Obesity in survivors of childhood acute lymphoblastic leukemia and lymphoma

Metabolic/endocrine disorders in survivors of childhood-onset and cranial radiotherapy- treated ALL/NHL: a meta-analysis

BACKGROUND

Cranial radiotherapy (CRT) is recommended to high-risk pediatric patients with acute lymphoblastic leukemia or aggressive non-Hodgkin's lymphoma (ALL/NHL). However, effects of CRT treatment on the development of metabolic/endocrine disorders remain unclear. This meta-analysis aimed to identify metabolic and endocrine disturbances in survivors of childhood-onset and CRT-treated ALL/NHL.

METHODS

Different online databases were searched using restricted search fields. Follow-up data and outcome measurements, including the prevalence of growth hormone (GH) deficiency, hypothyroidism, vitamin D deficiency, overweight/obesity, and hypogonadism were recorded. The height data was indicated by height-standard deviation score (height-SDS). Statistical estimates such as odds ratio (OR) and weighted standard mean difference (SMD) were compared between additional CRT treatment group and non-CRT treatment group. Study-to-study heterogeneity was calculated by calculating I-squared statistic, and fixed/random effect was applied to synthesize and analyze extracted data.

RESULTS

Fifteen studies were included (4269 patients in total). Adult height SDS was lower in CRT-treated patients (pooled SMD = -0.581, 95% CI: -0.649--0.512), and CRT-treated patients were likely to develop short stature (pooled OR = 2.289, 95% CI:1.674-3.130). Regardless of the study year, which potentially reflects the state-of-the-art CRT technique, the prevalence of short stature and GH deficiency was time-independent. Additionally, previous CRT can increase the risk of precocious puberty (pooled OR = 2.937, 95% CI: 1.281-6.736), hypothyroidism (pooled OR = 2.057, 95% CI:1.510-2.801), and hypogonadism (pooled OR = 3.098, 95% CI:2.521-3.807). However, the risk of being overweight/obese was similar between the patients with and without CRT (pooled OR = 1.278, 95% CI: 0.675-2.421).

CONCLUSION

Childhood-onset and CRT-treated ALL/NHL survivors are likely to have shorter height, precocious puberty, hypothyroidism, and hypogonadism.

Weight status in survivors of childhood acute lymphocytic leukemia in South Korea: a retrospective descriptive study

PURPOSE

This study investigated weight status in survivors of childhood acute lymphocytic leukemia (ALL) and identified related factors.

METHODS

A retrospective review of the electronic medical records of survivors of childhood ALL (n=230) was conducted. We analyzed the survivors' characteristics, including sex, age, weight status at diagnosis, central nervous system involvement, risk classification, length of treatment, radiation therapy, and hematopoietic stem cell transplantation. Analysis of variance and the chi-squared test were applied to investigate influencing factors.

RESULTS

The weight status distribution was as follows: 23 individuals (10.0%) were classified as underweight, 151 individuals (65.7%) were healthy weight, and 56 individuals (24.3%) were overweight/obese. Age at diagnosis (F=10.03, p<.001), weight status at diagnosis (x2=43.41, p<.001), and risk classification (F=10.98, p=0.027) showed significant differences among the weight status groups. Survivors who were older at diagnosis and those in the very high-risk category had a higher likelihood of experiencing underweight status during their survivorship, while survivors who were overweight/obese at diagnosis were more likely to remain overweight/obese at the time of survival.

CONCLUSION

Considering the potential health implications related to an unhealthy weight status in survivors of ALL, it is imperative to undertake early identification and implement interventions for at-risk individuals.

Body mass trajectory from diagnosis to the end of treatment in a pediatric acute lymphoblastic leukemia cohort

The advances in pediatric acute lymphoblastic leukemia (ALL) care have substantially increased survival, and the late effects of treatment are a growing concern. Obesity development is frequent following ALL therapy and may significantly contribute to long-term morbidity and mortality. We examined the body mass trajectory of 208 children with ALL, from the diagnosis to the completion of therapy. We found that 7.2% of children were overweight or obese at diagnosis, which increased to 19.7% at the end of induction therapy and 20.8% after completion of treatment. In a multivariable linear regression model, age at ALL diagnosis, the type of chemotherapy regimen, and body mass index (BMI) z-score at diagnosis were significant predictors of BMI z-score after induction therapy, whereas BMI z-score at diagnosis was the only significant predictor of BMI z-score at the completion of treatment. In a subgroup of 120 children, we found no association between nutrition status at diagnosis and the risk of ALL relapse or poorer overall survival. Our findings indicate that weight gain occurs early during ALL therapy and is predicted by weight status at diagnosis. Therefore, nutritional status should be assessed throughout treatment, and weight management interventions should be considered early, particularly for patients with higher weight at diagnosis.

Genetic risk score enhances the risk prediction of severe obesity in adult survivors of childhood cancer

Adult survivors of childhood cancer have high rates of obesity, which, in combination with the cardiotoxic effects of specific cancer therapies, places them at high risk for cardiovascular morbidity. Here we show the contribution of genetic risk scores (GRSs) to increase prediction of those survivors of childhood cancer who are at risk for severe obesity (body mass index ≥40 kg m^-2) as an adult. Among 2,548 individuals of European ancestry from the St. Jude Lifetime Cohort Study who were 5-year survivors of childhood cancer, the GRS was found to be associated with 53-fold-higher odds of severe obesity. Addition of GRSs to risk prediction models based on cancer treatment exposures and lifestyle factors significantly improved model prediction (area under the curve increased from 0.68 to 0.75, resulting in the identification of 4.3-times more high-risk survivors), which was independently validated in 6,064 individuals from the Childhood Cancer Survivor Study. Genetic predictors improve identification of patients who could benefit from heightened surveillance and interventions to mitigate the risk of severe obesity and associated cardio-metabolic complications.

Changes in body mass index, weight, and height in children with acute myeloid leukemia and the associations with outcome

Little is known about body composition changes in patients with acute myeloid leukemia (AML) during and after treatment or their associations with outcomes. Z-scores for body mass index (BMI), weight, and height at diagnosis, their longitudinal changes from diagnosis to 5 years off therapy, and their associations with adverse effects and outcomes were evaluated in 227 pediatric patients with AML enrolled in the AML02 and AML08 trials at St. Jude Children's Research Hospital between 2002-2017. The median Z-scores for baseline weight, height, and BMI were 0.193, 0.209, and 0.170, respectively, and those for weight and height decreased significantly during therapy to -0.038 and -0.163, respectively, at off-therapy (P < .001 for both). At 5 years off therapy, the Z-scores for weight and BMI had increased significantly to 0.492 (P = .003) and 0.911 (P < .001), respectively, whereas the height Z-score remained significantly lower at -0.066 (P < .001) compared with baseline. The height Z-score of transplant recipients decreased further from -0.211 at transplant to -0.617 12 months later (P < .001). Baseline BMI category and Z-score were not associated with outcomes, but higher weight Z-scores were associated with lower incidences of refractory or relapsed disease (hazard ratio [HR], 0.82; 95% confidence interval [CI], 0.67-0.99) and higher incidences of death in remission (HR, 1.31; 95% CI, 1.01-1.70). Furthermore, weight Z-score decrease during induction therapy was associated with gastrointestinal, hepatic, and infection toxicities during subsequent therapy and with death in remission (HR, 2.66; 95% CI, 1.11-6.45). Multidisciplinary monitoring for weight changes and short stature is required from diagnosis to the off-therapy period.

The triponderal mass index as a measure of adiposity in pediatric survivors of acute lymphoblastic leukemia: a cross-sectional study

Acute lymphoblastic leukemia (ALL) is the most common type of childhood cancer. Treatments of ALL predispose survivors to obesity, which increases the risk of cardiovascular disease and diabetes. The hallmark of obesity is excess fat mass, and adiposity is a superior predictor of cardiometabolic risk when compared to Body Mass Index (BMI), yet clinical measures of adiposity in children are lacking. The Tri-Ponderal Mass Index (TMI) (kg/m³) is a more accurate adiposity measure compared to BMI z-score in the general pediatric population. This cross-sectional study aimed to validate TMI as an adiposity measure against DEXA scan-derived adiposity, and to compare it to BMI z-score, in pediatric ALL survivors. This study was a retrospective chart review of pediatric ALL survivors diagnosed between 2004 and 2015 at McMaster Children’s Hospital, a tertiary pediatric center in Ontario, Canada. One hundred and thirteen patients (Female n = 55, 48.70%) were included, and adiposity was measured using DEXA scans. Exploratory partial correlations and linear regression analyses were adjusted for age, sex, ethnicity, and ALL risk status. Both TMI and BMI z-score correlated with the DEXA-measured fat mass percentage (FM%) (partial correlation TMI versus FM% r = 0.56; p value < 0.0001; BMI z-score versus FM% r = 0.55; p value < 0.0001). In regression analyses, the association of TMI was not inferior to BMI z-score in assessing adiposity (TMI versus FM% estimated unstandardized B 0.80, 95% CI 0.56, 1.02; p value < 0.0001; BMI z-score versus FM% (unstandardized B 0.37, 95% CI 0.26, 0.49; p value < 0.0001). The TMI is a useful clinical adiposity-specific measure in survivors of pediatric ALL.

Frequency of obesity and metabolic syndrome in childhood leukemia and lymphoma survivors

OBJECTIVES

In this study, it was aimed to determine the prevalence and clinical features of obesity and metabolic syndrome, which are long-term effects of survivors after treatment in children with leukemia and lymphoma.

PATIENTS AND METHODS

Patients with leukemia and lymphoma, who were diagnosed between 2000 and 2012 (at least 2 two years after remission) were included. Data obtained through reviewing the family history, demographic characteristics, anthropometric measurements, and laboratory parameters (blood glucose, lipid, and insulin levels) were analyzed and compared at the time of diagnosis, after the treatment and at time of the study.

RESULTS

Eighty nine patients (45 boys, 44 girls) were included (mean age: 14.7 ± 4.3 years): 77.5% had acute lymphoblastic leukemia, 11.2% had acute myeloid leukemia, and 11.2% had lymphoma. Overall, 46% patients had received radiotherapy, 7% had undergone surgery, and 2.2% had received stem cell transplantation in addition to chemotherapy. The mean duration of treatment was 2.4 years, and the time elapsed after treatment was 4.9 years. While only one had obesity at the diagnosis, a significant increase in obesity (20%), hypertension (15.7%), hyperglycemia (15%), insulin resistance (35%) were observed at the time of study, and family history of hypertension, dyslipidemia, and cardiovascular diseases were significantly higher in this subgroup.

CONCLUSION

The prevalence of metabolic syndorme is higher in children with leukemia and lymphoma after treatment, and begins to increase with the initiation of treatment and continues to increase over time. These children should be followed-up for late-effects including metabolic syndrome through life-long period.

Prevalence of Obesity/Abdominal Obesity and Related Factors in Pediatric ALL Survivors

OBJECTIVE

Obesity has been increasingly recognized in pediatric acute lymphoblastic leukemia (ALL) survivors. The aim of the current study was to determine the prevelance and related factors of obesity/abdominal obesity and evaluate the association between nutrition and overweight/obesity after cancer treatment in pediatric ALL survivors.

METHOD

An observational retrospective cohort study was performed among 67 volunteers (aged 5-15). Participants completed 3 consecutive days (2 weekdays and 1 weekend day) recording food consumption and physical activity simultaneously. Weight, height, and waist circumference measurements were performed in remission period, and retrospective data were obtained from patient records. We examined data at three periods: diagnosis, end of treatment, and remission. Subjects were classified into four groups according to body mass index for age z score (BAZ): underweight, normal weight, overweight, and obese. Abdominal obesity was defined waist-to-height ratio ≥ 0.5.

RESULTS

Prevalence of overweight, obesity, and abdominal obesity were 25.3%, 23.9%, 38.8%, respectively in remission. BAZ at diagnosis and at treatment completion, dietary energy intake, and physical activity were associated with an increased risk of being overweight/obese in remission (p < .05). Gender, age at diagnosis, cranial radiotherapy, and treatment risk category were not significant (p > .05).

CONCLUSIONS

As in obesity, abdominal obesity was found an important problem in pediatric ALL survivors. Therefore, nutritional targets are needed to prevent obesity. Survivors should be closely monitored in terms of nutritional status during and after treatment and informed about and supported for healthy lifestyle (balanced and adequate nutrition, increase in physical activity).

Adiposity in Survivors of Cancer in Childhood: How is it Measured and Why Does it Matter?

Survival of cancer in childhood is increasingly common with modern therapeutic protocols but leads frequently to adverse long-term impacts on health, including metabolic and cardiovascular disease. Changes in body composition, especially an increase in fat mass and a decrease in muscle mass, are found early in patients with pediatric cancer, persist long after treatment has been completed and seem to contribute to the development of chronic disease. This review details the effects of such changes in body composition and reviews the underlying pathophysiology of the development of sarcopenic obesity and its adverse metabolic impact. The authors discuss the particular challenges in identifying obesity accurately in survivors of pediatric cancer using available measurement techniques, given that common measures, such as body mass index, do not distinguish between muscle and adipose tissue or assess their distribution. The authors highlight the importance of a harmonized approach to the assessment of body composition in pediatric cancer survivors and early identification of risk using "gold-standard" measurements. This will improve our understanding of the significance of adiposity and sarcopenia in this population, help identify thresholds predictive of metabolic risk, and ultimately prevent or ameliorate the long-term metabolic and cardiovascular impacts on health experienced by survivors of cancer in childhood.

Is There A Causal Relationship between Childhood Obesity and Acute Lymphoblastic Leukemia? A Review

Simple Summary

The childhood obesity epidemic is impacting tens of millions of children globally. While obesity causes several cancers in adults, its potential role in causing pediatric cancers remains unclear. In this review, we assess the potential contribution of obesity to the development of acute lymphoblastic leukemia (ALL), the most common pediatric cancer. We review the possible mechanisms by which the adipose tissue attracts and protects leukemia cells and how it interferes with the actions of chemotherapies used in ALL treatment. We also examine adipose tissue-secreted molecules and fuels that may support leukemia development. While there are no current definite causal links between obesity and ALL, there are plausible mechanisms that need further investigation to explore the impact of obesity on causing ALL and on impacting treatment outcomes.

Abstract

Childhood obesity is a growing epidemic with numerous global health implications. Over the past few years, novel insights have emerged about the contribution of adult obesity to cancer risk, but the evidence base is far more limited in children. While pediatric patients with acute lymphoblastic leukemia (ALL) are at risk of obesity, it is unclear if there are potential causal mechanisms by which obesity leads to ALL development. This review explores the endocrine, metabolic and immune dysregulation triggered by obesity and its potential role in pediatric ALL’s genesis. We describe possible mechanisms, including adipose tissue attraction and protection of lymphoblasts, and their impact on ALL chemotherapies’ pharmacokinetics. We also explore the potential contribution of cytokines, growth factors, natural killer cells and adipose stem cells to ALL initiation and propagation. While there are no current definite causal links between obesity and ALL, critical questions persist as to whether the adipose tissue microenvironment and endocrine actions can play a causal role in childhood ALL, and there is a need for more research to address these questions.

Long-Term Endocrine and Metabolic Consequences of Cancer Treatment: A Systematic Review

The number of patients surviving ≥5 years after initial cancer diagnosis has significantly increased during the last decades due to considerable improvements in the treatment of many cancer entities. A negative consequence of this is that the emergence of long-term sequelae and endocrine disorders account for a high proportion of these. These late effects can occur decades after cancer treatment and affect up to 50% of childhood cancer survivors. Multiple predisposing factors for endocrine late effects have been identified, including radiation, sex, and age at the time of diagnosis. A systematic literature search has been conducted using the PubMed database to offer a detailed overview of the spectrum of late endocrine disorders following oncological treatment. Most data are based on late effects of treatment in former childhood cancer patients for whom specific guidelines and recommendations already exist, whereas current knowledge concerning late effects in adult-onset cancer survivors is much less clear. Endocrine sequelae of cancer therapy include functional alterations in hypothalamic-pituitary, thyroid, parathyroid, adrenal, and gonadal regulation as well as bone and metabolic complications. Surgery, radiotherapy, chemotherapy, and immunotherapy all contribute to these sequelae. Following irradiation, endocrine organs such as the thyroid are also at risk for subsequent malignancies. Although diagnosis and management of functional and neoplastic long-term consequences of cancer therapy are comparable to other causes of endocrine disorders, cancer survivors need individually structured follow-up care in specialized surveillance centers to improve care for this rapidly growing group of patients.

Weight trends in a multiethnic cohort of pediatric acute lymphoblastic leukemia survivors: A longitudinal analysis

BACKGROUND

As survival rates for childhood acute lymphoblastic leukemia (ALL) continue to improve, there is growing concern over the chronic health conditions that survivors face. Given that survivors of childhood ALL are at increased risk of cardiovascular complications and obesity, we sought to characterize BMI trends from diagnosis through early survivorship in a multi-ethnic, contemporary cohort of childhood ALL patients and determine if early weight change was predictive of long-term weight status.

METHODS

The study population consisted of ALL patients aged 2-15 years at diagnosis who were treated with chemotherapy alone at Texas Children's Hospital. Each patient had BMI z-scores collected at diagnosis, 30-days post-diagnosis, and annually for five years. Linear regression models were estimated to evaluate the association between: 1) BMI z-score change in the first 30 days and BMI z-scores at five-years post-diagnosis; and 2) BMI z-score change in the first year post-diagnosis and BMI z-scores at five-years post-diagnosis.

RESULTS

This retrospective cohort study included longitudinal data from 121 eligible patients. The mean BMI z-scores for the population increased significantly (p-value<0.001) from baseline (mean = 0.25) to 30 days post-diagnosis (mean = 1.17) before plateauing after one year post-diagnosis (mean = 0.99). Baseline BMI z-scores were statistically significant predictors to five year BMI z-scores (p <0.001). Independent of baseline BMI z-score and other clinical factors, the BMI z-score at one year post-diagnosis was significantly associated with BMI z-score at five-years post-diagnosis (β = 0.63, p <0.001), while BMI z-score at 30 days post-diagnosis was not (β = 0.10, p = 0.23).

CONCLUSION

Our results suggest that weight gain within the first year after diagnosis is more strongly associated with long-term BMI than early weight gain (within 30 days). If confirmed, this information may help identify a window of time during therapy when ALL patients would benefit most from weight management directed interventions.

Long-term effects on growth, development, and metabolism of ALL treatment in childhood

INTRODUCTION

One aim of the long-term care in survivors from acute lymphoblastic leukemia (ALL) during childhood is to avoid or limit complications caused by aggressive therapeutic strategies.

AREAS COVERED

ALL survivors are a heterogeneous group according to therapeutic protocols. In the last decades, cranial radiotherapy (cRT) has been largely replaced by intrathecal chemotherapy (CT) with a reduction of endocrine sequelae. Published studies are generally difficult to be interpreted because patients were treated according to different risk-adapted protocols and results are conflicting. We perform this review on endocrine long-term effects in childhood ALL survivors focusing on studies published in the last decades. Articles were selected using the following terms (Mesh terms): 'acute lymphoblastic leukemia' AND 'survivors' AND 'childhood' AND 'growth/puberty/fertility/obesity/metabolic syndrome/bone'.

EXPERT COMMENTARY

Most childhood ALL survivors treated with CT alone attain normal height and have adequate pubertal development. Despite recent protocols improvements, ALL survivors still develop long-term metabolic complications (overweight, obesity, and cardiovascular disease) especially the female gender and patients with an increased body mass index (BMI) at diagnosis. The aim of this review is to describe the state of the art on these topics. We should be able to anticipate, prevent, and treat endocrine long-term morbidities through a well-established follow-up strategy.

Reproductive and developmental F1 toxicity following exposure of pubescent F0 male mice to bisphenol A alone and in a combination with X-rays irradiation

Exposure to environmental toxicants may affect reproduction and development of subsequent generations. This study was aimed at determining the male-mediated F1 effects induced following 8-weeks of subchronic exposure of F0 male mice to bisphenol A (BPA) alone and in a combination with X-rays irradiation (IR) started during their puberty. 4.5 weeks old F0 male mice were exposed to BPA dissolved in ethyl alcohol and diluted in drinking water at the following doses: 5 mg/kg bw, 10 mg/kg bw, 20 mg/kg bw or irradiated with X-rays (0.05 Gy) or exposed to a combination of low doses of both agents (0.05 Gy + 5 mg/kg bw BPA). Immediately after the end of the 8 weeks exposure F0 males were caged with two unexposed females each. Three quarters of the mated females from each group were sacrificed 1 day before expected parturition for examination of prenatal development of the offspring. The remainder of the females from each group were allowed to deliver and rear litters. Pups of exposed males were monitored for postnatal development for 8 weeks. At 8-9 weeks of age 6-8 males from each group of F1 generation were sacrificed to determine sperm count and quality. The current results, compared to the earlier results, showed that exposure of pubescent males to BPA alone or in combination with irradiation may be more damaging to their offspring than the exposure of adult males. The exposure of pubescent males to BPA alone and in combination with irradiation significantly increased the frequency of abnormal skeletons of surviving fetuses, increased the percent of mortality of pups in the F1 generation, reduced the sperm motility of F1 males and may induce obesity. Additionally, the combined BPA and irradiation exposure reduced the number of total and live implantations, whereas the exposure to BPA alone disturbed the male:female sex ratio. The above results may be caused by genetic or by epigenetic mechanisms. Limitation of use of products including BPA, especially by children and teenagers, is strongly recommended.

Risk Factors and the Prevention of Weight Gain During Induction Chemotherapy in Children With Acute Lymphoblastic Leukemia

Weight gain is often observed in children with acute lymphoblastic leukemia (ALL) who undergo chemotherapy including steroids. An increase in body mass index (BMI)-standard deviation score (SDS) during induction therapy is reported as a risk factor for obesity after treatment. However, risk factors of an increase in BMI-SDS during induction therapy are not known. Ninety-six patients with ALL who were treated at our hospital between 1996 January and September 2013 were analyzed retrospectively. Daily body weight measurement was initiated in July 2005 in an attempt to control weight. Fifty-four patients were boys and 42 were girls. The median age at onset was 5.1 years (0.5-16.6 y), and 7.3% of patients were overweight/obese at onset. BMI-SDS increased +0.1% (-3.3% to +3.2%) during induction therapy. BMI-SDS increased by 1 and 2 or more SDs in 20% and 3% of patients, respectively. In multivariate analysis, non-high-risk treatment and earlier treatment start date (before daily body weight measurement) were independent risk factors. Ten percent of patients were overweight/obese at 3 years after completion therapy, and high BMI-SDS after induction therapy was a risk factor. Daily body weight measurement might prevent excess weight gain during induction therapy, resulting in patients maintaining a healthy weight after ALL treatment.

Overweight and obesity management strategies in survivors of paediatric acute lymphoblastic leukaemia: a systematic review protocol

INTRODUCTION

Acute lymphoblastic leukaemia is the most common paediatric cancer. Survivors of childhood acute lymphoblastic leukaemia (SALL) are at risk of obesity and related cardiometabolic diseases including type 2 diabetes, hypertension, stroke and cardiovascular events. Therefore, it is important to address obesity in this population as this may help mitigate future cardiometabolic comorbidities. In this systematic review, we aim to assess current treatment strategies including lifestyle interventions, pharmacotherapy and bariatric surgery to manage overweight and obesity in SALL.

METHODS AND ANALYSIS

We will search the following databases for primary studies: CINAHL, SPORTDiscus, EMBASE, MEDLINE, PsycINFO, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews. In addition, unpublished primary studies will be searched in ClinicalTrials.gov as well as conference proceedings, presentations, abstracts, editorials and ProQuest Dissertations and Theses A&I. Reviewers will perform title, abstract, and full-text screening as well as data abstraction and risk of bias assessment independently with a third reviewer to be consulted to resolve disagreements. Searches will be run and updated through May 1st, 2018. The overall quality of the evidence will be determined using the Grading of Recommendations, Assessment, Development, and Evaluation criteria for each outcome. A meta-analysis will be performed if two studies deploying similar interventions, populations, and design and outcomes are identified.

ETHICS AND DISSEMINATION

As individual patient data will not be included, we do not require ethics approval. This review will be published in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42016051031.

Overweight in childhood cancer patients at diagnosis and throughout therapy: A multicentre cohort study

BACKGROUND

Childhood cancer patients (CCP) have been reported to be at increased risk of becoming overweight during treatment. We assessed prevalence of overweight in CCP at diagnosis and at the end of treatment, determined risk factors, and identified weight change during treatment by type of cancer.

METHODS

In a multicentre cohort study, we collected height and weight measurements of CCP at diagnosis and repeatedly during treatment. We calculated age- and sex-adjusted BMI Z-scores using references of the International Obesity Taskforce for children. Risk factors were described by multivariable linear regression, and weight change during treatment by multilevel segmented linear regression.

RESULTS

The study included 327 CCP with a median age of 7 years (IQR 3-12) at diagnosis (55% boys), who had been diagnosed with acute lymphoblastic leukaemia (ALL, 29%), lymphoma (16%), central nervous system (CNS) tumours (13%), sarcoma (18%), and other types of cancer (24%). At diagnosis, 27 CCP (8%) were overweight. This increased to 43 (13%) at end of treatment, on average 0.7 years after diagnosis. Being a boy (p = 0.005) and having been diagnosed with ALL or lymphoma (p < 0.001) were risk factors for weight gain during treatment. During the first half of treatment, BMI Z-scores increased in ALL (regression slope β = 0.4, 95% CI 0.1-0.7) and lymphoma (β = 1.5, 95% CI 0.2-2.9) patients, whereas for patients with CNS tumours (β = -1.4, 95% CI -2.7 to -0.2), sarcoma (β = -1.4, 95% CI -2.0 to -0.7), or other types of cancer (β = -0.3, 95% CI -1.5-0.9) BMI Z-scores tended to drop initially. During the second half of treatment BMI Z-scores of all patients tended to increase. Exploratory analyses showed that BMI Z-scores of younger ALL patients (<7 years at diagnosis) increased during induction (β = 3.8, 95% CI 0.5-7.0). The inverse was seen for older ALL patients (≥7 years at diagnosis), in whom BMI Z-scores tended to decrease during induction (β = -1.5, -5.1-2.2), both groups tended to increase afterwards.

CONCLUSION

CCP diagnosed with ALL or lymphoma are at increased risk of weight gain during treatment, and might particularly benefit from early lifestyle interventions.

Comparison of Resting Energy Expenditure Assessment in Pediatric Oncology Patients

BACKGROUND

Evaluation of energy requirements is an important part of the nutrition assessment of pediatric oncology patients. Adequate provision of energy in this population is of extreme importance because of the prevalence of malnutrition and its effect on growth, development, quality of life, morbidity, and mortality. Numerous methods are used in clinical practice for estimating the resting energy expenditures (REE), specifically indirect calorimetry and predictive equations. A relatively new instrument used to assess REE is the hand-held indirect calorimeter. The purpose of this quality improvement project was to compare the accuracy of REE measurements taken by a hand-held indirect calorimeter and predictive equations to that of a standard indirect calorimeter metabolic cart.

METHODS

Patients receiving therapy for pediatric cancer, aged 7-18 years, and having a weight ≥15 kg and scheduled for a REE nutrition assessment were eligible. Sequentially, the patient's REE was assessed with the cart and the hand-held indirect calorimeter along with the predictive equation calculation.

RESULTS

Post hoc pairwise comparisons revealed that all 3 methods were significantly different from one another (P < .0001). When compared with the cart, the portable hand-held calorimeter was found to underestimate REE by 11.9%, whereas predictive equations overestimated REE by 12.4%.

CONCLUSION

Our quality improvement project suggests that the hand-held indirect calorimeter underestimated REE, and predictive equations overestimated REE in pediatric oncology nutrition assessment. Therefore, we recommend that these limitations in assessment be considered when assessing REE using a hand-held indirect calorimeter or predictive equations.

Prevalence and characteristics of metabolic syndrome in adults from the French childhood leukemia survivors' cohort: a comparison with controls from the French population

The prevalence of the metabolic syndrome among adults from the French LEA childhood acute leukemia survivors' cohort was prospectively evaluated considering the type of anti-leukemic treatment received, and compared with that of controls. The metabolic profile of these patients was compared with that of controls. A total of 3203 patients from a French volunteer cohort were age- and sex-matched 3:1 to 1025 leukemia survivors (in both cohorts, mean age: 24.4 years; females: 51%). Metabolic syndrome was defined according to the National Cholesterol Education Program's Adult Treatment Panel III criteria. Metabolic syndrome was found in 10.3% of patients (mean follow-up duration: 16.3±0.2 years) and 4.5% of controls, (OR=2.49; P<0.001). Patients transplanted with total body irradiation presented the highest risk (OR=6.26; P<0.001); the other treatment groups also showed a higher risk than controls, including patients treated with chemotherapy only. Odd Ratios were 1.68 (P=0.005) after chemotherapy only, 2.32 (P=0.002) after chemotherapy and cranial irradiation, and 2.18 (P=0.057) in patients transplanted without irradiation. Total body irradiation recipients with metabolic syndrome displayed a unique profile compared with controls: smaller waist circumference (91 vs 99.6 cm; P=0.01), and increased triglyceride levels (3.99 vs 1.5 mmol/L; P<0.001), fasting glucose levels (6.2 vs 5.6 mmol/L; P=0.049), and systolic blood pressure (137.9 vs 132.8 mmHg; P=0.005). By contrast, cranial irradiation recipients with metabolic syndrome had a larger waist circumference (109 vs 99.6 cm; P=0.007) than controls. Regardless of the anti-leukemic treatment, metabolic syndrome risk was higher among childhood leukemia survivors. Its presentation differed depending on the treatment type, thus suggesting a divergent pathophysiology. This study is registered at clinicaltrials.gov identifier: 01756599.

Overweight in childhood cancer survivors: the Swiss Childhood Cancer Survivor Study

Background

An increased risk of becoming overweight has been reported for childhood cancer survivors (CCSs), in particular leukemia survivors, although the evidence is inconclusive.

Objective

We assessed the prevalence of overweight in CCSs, with a focus on leukemia survivors, compared it with their peers, and determined potential risk factors.

Design

As part of the Swiss Childhood Cancer Survivor Study, we sent a questionnaire between 2007 and 2013 to all Swiss resident CCSs aged <21 y at diagnosis who had survived ≥5 y. We calculated body mass index (BMI) from medical records at diagnosis and self-reported heights and weights at survey. We calculated BMI z scores by using Swiss references for children and compared overweight prevalence in CCSs, their siblings, and the general population with the use of the Swiss Health Survey (SHS) and assessed risk factors for being overweight by using multivariable logistic regression.

Results

The study included 2365 CCSs, 819 siblings, and 9591 SHS participants. At survey, at an average of 15 y after diagnosis, the prevalence of overweight in CCSs overall (26%) and in leukemia survivors (26%) was similar to that in siblings (22%) and the general population (25%). Risk factors for being overweight in CCSs were male sex (OR: 1.8; 95% CI: 1.5, 2.1), both young (OR for ages 5-14 y: 1.6; 95% CI: 1.2, 2.3) and older (range-OR for ages 25-29 y: 1.7; 95% CI: 1.2, 2.4; OR for ages 40-45 y: 4.0; 95% CI: 2.5, 6.5) age at study, lower education (OR: 1.4; 95% CI: 1.1, 1.8), migration background (OR: 1.3; 95% CI: 1.1, 1.7), and no sports participation (OR: 1.4; 95% CI: 1.1, 1.7). Risk factors for overweight were similar in peers. CCSs treated with cranial radiotherapy (≥20 Gy) were more likely to be overweight than their peers (OR: 1.6; 95% CI: 1.2, 2.2).

Conclusions

The prevalence of and risk factors for being overweight are similar in long-term CCSs and their peers. This suggests that prevention methods can be the same as in the general population. An important exception is CCSs treated with cranial radiotherapy ≥20 Gy who may need extra attention during follow-up care. This study was registered at clinicaltrials.gov as NCT03297034.

Cardiometabolic Risk Factors in Childhood, Adolescent and Young Adult Survivors of Acute Lymphoblastic Leukemia - A Petale Cohort

Our objectives were to assess the prevalence of cardiometabolic complications in children, adolescents, and young adult survivors of childhood acute lymphoblastic leukemia (cALL), to identify their predictors and the risk compared to the Canadian population. We performed a cardiometabolic assessment of cALL survivors from the PETALE cohort (n = 247, median age at visit of 21.7 years). In our group, overweight and obesity affected over 70% of women. Pre-hypertension and hypertension were mostly common in men, both adults (20%) and children (19%). Prediabetes was mainly present in women (6.1% of female adult survivors) and 41.3% had dyslipidemia. Cranial radiation therapy was a predictor of dyslipidemia (RR: 1.60, 95% CI: 1.07–2.41) and high LDL-cholesterol (RR: 4.78, 95% CI: 1.72–13.28). Male gender was a predictor for pre-hypertension and hypertension (RR: 5.12, 95% CI: 1.81–14.46). Obesity at the end of treatment was a predictor of obesity at interview (RR: 2.07, 95% CI: 1.37–3.14) and of metabolic syndrome (RR: 3.04, 95% CI: 1.14–8.09). Compared to the general population, cALL survivors were at higher risk of having the metabolic syndrome, dyslipidemia, pre-hypertension/hypertension and high LDL-cholesterol, while the risk for obesity was not different. Our results support the need for early screening and lifestyle intervention in this population.

Growth and pubertal patterns in young survivors of childhood acute lymphoblastic leukemia

BACKGROUND

Survivors of acute lymphoblastic leukemia (ALL) may experience endocrine dysfunction. This study evaluated growth and pubertal patterns in survivors of childhood ALL.

METHODS

Longitudinal assessment of anthropometric measurements and pubertal status was performed in a retrospective cohort of survivors (n=183). Median age at last endocrine visit was 16.1 years (range 8.2-27.6); median follow-up time was 8.7 years (range 3-21.4).

RESULTS

Treatment with chemotherapy+prophylactic cranial radiation (pCRT, n=29) was associated with lower mean height standard deviation score (SDS) than chemotherapy alone (n=154) (p=0.001) and higher prevalence of adult short stature (13% vs. 2.2%). Mean age at pubertal onset was normal (girls: 10.3±1.3 years; boys: 12.0±1.3 years). Precocious puberty, diagnosed in 8.7% of patients, was more prevalent in pCRT-treated girls. Rates of overweight and obesity were 22.9% and 9.3%, respectively. Predictors of endocrine disorders were pCRT (p=0.031) and female gender (p=0.041); of obesity, higher body mass index (BMI)-SDS at diagnosis (p=0.001); and of short stature, lower height-SDS at diagnosis (p=0.038).

CONCLUSIONS

Most childhood ALL survivors given chemotherapy alone attain normal adult height and puberty. Childhood ALL survivors are at increased risk of overweight, especially those with increased BMI at diagnosis. Clinicians should screen for overweight early in survivorship and introduce early interventions.

Weight Trajectories of Israeli Pediatric Cancer Survivors

Objective

Cross-national replication of the high rates of overweight/obesity among U.S. pediatric cancer survivors (PCS) is limited. Predictors of weight trajectories of Israeli PCS were examined from diagnosis and end of active cancer treatment to 3 years posttreatment.

Methods

World Health Organization-derived body mass index (z-BMI) values were calculated at each time point from medical records of 135 Israeli PCS ( M diagnosis age = 11.4). A three-section piecewise multilevel model including age, ethnicity, gender, treatment length, and diagnosis as predictors was used to estimate z-BMI trajectories.

Results

Most participants remained at a healthy weight at all time points. Differing weight trajectories emerged for PCS diagnosed with lymphoma/leukemia versus other cancer diagnoses from diagnosis to end of treatment, but similar weight change patterns were observed posttreatment.

Conclusion

Replication of U.S. PCS weight trajectories was not observed in Israeli PCS, suggesting the importance of exploring environmental risk factors contributing to obesity among PCS.

Non-alcoholic fatty liver disease is associated with early left ventricular dysfunction in childhood acute lymphoblastic leukaemia survivors

BACKGROUND

Childhood acute lymphoblastic leukaemia (ALL) survivors have an increased risk of metabolic and cardiovascular disease. We aimed to assess the presence of non-alcoholic fatty liver disease (NAFLD) in childhood ALL and if it is associated with early cardiovascular dysfunction.

METHODS

In total, 53 childhood ALL survivors and 34 controls underwent auxological evaluation, biochemical assay, liver, heart and vascular ultrasound study.

RESULTS

NAFLD was more frequent in ALL patients than in controls (39.6% vs 11.7%, P < 0.01). Patients with NAFLD were more obese and insulin resistant than patients without NAFLD. Flow-mediated dilatation and interventricular septum were lower in the ALL group than those in the control group (P < 0.001 for both). The patients with NAFLD showed lower left ventricular ejection fraction than those without NAFLD (P = 0.011). In ALL survivors, BMI-SDS and subcutaneous fat were the strongest predictors of NAFLD, whereas preperitoneal adipose tissue and C-reactive protein were the strongest predictors of left ventricular ejection fraction.

CONCLUSIONS

Childhood ALL survivors had higher prevalence of NAFLD than healthy controls, which is associated with early left ventricular impairment. In the case of fatty liver, a comprehensive heart evaluation is mandatory. We strongly recommend to prevent visceral adiposity in ALL survivors, to search for metabolic syndrome or its components and to reinforce the need of intervention on diet and lifestyle during the follow-up of these patients.

Association of energy intake and expenditure with obesity: A cross-sectional study of 150 pediatric patients following treatment for leukemia

Increased obesity in leukemia survivors has been attributed to chemotherapy and radiation. Data on total energy intake (TEI) and total energy expenditure (TEE) are lacking in obese childhood leukemia patients after completion of therapy from India. We conducted a cross-sectional study in pediatric acute leukemia patients after completion of therapy wherein energy intake was assessed by 24-hour recall method. TEE was calculated using Harris-Benedict equation, by assessing the physical activity level using Physical Activity Questionnaire for children and basal metabolic rate by World Health Organization equation. Indian Academy of Pediatrics 2015 guidelines for BMI were used for defining overweight and obesity. Nutritional status was assessed in 150 leukemia patients after completion of therapy. Twenty-five percent of leukemia patients after completion of therapy were overweight and obese versus 11% of healthy controls (p = 0.042). The mean ratio of TEI/required energy intake (REI), TEE/required energy expenditure (REE), and (TEI:REI)/(TEE:REE) were significantly higher in overweight and obese group versus nonobese survivors (p < 0.001, p = 0.091, p < 0.001, respectively). Multivariate analysis showed higher income (HR-2.3, p = 0.04), increased TEI/REI (HR-4, p = 0.049) and higher (TEI:REI)/(TEE:REE) (HR-3.1, p = 0.039) to be significant factors predicting obesity. Obesity in leukemia patients after completion of therapy is associated with increased energy intake, causing imbalance between energy intake and TEE in these patients.

The Estimation of Intima-Media Thickness and Cardiovascular Risk Factors in Young Survivors of Childhood Cancer

Cancer treatment in childhood is thought to accelerate the development of atherosclerosis, leading to significant cardiovascular complications and, ultimately, increasing cardiovascular mortality in childhood cancer survivors, which explains the need to assess vascular status in this group. The purpose of this paper was to assess early atherosclerotic lesions based on the analysis of intima-media thickness (IMT) of the common carotid artery, as well as to analyze cardiovascular risk factors in young childhood cancer survivors. The analysis of 158 patients aged 6 to29 years, with a history of previous cancer treatment for different childhood malignancies, revealed a statistically significant difference in IMT between them and 66 age-matched healthy controls. The observed higher IMT scores in childhood cancer survivors may be indicative of premature atherosclerosis. The actual scores were 0.056±0.007 versus 0.052±0.003 (P=0.0001) as a mean score for both carotid arteries in the study group and controls, respectively. We did not observe significant differences in IMT between cancer survivors treated with chemotherapy only versus those treated with chemotherapy and radiotherapy. Similar to the general population, childhood cancer survivors are affected by different cardiovascular risk factors. These factors may enhance the direct cardiotoxicity of cancer treatment, leading to symptomatic incidents in further life, which emphasizes the need of early prevention and/or treatment in this subpopulation.

Assessment of problems and symptoms in survivors of childhood acute lymphoblastic leukaemia

Significant physical and psychosocial problems and related symptoms are observed in cancer survivors after treatment as well as during the treatment period. This study was aimed to assess problems and symptoms in childhood acute lymphoblastic leukaemia (ALL) survivors. Study was applied in three hospitals in Ankara/Turkey with 91 children who were diagnosed and treated with ALL and with their family. Data were collected using the data collection form developed by the researchers. The variables were investigated using the Mann-Whitney U and chi-square test. The most common physical problems and symptoms seen in survivors are respiratory system infections (40.7%), reduction in bone mineral density (26.4%), exercise intolerance (45.1%), pain (41.8%) and fatigue (29.7%). Among the most frequent social problems experienced, educational problems (19.8%) is indicated. In children carrying increased duration of therapy, urinary system infections (p = .016), anorexia (0.020) and pain (p = .007) rates are increasing. Many problems and symptoms related to disease and treatment in survivors of ALL have been realised. Therefore, planning and implementation of nursing interventions required to sustaining and developing survivor's health status are important.

Space radiation exposure persistently increased leptin and IGF1 in serum and activated leptin-IGF1 signaling axis in mouse intestine

Travel into outer space is fraught with risk of exposure to energetic heavy ion radiation such as ⁵⁶Fe ions, which due to its high linear energy transfer (high-LET) characteristics deposits higher energy per unit volume of tissue traversed and thus more damaging to cells relative to low-LET radiation such as γ rays. However, estimates of human health risk from energetic heavy ion exposure are hampered due to lack of tissue specific in vivo molecular data. We investigated long-term effects of ⁵⁶Fe radiation on adipokines and insulin-like growth factor 1 (IGF1) signaling axis in mouse intestine and colon. Six- to eight-week-old C57BL/6J mice were exposed to 1.6 Gy of ⁵⁶Fe ions. Serum and tissues were collected up to twelve months post-irradiation. Serum was analyzed for leptin, adiponectin, IGF1, and IGF binding protein 3. Receptor expressions and downstream signaling pathway alterations were studied in tissues. Irradiation increased leptin and IGF1 levels in serum, and IGF1R and leptin receptor expression in tissues. When considered along with upregulated Jak2/Stat3 pathways and cell proliferation, our data supports the notion that space radiation exposure is a risk to endocrine alterations with implications for chronic pathophysiologic changes in gastrointestinal tract.

Prevalence and Predictors of Overweight and Obesity Among a Multiethnic Population of Pediatric Acute Lymphoblastic Leukemia Survivors: A Cross-Sectional Assessment

As previous studies of obesity in survivors of pediatric acute lymphoblastic leukemia (ALL) have primarily been conducted among non-Hispanic white survivors or children treated on older protocols, our objective was to describe the prevalence and correlates of overweight status among an ethnically diverse population of pediatric ALL survivors, largely treated with more contemporary therapies. We evaluated the overweight/obesity status of pediatric ALL survivors (n=406) followed in the Texas Children's Cancer Center between 2004 and 2014. Survivors were classified as underweight, normal weight, overweight, or obese on the basis of their body mass index at their most current follow-up visit. Our results showed that Hispanic ethnicity (39% of the subjects) was associated with being overweight (adjusted odds ratio=1.88; 95% confidence interval, 1.13-3.14) or obese (adjusted odds ratio=2.84; 95% confidence interval, 1.59-5.06) at follow-up, even after adjusting for cranial radiotherapy (CRT) exposure. Body mass index z-score at diagnosis was also associated with overweight/obesity at follow-up. In addition, there was a statistically significant interaction between younger age at diagnosis and CRT, indicating that younger age at diagnosis was associated with obesity among patients who received CRT. These findings may help identify pediatric ALL patients that are at increased risk of being overweight or obese after treatment.

Evaluation of Endocrine Late Complications in Childhood Acute Lymphoblastic Leukemia Survivors: A Report of a Single-Center Experience and Review of the Literature

Objective:

Improvement in long-term survival in patients with acute lymphoblastic leukemia (ALL) in childhood has led to the need for monitorization of treatment-related morbidity and mortality. In the current study, we aimed to evaluate endocrine side effects of treatment in ALL survivors who were in remission for at least 2 years.

Materials and Methods:

Sixty patients diagnosed with ALL, who were in remission for at least 2 years, were cross-sectionally evaluated for long-term endocrine complications.

Results:

The median age of the patients at the time of diagnosis, at the time of chemotherapy completion, and at the time of the study was 5 years (minimum-maximum: 1.7-13), 8 years (minimum-maximum: 4.25-16), and 11.7 years (minimum-maximum: 7-22), respectively, and median follow-up time was 4 years (minimum-maximum: 2-10.1). At least one complication was observed in 81.6% of patients. Vitamin D insufficiency/deficiency (46.6%), overweight/obesity (33.3%), and dyslipidemia (23.3%) were the three most frequent endocrine complications. Other complications seen in our patients were hyperparathyroidism secondary to vitamin D deficiency (15%), insulin resistance (11.7%), hypertension (8.3%), short stature (6.7%), thyroid function abnormality (5%), precocious puberty (3.3%), and decreased bone mineral density (1.7%). There were no statistically significant correlations between endocrine complications and age, sex, and radiotherapy, except vitamin D insufficiency/deficiency, which was significantly more frequent in pubertal ALL survivors compared to prepubertal ALL survivors (57.5% and 25%, respectively, p=0.011).

Conclusion:

A high frequency of endocrine complications was observed in the current study. The high frequency of late effects necessitates long-term surveillance of this population to better understand the incidence of late-occurring events and the defining of high-risk features that can facilitate developing intervention strategies for early detection and prevention.

Trajectories of Obesity and Overweight Rates Among Survivors of Childhood Acute Lymphoblastic Leukemia

PURPOSE/OBJECTIVES

To describe the trajectories of obesity/overweight rates by age group among survivors of childhood acute lymphoblastic leukemia (ALL) from diagnosis through several years post-therapy.

DESIGN

Longitudinal, descriptive.

SETTING

Hematology/oncology clinic in the southwestern United States.

SAMPLE

62 child and adolescent ALL survivors receiving treatment and follow-up care from 1999-2013.

METHODS

Retrospective chart review of height, weight, and body mass index.

MAIN RESEARCH VARIABLES

Annual obesity/overweight rates and developmental age groups.

FINDINGS

Different trajectories of obesity/overweight rates existed among age groups. Forty-seven percent of adolescents met the Centers for Disease Control and Prevention criteria for obesity/overweight status at some point following diagnosis, compared to 68% of school-age and 73% of preschool children. Preschool children demonstrated the most rapid rate increase following diagnosis, with a particularly susceptible period in the years immediately following therapy. Obesity/overweight persistence was most characteristic of school-age children.

CONCLUSIONS

Important variations in rate and pattern of weight status trajectories exist by age group, demonstrating that children diagnosed with ALL during the preschool and school-age developmental years have the greatest vulnerability of developing obesity/overweight status.

IMPLICATIONS FOR NURSING

Obesity/overweight prevention efforts are greatly needed in children with ALL, and efforts should occur before ALL treatment completion in preschool and school-age children.

Is there an increased risk of metabolic syndrome among childhood acute lymphoblastic leukemia survivors? A developing country experience

Data on metabolic syndrome (MS) in survivors of childhood acute lymphoblastic leukemia (ALL) from developing countries are lacking. The purpose of this single-center, uncontrolled, observational study was to assess the frequency of MS in our survivors. The survivors of ALL ≤15 years at diagnosis, who had completed therapy ≥2 years earlier, were enrolled. Anthropometric measurements (weight, height, waist circumference), biochemistry (glucose, insulin, triglycerides, high-density lipoprotein [HDL], thyroid function tests, C-reactive protein [CRP], magnesium), measurement of blood pressure, and Tanner staging were performed. MS was defined by International Diabetes Federation (IDF) and the National Cholesterol Education Program Third Adult Treatment Panel guidelines (NCEP ATP III) criteria, modified by Cook et al. (Arch Pediatr Adolesc Med. 2003;157:821-827) and Ford et al. (Diabetes Care. 2005;28:878-881). The median age of 76 survivors was 11.9 years (interquartile range [IQR]: 9.6-13.5). Twenty-four (32%) survivors were obese or overweight. The prevalence of insulin resistance (17%), hypertension (7%), hypertriglyceridemia (20%), and low HDL (37%) was comparable to the prevalence in children/adolescents in historical population-based studies from India. The prevalence of MS ranged from 1.3% to 5.2%, as per different defining criteria. Cranial radiotherapy, age at diagnosis, sex, or socioeconomic status were not risk factors for MS. The prevalence of MS in survivors of childhood ALL, at a median duration of 3 years from completion of chemotherapy, was comparable to the reference population. The prevalence of being obese or overweight was, however, greater than historical controls.

Genetic and clinical factors associated with obesity among adult survivors of childhood cancer: A report from the St. Jude Lifetime Cohort

BACKGROUND

The objective of this study was to identify treatment and genetic factors associated with obesity among childhood cancer survivors.

METHODS

Participants included 1996 survivors who previously received treatment for cancer at St. Jude Children's Research Hospital and who survived ≥10 years from diagnosis (median age at diagnosis, 7.2 years; median age at follow-up, 32.4 years). Obesity was defined as a body mass index ≥30 kg/m(2) . The factors associated with adult obesity were identified by subgroup-specific (cranial radiation [CRT] exposure status) multivariable logistic regression. Single nucleotide polymorphisms (SNPs) associated with obesity were identified by subgroup-specific, exploratory, genome-wide association analyses using a 2-stage resampling approach with a type I error rate of 5 × 10(-6) .

RESULTS

Forty-seven percent of survivors who received CRT and 29.4% of those who did not receive CRT were obese at evaluation. In multivariable analyses, abdominal/pelvic radiation exposure was associated with decreased prevalence of obesity among survivors regardless of CRT status (P < .0001). The odds of obesity were increased among survivors who received CRT who had also received glucocorticoids (P = .014) or who were younger at diagnosis (P = .013). Among the survivors who had received CRT, 166 SNPs were associated with obesity. The strongest association was observed with reference SNP rs35669975 (P = 3.3 × 10(-8) ) on segment 33.3 of the long arm of chromosome 13 (13q33.3), approximately 30 kb downstream of FAM155A (family with sequence similarity 155, member A). SNPs within the glycine receptor α3 (GLRA3) gene and near the sex-determining region Y box 11 (SOX11) and cadherin 18 type 2 (CDH18) genes also were identified. These genes have been implicated in neural growth, repair, and connectivity.

CONCLUSIONS

Obesity in childhood cancer survivors remains associated with previous exposure to CRT and glucocorticoids. Genetic variants related to neural connectivity may modify the risk of obesity among survivors who receive CRT. Validation of these findings in independent cohorts is required.

Survivors of standard risk acute lymphoblastic leukemia do not have increased risk for overweight and obesity compared to non-cancer peers: a report from the Children's Oncology Group

BACKGROUND

We sought to determine whether survivors of standard risk ALL (SR-ALL) treated without cranial radiation have increased risk for obesity by assessing changes in body mass index (BMI) during and after treatment; identifying contributing patient and treatment factors; comparing rates of overweight/obese to national health data.

PROCEDURE

Eligibility for this retrospective cohort study included: (i) previous enrollment on legacy therapy trials CCG1922 or CCG1952; (ii) continuous first remission; and (iii) age at follow-up evaluation of 6-16.99 years. Height and weight from diagnosis, consolidation, start of maintenance, last cycle of maintenance, and off-therapy were analyzed.

RESULTS

The 269 subjects were a median age of 3.5 years at diagnosis and 13.3 years at follow-up. BMI% significantly increased from induction to consolidation (+17.6 ± 1.6%), start of maintenance to end-of-treatment (+3.3 ± 1.6%) and decreased from end-of-treatment to follow-up (-3.5 ± 1.6%,). Higher BMI% at follow-up was associated with higher BMI% at diagnosis (P < 0.0001), but not age at diagnosis, gender, or race. Patients previously randomized to dexamethasone had a stronger association between BMI% at diagnosis and BMI% at follow-up than those who received prednisone (P = 0.0005). At follow-up, 39% of survivors were overweight or obese; the relative risk of overweight/obese was 1.028 (P = 0.738) compared to the general population.

CONCLUSIONS

Our study of patients with SR-ALL found a significant increase in BMI% largely during the first month of therapy that is greater with dexamethasone than prednisone. However, after therapy, there was no increased risk of overweight/obese BMI compared to non-cancer peers.

Metabolic syndrome in childhood leukemia survivors: a meta-analysis

A significant number of long-term complications have been described in childhood leukemia survivors. In particular, these patients may present features of metabolic syndrome (MetS), and therefore increased risk for cardiovascular diseases. The aim of this meta-analysis is to evaluate the prevalence and the risk of MetS in survivors of childhood leukemia. Two authors independently performed a systematic literature search in PubMed and EMBASE to March 2014, reviewed and selected articles, based on pre-determined selection criteria. Twelve articles, comprising 2,337 participants (1,462 cases and 875 controls), were included in the meta-analysis. Only three of them were case-control studies eligible for the meta-analysis. The childhood leukemia survivors showed an increased risk of MetS as compared to healthy controls (OR = 4.36; 95 % CI 1.19-16.22). The risk was significantly increased only in patients treated with chemotherapy and radiotherapy (OR = 7.79; 95 % CI 1.27-47.77), and not in patients treated with only chemotherapy (OR = 2.35; 95 % CI 0.40-13.78). Childhood leukemia survivors, in particular if treated also with radiotherapy, are prone to develop MetS more than healthy controls. Monitoring of MetS components in these patients is necessary to avoid cardiovascular consequences later in life.

Weight change during childhood acute lymphoblastic leukemia induction therapy predicts obesity: a report from the Children's Oncology Group

BACKGROUND

Obesity is a well documented problem associated with childhood acute lymphoblastic leukemia (ALL) with increasing body mass index often observed during therapy. This study aims to evaluate if weight gain, early in therapy, is predictive of obesity at the end of treatment.

PROCEDURE

In this secondary analysis, data from 1,017 high-risk ALL patients previously treated on a Children's Oncology Group protocol (CCG study 1961) were reviewed. Logistic regression was used to examine whether change in BMI z-score at Induction or Delayed Intensification (DI) 1 were predictive of obesity at the end of therapy.

RESULTS

The BMI z-score at the beginning of Induction and the change in BMI z-score during Induction were both significant predictors of obesity at the end of therapy. The change in BMI z-score during cycle 1 of DI was not found to be associated with obesity.

CONCLUSIONS

It is well know that obesity at the beginning of therapy is predictive of obesity at the end of ALL therapy. The new, and more important, finding from this study is that even after adjusting for baseline weight, the increase in BMI z-scores during induction was an independent predictor of obesity at the end of therapy. Most researchers agree that prevention is the best form of treatment for obesity as it is difficult to reverse once it is present. This study suggests that monitoring weight trends during Induction may be useful in guiding healthcare practitioners in identifying which patients are at highest risk for obesity development so that early intervention may occur.

Improving access to novel agents for childhood leukemia

Leukemia is the most common pediatric cancer. Despite great progress in the development of curative therapy, leukemia remains a leading cause of death from disease in childhood, and survivors are at life-long risk of complications of treatment. New agents are needed to further increase cure rates and decrease treatment-associated toxicities. The complex biology and aggressive nature of childhood leukemia, coupled with the relatively small patient population available for study, pose specific challenges to the development of new therapies. In this review, the authors discuss strategies and initiatives designed to improve access to new agents in the treatment of pediatric leukemia.

Age-dependent changes in health status in the Childhood Cancer Survivor cohort

PURPOSE

To compare age-dependent changes in health status among childhood cancer survivors and a sibling cohort.

METHODS

Adult survivors of childhood cancer and siblings, all participants of the Childhood Cancer Survivor Study, completed three surveys assessing health status. At each of three time points, participants were classified as having poor outcomes in general health, mental health, function, or daily activities if they indicated moderate to extreme impairment. Generalized linear mixed models were used to compare survivors with siblings for each outcome as a function of age and to identify host- and treatment-related factors associated with age-dependent worsening health status.

RESULTS

Adverse health status outcomes were more frequent among survivors than siblings, with evidence of a steeper trajectory of age-dependent change among female survivors with impairment in at least one health status domain (P = .01). In adjusted models, survivors were more likely than siblings to report poor general health (prevalence ratio [PR], 2.37; 95% CI, 2.09 to 2.68), adverse mental health (PR, 1.66; 95% CI, 1.52 to 1.80), functional impairment (PR, 4.53; 95% CI, 3.91 to 5.24), activity limitations (PR, 2.38; 95% CI, 2.12 to 2.67), and an adverse health status outcome in any domain (PR, 2.10; 95% CI, 1.97 to 2.23). Cancer treatment and health behaviors influence the magnitude of differences by age groups. Chronic conditions were associated with adverse health status outcomes across organ systems.

CONCLUSION

The prevalence of poor health status is higher among survivors than siblings, increases rapidly with age, particularly among female participants, and is related to an increasing burden of chronic health conditions.

Final height and body mass index in adult survivors of childhood acute lymphoblastic leukemia treated without cranial radiotherapy: a retrospective longitudinal multicenter Italian study

Background

Young adult survivors of childhood acute lymphoblastic leukemia (ALL) treated with protocols including cranial radiotherapy demonstrate a persistent weight gain and reduced final height. Published reports on the effects on growth of different oncologic therapies are conflicting and difficult to interpret because they combined children treated with both cranial irradiation and multi-agent chemotherapy. Our study investigated the effect of chemotherapy alone on body mass index (BMI) and on growth at the achievement of final height in a homogeneous cohort of Italian childhood ALL survivors.

Methods

We retrospectively studied 162 Caucasian patients treated on the Italian Association of Pediatric Hematology and Oncology protocols without radiotherapy between 1989 and 2000 at five Italian centers with 107 inclusions (58 males). Height- and BMI-standard deviation score (SDS) were collected at diagnosis of ALL, at the end of treatment and at the achievement of final height. Changes in height SDS and BMI SDS with time were analyzed using dependent sample Student's t-test.

Results

A significant reduction of height-SDS was documented during treatment in both genders. This reduction of height-SDS was not followed by an appropriate catch-up growth, despite the achievement of a mean final height within the normal range. At diagnosis females showed a lower mean BMI-SDS than males. During treatment, in the whole population, BMI-SDS increased significantly. After it, while males lost BMI-SDS, females showed its persistent increase.

Conclusions

Survivors of childhood ALL generally seemed to achieve a normal final height with a BMI within the normal range. These parameters appeared to be only minimally affected by chemotherapy. Nevertheless, height catch-up growth was not completed after chemotherapy in both genders and all patients experienced an increase of BMI-SDS during chemotherapy that only females seemed to conserve until the achievement of final height.

What are the long-term effects of treatment on survivors of childhood leukaemia? A review of the literature

Purpose

Key advances in cancer treatment have led to an increasing number of long-term cancer survivors. Knowledge of the long-term effects of cancer treatment on leukaemia survivors is to some degree limited. This article investigates the effects of the treatment of childhood leukaemia on the quality of life (QOL), the physical and the psychological wellbeing and general development of survivors. This article reviews current literature to examine existing gaps in knowledge and identify a potential focus of future research and clinical practice.

Materials and methods

Online systematic searching, along with historical searching took place in order to retrieve relevant primary research papers for the review. Strict inclusion and exclusion criteria were applied to the literature, to create a manageable amount of research papers.

Results

The extent of intellectual impairment among radiotherapy patients was significantly greater than those treated with chemotherapy only. Body composition, including endocrine function, is readily affected by cancer treatment. Early identification and interventions can greatly improve the QOL of survivors.

Conclusion

Further research into the effect of treatment modality on the extent of chronic effects, along with investigations into the needs of the whole family unit, is required. Future practice must take into account long-term implications while ensuring effective holistic care.

Predictors of being overweight or obese in survivors of pediatric acute lymphoblastic leukemia (ALL)

BACKGROUND

A high prevalence of obesity has been increasingly recognized in survivors of pediatric ALL. However, longitudinal patterns of weight change during and after treatment, and associated factors, are less well elucidated.

PROCEDURE

In a retrospective cohort of 83 pediatric patients with ALL diagnosed between 1985 and 2010, we examined body mass index (BMI) status at several key time points: diagnosis; end of induction; end of consolidation; every 6 months during maintenance; and yearly for up to 5 years post-treatment.

RESULTS

At diagnosis, 21% were overweight (BMI = 85-94.9th percentile) or obese (BMI ≥ 95th percentile). At the end of treatment and 5 years post-treatment, approximately 40% were overweight or obese. The mean BMI z-score was 0.2 (58th percentile) at diagnosis and increased significantly during induction (Δ = 0.5, P < 0.0001). It increased again during the first 6 months of maintenance (Δ = 0.2, P < 0.01) and did not significantly change over the remainder of maintenance (BMI z-score at the end of treatment = 0.8, 79th percentile) and 5 years post-treatment (BMI z-score = 0.7, 76th percentile). High BMI z-score at diagnosis was associated with an increased risk of being overweight/obese at treatment completion (OR = 2.9, 95% CI: 1.6-5.1). Weight gain during treatment was associated with being overweight/obese 5 years post-treatment (OR = 3.8, 95% CI: 1.1-12.5).

CONCLUSION

Children with ALL are at risk of becoming overweight/obese early in treatment. Increases in weight are maintained throughout treatment and beyond. Lifestyle interventions are needed targeting weight control early during treatment, particularly for patients overweight/obese at diagnosis and those who experience substantial weight gain during treatment.

Screening for vitamin D insufficiency in pediatric cancer survivors

BACKGROUND

Corticosteroids increase risk for decreased bone mineral density, which can be worsened by vitamin D insufficiency (VDI) or deficiency (VDD).

PROCEDURE

In the Vanderbilt cancer survivorship clinic, we obtained screening total 25-hydroxy vitamin D levels (VDL) in 171 cancer survivors <23 years old who were treated with prolonged corticosteroids for their cancer, and compared this group to a control group of 97 healthy pediatric patients.

RESULTS

VDD was diagnosed in 15.8% and VDI in 34.5% of cancer survivors and VDD/VDI combined was associated with body mass index (BMI) >85th percentile (Odds ratio [OR] = 5.4; P < 0.001), older age (OR = 2.2; P = 0.012), non-Caucasian or Hispanic race (OR = 4.5; P = 0.008) and summer versus winter season (OR = 0.12; P < 0.001). In multivariable analysis, VDI/VDD prevalence did not differ from the control group (VDI/VDD (43.3%)). In the combined survivor/control group multivariable analysis, cancer diagnosis did not increase VDI/VDD risk, but significant associations persisted with elevated BMI (P < 0.001), age (P = 0.004), non-Caucasian or Hispanic race (P < 0.001), and seasonality (P < 0.001).

CONCLUSION

VDD/VDI is equally common in pediatric cancer survivors treated with corticosteroids and healthy children. The impact of VDD/VDI in cancer survivors may be greater due to risk for impaired bone health superimposed on that conferred from corticosteroid exposure. Thus, screening VDLs should be obtained in pediatric cancer survivors treated with corticosteroids, particularly in those with elevated BMI, older age, or non-Caucasian race. Prospective studies evaluating the impact of interventions to minimize VDD/VDI on long-term bone health in survivors are required.

Obesity in pediatric ALL survivors: a meta-analysis

BACKGROUND AND OBJECTIVE

Previous studies of survivors of pediatric acute lymphoblastic leukemia (ALL) have drawn heterogeneous conclusions regarding the prevalence of obesity and risk factors for developing obesity in pediatric ALL survivors. We sought to determine the prevalence of obesity in pediatric ALL survivors and examine risk factors for obesity through a systematic review and meta-analysis.

METHODS

A MEDLINE search was performed from its inception through 2013. Studies met the inclusion criteria if they (1) included at least 10 survivors of pediatric ALL; (2) assessed the prevalence or indicators of obesity; and (3) compared obesity among ALL survivors to a reference population or external control group. Extracted data included patient and treatment characteristics, study design, population used for comparison, and prevalence of obesity.

RESULTS

Forty-seven studies met the inclusion criteria. Despite significant heterogeneity among the studies (I(2) = 96%), the mean BMI z score in 1742 pediatric ALL survivors was 0.83 (95% confidence interval: 0.60-1.06), which corresponds to the 80th BMI percentile, indicating a significantly higher BMI in pediatric ALL survivors than the reference population. Subgroup analyses found a high prevalence of obesity in ALL survivors regardless of survivors' receipt of cranial irradiation, gender, or age at diagnosis.

CONCLUSIONS

Obesity is prevalent in pediatric ALL survivors and is independent of patient- and treatment-related characteristics. Clinicians need to screen for obesity and its associated health conditions early in survivorship.

A population-based study of childhood cancer survivors' body mass index

Background. Population-based studies are needed to estimate the prevalence of underweight or overweight/obese childhood cancer survivors. Procedure. Adult survivors (diagnosed ≤20 years) were identified from the linked Utah Cancer Registry and Utah Population Database. We included survivors currently aged ≥20 years and ≥5 years from diagnosis (N = 1060), and a comparison cohort selected on birth year and sex (N = 5410). BMI was calculated from driver license data available from 2000 to 2010. Multivariable generalized linear regression models were used to calculate prevalence relative risks (RR) and 95% confidence intervals (95% CI) of BMI outcomes for survivors and the comparison cohort. Results. Average time since diagnosis was 18.5 years (SD = 7.8), and mean age at BMI for both groups was 30.5 (survivors SD = 7.7, comparison SD = 8.0). Considering all diagnoses, survivors were not at higher risk for being underweight or overweight/obese than the comparison. Male central nervous system tumor survivors were overweight (RR = 1.12, 95% CI 1.01-1.23) more often than the comparison. Female survivors, who were diagnosed at age 10 and under, had a 10% higher risk of being obese than survivors diagnosed at ages 16-20 (P < 0.05). Conclusion. While certain groups of childhood cancer survivors are at risk for being overweight/obese, in general they do not differ from population estimates.

Feasibility and initial effectiveness of home exercise during maintenance therapy for childhood acute lymphoblastic leukemia

PURPOSE

Children with acute lymphoblastic leukemia (ALL) are at increased risk of obesity and deconditioning from cancer therapy. This pilot study assessed feasibility/initial efficacy of an exercise intervention for patients with ALL undergoing maintenance therapy.

METHODS

Participants were aged 5 to 10 years, receiving maintenance therapy, in first remission. A 6-month home-based intervention, with written and video instruction, was supervised with weekly calls from an exercise coach. Pre- and poststudy testing addressed strength, flexibility, fitness, and motor function.

RESULTS

Seventeen patients enrolled (participation 63%). Twelve (71%) finished the intervention, completing 81.7 ± 7.2% of prescribed sessions. Improvements of 5% or more occurred in 67% for knee and 75% for grip strength, 58% for hamstring/low-back and 83% for ankle flexibility, 75% for the 6-Minute Walk Test, and 33% for performance on the Bruininks-Oseretsky Test of Motor Proficiency Version 2.

CONCLUSIONS

This pilot study demonstrated that exercise intervention during ALL therapy is feasible and has promise for efficacy.