Can Steps per Day Reflect Symptoms in Children and Adolescents Undergoing Cancer Treatment?

Metabolomic Associations With Fatigue and Physical Function in Children With Cancer: A Pilot Study

Background: Fatigue is a frequently reported symptom in children undergoing cancer treatment. Prior research shows an inverse relationship between fatigue and physical activity. Less is known about fatigue's relationship with physical function or the underlying biological mechanisms of fatigue. This study explored associations among fatigue, physical function, and associated metabolites. Methods: Children (7-18 years) provided serum samples and self-reports of fatigue and lower extremity physical function (mobility) using Pediatric Patient-Reported Outcomes Measurement Information System (PROMIS) surveys at two timepoints during cancer therapy. PROMIS scores were categorized as high/low per established cut points (high fatigue T >47.5; high physical function T >51.5). High-resolution liquid chromatography-mass spectrometry extracted 29 metabolites hypothesized a priori to be associated with fatigue or physical function. Descriptive statistics summarized PROMIS scores, and linear mixed effect models estimated metabolite associations adjusting for age, gender and steroid use. Results: Forty children participated (female, 53%; 7-12 years, 38%; 13-18 years 62%; Hodgkins Lymphoma, 33%; Acute Lymphoblastic/Lymphocytic Leukemia, 40%; Osteosarcoma, 10%; Other, 17%). Physical function and fatigue were inversely related: T1 (r = -0.64; p < .001) and T2 (r = -0.63; p < .001). One metabolite (indole-3-latic acid) differentiated between low and high fatigue. Five metabolites differentiated significantly between low and high physical function (4-Hydroxybenzoic acid, m-Coumaric acid, myoinositol, tryptophan, and tyrosine). Conclusions:These findings substantiate prior studies showing metabolites, particularly amino acids, significantly associated with fatigue and physical function. All significant metabolites were associated with the gut microbiome. Physical function was inversely corelated with fatigue providing another potential intervention for fatigue management.

Analysis Method of Real-World Digital Biomarkers for Clinical Impact in Cancer Patients

Introduction

Wearable technologies can enhance measurements completed from home by participants in decentralized clinical trials. These measurements have shown promise in monitoring patient wellness outside the clinical setting. However, there are challenges in handling data and its interpretation when using consumer wearables, requiring input from statisticians and data scientists. This article describes three methods to estimate daily steps to address gaps in data from the Apple Watch in cancer patients and uses one of these methods in an analysis of the association between daily step count estimates and clinical events for these patients.

Methods

A cohort of 50 cancer patients used the DigiBioMarC app integrated with an Apple Watch for 28 days. We identified different gap types in watch data based on their length and context to estimate daily steps. Cox proportional hazards regression models were used to determine the association between step count and time to death or time to first clinical event. Decision tree modeling and participant clustering were also employed to identify digital biomarkers of physical activity that were predictive of clinical event occurrence and hazard ratio to clinical events, respectively.

Results

Among the three methods explored to address missing steps, the method that identified different step data gap types according to their duration and context yielded the most reasonable estimate of daily steps. Ten hours of waking time was used to differentiate between sufficient and insufficient measurement days. Daily step count on sufficient days was the most promising predictor of time to first clinical event (p = 0.068). This finding was consistent with participant clustering and decision tree analyses, where the participant clusters emerged naturally based on different levels of daily steps, and the group with the highest steps on sufficient days had the lowest hazard probability of mortality and clinical events. Additionally, daily steps on sufficient days can also be used as a predictor of whether a participant will have clinical events with an accuracy of 83.3%.

Conclusion

We have developed an effective way to estimate daily steps of consumer wearable data containing unknown data gaps. Daily step counts on days with sufficient sampling are a strong predictor of the timing and occurrence of clinical events, with individuals exhibiting higher daily step counts having reduced hazard of death or clinical events.

Extended Reality Gaming for Exercise and Mindfulness Throughout Pediatric Cancer Rehabilitation: Protocol for a Randomized Controlled Trial

BACKGROUND

Pediatric patients with cancer have limited options to self-manage their health while they are undergoing treatments in the hospital and after they are discharged to their homes. Extended reality (ER) using head-mounted displays has emerged as an immersive method of improving pain and mental health and promoting health-enhancing physical activity among a variety of clinical groups, but there is currently no established protocol for improving both physical and mental health in pediatric cancer rehabilitation.

OBJECTIVE

This phase I, pilot, feasibility randomized controlled trial aims to investigate the potential effects of a 14-week ER program on physical activity participation and indicators of health among pediatric patients with cancer who undergo bone marrow transplantation. An ancillary aim is to evaluate the feasibility of the program through participant engagement.

METHODS

This study includes a 2-arm parallel group design with a 1-group crossover (the control group will start the intervention after a waiting period). Overall, 16 pediatric patients with cancer undergoing rehabilitation (aged ≥8 years) at a children's hospital will be randomly allocated into one of two groups: (1) an immediate start group that undergoes an ER program in the hospital until discharge and then for 8 weeks at home (total duration of approximately 14 weeks), and (2) a waitlist control group that undergoes usual care in the hospital and for 8 weeks at home, before receiving the 8-week home ER program. The program will include active video gaming with rhythmic music exercises as well as mindfulness-based practices using a high-quality app. Home-based programming will include behavioral coaching calls. Physical activity will be measured daily through step counts using a tri-axial accelerometer. Health outcomes will be measured across time and include global health, measured by the National Institutes of Health Patient-Reported Outcomes Measurement Information System (PROMIS) Pediatric Global Health Scale Short Form 7+2, and lung function, measured by a forced expiratory volume using a peak flow meter. Feasibility will be evaluated through participant engagement metrics, such as enrollment, dropout, adverse events, and attendance rates. Descriptive statistics will be obtained for all study variables. Outcomes will be modeled using mixed modeling procedures, and changes in means will be estimated with CIs.

RESULTS

The study was funded in February 2024. Recruitment procedures started on June 27, 2024. All data are anticipated to be collected by February 2026. Full trial results are anticipated to be analyzed and submitted for publication by March 2026. The study's anticipated end date is March 31, 2026.

CONCLUSIONS

This trial tests an accessible remote program for improving both physical and mental health among pediatric patients with cancer. The knowledge obtained from this study will inform the development of a larger trial.

TRIAL REGISTRATION

ClinicalTrials.gov NCT06298357; https://clinicaltrials.gov/study/NCT06298357.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/64879.

Cardiopulmonary Exercise Test and Daily Physical Activity in Pediatric Congenital Heart Disease: an Exploratory Analysis

Sedentary lifestyle is reported to be associated with diminished exercise capacity, resulting in increased cardiovascular risk in adults with congenital heart disease (CHD). This cross-sectional study examined the association between objectively measured physical activity (PA) and exercise capacity in children and adolescents with CHD. Therefore, 107 patients (aged 13.0 ± 2.7 years, 41 girls) with various CHD performed a cardiopulmonary exercise test to quantify their peak oxygen uptake (peakV'O2). Moderate to vigorous PA (MVPA) and daily step count were assessed using Garmin vivofit jr. (Garmin, Germany) for 7 consecutive days. For association between PA and submaximal exercise capacity, Spearman correlation was performed. Patients with CHD showed almost normal values compared with the reference (79.5 ± 17.2% [31.6 to 138.1] %peakV'O2 predicted), with roughly normal ventilatory anerobic thresholds (50.6 ± 14.0% [20.3 to 97.9] % oxygen uptake at ventilatory anaerobic threshold [VATV'O2]). Step counts are below the recommendations (9,304 ± 3,792 steps/day [1,701 to 20,976]), whereas MVPA data are above the recommendations for children with ≥60 min/day (83.6 ± 34.6 min/day [10.1 to 190.9]). The Spearman rho showed significant positive correlations to VATV'O2 (r = 0.353, p <0.001) and %VATV'O2 (r = 0.307, p = 0.001), with similar results regarding MVPA (VATV'O2: r = 0.300, p = 0.002 and %VATV'O2: r = 0.270, p = 0.005). In conclusion, submaximal exercise capacity and PA correlate positively, making both assessments relevant in a clinical setting: PA in the context of cardiovascular prevention and peakV'O2 as the strongest predictor for morbidity and mortality.

Physical activity and sleep changes among children during the COVID-19 pandemic

Daily routines, including in-person school and extracurricular activities, are important for maintaining healthy physical activity and sleep habits in children. The COVID-19 pandemic significantly disrupted daily routines as in-person school and activities closed to prevent spread of SARS-CoV-2. We aimed to examine and assess differences in objectively measured physical activity levels and sleep patterns from wearable sensors in children with obesity before, during, and after a period of school and extracurricular activity closures associated with the COVID-19 pandemic. We compared average step count and sleep patterns (using the Mann-Whitney U Test) before and during the pandemic-associated school closures by using data from activity tracker wristbands (Garmin VivoFit 3). Data were collected from 94 children (aged 5-17) with obesity, who were enrolled in a randomized controlled trial testing a community-based lifestyle intervention for a duration of 12-months. During the period that in-person school and extracurricular activities were closed due to the COVID-19 pandemic, children with obesity experienced objectively-measured decreases in physical activity, and sleep duration. From March 15, 2020 to March 31, 2021, corresponding with local school closures, average daily step count decreased by 1655 steps. Sleep onset and wake time were delayed by about an hour and 45 min, respectively, while sleep duration decreased by over 12 min as compared with the pre-closure period. Step counts increased with the resumption of in-person activities. These findings provide objective evidence for parents, clinicians, and public health professionals on the importance of in-person daily activities and routines on health behaviors, particularly for children with pre-existing obesity. Trial Registration: Clinical trial registration: NCT03339440.

Symptoms, Physical Activity, and Biomarkers in Children at the End of Leukemia Maintenance Therapy

Background: Symptoms in children with acute lymphocytic leukemia (ALL) change over the trajectory of treatment but little is known about their symptoms as treatment ends. Physical activity may help decrease symptom distress and is vital for ongoing development. The role of biomarkers in symptom science is emerging. The purpose of the study was to explore relationships between self-report of symptoms and physical activity, actigraphy measures, and cerebrospinal fluid (CSF) biomarkers. Methods: Participants were children who were ages 3 to 18 years at the time of ALL diagnosis and were now in the last 12-week cycle of ALL maintenance. Self-reports of fatigue, sleep disturbance, depressive symptoms, and physical activity were completed by participants and parents of younger children. Participants wore a wrist actigraph continuously for the 7 days before other measurements. F2-isoprostanes and interleukin-8 were evaluated in CSF samples. Results: Among the 15 participants, self-report of symptoms and physical activity indicated levels similar to healthy peers. F2-isoprostane had a strong positive correlation with fatigue levels and with depressive symptoms. Fatigue, sleep disturbance, and depressive symptoms positively correlated with each other. Actigraph measures showed children met the CDC guidelines for 60 min of daily moderate to vigorous activity; sleep time was slightly less than healthy norms. Discussion: During maintenance therapy, most children return to healthy norms in symptom burden and physical activity. F2-isoprostane in the CSF is a biomarker for fatigue and depressive symptoms. Children who had persistent symptoms experienced them as a cluster, which confirms previous symptom cluster research.

Physical activity in 9-15 year-old pediatric cancer survivors compared to a nationwide sample

INTRODUCTION

Sufficient physical activity (PA) has the potential to mitigate late effects of cancer, but objective data of PA levels in adolescents are scarce. The aim of this study was to investigate differences in PA behavior between childhood cancer survivors (CCS) and healthy peers.

METHODS

PA levels of n = 74 CCS and n = 1304 healthy peers from the MoMo study aged 9-15 years were assessed with validated objective accelerometry and group means were compared. A binary multiple logistic regression was performed to investigate the potential predictors of PA.

RESULTS

CCS spent significantly more time sedentary (p < 0.001) and less time in moderate-to-vigorous physical activity (p = 0.002) compared to the healthy cohort. Subgroup analysis revealed the largest deviations of PA levels for CCS aged 9-11 years who fulfilled international PA recommendations on significantly fewer days than MoMo (p < 0.01). Health conditions seem to be a predictor concerning the fulfillment of international PA recommendations by the WHO (p = 0.015).

CONCLUSIONS

Our study identified vulnerable groups which seem to require targeted exercise and health behavior change programs to increase physical activity and reduce sedentary time. The presence of treatment sequelae as a significant predictor of insufficient physical activity underlines the need of multidisciplinary supportive care approaches.

Convergent Validity of the Patient Reported Outcome Measurement Information System-Pediatric Physical Activity Instrument (PROMIS®-PA) with Wearable Devices in Adolescents

The study was conducted mainly to examine the convergent validity of the Patient Reported Outcome Measurement Information System-Pediatric Physical Activity instrument (PROMIS^®®®-PA) with step counts from wearable devices and another validated self-reported outcome measure. As a secondary aim, we explored the effect of different recall time frames (7-day, end-of-day [EoD], and ecological momentary assessment [EMA] time frames during the day) in terms of their feasibility and associations with each other and with step counts. This was a prospective cohort study that examined the associations between measures of PA in school-age children and adolescents (n = 84, aged 10-20). The participants wore Fitbit devices for 7 consecutive days, and then completed the 7-day-recall PROMIS-PA short form and Youth Activity Profile (YAP). Additional analyses were completed in a sub-sample (n = 25, aged 11-18 years) using the PROMIS-PA for the EMA at five intervals during the day (shorter form) and at the EoD. In the total sample, the PROMIS-PA results showed positive moderate correlations with the YAP and average daily steps (r = 0.533, p < 0.001 and r = 0.346, p = 0.002, respectively). In the sub-sample, the 7-day PROMIS-PA was highly correlated with the averaged EMA or EoD ratings for the week, and moderately correlated with the daily step counts. These findings support the validity of the PROMIS-PA as a measure of self-reported physical activity. Adolescents demonstrated higher compliance rates and preference for the 7-day recall and EoD assessments compared to more frequent EMA reporting.