Physical activity and pediatric cancer survivorship

Healthcare providers' promotion of physical activity among child and adolescent cancer survivors: strategies and challenges

PURPOSE

This study aims to investigate how healthcare providers (HCPs) promote physical activity (PA) to child and adolescent cancer survivors.

METHODS

Semi-structured interviews were conducted with HCPs (n = 16; women n = 12; men n = 4) who provide care for cancer survivor youth (age 3 to 18). Participants represented 7 professions, including child life specialists, oncologists, nurse practitioners, physical therapists, and social workers. A reflexive thematic analysis was conducted to explore the techniques that HCPs use to promote PA for this patient population and ways PA promotion can improve.

RESULTS

HCPs use five strategies to promote PA to cancer survivor youth: (1) broadening the definition of PA, (2) tailoring PA recommendations, (3) including families, (4) connecting patients to programming, and (5) promoting patient motivation.

CONCLUSIONS

This research highlights techniques that HCPs use to promote PA to young cancer survivors and reveals the need for additional ways to support HCPs to improve PA promotion for child and adolescent cancer survivors. While HCPs emphasized the importance of PA for this patient population, they navigate barriers that limit the quality of PA discussions.

IMPLICATIONS FOR CANCER SURVIVORS

Further research should explore interventions to improve PA promotion and PA participation among child and adolescent cancer survivors. By understanding the perspectives of HCPs, patients, and their families, PA promotion strategies can be improved, and more programs that support both patients and practitioners may be developed.

Physical activity for pediatric cancer survivors: a systematic review of randomized controlled trials

Purpose

To collate evidence and evaluate the effects of physical activity interventions on physical activity level among pediatric cancer survivors who had completed active cancer treatment.

Methods

Relevant published studies were identified in May 2020 via five databases and reference checking. Searches were limited to randomized controlled trials or controlled clinical trials, published in English involving pediatric cancer survivors aged 18 years or below. Interventions were related to promote physical activity among the survivors. Included studies were assessed using the revised version of the Cochrane’s Risk of Bias Tool.

Results

Eight randomized controlled trials (620 pediatric cancer survivors and 53 caregivers of pediatric cancer survivors) were included. All studies investigated interventions for pediatric cancer survivors to increase their physical activity level. The interventions used varied across the eight included studies: three mHealth—medical and public health practice supported by mobile devices; two eHealth—the use of information and communication technologies to improve health care; two adventure-based training; and one educational program. Measures of physical activity level also varied: five used various objective measurements (i.e., accelerometer, pedometer, multisensory activity monitor); three used different self-reported questionnaires. Owing to high variability of the interventions and measures, it was impossible to perform meta-analysis. Overall, eHealth and mHealth interventions showed effectiveness and feasibility to promote physical activity among pediatric cancer survivors.

Conclusions

eHealth and mHealth interventions appear to be increasingly important strategies to promote physical activity among pediatric cancer survivors.

Implications for Cancer Survivors

Future larger-scale studies using a core-set of assessment tools are warranted to further promote regular physical activity in pediatric cancer survivors.

The Use of Activity Trackers in Interventions for Childhood Cancer Patients and Survivors: A Systematic Review

Activity trackers have emerged as promising devices used to motivate and/or objectively monitor physical activity (PA) levels. It is unknown how activity trackers have been used in interventions for children and adolescents affected by cancer. This review aimed to investigate the effectiveness of wearable activity trackers to monitor and/or improve PA levels and health outcomes in pediatric oncology. Based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses, we conducted an electronic search of four databases (Cumulative Index to Nursing and Allied Health Literature [CINAHL], Medline, Embase, and SportDiscus) between January 2000 and March 2020. The review included PA interventions that used an activity tracker with children (≤18 years) diagnosed with cancer. We excluded studies including adult participants (>18 at time of study participation) and cross-sectional or case-report studies. Twelve studies examining 517 children and adolescent patients and survivors of pediatric cancer (age range: 4-18 years) were included. Intervention delivery ranged from 2 weeks to 12 months. Two of 12 studies reported increases in PA and 6 showed improvements in health outcomes, including aerobic fitness and negative mood. PA interventions using activity trackers within pediatric oncology are highly diverse in study design, study population, and intervention features. Preliminary data suggest that interventions using wearable activity trackers may have a positive impact on health outcomes in children and adolescents affected by cancer. Future research is needed to establish optimal intervention approaches to using activity trackers to increase PA in children affected by cancer.

Feasibility of FitSurvivor: A technology-enhanced group-based fitness intervention for adolescent and young adult survivors of childhood cancer

BACKGROUND

This study evaluated the feasibility of a technology-enhanced group-based fitness intervention for adolescent and young adult (AYA) survivors of childhood cancer.

PROCEDURE

AYA survivors ages 13-25 years were randomized to the intervention (eight in-person group sessions with mobile app and FitBit followed by 4 weeks of app and FitBit only) or waitlist control. Assessments were at 0, 2, 3, 6, and 9 months. Feasibility was evaluated by enrollment, retention, attendance, app engagement, and satisfaction. Secondary outcomes included physical activity, muscular strength/endurance, cardiorespiratory fitness, health-related quality of life, and fatigue.

RESULTS

A total of 354 survivors were mailed participation letters; 68 (19%) were screened, of which 56 were eligible and 49 enrolled (88% of those screened eligible, 14% of total potentially eligible). Forty-nine survivors (M_age  = 18.5 years, 49% female) completed baseline assessments and were randomized (25 intervention, 24 waitlist). Thirty-seven (76%) completed the postintervention assessment and 32 (65%) completed the final assessment. On average, participants attended 5.7 of eight sessions (range 1-8). Overall intervention satisfaction was high (M = 4.3, SD = 0.58 on 1-5 scale). Satisfaction with the companion app was moderately high (M = 3.4, SD = 0.97). The intervention group demonstrated significantly greater improvement in lower body muscle strength compared to the waitlist postintervention, and small but not statistically significant changes in other secondary measures.

CONCLUSIONS

A group-based intervention with a mobile app and fitness tracker was acceptable but has limited reach due to geographical barriers and competing demands experienced by AYA survivors.

Investigation of the effect of task-orientated rehabilitation program on motor skills of children with childhood cancer: a randomized-controlled trial

Problems have been reported in the execution and development of motor skills and its treatment as a cause of cancer in children. The purpose of this study was to examine the effect of the task-orientated rehabilitation program (ToRP) on motor skills of children with childhood cancer. Following the consort guideline, 93 children (49 males and 44 females) with pediatric cancer were randomized to either study (n = 52; 12.35 ± 3.43 years) or control (n = 41; 11.89 ± 3.56 years) groups. The study group received ToRP, and the control group received a home-based therapeutic strategies program for 20 sessions. Motor skill outcomes were assessed with Bruininks-Oseretsky Test of Motor Proficiency, Short Form (BOTMP-SF) by assessor who was blind to group allocation and interventions. The groups were homogenous in terms of demographic characteristics and motor skills. The study group showed a significant increase in both gross and fine motor skills (P values for all subtests: P < 0.001), whereas running speed, bilateral coordination, strength, response speed and visual motor control did not show significant improvement with the control group (P > 0.05). The ToRP appears to provide beneficial effects in improving motor skills at the early stages of rehabilitation for children with childhood cancer.

The effect of an active video game intervention on physical activity, motor performance, and fatigue in children with cancer: a randomized controlled trial

Objective

To evaluate the effect of active video games in promoting physical activity and motor performance, and reducing fatigue in children with cancer. A randomized controlled trial was conducted. The intervention included playing Nintendo Wii™Fit (Nintendo Co., Ltd., Kyoto, Japan) for 30 min/day for 8 weeks. Physical activity was estimated with accelerometers, physical activity diaries and questionnaires. Movement-ABC2 and PedsQL™ were used to examine motor performance and fatigue. Intervention experiences and fidelity were examined with an interview.

Results

Participants (n = 36 children with cancer, 3–16 years-old) were randomly assigned to the intervention and control groups. The median [min–max] accelerometer counts/h (500 [131–1130] vs 385 [116–1012], p = 0.63) and physical activity min/day (34 [0–150] vs 23 [0–260], p = 0.95) did not differ between the groups. Change between the pre-test and post-test regarding motor performance and fatigue was similar in both groups (motor performance p = 0.77; fatigue p = 1.00). Participants experienced playing active video games meaningful, but the intervention was not followed completely as instructed. Overall, the physical activity levels were low and one fourth of the children had or were at risk of having movement difficulties.

Trial registration: ClinicalTrials.gov identifier: NCT01748058 (October 15, 2012)

Feasibility and benefits of a combined programme of exercise and play for paediatric cancer survivors: A pilot study

OBJECTIVE

This study aimed to determine the feasibility and benefits of a combined programme of exercise and play for childhood cancer survivors on health-related quality of life (HRQOL), post-traumatic growth and physical strength levels.

METHODS

Six childhood cancer survivors participated in the 8-week intervention consisting of supervised play and exercise sessions two times per week. The participants performed joint exercises, independently, at home, on the 5 days that they were unable to participate in group exercises. Participants completed measures assessing HRQOL, post-traumatic growth and physical strength levels at baseline and post-intervention.

RESULTS

Recruitment, retention and attendance rates in the 8-week combined programme were 87.5%, 85.7% and 89.6%, respectively, with no adverse reactions. Statistically significant improvement was observed in post-traumatic growth (z = -2.20, p = 0.03), subscales of HRQOL school functioning (z = -2.06, p = 0.04) and total score (z = -2.0.3, p = 0.04). Moreover, physical strength measurements using the physical activity promotion system showed that, out of the five total categories, muscle strength (z = -2.02, p = 0.04) and total physical strength (z = -2.03, p = 0.04) scores were statistically significantly improved.

CONCLUSION

The 8-week combined programme of exercise and play was feasible and provided preliminary evidence for the benefits of exercise on HRQOL, post-traumatic growth and physical activity levels in childhood cancer survivors.

Participation in Physical Activity and Physical Education in School Among Children With Acute Lymphoblastic Leukemia After Intensive Chemotherapy

Background: Low physical activity (PA) level has been reported among survivors of childhood acute lymphoblastic leukemia (ALL). The present study was performed to determine the level of participation in general PA and physical education in school (PES) among children with ALL who completed intensive chemotherapy and identify possible barriers that influence adherence to PA and PES. Methods: A cross-sectional, single-center study was conducted over 1 year in a tertiary pediatric hematology and oncology referral center in Kuala Lumpur, Malaysia. A total of 47 children with ALL aged 7-18 years old who were off-treatment and attended school on a regular basis were recruited. A modified structured questionnaire adapted from the Youth Risk Behavior Surveillance System, Division of Adolescent and School Health, the Centers for Disease Control and Prevention (CDC) was used to assess the children's level of PA and PES participation. Results: Among the 47 children will ALL included herein, 11 (23.4%) were physically active for at least 60 min a day for 5 days or more, following CDC recommendations. The median duration from completion of intensive chemotherapy was 4.95 years (25th, 3.29; 75th, 7.95). Younger age at study entry (median, 8.7 years old vs. 12.2 years old) and younger age at diagnosis (median, 2.9 years old vs. 4.3 years old) were significantly associated with higher PA level. Almost all children (45/47, 95.7%) participated in PES. Barriers to non-participation in PES mainly included exhaustion or fear of injury. Conclusions: Majority of the children with ALL included herein had low levels of daily PA after intensive chemotherapy. Nonetheless, their participation in PES was encouraging. PA should thus be promoted during and after cessation of ALL treatment to prevent long-term health risks and improve overall quality of life.

Difficulties faced by long-term childhood cancer survivors: A qualitative study

PURPOSE

Due to improved survival rates of childhood cancer, there has been growing attention to survivors. In addition, experiences of illness in youth, during growth and development, affect the lives of these individuals in numerous ways. With a sample of long-term survivors of childhood cancer, this study investigated their difficult experiences after treatment completion and provided fundamental data for intervention programs that can assist growth.

METHODS

Data from 15 survivors aged 15-28 years old were collected through face-to-face interviews; analysis used Giorgi's phenomenological method.

RESULTS

The long-term survivors' lives involved a process of struggle to overcome the difficulties. Survivors had physical vestiges of cancer treatments, such as physical strength limitations, appearance changes, and sexual problems. Additionally, they experienced social withdrawal and awkwardness due to adaptation difficulties caused by social life interruption, family issues, social prejudice, and discrimination. These physical and social struggles led to experiences of mental stress and psychological withdrawal, but were followed by rebound.

CONCLUSIONS

Long-term survivors of childhood cancer experienced physical, social, and emotional struggles following treatment completion. These results can yield improved understanding of this population, facilitate attention to their challenges, and contribute to their more effective integration into society, helping them live healthy and positive lives.

Inhospital Exercise Training in Children With Cancer: Does It Work for All?

Purpose: Physical exercise training might counteract the weakening effects of both pediatric cancer and anti-cancer treatment. We aimed to analyze the prevalence of "responders" and "non-responders" to inhospital exercise training in children with cancer and to identify the factors that could influence responsiveness, which might help personalize exercise interventions for this patient population. Methods: We performed an ancillary analysis of the randomized controlled trial "Physical activity in Pediatric Cancer" (NCT01645436), in which 49 children with solid tumors were allocated to an inhospital exercise intervention or control group. The present study focused on the children in the former group (n = 24, 10 ± 4 years), who performed 3 weekly training sessions (aerobic + strength exercises). The intervention lasted 19 ± 8 weeks (i.e., from the start to the end of neoadjuvant chemotherapy treatment). A responder-vs-non-responder analysis was performed for physical capacity-related endpoints (five-repetition maximum strength, functional mobility tests, and cardiorespiratory fitness [CRF]). Only those participants showing improvements in a given test of a magnitude greater than both the random error and the threshold for clinically meaningful changes were considered responders. Results: Most participants improved their performance in the strength tests, with 80, 88, and 93% of total showing a positive response for seated bench press, lateral row, and leg press, respectively (p < 0.001). No significant improvements were observed for the functional mobility tests or CRF (p > 0.05, rate of responsiveness ≤ 50%). No differences between responders and non-responders were observed for sex, age, type of cancer, or treatment (i.e., including or not anthracyclines/radiotherapy). However, significant differences (p < 0.05) were observed between responders and non-responders for baseline performance in all the tests, and a significant (p < 0.05) inverse relationship was found between baseline performance and relative improvement for most endpoints. Conclusions: Although most children improved their muscle strength after the exercise intervention, a considerable individual variability was observed for the training responsiveness of functional mobility and CRF. A lower baseline performance was associated with a higher responsiveness for all the study endpoints, with the fittest children at the start of treatment showing the lowest responses. Efforts to individualize exercise prescription are needed to maximize responsiveness in pediatric cancer patients.

Factors associated with physical activity among adolescent and young adult survivors of early childhood cancer: A report from the childhood cancer survivor study (CCSS)

OBJECTIVE

To evaluate concurrent and longitudinal associations between psychosocial functioning and physical activity in adolescent and young adult survivors of early childhood cancer.

METHODS

Adolescent survivors of early childhood cancer (diagnosed before age four) participating in the Childhood Cancer Survivor Study completed the Coping Health and Illness Profile-Adolescent Edition (CHIP-AE; n = 303; mean age at survey: 17.6 years). A subset of these survivors (n = 248) completed a follow-up survey an average of 6.0 years later (range: 4-10). Logistic regression identified associations between psychosocial functioning in adolescence and physical activity levels in adolescence and young adulthood.

RESULTS

Survivors reported low physical activity as adolescents (46.1% scored below CHIP-AE cut-point) and young adults (40.8% below Centers for Disease Control guidelines). Poor physical activity during adolescence was associated with female sex (OR = 2.06, 95% CI, 1.18-3.68), parents with less than a college education (OR = 1.91, 95% CI, 1.11-3.32), previous treatment with cranial radiation (OR = 3.35, 95% CI, 1.69-6.88), TV time (OR = 1.77, 95% CI, 1.00-3.14), and limitations of activity due to health or mobility restrictions (OR = 8.28, 95% CI, 2.87-30.34). Poor diet (OR = 1.84, 95% CI, 1.05-3.26) and low self-esteem (OR = 1.80, 95% CI, 0.99-3.31) during adolescence were associated with lower odds of meeting Centers for Disease Control physical activity guidelines in young adulthood.

CONCLUSION

These findings provide targets for future interventional studies to improve physical activity in this high-risk population.

Influence of a Moderate-Intensity Exercise Program on Early NK Cell Immune Recovery in Pediatric Patients After Reduced-Intensity Hematopoietic Stem Cell Transplantation

Introduction: After allogeneic hematopoietic stem cell transplantation (HSCT), NK cell reconstitution, which is crucial for positive outcomes, is dominated by the CD56^bright subset with low NK cell cytotoxicity (NKCC) activity. Moderate exercise has been described as a potent NK cell stimulus in adults with cancer. Purpose: To determine the effects of a moderate-intensity exercise program on NK cell recovery early after HSCT and the feasibility of this intervention. Methods: Six children undergoing allogeneic HSCT were randomized to an exercise program (EP) or control (CT) group. The EP group performed a 10-week training combining in-hospital and home-based EP. Results: We observed a significant increase in the posttraining/pretraining ratio of the CD56^dim subset (EP = 1.27 ± 0.07; CT = 0.99 ± 0.08; P < .005) of the EP group. The ratio of NKCC was 8 times greater in the EP group. Conclusion: Data suggest that a moderate-intensity EP program performed early after HSCT is feasible and might redistribute the CD56^dim/CD56^brigh NK cell subset, improving NKCC. The results are still preliminary and must be interpreted with caution.

Rehabilitative intervention during and after pediatric hematopoietic stem cell transplantation: An analysis of the existing literature

Hematopoietic stem cell transplantation is a therapeutic strategy for several oncohematological diseases. It increases survival rates but leads to a high incidence of related effects. The objective of this paper was to examine the existing literature on physical exercise interventions among pediatric HSCT recipients to explore the most often utilized rehabilitative assessment and treatment tools. Studies published from 2002 to April 1, 2015 were selected: 10 studies were included. A previous literary review has shown that rehabilitation programs have a positive impact on quality of life. Our analysis identified some significant outcome variables and shared intervention areas.

Effects of a 6-Month, Group-Based, Therapeutic Exercise Program for Childhood Cancer Outpatients on Motor Performance, Level of Activity, and Quality of Life

BACKGROUND

Exercise interventions in pediatric oncology are feasible and safe. However, scarce data are available with regard to the effectiveness of outpatient, group-based exercise interventions. As well, the potential role of exercise to improve motor performance has not been adequately explored despite being a meaningful outcome during childhood with important implications for physical activity behavior. No study has yet demonstrated significant changes in motor performance after an exercise intervention.

PROCEDURES

This explorative, prospective study was designed to evaluate the effects of a 6-month, group-based, therapeutic exercise program for a mixed childhood cancer population on motor performance, level of activity, and quality of life. After cessation of inpatient medical treatment, childhood cancer outpatients aged 4-17 years exercised once a week during a 6-month period (IG). Comparison groups included childhood cancer outpatients receiving care as usual (CG(1)), as well as healthy peers (matched to IG by age and gender) (CG(2)).

RESULTS

Overall motor performance, various motor dimensions, activity in sport clubs and school sports, as well as physical and emotional well-being were significantly reduced in the IG at baseline. Significant differences between the IG and CG(1) and/or CG(2) were identified in the change of overall motor performance, single motor dimensions, overall level of activity, and emotional well-being from baseline to post-intervention.

CONCLUSIONS

The exercise intervention was beneficial in terms of motor performance, level of activity, and emotional well-being. As such, this study provides support for group-based exercise as a potential strategy to improve these outcomes after inpatient medical treatment.

Needs and Lifestyle Challenges of Adolescents and Young Adults With Cancer: Summary of an Institute of Medicine and Livestrong Foundation Workshop

BACKGROUND

Among adolescents and young adults (AYAs) in the United States, cancer is the leading cause of disease-related death. AYA survivors face numerous short- and long-term health and psychosocial issues, as well as increased risk for behavioral and lifestyle challenges, including poor diet, low physical activity (PA), and substance abuse. Many of these behaviors are modifiable, but gaps in care serve as barriers for AYA survivors.

OBJECTIVES

The purpose of this article is to (a) raise awareness of AYAs' increased risk for poor diet, low PA, and substance abuse; (b) examine previous interventions addressing these issues; and (c) provide recommendations for future directions.

METHODS

This article summarizes a workshop coordinated by the Institute of Medicine and the Livestrong Foundation to address AYA survivors' needs and ways to enhance their quality of care.

FINDINGS

Oncology nurses can promote the inclusion of lifestyle behaviors in survivorship care plans of AYA patients and serve as a valuable resource in improving AYA care on a larger scale. In addition, oncology nurse researchers may offer greater understanding of AYA patients' and survivors' needs and best practices by conducting much-needed research with this understudied population.

The feasibility and benefits of a 12-week yoga intervention for pediatric cancer out-patients

BACKGROUND

Increasing rates of survival present a new set of psychosocial and physical challenges for children undergoing treatment for cancer. Physical activity (PA) has been shown to be a safe and effective strategy to mitigate the significant burden of cancer and its treatments, with yoga increasingly gaining recognition as a gentle alternative. The purpose of this study was to determine the feasibility and benefits of a 12-week community-based yoga intervention on health-related quality of life (HRQL), select physical fitness outcomes and PA levels (PAL).

PROCEDURE

Eight pediatric cancer out-patients (4 male; 4 female; Mage  = 11.88, SD = 4.26) participated in the 12-week intervention consisting of supervised yoga sessions 2 times/week. Participants (patients and parent proxies) completed measures assessing HRQL, physical fitness and PAL at baseline and post-intervention.

RESULTS

Rates of recruitment, retention, attendance and adverse events indicated the program was feasible. Wilcoxon Signed Rank tests indicated significant improvements for patient (P = 0.02) and parent reported HRQL (P = 0.03), functional mobility (P = 0.01), hamstring flexibility (left, P = 0.01 and right P = 0.02), and total PAL (P = 0.02) pre to post intervention.

CONCLUSION

This 12-week community-based yoga intervention was feasible and provides preliminary evidence for the benefits of yoga on HRQL, physical fitness and PAL in pediatric cancer out-patients. In a population where sedentary behavior and the associated co-morbidities are a growing concern, these results promote the continued exploration of yoga programming.

Active video games to promote physical activity in children with cancer: a randomized clinical trial with follow-up

Background

Low levels of physical activity, musculoskeletal morbidity and weight gain are commonly reported problems in children with cancer. Intensive medical treatment and a decline in physical activity may also result in reduced motor performance. Therefore, simple and inexpensive ways to promote physical activity and exercise are becoming an increasingly important part of children’s cancer treatment.

Methods

The aim of this study is to evaluate the effect of active video games in promotion of physical activity in children with cancer. The research is conducted as a parallel randomized clinical trial with follow-up. Patients between 3 and 16 years old, diagnosed with cancer and treated with vincristine in two specialized medical centers are asked to participate. Based on statistical estimates, the target enrollment is 40 patients. The intervention includes playing elective active video games and, in addition, education and consultations for the family. The control group will receive a general recommendation for physical activity for 30 minutes per day. The main outcomes are the amount of physical activity and sedentary behavior. Other outcomes include motor performance, fatigue and metabolic risk factors. The outcomes are examined with questionnaires, diaries, physical examinations and blood tests at baseline and at 2, 6, 12 and 30 months after the baseline. Additionally, the children’s perceptions of the most enjoyable activation methods are explored through an interview at 2 months.

Discussion

This trial will help to answer the question of whether playing active video games is beneficial for children with cancer. It will also provide further reasoning for physical activity promotion and training of motor skills during treatment.

Trial registration

ClinicalTrials.gov identifier: NCT01748058 (October 15, 2012).

Clinical exercise interventions in pediatric oncology: a systematic review

Studies in pediatric oncology have shown a positive effect of physical activity on disease- and treatment-related side effects. Although several reviews have approved the benefits of therapeutic exercise for adult cancer patients, no systematic review exists summarizing the evidence of physical activity in pediatric oncology. We identified a total of 17 studies using the PubMed database and Cochrane library. To evaluate the evidence, we used the evaluation system of the Oxford Center for Evidence-Based Medicine 2001. The findings confirm that clinical exercise interventions are feasible and safe, especially with acute lymphoblastic leukemia (ALL) patients and during medical treatment. No adverse effects have been reported. Positive effects were found on fatigue, strength, and quality of life. Single studies present positive effects on the immune system, body composition, sleep, activity levels, and various aspects of physical functioning. Child-specific aspects such as cognitive abilities, growth, adolescence, and reintegration into peer-groups, school, and sports have barely been taken into consideration. The evidence for exercise interventions in pediatric oncology is rated level "3." Although the results are very promising, future research of high methodological quality and focusing on child-specific aspects is needed to establish evidence-based exercise recommendations, particularly for childhood cancer patients.

Health promotion in adolescent and young adult cancer survivors: mobilizing compliance in a multifaceted risk profile

With rising cure rates of childhood cancer, nurse practitioners have an increased chance of encountering a large survivor cohort in practice. A variety of late effects programs exist; however, funding is limited for these programs and is not accessible for all patients. Primary providers may increasingly act as a medical home for childhood cancer survivors (CCS). Understanding the inherent risks of cytotoxic treatment and the progressive consequences of late effects is vital to limit morbidity and mortality. Adolescent and young adult survivors (AYA) are particularly apt to make health behavior decisions that create risks for comorbidities. Developmentally appropriate experimentation with drug, alcohol, or tobacco use and increased ultraviolet ray exposure intensifies the risk for secondary malignancies and novel diseases. The paucity of evidence-based surveillance guidelines and survivor-specific health promotion programs cumulatively widen the gap in noncompliance and misinformation. This article overviews the risk profile of CCS. It explores health practices, as well as emerging health promotion techniques, within the AYA survivor population and the role nurse practitioners have in enhancing health maintenance.

Neurogenesis, exercise, and cognitive late effects of pediatric radiotherapy

Brain cancer is a common type of childhood malignancy, and radiotherapy (RT) is a mainstay of treatment. RT is effective for tumor eradication, and survival rates are high. However, RT damages the brain and disrupts ongoing developmental processes, resulting in debilitating cognitive “late” effects that may take years to fully manifest. These late effects likely derive from a long-term decrement in cell proliferation, combined with a neural environment that is hostile to plasticity, both of which are induced by RT. Long-term suppression of cell proliferation deprives the brain of the raw materials needed for optimum cognitive performance (such as new neurons in the hippocampus and new glia in frontal cortex), while chronic inflammation and dearth of trophic substances (such as growth hormone) limit neuroplastic potential in existing circuitry. Potential treatments for cognitive late effects should address both of these conditions. Exercise represents one such potential treatment, since it has the capacity to enhance cell proliferation, as well as to promote a neural milieu permissive for plasticity. Here, we review the evidence that cognitive late effects can be traced to RT-induced suppression of cell proliferation and hostile environmental conditions, as well as emerging evidence that exercise may be effective as an independent or adjuvant therapy.

Physical Activity in Child and Adolescent Cancer Survivors: A Review

Childhood cancer survivors are at increased risk for future health problems. As such, physical activity (PA) has been targeted as a health promotion priority in child and adolescent cancer survivors. Research indicates that a large portion of pediatric survivors do not meet PA recommendations. Using Bronfenbrenner's ecological theory as a framework, this review presents a conceptual model to explain child and adolescent survivors' PA. The model considers predictors of PA across six domains: (1) demographic; (2) medical; (3) cognitive/emotional; (4) behavioral; (5) social/cultural; and (6) environmental. A structured literature review found 14 empirical articles examining those predictors of PA among child and adolescent cancer survivors. Much existing research is cross-sectional, but suggests multiple factors work together to encourage or discourage PA among survivors of child/adolescent cancer. The conceptual model, which is based in empirical findings to date, can be used to understand the process through which PA is promoted and maintained, to inform the development of empirically-supported clinical interventions, and to guide future research objectives and priorities.

Physical performance limitations in adolescent and adult survivors of childhood cancer and their siblings

PURPOSE

This study investigates physical performance limitations for sports and daily activities in recently diagnosed childhood cancer survivors and siblings.

METHODS

The Swiss Childhood Cancer Survivor Study sent a questionnaire to all survivors (≥ 16 years) registered in the Swiss Childhood Cancer Registry, who survived >5 years and were diagnosed 1976-2003 aged <16 years. Siblings received similar questionnaires. We assessed two types of physical performance limitations: 1) limitations in sports; 2) limitations in daily activities (using SF-36 physical function score). We compared results between survivors diagnosed before and after 1990 and determined predictors for both types of limitations by multivariable logistic regression.

RESULTS

The sample included 1038 survivors and 534 siblings. Overall, 96 survivors (9.5%) and 7 siblings (1.1%) reported a limitation in sports (Odds ratio 5.5, 95%CI 2.9-10.4, p<0.001), mainly caused by musculoskeletal and neurological problems. Findings were even more pronounced for children diagnosed more recently (OR 4.8, CI 2.4-9.6 and 8.3, CI 3.7-18.8 for those diagnosed <1990 and ≥ 1990, respectively; p=0.025). Mean physical function score for limitations in daily activities was 49.6 (CI 48.9-50.4) in survivors and 53.1 (CI 52.5-53.7) in siblings (p<0.001). Again, differences tended to be larger in children diagnosed more recently. Survivors of bone tumors, CNS tumors and retinoblastoma and children treated with radiotherapy were most strongly affected.

CONCLUSION

Survivors of childhood cancer, even those diagnosed recently and treated with modern protocols, remain at high risk for physical performance limitations. Treatment and follow-up care should include tailored interventions to mitigate these late effects in high-risk patients.

EXERCISE in pediatric autologous stem cell transplant patients: a randomized controlled trial protocol

Background

Hematopoietic stem cell transplantation is an intensive therapy used to improve survivorship and cure various oncologic diseases. However, this therapy is associated with high mortality rates and numerous negative side-effects. The recovery of the immune system is a special concern and plays a key role in the success of this treatment. In healthy populations it is known that exercise plays an important role in immune system regulation, but little is known about the role of exercise in the hematological and immunological recovery of children undergoing hematopoietic stem cell transplant. The primary objective of this randomized-controlled trial (RCT) is to study the effect of an exercise program (in- and outpatient) on immune cell recovery in patients undergoing an autologous stem cell transplantation. The secondary objective is to determine if an exercise intervention diminishes the usual deterioration in quality of life, physical fitness, and the acquisition of a sedentary lifestyle.

Methods

This RCT has received approval from The Conjoint Health Research Ethics Board (CHREB) of the University of Calgary (Ethics ID # E-24476). Twenty-four participants treated for a malignancy with autologous stem cell transplant (5 to 18 years) in the Alberta Children’s Hospital will be randomly assigned to an exercise or control group. The exercise group will participate in a two-phase exercise intervention (in- and outpatient) from hospitalization until 10 weeks after discharge. The exercise program includes strength, flexibility and aerobic exercise. During the inpatient phase this program will be performed 5 times/week and will be supervised. The outpatient phase will combine a supervised session with two home-based exercise sessions with the use of the Wii device. The control group will follow the standard protocol without any specific exercise program. A range of outcomes, including quantitative and functional recovery of immune system, cytokine levels in serum, natural killer (NK) cells and their subset recovery and function, and gene expression of activating and inhibitory NK cell receptors, body composition, nutrition, quality of life, fatigue, health-related fitness assessment and physical activity levels will be examined, providing the most comprehensive assessment to date.

Discussion

We expect to find improvements in immunological recovery and quality of life, and decreased acquisition of sedentary behavior and fitness deconditioning. The comprehensive outcomes generated in this RCT will provide preliminary data to conduct a multisite study that will generate stronger outcomes.

Trial registration

Gov identification # NCT01666015

Implementing the exercise guidelines for cancer survivors

In 2009, the American College of Sports Medicine convened an expert roundtable to issue guidelines on exercise for cancer survivors. This multidisciplinary group evaluated the strength of the evidence for the safety and benefits of exercise as a therapeutic intervention for survivors. The panel concluded that exercise is safe and offers myriad benefits for survivors including improvements in physical function, strength, fatigue, quality of life, and possibly recurrence and survival. Recommendations for situations in which deviations from the US Physical Activity Guidelines for Americans are appropriate were provided. Here, we outline a process for implementing the guidelines in clinical practice and provide recommendations for how the oncology care provider can interface with the exercise and physical therapy community.

Cognitive influences as mediators of family and peer support for pediatric cancer survivors' physical activity

OBJECTIVE

The objective of this study was to determine the extent to which self-efficacy mediates the relations between social support and childhood cancer survivors' physical activity (PA).

METHODS

A structured telephone survey was conducted with 105 childhood cancer survivors aged 8-16 years. Participants completed measures assessing their PA as well as proposed predictors of PA including various demographic, medical, cognitive, and social influences. Multiple mediation analyses were utilized to evaluate the relations between social support, cognitive influences, and survivor PA.

RESULTS

Cognitive influences, including perceived benefits, barriers, and self-efficacy for PA, partially mediated the influence of family and peer support on survivor PA. Self-efficacy emerged as a significant unique mediator, indicating that higher levels of family and peer support are associated with higher levels of survivor PA via increases in survivor self-efficacy.

CONCLUSIONS

Social support has both direct and indirect influences on survivor PA. Indirectly, social support influences PA via survivor self-efficacy. Interventions should target family and peer support as well as self-efficacy to increase survivor PA.

Clustering of health behaviours in adult survivors of childhood cancer and the general population

BACKGROUND

Little is known about engagement in multiple health behaviours in childhood cancer survivors.

METHODS

Using latent class analysis, we identified health behaviour patterns in 835 adult survivors of childhood cancer (age 20-35 years) and 1670 age- and sex-matched controls from the general population. Behaviour groups were determined from replies to questions on smoking, drinking, cannabis use, sporting activities, diet, sun protection and skin examination.

RESULTS

The model identified four health behaviour patterns: 'risk-avoidance', with a generally healthy behaviour; 'moderate drinking', with higher levels of sporting activities, but moderate alcohol-consumption; 'risk-taking', engaging in several risk behaviours; and 'smoking', smoking but not drinking. Similar proportions of survivors and controls fell into the 'risk-avoiding' (42% vs 44%) and the 'risk-taking' cluster (14% vs 12%), but more survivors were in the 'moderate drinking' (39% vs 28%) and fewer in the 'smoking' cluster (5% vs 16%). Determinants of health behaviour clusters were gender, migration background, income and therapy.

CONCLUSION

A comparable proportion of childhood cancer survivors as in the general population engage in multiple health-compromising behaviours. Because of increased vulnerability of survivors, multiple risk behaviours should be addressed in targeted health interventions.

Daily physical activities and sports in adult survivors of childhood cancer and healthy controls: a population-based questionnaire survey

BACKGROUND

Healthy lifestyle including sufficient physical activity may mitigate or prevent adverse long-term effects of childhood cancer. We described daily physical activities and sports in childhood cancer survivors and controls, and assessed determinants of both activity patterns.

METHODOLOGY/PRINCIPAL FINDINGS

The Swiss Childhood Cancer Survivor Study is a questionnaire survey including all children diagnosed with cancer 1976-2003 at age 0-15 years, registered in the Swiss Childhood Cancer Registry, who survived ≥5 years and reached adulthood (≥20 years). Controls came from the population-based Swiss Health Survey. We compared the two populations and determined risk factors for both outcomes in separate multivariable logistic regression models. The sample included 1058 survivors and 5593 controls (response rates 78% and 66%). Sufficient daily physical activities were reported by 52% (n = 521) of survivors and 37% (n = 2069) of controls (p<0.001). In contrast, 62% (n = 640) of survivors and 65% (n = 3635) of controls reported engaging in sports (p = 0.067). Risk factors for insufficient daily activities in both populations were: older age (OR for ≥35 years: 1.5, 95CI 1.2-2.0), female gender (OR 1.6, 95CI 1.3-1.9), French/Italian Speaking (OR 1.4, 95CI 1.1-1.7), and higher education (OR for university education: 2.0, 95CI 1.5-2.6). Risk factors for no sports were: being a survivor (OR 1.3, 95CI 1.1-1.6), older age (OR for ≥35 years: 1.4, 95CI 1.1-1.8), migration background (OR 1.5, 95CI 1.3-1.8), French/Italian speaking (OR 1.4, 95CI 1.2-1.7), lower education (OR for compulsory schooling only: 1.6, 95CI 1.2-2.2), being married (OR 1.7, 95CI 1.5-2.0), having children (OR 1.3, 95CI 1.4-1.9), obesity (OR 2.4, 95CI 1.7-3.3), and smoking (OR 1.7, 95CI 1.5-2.1). Type of diagnosis was only associated with sports.

CONCLUSIONS/SIGNIFICANCE

Physical activity levels in survivors were lower than recommended, but comparable to controls and mainly determined by socio-demographic and cultural factors. Strategies to improve physical activity levels could be similar as for the general population.

Body composition abnormalities in long-term survivors of pediatric hematopoietic stem cell transplantation

OBJECTIVE

To quantify lean mass (LM) and fat mass (FM) in survivors of childhood allogeneic hematopoietic stem-cell transplantation (alloHSCT) compared with healthy reference participants and identify risk factors for body composition abnormalities.

STUDY DESIGN

Whole body LM and FM were measured with dual energy x-ray absorptiometry in 54 survivors (ages 5-25 years) and 894 healthy reference participants in a cross-sectional study. Multivariate regression models were used to compare sex- and race-specific Z-scores for LM for height (LM-Ht) and FM for height (FM-Ht) in survivors and reference participants and to identify correlates of LM-Ht and FM-Ht Z-scores in alloHSCT.

RESULTS

Height Z-scores were significantly lower in alloHSCT survivors (P < .001) compared with reference participants; body mass index Z-scores did not differ (P = .13). Survivors had significantly lower mean LM-Ht Z-scores (-0.72; 95% CI, -1.02--0.42; P < .001) and greater FM-Ht Z-scores (1.10; 95% CI, 0.84-1.39; P < .001) compared with reference participants. LM-Ht Z-score deficits in alloHSCT survivors were larger (-1.26; 95% CI, -1.53--0.99; P < .001) after adjustment for FM-Ht Z-scores. Endocrinopathies and alloHSCT characteristics were not associated with LM-Ht or FM-Ht Z-scores.

CONCLUSION

Survivors of childhood alloHSCT have significant LM deficits and FM excess. Future studies should identify the mechanism and consequences of these abnormalities.

Exercise interventions in children with cancer: a review

The purpose of this review is to summarize literature that describes the impact of exercise on health and physical function among children during and after treatment for cancer. Relevant studies were identified by entering the following search terms into Pubmed: aerobic training; resistance training; stretching; pediatric; children; AND cancer. Reference lists in retrieved manuscripts were also reviewed to identify additional trials. We include fifteen intervention trials published between 1993 and 2011 that included children younger than age 21 years with cancer diagnoses. Nine included children with an acute lymphoblastic leukemia (ALL) diagnosis, and six children with mixed cancer diagnoses. Generally, interventions tested were either in-hospital supervised exercise training or home based programs designed to promote physical activity. Early evidence from small studies indicates that the effects of exercise include increased cardiopulmonary fitness, improved muscle strength and flexibility, reduced fatigue and improved physical function. Generalizations to the entire childhood cancer and childhood cancer survivor populations are difficult as most of the work has been done in children during treatment for and among survivors of ALL. Additional randomized studies are needed to confirm these benefits in larger populations of children with ALL, and in populations with cancer diagnoses other than ALL.