Adverse Late Effects of Childhood Cancer and Its Treatment on Health and Performance

Associations between perceived cancer impact and measures of health behavior in survivors of childhood cancer

PURPOSE

Perceived cancer impact (PCI) is the degree to which one feels cancer has impacted one's life. It is unknown if PCI is associated with health behaviors. The aim of this study is to determine associations between PCI and health behaviors in childhood cancer survivors.

METHODS

Participants were ≥ 5-year survivors enrolled in the St. Jude Lifetime (SJLIFE) cohort. The Brief Cancer Impact (BCIA) assessed PCI across four domains (caregiving/finances, diet/exercise, social/emotional functioning, religiosity). Responses were categorized as negative, neutral, or positive impact. Smoking, risky drinking, illicit drug use, and diet quality data were obtained via self-report. Physical activity (PA) was assessed via self-report and actigraphy. Cross-sectional and longitudinal associations between PCI and health behaviors were evaluated via multivariable logistic regression.

RESULTS

A total of 3623 participants (mean age 30.4 ± 8.3 years, 49.6% female, 81.5% NH White) were included in baseline cross-sectional analysis; 1709 had a second visit 5.0 ± 1.4 years later and were included in longitudinal analysis. At baseline, the percentage of participants who endorsed cancer as having a negative impact on caregiving/finances was 37.5%, diet/exercise 30.5%, social/emotional functioning 40.6%, and religiosity 8.7%. Negative and neutral PCI across all four domains were cross-sectionally associated with all behaviors except illicit drug use. Negative and neutral PCI at the first time point across all four domains were associated with smoking, diet quality, and PA (ORs ranging from 1.35 to 2.41) in longitudinal analyses.

CONCLUSIONS

Endorsing negative or neutral PCI is associated with adverse health behaviors.

IMPLICATIONS FOR CANCER SURVIVORS

Promoting optimal health behavior should include addressing PCI.

A Systematic Review of Telehealth-Based Pediatric Cancer Rehabilitation Interventions on Disability

Background: Telehealth is an emerging method which may overcome barriers to rehabilitation access for pediatric cancer survivors (aged ≤19 years). This systematic review aimed to examine telehealth-based rehabilitation interventions aimed at preventing, maintaining, or improving disability in pediatric cancer survivors. Methods: We performed systematic searches in Ovid MEDLINE, Ovid EMBASE, Cochrane Library, SCOPUS, Web of Science, and CINAHL Plus between 1994 and 2022. Eligible studies included telehealth-based interventions assessing disability outcomes in pediatric cancers. Results: Database searches identified 4,040 records. Nine unique interventions met the eligibility criteria. Telehealth delivery methods included telephone (n = 6), email (n = 3), mobile health applications (n = 3), social media (n = 3), videoconferencing (n = 2), text messaging (n = 2), active video gaming (n = 2), and websites (n = 2). Interventions focused on physical activity (n = 8) or self-management (n = 1). Outcomes assessing disability varied (n = 6). Three studies reported statistically and clinically significant results. Narrative synthesis of findings was constructed based on the Picker's principles for patient-centered care: (1) values, preferences, and needs; (2) involve family and friends; (3) coordination of care; (4) provide social support; (5) holistic well-being; and (6) information and communication. Conclusions: Telehealth-based rehabilitation interventions for pediatric cancer survivors is an emerging research area with potential to improve disability outcomes. Adequately powered trials with consistency in disability outcome measures are warranted. Additional research is needed to determine the effectiveness and best practices for telehealth-based pediatric cancer rehabilitation.

Physical late effects of treatment among survivors of childhood cancer in low- and middle-income countries: a systematic review

PURPOSE

Physical late effects of treatment are well-documented among childhood cancer survivors in high-income countries, but whether prevalence and risk factors are comparable in low- and middle-income countries (LMICs) is unclear. We conducted a systematic review to assess physical late effect outcomes among childhood cancer survivors in LMICs.

METHODS

Five health sciences databases were searched from inception to November 2022 in all languages. We included observational studies conducted in LMICs that evaluated physical late effects of treatment in childhood cancer survivors. Mean or median cohort follow-up must have been ≥ 5 years from original cancer diagnosis.

RESULTS

Sixteen full articles and five conference abstracts were included. Studies were conducted in lower-middle (n = 12, 57%) or upper-middle income (n = 9, 43%) countries; nearly half (n = 9, 43%) were conducted in India. Five cohorts (24%) were comprised entirely of 5-year survivors. Subsequent malignant neoplasms were reported in 0-11% of survivors (n = 10 studies). Hypothyroidism and metabolic syndrome prevalence ranged from 2-49% (n = 4 studies) and 4-17% (n = 5 studies), respectively. Gonadal dysfunction ranged from 3-47% (n = 4 studies). Cardiac dysfunction ranged from 1-16% (n = 3 studies). Late effects of the musculoskeletal and urinary systems were least investigated.

CONCLUSIONS

Substantial knowledge gaps exist in LMIC childhood cancer survivorship. No low-income country data were found. In middle-income countries, late effects were defined and assessed variably and limited by selection bias and small sample sizes.

IMPLICATIONS FOR CANCER SURVIVORS

Survivors in LMICs can experience physical late effects of treatment, though additionally systematically collected data from survivor cohorts are needed to fill knowledge gaps.

Investigation of cognitive functions in children with bone tumours and lymphoma in treatment process

BACKGROUND

Neurocognitive sequelae are among the most debilitating effects of cancer observed in children. Yet we know very little about the impact on neurocognitive functioning, especially cancer types that develop outside the central nervous system. This study aimed to assess and compare the cognitive functions (CoF) of children with bone tumours and lymphoma in the treatment process.

METHODS

The CoF of children with bone tumours (n = 44), lymphoma (n = 42) and their non-cancer peers (n = 55) were assessed with Dynamic Occupational Therapy Assessment for Children. The CoF of children with cancer were compared with their non-cancer peers. Then, children with bone tumours and lymphoma were compared in binary.

RESULTS

One-hundred forty-one children aged 6-12 years with a mean age of 9.4 (SD = 1.5) were included in this study. The orientation and visuomotor construction functions of children with bone tumours and orientation, praxis and visuomotor construction functions of children with lymphoma performed worse than their non-cancer peers (pk  < 0.001). While orientation, spatial perception, visuomotor construction and thinking operations functions of children with bone tumours and lymphoma were similar (pk  > 0.016), praxis functions of children with lymphoma were found to be worse than children with bone tumours (pk  < 0.016).

CONCLUSIONS

Our findings show that children with bone tumours and lymphoma in the process of treatment are at risk for impairment of their CoF. The findings highlight the importance of assessing CoF in children with bone tumours and lymphoma and considering specific differences between groups. It is essential to assess CoF and develop early intervention plans in these children.

Subsequent primary neoplasms after childhood cancer therapy - design and description of the German nested case-control study STATT-SCAR

BACKGROUND

Subsequent primary neoplasms (SPN) are among the most severe late effects and the second most frequent cause of death in childhood cancer patients. In this paper we introduce method and properties of the STATT-SCAR study (Second Tumor After Tumor Therapy, Second Cancer After Radiotherapy), which is a joint nested matched case-control study to evaluate the impact of chemotherapy (STATT) as well as radiotherapy (SCAR) on the risk of developing a SPN.

METHODS

Based on the cohort of the German childhood cancer registry (GCCR), we selected patients diagnosed with a first neoplasm before age 15 or younger between 1980 and 2014. We selected those with a SPN at least half a year after the first neoplasm, and matched up to four controls to each case. Therapy data were acquired from various sources, including clinical study centers and treating hospitals. To analyze the impact of radiotherapy, organ doses were estimated by using reconstructed treatment plans. The effect of chemotherapy was analyzed using substance groups summarized after isotoxic dose conversion.

RESULTS

1244 cases with a SPN were identified and matched with 4976 controls. Treatment data were acquired for 83% of all match groups (one case and at least one control). Based on preliminary analyses, 98% of all patients received chemotherapy and 54% of all patients were treated with radiotherapy.

CONCLUSIONS

Based on our data, detailed analyses of dose response relationships and treatment element combinations are possible, leading to a deeper insight into SPN risks after cancer treatments.

TRIAL REGISTRATION

The study is registered at the German clinical trial register (DRKS) under number DRKS00017847 [45].

Surveillance cardiopulmonary exercise testing can risk-stratify childhood cancer survivors: underlying pathophysiology of poor exercise performance and possible room for improvement

BACKGROUND

Asymptomatic childhood cancer survivors (CCS) frequently show decreased exercise performance. Poor exercise performance may indicate impaired future cardiovascular health.

METHODS

Cardiopulmonary exercise testing (CPET) was performed in asymptomatic off-treatment CCS (age ≥ 10 years). Patients were divided into Normal and Poor performance groups by %predicted maximum VO2 at 80%. Both peak and submaximal CPET values were analyzed.

RESULTS

Thirty-eight males (19 Normal, 19 Poor) and 40 females (18 Normal, 22 Poor) were studied. Total anthracycline dosage was comparable among 4 groups. The body mass index (BMI), although normal, and weight were significantly higher in Poor groups. Peak heart rate (HR) and peak respiratory exchange ratio (RER) were comparable in all four groups. Peak work rate (pWR)/kg, peak oxygen consumption (pVO2)/kg, peak oxygen pulse (pOP)/kg, and ventilatory anaerobic threshold (VAT)/kg were significantly lower, whereas heart rate (HR) increase by WR/kg (ΔHR/Δ[WR/kg] was significantly higher in Poor groups. Simultaneously plotting of weight & pVO2 and ΔHR/ΔWR & ΔVO2/ΔHR revealed a distinct difference between the Normal and Poor groups in both sexes, suggesting decreased skeletal muscle mass and decreased stroke volume reserve, respectively, in Poor CCS. The relationship between VAT and pVO2 was almost identical between the two groups in both sexes. Ventilatory efficiency was mildly diminished in the Poor groups.

CONCLUSIONS

Decreased skeletal muscle mass, decreased stroke volume reserve, and slightly decreased ventilatory efficiency characterize Poor CCS in both sexes. This unique combined CPET analysis provides useful clinical biomarkers to screen subclinical cardiovascular abnormality in CCS and identifies an area for improvement.

Cancer-Related Worry as a Predictor of 5-yr Physical Activity Level in Childhood Cancer Survivors

PURPOSE

Cancer-related worry (CRW; concerns related to cancer and its late effects) is prevalent among childhood cancer survivors. Elevated CRW has been associated with self-reported suboptimal physical activity. The aim of this investigation was to describe associations between CRW and objectively assessed physical activity in childhood cancer survivors.

METHODS

CRW was assessed at a baseline evaluation using six survey items. Weekly minutes of moderate and vigorous physical activity were captured by actigraphy 5.25 (3.8-8.0) yr later. Factor analysis was used to identify types of worry; multiple regression determined independent associations between CRW and moderate and vigorous physical activity adjusting for sex, race, diagnosis, age at baseline, anxiety level at baseline, self-reported physical activity at baseline, and pain interference at baseline.

RESULTS

Participants ( n = 1223) were an average of 30.9 (SD, 6.9) yr at baseline and 36.1 (SD, 7.1) yr at follow-up. Thirty-seven percent were survivors of leukemia, 26% of non-CNS solid tumors, 19% of lymphoma, 11% of CNS tumors, and 6% of other malignancies. Two types of CRW were identified: "body-focused" and "general fear." Body-focused CRW ( β = -19.6, P = 0.012), endorsing pain interference ( β = -27.7, P = 0.002) at baseline, and having a diagnosis of CNS tumor ( β = -41.3, P = 0.0003) or non-CNS solid tumor ( β = -19.4, P = 0.02) were negatively associated with physical activity at follow-up.

CONCLUSIONS

CRW related to bodily function and appearance is associated with decreased physical activity. Clinicians should consider the potential negative impact of CRW on physical activity levels and provide behavioral counseling.

Long-term postoperative quality of life in childhood survivors with cerebellar mutism syndrome

Background

To investigate the long-term quality of life (QoL) of children with cerebellar mutism syndrome (CMS) and explore the risk factors for a low QoL.

Procedure

This cross-sectional study investigated children who underwent posterior fossa surgery using an online Pediatric Quality of Life Inventory questionnaire. CMS and non-CMS patients were included to identify QoL predictors.

Results

Sixty-nine patients were included (male, 62.3%), 22 of whom had CMS. The mean follow-up time was 45.2 months. Children with CMS had a significantly lower mean QoL score (65.3 vs. 83.7, p < 0.001) and subdomain mean scores (physical; 57.8 vs. 85.3, p < 0.001; social: 69.5 vs. 85.1, p = 0.001; academic: p = 0.001) than those without CMS, except for the emotional domain (78.0 vs. 83.7, p = 0.062). Multivariable analysis revealed that CMS (coefficient = -14.748.61, p = 0.043), chemotherapy (coefficient = -7.629.82, p = 0.013), ventriculoperitoneal (VP) shunt placement (coefficient = -10.14, p = 0.024), and older age at surgery (coefficient = -1.1830, p = 0.007) were independent predictors of low total QoL scores. Physical scores were independently associated with CMS (coefficient = -27.4815.31, p = 0.005), VP shunt placement (coefficient = -12.86, p = 0.025), and radiotherapy (coefficient = -13.62, p = 0.007). Emotional score was negatively associated with age at surgery (coefficient = -1.92, p = 0.0337) and chemotherapy (coefficient = -9.11, p = 0.003). Social scores were negatively associated with male sex (coefficient = -13.68, p = 0.001) and VP shunt placement (coefficient = -1.36, p = 0.005), whereas academic scores were negatively correlated with chemotherapy (coefficient = -17.45, p < 0.001) and age at surgery (coefficient = -1.92, p = 0.002). Extent of resection (coefficient = 13.16, p = 0.021) was a good predictor of higher academic scores.

Conclusion

CMS results in long-term neurological and neuropsychological deficits, negatively affecting QoL, and warranting early rehabilitation.

Design and methods of a randomized web-based physical activity intervention among children with cancer: A report from the Children's Oncology Group

BACKGROUND

Promoting physical activity soon after treatment for childhood cancer may benefit health because sedentary lifestyle during curative therapy may perpetuate physical and emotional complications. The primary goals of this study are to evaluate the effects of a 6-month web-based, rewards-based physical activity intervention on fitness, biomarkers of cardiometabolic health, inflammation, adipokine status, quality of life and school attendance, and determine if effect of intervention on markers of cardiometabolic health is mediated by changes in fitness. The primary outcome of interest is fitness (physiological cost index, six-minute walk test) measured at end of intervention.

METHODS

This ongoing study is a two-arm, prospective, randomized design with accrual goals of 192 children for intervention and control groups. Children ≥8 years and < 16 years of age, not meeting recommended levels of physical activity, who completed therapy within the past 12 months are eligible. Both groups receive: 1) educational materials encouraging physical activity, 2) activity monitor, 3) access to web-based interface designed to motivate physical activity, 4) rewards based on physical activity levels, and 5) access to their activity data on the web-interface. Those randomized to intervention: 1) can view others' activity and interact with other participants, and 2) receive rewards based on physical activity levels throughout the intervention (vs. at the end of the intervention for control group).

CONCLUSION

Unique, scalable, and portable physical activity interventions that motivate young survivors are needed. This study will inform future web-based physical activity interventions for children with cancer by demonstrating effects of rewards and social interaction.

CLINICAL TRIALS

ClinicalTrials.gov Identifier: NCT03223753; COG Identifier: ALTE1631.

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.

A narrative review of the late effects of paediatric cancer treatment within an educational setting: Existing evidence and where do we go from here?

OBJECTIVES

The late effects of paediatric cancer treatment within an educational context are an area that is relatively under researched within the United Kingdom.

METHODS

To support this narrative review, systematic searches were conducted in key scientific databases between May and December 2020.

RESULTS

Upon reviewing literature within this field, there are key considerations that should be addressed to provide clear and concise findings. These key considerations include clarification on whether the research undertaken focuses on the late or long term effects of paediatric cancer treatment, taking a consistent approach to data analysis with the aim to improve the validity of the study findings, utilising a mixed methodology to gain further depth to the findings as well as increasing the number of studies that focus on a specific tumour type rather than numerous types to allow a detailed study to be undertaken into the potential late effects a treatment for a specific tumour may elicit.

DISCUSSION

If these key considerations are taken into account when conducting further research within this field, it would enable consistent findings to be utilised in providing the optimum educational provision for survivors of paediatric cancer who remain within the education system.

Occupational Performance Outcome for Survivors of Childhood Cancer: Feasibility of the Canadian Occupational Performance Measure

The aim of the study was to determine the feasibility of the Persian version of the Canadian Occupational Performance Measure (COPM) to assess self-reported occupational performance in a group of children with cancer at least one-year post-cancer diagnosis and intervention and to describe the self-reported occupational performance problems of children with cancer. Forty-three children with cancer (mean age 11.59 years; SD 4.94) participated in a cross-sectional study, using a convenience sampling approach. Performance and satisfaction were assessed through a validated Persian version of the COPM and feasibility and ease of administration were also considered. This study showed that feasibility was found to be adequate and this measurement was perceived as easy to understand; completion took from 20 to 51 minutes. Children with cancer prioritized 115 occupations within six of the nine COPM subcategories. Among the prioritized occupations, the highest number was found in self-care 61.7%, followed by productivity (26%), and leisure (12.1%). The mean ratings of performance varied from 3.7 to 8.4. The lowest mean rating was in the subgroup play/school (3.7). For satisfaction, the mean ratings were from 2.6 to 5.2, with functional mobility as the highest and play/school the lowest. The results support the use of the COPM in clinical practice for children with cancer. Based on these findings, children with cancer perceive problems with occupations related to all aspects of daily life. This underlines the need to provide rehabilitation services, especially occupational therapy services for these children.

How Has the Occupational Performance and Participation Levels of Children with Cancer Changed during the COVID-19 Pandemic?

Aim: To examine how the occupational performance (OP) and participation levels of children with cancer changed during the COVID-19 pandemic.Methods: Sixty-seven children with cancer (aged 6-12 years) completed the Canadian Occupational Performance Measure by giving information about their OP and participation, and their parents completed the Child and Adolescent Scale of Participation via online interview techniques. Evaluations were repeated twice in April and September 2020 to determine the change in OP and participation levels of children with cancer due to the COVID-19.Results: OP of children with cancer decreased significantly (Z=-7.02, p < 0.001) during the pandemic period. The home participation of these children did not change significantly (Z=-0.98, p = 0.32) before and during the pandemic; and was limited in both periods. Community participation decreased significantly (Z=-4.84, p < 0.001) from limited level to very limited level.Conclusions: Findings emphasize the need to increase the levels of OP and participation levels of children with various types of cancer due to the ramifications of the COVID-19 pandemic.

Better detection of reduced motor functioning in brain tumor survivors based on objective motor assessments: an incentive for improved standardized follow-up

Long-term sequelae are well-known in childhood brain tumor survivors, but motor functioning remains poorly described. This cross-sectional study aimed to assess objective motor functioning, patient-specific risk factors, and parental perceptions. Fifty-two childhood brain tumor patients (pilocytic astrocytoma, medulloblastoma, and other types) who were at least 6 months out of treatment were evaluated. Mean age at testing was 11.7 years. Objective motor functioning was assessed with the Movement Assessment Battery for Children (MABC-2-NL) and/or Bruininks-Oseretsky test of motor proficiency (BOT-2). Functional walking capacity was assessed with the 6-min walk test (6MWT). Parent-reported motor functioning was addressed using the ABILHAND-Kids, ABILOCO-Kids questionnaires, and a standardized anamnesis. Patients showed impaired motor functioning in all domains (p < 0.001). Regarding risk factors, younger age at diagnosis (< 5 year) was significantly associated with lower scores on body coordination (p = 0.006). Adjuvant treatment resulted in lower scores for fine manual control of the BOT-2 (p = 0.024) and balance of MABC-2-NL (p = 0.036). Finally, questionnaires revealed an underestimation of motor problems as perceived by the parents. In conclusion, many children who are in follow-up for a brain tumor show impaired motor functioning on multiple aspects, with younger age at diagnosis and adjuvant treatment as specific risk factors. Based on the questionnaires and anamnesis, motor problems appear to be underestimated by the parents.  Conclusion: These findings point to the need for timely prospective screening of motor functioning. Based on a screening assessment, adequate rehabilitation programs can be applied in childhood brain tumor survivors, aiming to reduce the adverse impact on their daily lives, both for functional activities and cardiovascular fitness. What is Known: • A pediatric brain tumor and its treatment are associated with potential long-term motor sequelae. • Test assessments could enable us to objectify motor functioning of these patients. What is New: • Pediatric brain tumors survivors show lower motor performance compared to the norm, which is often underestimated by parents. • Younger age at diagnosis and adjuvant treatment could be specific risk factors.

Family Formation and Socio-Economic Status among 35-Year-Old Men Who Have Survived Cancer in Childhood and Early Adulthood: A Register-Based Cohort Study

INTRODUCTION

The number of children and young adults who survive cancer has steadily increased over the past decades. Consequently, life circumstances after cancer have gained increasing importance. The aim of this study was to explore family formation and socio-economic status among 35-year-old men having survived cancer in childhood or early adulthood compared to an age-matched comparison group.

METHODS

This study is a national, register-based cohort study among 35-year-old men. Men diagnosed with cancer in childhood and early adulthood were registered between 1978 and 2016. At the time of diagnosis, each patient was randomly matched with 150 men without cancer from the background population within the same birth year. Those still alive at the age of 35 years were included in the study population.

RESULTS

The study population consisted of 4,222 men diagnosed with cancer in childhood or early adulthood and 794,589 men in the age-matched comparison group. Men who have survived cancer during childhood or early adulthood have a reduced probability of having children, and lower probability of getting married or of cohabitation than those from an age-matched comparison group. Men who have survived CNS cancer also have a lower probability of having a higher education than high school and a higher probability of being outside the workforce than those from an age-matched comparison group.

DISCUSSION/CONCLUSION

Many men who have survived cancer during childhood or early adulthood are influenced by their cancer later in life, which was apparent in family formation, educational achievements, and labour market attachment. Continued focus on rehabilitation and needs for support among the male survivors of childhood and youth cancer is warranted.

Individual, Interpersonal, and Home Environmental Factors Influencing Health Behaviors Among Chinese Childhood Cancer Survivors: A Structural Equation Analysis

BACKGROUND

Childhood cancer survivors (CCSs) are at increased risk of chronic health conditions, which could be controlled with health behaviors. However, the health behaviors and related factors of Chinese CCSs remain unclear.

OBJECTIVE

The aims of this study were to examine multiple health behaviors among Chinese CCSs and explore the individual, interpersonal, and home environmental factors affecting health behaviors.

METHODS

This cross-sectional study recruited 204 participants from 3 grade-A tertiary hospitals in Guangzhou, China. Participants provided data on health behaviors (smoking, drinking, drug use, screen time, internet addiction, dietary behaviors, physical activity, and sleep behaviors) and their determining factors. Structural equation modeling was used to analyze the data.

RESULTS

Chinese CCSs reported low rates of smoking, drinking, and drug use (0%-6.4%), but only 51% of survivors met screen time recommendations, and 24.5% of them had Internet addiction. Few survivors reported frequent soft-drink, sugar, and fast-food intake (2.0 to 7.4%), but many were finicky eaters (55.4%) or seldom drank milk (41.7%). In addition, 67.6% and 47.5% of survivors did not meet physical activity and sleep time recommendations. Childhood cancer survivors' health behaviors were influenced by the individual (age, education level, and time since diagnosis), interpersonal (peer and family support), and home environmental (residential location, parents' educations level, and household income) factors.

CONCLUSIONS

There were suboptimal health behaviors among Chinese CCSs. Targeted interventions should consider their individual, interpersonal, and home environmental factors.

IMPLICATIONS FOR PRACTICE

Knowledge of health behaviors and related factors of Chinese CCSs would help healthcare professionals develop further interventions to improve their care of this population.

Health-related quality of life of children born to childhood cancer survivors in Germany

OBJECTIVE

Rising childhood cancer survival rates have increased the importance of health-related quality of life (HRQL) assessment. While survivors show comparable HRQL to peers, concerns that cancer treatment could impact the health of prospective children were reported. No previous publications address HRQL of childhood cancer survivor offspring.

METHODS

We assessed survivor offspring HRQL using the parental KINDL questionnaire. Matched-pair analysis was conducted with data from the general population (KiGGS study) using age, gender and education (1:1, n = 1206 cases). Multivariate analyses were conducted to detect the influence of parental diagnose and treatment on offspring HRQL.

RESULTS

Overall, within KINDL dimensions, survivors reported comparable to higher HRQL for their children than the general population. Survivor parents reported significantly (p < 0.001) higher psychological (86.7% vs. 83.0%, Cohen's d = 0.3) and self-esteem (79.1% vs. 73.3%, Cohen's d = 0.5) well-being scores for younger children (3-6-year-olds). As time since diagnosis increased, parents reported higher well-being scores. Accordingly, recently diagnosed survivors reported significantly lower psychological well-being scores (p = 0.28; OR = 0.457; 95% CI = 0.228-0.918) for their children. With increasing age, average HRQL scores decreased in both cohorts; yet, this drop was less pronounced for survivor offspring. The biggest difference between age groups (7-10- vs. 14-17-year-olds) was found for school-specific well-being (6.2-point drop in survivor offspring vs. 18.2-point drop in KiGGS offspring).

CONCLUSION

Comparable to higher parentally assessed HRQL was reported for survivor offspring compared to peers. These findings are reassuring and consistent with self-reported HRQL in childhood cancer survivors. Type of parental cancer diagnosis and treatment showed no negative impact on offspring HRQL.

Living with the cerebellar mutism syndrome: long-term challenges of the diagnosis

BACKGROUND

After posterior fossa tumour surgery, up to 39% of children experience postoperative cerebellar mutism syndrome (CMS) characterized by mutism and other motor and cognitive impairments. There is a lack of knowledge on the patient-reported challenges and long-term needs. Consequently, no specific recommendations exist for rehabilitative and supportive interventions for patients with CMS. The aims of this study were to explore the patients' experiences related to the sequelae of CMS, to identify challenges and needs regarding support and rehabilitation in the period of growing from child to adult and to add perspectives for future developments of supportive care and rehabilitative guidelines.

METHODS

Ten semi-structured interviews were conducted with young adults diagnosed with CMS as children. A thematic analysis identified four themes describing challenges impacting aspects of the participants' lives.

RESULTS

Four main themes were identified and highlight the rehabilitative need for focus on verbal and non-verbal communication skills in addition to the physical impairments. We found that brain tumour survivors with CMS can benefit from social and educational rehabilitation, straightforward and truthful information, support in structuring their everyday lives and increased public knowledge of CMS.

CONCLUSION

Children with CMS face a variety of challenges affecting many aspects of their everyday lives. They should be entitled to the elements of a current rehabilitation initiative for childhood cancer to support patients' social disability and educational decline. Finally, we identified a need for an official information publication.

Functional outcomes of pediatric patients in Short-term Pediatric Rehabilitation Intensive Therapy (SPRINT) while receiving acute oncologic and hematologic care

BACKGROUND

Pediatric patients with oncologic and hematologic diagnoses who experience newly acquired functional deficits during a hospitalization may benefit from intensive therapies. However, acute medical issues or disease treatment plans may prevent a safe transfer to the inpatient rehabilitation unit. Accordingly, Short-term Pediatric Rehabilitation Intensive Therapy (SPRINT), a 2-week inpatient intensive therapy program, was developed for pediatric patients on an acute care service.

OBJECTIVE

To assess functional outcomes of SPRINT participants, adverse events associated with the program, and measures of patients' fatigue, sadness, nervousness, and pain by parents and patients at the start and end of SPRINT.

DESIGN

Retrospective cohort study.

SETTINGS

Hematology-Oncology and Bone Marrow Transplant units at regional pediatric tertiary care hospital.

PARTICIPANTS

Eighteen pediatric patients (50% female, age 1.9-17.8 years) participated in SPRINT, and 11 parents and 4 children completed questionnaires.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Functional outcomes of SPRINT participants measured by Caregiver Assistance section of the Pediatric Evaluation of Disability Inventory (PEDI), adverse events identified on chart review, and inquiry of participants' symptoms before and after SPRINT with a questionnaire.

RESULTS

Common diagnoses included leukemia and lymphoma (N = 9, 50%) and central nervous system tumor (N = 6, 33%). Deconditioning (N = 18, 100%) and peripheral neuropathy (N = 8, 44.4%) were common rehabilitation diagnoses. Significant gains were found in tasks in self-care and mobility domains of PEDI (all P < .05), as well as functional expression in social function domain (P = .03). No adverse events related to SPRINT participation were identified. There was no significant difference between pre- and post-SPRINT questionnaire responses.

CONCLUSIONS

SPRINT is an alternative model for intensive rehabilitation care delivery. Data suggested that SPRINT participation was safe and resulted in significant gains in mobility, self-care, and functional expression for pediatric patients with hematologic and oncologic diagnoses while receiving acute care. No difference was found in questionnaire responses after SPRINT participation.

Worry about somatic symptoms as a sign of cancer recurrence: prevalence and associations with fear of recurrence and quality of life in survivors of childhood cancer

OBJECTIVE

Somatic symptoms (e.g., pain, fatigue) are common after childhood cancer and are associated with greater fear of cancer recurrence and poorer health-related quality of life (HRQoL). Qualitative studies indicate that survivors of childhood cancer (SCCs) worry about somatic symptoms as indicating cancer recurrence, which could in part explain associations between symptoms and poorer psychosocial outcomes. However, the prevalence, characteristics, and impact of symptom worry has not been quantitatively studied.

METHODS

SCCs (N = 111; 52% female; Mage at study = 17.67 years, range = 8-25 years; Mage at diagnosis = 6.70 years) across a variety of diagnoses were recruited from a pediatric cancer center in Canada and completed self-report measures of symptom worry, symptom frequency, general anxiety, fear of cancer recurrence, and HRQoL.

RESULTS

A majority (62%) of SCCs worried about at least one symptom as a sign of recurrence. Pain was the most worrisome symptom, but SCCs also reported worrying about symptoms that are rarely associated with cancer recurrence such as hunger, dizziness, and feeling cold. Symptom worry was more strongly associated with fear of cancer recurrence than the mere frequency of those symptoms, and this relationship held while controlling for treatment factors and general anxiety. Symptom worry and frequency each explained unique variance in HRQoL.

CONCLUSIONS

Worry about somatic symptoms as a sign of cancer recurrence is common and may be impactful after childhood cancer. Excessive worry about somatic symptoms could be an important target to reduce fear of recurrence and increase HRQoL in SCCs.

Predictors of cognitive function in pediatric brain tumor patients: Pre-surgery through 24-month follow-up

The aim of this study was to examine the feasibility of cognitive assessment from pre-surgery through 2-year follow-up in a sample of pediatric brain tumor (BT) patients. We sought to investigate cognitive function over the course of diagnosis and treatment, and as a function of presenting problems, tumor location, treatment type, and tumor severity. Using a prospective, longitudinal design, standardized IQ measures were administered to pediatric BT patients (ages 6-16) prior to surgery (n = 25), 6 months post-diagnosis (n = 24), and 24 months post-diagnosis (n = 23). Group differences emerged based on tumor severity and treatment type at multiple time points, including prior to surgical intervention; children with high grade tumors performed more poorly than children with low grade tumors, and children receiving surgery plus adjuvant therapy performed more poorly than children who received surgery only. When considered together, an analysis of covariance demonstrated that tumor grade significantly accounted for variability in cognitive functioning, while treatment type did not. Although there is overlap clinically between tumor severity and treatment received, results suggest that tumor severity is an important factor contributing to variability in cognitive functioning and should also be considered when monitoring risk for cognitive deficits in children diagnosed with BT.

Dietary behaviours, physical activity and quality of life among childhood cancer survivors in Mainland China: A cross-sectional study

OBJECTIVE

To examine the dietary behaviours, physical activity (PA) and quality of life (QoL) of childhood cancer survivors (CCS) in Mainland China and explore the relationships between these behaviours and QoL.

METHODS

This cross-sectional study recruited 181 CCS from three Grade-A tertiary hospitals in Guangzhou. Survivors completed questionnaires assessing their dietary behaviours, PA and QoL.

RESULTS

Only 2.2%, 7.7% and 2.2% of CCS reported frequent soft drinks, sugar and fast food intake, which were lower compared to CCS in Western studies. Most survivors (72.9%) failed to drink milk daily, and many (54.7%) were picky eating. Sixty percent of CCS reported less moderate-to-vigorous physical activity (MVPA) time than 60 min/day recommended by WHO. Picky eating was significantly associated with lower overall (p < 0.001), physical (p < 0.001) and psychosocial (p < 0.001) QoL. MVPA was significantly positively associated with overall (p < 0.05) and psychosocial (p < 0.01) QoL.

CONCLUSIONS

Chinese CCS engaged better dietary behaviours of less soft drinks, sugar and fast food consumption, but many were picky eaters and did not meet milk intake and PA recommendations. Early behavioural interventions aimed at increasing the dietary diversity and MVPA level of this population should be taken to improve their QoL.

Parents' perception of their children's process of reintegration after childhood cancer treatment

Our objective was to further the understanding of the process of reintegration of childhood cancer patients after treatment and to identify factors influencing that process. Using a qualitative approach, we conducted 49 interviews with parents (n = 29 mothers, n = 20 fathers) from 31 families with a child (<18 years) with leukemia or CNS tumor. Interviews were conducted about 16 to 24 months after the end of the treatment. We used a semi-structured interview guideline and analyzed the data using content analysis. Average age of pediatric cancer patients was 5.5 years at the time of diagnosis; mean time since diagnosis was 3.5 years. Parents reported immediate impact of the disease on their children. Reintegration had gone along with delayed nursery/school enrollment or social challenges. In most cases reintegration was organized with a gradual increase of attendance. Due to exhaustion by obligatory activities, reintegration in leisure time activities was demanding and parents reported a gradual increase of activity level for their children. Parents described several barriers and facilitators influencing the reintegration process into nursery/school and leisure time activities (structural support, social support, health status, intrapersonal aspects). Although many children reintegrate well, the process takes lots of effort from parents and children. Childhood cancer survivors and their families should be supported after the end of intensive treatment to facilitate reintegration.

Relationships between executive functions and occupational performance of children with medulloblastoma

Introduction

This study examines executive functions and occupational performances of children with medulloblastoma and children with typical development. The aim was to compare the executive function and occupational performance levels of children with medulloblastoma and children with typical development and to investigate the relationship between the executive function and occupational performance levels of children with medulloblastoma.

Method

Parents of 105 children (6–12 years) completed the Childhood Executive Function Inventory. A total of 105 children were administered the Canadian Occupational Performance Measurement to obtain information on occupational performance areas. Executive functions and occupational performance levels of children with medulloblastoma ( n = 52) and typical development ( n = 53) were compared. Correlation analysis was conducted between the executive functions and occupational performances of children with medulloblastoma.

Results

Executive function and occupational performance levels of children with medulloblastoma were lower than those with typical development. Significant relationships were found between the executive functions and occupational performances of children with medulloblastoma ( p < 0.05, p < 0.001).

Conclusion

It is clear that the executive functions of children with medulloblastoma significantly affect their occupational performance level. Client-centered, occupation-oriented cognitive therapy interventions prepared according to occupational therapy theories and models might be useful to increase the occupational performance level of children with medulloblastoma.

Physical Rehabilitation Practices for Children and Adolescents with Cancer in Canada

Purpose: Children and adolescents with cancer who undergo cancer treatment are at high risk of developing adverse effects, many of which may be amenable to physical rehabilitation. We aimed to identify the current clinical physical rehabilitation practice patterns, services, and programmes available for children and adolescents with cancer in Canada. Method: A cross-sectional survey in English and French was conducted. Participants were health care professionals (HCPs) who provided physical rehabilitation services to children and adolescents with cancer in Canada. The survey included questions on the HCPs' practice patterns and the programmes and services they provided. Results: A total of 35 HCPs responded: 27 physical therapists (77%), 6 occupational therapists (17%), 1 exercise professional (3%), and 1 speech-language pathologist (3%). Overall, they reported activity limitations, alterations in motor performance, muscle weakness, peripheral neuropathy, and fatigue as the top priorities for rehabilitation services. HCPs believed that interventions were valuable in reducing the burden of cancer effects; however, issues such as space, resources, and lack of clinical practice guidelines were viewed as barriers to providing services. Conclusions: Paediatric oncology rehabilitation services exist in some regions in Canada. HCPs strongly support the need to develop clinical practice guidelines for paediatric oncology rehabilitation.

Changes in nutritional status in adolescents surviving leukemia and lymphoma

ABSTRACT Objective To examine the changes in the nutritional status of adolescents aged 10-19 years after a minimum 12 months interval following oncological treatment for leukemias and lymphomas. Methods Longitudinal design quantitative study conducted at Hospital de Clínicas, Porto Alegre. Adolescents aged 10-19 years after a minimum 12 months interval following oncological treatment for leukemias and lymphomas were included. The measures of weight, height, brachial circumference, triceps skinfold thickness, arm muscle circumference and abdominal circumference were collected. Results The sample comprised 50 adolescents who had survived leukemias and lymphomas. In the follow up 38% of the patients were classified as overweight according to the body mass index for their age. There was a significant increase in body mass index for age between the beginning and the end of treatment and follow up (p=0.013) in female individuals, compared to males. The results indicate a reduction in the Z-score means of height for age, with significant differences between the beginning of treatment and follow up (p=0.016); and end of treatment and follow up (p=0.006) in patients of both genders Conclusion The anthropometric indicators show an important frequency of excess weight and increased tricipital skinfold, as well as a significant increase of the body mass index for age and also a growth deficit among the survivors.

Control by Viability in a Chemotherapy Cancer Model

The aim of this study is to provide a feedback control, called the Chemotherapy Protocol Law, with the purpose to keep the density of tumor cells that are treated by chemotherapy below a "tolerance level" [Formula: see text], while retaining the density of normal cells above a "healthy level" [Formula: see text]. The mathematical model is a controlled dynamical system involving three nonlinear differential equations, based on a Gompertzian law of cell growth. By evoking viability and set-valued theories, we derive sufficient conditions for the existence of a Chemotherapy Protocol Law. Thereafter, on a suitable viability domain, we build a multifunction whose selections are the required Chemotherapy Protocol Laws. Finally, we propose a design of selection that generates a Chemotherapy Protocol Law.

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.

Quality of life in survivors of childhood brain tumour and the association of children's diseases on quality of their parents life

OBJECTIVE

Evaluation of children's quality of life (QoL) after finished brain tumour treatment and the association of children's diseases on quality of their parents' life.

METHODS

The study group was consisted of 46 children after brain tumour treatment (aged 4, 5, to 29 years old). The control group was composed of 104 students of primary, secondary, and high schools. One hundred fifty (104 + 46) parents were included in the study. Standardised QoL questionnaires (PEDsQL-4.0, WHOQOL-BREF) were used. Survivors' QoL was assessed from patients' and their parents' point of view, also the association of children's diseases on quality of their parents' life was estimated.

RESULTS

QoL of children after brain tumour treatment was lower than in the control group according to the children (P < 0.001) and their parents (P < 0.001). The survivors worst rated their ability to social functioning (P < 0.0010) and physical functioning (P < 0.001) in comparison with self-assessment of healthy children. According to their parents, the functioning of children in all zones was worse than in the control group, mostly in social (P < 0.001) and physical sphere (P < 0.001), too. QoL of children with low-grade tumour was comparable with QoL of children with high-grade tumour). QoL of survivors' caregivers in study was higher than QoL of parents of control groups (P = 0.023).

CONCLUSIONS

The quality of patients' life after brain tumour treatment is lower in comparison with healthy children. QoL of the parents of survivor is higher than the QoL of healthy children parents. The assessment of QoL of children after brain tumour treatment should be an inherent element of health monitoring.

Physical activity for children with chronic disease; a narrative review and practical applications

BACKGROUND

Physical activity (PA) is associated with a diverse range of health benefits. International guidelines suggest that children should be participating in a minimum of 60 min of moderate to vigorous intensity PA per day to achieve these benefits. However, current guidelines are intended for healthy children, and thus may not be applicable to children with a chronic disease. Specifically, the dose of PA and disease specific exercise considerations are not included in these guidelines, leaving such children with few, if any, evidence-based informed suggestions pertaining to PA. Thus, the purpose of this narrative review was to consider current literature in the area of exercise as medicine and provide practical applications for exercise in five prevalent pediatric chronic diseases: respiratory, congenital heart, metabolic, systemic inflammatory/autoimmune, and cancer.

METHODS

For each disease, we present the pathophysiology of exercise intolerance, summarize the pediatric exercise intervention research, and provide PA suggestions.

RESULTS

Overall, exercise intolerance is prevalent in pediatric chronic disease. PA is important and safe for most children with a chronic disease, however exercise prescription should involve the entire health care team to create an individualized program.

CONCLUSIONS

Future research, including a systematic review to create evidence-based guidelines, is needed to better understand the safety and efficacy of exercise among children with chronic disease.

Roles of positive psychological outcomes in future health perception and mental health problems: A report from the Childhood Cancer Survivor Study

OBJECTIVE

Positive psychological outcomes among adolescent and young adult survivors of childhood cancer may influence long-term health status. We examined posttraumatic growth (PTG) and Life satisfaction (LS) in adolescence, and their impact on future emotional and physical health status in young adulthood.

METHODS

Survivors (n = 2802) from the Childhood Cancer Survivor Study were longitudinally analyzed across social, emotional, and physical factors during adolescence (12-17 years old), and PTG (PTG-Inventory) and LS (Cantril-Ladder-of-Life) during young adulthood (19-24 years old). The impact of PTG and LS on survivors' future long-term mental health, physical health, and social skills was also examined (23-28 years old) using Structural Equation Modeling.

RESULTS

Survivors reported high levels of LS (M = 7.43, range 1 to 10) and a positive impact from their cancer experience (M = 48.78, range 0 to 105). Adolescent predictors of higher PTG included older age at diagnosis (p = 0.001), experiencing more severe chronic health conditions (p = 0.01), cancer recurrence/relapse (p = 0.01), and being diagnosed with a non-CNS cancer (p = 0.001). Higher perceived general health (p = 0.01), higher social skills (p = 0.001), and diagnosis with a non-CNS cancer (p = 0.02) were associated with higher LS. Higher PTG during young adulthood predicted poorer perceived health (p = 0.04) and worse emotional health (p = 0.001) in later adulthood. Higher LS predicted better emotional health (p = 0.001) and better perceived health (p = 0.001).

CONCLUSIONS

While LS was found to help survivors have better perceived long-term emotional and physical health outcomes, survivors with higher PTG fond both positive and negative impacts from cancer. Future therapeutic trials to improve LS should be considered.

Aspectos psicosociales de la calidad de vida en supervivientes pediátricos de tumores en el sistema nervioso central

Introducción: Los supervivientes de tumores del sistema nervioso central (TSNC) presentan peor calidad de vida en relación a la salud (CVRS) que los supervivientes de otras neoplasias y la población normativa. El tipo y gravedad de las secuelas no parecen tener un impacto claro en la CVRS, pero la afectación del cociente intelectual (CI) sí podría modular la CVRS. Además, las estrategias de afrontamiento del paciente y de los progenitores y el malestar emocional parental podrían también actuar sobre la CVRS. Objetivo: Determinar si las estrategias de afrontamiento del adolescente y su CI, y las estrategias de afrontamiento, el estrés general y el malestar emocional parental, modulan las dimensiones psicosociales de la CVRS del superviviente. Método: Estudio transversal descriptivo-correlacional. Se reclutaron 37 adolescentes (12-19 años) que llevaban ≥1 año fuera de tratamiento oncológico y 44 progenitores. Resultados: En la CVRS valorada por los adolescentes, las dimensiones Relación con los Padres y Vida Familiar, Amigos y Apoyo Social, y Entorno Escolar dependen de la estrategia de afrontamiento de resolución del problema usada por el adolescente. La dimensión Aceptación Social depende del estilo de afrontamiento improductivo del adolescente y del estilo de búsqueda de ayuda social de los padres. La CVRS valorada por los padres depende de las secuelas, el CI del adolescente y, el tipo de tratamiento oncológico recibido. Discusión y conclusiones: Las estrategias de afrontamiento centradas en la resolución del problema, deben ser consideradas para valorar e intervenir en la mejora de la CVRS de los supervivientes TSNC.

Testing physical function in children undergoing intense cancer treatment-a RESPECT feasibility study

BACKGROUND

The physical function of children with cancer is reduced during treatment, which can compromise the quality of life and increase the risk of chronic medical conditions. The study, "REhabilitation, including Social and Physical activity and Education in Children and Teenagers with cancer" (Clinicaltrials.gov: NCT01772862) examines the efficacy of multimodal rehabilitation strategies introduced at cancer diagnosis. This article addresses the feasibility of and obstacles to testing physical function in children with cancer.

METHODS

The intervention group comprised 46 males and 29 females aged 6-18 years (mean ± SD: 11.3 ± 3.1 years) diagnosed with cancer from January 2013 to April 2016. Testing at diagnosis and after 3 months included timed-up-and-go, sit-to-stand, flamingo balance, handgrip strength, and the bicycle ergometer cardiopulmonary exercise test (CPET).

RESULTS

Of the 75 children, 92% completed a minimum of one test; two children declined testing and four were later included. Completion was low for CPET (38/150, 25%) but was high for handgrip strength (122/150, 81%). Tumor location, treatment-related side effects, and proximity to chemotherapy administration were primary obstacles for testing physical function. Children with extracranial solid tumors and central nervous system tumors completed significantly fewer tests than those with leukemia and lymphoma. Children with leukemia demonstrated reduced lower extremity function, that is, 24% reduction at 3 months testing in timed-up-and-go (P = 0.005) and sit-to-stand (P = 0.002), in contrast with no reductions observed in the other diagnostic groups.

CONCLUSION

Children with cancer are generally motivated to participate in physical function tests. Future studies should address diagnosis specific obstacles and design testing modalities that facilitate physical function tests in this target group.

Cycling Through Cancer: Exploring Childhood Cancer Survivors' Experiences of Well- and Ill-Being

The benefits of informal physical activity during recovery from childhood cancer have rarely been investigated. This study adopted a multiple case study approach to explore the impact of recreational cycling on childhood cancer survivors' experiences of well- and ill-being. Three semistructured interviews were conducted over a 3-month period with four survivors to explore their experiences of physical, psychological, and social well- and ill-being. Within-case analysis followed by cross-case analysis identified three themes that captured their well- and ill-being experiences with recreational cycling and cancer: (a) cultivating feelings and emotions, (b) experiencing physical changes, and (c) encountering positive and negative social interactions. The results from this study show that recreational cycling may be a useful adjunct to conventional treatments for the self-management of multiple domains of well- and ill-being during recovery from childhood cancer.

Health-related quality of life in parents of pediatric brain tumor survivors at the end of tumor-directed therapy

OBJECTIVE

This study examines theoretical covariates of health-related quality of life (HRQL) in parents of pediatric brain tumor survivors (PBTS) following completion of tumor-directed therapy.

METHODS

Fifty PBTS (ages 6-16) completed measures of neurocognitive functioning and their parents completed measures of family, survivor, and parent functioning.

RESULTS

Caregiving demand, caregiver competence, and coping/supportive factors were associated with parental physical and psychosocial HRQL, when controlling for significant background and child characteristics.

CONCLUSION

Study findings can inform interventions to strengthen caregiver competence and family functioning following the completion of treatment, which may improve both parent and survivor outcomes.

Balance in children with acute lymphoblastic leukemia

BACKGROUND

Treatment for acute lymphoblastic leukemia (ALL) can affect balance via different mechanisms, including sensory and motor peripheral neuropathy, cognitive impairment, and reduced muscle strength and flexibility. To provide an overview of what is currently known about the effects of cancer treatment on balance in pediatric ALL patients and survivors, and of the predictors of poor balance, a review of the literature was conducted.

METHODS

Five databases were searched for English-language original research articles on balance during or after treatment for pediatric ALL.

RESULTS

From a total of nine studies, six identified significant balance problems in children with ALL during or after treatment. The percentage of patients or survivors with impaired balance varied between 27% and 69% during treatment, 7% and 65% a few years after completion of treatment, and 14% and 17% many years after the completion of treatment. Factors associated with impaired balance were higher body mass index; higher intrathecal methotrexate dose; cranial radiation; knee extensor weakness; and impaired cognition.

CONCLUSION

Although heterogeneity between the studies regarding patient age; age at diagnosis; time since completion of treatment; and methods of quantifying balance make it difficult to reach a single conclusion, the evidence suggests that survivors may experience short- and/or long-term balance difficulties. While there is a need for additional studies to better understand the effects of impaired balance in survivors, clinicians treating both child and adult survivors of ALL need to be aware of these potential risks.

Constraint-Induced Movement Therapy for Children With Brain Tumors

PURPOSE

The purpose of this pilot study was to investigate the feasibility of a 3-week constraint-induced movement therapy program in children with brain tumors and upper extremity hemiplegia and to describe resultant change in extremity use.

METHODS

Affected arm use, health-related quality of life, and parent-reported feasibility of program participation were measured before and after the intervention and at a 3-month follow-up visit.

RESULTS

All 9 participants completed the entire study. The quality and amount of affected arm use improved significantly; gains were maintained at the 3-month follow-up evaluation. Some parents (44%) reported that program participation was difficult; however, all reported satisfaction with the program. Participants did not experience negative changes in health-related quality of life during the intervention, indicating that they tolerated the program well.

CONCLUSIONS

Findings suggest that a child with hemiplegia as a result of a brain tumor can adhere to and benefit from a constraint-induced movement therapy program.

Feasibility of group intervention for bereaved siblings after pediatric cancer death

This study evaluated the feasibility (acceptability, recruitment, retention rates, treatment fidelity, and outcome measures) of implementing a manualized group intervention for bereaved siblings after pediatric cancer death. A convenience sample of 10 siblings participated. The intervention consisted of eight 2-hour sessions that focused on strategies for coping with grief, relationships, and emotional growth. Positive outcomes were obtained with respect to acceptability, recruitment, retention rates, and treatment fidelity. Preliminary outcomes were mixed. Parent pre- and post-intervention outcomes suggested improvements in siblings' overall emotional and social quality of life. Siblings' self-reports reflected no improvements. These data support the feasibility of conducting this intervention and suggest beneficial outcomes based on parental reports. Further research is recommended to evaluate the group intervention efficacy with a large sample using a randomized controlled trial to address the needs of bereaved siblings.

Exercise and Fatigue in Adolescent and Young Adult Survivors of Hodgkin Lymphoma: A Report from the Children's Oncology Group

Fatigue is a significant problem for adolescent and young adult (AYA) Hodgkin lymphoma (HL) survivors. The relationship between exercise and fatigue is complex. This study explored the trajectory of and the relationship between exercise and fatigue over 36 months post-therapy in a cohort of 103 AYA-aged HL survivors treated on Children's Oncology Group (COG) study AHOD0031. Descriptive statistics and generalized estimating equations were used in this secondary data analysis. Exercise and fatigue improved over time but were unrelated; amount of exercise at end of therapy predicted amount of exercise at 12 (p = 0.02) and 36 (p = 0.0008) months post-therapy.

Muscle strength and quality of life in patients with childhood cancer at early phase of primary treatment

Cancer- and treatment-related side effects in patients with childhood cancer may cause limitations in motor performance affecting activities of daily living (ADLs). Data focusing on long-term effects are available, but little is known with regard to the short-term perspective. Therefore, the purpose of this study was to assess muscle strength performance and quality of life (QoL) in children and adolescents with cancer at the beginning of primary treatment. Forty children and adolescents aged 5-18 years (mean: 11.39 ± 4.08 years) with different types of childhood cancer were enrolled. On average 36 ± 20.5 days after diagnosis, strength performance in 7 muscle groups was assessed by handheld dynamometry. KINDL questionnaires were completed to evaluate QoL (children's self-report and parents' report). All parameters were compared with age- and gender-matched reference values. Patients with childhood cancer showed significantly lower strength values in all muscle groups (P < .01) compared with age- and gender-matched controls. Most affected were the lower extremities, with a -57.1% ± 10.4%, median: -59.2%, minimum: -75.4%, maximum: -41.4% percentage deviation in knee flexion from healthy peers. Children themselves and parents assessed total QoL significantly below age- and gender-matched reference values (P < .01). Correlation between elbow flexion and self-reported QoL was detected. Broader correlations were found for the parents' report. Muscle weakness and decreased QoL in children and adolescents seem to persist already at the beginning of anticancer treatment. This underlines the need of counteracting measures, such as exercise intervention programs, starting as early as possible during the treatment process. Efforts on this topic are currently being carried out by our group.

Long term cause specific mortality among 34 489 five year survivors of childhood cancer in Great Britain: population based cohort study

OBJECTIVE

 To determine whether modern treatments for cancer are associated with a net increased or decreased risk of death from neoplastic and non-neoplastic causes among survivors of childhood cancer.

DESIGN

 Population based cohort study.

SETTING

 British Childhood Cancer Survivor Study.

PARTICIPANTS

 Nationwide population based cohort of 34 489 five year survivors of childhood cancer with a diagnosis from 1940 to 2006 and followed up until 28 February 2014.

MAIN OUTCOME MEASURES

 Cause specific standardised mortality ratios and absolute excess risks are reported. Multivariable Poisson regression models were utilised to evaluate the simultaneous effect of risk factors. Likelihood ratio tests were used to test for heterogeneity or trend.

RESULTS

 Overall, 4475 deaths were observed, which was 9.1 (95% confidence interval 8.9 to 9.4) times that expected in the general population, corresponding to 64.2 (95% confidence interval 62.1 to 66.3) excess deaths per 10 000 person years. The number of excess deaths from all causes declined among those treated more recently; those treated during 1990-2006 experienced 30% of the excess number of deaths experienced by those treated before 1970. The corresponding percentages for the decline in excess deaths from recurrence or progression and non-neoplastic causes were 30% and 60%, respectively. Among survivors aged 50-59 years, 41% and 22% of excess deaths were attributable to subsequent primary neoplasms and circulatory conditions, respectively, whereas the corresponding percentages among those aged 60 years or more were 31% and 37%.

CONCLUSIONS

 The net effects of changes in cancer treatments, and surveillance and management for late effects, over the period 1940 to 2006 was to reduce the excess number of deaths from both recurrence or progression and non-neoplastic causes among those treated more recently. Among survivors aged 60 years or more, the excess number of deaths from circulatory causes exceeds the excess number of deaths from subsequent primary neoplasms. The important message for the evidence based surveillance aimed at preventing excess mortality and morbidity in survivors aged 60 years or more is that circulatory disease overtakes subsequent primary neoplasms as the leading cause of excess mortality.

Nutritional interventions for survivors of childhood cancer

BACKGROUND

Childhood cancer survivors are at a higher risk of developing health conditions such as osteoporosis, and cardiovascular disease than their peers. Health-promoting behaviour, such as consuming a healthy diet, could lessen the impact of these chronic issues, yet the prevalence rate of health-protecting behaviour amongst survivors of childhood cancer is similar to that of the general population. Targeted nutritional interventions may prevent or reduce the incidence of these chronic diseases.

OBJECTIVES

The primary aim of this review was to assess the efficacy of a range of nutritional interventions designed to improve the nutritional intake of childhood cancer survivors, as compared to a control group of childhood cancer survivors who did not receive the intervention. Secondary objectives were to assess metabolic and cardiovascular risk factors, measures of weight and body fat distribution, behavioural change, changes in knowledge regarding disease risk and nutritional intake, participants' views of the intervention, measures of health status and quality of life, measures of harm associated with the process or outcomes of the intervention, and cost-effectiveness of the intervention

SEARCH METHODS

We searched the electronic databases of the Cochrane Central Register of Controlled Trials (CENTRAL; 2013, Issue 3), MEDLINE/PubMed (from 1945 to April 2013), and Embase/Ovid (from 1980 to April 2013). We ran the search again in August 2015; we have not yet fully assessed these results, but we have identified one ongoing trial. We conducted additional searching of ongoing trial registers - the International Standard Randomised Controlled Trial Number register and the National Institutes of Health register (both screened in the first half of 2013) - reference lists of relevant articles and reviews, and conference proceedings of the International Society for Paediatric Oncology and the International Conference on Long-Term Complications of Treatment of Children and Adolescents for Cancer (both 2008 to 2012).

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) that compared the effects of a nutritional intervention with a control group which did not receive the intervention in this review. Participants were childhood cancer survivors of any age, diagnosed with any type of cancer when less than 18 years of age. Participating childhood cancer survivors had completed their treatment with curative intent prior to the intervention.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected and extracted data from each identified study, using a standardised form. We assessed the validity of each identified study using the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions. We used the GRADE criteria to assess the quality of each trial.

MAIN RESULTS

Three RCTs were eligible for review. A total of 616 participants were included in the analysis. One study included participants who had been treated for acute lymphoblastic leukaemia (ALL) (275 participants). Two studies included participants who had all forms of paediatric malignancies (266 and 75 participants). All participants were less than 21 years of age at study entry. The follow-up ranged from one month to 36 months from the initial assessment. All intended outcomes were not evaluated by each included study. All studies looked at different interventions, and so we were unable to pool results. We could not rule out the presence of bias in any of the studies.There was no clear evidence of a difference in calcium intake at one month between those who received the single, half-day, group-based education that focused on bone health, and those who received standard care (mean difference (MD) 111.60, 95% confidence interval (CI) -258.97 to 482.17; P = 0.56, low quality evidence). A regression analysis, adjusting for baseline calcium intake and changes in knowledge and self-efficacy, showed a significantly greater calcium intake for the intervention as compared with the control group at the one-month follow-up (beta coefficient 4.92, 95% CI 0.33 to 9.52; P = 0.04). There was statistically significant higher, self-reported milk consumption (MD 0.43, 95% CI 0.07 to 0.79; P = 0.02, low quality evidence), number of days on calcium supplementation (MD 11.42, 95% CI 7.11 to 15.73; P < 0.00001, low quality evidence), and use of any calcium supplementation (risk ratio (RR) 3.35, 95% CI 1.86 to 6.04; P < 0.0001, low quality evidence), with those who received this single, face-to-face, group-based, health behaviour session.There was no clear evidence of a difference in bone density Z-scores measured with a dual-energy X-ray absorptiometry (DEXA) scan at 36 months follow-up (MD -0.05, 95% CI -0.26 to 0.16; P = 0.64, moderate quality evidence) between those who received calcium and vitamin D supplementation combined with nutrition education and those who received nutrition education alone. There was also no clear evidence of a difference in bone mineral density between the intervention and the control group at the 12-month (median difference -0.17, P = 0.99) and 24-month follow-up (median difference -0.04, P = 0.54).A single multi-component health behaviour change intervention, focusing on general healthy eating principles, with two telephone follow-ups brought about a 0.17 lower score on the four-point Likert scale of self-reported junk food intake compared with the control group (MD -0.17, 95% CI -0.33 to -0.01; P = 0.04, low quality evidence); this result was statistically significant. There was no clear evidence of a difference between the groups in the self-reported use of nutrition as a health protective behaviour (MD -0.05, 95% CI -0.24 to 0.14; P = 0.60, low quality evidence).

AUTHORS' CONCLUSIONS

Due to a paucity of studies, and the heterogeneity of the studies included in this review, we are unable to draw conclusions regarding the effectiveness of nutritional interventions for use with childhood cancer survivors. Although there is low quality evidence for the improvement in health behaviours using health behaviour change interventions, there remains no evidence as to whether this translates into an improvement in dietary intake. There was also no evidence that the studies reduced the risk of cardiovascular and metabolic disorders in childhood cancer survivors, although no evidence of effect is not the same as evidence of no effect. This review highlights the need for further well designed trials to be implemented in this population.

Dietary Protein Intake and Lean Muscle Mass in Survivors of Childhood Acute Lymphoblastic Leukemia: Report From the St. Jude Lifetime Cohort Study

BACKGROUND

Survivors of childhood acute lymphoblastic leukemia (ALL) are at risk for low lean muscle mass and muscle weakness, which may contribute to inactivity and early development of chronic diseases typically seen in older adults. Although increasing protein intake, in combination with resistance training, improves lean muscle mass in other populations, it is not known whether muscular tissue among survivors of ALL, whose impairments are treatment-related, will respond similarly.

OBJECTIVE

The aim of this study was to evaluate associations among dietary protein intake, resistance training, and lean muscle mass in survivors of ALL and age-, sex-, and race-matched controls.

DESIGN

This was a cross-sectional study.

METHODS

Lean muscle mass was determined with dual-energy x-ray absorptiometry, dietary information with 24-hour recalls, and participation in resistance training with a questionnaire. Participants were 365 survivors of ALL (52% male; 87% white; median age=28.5 years, range=23.6-31.7) and 365 controls with no previous cancer.

RESULTS

Compared with controls, survivors of ALL had lower lean muscle mass (55.0 versus 57.2 kg, respectively) and lower percentage of lean muscle mass (68.6% versus 71.4%, respectively) than controls. Similar proportions of survivors (71.1%) and controls (69.7%) met recommended dietary protein intake (0.8 g/kg/d). Survivors (45.4%) were less likely to report resistance training than controls (53.8%). In adjusted models, 1-g higher protein intake per kilogram of body mass per day was associated with a 7.9% increase and resistance training ≥1×wk, with a 2.8% increase in lean muscle mass.

LIMITATIONS

The cross-sectional study design limits temporal evaluation of the association between protein intake and lean muscle mass.

CONCLUSIONS

The findings suggest that survivors of childhood ALL with low lean muscle mass may benefit from optimizing dietary protein intake in combination with resistance training. Research is needed to determine whether resistance training with protein supplementation improves lean muscle mass in survivors of childhood ALL.

Smoking behavior among adult childhood cancer survivors: what are we missing?

PURPOSE

Childhood cancer survivors are a growing population at increased risk for smoking-related health complications. This study compared smoking prevalence, age at smoking initiation, and time trend of smoking prevalence from 1997 to 2010 between adult survivors of childhood cancer and adults without a cancer history (controls) and identified predictors of smoking among these survivors.

METHODS

Data were pooled from the 1997-2010 National Health Interview Survey (survivors, n = 1438; controls, n = 383,805). Smoking prevalence by age group was calculated using weighted least square regression analysis and weighted linear regression of prevalence on year for trend analysis. Logistic regression analyses adjusting for sample weights and design effects were performed to identify predictors of smoking among survivors.

RESULTS

Compared to controls, survivors were significantly more likely to be younger, female, non-Hispanic White, unemployed, with lower income, and to weigh less and smoke more. Survivors initiated smoking earlier than controls. Smoking prevalence among survivors peaked at age 30 and 40 years old, compared to age 25 years in controls. Smoking prevalence decreased consistently from 1997 to 2010 among controls, with larger significant declines in survivors that were subject to more year-to-year variability. Compared to nonsmoking survivors, those who smoke were significantly more likely to be non-Hispanic White, young, uninsured, poor, to have a high school education or less, and to report drinking alcohol.

CONCLUSION

Smoking in adult survivors of childhood cancer continues as a persistent risk factor across socioeconomic groups.

IMPLICATIONS FOR CANCER SURVIVORS

Targeted and tailored smoking cessation/prevention interventions for these survivors are needed.

Presurgical assessment of cognitive function in pediatric brain tumor patients: feasibility and initial findings

BACKGROUND

Establishing a presurgical baseline of neurocognitive functioning for pediatric brain tumor patients is a high priority to identify level of functioning prior to medical interventions. However, few studies have obtained adequate samples of presurgery assessments.

METHODS

This study examines the feasibility of completing tests to assess pre-surgical neurocognitive functioning in 59 identified pediatric brain tumor patients.

RESULTS

Eighty-five percent of patients (n = 50) were referred by the neurosurgery team before surgery and 83% of patients (n = 49) enrolled in the study. A full battery, including both performance-based and parent-report measures of neurocognitive function, was completed for 54% (n = 32) of patients. Rates of completion for either parent-report or performance-based measures were 68% (n = 40) and 69% (n = 41), respectively. While the performance-based assessment fell within the average range (M = 95.4, SD = 14.7, 95% CI, 90.7-100.0), 32% of participants had scores one or more standard deviations below the mean, or twice the expected rate. Parent-reports indicated higher level of concern than the general population (M = 55.4, SD = 11.3, 95% CI, 51.8-59.0) and found that 35% fell one or more standard deviations above the mean, or more than twice the expected rate.

CONCLUSIONS

Results suggest it is feasible to conduct pre-surgical assessments with a portion of pediatric brain tumor patients upon diagnosis and these results compare favorably with prior research. However, nearly half of identified patients did not receive a full test battery. Identifying barriers to enrollment and participation in research are discussed as well as recommendations for future research.

Physical activity and screen-time of childhood haematopoietic stem cell transplant survivors

AIM

Reduced bone mineral density, impaired cardiovascular fitness and increased risk of obesity are well-known late effects of haematopoietic stem cell transplantation (HSCT) in survivors of childhood cancer. These comorbidities can be mitigated through physical activity and limiting screen-time (ST). This study aims to increase the understanding of physical activity and ST behaviours for children following HSCT.

METHODS

Children were recruited from two oncology follow-up clinics and completed a questionnaire on their physical activity levels and screen-time. Children were classified as short (≤2 years) and long-term (>2 years) survivors.

RESULTS

Fifty-eight children were eligible, of whom forty children of age 6-18 years (60% males) participated in the study. Less than half (47.5%) met the daily recommendations for physical activity and one-third met the ST recommendations. Late survivors reported higher daily physical activity and less ST than early survivors. Among late survivors, females reported higher daily physical activity and less ST than males.

CONCLUSION

Our findings suggest that the majority of children following HSCT were not sufficiently active and had excessive screen-time; however, this was comparable to healthy populations. Appropriately designed physical activity and screen-time intervention programmes should be explored early following transplant for children undergoing HSCT.

Developing a healthy web-based cookbook for pediatric cancer patients and survivors: rationale and methods

Background

Obesity has been a growing problem among children and adolescents in the United States for a number of decades. Childhood cancer survivors (CCS) are more susceptible to the downstream health consequences of obesity such as cardiovascular disease, endocrine issues, and risk of cancer recurrence due to late effects of treatment and suboptimal dietary and physical activity habits.

Objective

The objective of this study was to document the development of a Web-based cookbook of healthy recipes and nutrition resources to help enable pediatric cancer patients and survivors to lead healthier lifestyles.

Methods

The Web-based cookbook, named “@TheTable”, was created by a committee of researchers, a registered dietitian, patients and family members, a hospital chef, and community advisors and donors. Recipes were collected from several sources including recipe contests and social media. We incorporated advice from current patients, parents, and CCS.

Results

Over 400 recipes, searchable by several categories and with accompanying nutritional information, are currently available on the website. In addition to healthy recipes, social media functionality and cooking videos are integrated into the website. The website also features nutrition information resources including nutrition and cooking tip sheets available on several subjects.

Conclusions

The “@TheTable” website is a unique resource for promoting healthy lifestyles spanning pediatric oncology prevention, treatment, and survivorship. Through evaluations of the website’s current and future use, as well as incorporation into interventions designed to promote energy balance, we will continue to adapt and build this unique resource to serve cancer patients, survivors, and the general public.

Design and rationale for NOURISH-T: a randomized control trial targeting parents of overweight children off cancer treatment

Approximately 40% of off-treatment pediatric cancer survivors (PCS) are overweight or obese, which increases their risk for negative long-term physical health complications. Consistent with the Institute of Medicine's (IOM) emphasis on patients transitioning from treatment to cancer survivorship and increasing long-term healthy behaviors in these survivors, we plan to conduct a pilot RCT to address the increasing overweight/obesity rates among PCS by targeting their caregivers as agents for PCS behavior change. We plan to focus on parents' behaviors, attitudes and roles in promoting healthier eating and physical activity (PA) in PCS and adapt an evidence-informed, manualized parent intervention - NOURISH - found to be effective for parents of overweight and obese children and adolescents in reducing child and adolescent BMI. We plan to adapt NOURISH for caregivers of 5-12 year old PCS (6 months-4 years off active cancer treatment). Our pilot feasibility RCT - NOURISH-T (Nourishing Our Understanding of Role modeling to Improve Support for Healthy Transitions) evaluates: 1) the preliminary efficacy of NOURISH-T for PCS, compared with an Enhanced Usual Care (EUC) control condition, and 2) factors to consider to improve future adaptations of the intervention. The project will enroll caregivers of PCS at two pediatric oncology clinics into the 6-week intervention (or EUC) with assessments occurring pre- and post-6 weeks of intervention, and at a 4-month follow-up.