculated.

Results

Pediatric cancer survivors had a lower motor ability (g_Hedges = 0.863), a lower physical self‐concept with regard to several scales of the PSDQ‐S (g_Hedges = 0.318–0.764) and a higher relative risk for a below average quality of life than controls (RR = 1.44). Children with a history of cancer involving the central nervous system showed poorer motor ability compared to those without central nervous system

involvement (g_Hedges = 0.591). Furthermore, the physical self‐concept significantly mediated the relationship between motor ability and quality of life in pediatric cancer survivors but not in typically developing children.

Conclusions

Results show the importance of monitoring and supporting the development of motor ability in the aftercare of pediatric cancer survivors. Physical activity interventions may be advisable to prevent physical activity‐related late effects and potentially improve related psychosocial variables such as quality of life.

Is health status impaired in childhood cancer survivors? A systematic review and meta-analysis

BACKGROUND

An increase in survival rates of childhood cancer is associated with long-term health issues in survivors.

METHODS

We conducted a systematic review and meta-analysis comparing health status-related endpoints in childhood cancer survivors (CCS) versus controls.

RESULTS

Eighty-six studies (n = 98,480 participants, 62% CCS) were included in the review. Of these, 73 studies (n = 96,550, 63% CCS) could be meta-analyzed. CCS showed a lower left ventricular ejection and fractional shortening (SMD=-0.59 and -0.55, respectively, both p < 0.01 [n=1,824 and 1,880]), a lower HDL-cholesterol concentration (SMD=-0.48, p<0.001, n=1,378) and a higher waist-to-hip ratio (SMD=0.61, p < 0.01, n=229) than their healthy peers. No significant differences were found for the remaining endpoints.

CONCLUSIONS

CCS is associated with a lower left ventricular function and HDL-cholesterol level, and a higher waist-to-hip ratio than healthy controls. These findings support the need to closely monitor the cardiometabolic health status of CCS and to implement preventive lifestyle interventions for this population.

Physical training interventions for children and teenagers affected by acute lymphoblastic leukemia and related treatment impairments

A decreased physical fitness has been reported in patients and survivors of acute lymphoblastic leukemia (ALL). This is influenced by the negative effects of the disease and by the treatments of childhood cancer.

In the past, children were advised to recover in bed, and to take as much relax as possible. Nowadays, it is considered that too much immobility may result in a further decrease of physical fitness and functioning. Exercise training for ALL children has frequently been reported to improve physical fitness and the well-being of the children, since it prevents the negative effects of a sedentary life-style, such as obesity and a poor skeletal health. In recent years, different studies and protocols on this subject has become available for children and young adults with cancer, both during and after treatment.

The efficacy of recent physical exercise training interventions, that act on several ALL impairments in children such as skeletal, musculoskeletal, neuromuscular, cardiopulmonary and cardiovascular systems, fatigue, body balance disorders and metabolism alterations have been examined.

These side effects might be prevented or significantly reduced by introducing a physical exercise program during or shortly after cancer treatment. Several interventions are discussed and presented for each impairment, reducing their level caused by the disease and thus suggesting the importance of physical training activity in ameliorating the children quality of life.