Amanda Wurz & Dr. S. Nicole Culos-Reed
As it is now nearing the end of August, you should be convinced of the importance of physical activity during childhood, a key factor in the development of healthy children and eventually healthy adults. As Andrew mentioned in “How Much Physical Activity do Children Need?”, physical inactivity in our children and youth is alarming. We know that less than half of children are meeting the Canadian Society for Exercise Physiology (CSEP) Physical Activity Guidelines. And research suggests that childhood cancer patients and survivors are more sedentary than their healthy peers1,2,3. It may seem counterintuitive to focus on physical activity levels while a child is battling cancer, as we typically think children should be resting and recovering from their treatment. However, the research consistently stresses the importance of exercise throughout the childhood cancer trajectory4,5,6,7.
Tremendous advances in research and technology over the past 30 years have resulted in improved treatment and survival rates, with over 80% of childhood cancer patients becoming long-term survivors8,9. Unfortunately, survivorship is often accompanied by negative side-effects that develop both during and after treatments10. Physical early side-effects impact a range of body tissues and functions during or shortly after treatment (i.e., increased risk of infections, bleeding and clotting complications, nausea, vomiting, allergic reactions, skin changes, temporary hair loss, fatigue). Physical late side-effects occur months or years after treatment ends and include, reduced muscular strength, damage to nerves in the extremities, reduced cardiovascular functioning due to damage to the lungs and heart, persistent fatigue. Psychosocial early side-effects include a range of negative social and emotional states that would be expected to occur during or shortly after treatment (i.e., anxiety, fear, depression, social isolation) with many of the late side-effects occurring months or years after treatment ends (i.e., poor social functioning, withdrawal, decreased health related quality of life). Several resources outlining the array and degree of side-effects experienced can be accessed online11,12. Unfortunately, adding physical inactivity into this mix not only worsens the side-effects experienced, but it also increases the likelihood of childhood survivors developing diseases such as hypertension, diabetes, osteoporosis and cancer recurrence4,13,14.
Across childhood cancers, patients report lower amounts and intensity levels of physical activity than healthy children. Pain, fear, anxiety, fatigue, difficulty accessing programs, and the overprotective attitudes of parents and educators have been commonly cited in the literature as barriers to physical activity in this population15,16. Additionally, it is suggested that the low levels of physical activity typically seen in this population may be due to the fact that pediatric cancers peak in incidence between the ages of 2-5 years, a time when many children are introduced to leisure time physical activity4,17. Thus, their disease may impede their ability to play with their peers and establish healthy physical activity habits. Likely it is a culmination of disease timing, fatigue, limited programming, parental attitudes, and an array of personal and familial characteristics that result in lower than average physical activity levels.
Fortunately, researchers and clinicians are aware of the importance of early intervention in this population. The last 15 years have shown physical activity’s beneficial impact on many of the negative physical and psychosocial side-effects of treatment2,4,5,18.
Although the field is still young and the majority of findings are preliminary, the existing evidence consistently suggests that mild to moderate exercise is safe, beneficial and feasible for both childhood cancer patients and survivors. As the field grows it will be important to:
(i) Share the research information we have;
(ii) Create tailored guidelines. Our lab is currently working with an international team to put out the first Pediatric Oncology Exercise Manual – POEM – which will be distributed to physicians and parents at the Alberta Children’s Hospital, as well as across Canada, and through our colleagues worldwide); and,
(iii) Create safe, evidence-informed programs to offer patients and survivors a safe space to exercise (that takes into account their compromised immune systems, lower level of physical functioning etc.). We have developed Pediatric Survivors Engaging in Exercise for Recovery (PEER), and will be launching Yoga Thrive for Youth (YTY) an innovative yoga program for childhood and adolescent cancer patients and survivors in Fall 2013. These programs have a central goal: Provide childhood cancer patients and survivors safe, accessible, evidence-informed activity programming that will enhance and restore their levels of physical and psychosocial functioning. We need to continue reaching out to childhood cancer patients and survivors to ensure they are meeting physical activity guidelines.
A more in depth article expressing our teams vision for the future of physical activity and pediatric oncology can be found here: Chamorro-Vina, C, Wurz, AJ, & Culos-Reed, SN (2013). Promoting physical activity in pediatric oncology. Where do we go from here? Frontiers in Oncology, 3(173), 1-4. doi: 10.3389/fonc.2013.00173
- Ness, K.K., Leisenring, W.M., Huang, S., Hudson, M.M., Gurney, J.G., Whelan, K. et al. (2009). Predictors of inactive lifestyle among adult survivors of childhood cancer: A report from the Childhood Cancer Survivor Study. Cancer, 115(9), 1984-1994.
- Kelly, A.K. (2011). Physical activity prescription for childhood cancer survivors. Current Sports Medicine Reports, 10(6), 352-359.
- Ness, K.K., Hudson, M.M., Ginsberg, J.P., Nagarajan, R., Kaste, S.C., Marina, M. et al. (2009). Physical performance limitations in the Childhood Cancer Survivor Study cohort. Journal of Clinical Oncology, 24(14), 2382-2389.
- San Juan, A.F., Wolin, K., & Lucia, A. (2011). Physical activity and pediatric cancer survivorship. In: Courneya K.S., & Friedenreich, C.M. (eds) Physical activity and cancer: Recent results in cancer research (pp.319-347). New York: Springer – Berlin Heidelberg.
- Huang, T-T., & Ness, K.K. (2011). Exercise interventions in children with cancer: A review. International Journal of Pediatrics, 1-11.
- Soares-Miranda, L., Fiuza-Luces, C., Lassaletta, A et al. (2013). Physical activity in pediatric cancer patients with solid tumors (PAPEC): Trial rationale and design. Contemporary Clinicial Trials, 5(1), 106-115.
- Winter, C., Muller, C., Brandes, M., Brinkmann, A., Hoffman, C., Hardes, J. et al. (2009). Level of activity in children undergoing cancer treatment. Pediatric Blood and Cancer, 53(3), 438-443.
- Jemal, A., Siegel, R., Ward, E., Hao, T., Xu, J., & Thun, M.J. (2009). Cancer statistics, 2009. CA – A Cancer Journal for Clinicians, 59(4), 225-229.
- Ellison, L.F., Prithwish, D., Mery, L.S., & Grundy, P.E. (2009). Canadian cancer statistics at a glance: Cancer in Children. Canadian Medical Association Journal, 180(4), 422-424.
- Oeffinger, K.C., Mertens, A.C., Sklar, C.A., Kawashima, T., Hudson, M.M., Meadows, A.T. et al. (2006). Chronic Health Conditions in Adult Survivors of Childhood Cancer. New England Journal of Medicine, 355, 1572-1582.
- Shad, A.T., Late Effects of Childhood Cancer and Treatment. (2010). http://emedicine.medscape.com/article/990815-overview.Retrieved August 28, 2013.
- American Cancer Society. (2012). Children diagnosed with cancer: Late effects of cancer treatment. http://www.cancer.org/treatment/childrenandcancer/whenyourchildhascancer/children-diagnosed-with-cancer-late-effects-of-cancer-treatment. Retrieved August 28, 2013.
- Finnegan, L., Wilkie, D.J., Wilbur, J., Campbell, R.T., Zong, S., & Katula, S. (2007). Correlates of physical activity in young adult survivors of childhood cancers. Oncology Nursing Forum, 34(5), E60-E69.
- Wolin, K.Y., Ruiz, J.R., Tuchman, H., & Lucia, A. (2010). Exercise in adult and pediatric hematological cancer survivors: An intervention review. Leukemia, 24(6), 1113-1120.
- Arroyave, W.D., Clipp, E.C., Miller, P.E., Jones, L.W., Ward, D.S., Bonner, M.J. et al. (2008). Childhood cancer survivors’ perceived barriers to improving exercise and dietary behavior. Oncology Nursing Forum, 35, 121-130.
- Aznar, S., Webster, A.L., San Juan, A.F., Chamorro-Vina, C., Mate-Munoz, J.L., Moral, S. et al. (2006). Physical activity during treatment in children with leukemia: A pilot study. Applied Physiology, Nutrition and Metabolism, 31, 407-413.
- Oeffinger, K.C., Buchanan, G.R., Eshelman, D.A., Denke, M.A., Andrews, T.C., Germak, J.A. et al. (2001). Cardiovascular risk factors in young adult survivors of childhood acute lymphoblastic leukemia. Journal of Pediatric Hematology/Oncology, 23(7), 424-430.
- Keats, M.R., & Culos-Reed, S.N. (2008). A community-based physical activity program for adolescents with cancer (project trek): Program feasibility and preliminary findings, Journal of Pediatric Hematology and Oncology, 30, 272-280.
A word from the DBL:
Many thanks to our guest contributors, Amanda Wurz and Dr. S. Nicole Culos-Reed. Dr. Culos-Reed is the director of the Health & Wellness Lab, University of Calgary, Faculty of Kinesiology. She is an Associate Professor in Health and Exercise Psychology in the Faculty of Kinesiology and Adjunct Associate Professor in the Department of Oncology in the Faculty of Medicine at the University of Calgary. She also holds a Research Associate appointment with the Department of Psychosocial Resources in the Tom Baker Cancer Centre. Her research is focused on the benefits of physical activity throughout the cancer trajectory. Amanda Wurz holds a BA in Psychology and is currently a MSc student at the University of Calgary, in the Health & Wellness Lab. Her research is exploring the effects of a 12-week yoga intervention in childhood cancer out-patients. Additionally, she assists with both the PEER and YTY programs.