Multiple risk behaviors among smokers in the childhood cancer survivors study cohort

Healthcare providers' perspectives on implementing a brief physical activity and diet intervention within a primary care smoking cessation program: a qualitative study

BACKGROUND

Post-smoking-cessation weight gain can be a major barrier to quitting smoking; however, adding behavior change interventions for physical activity (PA) and diet may adversely affect smoking cessation outcomes. The "Picking up the PACE (Promoting and Accelerating Change through Empowerment)" study assessed change in PA, fruit/vegetable consumption, and smoking cessation by providing a clinical decision support system for healthcare providers to utilize at the intake appointment, and found no significant change in PA, fruits/vegetable consumption, or smoking cessation. The objective of this qualitative study was to explore the factors affecting the implementation of the intervention and contextualize the quantitative results.

METHODS

Twenty-five semi-structured interviews were conducted with healthcare providers, using questions based on the National Implementation Research Network's Hexagon Tool. The data were analyzed using the framework's standard analysis approach.

RESULTS

Most healthcare providers reported a need to address PA and fruit/vegetable consumption in patients trying to quit smoking, and several acknowledged that the intervention was a good fit since exercise and diet could improve smoking cessation outcomes. However, many healthcare providers mentioned the need to explain the fit to the patients. Social determinants of health (e.g., low income, food insecurity) were brought up as barriers to the implementation of the intervention by a majority of healthcare providers. Most healthcare providers recognized training as a facilitator to the implementation, but time was mentioned as a barrier by many of healthcare providers. Majority of healthcare providers mentioned allied health professionals (e.g., dieticians, physiotherapists) supported the implementation of the PACE intervention. However, most healthcare providers reported a need for individualized approach and adaptation of the intervention based on the patients' needs when implementing the intervention. The COVID-19 pandemic was found to impact the implementation of the PACE intervention based on the Hexagon Tool indicators.

CONCLUSION

There appears to be a need to utilize a flexible approach when addressing PA and fruit/vegetable consumption within a smoking cessation program, based on the context of clinic, the patients' it is serving, and their life circumstances. Healthcare providers need support and external resources to implement this particular intervention.

NAME OF THE REGISTRY

Clinicaltrials.gov.

TRIAL REGISTRATION NUMBER

NCT04223336.

DATE OF REGISTRATION

7 January 2020 Retrospectively registered. URL OF TRIAL REGISTRY RECORD: https://classic.

CLINICALTRIALS

gov/ct2/show/NCT04223336 .

Impact of a Clinical Decision Support System for Addressing Physical Activity and/or Healthy Eating during Smoking Cessation Treatment: Hybrid Type I Randomized Controlled Trial (Preprint)

Background

People who smoke have other risk factors for chronic diseases, such as low levels of physical activity and poor diet. Clinical decision support systems (CDSSs) might help health care practitioners integrate interventions for diet and physical activity into their smoking cessation programming but could worsen quit rates.

Objective

The aims of this study are to assess the effects of the addition of a CDSS for physical activity and diet on smoking cessation outcomes and to assess the implementation of the study.

Methods

We conducted a pragmatic hybrid type I effectiveness-implementation trial with 232 team-based primary care practices in Ontario, Canada, from November 2019 to May 2021. We used a 2-arm randomized controlled trial comparing a CDSS addressing physical activity and diet to treatment as usual and used the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework to measure implementation outcomes. The primary outcome was self-reported 7-day tobacco abstinence at 6 months.

Results

We enrolled 5331 participants in the study. Of these, 2732 (51.2%) were randomized to the intervention group and 2599 (48.8%) to the control group. At the 6-month follow-up, 29.7% (634/2137) of respondents in the intervention arm and 27.3% (552/2020) in the control arm reported abstinence from tobacco. After multiple imputation, the absolute group difference was 2.1% (95% CI −0.5 to 4.6; F_1,1000.42=2.43; P=.12). Mean exercise minutes changed from 32 (SD 44.7) to 110 (SD 196.1) in the intervention arm and from 32 (SD 45.1) to 113 (SD 195.1) in the control arm (group effect: B=−3.7 minutes; 95% CI −17.8 to 10.4; P=.61). Servings of fruit and vegetables changed from 2.64 servings to 2.42 servings in the intervention group and from 2.52 servings to 2.45 servings in the control group (incidence rate ratio for intervention group=0.98; 95% CI 0.93-1.02; P=.35).

Conclusions

A CDSS for physical activity and diet may be added to a smoking cessation program without affecting the outcomes. Further research is needed to improve the impact of integrated health promotion interventions in primary care smoking cessation programs.

Trial Registration

ClinicalTrials.gov NCT04223336 https://www.clinicaltrials.gov/ct2/show/NCT04223336

International Registered Report Identifier (IRRID)

RR2-10.2196/19157

Systematic Review of Substance Use Measurement Tools in Adolescent and Young Adult Childhood Cancer Survivors

Substance use among adolescents and young adults (AYAs) is associated with an increased risk of poor physical and mental health outcomes. For AYA childhood cancer survivors (CCSs), substance use may also increase their likelihood of experiencing late effects. As a result, professional organizations recommend that AYA CCSs be regularly screened for risk behaviors, including substance use. The best methods for assessing these behaviors as part of clinical care for AYA CCSs, however, remain unclear. To begin to address this gap, the purpose of this study was to systematically review written substance use measures that have been used with AYA CCSs and published between 2000 and 2020. A search of PubMed, PsycINFO, and CINAHL using terms related to substance use and AYA CCSs identified 47 articles representing 20 different written substance use measures that evaluated current substance use (i.e., use of alcohol, tobacco, marijuana, prescription medications taken in a manner other than as prescribed, and/or other illicit substances within the 12 months). Measures varied in domains assessed, item formats, and response formats. Results are presented alongside recommendations for selecting screening tools for use with AYA CCS populations in both clinical and research settings.

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).

Health-Promoting Lifestyle and Its Predictors in Adolescent Survivors of Childhood Cancer

Background: Cancer survivors are at increased risk of long-term adverse effects related to the disease or treatment. Thus, it is important for cancer survivors to adopt a health-promoting lifestyle (HPL). This study aims to: (1) describe health behavior self-efficacy (HBSE) and HPL of adolescent survivors of childhood cancer, (2) examine the relationships between HBSE, HPL, and various demographic factors, and (3) identify determinants of HPL among adolescent survivors of childhood cancer. Method: A descriptive cross-sectional study was conducted with adolescent survivors of childhood cancer, ranged in age from 11 to 19 years (n = 82). Participants were recruited from pediatric oncology follow-up clinics at two medical centers in southern Taiwan. Data for each participant were collected from questionnaires assessing HBSE and HPL. Results: Only 61% of the adolescent survivors were considered as normal weight. The exercise was the lowest scoring HBSE subscale. Factors associated with better HPL included: education level, HBSE, well-being, and a healthy diet. Specifically, survivors diagnosed with cancer during adolescence exhibited significantly greater self-efficacy with stress management (F = 3.20, p = .04) compared with those diagnosed at pre-school ages. HBSE scores for well-being and a healthy diet were significant predictors of HPL, accounting for 43.8% of the total variance observed. Discussion: Our findings suggest that the age of diagnosis of childhood cancer significantly modulates the frequency of health-promoting behaviors of adolescent survivors. Thus, interventions designed to enhance adolescents' well-being and the management of a healthy diet may enhance HPL in survivors of childhood cancer.

Impact of a Web-Based Clinical Decision Support System to Assist Practitioners in Addressing Physical Activity and/or Healthy Eating for Smoking Cessation Treatment: Protocol for a Hybrid Type I Randomized Controlled Trial

BACKGROUND

Modifiable risk factors such as tobacco use, physical inactivity, and poor diet account for a significant proportion of the preventable deaths in Canada. These factors are also known to cluster together, thereby compounding the risks of morbidity and mortality. Given this association, smoking cessation programs appear to be well-suited for integration of health promotion activities for other modifiable risk factors. The Smoking Treatment for Ontario Patients (STOP) program is a province-wide smoking cessation program that currently encourages practitioners to deliver Screening, Brief Intervention, and Referral to treatment for patients who are experiencing depressive symptoms or consume excessive amounts of alcohol via a web-enabled clinical decision support system. However, there is no available clinical decision support system for physical inactivity and poor diet, which are among the leading modifiable risk factors for chronic diseases.

OBJECTIVE

The aim of this study is to assess whether adding a computerized/web-enabled clinical decision support system for physical activity and diet to a smoking cessation program affects smoking cessation outcomes.

METHODS

This study is designed as a hybrid type 1 effectiveness/implementation randomized controlled trial to evaluate a web-enabled clinical decision support system for supporting practitioners in addressing patients' physical activity and diet as part of smoking cessation treatment in a primary care setting. This design was chosen as it allows for simultaneous testing of the intervention, its delivery in target settings, and the potential for implementation in real-world situations. Intervention effectiveness will be measured using a two-arm randomized controlled trial. Health care practitioners will be unblinded to their patients' treatment allocation; however, patients will be blinded to whether their practitioner receives the clinical decision support system for physical activity and/or fruit/vegetable consumption. The evaluation of implementation will be guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework.

RESULTS

Recruitment for the primary outcome of this study is ongoing and will be completed in November 2020. Results will be reported in March 2021.

CONCLUSIONS

The findings of the study will provide much needed insight into whether adding a computerized/web-enabled clinical decision support system for physical activity and diet to a smoking cessation program affects smoking cessation outcome. Furthermore, the implementation evaluation would provide insight into the feasibility of online-based interventions for physical activity and diet in a smoking cessation program. Addressing these risk factors simultaneously could have significant positive effects on chronic disease and cancer prevention.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04223336; https://clinicaltrials.gov/ct2/show/NCT04223336.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/19157.

Identifying contexts and mechanisms in multiple behavior change interventions affecting smoking cessation success: a rapid realist review

Background

Smoking continues to be a leading cause of preventable chronic disease-related morbidity and mortality, excess healthcare expenditure, and lost work productivity. Tobacco users are disproportionately more likely to be engaging in other modifiable risk behaviours such as excess alcohol consumption, physical inactivity, and poor diet. While hundreds of interventions addressing the clustering of smoking and other modifiable risk behaviours have been conducted worldwide, there is insufficient information available about the context and mechanisms in these interventions that promote successful smoking cessation. The aim of this rapid realist review was to identify possible contexts and mechanisms used in multiple health behaviour change interventions (targeting tobacco and two or more additional risk behaviours) that are associated with improving smoking cessation outcome.

Methods

This realist review method incorporated the following steps: (1) clarifying the scope, (2) searching for relevant evidence, (3) relevance confirmation, data extraction, and quality assessment, (4) data analysis and synthesis.

Results

Of the 20,423 articles screened, 138 articles were included in this realist review. Following Michie et al.’s behavior change model (the COM-B model), capability, opportunity, and motivation were used to identify the mechanisms of behaviour change. Universally, increasing opportunities (i.e. factors that lie outside the individual that prompt the behaviour or make it possible) for participants to engage in healthy behaviours was associated with smoking cessation success. However, increasing participant’s capability or motivation to make a behaviour change was only successful within certain contexts.

Conclusion

In order to address multiple health behaviours and assist individuals in quitting smoking, public health promotion interventions need to shift away from ‘individualistic epidemiology’ and invest resources into modifying factors that are external from the individual (i.e. creating a supportive environment).

Trial registration

PROSPERO registration number: CRD42017064430

Nutritional concerns of survivors of childhood cancer: A "First World" perspective

Childhood cancer survivor (CCS) numbers are increasing as a result of advances in both treatment and supportive care. This positive outcome is tempered by the recognition of a high burden of chronic health conditions. Here, we review the nutritional concerns of CCS, including dietary habits after treatment and the factors during treatment that may contribute to chronic health conditions. Dietary interventions that have been conducted in CCS will be summarized along with focused goals of these interventions. We will also address the need to leverage these interventions to reduce the risk of chronic disease in CCS.

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

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

Summer sun-exposure in Australian childhood cancer survivors and community reference groups

PURPOSE

Sun-exposure can cause health problems, including melanoma and nonmelanoma skin cancer, especially in Australia where the incidence of skin cancer is particularly high. Childhood cancer survivors (CCSs) have an augmented risk due to previous cancer history and treatment. Despite recommendations advising sun protection, CCSs may be placing themselves at risk. We considered daily summer sun-exposure in an Australian cohort of CCSs and in community reference groups, and identified factors associated with sun-exposure in these populations.

METHODS

Summer sun-exposure data were collected on 471 CCSs (119 parents of survivors aged <16, and 352 survivors aged ≥16) and a reference group of 470 participants from the community (155 parents of children aged <16, and 355 adults aged ≥16). Survivors completed paper questionnaires and the reference groups completed an online survey. Medical records confirmed survivors' clinical information. Ordinal logistic regressions identified factors associated with daily summer sun-exposure.

RESULTS

More daily summer sun-exposure was reported by both parents reporting for the young survivors (U = 5,522.5, P < .001; U = 31,412, P < .001) and by older survivors (U = 5,039.5, P < .001; U = 29,913, P < .001). Among younger participants greater sun-exposure was associated with being a CCS, while in older participants, greater sun-exposure was associated with being a CCS, a male, smoker/ex-smoker and was also increased in those with more sensitive skin reaction to sunlight. Focusing only on the CCSs, when treatments were considered, none statistically predicted sun-exposure in young CCSs while older CCSs who received radiotherapy were less likely to spend excess time in the sun.

CONCLUSION

CCSs have sun-exposure at times of day when sun-related skin damage is highest, despite advice to avoid highest risk times. This data can inform sun-protection programs and lifestyle advice aimed at ameliorating the potential increased risk of skin cancer in CCSs.

Cardiovascular Risk Reduction in High-Risk Pediatric Patients: A Scientific Statement From the American Heart Association

This scientific statement presents considerations for clinical management regarding the assessment and risk reduction of select pediatric populations at high risk for premature cardiovascular disease, including acquired arteriosclerosis or atherosclerosis. For each topic, the evidence for accelerated acquired coronary artery disease and stroke in childhood and adolescence and the evidence for benefit of interventions in youth will be reviewed. Children and adolescents may be at higher risk for cardiovascular disease because of significant atherosclerotic or arteriosclerotic risk factors, high-risk conditions that promote atherosclerosis, or coronary artery or other cardiac or vascular abnormalities that make the individual more vulnerable to the adverse effects of traditional cardiovascular risk factors. Existing scientific statements and guidelines will be referenced when applicable, and suggestions for risk identification and reduction specific to each setting will be described. This statement is directed toward pediatric cardiologists, primary care providers, and subspecialists who provide clinical care for these young patients. The focus will be on management and justification for management, minimizing information on pathophysiology and epidemiology.

Integrative Medicine in Childhood Cancer

The diagnosis of cancer in a child leaves parents and families devastated and vulnerable. In an effort to do everything possible, families often choose an integrative medicine approach to their child's care. Surveys have found that 31%-84% of children with cancer use complementary and alternative medicine and most often as supportive care agents. Several systematic reviews have demonstrated a clinical benefit for some select therapies; however, the safety and efficacy of the combination of biological therapies with conventional treatment remain largely unknown and garner concern due to the potential for interactions with conventional therapy. Given the sustained use and potential benefit of integrative medicine, additional research is warranted in pediatric oncology. Utilizing the available literature, clinical providers should aim to conduct open and nonjudgmental discussions with families about the use of integrative medicine so as to guide the safe integration of the two modalities.

The effects of interventions targeting multiple health behaviors on smoking cessation outcomes: a rapid realist review protocol

BACKGROUND

Health behaviors directly impact the health of individuals, and populations. Since individuals tend to engage in multiple unhealthy behaviors such as smoking, excessive alcohol use, physical inactivity, and eating an unhealthy diet simultaneously, many large community-based interventions have been implemented to reduce the burden of disease through the modification of multiple health behaviors. Smoking cessation can be particularly challenging as the odds of becoming dependent on nicotine increase with every unhealthy behavior a smoker exhibits. This paper presents a protocol for a rapid realist review which aims to identify factors associated with effectively changing tobacco use and target two or more additional unhealthy behaviors.

METHODS

An electronic literature search will be conducted using the following bibliographic databases: MEDLINE, Embase, PsycINFO, Cumulative Index to Nursing and Allied Health Literature (CINAHL), The Cochrane Library, Social Science Abstracts, Social Work Abstracts, and Web of Science. Two reviewers will screen titles and abstracts for relevant research, and the selected full papers will be used to extract data and assess the quality of evidence. Throughout this process, the rapid realist approach proposed by Saul et al., 2013 will be used to refine our initial program theory and identify contextual factors and mechanisms that are associated with successful multiple health behavior change.

DISCUSSION

This review will provide evidence-based research on the context and mechanisms that may drive the success or failure of interventions designed to support multiple health behavior change. This information will be used to guide curriculum and program development for a government funded project on improving smoking cessation by addressing multiple health behaviors in people in Canada.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42017064430.

Early Nutrition and Physical Activity Interventions in Childhood Cancer Survivors

PURPOSE OF REVIEW

Childhood cancer survivors experience excessive weight gain early in treatment. Lifestyle interventions need to be initiated early in cancer care to prevent the early onset of obesity and cardiovascular disease (CVD). We reviewed the existing literature on early lifestyle interventions in childhood cancer survivors and consider implications for clinical care.

RECENT FINDINGS

Few lifestyle interventions focus on improving nutrition in childhood cancer survivors. A consistent effect on reducing obesity and CVD risk factors is not evident from the limited number of studies with heterogeneous intervention characteristics, although interventions with a longer duration and follow-up show more promising trends. Future lifestyle interventions should be of a longer duration and include a nutrition component. Interventions with a longer duration and follow-up are needed to assess the timing and sustainability of the intervention effect. Lifestyle interventions introduced early in cancer care are both safe and feasible.

Lifestyle behavior interventions delivered using technology in childhood, adolescent, and young adult cancer survivors: A systematic review

Childhood, adolescent, and young adult cancer survivors demonstrate increased cardio-metabolic risk factors, which are amenable to lifestyle changes. The use of technology to impact lifestyle change expands previously limited intervention access, yet little is known about its use. We summarized lifestyle interventions for survivors delivered using technology, finding six studies, primarily targeting physical activity. Study samples were small and durations ranged from 5 to 16 weeks and outcomes modest. Participants were older, white, survivors of leukemia or brain tumors, and the majority received Web-based interventions. Study quality was moderate. Few technology-based interventions have been developed, suggesting an area of opportunity for survivors.

Does the Relationship Between Cigarette Smoking and Other Key Health Behaviors Vary by Geographic Area Among US Young Adults? A Multilevel Analysis

BACKGROUND

Although researchers and practitioners have long been aware of interdependence among health behaviors, they tend to compartmentalize health behaviors in research and practice. This kind of approach often fails to acknowledge the syndemic nature of health behaviors.

PURPOSE

This study investigated differences in the relationship between cigarette smoking and other key health behaviors, such as vigorous physical activity, fruit and vegetable consumption, and binge drinking among young adults (ages 18 to 30 years) across 180 metropolitan and micropolitan statistical areas (MMSAs) in the USA.

METHOD

A total of 19,027 young adults in the 2009 Behavioral Risk Factor Surveillance System (BRFSS) data were analyzed using multilevel logistic regression models.

RESULTS

Both vigorous physical activity and fruit and vegetable consumption were negatively associated with cigarette smoking, whereas binge drinking was positively associated with smoking. There were significant differences in the relation of smoking with vigorous physical activity, fruit and vegetable consumption, and binge drinking across the 180 MMSAs. These differences were associated with the prevalence of cigarette smoking and binge drinking for each MMSA.

CONCLUSION

As indicated by the social learning theory, geographic area-specific prevalence of health behaviors appears to reflect group norms regarding those behaviors which, in turn, affect the clustering of health behaviors in the respective area.

Obesity in Childhood Cancer Survivors: Call for Early Weight Management

A high prevalence of obesity and cardiometabolic conditions has been increasingly recognized in childhood cancer survivors. In particular, survivors of pediatric acute lymphoblastic leukemia have been found to be at risk of becoming overweight or obese early in treatment, with increases in weight maintained throughout treatment and beyond. Nutrition plays an important role in the etiology of obesity and cardiometabolic conditions and is among the few modifiable factors that can prevent or delay the early onset of these chronic conditions. However, nutritional intake in childhood cancer survivors has not been adequately examined and the evidence is built on data from small cohorts of survivors. In addition, the long-term impact of cancer diagnosis and treatment on survivors' nutritional intake as well as how survivors' nutritional intake is associated with chronic health conditions have not been well quantified in large-scale studies. Promoting family-based healthy lifestyles, preferably at a sensitive window of unhealthy weight gain, is a priority for preventing the early onset of obesity and cardiometabolic conditions in childhood cancer survivors.

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.

Health Behaviors of Childhood Cancer Survivors

There has been a dramatic increase in the number of childhood cancer survivors living to an old age due to improved cancer treatments. However, these survivors are at risk of numerous late effects as a result of their cancer therapy. Engaging in protective health behaviors and limiting health damaging behaviors are vitally important for these survivors given their increased risks. We reviewed the literature on childhood cancer survivors’ health behaviors by searching for published data and conference proceedings. We examine the prevalence of a variety of health behaviors among childhood cancer survivors, identify significant risk factors, and describe health behavior interventions for survivors.

Nutritional Counseling in Survivors of Childhood Cancer: An Essential Component of Survivorship Care

There is a growing body of evidence suggesting that nutritional status during treatment for cancer has a significant impact on treatment-related toxicities and outcomes among children and adolescents with cancer. The effects of nutritional status appear to extend into survivorship with a large proportion of survivors at risk for a variety of nutrition-related morbidities. The influence of dietary intake on overall treatment outcomes and long-term morbidities is largely unknown. In adults, evidence suggests that greater adherence to cancer prevention dietary guidelines improves long-term health outcomes among survivors of cancer. Surveys describing dietary intake among survivors of childhood cancer have found that most survivors are not meeting the recommended guidelines for many dietary nutrients and this may have an unfavorable effect on nutrition-related outcomes. However, more research is needed in this area so that well-designed clinical trials may be developed and tested. This review presents an overview of the existing literature describing dietary intake among survivors of childhood cancer, the clinical implications of reported dietary behaviors among survivors, and identifies areas for future research.

Health-related quality of life, lifestyle behaviors, and intervention preferences of survivors of childhood cancer

PURPOSE

Childhood cancer survivors (CCSs) are at increased risk for poor health-related quality of life (HRQOL) and chronic health conditions-both of which can be exacerbated by unhealthy lifestyle behaviors. Developing a clearer understanding of the associations between HRQOL, lifestyle behaviors, and medical and demographic variables (e.g., age/developmental stage at time of diagnosis) is an important step toward developing more targeted behavioral interventions for this population.

METHOD

Cross-sectional questionnaires were completed by 170 CCSs who were diagnosed with leukemia, lymphoma, sarcoma, or a cancer of the central nervous system (CNS) and treated at a comprehensive cancer center between 1992 and 2007. Questionnaires addressed weight status, lifestyle behaviors, aspects of HRQOL, and intervention preferences.

RESULTS

Adolescent and young adult survivors (AYAs) and survivors of CNS tumors or lymphoma reported significantly (p < .05) poorer HRQOL across multiple domains compared to those diagnosed at an earlier age, survivors of leukemia or sarcoma, and healthy populations. A significant proportion also failed to meet national recommendations for dietary intakes (39-94 %) and physical activity (65 %). Female survivors reported poorer physical functioning and consumed less dietary fiber and fruits and vegetables than did male survivors. They also expressed the strongest interest in participating in diet and exercise interventions.

CONCLUSION

Findings support the premise that females, AYAs, and survivors of cancers of the CNS or lymphoma are "at risk" subgroups within the CCS population for poor dietary practices, sedentary behaviors, and poor HRQOL. Future research should focus on developing diet and PA interventions to improve HRQOL that target these groups.

IMPLICATIONS FOR CANCER SURVIVORS

Greater consideration of the role of gender, developmental stage, and the HRQOL challenges facing CCSs may help researchers to develop targeted behavioral interventions for those who stand to benefit the most.

Do childhood cancer survivors with physical performance limitations reach healthy activity levels?

BACKGROUND

The extent to which physical performance limitations affect the ability of childhood cancer survivors to reach healthy activity levels is unknown. Therefore this study aims to describe the effect of different types of limitations on activity levels in survivors.

PROCEDURE

Within the Swiss Childhood Cancer Survivor Study we sent a questionnaire to all survivors (≥16 years) registered in the Swiss Childhood Cancer Registry, who survived >5 years and were diagnosed 1976-2005 aged <16 years. We measured healthy activity levels using international guidelines and assessed different kinds of performance limitations (visual impairment, weight and endurance problems, cardiorespiratory, musculoskeletal, and neurological problems, pain and fatigue syndromes).

RESULTS

The sample included 1,560 survivors (75% response rate), of whom 209 (13.5%) reported they have performance limitations. Forty-two percent of survivors with limitations reached healthy activity levels, compared to 57% of survivors without limitations. Least active were survivors with vision impairments (25% active), weight and endurance problems (27.3%), cardiorespiratory problems (36.4%), and musculoskeletal problems (43.1%). After adjusting for socio-demographic variables and type of cancer, we found that survivors with limitations were 1.4 (95%CI 1.0-2.0; P = 0.047) times more likely to be inactive.

CONCLUSIONS

Although many survivors with physical performance limitations maintain healthy activity levels, there is room for improvement. Adapted and targeted physical activity counseling for survivors with performance limitations might help them to raise level of activity and pursue a healthy lifestyle.

Do Childhood Cancer Survivors Meet the Diet and Physical Activity Guidelines? A Review of Guidelines and Literature

Despite advances in cancer treatment, childhood cancer survivors are at higher risk of developing chronic health conditions than peers who have not had cancer. Being overweight or obese adds to the already elevated risk of cardiovascular diseases and metabolic abnormalities. Diet and physical activity are modifiable behaviors that reduce obesity risk and have been shown to improve cancer survival in adult cancer survivors. Specific guidelines have been developed for cancer survivors that provide advice on nutrition, physical activity and weight management following cancer diagnosis and treatment. In this review, we report on existing nutrition and physical activity guidelines for cancer survivors, supplemented by available literature on diet and physical activity status of childhood cancer survivors and their associations with health-related outcomes. The 2012 American Cancer Society (ACS) and the 2008 Children’s Oncology Group (COG) guidelines provide similar advice on diet but the ACS guidelines also offer specific advice on physical activity and weight management. Thirty-one observational studies and 18 intervention trials published prior to June 2012 that met the inclusion criteria were reviewed. Results suggest that a high proportion of childhood cancer survivors had poor adherence to dietary and physical activity guidelines. Although findings from existing intervention trials are preliminary due to small sample size, available evidence suggests that exercise intervention is safe and feasible for patients and survivors of childhood cancer. Childhood cancer survivors should be encouraged to engage in physical activity, adopt a healthy diet, and maintain a healthy weight throughout cancer survivorship.

Who tended to continue smoking after cancer diagnosis: the national health and nutrition examination survey 1999-2008

Background

It has been estimated that there are approximately 12 million cancer survivors in the United States. Continued smoking after a cancer diagnosis is linked to adverse effects among cancer survivors on overall survival, treatment effectiveness, and quality of life. Little is known about who is more likely to quit smoking after his/her cancer diagnosis. The objective of this study is to evaluate factors associated with smoking cessation in cancer survivors, which to date has not been well studied.

Method

The National Health and Nutrition Examination Survey (NHANES) 1999–2008 surveys were used in this study. A total of 2,374 cancer survivors aged 20 and over with valid smoking status in the NHANES 99–08 survey were included in this study. Among them, 566 cancer survivors who regularly smoked at the time of their cancer diagnosis were included in the analyses.

Results

Around 50.6% of cancer survivors smoked regularly prior to their cancer diagnosis and only 36.1% of them quit smoking after their cancer diagnosis. Racial disparity was observed in smoking cessation among cancer survivors. Hispanics (OR = 0.23, 95% CI = 0.10-0.57) were less likely to quit smoking than Whites after their cancer diagnosis.

Conclusion

Two-thirds of cancer survivors continued smoking after cancer diagnosis. Our study observed that the high risk group of continued smokers among cancer survivors is made up of those who are female, younger, Hispanic, with longer smoking history, underweight or with normal weight and without smoking-related cancer. These findings suggest that smoking cessation for cancer survivors should target on the high risk subgroups.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

METHODOLOGY/PRINCIPAL FINDINGS

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

CONCLUSIONS/SIGNIFICANCE

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

Alcohol consumption and binge drinking in young adult childhood cancer survivors

BACKGROUND

This study compared frequency of alcohol consumption and binge drinking between young adult childhood cancer survivors and the general population in Switzerland, and assessed its socio-demographic and clinical determinants.

PROCEDURE

Childhood cancer survivors aged <16 years when diagnosed 1976-2003, who had survived >5 years and were currently aged 20-40 years received a postal questionnaire. Reported frequency of alcohol use and of binge drinking were compared to the Swiss Health Survey, a representative general population survey. Determinants of frequent alcohol consumption and binge drinking were assessed in a multivariable logistic regression.

RESULTS

Of 1,697 eligible survivors, 1,447 could be contacted and 1,049 (73%) responded. Survivors reported more often than controls to consume alcohol frequently (OR = 1.7; 95%CI = 1.3-2.1) and to engage in binge drinking (OR = 2.9; 95%CI = 2.3-3.8). Peak frequency of binge drinking in males occurred at age 24-26 years in survivors, compared to age 18-20 in the general population. Socio-demographic factors (male gender, high educational attainment, French and Italian speaking, and migration background from Northern European countries) were most strongly associated with alcohol consumption patterns among both survivors and controls.

CONCLUSIONS

The high frequency of alcohol consumption found in this study is a matter of concern. Our data suggest that survivors should be better informed on the health effects of alcohol consumption during routine follow-up, and that such counseling should be included in clinical guidelines. Future research should study motives of alcohol consumption among survivors to allow development of targeted health interventions for this vulnerable group.

Health behaviors and weight status of childhood cancer survivors and their parents: similarities and opportunities for joint interventions

Childhood cancer survivors are at increased risk for chronic health conditions that may be influenced by their cancer treatment and unhealthy lifestyle behaviors. Despite the possibility that interventions targeting the survivor-parent dyad may hold promise for this population, a clearer understanding of the role of family factors and the lifestyle behaviors of both survivors and parents is needed. A mailed cross-sectional survey was conducted in 2009 to assess weight status (body mass index), lifestyle behaviors (eg, diet, physical activity), and the quality of the parent-child relationship among 170 childhood cancer survivors who were treated at MD Anderson Cancer Center and 114 of their parents (80% mothers). Survivors were more physically active and consumed more fruits and vegetables than their parents. However, fewer than half of survivors or parents met national guidelines for diet and physical activity, and their weight status and fat intakes were moderately correlated (r=.30-.57; P<0.001). Multilevel models showed that, compared with survivors with better than average relationships, those with poorer than average relationships with their parents were significantly more likely to consume high-fat diets (P<0.05). Survivors and their parents may thus benefit from interventions that address common lifestyle behaviors, as well as issues in the family environment that may contribute to an unhealthy lifestyle.

Diet and physical activity in childhood cancer survivors: a review of the literature

Treatment advances have led to a growing population of childhood cancer survivors. Many are at risk for developing treatment-related late effects. Diet and physical activity may affect levels of health risk. A number of papers have examined these behaviors in childhood cancer survivors. The purpose of this study was to provide a review and summary of the published studies in the areas of diet, physical activity, and related interventions among childhood cancer survivors. A systematic search was conducted for studies published prior to October 2009. Descriptive and intervention studies that included survivors of childhood cancers and a measurement of diet and/or physical activity were reviewed. Twenty-six manuscripts met criteria: ten addressed diet; 20 addressed physical activity, and six included intervention studies. Results suggest that childhood cancer survivors engage in health-promoting activities at rates comparable to the general population. Behavioral interventions have mostly targeted physical activity. Results, overall, are not encouraging, due primarily to difficulties recruiting and retaining participants. Although more rigorous studies are needed, recommendations for health-promoting behaviors should be a regular topic of discussion between health care providers and their childhood cancer survivor patients.

Design and recruitment of the Chicago Healthy Living Study: a study of health behaviors in a diverse cohort of adult childhood cancer survivors

BACKGROUND

Adult childhood cancer survivors are at higher risk for developing late medical effects related to their cancer treatments. Health-promoting behaviors may reduce the risk of some late effects and the severity of others. This article describes the design and recruitment of the Chicago Healthy Living Study (CHLS), an on-going study designed to examine the health behaviors and body mass index of minority adult childhood cancer survivors compared with nonminority survivors and noncancer controls.

METHODS

Survivors are identified by the hospital cancer registries at 5 treating institutions in the Chicago area; then, a multilevel recruitment plan will be implemented with the objective of enrolling 450 adult survivors of childhood cancer (150 in each racial/ethnic group). Simultaneously, 375 adult African-American, Hispanic, and non-Hispanic white noncancer controls (125 in each racial/ethnic group) living in the Chicago area will be recruited by using listed, targeted digit dialing. All participants will complete a 2-hour interview of questionnaires related to diet, physical activity, smoking, and associated mediators. Height and weight also will be measured.

CONCLUSIONS

The CHLS will provide important information on the health behaviors of adult minority childhood cancer survivors that can be used to inform the development of interventions to improve modifiable risks.

The Childhood Cancer Survivor Study: a National Cancer Institute-supported resource for outcome and intervention research

Survival for childhood cancer has increased dramatically over the last 40 years with 5-year survival rates now approaching 80%. For many diagnostic groups, rapid increases in survival began in the 1970s with the broader introduction of multimodality approaches, often including combination chemotherapy with or without radiation therapy. With this increase in rates of survivorship has come the recognition that survivors are at risk for adverse health and quality-of-life outcomes, with risk being influenced by host-, disease-, and treatment-related factors. In 1994, the US National Cancer Institute funded the Childhood Cancer Survivor Study, a multi-institutional research initiative designed to establish a large and extensively characterized cohort of more than 14,000 5-year survivors of childhood and adolescent cancer diagnosed between 1970 and 1986. This ongoing study, which reflects the single most comprehensive body of information ever assembled on childhood and adolescent cancer survivors, provides a dynamic framework and resource to investigate current and future questions about childhood cancer survivors.

Promoting physical activity in childhood cancer survivors: results from the Childhood Cancer Survivor Study

BACKGROUND

Although physical activity may modify the late effects of childhood cancer treatment, from 20% to 52% of adult survivors are sedentary. The authors of this report sought to identify modifiable factors that influence survivors' participation in physical activity.

METHODS

Structural equation modeling of data were derived from the Childhood Cancer Survivors Study of adult survivors (current mean age, 30.98 years; mean years since diagnosis, 23.74; mean age at diagnosis, 9.25 years) who were diagnosed between 1970 and 1986.

RESULTS

Approximately 40% of the variance in male survivors' recent participation versus nonparticipation in physical activity was explained directly and/or indirectly by self-reported health fears (P = .01), perceived primary-care physician (PCP) expertise (P = .01), baseline exercise frequency (P < or = .001), education level (P = .01), self-reported stamina (P = .01), cancer-related pain (P < or = .001), fatigue (P < or = .001), age at diagnosis (P = .01), cancer-related anxiety (P < or = .001), motivation (P = .01), affect (P = .01), and discussion of subsequent cancer risk with the PCP (P < or = .001) (N = 256; chi-square test statistic = 53.38; degrees of freedom [df] = 51; P = .38, Comparative Fit Index [CFI] = 1.000; Tucker Lewis Index [TLI] = 1.000; root mean square of approximation [RMSEA] = 0.014; weighted root mean square residual [WRMR] = 0.76). Thirty-one percent of the variance in women' recent physical activity participation was explained directly and/or indirectly by self-reported stamina (P < or = .001), fatigue (P = .01), baseline exercise frequency (P = .01), cancer-related pain (P < or = .001), cancer-related anxiety (P = .01), recency of visits with PCP (<0.001), quality of interaction with the PCP (P = .01), and motivation (P < or = .001; N = 366; chi-square test statistic = 67.52; df = 55; P = .12; CFI = 0.98; TLI = 0.98; RMSEA = 0.025; WRMR = 0.76).

CONCLUSIONS

Gender-tailored intervention strategies in which providers specifically target motivation, fear, and affect may support physical activity in childhood cancer survivors.

Health behaviors, medical care, and interventions to promote healthy living in the Childhood Cancer Survivor Study cohort

Childhood cancer survivors are at risk for medical and psychosocial late effects as a result of their cancer and its therapy. Promotion of healthy lifestyle behaviors and provision of regular risk-based medical care and surveillance may modify the evolution of these late effects. This manuscript summarizes publications from the Childhood Cancer Survivor Study (CCSS) that have examined health behaviors, risk-based health care, and interventions to promote healthy lifestyle practices. Long-term survivors use tobacco and alcohol and have inactive lifestyles at higher rates than is ideal given their increased risk of cardiac, pulmonary, and metabolic late effects. Nearly 90% of survivors report receiving some form of medical care. However, only 18% report medical visits related to their prior cancer that include discussion or ordering of screening tests or counseling on how to reduce the specific risks arising from their cancer. One low-cost, peer-driven intervention trial has been successful in improving smoking cessation within the CCSS cohort. On the basis of data from CCSS investigations, several trials to promote improved medical surveillance among high-risk groups within the cohort are underway. Despite their long-term risks, many survivors of childhood cancer engage in risky health behaviors and do not receive adequate risk-based medical care.

Prevalence of multiple health-related behaviors in adolescents with cancer

OBJECTIVE

This preliminary study investigated prevalence rates of multiple health-related behaviors (ie, tobacco, alcohol, and other drug use; sexual risk-taking; nutrition/physical activity; overweight and dietary behaviors; sun safety) among 42 adolescents on active treatment for cancer, as compared with healthy adolescent norms.

METHODS

Health-related behaviors were assessed using the 2005 National Youth Risk Behavior Survey, for which healthy adolescent norms were publicly available.

RESULTS

Adolescents with cancer reported significantly lower current and lifetime rates of tobacco, alcohol, and other drug use; fruit/vegetable consumption; physical activity; and dietary behavior, in addition to lower rates of lifetime sexual intercourse, early-onset sexual intercourse, and alcohol/drug use before last sexual intercourse, compared with healthy peers. Among those who have previously engaged in sexual intercourse, there appeared to be a trend toward increased partners, current sexual activity, and lack of protection at last episode of sexual intercourse. Adolescents with cancer also reported significantly higher rates of television watching compared with healthy peers.

CONCLUSIONS

Adolescents on active treatment for cancer are engaging in multiple health-risk behaviors, including sedentary behavior, poor nutrition, lack of sun safety, and sexual risk-taking (eg, multiple partners, lack of protection at last sexual intercourse). Health promotion interventions are needed during active treatment to facilitate the acquisition of good health practices as adolescents transition into survivorship.

Poor adherence to dietary guidelines among adult survivors of childhood acute lymphoblastic leukemia

Recent studies indicate that survivors of childhood acute lymphoblastic leukemia (ALL) are at increased risk of obesity and cardiovascular disease, conditions that healthy dietary patterns may help ameliorate or prevent. To evaluate the usual dietary intake of adult survivors of childhood ALL, food frequency questionnaire data were collected from 72 participants, and compared with the 2007 World Cancer Research Fund/American Institute for Cancer Research (WCRF/AICR) Cancer Prevention recommendations, the Dietary Approaches to Stop Hypertension (DASH) diet, and the 2005 United States Department of Agriculture (USDA) Food Guide. Mean daily energy intake was consistent with estimated requirements; however, mean body mass index was 27.1 kg/m2 (overweight). Dietary index scores averaged fewer than half the possible number of points on all 3 scales, indicating poor adherence to recommended guidelines. No study participant reported complete adherence to any set of guidelines. Although half the participants met minimal daily goals for 5 servings of fruits and vegetables (WCRF/AICR recommendations) and Collapse

Key Words Collapse

MESH Headings

• Adult
• Body Mass Index
• Cardiovascular Diseases/prevention & control
• Child
• Diet/standards
• Energy Intake
• Feeding Behavior
• Female
• Guideline Adherence
• Health Status
• Humans
• Male
• Nutrition Policy
• Patient Compliance
• Precursor Cell Lymphoblastic Leukemia-Lymphoma/diet therapy
• Surveys and Questionnaires
• Survivors

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Grants

• M01 RR000400 NCRR NIH HHS
• U24 CA055727 NCI NIH HHS
• M01-RR00400 NCRR NIH HHS
• K23 CA085503 NCI NIH HHS
• R21 CA106778 NCI NIH HHS
• R21-CA106778 NCI NIH HHS
• K23-CA85503 NCI NIH HHS
• U24-CA55727 NCI NIH HHS
• R21 CA106778-02 NCI NIH HHS

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Affiliation(s)

Kim Robien Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, 1300 S. Second St, 300 WBOB, Minneapolis, MN 55454, USA.
Kirsten K Ness
Lisa M Klesges
K Scott Baker
James G Gurney

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Smoking and binge drinking among Canadian survivors of childhood and adolescent cancers: a comparative, population-based study

BACKGROUND

Objectives of this study were to describe the prevalence of smoking and binge drinking among survivors of childhood and adolescent cancer compared to controls who had never had cancer, and to identify factors associated with these behaviors.

PROCEDURE

Data came from a national, multi-centre, population-based study of survivors of childhood and adolescent cancer (n = 1,263) aged 16 to 37 years and an age and gender matched control group (n = 1,422). Logistic regression analyses were performed to determine the likelihood and predictors of current smoking and binge drinking.

RESULTS

Survivors were less likely to be current smokers (OR(adj) = 0.65, 95% CI = 0.54-0.77) and binge drinkers (OR(adj) = 0.66, 95% CI = 0.55-0.78) than the controls. Still, a substantial proportion of survivors reported smoking (23%) and binge drinking (25%). Survivors' smoking and binge drinking did not vary substantially by the clinical factors assessed. Survivors who received therapy associated with cardiac and/or pulmonary toxicity were as likely to smoke as non-exposed survivors. For both the survivors and controls current smoking and binge drinking were associated with lower education and higher reported stress. Binge drinking was also associated with being male and life dissatisfaction in both groups.

CONCLUSIONS

This study indicates a need to reduce smoking and binge drinking among survivors of childhood and adolescent cancer and to design interventions addressing the underlying reasons for adopting unhealthy behaviors despite their risk for late effects. We identified factors related to smoking and binge drinking among survivors: being male, lower educational attainment, life dissatisfaction and high stress, which should help inform intervention development.

Promoting a healthy lifestyle among cancer survivors

With improving longevity, the late-occurring adverse effects of cancer and its treatment are becoming increasingly apparent. As in other clinical populations, healthy lifestyle behaviors encompassing weight management, a healthy diet, regular exercise, and smoking cessation have the potential to reduce morbidity and mortality significantly in cancer survivors. This article addresses the strength of evidence for recommendations in areas of weight management, diet, exercise, and smoking cessation; and the current evidence examining the efficacy of various intervention approaches to promote health behavior changes among adult cancer survivors.

Correlates of physical activity in young adult survivors of childhood cancers

PURPOSE/OBJECTIVES

To examine correlates of participation in regular physical activities among young adult survivors of childhood cancers.

DESIGN

Descriptive, correlational.

SETTING

Web-based survey.

SAMPLE

117 well-educated, predominately Caucasian survivors of various types of childhood cancers (-X age = 24 years).

METHODS

Participants completed four rating scales, a stages of change measure, and background questions. Logistic regression and graphical methods were used to examine relationships among physical activity correlates and physical activity.

MAIN RESEARCH VARIABLES

Physical activity stages of change, autonomous motivation, physical activity pros and cons, self-efficacy, and self-reported worries.

FINDINGS

More than 80% of participants reported that they were physically active. Survivors who were autonomously motivated and who perceived fewer cons to being physically active were more likely to report being active than survivors with lower autonomous motivation scores and higher physical activity cons scores. Worries about the present and future moderated the effect of physical activity cons on physical activity. The estimated probabilities of reporting being active for women and men changed as the collective contribution of autonomous motivation, physical activity cons, and worries varied from low to high values.

CONCLUSIONS

Engaging in physical activity willingly and without a sense of pressure (autonomous motivation), perceiving fewer cons to physical activity participation (cognitive appraisal), and worrying about the present and future (affective response) were important correlates of self-reported physical activity beyond the influence of gender.

IMPLICATIONS FOR NURSING

Interventions that promote autonomous motivation, decrease physical activity cons, and address present and future worries may increase physical activity in young adult cancer survivors and may have a greater impact on women than men.

Health behaviours in childhood cancer survivors: a systematic review

AIM

To review (1) prevalence and predictors of risk behaviours especially smoking and (2) values of interventions to reduce risk behaviours in childhood cancer survivors.

METHOD

A systematic search of four databases (OVID Medline (1966 to May week 2, 2006), CINAHL, EMBASE, and Pubmed (US Library of Medicine and National Institute of Health)) for articles published between January 1990 and May 2006.

RESULTS

Twenty-three eligible articles. Incidence of risk behaviours are comparable with, or lower than the general population and controls. Socio-demographic (age, socio-economic status, diagnosis, ethnic group) and psychological variables (perceived vulnerability) predict risk behaviour. Improved knowledge and awareness of vulnerability have been found after interventions, but no changes in health behaviours.

CONCLUSION

This review illustrates an optimistic picture of low participation in substance use amongst survivors, although based mainly on smoking. However, smoking might not be the major problem for survivors and attention must also be directed to other health behaviours including exercise and healthy diet.

Multiple behavioral risk factors among adolescent survivors of childhood cancer in the Survivor Health and Resilience Education (SHARE) program

BACKGROUND

Health-compromising behaviors among survivors of childhood cancer may increase their risks of cancer recurrence and the onset of chronic disease in adulthood. Regardless of whether such behaviors occur singly or in combination with one another, multiple behavioral risk factors must be identified and addressed early to promote better health outcomes within this special population. Adolescent survivors may be especially vulnerable, as reported rates of smoking and other risky behaviors are at or near levels of their healthy peers. The psychological literature suggests stress may play a role in risk behavior initiation and maintenance, including multiple behavioral risks, and that adolescent survivors are stress-prone. This report focuses on the prevalence and co-occurrence of three behavioral risk factors (cigarette use, insufficient physical activity, and non-adherence to sun protection recommendations) and describes stress-health behavior relationships in this special population.

PROCEDURE

All patients in this study (n = 75) were adolescent survivors of childhood cancer and completed a baseline assessment of their health behaviors and stress as part of a randomized controlled trial of health promotion.

RESULTS

Twenty-eight percent of the patients reported one of three risk factors, 12% reported two of three risk factors, and 7% reported all three risk factors. Non-adherence to sun protection was the single most common risk factor; physical inactivity and non-adherent sun protection were the most common co-occurring risk factors. Greater age and stress were significantly associated with the presence of more behavioral risk factors.

CONCLUSIONS

The evidence suggests interventions to reduce multiple health-compromising behaviors in these patients are warranted, and that efforts to address these patients' personal and family stress levels are important as well.

A process evaluation of a telephone-based peer-delivered smoking cessation intervention for adult survivors of childhood cancer: the partnership for health study

OBJECTIVE

We report on the process evaluation of an efficacious national smoking cessation intervention for adult survivors of childhood cancer. We examine associations between intervention implementation characteristics and study outcomes, as well as participant characteristics related to level of involvement in the intervention.

METHODS

The study was conducted at the Dana-Farber Cancer Institute in Boston, Massachusetts, from 1999-2001. Participants (n = 398) were randomly assigned to receive a proactive telephone-based peer counseling intervention. They received up to 6 counseling calls, individually tailored and survivor-targeted materials, and nicotine replacement therapy (NRT) patches if they were prepared to quit smoking.

RESULTS

Forty-two percent of survivors participated in the maximum number of calls (5-6), and 29% of participants requested and received NRT. Total counseling time was an average of 51 min. Quit status at follow-up was related to intervention dose, and participants who received NRT were significantly more likely to make a 24-h quit attempt. Demographic variables (females, White), higher daily smoking rate, poorer perceived health and moderate perceived risk of smoking were significantly related to greater intervention involvement.

CONCLUSIONS

A brief peer-delivered, telephone counseling intervention is an effective way to intervene with adult survivors of childhood cancer who are smoking. Findings from the process evaluation data (call length and number, frequency, and spacing) will inform future telephone counseling cessation programs.

Predicting and modifying substance use in childhood cancer survivors: application of a conceptual model

PURPOSE/OBJECTIVES

To identify factors that predict or modify substance use in childhood cancer survivors and to describe how a risk-counseling intervention reduced young survivors' substance use.

DESIGN

Secondary analysis of clinical trial data and primary analysis of medical record data.

SETTING

Outpatient clinic.

SAMPLE

149 females and 118 males 12-18 years of age whose cancer had been in remission for at least two years were randomly assigned to intervention (n = 132) and standard care (n = 135) groups.

METHODS

Self-report questionnaires, abstracted medical record data, confirmatory factor analysis, and structural equation modeling.

MAIN RESEARCH VARIABLES

Smoking, alcohol consumption, knowledge, risk perceptions, motivation, and worry about cancer and treatment effects.

FINDINGS

Three factors directly predicted substance use at baseline: being in a higher grade in school (independent of age), feelings of being more susceptible to late effects of cancer therapy, and worrying more about cancer and its treatment. At follow-up a year later, grade in school and worry predicted increased substance use. In addition, a desire to change health behavior, influenced by the intervention and gender, predicted decreased substance use. The mechanism of influence of the intervention was evident: The intervention led to a need to change, which precipitated a desire to change and ultimately resulted in decreased substance use.

CONCLUSIONS

Young survivors' worries and concerns about their cancer and treatment-related late effects are a new intervention target. Motivation is sensitive to behavioral change interventions and positively affects risk reduction.

IMPLICATIONS FOR NURSING

Two new intervention strategies to address the impact of survivors' concerns about their cancer and its treatment are implied: (a) Replace substance use with new coping methods to reduce fear and anxiety, and (b) tailor motivation-based interventions to age and gender to communicate graphically and realistically to survivors the personal importance of behavioral change in modifying the risks of late effects.

Survivors of childhood cancer and their guardians

BACKGROUND

Survivors of childhood cancer are at increased risk for osteoporosis, cardiovascular disease, and second malignancies-conditions for which modifiable risk factors are recognized and lifestyle interventions have shown benefit. Although some data regarding health behaviors of this population exist, receptivity to health promotion is largely unknown.

METHODS

A survey was mailed to 380 survivors (age range, 11-33 years) of childhood leukemia, lymphoma, or central nervous system carcinomas (and guardians of survivors < 18 years old) to elicit data on exercise, dietary intake of calcium, fat, and fruits and vegetables, smoking status, readiness to pursue lifestyle change, quality of life, and interest in various health interventions.

RESULTS

Responses from 209 survivors (a 55% response rate) suggested that most did not meet guidelines for fruit and vegetable consumption (79%), calcium intake (68%), or exercise (52%), 42% were overweight/obese, and 84% consumed > 30% of calories from fat. Older (> 18 years) compared with younger (< 18 years) survivors were more likely to smoke (17% vs. 1%), to be obese (21.6% vs. 14.6%), and to have suboptimal calcium intakes (75.6% vs. 57.6%). No differences in lifestyle behaviors were observed between cancer groups. Compared with interventions aimed at weight control, improving self-esteem, or smoking cessation, the highest levels of interest were found consistently for interventions aimed at getting in shape and eating healthy. Survivors preferred mailed interventions to those delivered in-person, by telephone counselors, or via computers.

CONCLUSIONS

Survivors of childhood cancer practiced several suboptimal health behaviors. Health promotion interventions aimed at areas of interest and delivered through acceptable channels have the potential to improve long-term health and function of this vulnerable population.