Comprehensive assessments and related interventions to enhance the long-term outcomes of child, adolescent and young adult cancer survivors - presentation of the CARE for CAYA-Program study protocol and associated literature review

Implementation of Regular Lifestyle Counseling During Long-Term Follow-Up Care of Childhood Cancer Survivors: Monocentric Prospective Study

Background

Many childhood cancer survivors (CCS) develop treatment-related late effects, including an increased risk of obesity and metabolic syndrome. A healthy lifestyle can reduce the risk of associated comorbidities. Therefore, at-risk CCS could benefit from lifestyle counseling during regular long-term follow-up (LTFU).

Objective

We implemented a new form of care to decrease the long-term morbidity among CCS and to gain new insights into the lifestyle of those patients.

Methods

Over a 1-year study period, lifestyle counseling was integrated into LTFU care. Metabolic disorders, including hypercholesterolemia, diabetes mellitus, overweight or underweight, and low activity levels, were assessed as screening parameters for various risk groups. The perspectives of CCS, physicians, and sports scientists were compared to identify those with the highest needs. Each lifestyle counseling included general recommendations for physical activity, as well as an assessment of individual preferences for and barriers to the implementation of a healthy lifestyle. A follow-up appointment after 1 month was performed.

Results

Of the 155 CCS aged 18 to 63 years (n=100, 65% female and n=55, 35% male), 112 (72%) had an indication for lifestyle counseling, identified by physicians, sports scientists, or the CCS themselves. Metabolic disorders affected 45% (n=70) of these CCS, and 46% (n=72) did not meet recommended activity levels. A total of 120 (77%) CCS received lifestyle counseling, including 8 initially uninterested individuals who became open to recommendations. Those with intensive cancer treatment history showed the greatest need. A total of 65 (54%) CCS were advised to change their lifestyle in both areas (diet and exercise) while 51 (43%) CCS received recommendations for only exercise (n=43 CCS, 36%) or diet (n=8 CCS, 7%). A total of 4 (3%) CCS, although interested in counseling, received no advice, as they already met the recommendations. Follow-up revealed high adherence to recommendations and successful integration into daily lives. In total, 97% (n=150) of survivors indicated that the provision of lifestyle counseling during LTFU would be generally beneficial.

Conclusions

Incorporating specialized health care professionals such as sports scientists into survivorship care enhances the multidisciplinary approach of LTFU care. Promoting a healthy lifestyle by offering guideline-based lifestyle counseling is broadly accepted among CCS and may reduce long-term morbidity.

A Systematic Review of the Characteristics and Effects of Physical Activity Interventions on Physical Activity Engagement, Long-Term and Late Effects, and Quality of Life in Adolescent and Young Adult Cancer Survivors

Physical activity (PA) may minimize long-term and late effects experienced by cancer survivors. However, the efficacy of PA interventions in increasing PA engagement among adolescent and young adult (AYA) cancer survivors diagnosed between 15 and 39 is not well understood. This systematic review aimed to examine the effects of moderate- to high-intensity or strength training PA interventions on PA engagement in AYA cancer survivors. Secondary aims included describing intervention components unique to efficacious interventions, identifying symptom management in PA interventions, and evaluating intervention effects on quality of life (QoL), and long-term or late effects of cancer. We searched PubMed, CINAHL, PsycINFO, SportDiscus, Cochrane Library, and Scopus databases from inception to August 2022 and identified 12 articles, including 8 randomized controlled trials and 4 quasi-experimental studies. The effect of PA interventions on PA engagement was mixed, with four studies reporting increases in PA engagement ranging from 18.4 to 113.8 min/week postintervention. There was great diversity in PA intervention components. Motivational interviewing, supervised and unsupervised PA sessions together, moderate-intensity PA only, and mindful meditation were components unique to efficacious interventions. No intervention incorporated symptom management components. Studies provided some evidence of PA interventions on potential long-term effects of cancer, with positive impact on fatigue, and some evidence of improved anxiety, sleep, and QoL. Given limited research with AYA cancer survivors, additional research is needed to identify effective intervention components, integrate symptom management strategies into PA interventions, and track effects of PA interventions on late and long-term effects of cancer in this population.

The experiences of children and adolescents with cancer returning to school: A qualitative meta-synthesis

BACKGROUND

Returning to school can be challenging for children and adolescents with cancer who have been absent for a long time. As there is little known about the return to school experience of children and adolescents with cancer, this meta-synthesis aimed to describe the experiences of children and adolescent cancer patients as they return to school.

METHODS

Seven English databases and three Chinese databases were searched from inception to March 14, 2023. The Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI-QARI) was used to appraise study quality. Data were synthesized using the Thomas and Harden thematic and content analysis method.

RESULTS

Twelve qualitative studies met the inclusion criteria and were analyzed into meta-synthesis. Data synthesis led to constructing four analytical themes and twelve sub-themes. The four major themes constructed were:benefits to school re-entry, barriers to school re-entry, motivators to school re-entry and the adaptation process after returning to school.

CONCLUSION

Children and adolescents with cancer were willing to return to education and can adapt to school life over time. But they were faced with challenges, including physical, psychological, and social barriers. Appropriate measures need to be taken to reduce those barriers.

IMPLICATIONS TO PRACTICE

Findings can be used to inform future research and interventions to support a successful return to education for children and adolescents with cancer. Healthcare providers should address the needs of children and adolescents at different stages and actively work with schools, hospitals and families to help childhood cancer survivors successfully return to school.

Adolescent Cancer Survivors and Their Parents' Experiences With the Transition Off Treatment to Survivorship: A Qualitative Interview Study

Background: Transitioning from active cancer treatment to survivorship represents a vulnerable yet underresearched phase for adolescents and their families. Knowledge of their support needs, the challenges they experience, and how they manage them are useful to inform tailored follow-up care. Thus, we aimed to explore their transition experiences. Method: We interviewed 15 adolescents (12-19 years) who had transitioned off of treatment 1 to 47 months prior at Oslo University Hospital's Department of Paediatric Haematology and Oncology and their biological parents (n = 16). The interviews were analyzed using inductive, reflexive thematic analysis inspired by Braun and Clarke. NVivo-12 was used for data management. Results: Four main themes were identified: (a) consequences of cancer beyond transition, (b) transition back to normalcy, (c) survivorship competence, and (d) changes in roles and relationships. The families described happiness and relief but also said that the lingering effects of cancer treatment had a profound impact on day-to-day living. The adolescents expressed closeness with and dependency on their parents, and they perceived family and friends as essential for social readjustment. Discussion: Although adolescent survivors and their parents described a wide variety of strategies for returning to "normalcy," their perspectives also illustrate ongoing psychosocial and educational support needs that changed over time. Our findings indicate a need for improved preparation for and support through the transition. Nurses are well positioned to provide continuous and structured transition support tailored to the needs of the individual survivors and their families.

A Multimodal Lifestyle Psychosocial Survivorship Program in Young Cancer Survivors: The CARE for CAYA Program-A Randomized Clinical Trial Embedded in a Longitudinal Cohort Study

Importance

There is a lack of trials examining the effect of counseling interventions for child, adolescent, and younger adult (CAYA) cancer survivors.

Objective

To assess lifestyle habits and the psychosocial situation of CAYAs to determine the efficacy of needs-based interventions in the CARE for CAYA program (CFC-P).

Design, Setting, and Participants

The CFC-P was conducted as a multicenter program in 14 German outpatient clinics, mainly university cancer centers. Recruitment began January 1, 2018; a randomized clinical trial was conducted until July 15, 2019; and intervention was continued as a longitudinal cohort study until March 31, 2021. Data preparation was conducted from April 1, 2021, and analysis was conducted from August 14, 2021, to May 31, 2022. Herein, predefined confirmatory analyses pertain to the RCT and descriptive results relate to the overall longitudinal study. Data analysis was based on the full analysis set, which is as close as possible to the intention-to-treat principle.

Intervention

A comprehensive assessment determined needs in physical activity, nutrition and psychooncology. Those with high needs participated in 1 to 3 modules. In the RCT, the IG received 5 counseling sessions plus newsletters, while the control group CG received 1 counseling session.

Main Outcomes and Measures

The primary outcome was the change in the rate of CAYAs with high needs at 52 weeks. Secondary outcomes were feasibility, modular-specific end points, satisfaction, quality of life, and fatigue.

Results

Of 1502 approached CAYAs aged 15 to 39 years, 692 declined participation. Another 22 CAYAs were excluded, resulting in 788 participants. In the randomized clinical trial, 359 CAYAs were randomized (intervention group [IG], n = 183; control group [CG], n = 176), and 274 were followed up. In the RCT, the median age was 25.0 (IQR, 19.9-32.2) years; 226 were female (63.0%) and 133 male (37.0%). After 52 weeks, 120 CAYAs (87.0%) in the IG and 115 (86.5%) in the CG still had a high need in at least 1 module (odds ratio, 1.04; 95% CI, 0.51-2.11; P = .91). Both groups reported reduced needs, improved quality of life, reduced fatigue, and high satisfaction with the CFC-P.

Conclusions and Relevance

In this randomized clinical trial, the implementation of a lifestyle program in this cohort was deemed necessary, despite not meeting the primary outcome. The interventions did not alter the rate of high needs. The results may provide guidance for the development of multimodal interventions in the follow-up care of CAYAs.

Trial Registration

German Clinical Trial Register: DRKS00012504.

Innovative strategies to predict and prevent the risk for malnutrition in child, adolescent, and young adult cancer survivors

Children, adolescents, and young adult cancer survivors (CAYAs) constitute a growing population requiring a customized approach to mitigate the incidence of severe complications throughout their lifetimes. During cancer treatment, CAYAs cancer survivors undergo significant disruptions in their nutritional status, elevating the risks of mortality, morbidity, and cardiovascular events. The assessment of nutritional status during cancer treatment involves anthropometric and dietary evaluations, emphasizing the necessity for regular assessments and the timely identification of risk factors. Proactive nutritional interventions, addressing both undernutrition and overnutrition, should be tailored to specific age groups and incorporate a family-centered approach. Despite encouraging interventions, a notable evidence gap persists. The goal of this review is to comprehensively examine the existing evidence on potential nutritional interventions for CAYAs cancer survivors. We explore the evidence so far collected on the nutritional intervention strategies elaborated for CAYAs cancer survivors that should target both undernutrition and overnutrition, being age-specific and involving a family-based approach. Furthermore, we suggest harnessing artificial intelligence (AI) to anticipate and prevent malnutrition in CAYAs cancer survivors, contributing to the identification of novel risk factors and promoting proactive, personalized healthcare.

Development of Quality of Life in Adolescents and Young Adults With Cancer Using a Patient Support Smartphone App: Prepost Interventional Study

BACKGROUND

Adolescents and young adults often experience existential concerns in addition to side effects during a cancer trajectory, which they often carry alone. Thus, cohesion with other adolescents and young adults with cancer is essential but difficult due to the relatively small, widely dispersed nationwide population. In cocreation, a smartphone app has been developed and includes an information bank, a symptom tracker, and a social community platform, aiming to improve the quality of life (QoL) in this patient group.

OBJECTIVE

This nationwide, multicenter study aimed to investigate the QoL in adolescents and young adults undergoing a cancer trajectory as they used the app for 6 weeks.

METHODS

Via youth support initiatives, participants were recruited from hospitals in all regions of Denmark. Inclusion criteria were patients with cancer aged 15-29 years who either initiated any cancer treatment or started follow-up after cancer treatment within 30 days. Participants used the adolescents and young adults cancer app for 6 weeks. Before and after the 6 weeks of app use, they completed the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30). The participants were divided into a treatment and a follow-up group for analysis. A high score for a functional scale or the global health or overall QoL represents a high or healthy level of functioning or high QoL, respectively; however, a high score for a symptom scale or item represents a high level of symptomatology.

RESULTS

Overall, 81 participants were recruited. However, 4 participants did not answer the questionnaire and 6 participants did not use the app. In the treatment group (n=36), significant improvement was found in 2 domains: "Role functioning" (baseline median 33.33, IQR 16.67-83.33 vs 6 weeks median 66.67, IQR 33.33-83.33; P=.04) and "Pain" (baseline median 33.33, IQR 16.67-50.00 vs 6 weeks median 16.67, IQR 0.00-33.33; P=.04). The "Global health/Overall QoL" scale remained stable (baseline median 58.33, IQR 45.83-77.08 vs 6 weeks median 62.50, IQR 41.67-75.00; P=.25). In the follow-up group (n=35), significant improvement was found in 3 domains: "Physical functioning" (baseline median 79.23, IQR 73.33-93.33 vs 6 weeks median 82.86, IQR 73.33-100.00; P=.03), "Cognitive functioning" (baseline median 62.38, IQR 50.00-83.33 vs 6 weeks median 69.52, IQR 50.00-100.00; P=.02), and "Social functioning" (baseline median 76.19, IQR 50.00-100.00 vs 6 weeks median 85.71, IQR 83.33-100.00; P=.05), as well as in the "Global health/Overall QoL" scale (baseline median 57.14, IQR 83.33-100.00 vs 6 weeks median 75.0, IQR 62.91-85.73; P<.001).

CONCLUSIONS

In this study, we found an improvement in specific QoL scales for both participants in treatment and follow-up when using the app for 6 weeks. The global health or overall QoL score improved significantly in the follow-up group. In the treatment group, it remained stable.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/10098.

Optimizing clinical nutrition research: the role of adaptive and pragmatic trials

Evidence-based nutritional recommendations address the health impact of suboptimal nutritional status. Efficacy randomized controlled trials (RCTs) have traditionally been the preferred method for determining the effects of nutritional interventions on health outcomes. Nevertheless, obtaining a holistic understanding of intervention efficacy and effectiveness in real-world settings is stymied by inherent constraints of efficacy RCTs. These limitations are further compounded by the complexity of nutritional interventions and the intricacies of the clinical context. Herein, we explore the advantages and limitations of alternative study designs (e.g., adaptive and pragmatic trials), which can be incorporated into RCTs to optimize the efficacy or effectiveness of interventions in clinical nutrition research. Efficacy RCTs often lack external validity due to their fixed design and restrictive eligibility criteria, leading to efficacy-effectiveness and evidence-practice gaps. Adaptive trials improve the evaluation of nutritional intervention efficacy through planned study modifications, such as recalculating sample sizes or discontinuing a study arm. Pragmatic trials are embedded within clinical practice or conducted in settings that resemble standard of care, enabling a more comprehensive assessment of intervention effectiveness. Pragmatic trials often rely on patient-oriented primary outcomes, acquire outcome data from electronic health records, and employ broader eligibility criteria. Consequently, adaptive and pragmatic trials facilitate the prompt implementation of evidence-based nutritional recommendations into clinical practice. Recognizing the limitations of efficacy RCTs and the potential advantages of alternative trial designs is essential for bridging efficacy-effectiveness and evidence-practice gaps. Ultimately, this awareness will lead to a greater number of patients benefiting from evidence-based nutritional recommendations.

Effect of a 1-year physical activity intervention on cardiovascular health in long-term childhood cancer survivors-a randomised controlled trial (SURfit)

BACKGROUND

This randomised controlled trial (RCT) assessed the effect of a 1-year, partially supervised, physical activity (PA) intervention on a cardiovascular disease (CVD) risk score in adult survivors of childhood cancer.

METHODS

We included childhood cancer survivors ≥16 y at enrolment, <16 y at diagnosis and ≥5 y in remission. The intervention group was asked to perform an additional ≥2.5 h of intense physical activity/week, controls continued exercise as usual; assessments were performed at baseline, 6 months (T6) and 12 months (T12). The primary endpoint was change in a CVD risk score (average z-score of waist circumference, blood pressure, fasting glucose, inverted high-density lipoprotein cholesterol, triglycerides, and inverted cardiorespiratory fitness) from baseline to T12. We performed intention-to-treat (ITT, primary) and 3 per protocol analyses.

RESULTS

We randomised 151 survivors (44% females, 30.4 ± 8.6 years). We found a significant and robust reduction of the CVD risk score in the intervention compared to the control group at T6 and T12 across all analyses; with a difference in the reduction of the CVD risk z-score of -0.18 (95% confidence interval -0.29 to -0.06, P = 0.003) at T12 in favour of the intervention group (ITT analysis).

CONCLUSIONS

This RCT showed that a long-term PA intervention can reduce CVD risk in long-term survivors of childhood cancer.

TRIAL REGISTRATION

Clinicaltrials.gov: NCT02730767.

Frailty and comorbidities among young adult cancer survivors enrolled in an mHealth physical activity intervention trial

PURPOSE

The physical frailty phenotype identifies individuals at risk for adverse health outcomes but has rarely been assessed among young adult cancer survivors (YACS). This study describes frailty status among YACS participating in a physical activity (PA) intervention trial.

METHODS

YACS were categorized at baseline using the 5-item FRAIL scale: fatigue; weight loss; illness; ambulation; resistance. Chi-square tests compared frailty and non-cancer comorbidities by characteristics. Prevalence rates (PRs) for the independent associations between characteristics, frailty, and comorbidities were estimated using modified Poisson regression models.

RESULTS

Among 280 YACS (82% female; mean (M) age = 33.4 ± 4.8 years, M=3.7 ± 2.4 years post-diagnosis), 11% frail, 17% prefrail; the most frequent criteria were fatigue (41%), resistance (38%), and ambulation (14%). Compared to BMI < 25, higher BMI was associated with increased likelihood of frailty (BMI 25-30, PR: 2.40, 95% CI: 1.38-4.17; BMI > 30, PR: 2.95, 95% CI: 1.71-5.08). Compared to 0, ≥ 30 min/week of moderate-to-vigorous PA was associated with reduced frailty (PR: 0.39, 95% CI: 0.25-0.60). Most YACS (55%) reported ≥ 1 comorbidity, most frequently depression (38%), thyroid condition (19%), and hypertension (10%). Comorbidities were more common for women (59% vs. 37%) and current/former smokers (PR: 1.71, 95% CI: 1.29-2.28).

CONCLUSION

Prevalence of frailty and comorbidities in this sample was similar to other YACS cohorts and older adults without cancer and may be an indicator of accelerated aging and increased risk for poor outcomes.

IMPLICATIONS FOR CANCER SURVIVORS

Assessment of frailty may help identify YACS at increased risk for adverse health outcomes.

Frailty and Comorbidities Among Young Adult Cancer Survivors Enrolled in an mHealth Physical Activity Intervention Trial

Purpose: The physical frailty phenotype identifies individuals at risk for adverse health outcomes but has rarely been assessed among young adult cancer survivors (YACS). This study describes frailty status among YACS participating in a PA intervention trial. Methods: YACS were categorized by frailty status at baseline using the 5-item FRAIL index: fatigue; weight loss; illness; ambulation; resistance. Chi-square tests compared frailty and comorbidities by characteristics. Prevalence rates (PRs) for the independent associations between characteristics, frailty, and comorbidities were estimated using modified Poisson regression models. Results: Among 280 YACS (82% female, M=33.4±4.8 years, M=3.7±2.4 years post-diagnosis), 14% had frailty, and 24% prefrailty; the most frequent criteria were fatigue (70%), resistance (38%), and ambulation (14%). Compared to BMI <25, higher BMI (BMI 25-30, PR: 1.65, 95% CI: 1.02-2.65; BMI > 30, PR: 2.36, 95% CI: 1.46-3.81) was associated with increased frailty status. Compared to 0, 1-50 minutes/week of moderate-to-vigorous PA was associated with reduced frailty (PR: 0.62, 95% CI: 0.43-0.90). Most YACS (55%) reported > 1 comorbidity, most frequently depression (38%), thyroid condition (19%), and hypertension (10%). Men were less likely to report comorbidities (PR: 0.63, 95% CI: 0.42-0.93). Current/former smokers (PR: 1.29, 95% CI: 1.01-1.64) were more likely to have comorbidities. Conclusion: Prevalence of frailty and comorbidities in this sample was similar to other YACS cohorts and may be an indicator of accelerated aging and increased risk for poor outcomes. Implications for Cancer Survivors: Assessment of frailty may help identify YACS at risk for adverse health outcomes.

Changes, challenges and support in work, education and finances of adolescent and young adult (AYA) cancer survivors: A qualitative study

PURPOSE

An increasing number of adolescents and young adults (AYA) are becoming cancer survivors and are dealing with long-term effects of the disease and its treatment. We aimed to collect detailed self-reported information about the areas of work, education, and the financial situation of AYA survivors after acute treatment. We further examined sources of support that were perceived as particular helpful.

METHOD

We conducted semi-structured interviews with a sample of 11 AYA cancer survivors (on average 5 years from diagnosis; mean age at diagnosis = 25.7 years) that had been recruited for the AYA-Leipzig longitudinal study. Interviews were transcribed and data were analysed using qualitative content analysis.

RESULTS

The following themes emerged as relevant: (1) career modifications and job loss, (2) career interruptions and delays, (3) uncertainty in the return-to-work process, (4) reduced work ability, (5) discrimination at the workplace, (6) changes in the personal importance of work and (7) financial burdens. Sources of considerable support included relatives as well as German social security institutions.

CONCLUSIONS

Health care providers should address the specific risk of a financial burden and the somewhat complex social legal situation of young adult survivors after cancer diagnosis. AYA cancer survivors need age-specific comprehensive cancer survivorship support programs. These should accompany them in the long term and be targeted to the individual need for career modification or reorientation - even after the completion of cancer treatment and rehabilitation.

The gap between expectations and reality: A qualitative study of psychosocial challenges of young childhood cancer survivors from the PACCS study

OBJECTIVE

In this sub-study from the 'PACCS' study, we explored the psychosocial experiences of children and adolescents in everyday life post-cancer treatment and the possible factors that can moderate these experiences.

METHODS

This is a qualitative explorative study using semi-structured interviews with 43 childhood cancer survivors between the ages of nine and 18 from Norway and Denmark. We conducted a secondary thematic analysis using Malterud's systematic text condensation.

RESULTS

Two main themes were identified: 'The post-treatment gap between expectations and reality' comprised two subthemes: (1) lack of mastery and feeling different and (2) lack of understanding and acceptance. The second main theme, 'Managing the gap', comprised three subthemes: (1) information and knowledge, (2) adjustments and adaptions and (3) social support and openness. The findings reveal that the psychosocial challenges resulted from the remaining ability gap(s). Measures such as tailored information, school adjustments and social support were potential dynamic factors affecting the gap(s) positively or negatively. Psychosocial challenges post-treatment are experiences of lack of acceptance and understanding from others.

CONCLUSION

To safeguard a positive transition back to everyday life, health care providers should support the survivors' psychosocial care, including getting back to school and re-entering social interactions.

Obstetric and perinatal outcomes in female survivors of childhood or adolescent cancer: Protocol of a meta-analysis of population-based cohort studies

Introduction

Approximately 80% of children, adolescents and young adults (CAYA) cancer patients are expected to fully recover and survive for five years or more. The reproductive health is a particular area of their concern. Evidence demonstrates that previous therapeutic treatments for cancer and comorbidities may have harmful effects on female fertility and delivery outcomes, which will significantly affect patient quality of life. However, these reports are heterogeneous. Therefore, the purpose of this study is to provide the up-to-date evidence on the risk of adverse obstetric and perinatal outcomes in female survivors of childhood or adolescent cancer.

Methods and analysis

This meta-analysis will be carried out and reported with adherence to the Meta-Analysis of Observational Studies in Epidemiology (MOOSE) guidelines and the Cochrane Handbook. We will search online databases including PubMed, Cochrane Library, and Embase from inception to August, 2022 to identify all relevant cohort studies examining the relationship between cancer and subsequent obstetric and perinatal outcomes. Data extraction from eligible studies will be conducted and crosschecked separately by two investigators using pre-tested standardized data extraction forms. Discrepancies will be resolved via a third investigator. Methodological quality assessment for each study will be conducted using the Newcastle–Ottawa scale (NOS) tool. We will apply the DerSimonian-Laird random-effects model to calculate the pooled estimates. Further sources of heterogeneity will be explored by performing subgroup analysis based on multiple study characteristics. Potential publication bias will be assessed by inspection of a funnel plot, Begg’s and Egger’s regression tests of funnel plot asymmetry.

Ethics and dissemination

Ethical approval will not be required as all data used for this pooled analysis will be obtained from published cohort studies. The results of this study will be disseminated in a peer-reviewed journal and conference presentation.

OSF registration number

DOI 10.17605/OSF.IO/K6QBG.

[Long-term survival in cancer: definitions, concepts, and design principles of survivorship programs]

Aufgrund von diagnostischen und therapeutischen Fortschritten in der Hämatologie und Onkologie und entsprechend steigenden Überlebensaussichten ist ein stetiger Zuwachs der Gruppe von Langzeitüberlebenden mit und nach Krebs (Cancer Survivor) in Deutschland zu verzeichnen. Obwohl das bereits vorhandene deutsche Gesundheitswesen vielfältige Versorgungsangebote vorhält, die auch für Langzeitüberlebende verfügbar sind, ist die Versorgungssituation dieser Gruppe nicht zufriedenstellend. So bedarf es zum einen der Entwicklung von Orientierungshilfen für Langzeitüberlebende, zum anderen sollten neue und innovative Versorgungsprogramme für Überlebende (Survivorship-Programme) entwickelt werden. Der Beitrag gibt einen Überblick über die Problematik, definiert relevante Begrifflichkeiten und formuliert Kernaspekte für die Ausgestaltung von Survivorship-Programmen für Langzeitüberlebende nach Krebserkrankung.

A visual model for prognostic estimation in patients with primary diffuse large B-cell lymphoma of small intestine and colon: analysis of 1,613 cases from the SEER database

BACKGROUND

Treatment modalities for primary diffuse large B-cell lymphoma of Small intestine and colon (PIC-DLBCL) have changed significantly during the past decades. However, limited information on the trends of clinical outcome of PIC-DLBCL patients has been reported, and the influence of marital status and medical insurance on prognosis is ignored.

METHODS

This was a retrospective analysis the survival of PIC-DLBCL patients using the Surveillance, Epidemiology, and End Results (SEER) database between 2002 and 2016. The patients were divided into the training and validation cohort. In the training cohort, univariate and multivariable Cox regression analysis, Log-rank test and the Kaplan-Meier method were used to find out the independent prognostic factors, from which the visual prognostic model (nomogram and graphical web page) was established. C-index and calibration plots were used to evaluate the prediction accuracy of the model. In the validation cohort, both Decision curve analysis (DCA) and Receiver operating characteristic (ROC) curve was performed to compare the model with the International Prognostic Index (IPI) scoring model which is universally used to estimate prognosis of PIC-DLBCL.

RESULTS

A total of 1,613 patients were collected, and the 5-year overall survival of all cases was 64.5%. Age at diagnosis (HR =2.58, 95% CI: 2.29-2.91), Ann Arbo stage (HR =1.34, 95% CI: 1.24-1.44), Divorced or Separated (HR=1.21, 95% CI: 1.06-1.38), Uninsured (HR =1.32, 95% CI: 1.19-1.45) and Primary colon (HR =1.23, 95% CI: 1.08-1.40) were associated with prognosis and were used to build up the visual model (nomogram and graphical web page). Both DCA and ROC curve showed that the model had better authentication capability than the IPI scoring model (AUC 0.820 vs. 0.714). The calibration plots showed that the model could accurately predict patient prognosis.

CONCLUSIONS

The visual model could output individual estimate prognosis simply and correctly, including marital status and medical insurance for the first time. Consideration of both medical and social factors, this study provided a new way to explore the improving prognosis of PIC-DLBCL.

Cardiotoxicity in pediatric lymphoma survivors

INTRODUCTION

Over the past five decades, the diagnosis and management of children with various malignancies have improved tremendously. As a result, an increasing number of children are long-term cancer survivors. With improved survival, however, has come an increased risk of treatment-related cardiovascular complications that can appear decades later.

AREAS COVERED

This review discusses the pathophysiology, epidemiology and effects of treatment-related cardiovascular complications from anthracyclines and radiotherapy in pediatric lymphoma survivors. There is a paucity of evidence-based recommendations for screening for and treatment of cancer therapy-induced cardiovascular complications. We discuss current preventive measures and strategies for their treatment.

EXPERT OPINION

Significant cardiac adverse effects occur due to radiation and chemotherapy received by patients treated for lymphoma. Higher lifetime cumulative doses, female sex, longer follow-up, younger age, and preexisting cardiovascular disease are associated with a higher incidence of cardiotoxicity. With deeper understanding of the mechanisms of these adverse cardiac effects and identification of driver mutations causing these effects, personalized cancer therapy to limit cardiotoxic effects while ensuring an adequate anti-neoplastic effect would be ideal. In the meantime, expanding the use of cardioprotective agents with the best evidence such as dexrazoxane should be encouraged and further studied.

Does allogeneic stem cell transplantation in survivors of pediatric leukemia impact regular physical activity, pulmonary function, and exercise capacity?

BACKGROUND

Allogeneic hematopoietic stem cell transplantation (allo-HSCT) has improved survival in high-risk childhood leukemia but is associated with long-term sequelae such as impaired pulmonary function and reduced exercise capacity impacting quality of life.

METHODS

A convenience sample of 17 patients after allo-HSCT (HSCT-12 male, age 15.7±6.7 years, time after HSCT 5.3±2.8 years) underwent pulmonary function testing, echocardiography, and an incremental exercise test on a bike. Physical activity and health-related quality of life were assessed by questionnaires (7-day physical activity recall, PEDS-QL). Seventeen healthy age- and gender-matched controls served as control group (CG) for results of pulmonary function and exercise testing.

RESULTS

HSCT showed reduced pulmonary function (HSCT vs. CG: FEV1 90.5±14.0 vs. 108.0±8.7%pred; FVC 88.4±19.3 vs. 107.6±6.9%pred, DLCO 75.3±23.6 vs. 104.9±12.8%pred) and exercise capacity (VO₂peak 89±30.8%pred, CG 98±17.5%pred; Wmax 84±21.7%pred, CG 115±22.8%pred), but no relevant cardiac dysfunction and a good quality of life (PEDS-QL mean overall score 83.3±10.7). Differences in peak oxygen uptake between groups were mostly explained by 5 adolescent patients who underwent total body irradiation for conditioning. They showed significantly reduced diffusion capacity and reduced peak oxygen uptake. Patients reported a mean time of inactivity of 777±159min/day, moderate activity of 110±107 min/day, hard activity of 35±36 min/day, and very hard activity of 23±22 min/day. A higher amount of inactivity was associated with a lower peak oxygen uptake (correlation coefficient tau -0.48, p=0.023).

CONCLUSIONS

This pilot study shows that although patients after allo-HSCT reported a good quality of life, regular physical activity and exercise capacity are reduced in survivors of stem cell transplantation, especially in adolescents who are treated with total body irradiation for conditioning. Factors hindering regular physical activity need to be identified and exercise counseling should be part of follow-up visits in these patients.

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.

"I have to do things differently now, but I make it work"-young childhood cancer survivors' experiences of self-management in everyday living

PURPOSE

Living with late effects can affect young childhood cancer survivors' (CCSs) self-management (SM) abilities. In this study, we explored different approaches to SM of everyday life by young CCS.

METHODS

This is a sub-study of a larger study on Physical Activity among Childhood Cancer Survivors (the PACCS study). We conducted individual interviews with 22 CCS aged 9 to 18 years who were at least 1 year off-treatment. An hybrid inductive-decductive thematic analysis was used.

RESULTS

Three main themes were identified: (1) managing everyday life with fatigue, (2) building self-management competence, and (3) cancer survivor as part of identity. Late effects, especially fatigue, contributed to a perceived ability gap compared to peers, limiting participation in everyday activities. CCS developed new SM skills to overcome such challenges and pushed themselves physically and mentally to master and balance activities and rest to regain energy. CCS changed activities, adapted their expectations, or legitimized their apparent lack of SM skills to regain a sense of self-efficacy. Managing the impact of cancer on relationships with family and friends also required use of SM strategies.

CONCLUSIONS

The findings expand our currently limited knowledge of young CCS and SM skills they develop to manage everyday life after treatment completion. These, combined with ongoing support from family and peers, "make it work".

IMPLICATIONS FOR CANCER SURVIVORS

The perspectives of young CCS illustrate their SM skills and support needs beyond transitioning off-treatment. Conceptualizing this within follow-up care may contribute to a feeling of mastery and increased satisfaction among CCS.

Effects of a structured counselling-based intervention to improve physical activity behaviour of adolescents and young adult cancer survivors - the randomized phase II Motivate AYA - MAYA trial

Objective:

To explore whether a structured counselling-based intervention increases vigorous physical activity behaviour of adolescent and young adult cancer survivors.

Design:

Randomized controlled phase II trial.

Setting:

University Cancer Center Hamburg, Germany.

Subjects:

Eighty-nine participants (mean age 24.1 ± 6.3) were randomized to control (n = 44) or intervention group (n = 45).

Interventions:

The intervention group was consulted about physical activity behaviour via interview (week 0), and telephone counselling (weeks 1, 3 and 12). The control group only received general physical activity guidelines for cancer survivors (week 0).

Main measures:

The primary outcome was the rate of participants with ⩾9 metabolic equivalent (MET)-hours per week of vigorous activity post-intervention, measured with the International Physical Activity Questionnaire. Secondary outcomes included assessing physical activity behaviour (e.g. amount and type of physical activity) and quality of life. Assessments were completed in weeks 0 (baseline), 12 (post-intervention) and 52 (follow-up).

Results:

Sixty-nine participants completed the post-intervention- and 47 the follow-up-assessment. The rate of participants performing vigorous physical activity increased from baseline to post-intervention for both without differing significantly (P = 0.541). Both increased their total metabolic equivalent from baseline to post-intervention (intervention group from 55.2 ± 43.7 to 61.7 ± 29.4, control group from 75.3 ± 81.4 to 88.3 ± 80.2). At follow-up the intervention group (73.7 ± 80.2) was more active than baseline when compared to the control group (78.5 ± 50.0).

Conclusions:

A structured counselling-based physical activity intervention did not significantly impact the level of vigorous physical activity behaviour in adolescent and young adult cancer survivors.

Long-Term Follow-Up of Children, Adolescents, and Young Adult Cancer Survivors

Background and Summary: Thanks to increasing cure rates to currently >80%, children, adolescents, and young adults (CAYA) survive their cancer much more frequently today than decades ago. Due to their long life expectancy, CAYA cancer survivors are at a particular risk of long-term sequelae from the cancer itself or the therapy applied; this requires specific follow-up, and preventative or even therapeutic interventions. Thus, compared to the normal population, morbidity and mortality may be significantly increased. In 2 of 3 survivors, the cancer and the respective treatment can lead to late effects, even after 30 years, which require specific therapy; in about one-third of these cases, these effects are classed as severe. Applying structured follow-up could identify these late effects at an early stage and initiate immediate treatment. In 2018, a working group dealing with long-term survival after cancer detected <40 years of age was founded within the framework of the National Cancer Plan of the German Federal Ministry of Health.