Clinical exercise interventions in pediatric oncology: a systematic review

The Italian Consensus Conference on the role of rehabilitation for children and adolescents with leukemia, central nervous system tumors, and bone cancer, part 2: general principles for the rehabilitation treatment of motor function impairments

In Italy, 1400 children and 800 adolescents are diagnosed with cancer every year. About 80% of them can be cured but are at high risk of experiencing severe side effects, many of which respond to rehabilitation treatment. Due to the paucity of literature on this topic, the Italian Association of Pediatric Hematology and Oncology organized a Consensus Conference on the role of rehabilitation of motor impairments in children/adolescents affected by leukemia, central nervous system tumors, and bone cancer to state recommendations to improve clinical practice. This paper includes the consensus on the rehabilitation of children and adolescents with these cancers.

Implementing a behavioral physical activity program in children and adolescent survivors of childhood cancer: a pilot randomized controlled trial

Purpose We aimed to document the acceptability (enrollment rate) and feasibility (phone call delivery rate) of implementing a behavioral PA intervention over 12 weeks, in addition to documenting its effects on patient-reported outcomes and physical functioning. This study also describes the costs of carrying out a behavioral PA intervention. A total of 40 participants were randomized in a 1:1 ratio. The tailored behavioral PA intervention was developed based on the most recent PA guidelines in pediatric oncology and on the COM-B framework to enact PA behavior changes. The prescription (frequency, intensity, time and type (FITT)) was adjusted each week during the weekly support calls. The control group did not receive the intervention. 26 males and 14 females (13.6 years old on average and 2.9 years post-cancer treatment on average) participated in our study. The acceptability rate was 90.9% and the feasibility rate was > 85%. We found that 85% improved PA frequency, 80% improved PA intensity, 100% improved PA time, and 50.0% achieved the recommended PA guidelines. No adverse events were reported over the duration of the intervention. Physical function improved with longer 6-minute walk distances in the intervention group (465.8 ± 74.5 m) than in the control group (398.7 ± 92.9 m) (p = 0.016). PROs scores for all participants were within the limits of the normal range. The estimated cost per participant of carrying out this intervention was USD $126.57. Our 12-week behavioral PA intervention, based on the COM-B framework, was found to be acceptable, feasible and safe in childhood cancer survivors. This study is an important step in the right direction to make exercise standard practice in pediatric oncology.

Barriers and facilitators to physical activity participation for child, adolescent, and young adult cancer survivors: a systematic review

PURPOSE

The aim of this systematic review is to explore and describe the barriers and facilitators to physical activity (PA) participation for child, adolescent, and young adult cancer survivors.

METHODS

MEDLINE, Embase, AMED, CINAHL, Cochrane, and Web of Science were searched for manuscripts published between January 2000 and February 2021. To be included in this review, studies had to report qualitative or quantitative data on barriers and facilitators to PA participation in child (4 to < 10 years), adolescent (10 to 19 years), and young adult (> 19 to < 40 years) cancer survivors. Six independent reviewers assessed methodological quality using the Mixed Methods Appraisal Tool (MMAT-version 18) in duplicate.

RESULTS

Fifteen studies were included in this systematic review. Fatigue and psychological factors were the most prevalent barriers shared between children, adolescents, and young adults. Support from others was a shared facilitator between age groups.

CONCLUSION

Psychological barriers and social support are important to address in younger cancer survivors. Clinicians can use these findings to create exercise interventions to facilitate and overcome barriers to PA participation.

IMPLICATIONS FOR CANCER SURVIVORS

While PA is beneficial for cancer survivors of all ages, different barriers and facilitators to PA participation exist depending on a survivors age and life stage. Survivors should discuss PA with their healthcare team at all timepoints in the cancer treatment trajectory in order to gain the associated benefits during and after treatment.

Fatigue in children who have recently completed treatment for acute lymphoblastic leukemia: a longitudinal study

BACKGROUND

This study examined fatigue in patients treated for childhood acute lymphoblastic leukemia (ALL) over a 2-year period (3- to 27-months post-treatment completion), from the perspective of children and parent caregivers, compared to a healthy comparison group.

METHODS

Eighty-three patients (4-16 years at enrolment) and their parents, reported on the child's fatigue using the Pediatric Quality of Life Inventory- Multidimensional Fatigue Scale (PedsQL-MFS), at 3- 15- and 27-months post-treatment completion, and 53 healthy children and their parents reported on fatigue across the same timepoints.

RESULTS

Parent proxy-reporting showed that parents of ALL patients reported more total fatigue than parents of the comparison group at all time points, with all subscales elevated (general, cognitive, and sleep/rest fatigue). In contrast, patient self-report of fatigue over this period differed from the comparison children for the general fatigue subscale only. Self-reported total fatigue was worse than the comparison group at the 27-month timepoint, with cognitive and sleep/rest fatigue symptoms contributing to this difference. Expected improvements in fatigue over time were not evident in either patient or parent report and no demographic risk factors were identified. Parents and children from both groups reported significantly more fatigue at all time points compared to commonly utilised normative population data.

CONCLUSIONS

Patients treated for childhood ALL are impacted by fatigue symptoms in the post-treatment and early survivorship period. These findings highlight that patients in the 2-years following treatment require increased symptom surveillance and may benefit particularly from interventions that target cognitive and sleep/rest fatigue.

Associations Between Fatigue, Sleep Disturbance, Physical Activity, and Quality of Life for Children With Cancer: A Correlational Study

BACKGROUND

Fatigue, sleep disturbance, and physical inactivity have been increasingly recognized as health issues that negatively affect quality of life (QoL) for children with cancer. Existing studies focus either on children receiving treatment or in survivorship, but not on both populations in a study. This causes difficulty in examining differences of these issues between treatment statuses and identifying associations of these issues with QoL.

OBJECTIVE

The aims of this study were to examine differences in fatigue, sleep disturbance, physical activity, and QoL between on- and off-treatment children and to identify their associations with QoL.

METHODS

The correlational study was conducted with 100 children with cancer 7 to 12 years old. Descriptive, bivariate, and multivariate regression analyses were used.

RESULTS

Participants undergoing treatment had higher degrees of fatigue ( P = .002), physical inactivity ( P = .004), and QoL distress ( P = .001) than those in survivorship. Mean sums (SDs) of sleep disturbance were 47.15 (8.23) and 48.48 (7.13) in the on- and off-treatment groups. Age ( P = .000), sex ( P = .023), fatigue ( P = .000), and sleep disturbance ( P = .004) were significantly associated with QoL distress.

CONCLUSIONS

This study is unique in that a frame of reference is addressed to gain insight into the distinct developmental issues of school-aged children undergoing cancer treatment and in survivorship. More studies are needed.

IMPLICATIONS FOR PRACTICE

Interventions to increase QoL should target children who are younger, male, and have higher levels of fatigue and sleep disturbance. Diagnosis and treatment of sleep disturbance should be considered as part of routine activities.

Peripheral Skeletal Muscle Impairment in Children After Treatment for Leukemia and Lymphoma

Exercise intolerance is a common adverse effect of childhood cancer, contributing to impaired health and well-being. While reduced aerobic fitness has been attributed to central cardiovascular deficiencies, the involvement of peripheral musculature has not been investigated. We studied peripheral muscle function in children following cancer treatment using noninvasive phosphorus-31 magnetic resonance spectroscopy. Ten acute lymphoblastic leukemia (ALL) and 1 lymphoma patient 8 to 18 years of age who completed treatment 6 to 36 months prior and 11 healthy controls participated in the study. Phosphorus-31 magnetic resonance spectroscopy was used to characterize muscle bioenergetics at rest and following an in-magnet knee-extension exercise. Exercise capacity was evaluated using a submaximal graded treadmill test. Both analysis of variance and Cohen d were used as statistical methods to determine the statistical significance and magnitude of differences, respectively, on these parameters between the patient and control groups. The patients treated for ALL and lymphoma exhibited lower anaerobic function ( P =0.14, d =0.72), slower metabolic recovery ( P =0.08, d =0.93), and lower mechanical muscle power ( d =1.09) during exercise compared with healthy controls. Patients demonstrated lower estimated VO 2peak (41.61±5.97 vs. 47.71±9.99 mL/min/kg, P =0.11, d =0.76), lower minutes of physical activity (58.3±35.3 vs. 114.8±79.3 min, P =0.12, d =0.99) and higher minutes of inactivity (107.3±74.0 vs. 43.5±48.3 min, d =1.04, P <0.05). Children treated for ALL and lymphoma exhibit altered peripheral skeletal muscle metabolism during exercise. Both deconditioning and direct effects of chemotherapy likely contribute to exercise intolerance in this population.

Promoting positive physical activity behaviors for children and adolescents undergoing acute cancer treatment: Development of the CanMOVE intervention using the Behavior Change Wheel

Background

Increasing participation in physical activity has the potential to improve outcomes for children and adolescents with cancer during treatment and into survivorship. The aim of this study is to outline the theoretical process behind development of CanMOVE, a behavior change intervention designed to increase physical activity for children and adolescents with cancer.

Study design

This study followed a theoretical design process consistent with the Behavior Change Wheel to inform the design of a complex intervention.

Materials and methods

The three stages of the Behavior Change Wheel intervention design process include: (1) understanding physical activity behavior within the pediatric cancer setting, (2) identifying potential intervention functions, and (3) identifying appropriate behavior change and implementation strategies. Qualitative and behavior change literature relevant to the pediatric cancer treatment setting were used to inform each stage.

Results

An individualized and flexible approach to physical activity promotion that considers intrinsic factors specific to the child/adolescent and their environment is required. Fifteen behavioral change strategies were identified to form the intervention components of CanMOVE. Implementation strategies were identified to build motivation, opportunity and capacity toward increasing physical activity behaviors. Key intervention components of CanMOVE include standardized assessment and monitoring (physical activity, physical function, and health-related quality of life), provision of an activity monitor to both child/adolescent and parent, and one-on-one capacity building sessions with a healthcare professional. Capacity building sessions include education, goal setting, an active supervised physical activity session, barrier identification and problem solving, and action planning.

Conclusion

CanMOVE is a novel approach to physical activity promotion in the pediatric cancer treatment setting. The use of a theoretical intervention design process will aid evaluation and replication of CanMOVE when it is assessed for feasibility in a clinical setting. The design process utilized here can be used as a guide for future intervention development.

Movement behaviours in paediatric cancer survivors during recovery and school weeks

Purpose

Paediatric cancer survivors (PCS) are a high-risk population, who can suffer from late effects of their treatment, such as metabolic syndrome, cardiovascular conditions, secondary tumours. Optimal movement behaviours (e.g., limited sedentary behaviour [SB] and sufficient physical activity [PA]) can reduce the side effects or avoid late effects of their treatment. The aims of this study were to analyse movement behaviours and meeting the recommendation of 60 minutes of moderate-to-vigorous physical activity (MVPA) a day in Czech PCS, and to compare their movement behaviours during recovery and school weeks in relation to gender, age, and cancer type.

Methods

Twenty-six PCS aged 7-15 years in remission stage took part in the cross-sectional study. Movement behaviours were measured with Actigraph wGT3X+ accelerometers worn 24 hour/day for 20 consecutive days covering recovery week (13 days at recovery camp) and school week (7 days). Based on cancer types, the PCS were categorized into haematological malignancy or solid tumours group.

Results

In the PCS, movement behaviours differed between recovery and school weeks. During recovery week, the PCS showed less SB (451.8 vs. 552.3 min/day, p < 0.001) and spent more time on light PA (350.3 vs. 255.1 min/day, p < 0.001), moderate PA (73.2 vs. 37.4 min/day, p < 0.001), and vigorous PA (10.3 vs. 4.0 min/day p < 0.001) than during school week. The PA recommendation was met by 77% (n = 20) PCS during recovery week, but only by 15% (n = 4) individuals during school week.

Conclusions

The PCS recorded higher levels of PA and lower levels of SB during recovery week than during school week. If provided with appropriate conditions, PCS in the remission stage are able to reach the PA level recommended for the healthy population. Recovery week can be a suitable platform for gaining experience that PCS are able to meet the recommended PA level and could be an integral part of reconditioning and resocialization programmes for PCS after the completion of their treatment.

Supervised Exercise Interventions in Childhood Cancer Survivors: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background: Childhood cancer survivors (CCSs) may suffer from a multitude of health impairments, resulting in a compromised quality of life (QoL). This review’s objective was to examine CCSs’ adherence to supervised exercise training interventions and the impact of these interventions on health outcomes. Methods: The following databases were searched in May 2022: PubMed, Embase, Cochrane Library, and Web of Science. The included studies were limited to randomized controlled trials (RCTs), published in English involving CCSs aged 18 years and below. Results: Nine RCTs (n = 642 participants) were included in the systematic review, and seven of them (n = 551 participants) were included in the meta-analysis. Both the mean retention rate and adherence to the supervised exercise interventions were 87%. Supervised exercise interventions significantly improved muscle strength (standardized mean difference (SMD) = 1.42, p = 0.03), level of daily physical activity (SMD = 1.05, p < 0.001), body mass index (BMI) (mean difference (MD) = 1.06, p = 0.03), and fatigue (SMD = −0.44, p < 0.001), while there was no statistical significance in the quality of life (QoL) (SMD = 0.21, p = 0.20). Conclusions: The adherence of CCSs to supervised exercise interventions is high, and supervised exercise interventions are safe and effective.

Insulin and cancer: a tangled web

For a century, since the pioneering work of Otto Warburg, the interwoven relationship between metabolism and cancer has been appreciated. More recently, with obesity rates rising in the U.S. and worldwide, epidemiologic evidence has supported a link between obesity and cancer. A substantial body of work seeks to mechanistically unpack the association between obesity, altered metabolism, and cancer. Without question, these relationships are multifactorial and cannot be distilled to a single obesity- and metabolism-altering hormone, substrate, or factor. However, it is important to understand the hormone-specific associations between metabolism and cancer. Here, we review the links between obesity, metabolic dysregulation, insulin, and cancer, with an emphasis on current investigational metabolic adjuncts to standard-of-care cancer treatment.

Effect of virtual reality-based exercise intervention on sleep quality in children with acute lymphoblastic leukemia and healthy siblings: A randomized controlled trial

OBJECTIVE

Sleep is one of the important measurements of the quality of life for children especially suffering from a chronic illness such as cancer. Our aim was to determine the changes in sleep quality and to investigate the effect of virtual reality-based exercise (VRBE) approaches on sleep in patients with acute lymphoblastic leukemia (ALL) off treatment.

METHOD

The participants (ALL and healthy siblings) were evaluated for sleep quality with polysomnography and "Children's Sleep Habit Questionnaire" before and after 12 weeks. The study randomized into two groups: an exercise group who received VRBE in two days in a week, 45 min of each session for 12 weeks and an control group who were managed with supportive measures. The VRBE comprised of aerobic exercise in four different games by Nintendo Wii Fit Plus®.

RESULTS

This randomized controlled trial was carried out on 38 participants. Before intervention, ALL patients (n = 24) and healthy siblings (n = 14) had similar sleep quality in terms of polysomnography and Children's Sleep Habit Questionnaire findings. After intervention, total time asleep (p = 0.023), respiratory disturbance index of hypopnea (p = 0.005), apnea/hypopnea index (p = 0.008), and number of apnea (p = 0.028) statistically significant improved.

SIGNIFICANCE OF RESULTS

Patients with ALL off treatment had similar values of sleep quality with healthy siblings. Novel types of exercises like VRBE have positive effects on sleep disorders in children with ALL and also healthy siblings. Future studies are needed comparing the different types of interventions.

A Bout of High-Intensity Interval Training (HIIT) in Children and Adolescents during Acute Cancer Treatment-A Pilot Feasibility Study

Low- and moderate-intensity exercise is safe and feasible during childhood cancer treatment. The feasibility of a bout of high-intensity interval training (HIIT) in this population has not been analyzed to date. Pediatric cancer patients aged between 6 and 18 years were selected based on clinical conditions to perform ten sets of 15 s HIIT (>90% of estimated maximal heart rate (HRmax)) and 1 min active recovery on a bicycle ergometer within the first three chemotherapy courses. We assessed safety and feasibility criteria and the following parameters: perceived exertion rate, heart rate, and lactate and adrenaline concentrations. Out of 212 eligible patients, 11 patients aged 13.9 ± 3.6 years (n = 7 ♂) with lymphoma, leukemia, rhabdomyosarcoma, nephroblastoma, and synovial sarcoma completed the bout of HIIT without serious adverse events. During exercise, patients reached a BORG value maxima of 16 ± 1.2, and their heart rates rose from 78 ± 17 beats per minute (bpm) at rest to 178 ± 12 bpm after exercise (90 ± 6% estimated HRmax). The power-to-weight ratio was 2 ± 0.5 W/kg (watt per kilogram). Blood lactate concentrations increased from 1.09 ± 0.50 mmol/L (millimole per liter) at rest to 5.05 ± 1.88 mmol/L post-exercise. Our preliminary data suggest that HIIT is applicable only in a small number of childhood cancer patients. Individually adapted exercise protocols for patients with multiple impairments are needed.

Disparities in economic burden for children with leukemia insured by resident basic medical insurance: evidence from real-world data 2015–2019 in Guangdong, China

Background

Pediatric leukemia is the most prevalent childhood cancer in China and incurs heavy economic burden to patients without sufficient insurance protection. Although all Chinese children are obliged to enroll in the national insurance scheme, “Resident Basic Medical Insurance (RBMI)”, the protection may vary among patient subgroups. This study is designed to measure the disparities in economic burden for patients with leukemia under RBMI protection and explore the influencing factors.

Methods

The included patients were aged ≤ 15 and diagnosed with acute lymphoblastic leukemia (ALL) or acute myeloid leukemia (AML, with/without transplantation). They all completed treatment course consecutively in Nanfang Hospital and Zhujiang Hospital from Jan.1, 2015, to Dec.30, 2019, in Guangzhou, China. Their inpatient treatment and insurance settlement data were drawn from the Hospital Information System (HIS) and Insurance Settlement System (ISS). A total of 765 consecutive patients and 14,477 inpatient medical records were included and analyzed. Their insurance status (6 subtypes), economic burden [total cost, out-of-pocket cost (OOP), reimbursement, reimbursement rate (RR)], and cost structures (operation/procedure, blood products, drug, simple treatment) were calculated respectively. Non-normally distributed costs were reported as the median and interquartile range (IQR). Wilcoxon test was used for univariate tests and generalized linear model with log link was used to explore the influencing factors.

Results

The insured patients who were treated in the location of insurance with instant reimbursement reported the highest total cost and reimbursement, while those who seek medical care cross-province with no instant reimbursement reported the lowest total cost and highest OOP payment. In terms of annual change, the total cost of children with leukemia decreased from 2015–2019 with stably increasing reimbursement rate. Blood products and drugs were the major components of total cost, but they decreased annually. Patients who received transplantation and treated across provinces were with a higher economic burden.

Conclusion

The economic burden for children with leukemia decreased overtime under the protection of RBMI, but disparities exist among subtypes. The payer-provider contract on instant reimbursement and drug cost control are effective measures for insurance administrators to curb the economic burdens of pediatric leukemia treatment.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07564-8.

Totally Excited about Moving Mobility and Exercise (TEAM Me): A Successful Multidisciplinary Exercise Quality Improvement Initiative for Pediatric and Young Adult Oncology and Stem Cell Transplant Inpatients

Background: Pediatric, adolescent and young adult (PAYA) patients are less active than their healthy counterparts, particularly during inpatient stays. Methods: We conducted a quality improvement initiative to increase activity levels in patients admitted to our pediatric oncology and cellular therapy unit using a Plan-Do-Study-Act (PDSA) model. An interdisciplinary team was assembled to develop an incentive-based inpatient exercise and activity program titled Totally Excited About Moving Mobility and Exercise (TEAM Me). As part of the program, patients were encouraged by their care team to remain active during their inpatient stay. As an additional incentive, patients earned stickers to display on TEAM Me door boards along with tickets that could be exchanged for prizes. Activity was assessed by documentation of physical therapy participation, tests of physical function, and surveys of staff perceptions of patient activity levels, motivations, and barriers. Results: Compared to baseline, patient refusals to participate in physical therapy decreased significantly (24% vs. 2%) (p < 0.02), and staff perceptions of patient motivation to stay active increased from 40% to 70% in the post implementation period. There were no changes in physical function tests. Conclusions: An incentive-based exercise program for young oncology inpatients greatly improved patient activity levels, participation in physical therapy and influenced professional caregivers’ beliefs.

Testing the Associations Between Body Image, Social Support, and Physical Activity Among Adolescents and Young Adults Diagnosed With Cancer

Physical activity (PA) is important for managing the side effects and long-term outcomes of cancer treatment, yet many adolescents and young adults diagnosed with cancer (AYAs) are not meeting PA guidelines. Body image and social support are two factors that can influence PA behavior and require further attention in this population. The purpose of this study was to examine the associations between body image, social support, and PA among AYAs. An online cross-sectional survey administered through the Research Electronic Data Capture platform was used to assess self-reported body image (body-related self-conscious emotions of appearance and fitness shame, guilt, authentic pride, and hubristic pride), social support (general and cancer-specific), and PA (mild, moderate-to-vigorous, and resistance exercise) in AYAs (N = 119; M age = 34.5 ± 5.5 years). Based on findings from path analyses, body image and social support were directly associated with PA (R 2 = 0.09-0.33). Social support was also directly associated with body image. However, there were no indirect effects. These findings provide preliminary support for the influential role of appearance and fitness body-related emotions and cancer-specific social support on PA. The results have important implications for the development of targeted strategies aimed at improving body image (e.g., cognitive dissonance and compassion-focused interventions) and social support (e.g., facilitating the provision of cancer-specific support), with the overall goal of increasing AYAs' PA.

Playing With a Purpose: The Impact of Therapeutic Recreation During Hospitalization

Background: Youth undergoing cancer treatment and hematopoietic stem cell transplant (HSCT) spend significant time in the hospital, which is disruptive to their physical, social, and emotional development. Therapeutic recreation (TR) can help individuals with an illness maintain or improve their health, quality of life, and physical functioning. TR is an understudied intervention, particularly with youth in the hospital setting. Methods: Forty-nine children (median age = 12 years, interquartile range [IQR] 11-15 years) hospitalized for cancer treatment or HSCT were assigned to participate in either the historical control or TR intervention. Participants wore a Fitbit charge HR for three days to measure movement. At the end of the study participation, they completed self-report measures of mood, social connectedness, and health-related quality of life. Results: Compared with historical controls, the TR intervention group had improved positive affect and decreased mood disturbance (p = 0.03); had better sleep quality (p = 0.003); and was more satisfied with the leisure activities offered in the hospital (p = 0.01). There were no differences in the number of steps taken per day, somatic distress, cooperation with cares, or interaction with medical personnel or caregivers. Both groups reported poor availability and support of peer companions. Discussion: TR is one avenue to increase leisure activities and positively impact mood. More thought needs to be given to how TR programs can be leveraged to increase physical activity and social connectedness.

Integrative Neuromuscular Training in Adolescents and Children Treated for Cancer (INTERACT): Study Protocol for a Multicenter, Two-Arm Parallel-Group Randomized Controlled Superiority Trial

BACKGROUND

Improved survival rates for children and adolescents diagnosed with cancer call for novel strategies for reducing short- and long-term treatment-related side effects. These include the physical and metabolic sequelae that are exacerbated by sedentary behavior and treatment-induced toxicities. We aim to investigate the effect of an integrative neuromuscular training intervention during the first 6 months of anti-cancer treatment primarily on muscle strength, and secondarily on exercise capacity, physical function, markers of metabolic syndrome, dysmetabolism, and health-related quality of life during and after ended treatment.

METHODS

One hundred and twenty-seven children and adolescents, newly diagnosed with malignant and benign neoplasia, aged 6-17 years, and treated with chemotherapy or radiation will be randomized to either the intervention or the control arm of the study. The intervention group will, in addition to usual care, be offered a combination of 6 months of supervised physical exercise (integrative neuromuscular training) and home-based exercise. The active control group will, in addition to usual care, receive information along an unsupervised written home-based training program. All participants, including parents, will receive information about the importance of physical exercise during the course of cancer treatment, at the start of treatment, and in 5 monthly sessions. The primary outcome is measured in terms of isometric quadriceps muscle strength. Secondary outcomes include muscle strength and endurance, markers of metabolic syndrome and dysmetabolism, exercise capacity, physical function and activity, days of hospitalization, and health-related quality of life. Assessment will be conducted at treatment initiation (baseline), at 3 and 6 months after inclusion, and 1 month and 1 year after ended treatment. The primary endpoint for lower-body muscle strength is at 6 months after treatment initiation. The effects of the intervention will be evaluated through a constrained linear mixed model.

DISCUSSION

This national randomized controlled study has the potential to provide new knowledge concerning the short- and long-term effects of a novel, inclusive approach for youth exercise programming (integrative neuromuscular exercise) in children and adolescents during anti-cancer treatment. Using a pragmatic, low-cost, and time-efficient training design, this intervention can be easily adapted to both hospital and home settings.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov (NCT04706676), first released January 5, 2021.

Muscle mass change during chemotherapy in children with high-risk neuroblastoma: a retrospective case series of 24 patients

The clinical characteristics, cause, and risk factors of sarcopenia are unclear in children. The aim of this study was to describe the course of and identify the factors related to muscle mass change during chemotherapy in children with neuroblastoma. A total of 24 consecutive patients aged below 18 years with newly diagnosed high-risk neuroblastoma between 2010 and 2018 in our hospital were enrolled in a case-series study. The psoas muscle index (PMI) was calculated as a parameter of muscle mass based on computer tomography (CT) images of the psoas muscle. PMIs were evaluated at 4 time points (TPs): TP1, at the diagnosis of neuroblastoma; TP2, after the first cycle of chemotherapy; TP3, after the third cycle of chemotherapy; and TP4, at the end of the induction chemotherapy. PMI recovery was defined as an increase in PMI between TP2 and TP4. The mean PMI decreased by 15% between TP1 and TP2 (TP1 7.09 ± 0.99 vs. TP2 6.01 ± 0.98, P < 0.001) and by 10% between TP1 and TP4 (TP1 7.09 vs. TP4 6.35, P = 0.004). PMI recovery between TP1 and TP2 was observed in 7 (29%) patients. The median age of patients with PMI recovery was significantly lower (2 vs. 4 years, P = 0.028), and the proportion of boys was significantly higher in patients with PMI recovery (100% vs. 41%, P = 0.017).Conclusion: This study demonstrated that prominent PMI reduction occurs during the early time of chemotherapy, and a younger age and male sex may be predictive factors for PMI recovery. What is Known: • Sarcopenia is a common disorder in elderly people. • Several causes and risk factors have been reported in adults. • Children with previous hematological malignancies have decreased physical activity. What is New: • Prominent muscle mass loss was observed early in children with high-risk neuroblastoma during chemotherapy. • Age and sex were found to be potentially associated with muscle mass recovery.

Exercise intervention decreases acute and late doxorubicin-induced cardiotoxicity

BACKGROUND

Doxorubicin (Dox) is one of the most effective chemotherapy agents used to treat adolescent and young adult sarcoma patients. Unfortunately, Dox causes cardiotoxicities that compromise long-term survival. We investigated whether exercise prevented cardiotoxicity and increased survival following myocardial infarction.

METHODS

Juvenile mice received Dox, Dox + exercise (Exer), Dox then exercise or were exercised during and after Dox. Mice were evaluated by echocardiography and histology immediately after therapy and 12 weeks later. Mice subjected to permanent ligation of the left anterior descending artery 90 days after therapy were assessed for survival at 45 and 100 days.

RESULTS

Mice treated with Dox, but not Dox + Exer, had decreased ejection fraction (EF) and fractional shortening (FS) immediately after Dox therapy, which continued to deteriorate over 12 weeks with the development of diastolic failure and fibrosis. Acute Dox-induced cardiotoxicity was documented by induction of autophagy and abnormal mitochondria and vascular architecture with decreased pericytes. These abnormalities persisted 12 weeks after therapy. These acute and late changes were not seen in the Dox + Exer group. Initiating exercise after Dox therapy promoted recovery of EF and FS with no functional or histologic evidence of Dox-induced damage 12 weeks after therapy. Survival rates at 100 days after MI were 67% for control mice, 22% for mice that received Dox alone, and 56% for mice that received Dox + Exer.

CONCLUSIONS

Exercise inhibited both early and late Dox-induced cardiotoxicity and increased recovery from an ischemic event. Exercise interventions have the potential to decrease Dox-induced cardiac morbidity.

Complex behavioral interventions targeting physical activity and dietary behaviors in pediatric oncology: A scoping review

As cancer and its treatment negatively impacts the long-term health and quality of life of survivors, there is a need to explore new avenues to prevent or minimize the impact of adverse effects in children with cancer and cancer survivors. Therefore, this scoping review aimed to report on the state of the evidence on the use and effects of complex behavioral interventions (CBI) targeting physical activity and/or dietary behaviors in pediatric oncology. Fourteen quantitative studies were included, evaluating interventions that used a combination of two or three different treatment modalities. Overall, studies demonstrated that it is feasible to implement CBI and that they can potentially improve physical activity and dietary behaviors as well as patient outcomes such as physical and psychological health. Unfortunately, due to a paucity of studies and the heterogeneity of the studies included in this review, no conclusive evidence favoring specific interventions were identified.

Implementation of a Prevention Program Based on Adapted Physical Activity and Recommendations for Adolescents and Young Adults with Cancer: PREVAPAJA Study

Purpose: In Europe, 20,000 Adolescent and Young Adults (AYAs) aged 15-25 years are diagnosed with cancer annually. Although prognosis is good, AYA cancer survivors are at greater risk of second primary cancers, cardiovascular disease, and various long-term effects. Benefits of physical activity (PA) in AYAs reported in current studies remain difficult to generalize; none has been performed in France. This single-arm intervention study tested the feasibility of combining hospital-based supervised and home-based unsupervised physical activity sessions (PAS) and providing cancer prevention recommendations for AYAs. Methods: The AYAs attended PAS concomitant to treatment and participated in one face-to-face prevention interview. PA (international physical activity questionnaire), 6-min walk distance (6MWD), sedentarity, anthropometrics, quality of life (QoL), and fatigue were assessed at baseline (T1) and end of intervention (T2). PA, satisfaction and cancer prevention behaviors were assessed 1 year after baseline (T3). Results: Fifty-nine AYAs (mean 19 years) participated in the study. Acceptability and attrition were 80% and 12%, respectively. Between T1 and T2, 6MWD and global QoL improved (p < 0.001), and fatigue decreased (p = 0.003). Total PA improved and sitting time decreased (p < 0.001) overall (T1-T3). Assessment at T3 showed interindividual differences in how participants considered risk factors (e.g., more attention to PA, UV exposures, nutrition). Conclusion: Combined supervised and unsupervised home-based PAS in AYAs undergoing cancer treatment is acceptable and feasible. The program contributes to maintaining and improving physical fitness and QoL, while reducing fatigue and other cancer and treatment symptoms. Larger randomized controlled trials are needed to confirm these results.

Non-pharmacological sleep interventions for pediatric cancer patients and survivors: a systematic review protocol

BACKGROUND

Sleep disturbances constitute a common complication in pediatric cancer patients and survivors and are frequently severe enough to warrant treatment. Suboptimal sleep has been associated with decreased emotional well-being and cognitive functioning and increased behavioral problems. Standardized guidelines for non-pharmacological sleep interventions for adults with cancer exist, but no standard of care intervention or standard guidelines are available to guide such intervention in pediatric cancer patients and survivors. Therefore, effective behavioral interventions for improving sleep quality need to be identified. The objective of the review is to evaluate the effect of non-pharmacological sleep interventions on sleep quality in pediatric cancer patients and survivors.

METHODS

The review will consider studies that include children and adolescents between 0 and 18 years diagnosed with cancer or who have a history of cancer who have non-respiratory sleep disturbance. We will include experimental and quasi-experimental studies evaluating non-pharmacological interventions such as psychological interventions, technical/device interventions, interventions targeting physical activity, and complementary and alternative medicine interventions (e.g., yoga, massage, music). Interventions involving medications, ingestible supplements, products purported to work through absorption, and medical devices will be excluded. Primary outcome will be sleep quality as measured by methods including retrospective ratings, daily sleep diary, and validated questionnaires. Secondary outcomes will include total sleep time, sleep onset latency, wake after sleep onset, daytime sleepiness, and daytime sleep duration (naps) as measured by retrospective ratings, daily sleep diary, validated questionnaires, and/or actigraphy. Databases will include MEDLINE (Ovid), EMBASE (Ovid), Cochrane Library, CINAHL (Ebsco), and PsycINFO (Ovid) and will be queried from database inception to present. Two reviewers will independently screen all citations, full-text articles, and extract data. The study methodological quality will be assessed using Joanna Briggs Institute (JBI) critical appraisal tools. Data will be extracted and findings pooled and synthesized using a meta-aggregation approach via the JBI System for the Unified Management, Assessment, and Review of Information (SUMARI). If feasible, we will conduct random effects meta-analysis. Additional analyses will be conducted to explore the potential sources of heterogeneity (e.g., methodological quality, study design, outcome measures).

DISCUSSION

This systematic review will synthesize and consolidate evidence on existing non-pharmacological interventions to improve sleep in pediatric cancer patients and survivors. Findings may help inform practitioners working with pediatric cancer patients and survivors experiencing sleep disturbances and is intended to identify gaps and opportunities to improve methodical quality of further non-pharmacological sleep intervention research in this population toward developing an eventual standard of care.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020200397 .

Feasibility of a combined supervised and home-based whole-body vibration intervention in children after inpatient oncological treatment

Purpose

Reduced physical performance due to therapy-related dysfunctions in children diagnosed with cancer contributes to insufficient physical activity levels. It is therefore essential that relevant functions are restored. Whole-body vibration (WBV) training, a neuromuscular stimulating exercise intervention, could have the potential to target those functions adequately. Therefore, the aim of this study was to evaluate the feasibility of a combined supervised and home-based WBV intervention with children after inpatient oncological treatment.

Methods

Eight children aged 6–21 years were included after cessation of their inpatient oncological treatment. They performed a 12-week WBV training including one supervised and two home-based sessions per week according to a standardized training protocol. Feasibility, adherence and compliance to the vibration protocol were documented. Subjective benefits and satisfaction were assessed using a questionnaire.

Results

Study participants attended 84.03 ± 13.09% of WBV sessions. No serious adverse events occurred. Some patients reported side effects partially resulting in modifications of the vibration protocol by therapists. Almost all children regarded the intervention as beneficial.

Conclusion

A combined supervised and home-based WBV intervention with children after inpatient oncological treatment is feasible and safe. The beneficial potential regarding relevant sensory and motor dysfunctions is now to be investigated.

Trial registration number and date of registration

DRKS00014713 15.05.2018

The international Pediatric Oncology Exercise Guidelines (iPOEG)

Physical activity (PA) and exercise are safe and beneficial for children and adolescents affected by cancer. Yet, this population is not active enough to receive benefits. PA guideline and recommendation statements can support individual behavior and practice change. The purpose of this project was to develop the international Pediatric Oncology Exercise Guidelines (iPOEG), comprised of guideline and recommendation statements, to promote PA among children and adolescents affected by cancer. Guideline development procedures, stakeholder engagement strategies, and the Delphi technique were used. Four online surveys were distributed to the iPOEG network (n = 9 core team members, n = 122 expert consensus committee members). Surveys included closed- and open-ended items informed by a literature synthesis and an in-person meeting. Responses were analyzed using descriptive statistics and content analysis. Consensus was defined as ≥ 80% agreement. Response rates to online surveys ranged from 82% to 91%. The iPOEG network agreed on four guideline and five recommendation statements, which highlight that movement is important for all children and adolescents affected by cancer. These statements are generic in nature as more research is still required to provide specific guidance on the frequency, intensity, time, and type of PA for this population. Nevertheless, the iPOEG statements represent available evidence and expert opinion, collectively suggesting that it is time for children and adolescents affected by cancer to move more.

Physical activity is safe and beneficial for children and adolescents affected by cancer. Yet, most are not active enough to receive benefits. Guideline and recommendation statements can help change individual behavior and practice. To develop such statements, guideline development procedures, stakeholder engagement strategies, and the Delphi technique were used. Four online surveys were distributed to an international network (n = 131 experts). Surveys asked closed- and open-ended questions informed by a literature synthesis and an in-person meeting. Findings from the online surveys resulted in the international Pediatric Oncology Exercise Guidelines statements, which highlight that it is time for children and adolescents affected by cancer to move more.

Supportive care for toxicities in children undergoing radiation therapy

Radiation therapy (RT) is an integral part of the management of many pediatric tumors; however, it is associated with both acute and permanent adverse events that can significantly impact a child's quality of life, lead to treatment delays, and potentially affect outcomes of cancer therapy. Prevention, early detection, and optimal management of these adverse effects will help reduce their impact on the patients' quality of life and overall well-being. Unfortunately, there has not been a coordinated effort to study the etiology, evaluate risk factors, and explore novel treatments for these conditions. Studies of supportive care for children undergoing RT are often small and uncontrolled. This review will focus on the impact of irradiation on the different organ systems and their current management. Further studies are required to improve our understanding of the contributing factors and explore novel treatment options for these adverse effects and to enable children and their families to better cope with some of the unavoidable toxicities following multimodality therapy.

Fatigue, Physical and Functional Mobility, and Obesity in Pediatric Cancer Survivors

BACKGROUND

Survivors of childhood cancer are prone to an increased risk of chronic issues such as cardiovascular disease, fatigue, weight-related problems, and emotional disturbances.

OBJECTIVE

This study utilized the biopsychosocial model to examine the hypothesis that greater depression and lower mobility would be significantly associated with greater fatigue and higher body mass index in survivors of childhood cancer.

METHODS

Data were analyzed for 144 children treated and followed up for an oncology condition at a southeastern academic medical center. Voluntarily, children completed the Patient-Reported Outcomes Measurement Information System 1.0, and parents completed the Family Symptom Inventory as part of a brief annual psychosocial screening battery. Height and weight were collected by a clinic nurse prior to questionnaire completion.

RESULTS

Hierarchical linear regression showed that shorter time since diagnosis (β = -.154, P < .05), greater child-reported depression (β = .396, P < .01), and lower mobility (β = .427, P < .01) significantly predicted greater fatigue (adjusted R = 0.54). Older age (β = .262, P < .01) and not receiving chemotherapy (β = -.209, P < .05) significantly predicted higher body mass index (adjusted R = 0.051).

CONCLUSIONS

Findings showed that fatigue tends to improve over time after treatment but may be predicted by greater depression symptoms and lower mobility in recent survivors of childhood cancer.

IMPLICATIONS FOR PRACTICE

For survivors of childhood cancer with higher levels of fatigue, treating symptoms of depression and maximizing physical and mobility may be of clinical value. With the impact of psychological and social factors not yet understood in pediatric cancer survivors, weight status in recent survivors of childhood cancer is likely a complex interaction between biological and treatment factors.

Self-efficacy in symptom management for adolescents and young adults with cancer: a systematic review

BACKGROUND

Adolescents and young adults (AYAs) have more frequent and intense adverse effects from cancer therapy than other age groups. Self-efficacy, the ability for persons to maintain health-related behavior change, may assist with symptom management but the role it plays in AYAs with cancer has not been thoroughly investigated. This review explores the role that self-efficacy has in symptom management for AYAs with cancer and provides guidance for clinicians to utilize self-efficacy as a means to reduce side effects of therapy.

METHODS

A systematic review of peer-reviewed literature was conducted to identify works discussing self-efficacy and symptom management for AYAs with cancer. Five databases were searched with key terms and articles that discussed relationships between self-efficacy and cancer therapy symptoms were retained for analysis.

FINDINGS

Twelve manuscripts representing 1180 individuals age 12 to 43 years were identified. Self-efficacy was found to be related to (1) health management behaviors, (2) psychosocial health, (3) sexual and reproductive health, and (4) physical symptoms. Self-efficacy had direct correlations with physical activity, nutritional intake, symptom regulation, mental health, sexual health, and fertility preservation. The included studies did not find significant relationships with medication adherence or pain management.

DISCUSSION

Self-efficacy is an attribute that impacts behavior change, health maintenance, and overall wellness and can be changed over time and through interventions to improve symptoms of cancer therapy. Self-efficacy should be evaluated as a construct in relevant studies aimed at improving side effects of cancer therapy to better understand outcomes from interventions. Symptoms, toxicities, and adverse effects of cancer therapy may be improved by increasing self-efficacy of patients.

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.

Effectiveness of a task-oriented training on occupational performance, functional independence, and fatigue in children with childhood cancer: a randomized-controlled trial

Abstract Objective The objective of the study is to explore the effectiveness of task-oriented training (TOT) on occupational performance, functional independence, and fatigue of children with cancer. Method Two hundred and thirteen children (101 females, 112 males) with cancer were randomized to experimental (n = 112; 9.53±2.23 years) or control (n = 101; 7.93±1.98 years) groups. The experimental group received a TOT together with a conventional occupational therapy (COT), while the control group received only a COT. Both groups received 20 sessions of therapy. The outcomes regarding occupational performance via the Canadian Occupational Performance Measure, functional independence via the Functional Independence Measure for Children and fatigue via the Visual Analog Scale were evaluated by the blind evaluators before and after the interventions in the hospital setting. Results The occupational performance and satisfaction (p<0.001) scores showed statistically significant differences in the experimental group compared to the control group (p<0.01). A statistically significant improvement was determined in functional independence for both groups (p< 0.001). The experimental group indicated a significant reduction in fatigue (p values for fatigue before, during, after activity, morning and evening: p< 0.001) and in the control group (P values for fatigue all situation: p< 0.05). Conclusion The TOT seems to ensure more beneficial effects in increasing occupational performance, improving functional independence in daily activities, and decreasing fatigue at the early phases of inpatient treatment of childhood cancer.

Childhood Cancer Survivorship: Daily Challenges

Survivors of childhood cancer are at risk of experiencing fatigue, pain, lower levels of physical activity, increased engagement in risky health behavior, and poor social adjustment, after finishing treatment. Risks are more pronounced for survivors of specific diagnoses or receiving specific treatment protocols. Interventions to address these outcomes are in their infancy. Future research should focus on exploring the antecedents and consequences of these outcomes. In the meantime, researchers and cancer centers should attempt to provide high-quality and accessible health information to survivors through various media outlets to encourage healthy behaviors.

[Oncologic supportive care for a personalized support of all patients]

Ever since the officialization of oncologic supportive care by the DHOS circular in February 22^nd, 2005 and measure 42 of the 2003-2007 Cancer Plan, their content has been enriched for inpatients and outpatients. A guaranteed care package was determined in February 2017 following a study lead by AFSOS and INCa. It adds adapted physical activity and sexual health support to basic supportive care such as pain relief, nutrition, psychology, social support. Supportive cares in pediatric oncology were defined in March 2004. They always were part of holistic pediatric care. The offer in supportive care for children and AYA and the offer in adult supportive care can complete, inspire or improve each other.

EFFECTS OF PHYSICAL EXERCISE DURING HOSPITALIZATION IN CHILDREN AND ADOLESCENTS WITH CANCER: A SYSTEMATIC REVIEW

Objective:

To identify the effects of exercise programs during hospitalization on children and adolescents with cancer.

Data source:

This is a systematic review, carried out in PubMed/ Medical Literature Analysis and Retrieval System Online (MEDLINE), Latin American and Caribbean Health Sciences Literature (LILACS), Scientific Electronic Library Online (SciELO), Latin American and Caribbean Center on Health Sciences Information (BIREME), and Physiotherapy Evidence Database (PEDro). We selected studies that included children and adolescents diagnosed with cancer (solid or hematologic) and submitted to exercise protocols during hospitalization. Studies involving patients with other pathologies or with a medical contraindication for exercise were excluded. We used the following search strategy: Neoplasm OR Leukemia OR Cancer OR Tumor OR Medical Oncology AND Hospitalization OR Inpatient Care Units OR Intrahospital AND Exercise. The methodological quality of the studies was analyzed by the PEDro scale.

Data synthesis:

Among the 626 articles found, only 9 fulfilled the inclusion criteria, obtaining a regular methodological quality. The samples had 172 participants, aged 4 to 18 years. Only 6 studies presented both intervention group and control group. The intervention group received strength, aerobic, and muscle stretching exercises, and games, among others. The control group received the standard treatment. The studies varied regarding time, frequency, intensity, and type of exercise. Most studies showed an increase in muscle strength (4/5), followed by an improvement in physical fitness (2/3) and functional capacity (2/4). No adverse events were reported during the interventions. The methodological quality was considered regular.

Conclusions:

The findings suggest that. during hospitalization of children and adolescents with cancer, exercise improves muscle strength, physical fitness, and functionality.

Feasibility and Acceptability Findings of an Energy Balance Data Repository of Children, Adolescents, and Young Adults with Cancer

Cancer patients suffer changes in energy balance (EB), the combination of energy intake (nutrition) and energy expenditure (physical activity (PA)), which may influence cancer-related morbidity, mortality, and quality of life. Significant gaps remain in our understanding of the frequency and magnitude of these EB changes. Herein, we report on the feasibility and acceptability of a longitudinal repository of EB outcomes in children, adolescents and young adults (AYA) with cancer along the cancer continuum to fill these gaps. This EB repository includes PA, nutrition, and physical function (PF) parameters. PA data were gathered through activity trackers. Nutritional data were gathered through food diaries and micronutrient labs. PF was assessed with validated objective and patient-reported measures. Feasibility was achieved with >50% enrollment of eligible patients (n = 80, Mage = 18.1 ± 7.5); 26 were children with cancer and 54 were AYAs with cancer. An 88.75% retention rate indicated acceptability. Despite COVID-19 disruptions, >50% of participants provided completed data for PA and micronutrient labs as of April 2020. Food diaries and PF data collection experienced disruptions. Methodological adaptations are in progress to minimize future disruptions. Overall, our findings demonstrate that prospective EB assessments are feasible and acceptable among children and AYAs with cancer.

Recommendations for the surveillance of cancer-related fatigue in childhood, adolescent, and young adult cancer survivors: a report from the International Late Effects of Childhood Cancer Guideline Harmonization Group

PURPOSE

Cancer-related fatigue (CRF) negatively affects the lives of childhood, adolescent, and young adult (CAYA) cancer survivors. We aimed to provide an evidence-based clinical practice guideline (CPG) with internationally harmonized CRF surveillance recommendations for CAYA cancer survivors diagnosed < 30 years.

METHODS

This CPG was developed by a multidisciplinary panel under the umbrella of the International Late Effects of Childhood Cancer Guideline Harmonization Group. After evaluating concordances and discordances of four existing CPGs, we performed systematic literature searches. We screened articles for eligibility, assessed quality, extracted, and summarized the data from included articles. We formulated recommendations based on the evidence and clinical judgment.

RESULTS

Of 3647 articles identified, 70 articles from 14 countries were included. The prevalence of CRF in CAYA cancer survivors ranged from 10-85%. We recommend that healthcare providers are aware of the risk of CRF, implement regular screening with validated measures, and recommend effective interventions to fatigued survivors.

CONCLUSIONS

A considerable proportion of CAYA cancer survivors suffers from CRF even years after the end of treatment.

IMPLICATIONS FOR CANCER SURVIVORS

We recommend that healthcare providers adopt regular screening to detect and treat CRF early and positively influence survivors' health and quality of life.

Social ecological interventions to increase physical activity in children and young people living with and beyond cancer: a systematic review

Objective: To identify the behaviour change techniques and intervention components associated with the promotion of physical activity (PA) for children and young people living with and beyond cancer. Design and main outcome measures: A systematic review and narrative synthesis was conducted on the evidence on PA interventions for children and young people (up to 30 years of age) living with and beyond cancer using a social ecological framework. Results: Out of 12 studies, 8 were shown to change PA. Intervention components included (1) behavioural (Instruction on how to perform the behaviour, credible source, behavioural demonstration and rehearsal), (2) cognitive-emotional (targeting attitude, perceived behavioural control, intentions, resilience and achievement) (3) socio-cultural (family and peer support for PA), (4) environmental (providing access to resources, environmental restructuring, safety), (5) demographic (child, adolescent, young adult or mixed) and (6) medical (tailored exercise depending on age and cancer stage). Conclusions: Interventions designed to increase physical activity participation and adherence during and beyond cancer treatment for young people should integrate psychosocial (behavioural, cognitive-emotional, social), environmental and medical intervention components. Our conceptual model can be used to inform the development of interventions and guides future research objectives and priorities.

Sport Medicine in the Prevention and Management of Cancer

Physical inactivity is a major concern in cancer patients despite the established preventative and therapeutic effects of regular physical exercise for this patient group. Sport not only plays an important role in supporting the development and maintenance of a physically active lifestyle but also is increasingly used as a health promotion activity in various populations. Nevertheless, the potential of sport as an effective strategy in the prevention and management of cancer has gained little attention. Based on the scant evidence to date, participation of cancer patients in supervised, well-tailored sport programs appears to be safe and feasible and is associated with an array of physical and psychological benefits. We propose that sport participation may serve as an alternative strategy in the prevention of cancer and sport medicine in the management of cancer. As with the traditional exercise modes, benefits derived from sport participation will be dependent on the sport undertaken and the physical/physiological, motor, and cognitive demands required. To this end, further work is required to develop a solid evidence base in this field so that targeted sport participation can be recommended for cancer patients.

Exercise as a Potential Intervention to Modulate Cancer Outcomes in Children and Adults?

Exercise is recommended for the healthy population as it increases fitness and prevents diseases. Moreover, exercise is also applied as an adjunct therapy for patients with various chronic diseases including cancer. Childhood cancer is a rare, heterogeneous disease that differs from adult cancer. Improved therapeutic strategies have increased childhood cancer survival rates to above 80% in developed countries. Although this is higher than the average adult cancer survival rate of about 50%, therapy results often in substantial long-term side effects in childhood cancer survivors. Exercise in adult cancer patients has many beneficial effects and may slow down tumor progression and improve survival in some cancer types, suggesting that exercise may influence cancer cell behavior. In contrast to adults, there is not much data on general effects of exercise in children. Whilst it seems possible that exercise might delay cancer progression or improve survival in children as well, there is no reliable data yet to support this hypothesis. Depending on the type of cancer, animal studies of adult cancer types show that the exercise-induced increase of the catecholamines epinephrine and norepinephrine, have suppressive as well as promoting effects on cancer cells. The diverse effects of exercise in adult cancer patients require investigating whether these results can be achieved in children with cancer.

The health behaviour status of teenage and young adult cancer patients and survivors in the United Kingdom

PURPOSE

The primary aim of this study was to investigate the health behaviour status of teenage and young adult (TYA) cancer patients and survivors; the secondary aim was to determine if TYA cancer patients and survivors health behaviour differs to general population controls.

METHODS

Two hundred sixty-seven young people with cancer (n =83 cancer patients receiving active treatment: n =174 cancer survivors, 57.1% >1 year since treatment completion) and 321 controls completed a health and lifestyle questionnaire which included validated measures of physical activity (PA) (Godin Leisure Time Exercise Questionnaire), diet (Dietary Instrument for Nutrition Education, DINE), smoking status, and alcohol consumption (AUDIT-C).

RESULTS

General population controls and cancer survivors were more likely to meet current (PA) recommendations (p <0.001) than TYA cancer patients undergoing treatment (54.8% vs 52.3% vs 30.1%, respectively). Less than 40% of young people with cancer and controls met fat intake, sugar intake, fibre intake or current fruit and vegetable recommendations. TYA cancer survivors were more likely to report binge drinking than controls (OR=3.26, 95% CI 2.12-5.02, p <0.001). Very few young people with in the study were current smokers. The majority of TYA cancer patients and survivors reported a desire to make positive changes to their health behaviour.

CONCLUSION

Consideration should be given to whether existing health behaviour change interventions which have demonstrated positive effects among the general TYA population could be adapted for young people with cancer.

Using a dyadic approach to explore parental support for physical activity among young cancer survivors

BACKGROUND

Physical activity confers many physical and psychosocial benefits for adolescent and young adult cancer survivors, yet most are not active enough to accrue benefits. Parental support for physical activity may be important to consider when exploring factors that influence physical activity in this population.

PURPOSE

Explore adolescent and young adult cancer survivors' experiences of parental support for physical activity received and their parents' experiences of support provided.

METHODS

Ten adolescent and young adult cancer survivors (M_age = 17.4 ± 3.2 years; 70% male) and one of their parents (50% fathers) were interviewed separately. Data were analyzed thematically.

RESULTS

Participants' experiences were summarized into three main themes: (1) the basics - instrumental, informational, and emotional support, (2) companionship support - doing it together, and (3) role modeling - a double-edged sword. In general, there was congruence between participants' perceptions of the types of support provided and received for physical activity. However, parents felt their role was to provide instrumental, informational, and emotional support, whereas adolescent and young adult cancer survivors emphasized the importance of companionship support.

CONCLUSIONS

Findings underscore the complexity of parental support for physical activity among adolescent and young adult cancer survivors. Developing and testing resources to empower adolescent and young adult cancer survivors to ask for parental support and to enable parents to support their child's physical activity is imperative.Implications for RehabilitationMany adolescent and young adult cancer survivors do not participate in enough physical activity to acquire physical and psychosocial benefits.Parental support may represent a key factor that influences physical activity participation.Rehabilitation professionals should consider the influence parents may have on adolescent and young adult cancer survivors' physical well-being post-diagnosis.Promoting co-participation may be a viable strategy to enhance physical activity participation among adolescent and young adult cancer survivors.

Benefits of Exercise Training for Children and Adolescents Undergoing Cancer Treatment: Results From the Randomized Controlled MUCKI Trial

Objective: In cancer patients, the impairment in muscle function is a frequently observed phenomenon. However, comprehensive evaluation of the effect of exercise training on muscle function in childhood cancer patients (CCPs) is sparse and therefore investigated in the MUCKI trial. Study Design: In the randomized controlled MUCKI trial, CCPs during intensive cancer treatment and aged 4-18 years were recruited. Eligible patients were enrolled soon after diagnosis as long as they were physically and mentally able to participate in exercise testing and training. Patients of the exercise group (n = 16) participated in average 2.7 ± 1.2 times per week in a combined resistance and endurance training with moderate exercise intensity, for a time period of 8.0 ± 2.1 weeks, while patients of the control group (n = 17) received usual care. Leg strength was evaluated as the primary endpoint. Secondary endpoints were 6-min walk performance, arm strength, body composition, fatigue, and health-related quality of life. Results: Comparisons of pre- and post-intervention results were evaluated by baseline and stratification criteria adjusted analysis and showed positive effects for the exercise group regarding leg strength [F _{(1, 20)} = 5.733; p = 0.027^*; η p 2 = 0.223], walking performance [F _{(1, 25)} = 4.270; p = 0.049^*; η p 2 = 0.146], fatigue [F _{(1, 13)} = 8.353; p = 0.013^*; η p 2 = 0.391], self-esteem [F _{(1, 6)} = 6.823; p = 0.040^*; η p 2 = 0.532], and self-reported strength and endurance capacity [F _{(1, 6)} = 6.273; p = 0.046^*; η p 2 = 0.511]. No significant differences were found for the other parameters. Conclusion: Within one of the first randomized controlled trials, the present study provides evidence for a positive effect of combined training in CCPs during intensive cancer treatment. Further research is needed to confirm these results and to evaluate their clinical impact. Clinical Trial Registration Number: NCT02612025.

Exercise and Physical Activity in Patients with Osteosarcoma and Survivors

Exercise has the potential to positively affect patients with osteosarcoma by improvement of function, mitigation of disability, and maintenance of independence and quality of life. Exercise may also directly impact cancer treatment efficacy. This chapter examines the feasibility and use of exercise or physical activity as therapy in the treatment of osteosarcoma and its survivors. It additionally presents the benefits of physical activity as treatment and rehabilitation both preoperatively (prehabilitation) and postoperatively. This chapter will also discuss barriers to exercise and physical activity for patients with osteosarcoma and its survivors, emphasizing the need for a comprehensive and cohesive support system to promote its incorporation into patient treatment plans and ensure compliance.

Evaluation Tools for Physical Activity Programs for Childhood Cancer: A Scoping Review

Research on the benefits of physical activity (PA) in childhood cancer has been translated into a handful of community-based programs. However, to foster further translation, an understanding of how to evaluate participant outcomes would be beneficial to provide feedback to participants and stimulate future research. Such a review would provide a summary of acceptable tools for work in this area. The purpose of this scoping review was to identify the evaluation tools that have been used in PA/exercise studies or programs for childhood cancer. This review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies included in the review used physical and psychosocial evaluation tools within PA and exercise programs or research for childhood cancer. In addition, studies with measures of health behavior such as PA levels and activities of daily living were included. Tools that assessed physical fitness and physical performance were excluded. Information on the types of evaluation tools used, mean age of participants, and type of cancer was extracted. Psychometric properties of each evaluation tool are reported. The most commonly assessed patient outcomes were motor performance, fatigue, well-being, functional mobility, and quality of life. Less commonly reported patient outcomes were hope, self-efficacy, and self-perception. None of the evaluation tools reported in the PA/exercise and pediatric oncology literature assess physical literacy. This review was the first step in a knowledge translation process, identifying evaluation tools that have been used in PA/exercise programs in childhood cancer survivors, that will guide the development and evaluation of current and future community-based programs.

Describing and exploring self-esteem, physical self-perceptions, physical activity and self-efficacy in adolescent and young adult cancer survivors

OBJECTIVES

(a) Describe levels of physical and global self-esteem and (b) explore the relationships between these types of self-esteem and physical activity (PA) behaviour, self-efficacy for PA and physical self-perceptions among adolescent and young adult (AYA) cancer survivors.

METHODS

A total of 87 AYA cancer survivors (M_age  = 32.90 ± 4.38 years), who were on average 2.08 ± 1.37 years post-treatment, participated in this cross-sectional observational study. Descriptive statistics, correlations and hierarchical multivariate linear regression analyses were used to analyse the data.

RESULTS

Moderate levels of physical and global self-esteem were reported. Both types of self-esteem were significantly related to physical self-perceptions, but not to PA behaviour nor self-efficacy for PA. Self-efficacy for PA moderated the relationship between physical self-perceptions and physical self-esteem, such that the association between physical self-perceptions and physical self-esteem was of stronger magnitude at higher levels of self-efficacy for PA than at lower levels of self-efficacy for PA.

CONCLUSION

This study provides a starting point for describing self-esteem and identifying the circumstances under which self-esteem may be optimised among AYA cancer survivors. Fostering feelings of confidence, competence and control over PA may help to promote psychological well-being among AYA cancer survivors.

Physical Activity, the Childhood Cancer Symptom Cluster-Leukemia, and Cognitive Function: A Longitudinal Mediation Analysis

BACKGROUND

Children undergoing leukemia treatment report co-occurring symptoms of fatigue, sleep disturbances, pain, nausea, and depression as a symptom cluster. Physical activity (PA) is essential for development and may influence symptom severity. Children with leukemia are at risk of cognitive impairments from central nervous system therapies. Using a longitudinal parallel-process model, relationships among function and symptom clusters were explored.

OBJECTIVE

This study examined the longitudinal mediation effects of PA on cognition via a symptom cluster during leukemia treatment.

METHODS

Symptoms, PA, and cognitive function of 327 children aged 3 to 18 years were measured over 4 intervals during the first year of leukemia treatment. Children 7 years or older self-reported and parents reported for younger children. Parents completed cognitive function measurements for all children. The influence of the first time point and the subsequent change between all 4 time points of PA on the symptom cluster were explored. Analysis determined whether the symptom cluster mediated the effect of cognition over the treatment period.

RESULTS

Patients with a higher PA at time 1 reduced their symptom cluster severity over the measurements. However, when PA increased over the measurements, symptom cluster severity also increased. When the symptom cluster was more severe at time 1, cognitive function was lower at time 1, and cognitive function decreased over time. When symptoms became more severe over time, cognitive function declined.

CONCLUSIONS

The symptom cluster acted as a mediator between PA and cognition.

IMPLICATIONS FOR PRACTICE

Symptom management during treatment may be an additional strategy for protecting cognitive function.

Kids Are Moving: A Physical Activity Program for Children With Cancer

Children undergoing cancer treatment are less active than healthy peers. Inactivity persists into survivorship, negatively influencing health and quality of life. Fatigue is one of the most prevalent symptoms during treatment yet children with increased physical activity (PA) have less fatigue. This pilot study evaluated the impact of coaching on PA and fatigue in children undergoing cancer treatment delivered by pediatric oncology nurse practitioners (NPs) during routine clinic visits. NPs used motivational interviewing during clinic visits to coach children and their families on strategies to increase PA at home. Self-report measures of PA and fatigue were completed at treatment months 2, 4, and 6. PA was also measured using actigraphy. Among 30 children ages 6 to 18 years, 7 had acute lymphoblastic leukemia (ALL), 11 had lymphoma, and 12 had solid tumors. Patterns of fatigue were different by disease group with trends to fatigue decreasing during treatment in the patients with ALL ( p = .09) and lymphoma ( p = .13) but increasing in those with solid tumors ( p = .06). Self-report PA was unchanged. Actigraph measurements remained stable for the group. NPs reported time challenges in implementing coaching during the clinic visit and in providing coaching continuity. The intensive, repeating chemotherapy cycles in solid tumor treatment may contribute to increasing fatigue. Treatment intensity decreases during ALL and lymphoma treatment, which may allow for improvement in fatigue. Inactivity persisted during treatment but did not progress. Future research is needed to evaluate more “dose-intensive” PA interventions in larger samples of specific disease groups.

Health-Related Physical Fitness and Arterial Stiffness in Childhood Cancer Survivors

Introduction: Despite decreasing mortality in pediatric oncology as a result of standardized treatment protocols, the high number of functional and cardiovascular late sequelae due to anticarcinogenic therapy remains unchanged. The aim of this study was to further assess functional limitations in Health-related Physical Fitness (HRPF) and cardiovascular risk by means of markers of arterial stiffness in Childhood Cancer Survivors (CCS).

Materials and Methods: Between March 2016 and August 2017 a total of 92 CCS (Age 12.5 ± 4.2 years, 43 girls) were recruited from their routine follow-up outpatient visit. HRPF was assessed using five Fitnessgram® tasks. Pulse Wave Velocity (PWV) along with peripheral and central blood pressure were assessed using oscillometric measurements performed by Mobil-O-Graph. Z-scores were used to compare the test results either to German reference values or to a recent healthy reference cohort.

Results: In CCS, the HRPF was significantly reduced (z-score: −0.28 ± 1.01, p = 0.011) as compared to healthy peers. The peripheral Systolic Blood Pressure (pSBP) was significantly increased (z-score: 0.31 ± 1.11, p = 0.017) and the peripheral Diastolic Blood Pressure (pDBP) was decreased (z-score: −0.30 ± 1.25, p = 0.040), resulting in an increased pulse pressure. The PWV (p = 0.649) and cSBP (p = 0.408), were neither increased nor showed any association to HRPF.

Discussion: CCS showed functional limitations in HRPF and an increased pulse pressure, which acts as an early onset parameter of arterial stiffness. Both a low HRPF and impaired hemodynamics are independent cardiovascular risk factors and needs to be taken into consideration in tertiary prevention of CCS.

Psychophysical effects of an exercise therapy during pediatric stem cell transplantation: a randomized controlled trial

This study evaluates the physical and psychosocial effects of an inpatient exercise program for children and adolescents undergoing hematopoietic stem cell transplantation (HSCT). Participants (n = 70) were randomized to an exercise intervention (IG: resistance, endurance, and flexibility training) or a non-exercise control group (CG: mental and relaxation training). Pre- (prior hospital admission; T0) and post- (day of discharge; T1) measurements included maximal isometric knee extension strength (KES; strain gauge force transducer), hand grip strength (HGS; JAMAR dynamometer), distance walked in 6 min (6MWD; 6-minute walk test), quality of life (QoL; KINDL-R) and medical parameters. Fifty-seven patients (IG: n = 28; 11.0 (5-17) years; CG: n = 29; 12.0 (6-18) years) completed the study. During hospitalization the IG and CG attended on average 3.1 (2-4) or 2.9 (0.3-4) training sessions weekly. KES, 6MWD, and HGS significantly decreased (p < 0.05) in the CG, while there were no changes in the IG. Pre- to post-changes in 6MWD and HGS differed significantly between groups (p < 0.05). QoL declined in both groups (p < 0.05). Our results indicate that a moderate exercise program is feasible and might counteract a treatment-associated decline of physical performance.

Impact of exercise on psychological burden in adult survivors of childhood cancer: A report from the Childhood Cancer Survivor Study

BACKGROUND

Childhood cancer survivors are at risk for adverse psychological outcomes. Whether exercise can attenuate this risk is unknown.

METHODS

In total, 6199 participants in the Childhood Cancer Survivor Study (median age, 34.3 years [range, 22.0-54.0 years]; median age at diagnosis, 10.0 years [range, 0-21.0 years]) completed a questionnaire assessing vigorous exercise and medical/psychological conditions. Outcomes were evaluated a median of 7.8 years (range, 0.1-10.0 years) later and were defined as: symptom level above the 90th percentile of population norms for depression, anxiety, or somatization on the Brief Symptom Inventory-18; cancer-related pain; cognitive impairment using a validated self-report neurocognitive questionnaire; or poor health-related quality of life. Log-binomial regression estimated associations between exercise (metabolic equivalent [MET]-hours per week^-1 ) and outcomes adjusting for cancer diagnosis, treatment, demographics, and baseline conditions.

RESULTS

The prevalence of depression at follow-up was 11.4% (95% CI, 10.6%-12.3%), anxiety 7.4% (95% CI, 6.7%-8.2%) and somatization 13.9% (95% CI, 13.0%-14.9%). Vigorous exercise was associated with lower prevalence of depression and somatization. The adjusted prevalence ratio for depression was 0.87 (95% CI, 0.72-1.05) for 3 to 6 MET hours per week^-1 , 0.76 (95% CI, 0.62-0.94) for 9 to 12 MET-hours per week^-1 , and 0.74 (95% CI, 0.58-0.95) for 15 to 21 MET-hours per week^-1 . Compared with 0 MET hours per week^-1 , 15 to 21 MET-hours per week^-1 were associated with an adjusted prevalence ratio of 0.79 (95% CI, 0.62-1.00) for somatization. Vigorous exercise also was associated with less impairment in the physical functioning, general health and vitality (P_trend  < .001), emotional role limitations (P_trend  = .02), and mental health (P_trend  = .02) domains as well as higher cognitive function in the domains of task completion, organization, and working memory (P < .05 for all), but not in the domain of cancer pain.

CONCLUSIONS

Vigorous exercise is associated with less psychological burden and cognitive impairment in childhood cancer survivors.