Benefits of Exercise Training for Children and Adolescents Undergoing Cancer Treatment: Results From the Randomized Controlled MUCKI Trial

Nutritional status, body composition and diet quality in children with cancer

During cancer treatment, nutritional status disorders such as malnutrition or obesity affect the tolerance of cancer treatment, quality of life, but also the pharmacokinetics of drugs. It is hypothesized that changes in fat and lean body mass can modify chemotherapy volume distribution, metabolism and clearance. In children with cancer, lean body mass decreases or remains low during treatment and fat mass increases. Body composition is influenced by the cancer itself, aggressive multimodal-therapies, changes in metabolism, unbalanced diet and reduced physical activity. Due to the side effects of treatment, including changes in the sense of taste and smell, nausea, vomiting, diarrhea, and stress, eating according to recommendation for macronutrients and micronutrients is difficult. Research indicates that throughout cancer treatment, the consumption of fruits, vegetables, and dairy products tends to be insufficient, whereas there is an elevated intake of sugar and unhealthy snacks. Children exhibit a preference for high-carbohydrate, salty, and strongly flavored products. This review revealed the importance of body composition and its changes during cancer treatment in children, as well as eating habits and diet quality.

Physical capacity in children and adolescents with newly diagnosed cancer: A systematic review and meta-analysis

OBJECTIVE

To review the body of evidence on cardiorespiratory fitness, muscle strength, and physical performance in children with newly diagnosed cancer, five databases (MEDLINE, Embase, CINAHL, CENTRAL, and Web of Science) were searched on December 19, 2022.

METHODS

Thirteen studies, embodying 594 participants within 1 month of cancer diagnosis and 3674 healthy controls were included. Eighteen different outcomes on cardiorespiratory fitness (n = 2), muscle strength (n = 5), physical performance (n = 10), and adverse events (n = 1) were analyzed.

RESULTS

Fifteen out of 17 outcomes on physical capacity showed severe impairments compared with healthy controls. Where possible, random-effects meta-analysis was conducted to synthesize the results. No adverse events were reported related to testing.

CONCLUSION

Children with cancer have impaired cardiorespiratory fitness, muscle strength, and physical performance within the first month after diagnosis. However, the evidence is based on a small number of studies with large clinical heterogeneity, limiting the certainty of evidence.

The views of parents of children with cancer and pediatric physical therapists on a network for continuity and optimal quality of care for children with cancer: KinderOncoNet

PURPOSE

Children with cancer require specific therapeutic guidance. Parents prefer physical therapy close to home, while pediatric physical therapists (PPTs) working in the community may lack specific knowledge. The aim of this study is to determine the needs of parents of children with cancer and PPTs to inform the design and development of a care network, named "KinderOncoNet."

METHODS

We explored the perspectives and needs of parents of children with cancer and PPTs in the community, and we investigated the added value that KinderOncoNet could offer. We used an iterative process; data collection consisted of (1) gathering information from parents of children with cancer and PPTs through a survey and (2) co-creation sessions with stakeholders.

RESULTS

In total, 98 parents and 177 PPTs participated in the survey. Parents (97%) and PPTs (93%) indicated that the care network would bring added value. All but one parent stressed the importance of a local PPT being aware of both the condition and the side and late effects of oncological treatment. Moreover, 40% of PPTs thought they do not have sufficient knowledge to provide high-quality therapy and that they would embrace opportunities for education. Through the co-creation sessions, a prototype of the care network was conceptualized.

CONCLUSION

KinderOncoNet can contribute to the continuity and quality of physiotherapy care for children with cancer during and after the oncological treatment. Such a network would allow for sharing knowledge, developing skills, and improving accessibility and communication in the Netherlands.

Children with cancer and their cardiorespiratory fitness and physical function-the long-term effects of a physical activity program during treatment: a multicenter non-randomized controlled trial

PURPOSE

We aimed to determine the effects of a classmate-supported, supervised, in-hospital physical activity program during treatment primarily on cardiorespiratory fitness and secondarily on physical function.

METHODS

A multicenter non-randomized controlled intervention study including children diagnosed with cancer, 6-18 years at diagnosis treated with chemo-/radiotherapy. The intervention comprised (i) an educational session on cancer in the child's school class; (ii) selection of two "ambassadors"-classmates who were co-admitted, supporting the child's everyday hospital life; and (iii) supervised in-hospital physical activity from diagnosis and throughout intensive treatment. One-year post-treatment, physical testing included cardiorespiratory fitness (primary outcome), Sit-to-Stand test, Timed-Up-and-Go, and Handgrip Strength.

RESULTS

The intervention group included 75 of 120 children (61% boys, 13.4 ± 3.1 years); the control groups included 33 of 58 children with cancer (58% boys, 13.5 ± 2.5 years), and 94 age- and sex-matched children without a cancer history. One-year post-treatment, cardiorespiratory fitness tended to be higher in the intervention group (37.0 ± 6.0 mL/kg/min) than in the patient control group with cancer (32.3 ± 9.7 mL/kg/min) (mean difference 4.7 [0.4 to 9.1], p = 0.034). The intervention group performed better in the secondary outcomes. Compared with community controls, both patient groups had lower cardiorespiratory fitness. The patient control group had lower Sit-to-Stand, Timed Up and Go, and Handgrip Strength, while the intervention group had strength comparable to that of the community controls.

CONCLUSIONS

Peer-supported, supervised, in-hospital physical activity during treatment may improve cardiorespiratory fitness and muscle strength 1-year post-treatment in children with cancer; however, survivors continue to have lower cardiorespiratory fitness than community controls.

IMPLICATIONS FOR CANCER SURVIVORS

Children with cancer may benefit from in-hospital physical activity in improving long-term cardiorespiratory fitness and muscle strength.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION

Clinicaltrials.gov: NCT02730767.

Guideline for the management of fatigue in children and adolescents with cancer or pediatric hematopoietic cell transplant recipients: 2023 update

Objective was to update a clinical practice guideline (CPG) for the management of fatigue in children and adolescents with cancer or pediatric hematopoietic cell transplant recipients. We reconvened a multi-disciplinary and multi-national panel. While the previous 2018 CPG evaluated adult and pediatric randomized controlled trials (RCTs) to manage fatigue, this 2023 update revised previous recommendations based only on pediatric RCTs. Twenty RCTs were included in the updated systematic review. Physical activity significantly reduced fatigue (standardized mean difference -0.44, 95% confidence interval -0.64 to -0.24; n = 8 RCTs). Using the 2018 recommendations as a basis, the panel continued to make strong recommendations to use physical activity, and to offer relaxation, mindfulness or both, to manage fatigue in pediatric patients. Cognitive or cognitive behavioral therapies may be offered. Pharmacological approaches should not be routinely used. The panel made a new good practice statement to routinely assess for fatigue, ideally using a validated scale.

Effect of concurrent training on physical performance and quality of life in children with malignancy: A systematic review and meta-analysis

Objective

This study aims to evaluate the intervention effect of concurrent training on children with malignant tumors to provide evidence for prescribing exercise for children with malignant tumors.

Methods

Twelve databases were searched from inception to October 15, 2022. Two researchers independently screened the literature, evaluated the quality, extracted the data, and performed the meta-analysis using R.

Result

A total of nine randomized controlled trials involving 371 children were included in this study. The meta-analysis revealed that muscle strength was significantly greater in the exercise group compared to the usual care group [SMD = 0.26, 95% CI (0.04, 0.48), P = 0.023], with subgroup analysis showing no significant difference in upper limb [SMD = 0.13, 95% CI (−0.17, 0.43), P = 0.318] and a considerable difference in lower limb strength [SMD = 0.41, 95% CI (0.08, 0.74), P = 0.015]. Physical activity [SMD = 0.57, 95% CI (0.03, 1.1), P = 0.038], timed up and down stairs test [SMD = −1.22, 95% CI (−2.04, −0.4), P = 0.004], 6-min walking ability [SMD = 0.75, 95% CI (0.38, 1.11), P &lt; 0.01], quality of life [SMD = 0.28, 95% CI (0.02, 0.53), P = 0.033], and cancer-related fatigue [SMD = −0.53, 95% CI (−0.86, −0.19), P = 0.002] were significantly better than the usual care group. There were no significant differences in peak oxygen uptake [SMD = 0.13, 95% CI (−0.18, 0.44), P = 0.397], depression [SMD = 0.06, 95% CI (−0.38, 0.5), P = 0.791], and withdrawal rates [RR = 0.59, 95% CI (0.21, 1.63), P = 0.308] between the two groups.

Conclusion

Concurrent training could improve physical performance for children with malignancy but had no significant effect on mental health. Because the quality level of evidence is mostly very low, future high-quality randomized controlled trials are required to confirm these findings.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=364140, identifier CRD42022308176.

Physical Activity as a Treatment for Cancer-Related Fatigue in Children, Adolescents and Young Adults: A Systematic Review

Background: Cancer-related fatigue (CRF) is one of the most common and distressing symptoms in paediatric oncology. Based on previous studies, physical activity interventions are considered to be effective in reducing CRF in adult cancer patients. Aim: The aim of this systematic review is to investigate whether physical activity interventions can reduce CRF in paediatric patients undergoing cancer treatment. Methodology: A systematic literature search was conducted in PubMed and Sport-Discus in October 2021 to identify intervention studies examining the effects of physical activity on CRF in cancer patients ≤ 21 years of age. Their methodological quality was assessed using the JBI Critical Appraisal Tool. Results: A total of 20 studies (seven randomized-controlled, six quasi-experimental and seven single-arm intervention trials) were included in the review. Nine studies reported significant positive effects of physical activity interventions on CRF in group comparison or within groups. Eleven trials reported no significant changes in CRF. Conclusion: Physical activity as a therapeutic intervention in paediatric oncology may have the potential to reduce CRF in childhood cancer patients undergoing cancer treatment. Further high-quality studies with large samples are needed to verify these results and to assess the interdependence of dose and response of physical activity interventions.

Effects of Exercise and Physical Activity Levels on Childhood Cancer: An Umbrella Review

Patients and survivors of childhood cancer experience adverse effects related to the disease and its treatment. These adverse effects are associated with both physiological and psychological health. Exercise helps manage the side effects and improve the health outcomes. The objective of this umbrella review is to search the current literature in the context of exercise and physical activity as complementary interventions on pediatric cancer and to provide comprehensive information about the derived health outcomes. A literature search was conducted on the Cochrane, PubMed, and Embase databases for systematic reviews published up to January 2023. Moreover, a hand search of reference lists was performed. We included participants under 19 years of age at diagnosis of any type of childhood cancer, without restriction on the type or phase of treatment, who participated in exercise interventions. The results showed a beneficial impact on fatigue, muscle strength, aerobic capacity, activity and participation levels, psychosocial health, cardiovascular/cardiorespiratory fitness, physical function, bone mineral density, and brain volume and structure, with limited and not serious adverse effects. These findings documented that exercise interventions had a positive effect on many physiological and psychological health outcomes in pediatric cancer patients and survivors.

The Moderated Mediating Effects of Nutrition and Physical Activity Between Fatigue and Quality of Life in Childhood Cancer Survivors

PURPOSE

The aim of this study was to investigate the associations between nutrition, physical activity, fatigue, and quality of life (QoL) among childhood cancer survivors. The specific purpose was to examine whether nutrition mediated and physical activity moderated the relationship between fatigue and QoL in this population.

METHODS

A pooled sample of 120 childhood cancer survivors was recruited at pediatric oncology wards and ambulatory settings between August 2020 and May 2021. We collected data on participants' demographic characteristics, fatigue, nutritional status, physical activity, and QoL. We then adapted Hayes Process Macro to examine the mediating and moderating effects of nutrition and physical activity on the relationship between fatigue and QoL.

RESULTS

In models adjusted for age and sex, (1) the simple mediation analysis identified the mediating effect of nutrition on the relationship between fatigue and QoL; and (2) the mediation and moderation analysis identified that the direct effect of nutrition between fatigue and QoL was significant when adding (a) physical activity and (b) fatigue × physical activity. There were significantly decreasing trends in physical activity at 1 standard deviation below the mean and at the mean, but not at 1 standard deviation above the mean.

CONCLUSIONS

Our findings demonstrate that nutrition mediated and physical activity moderated the relationship between fatigue and QoL. This highlights an opportunity to enhance QoL among childhood cancer survivors through healthy lifestyle interventions. To ensure that future interventions address children's needs and promote the greatest impact, such interventions should include nutrition and physical activity components that involve nurses, pediatric oncology physicians, nutritionists, and physical therapists.

Effects of physical activity interventions on physical activity and health outcomes in young people during treatment for cancer: a systematic review and meta-analysis of randomised controlled trials

Objective

Physical activity may improve health and reduce the adverse effects of cancer and/or its treatment in young people, therefore, interventions that promote physical activity are important. This systematic review and meta-analysis aims to synthesise evidence from randomised controlled trials (RCTs) that have assessed the effectiveness of physical activity interventions on health outcomes in young people undergoing cancer treatment.

Design

Systematic review with meta-analyses.

Data sources

Embase, PubMed, Medline, PsycINFO, PsychArticles, SPORTDiscus, Scopus, Web of Science and The Cochrane Library were searched from inception to January 2022.

Eligibility criteria for selecting studies

Studies were eligible for inclusion if they were RCTs, recruited young patients with cancer receiving cancer treatment and tested an aerobic physical activity intervention. Title/abstract reports were screened against the review eligibility criteria.

Results

Searches revealed seven eligible trials that had recruited 317 participants. No differences were found in minutes per day of participation in moderate to vigorous intensity physical activity (MD 2.61, 95% CI -3.67 to 8.89, p=0.42), total physical activity (standardised mean difference, SMD 0.35, 95% CI -0.39 to 1.09, p=0.35) or fatigue (SMD -0.50, 95% CI -1.03 to 0.02, p=0.06). Sensitivity analyses where trials with a high risk of bias were excluded, revealed significant effects for total physical activity (SMD 0.87, 95% CI 0.17 to 1.57, p=0.02) and fatigue (SMD 0.74, 95% CI -1.13 to -0.35), p=0.0002).

Conclusion

Evidence regarding the effects of physical activity interventions on the health of young people undergoing treatment for cancer is limited and mixed, where results from high-quality trials showed some promise.

Quantifying muscle strength, size, and neuromuscular activation in adolescent and young adult survivors of musculoskeletal sarcoma: Identifying correlates and responses to functional strengthening

BACKGROUND

Medical and surgical treatment for musculoskeletal sarcoma (MSS) place survivors at risk for impairments in muscle properties including muscle strength, muscle size, and neuromuscular activation. The purpose of this study was to explore muscle properties, gross motor performance, and quality of life (QoL) and the changes in response to a 6-week functional strengthening intervention (PT-STRONG) in MSS survivors of childhood cancer (CCS).

METHODS

Eight lower extremity MSS CCS (13-23 years old) performed baseline testing and three completed PT-STRONG. Participants completed measurements of knee extension strength using handheld dynamometry, vastus lateralis (VL) and rectus femoris (RF) muscle thickness using ultrasonography at rest, and neuromuscular activation using electromyography during strength testing and a step-up task. Participants also completed gross motor and QoL assessments.

RESULTS

Compared with the non-surgical limb, MSS CCS had lower surgical limb knee extension strength, VL muscle thickness, and RF step-up muscle rate of activation (RoA). Compared with normative values, MSS CCS had decreased bilateral knee extension strength, gross motor performance, and physical QoL. Positive correlations among muscle strength, muscle thickness, and gross motor performance were identified. After PT-STRONG, MSS CCS had improvements in VL muscle thickness, VL and RF RoA duing step-up, gross motor performance, and physical QoL.

CONCLUSIONS

Positive association between larger muscle thickness with greater knee extension strength, and higher knee extension strength with better gross motor performance indicate that comprehensive physical therapy assessment and interventions that identify and target impairments in muscle properties to guide clinical decision making should be considered for MSS CCS into survivorship.

Nonpharmacological interventions for treating fatigue in adolescents: A systematic review and narrative synthesis of randomised controlled trials

OBJECTIVE

Fatigue is common in adolescence and can be highly disabling if experienced persistently, with adverse psychosocial outcomes. There is a need to better understand what nonpharmacological treatments are available for adolescents suffering with persistent fatigue. The current review systematically identified, synthesised, and evaluated the evidence regarding nonpharmacological interventions for fatigue in adolescents, focusing on evaluating effectiveness, describing intervention components, and mapping interventions onto the behaviour change technique taxonomy (BCTT).

METHODS

CENTRAL, EMBASE, PsycINFO, PubMed, and Web of Science were systematically searched for articles including (1) adolescents aged 10-19 years old, (2) fatigue as a primary or secondary outcome, (3) nonpharmacological interventions, and (4) randomised controlled trials. Study screening, data extraction, quality assessment, and BCTT mapping were performed independently by two reviewers. Findings were presented as a narrative synthesis, with interventions ranked by promise.

RESULTS

5626 papers were identified and double-screened, resulting in the inclusion of 21 articles reporting 16 trials. Five interventions were classified as likely promising. Interventions often involved psychoeducation, cognitive behavioural therapy, and/or physical activity, incorporating various BCTT domains, most commonly shaping knowledge, repetition and substitution, and goals and planning. However, there did not seem to be any observable differences between fatigue-targeted and non-fatigue-targeted interventions. Overall study quality was mixed, particularly in relation to power and outcome measures.

CONCLUSION

There are several promising nonpharmacological interventions for adolescent fatigue, although further work is needed to determine effectiveness. Future trials need to ensure design rigour, focusing on adequate powering, validated outcome measures, and adhering to best practice reporting guidelines.

Multidisciplinary Network ActiveOncoKids guidelines for providing movement and exercise in pediatric oncology: Consensus-based recommendations

BACKGROUND

Pediatric cancer leads to reduced participation in exercise and only few patients comply with national physical activity recommendations. Physically inactive behavior hinders motor development and increases physical and psychological adverse effects of therapy and incidence of sequelae. Currently, there is neither nationwide coverage nor uniform level of knowledge regarding exercise promotion. The objective of the guideline is to facilitate qualified exercise interventions through standardized procedures in addition to regular physiotherapy and overall avoid physical inactivity in pediatric cancer patients.

METHODS

This guideline addresses the multidisciplinary treatment team and informs physiotherapists and decision-makers in tertiary care hospitals and health insurance companies. The requirements of the Association of the Scientific Medical Societies in Germany were followed. Contents were based on best practice experience of experts, patient advocates, as well as on scientific evidence.

RESULTS

The guideline includes 11 recommendations. Recommendations 1-4 declare the relevance of implementing exercise interventions and address general framework conditions. Recommendations 5-11 focus on the design of exercise programs, prevention and safety issues, relative contraindications for specific training loads, and options to overcome barriers to exercise.

CONCLUSION

This guideline summarizes existing and established structures and evidence in the context of movement and exercise in pediatric oncology. It takes into consideration the rights, varying needs, and characteristics of children and adolescents as well as national and international experience in this field. In the future, relevant research gaps need to be addressed by high-quality intervention studies to provide the scientific background for a stronger evidence-based guideline.

The rehabilitation including structured active play (RePlay) model: A conceptual model for organizing physical rehabilitation sessions based on structured active play for preschoolers with cancer

Anti-cancer treatments, as well as cancer itself, reduce children's cardiorespiratory fitness, muscle strength, and gross motor functions. Early rehabilitation programs, including physical activity for childhood cancer patients, can counteract these adverse effects. Previous studies of school-aged children (6-18 years old) indicate that physical activity, including aerobic and resistance training, is safe, feasible, and effective. The goal of structured physical activity rehabilitation for preschool children (1-5 years old) is to support gross motor development and opportunities to move freely in various ways. Specific rehabilitation for preschoolers diagnosed with cancer is needed to promote physical-, social-, and personal development. This paper introduces a conceptual model-The RePlay (Rehabilitation including structured active play) Model-for organizing physical rehabilitation sessions based on structured active play for preschoolers with cancer. The theory and empirically based model combine knowledge of early childhood development, play, physical activity and rehabilitation for children with cancer, and cancer treatment. With this model, we propose how to structure rehabilitation sessions, including goal-oriented, age-sensitive, fun movement activities that facilitate preschoolers to develop gross motor skills while enhancing their social and personal skills, through four core principles: (1) ritual practices, (2) reinforcement of movement through repetition, (3) development through appropriate challenge, and (4) adjusting activities to accommodate treatment-related side effects. This model holds promise for use with preschoolers diagnosed with cancer, as it is scalable and pragmatic and accounts for the children's fluctuating physical capacity and daily wellbeing during cancer treatment.

A randomised controlled trial investigating the ability for supervised exercise to reduce treatment-related decline in adolescent and young adult cancer patients

Introduction

Exercise is recognised as integral in mitigating a myriad negative consequences of cancer treatment. However, its benefit within adolescent and young adult (AYA) cancer cohorts remains relatively under researched, and caution should be taken in extrapolating outcomes from adult and paediatric populations given AYA distinctly different physiological and psychosocial contexts. This study sought to evaluate the impact of an exercise intervention on mitigating the expected decline in fitness, strength, physical functioning, and quality of life (QOL) in AYA undergoing cancer treatment.

Methods

This prospective, randomised controlled trial (FiGHTINGF!T) allocated 43 participants (63% male, mean age 21.1 years) to a 10-week, multimodal, bi-weekly exercise intervention (EG) or control group (CG) undergoing usual care. Pre- and post-intervention assessments included cardiopulmonary exercise tests, one-repetition maximum (1RM) strength, functional tests, and QOL patient-reported outcome measures. Data were analysed via linear mixed models and regression.

Results

While no significant group differences (p > 0.05) were observed, neither group significantly declined (p > 0.05) in any outcome measure over the 10-week period. No significant (p˃0.05) strength or functional improvements were observed in the CG, though the EG demonstrated significant improvements in their 1RM leg press (p = 0.004) and chest press (p = 0.032), maximal push ups (p = 0.032), and global QOL (p = 0.011). The EG reported a significant increase in fatigue (p = 0.014), while the CG reported significant positive changes in anxiety measures (p = 0.005).

Conclusion

The exercise intervention produced superior improvements in strength and global QOL, compared with the CG. Regardless of group allocation, enrolment in the exercise study appeared to mitigate the treatment-related decline expected in AYA undergoing cancer treatment.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00520-022-07217-w.

Supervised Exercise Interventions in Childhood Cancer Survivors: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background: Childhood cancer survivors (CCSs) may suffer from a multitude of health impairments, resulting in a compromised quality of life (QoL). This review’s objective was to examine CCSs’ adherence to supervised exercise training interventions and the impact of these interventions on health outcomes. Methods: The following databases were searched in May 2022: PubMed, Embase, Cochrane Library, and Web of Science. The included studies were limited to randomized controlled trials (RCTs), published in English involving CCSs aged 18 years and below. Results: Nine RCTs (n = 642 participants) were included in the systematic review, and seven of them (n = 551 participants) were included in the meta-analysis. Both the mean retention rate and adherence to the supervised exercise interventions were 87%. Supervised exercise interventions significantly improved muscle strength (standardized mean difference (SMD) = 1.42, p = 0.03), level of daily physical activity (SMD = 1.05, p < 0.001), body mass index (BMI) (mean difference (MD) = 1.06, p = 0.03), and fatigue (SMD = −0.44, p < 0.001), while there was no statistical significance in the quality of life (QoL) (SMD = 0.21, p = 0.20). Conclusions: The adherence of CCSs to supervised exercise interventions is high, and supervised exercise interventions are safe and effective.

Evidencia del ejercicio en el tratamiento de la fatiga relacionada al cáncer infantil. Revisión temática

Objetivo Recopilar la evidencia más reciente que soporte el uso del ejercicio y la actividad física para disminuir la fatiga relacionada al cáncer infantil. Métodos Se llevó a cabo una búsqueda electrónica de literatura no mayor a cinco años. Posteriormente, los artículos se agruparon en categorías por tipo de estudio y se analizaron sus resultados de acuerdo con el objetivo planteado. Resultados Fueron incluidos 16 artículos de diferentes diseños, incluyendo estudios clínicos y revisiones sistemáticas. De manera general, se muestran diferencias significativas en favor del ejercicio para disminuir la fatiga; también se reportan efectos positivos en otros aspectos como la movilidad funcional y la calidad de vida. Conclusión Se respalda la idea de continuar generando evidencias para conocer de manera más puntual la dosificación del ejercicio dependiendo de todas las variables que se pueden presentar en el pediátrico oncológico.

A Bout of High-Intensity Interval Training (HIIT) in Children and Adolescents during Acute Cancer Treatment-A Pilot Feasibility Study

Low- and moderate-intensity exercise is safe and feasible during childhood cancer treatment. The feasibility of a bout of high-intensity interval training (HIIT) in this population has not been analyzed to date. Pediatric cancer patients aged between 6 and 18 years were selected based on clinical conditions to perform ten sets of 15 s HIIT (>90% of estimated maximal heart rate (HRmax)) and 1 min active recovery on a bicycle ergometer within the first three chemotherapy courses. We assessed safety and feasibility criteria and the following parameters: perceived exertion rate, heart rate, and lactate and adrenaline concentrations. Out of 212 eligible patients, 11 patients aged 13.9 ± 3.6 years (n = 7 ♂) with lymphoma, leukemia, rhabdomyosarcoma, nephroblastoma, and synovial sarcoma completed the bout of HIIT without serious adverse events. During exercise, patients reached a BORG value maxima of 16 ± 1.2, and their heart rates rose from 78 ± 17 beats per minute (bpm) at rest to 178 ± 12 bpm after exercise (90 ± 6% estimated HRmax). The power-to-weight ratio was 2 ± 0.5 W/kg (watt per kilogram). Blood lactate concentrations increased from 1.09 ± 0.50 mmol/L (millimole per liter) at rest to 5.05 ± 1.88 mmol/L post-exercise. Our preliminary data suggest that HIIT is applicable only in a small number of childhood cancer patients. Individually adapted exercise protocols for patients with multiple impairments are needed.

Physical and functional performance assessment in pediatric oncology: a systematic review

BACKGROUND

Research indicates reduced physical performance from diagnosis into survivorship of pediatric cancer patients. However, there is no systematic information or guideline available on the methods to assess physical performance and function in this population. The purpose was to systematically compile and describe assessments of physical performance and function in patients and survivors of pediatric cancer, including cardiorespiratory fitness, muscle strength, speed, balance, flexibility, functional mobility, gait and motor performance test batteries.

METHODS

We searched the databases PubMed, SPORTDiscus, and Cochrane Database and performed abstract and full-text selection of 2619 articles according to the Cochrane Handbook of Systematic Reviews. Information on patients characteristics, assessments, information on validity and reliability, and relevant references was extracted.

RESULTS

In summary, 63 different assessments were found in 149 studies including 11639 participants. Most studies evaluated cardiorespiratory fitness and muscle strength with the majority conducted off treatment. Some outcomes (e.g. speed) and diagnoses (e.g. neuroblastoma) were severely underrepresented. With the exception of gait, leukemia patients represented the largest group of individuals tested.

CONCLUSIONS

Insufficient data and patient heterogeneity complicate uniform recommendations for assessments. Our results support researchers and practitioners in selecting appropriate assessment to meet their specific research questions or individual daily practice needs.

IMPACT

This systematic review includes 149 studies and provides a comprehensive summary of 63 assessments to evaluate cardiorespiratory fitness, muscle strength, speed, balance, flexibility, functional mobility, gait or motor performance test batteries in patients and survivors of pediatric cancer. We present the most studied fields within the pediatric cancer population, which are cardiorespiratory fitness and muscle strength, off treatment phase, and leukemia patients. We propose research priorities by identification of subgroups in terms of cancer type, phase of treatment, and outcome of interest that are underrepresented in studies currently available.

The Impact of a Precision-Based Exercise Intervention in Childhood Hematological Malignancies Evaluated by an Adapted Yo-Yo Intermittent Recovery Test

During cancer treatments in childhood hematological malignancies, reduced exercise tolerance is one of the main hardships. Precision-based training programs help children, adolescents, and young adults and their families to resume regular physical activity, exercise, and sports once they return to their communities after the intensive phases spent in hospital. This study was aimed at verifying whether an intermittent recovery test, the Yo-Yo AD, could provide a simple and valid way to evaluate an individual’s capacity to perform repeated intense exercise and to follow up on the impact of tailored exercise in children, adolescents, and young adults with hematological malignancies. The Yo-Yo AD involved the repetition of several shuttles to muscle exhaustion, at pre-established speeds (walking and slow running). The heart rate (HR) and oxygen saturation (SaO2) were monitored during the test. The total distance and the walking/running ability, measured as the slope of the HR vs. distance correlation, were investigated before (T0) and after 11 weeks (T1) of precision exercise intervention. The Yo-Yo AD was also performed by healthy children (CTRL). Ninety-seven patients (10.58 ± 4.5 years, 46% female) were enrolled. The Yo-Yo AD showed the positive impact of the exercise intervention by increasing the distance covered by the individuals (T0 = 946.6 ± 438.2 vs. T1 = 1352.3 ± 600.6 m, p < 0.001) with a more efficient walking/running ability (T0 = 2.17 ± 0.84 vs. T1 = 1.73 ± 0.89 slope, p < 0.0164). CTRLs performed better (1754.0 ± 444.0 m, p = 0.010). They were equally skillful (1.71 ± 0.27 slope) when compared to the patients after they received the precision-based intervention. No adverse events occurred during the Yo-Yo AD and it proved to be an accurate way of correctly depicting the changes in performance in childhood hematological malignancies.

Effects of strength exercise interventions on activities of daily living, motor performance, and physical activity in children and adolescents with leukemia or non-Hodgkin lymphoma: Results from the randomized controlled ActiveADL Study

OBJECTIVES

Pediatric patients with cancer experience impairments in muscle strength and physical activity (PA) that may reduce autonomy during hospitalization. To determine the effects of strength exercise interventions on the accomplishment of activities of daily living (ADLs), motor performance, and PA in children with leukemia or non-Hodgkin lymphoma, we randomly allocated patients (4-18 years) immediately after diagnosis into two exercise groups.

METHODS

The intervention group (IG; n = 21) received a specific strength training combined with a standard care exercise program, whereas the control group (CG; n = 20) was provided standard care exercise program without any targeted muscle strengthening. After the baseline visit, participants were followed-up three times until intensive treatment cessation. We assessed physical function limitations using the Activities Scale for Kids© (ASK) and Functional ADL Screen. Secondary outcomes were PA levels using accelerometer and motor performance as measured by MOON-test (motor performance in pediatric oncology-test).

RESULTS

In both groups, ADL accomplishment had significantly increased (p < 0.05). However, no significant between-group differences for ASK outcome were noted. Motor performance was reduced in all motor abilities.

CONCLUSIONS

Both exercise interventions were effective to maintain ADLs and motor performance during intensive treatment. In comparison, regular strength exercise interventions in the course of therapy tended to be more beneficial with regards to muscular explosive and endurance strength.

Exercise and Childhood Cancer-A Historical Review

Simple Summary

Childhood cancer survivors are at risk of developing important adverse effects, but there is growing evidence that physical exercise could help in this regard. The present review summarizes the history of pediatric exercise oncology and the main milestones achieved along the way. Overall, physical exercise appears to be safe and beneficial even during the most aggressive phases of pediatric cancer treatment and can represent an effective coadjuvant therapy for attenuating cancer-related adverse effects.

Abstract

Childhood cancer survivors are at risk of developing important adverse effects, many of which persist for years after the end of treatment. The implementation of interventions aiming at attenuating tumor/treatment-associated adverse effects is therefore a major issue in pediatric oncology, and there is growing evidence that physical exercise could help in this regard. The present review aims to summarize the main milestones achieved in pediatric exercise oncology. For this purpose, we conducted a systematic review of relevant studies written in English in the electronic database PubMed (from inception to 14 August 2021). This review traces the field of pediatric exercise oncology throughout recent history based on three fundamental pillars: (i) exercise during childhood cancer treatment; (ii) exercise during/after hematopoietic stem cell transplantation; and (iii) exercise after childhood cancer treatment. Accumulating evidence––although still preliminary in many cases––supports the safety and potential benefits of regular exercise (with no major contraindications in general) in the childhood cancer continuum, even during the most aggressive phases of treatment. Exercise can indeed represent an effective coadjuvant therapy for attenuating cancer-related adverse effects.

Exercise reduces systemic immune inflammation index (SII) in childhood cancer patients

While exercise and physical activity have been suggested to reduce mortality and symptoms in cancer, knowledge on these associations in patients with childhood cancer (CCPs) is sparse. Anti-inflammatory properties of exercise might mediate these beneficial effects. We investigated the influence of exercise on the inflammation markers neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, and systemic-immune-inflammation index (SII) and associations to patient-reported-outcomes in CCPs in a randomized-controlled trial. Results show associations between inflammation markers and patient-reported outcomes. Compared to the control group, SII was significantly reduced following exercise (p=0.036). Anti-inflammatory effects of exercise are also present in CCPs and may underlie exercise-induced benefits on symptoms. Clinical Trial Registration Number: NCT02612025

Muscle mass change during chemotherapy in children with high-risk neuroblastoma: a retrospective case series of 24 patients

The clinical characteristics, cause, and risk factors of sarcopenia are unclear in children. The aim of this study was to describe the course of and identify the factors related to muscle mass change during chemotherapy in children with neuroblastoma. A total of 24 consecutive patients aged below 18 years with newly diagnosed high-risk neuroblastoma between 2010 and 2018 in our hospital were enrolled in a case-series study. The psoas muscle index (PMI) was calculated as a parameter of muscle mass based on computer tomography (CT) images of the psoas muscle. PMIs were evaluated at 4 time points (TPs): TP1, at the diagnosis of neuroblastoma; TP2, after the first cycle of chemotherapy; TP3, after the third cycle of chemotherapy; and TP4, at the end of the induction chemotherapy. PMI recovery was defined as an increase in PMI between TP2 and TP4. The mean PMI decreased by 15% between TP1 and TP2 (TP1 7.09 ± 0.99 vs. TP2 6.01 ± 0.98, P < 0.001) and by 10% between TP1 and TP4 (TP1 7.09 vs. TP4 6.35, P = 0.004). PMI recovery between TP1 and TP2 was observed in 7 (29%) patients. The median age of patients with PMI recovery was significantly lower (2 vs. 4 years, P = 0.028), and the proportion of boys was significantly higher in patients with PMI recovery (100% vs. 41%, P = 0.017).Conclusion: This study demonstrated that prominent PMI reduction occurs during the early time of chemotherapy, and a younger age and male sex may be predictive factors for PMI recovery. What is Known: • Sarcopenia is a common disorder in elderly people. • Several causes and risk factors have been reported in adults. • Children with previous hematological malignancies have decreased physical activity. What is New: • Prominent muscle mass loss was observed early in children with high-risk neuroblastoma during chemotherapy. • Age and sex were found to be potentially associated with muscle mass recovery.

Effects of Exercise Interventions on Immune Function in Children and Adolescents With Cancer and HSCT Recipients - A Systematic Review

Background

Pediatric cancer patients are at high risk for life-threatening infections, therapy associated complications and cancer-related side effects. Exercise is a promising tool to support the immune system and reduce inflammation. The primary objective of this systematic review was to evaluate the effects of exercise interventions in pediatric cancer patients and survivors on the immune system.

Methods

For this systematic review (PROSPERO ID: CRD42021194282) we searched four databases (MEDLINE, Cochrane Library, ClinicalTrials.gov, SPORTDiscus) in June 2021. Studies with pediatric patients with oncological disease were included as main criterion. Two authors independently performed data extraction, risk of bias assessment, descriptive analysis and a direction ratio was calculated for all immune cell parameters.

Findings

Of the 1448 detected articles, eight studies with overall n = 400 children and adolescents with cancer and n = 17 healthy children as controls aged 4-19 years met the inclusion criteria. Three randomized, four non-randomized controlled trials and one case series were analyzed descriptively. The exercise interventions had no negative adverse effects on the immune system. Statistically significant results indicated enhanced cytotoxicity through exercise, while changes in immune cell numbers did not differ significantly. Interventions further reduced days of in-hospitalization and reduced the risk of infections. Several beneficial direction ratios in immune parameters were identified favoring the intervention group.

Interpretation

Exercise interventions for pediatric cancer patients and survivors had no negative but promising beneficial effects on the immune system, especially regarding cytotoxicity, but data is very limited. Further research should be conducted on the immunological effects of different training modalities and intensities, during various treatment phases, and for different pediatric cancer types. The direction ratio parameters given here may provide useful guidance for future clinical trials.

Systemic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021194282, Prospero ID: CRD42021194282.

A Systematic Review and Narrative Synthesis of Exercise Interventions to Manage Fatigue Among Children, Adolescents, and Young Adults with Cancer

Exercise is known to improve fatigue among adult cancer patients however there is limited understanding of this relationship in children, adolescents, and young adults (AYA) with cancer. The aim is to evaluate the effect of exercise on fatigue outcomes among children and AYA with cancer and to identify important parameters of exercise (frequency, intensity, time, type, and setting), which may be relevant for future intervention design. A systematic search of PubMed, MedLine, CENTRAL, Embase, and Web of Science databases was conducted in December 2019, for studies within the last decade, reporting the effect of exercise on fatigue among cancer patients and survivors 0-24 years of age. Quality assessment was conducted using the Physiotherapy Evidence Database (PEDro) and "Before/After Studies with No Control Group" scales. Seventeen studies (n = 681 participants) were included, of which six were randomized controlled trials (RCTs), and the remaining being pilot (n = 5) or feasibility studies (n = 6). Across studies there was great heterogeneity in intervention delivery, frequency (range: 1-7 days a week), time (range: 10-60 minutes), and duration (range: 3-24 weeks). A positive effect of exercise on fatigue was observed, however, most changes in fatigue were not statistically significant. Exercise is beneficial for reducing fatigue in young cancer patients. However, due to the heterogeneity and quality of existing interventions, firm conclusions about the most effective mode and format of exercise intervention cannot be drawn. There is a need for more definitive large-scale RCTs that can provide data of sufficient quality.

Adverse Events During Supervised Exercise Interventions in Pediatric Oncology-A Nationwide Survey

Objectives: Exercise interventions during and after treatment for pediatric cancer are associated with beneficial physical, psychological, and social effects. However, valid data about adverse events (AEs) of such interventions have rarely been evaluated. This retrospective study evaluates AEs that occurred during supervised oncological exercise programs for pediatric cancer patients and survivors. Methods: This Germany-wide study used a self-administered online survey focusing on general program characteristics and AEs retrospectively for 2019. The questionnaire included (a) basic data on the offered exercise program, (b) AEs with consequences (Grade 2-5) that occurred in 2019 during an exercise intervention, (c) number of Grade 1 AEs, (d) safety procedures as part of the exercise programs, and (e) possibility to give feedback and describe experience with AEs in free text. Results: Out of 26 eligible exercise programs, response rate of program leaders was 92.3% (n = 24). Representatives working for Universities (n = 6), rehabilitation clinics (n = 3), acute cancer clinics (n = 12), and activity camps (n = 3) participated. In total, 35,110 exercise interventions with varying duration were recorded for 2019. Six AEs with consequences (Grade 2-3) occurred during exercise interventions after cancer treatment resulting in an incidence of 17 per 100,000 exercise interventions (0.017%). No life-threatening consequences or death were reported and no serious AE occurred during acute cancer treatment. Grade 1 AE occurred with a frequency of 983, corresponding to an incidence of 2,800 per 100,000 interventions (2.8%). Most frequent Grade 1 AE were muscle soreness, circulatory problems, and abdominal pain. The most frequent preventive safety procedures at the institutions were regular breaks, consultations with the medical treatment team, and material selection with low injury potential. Conclusions: Supervised exercise interventions for pediatric cancer patients and survivors seem to be safe and AEs with consequences comparatively rare when compared to general childhood population data. Occurrence of grade 1 AEs was common, however, causality was probably not evident between AEs and the exercise intervention. Future research should standardize assessment of AEs in clinical practice and research, and prospectively register and evaluate AEs that occur in the context of exercise interventions in pediatric cancer patients and survivors.

Positive Impact of Organized Physical Exercise on Quality of Life and Fatigue in Children and Adolescents With Cancer

Background: Cancer and its treatment can cause serious health issues that impair physical and mental well-being in children and adolescents. Exercise may be a valid strategy for managing some symptoms, including fatigue. In the light of our experience, we provide further justification for including exercise as part of routine childhood cancer care. Methods: Forty-four children and adolescents who had solid cancers not contraindicating their movement were invited to join an in-hospital 6-week supervised exercise program, and asked afterwards to complete validated quality of life and fatigue scales. The program consisted of personalized workout sessions of aerobic, resistance and flexibility exercises. The results obtained on the scales were compared between 21 patients who engaged in the exercise program (GYM group) and 23 who refused (No-GYM group), examining the different dimensions of health-related quality of life (physical, emotional, cognitive, social) and fatigue (general, sleep/rest, cognitive) in the two groups. Results: Being diagnosed with cancer initially prompted all but one of the respondents to drop-out of previous routine exercise or sports although their continuation had not been contraindicated. After 6 weeks of exercise, the GYM group's scores for quality of life and fatigue showed a statistically significant better perceived emotional functioning, and a trend toward a better social functioning than in the No-GYM group. Conclusion: We suggest that exercise improves the satisfaction of children and adolescents with cancer with their physical, mental and social functioning. We would emphasize the potential benefits of general practitioners discussing and recommending exercise for their young patients with cancer.