Effects of Exercise and Physical Activity Levels on Childhood Cancer: An Umbrella Review
Abstract
:1. Introduction
2. Materials and Methods
2.1. Selection Criteria
2.1.1. Types of Studies
2.1.2. Types of Participants
2.1.3. Types of Interventions
2.1.4. Types of Outcome Measures
2.2. Search Methods for Identification of Reviews
Electronic Searches and Other Resources
2.3. Data Collection and Analysis
2.3.1. Selection of Reviews
2.3.2. Data Extraction and Management
2.3.3. Quality of Evidence
2.3.4. Data Synthesis
3. Results
3.1. Description of Included Reviews
3.1.1. Search Outcomes
3.1.2. Characteristics of Eligible Systematic Reviews
3.1.3. Methodological Quality of Included Reviews
3.2. Effects of Interventions
3.2.1. Cancer-Related Fatigue
3.2.2. Muscle Strength
3.2.3. Aerobic Capacity
3.2.4. Cancer-Related Pain
3.2.5. Body Composition
3.2.6. Activity and Participation Levels
3.2.7. Psychosocial Health Indices
3.2.8. Health-Related Quality of Life
3.2.9. Cardiorespiratory Fitness
3.2.10. Cardiovascular Fitness
3.2.11. Cardiovascular Function and Structure
3.2.12. Flexibility/Range of Motion
3.2.13. Coordination
3.2.14. Physical Fitness
3.2.15. Physical Function
3.2.16. Functional Capacity
3.2.17. Physical Capacity
3.2.18. Biochemical Indicators
3.2.19. Bone Mineral Density
3.2.20. Brain Volume and Structure
3.2.21. Cognitive Function
3.2.22. Energy Consumption
3.2.23. General Health Domain
3.2.24. Adverse Effects
4. Discussion
4.1. Summary of Main Results and Overall Completeness and Applicability of Evidence
4.2. Quality of the Evidence
4.3. Study Limitations
4.4. Potential Biases in the Review Process
5. Conclusions
5.1. Implications for Practice
5.2. Implications for Research
Supplementary Materials
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
References
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Study | Assessment of Bias | Sample Demographics | Type of Cancer | Cancer Treatment-Stage of Cancer | Intervention Characteristics | Main Results |
---|---|---|---|---|---|---|
[24] | Critically low | − 4–18 y (and adults) − n = 209 | Any type of hematological cancer | − Pediatric survivors not receiving hematopoietic stem cell transplantation − Pediatric survivors undergoing HSCT | Type: Aerobic or a combination of aerobic and resistance exercise Frequency: NR Intervention duration: Not receiving HSCT: 12–20 weeks; Receiving HSCT: 8 weeks Exercise duration: ranged from 30–120 min Intensity: NR Supervised: home-based, intrahospital | − Strong evidence for a benefit on muscle strength (particularly if training was conducted in the hospital setting) − Body composition: weak evidence − ↑ Cardiorespiratory fitness − Ankle dorsiflexion: weak evidence − Physical functioning: weak evidence − No adverse effects |
[16] | Low | − 6–18 y − n = 155 | ALL (the most common), solid tumors, AML, and lymphoma | − Maintenance stage of chemotherapy − Just received their first round of chemotherapy − Had completed two courses of treatment (4–8 weeks each) − Survivor stage | Type: home-based aerobic exercise using a video compact disc; use of a bicycle-style exerciser; aerobics and various types of physical activities and strength-building exercises Frequency: ranged from 2 to 3 days/week to twice/day Intervention duration: ranged from 2 days–16 weeks Exercise duration: ranged from 10–45 min Intensity: heart rate of >90% of the maximum heart rate (HR max), or the increase in the percentage of heart rate reserve (% HRR) of 40–60% Supervised: intrahospital, home-based, community | − ↓ Fatigue (11% mean reduction) after 12 weeks of training in 6–14 years for ALL survivors − ↓ General fatigue levels after 8 weeks of training and at a 3-month follow-up in 14–18-year-old patients with cancer − No adverse effects |
[6] | Low | − 0–18 y − n = 278 | Mixed cancer diagnoses, ALL, osteosarcoma or Ewing’s sarcoma of the lower limb, hematological cancer, solid tumor, hematological disorders | − Intense phase − Intense cancer treatment included hematopoietic stem cell transplantation and all treatment phases except the ‘maintenance phase’ of leukemia therapy | Type: aerobic, strengthening and stretching exercises, games, and yoga Frequency: ranged from 1 day/week to twice/day Intervention duration: ranged from 3 weeks–3 months Exercise duration: ranged from 15–60 min Intensity: NR Supervised: intrahospital supervised, home-based | − ↑ Muscle strength − ↑ Aerobic capacity − ↓ Pain − ↑ Role/social–physical, self-esteem, and mental health − HRQOL: ↑ when assessed by the Oncology Module KINDL scale, but ↓ when assessed by the generic version of the KINDL − ↑ Physical function − General health domain: parent’s responses-significant findings, child data-non-significant findings − No adverse effects |
[5] | High | − <19 y at diagnosis − n = 171 (males: n = 98, females: n = 70) − Participants in the training program needed to be no more than 5 years from diagnosis | ALL | − During chemotherapy − During the maintenance treatment period − Shortly after diagnosis | Type: strength and inspiratory training Frequency: NR Intervention duration: ranged from 10 weeks–2 years Exercise duration: ranged from 15–60 min Intensity: NR Supervised: at least a home-based exercise program with guidance from a therapist of the treating hospital | − Fatigue, general fatigue: non-significant differences between the control and intervention groups (limited data) − Sleep/rest fatigue, cognitive fatigue: no intervention effect − ↑ back and leg strength combination score − BMI: no statistically significant differences − ↑ BMD for the intervention group compared to the control group − Activity levels: no statistically significant differences (limited data) − HRQOL: some positive effects in favor of the intervention group (assessed by the PedsQL Cancer Module) − ↑ Cardiorespiratory fitness (defined as: VO2 peak, Wmax, or endurance time) was significantly improved by the 9-min run-walk test, timed up and down stairs test, the timed up and go time test, and the 20-m shuttle run test, but not the timed up and down stairs test − Flexibility: ↑ Passive ankle dorsiflexion but no active ankle dorsiflexion and body flexibility − No adverse effects (limited data) |
[15] | Critically low | − 0–18 y − n = 116 (55 of all participants in exercise interventions) | Cancer | − Active treatment − Post-chemotherapy and following treatment | Type: aerobics, pedaling a stationary bicycle, and physiotherapy practice sessions Frequency: NR Intervention duration: NR Exercise duration: NR Intensity: NR Supervised: intrahospital, home-based | − ↓ Fatigue scores among intervention groups (with no statistically significant differences) |
[20] | Critically low | − < 18 y at diagnoses − n = 270 (54% females) | ALL, solid tumor survivors, brain tumor survivors, childhood cancer survivors of mixed diagnoses | − Maintenance chemotherapy > 20 years following intensive treatment −Within 5 years of treatment completion − More than 5 years following intensive treatment completion | Type: aerobic based only, combinations of aerobic, resistance, interval, functional, and flexibility training Frequency: ranged from daily to twice/week and from 60–420 min/week Intervention duration: ranged from 2 weeks–1 year Exercise duration: NR Intensity: between 40 and 70% of heart rate reserve and 66–90% of maximum heart rate, at a ‘moderate to vigorous’ intensity Supervised: ≥50% of the intervention was unsupervised, home-based, supervised in the treating clinic, or community-based | − Muscle strength: collectively improved − Activity levels: non-significantly increased self-reported physical activity levels − Psychosocial health indices: collectively improved negative mood, interpersonal problems, self-esteem, ineffectiveness, anhedonia, and fatigue − ↑ Cardiovascular fitness − ↑ Flexibility − Biochemical indicators: did not improve hemoglobin and HbA1c levels − No adverse effects (limited data) |
[21] | Critically low | − 6–41 y (the age at diagnosis, the time since diagnosis, and the time since the end of treatment ranged from 0–15 y, from 1–22 y, and from 1–21 y) − n = 296 (intervention: n = 189, females: n = 96) (control: n = 107, females: n = 48) | Different types of childhood cancer (the most common being hematological malignancies (leukemia) and brain tumors in childhood cancer), and survivors who had finished anticancer therapy ≥ 1 year before the study | N/R | Type: aerobic or a combination of aerobic and resistance exercise Frequency: ranged from two to five sessions/week Intervention duration: from 8 weeks–6 months Exercise duration: N/R Intensity: 50–60% of one-repetition maximum for resistance exercise and between 40% of heart rate (HR) reserve and > 90% of maximum HR for aerobic exercise Supervised: NR | − Body composition: ↓ central adiposity (waist circumference and waist-to-hip ratio) − ↑ in total body bone mineral content and femoral neck bone mineral density − ↑ Activity levels − Cardiovascular function and structure: improved endothelial function − Brain volume and structure: benefits on white matter fractional anisotropy and hippocampal volume and on cortical thickness and white matter volume (preliminary evidence) − Some adverse effects or problems regarding tolerance or safety (limited data) |
[22] | Critically low | − 4–18 y − n = 172 | Solid or hematologic (most of them ALL) cancer with no previous organ transplantation, post radiotherapy/chemotherapy sessions, or medical contraindication for exercise (solid tumors, extracranial solid tumors, ALL, AA, ALCL, AML, MPD, hematological malignancy, rhabdomyosarcoma, neuroblastoma, undetermined) | N/R | Type: combination of strength and aerobic training, balance activities, stretching, and games Frequency: ranged from two to five sessions/week Intervention duration: from 3 to 22 weeks Exercise duration: ranged from 10–120 min Intensity: N/R Supervised: during hospitalization | − ↑ Muscle strength and maintained for 20 weeks after the end of the study − HRQOL: non-significant differences − ↑ Physical fitness and maintained for 20 weeks after the end of the study − Functional capacity: ↑ when measured by the TUDS test, but non-significant differences when measured by 6MWT − No adverse effects |
[17] | Critically low | − 0–18 y − n = 508 (intervention: n = 282, control: n = 226) | ALL | Acute chemotherapy, maintenance chemotherapy, post-treatment survivorship, multiple phases | Type: Aerobic training, general strengthening and/or ankle dorsiflexor strengthening, gastrocsoleus stretching and/or general stretching, bone strengthening, balance training, and motor skill training Frequency: − Maintenance chemotherapy: 2 days/month–7 days/week − Post-treatment survivorship: 2 days/month–7 days/week − Across multiple phases of treatment: 1–2 days/month–7 days/week Intervention duration: − Acute chemotherapy: 3 weeks − Maintenance chemotherapy: 2 weeks–12 months − Post-treatment survivorship: 2 weeks–4 months − Across multiple phases of treatment: 12–135 weeks Exercise duration: − Maintenance chemotherapy: 15–120 min - Post-treatment survivorship: 15–120 min − Across multiple phases of treatment: 45–60 min Intensity: NR Supervised: NR | − Fatigue: ↓ after aerobic training intervention during acute chemotherapy and maintenance chemotherapy − Muscle strength: ↑ during maintenance chemotherapy, post-treatment survivorship and multiple-phase interventions − Activity levels: ↑ during maintenance chemotherapy and multiple-phase interventions − Participation: ↑ during multiple-phase interventions − Flexibility: ↑ range of motion during maintenance chemotherapy and post-treatment survivorship − Functional mobility: ↑ during post-treatment survivorship − Coordination: ↑ during multiple-phase interventions − Bone mineral density: ↑ during maintenance chemotherapy − Some specific adverse events (none of them reported harm, injury, or adverse effects associated with motor interventions) |
[19] | Critically low | − 3–18 y − n = 91 (intervention: n = 45, control: n = 46) | Cancer, HSCT | HSCT | Type: mixed exercise program with aerobic and strength training Frequency: ranged from 3 to 7 days/week Intervention duration: from 6–8 weeks Exercise duration: ranged from 20–120 min Intensity: mild to moderate Supervised: predominantly or partially supervised | − Muscle strength: positive responses regarding peripheral muscle strength (not clearly demonstrated) − HRQOL: significant ↑ in children’s comfort and resilience − Functional capacity: significant ↑ in TUDS test but no difference in 6MWT − No adverse effects |
[9] | Critically low | − 5–38 y (the age at diagnosis ranged from 0–15 y, the time since diagnosis from 1–22 y, and the time since the end of treatment of those with CCS who had already finished treatment from 0–21 y) − n = 697 (CCS: n = 669, healthy: n = 28) | Childhood cancer survivors, different types of childhood cancer (the most common being ALL) | During or after treatment | Type: aerobic or a combination of aerobic and resistance exercise Frequency: ranged from 1 to 6 days/week Intervention duration: from 3 weeks–2.5 years Exercise duration: NR Intensity: ranged from 50–60% of 1 repetition maximum for resistance exercise and between 50 and >90% heart | − Cardiorespiratory fitness: non-significant trend towards an improvement in peak oxygen uptake (VO2peak) − Cardiovascular function and structure: preserved left ventricular ejection fraction from decline − ↑ Physical capacity or attenuating the decline − Some adverse effects: a patella dislocation, a fall during an exercise session, headache, muscle soreness, fatigue, and hyperventilation during the exercise interventions |
[18] | Critically low | − 1–23 (1–10 years from the conclusion Of the treatment, or 1–5 years from the conclusion of the treatment, or during treatment in two studies that include ages between 4–18) − n = 306 | Pediatric brain tumors (hemispheric or posterior fossa brain tumors in most studies) | Patients or survivors: children who had undergone either cranial or craniospinal radiation therapy (a number of them had also undergone surgical operations with or without chemotherapy) | Type: aerobic exercise, combinations of aerobic and strengthening exercises, yoga Frequency: ranged from 2 to 5 days/week Intervention duration: from 12–24 weeks Exercise duration: NR Intensity: NR Supervised: − intrahospital: under the supervision of a physiotherapist or a kinesiologist − home-based: under the supervision of their parents | − Aerobic capacity: submaximal aerobic capacity enhancement and endurance improvement − ↑ Physical activity levels − Psychosocial health indices: ↓ depression level showed a positive correlation with the increased thickness of the cortex (assessed by the CDI-2 questionnaire) − ↑ HRQOL: after 4 weeks of inpatient rehabilitation and after 12 weeks of yoga intervention (but the result did not last for a year) (assessed by the KINDL health related quality of life and the Peds 4.0 General Module) − Cardiovascular fitness: the distance covered in 6 min increased after a 12-week training period (assessed by 6 min walk test) − ↑ Hamstring flexibility after a 12-week yoga intervention in pediatric cancer out-patients − Physical fitness: after a 12-week yoga program, the participants performed the TUG-3m test significantly faster than the pre-test − Coordination: after a 12-week exercise training, the bilateral coordination increased while balance remained unchanged (improved performance maintained even 12 weeks after the training had ended) (measured by the Bruininks-Oseretsky Test2) − Brain volume and structure: ▪ Increased right somatosensory cortical thickness ▪ Increased fractional anisotropy (FA) in the corpus callosum, in the right corticospinal pathway, and in the cingulum − Cognitive function: improvement of reaction time after 12 weeks of training that was maintained for 12 weeks after training had ended (measured by the Cambridge Neuropsychological Test Automated Battery) − Energy consumption: no noticeable changes with active video gaming [assessed by the Metabolic Equivalent Task (MET)] |
[23] | High | − 4–18 y − n = 642 (intervention: n = 322, control: n = 320) | Childhood cancer survivors with mixed types of cancer | During or after treatment | Type: aerobic, anaerobic, resistance, or combined physical exercise training Frequency: mean 2.25 sessions/week Intervention duration: mean 16.6 weeks Exercise duration: mean 152.36 min Intensity: low, Medium, high Supervised: supervised by health professionals, medical staff, or coaches | − ↓ Fatigue − ↑ Muscle strength − ↑ BMI, but non-significant effects on body composition − ↑ Level of daily physical activity − ↑ self-efficacy − HRQOL: no significant effect − ↑ cardiopulmonary fitness − ↑ Flexibility and balance (limited data) − Physical function: no intervention effect in pediatric patients with solid tumors (limited data) |
Outcome (Number of Studies) | Effect | Study | Type of Cancer |
---|---|---|---|
Fatigue (5) | ↓ | [15,16,17,23] | ALL (the most common), solid tumors, AML, lymphoma, CCS with mixed types of cancer |
↔ | [5] | ALL | |
Physical function: | |||
Muscle strength (8) | ↑ | [5,6,17,19,20,22,23,24] | Hematological cancer (ALL, AA, ALCL, AML, MPD), osteosarcoma or Ewing’s sarcoma of the lower limb, solid tumor, extracranial solid tumor, rhabdomyosarcoma, neuroblastoma, undetermined hematological disorders, hematopoietic stem cell transplantation, CCS with mixed types of cancer |
Flexibility (5) | ↑ | [18,20,23] | ALL, brain tumors, CCS with mixed types of cancer |
↔ | [5] | ALL | |
Weak evidence | [24] | Hematological cancer | |
Range of motion (1) | ↑ | [16] | ALL (undergoing maintenance chemotherapy and during post-treatment survivorship) |
Coordination (2) | ↑ | [17,18] | ALL, pediatric brain tumors |
Physical fitness (2) | ↑ | [18,22] | Solid tumors, extracranial solid tumor, hematological cancer (ALL, AA, ALCL, AML, MPD), rhabdomyosarcoma, neuroblastoma, brain tumors |
Motor performance (4) | ↑ | [6,20] | ALL, solid tumors, solid tumor survivors, brain tumor survivors, osteosarcoma or Ewing’s sarcoma of the lower limb, hematological cancer, hematological disorders, CCS with mixed types of cancer |
↔ | [23] | CCS with mixed types of cancer | |
Weak evidence | [24] | Hematological cancer | |
Functional capacity (3) | ↑ | [17,19,22] | ALL, solid tumors, extracranial solid tumor, hematological cancer (AA, ALCL, AML, MPD), rhabdomyosarcoma, neuroblastoma, hematopoietic stem cell transplantation |
Physical capacity (1) | ↑ | [8] | Different types of childhood cancer, CCS with mixed types of cancer |
CRF: | |||
Aerobic capacity (2) | ↑ | [6,18] | ALL, osteosarcoma or Ewing’s sarcoma of the lower limb, hematological cancer, solid tumor, hematological disorders, brain tumors |
Cardiorespiratory fitness (4) | ↑ | [5,23,24] | Hematological cancer (ALL and others), CCS with mixed types of cancer |
↔ | [8] | Different types of childhood cancer, CCS with mixed types of cancer | |
Cardiovascular fitness (2) | ↑ | [18,20] | ALL, brain tumors, CCS with mixed types of cancer (solid tumor survivors, brain tumor survivors, and others) |
Cardiovascular function and structure (2) | ↑ | [8,22] | Different types of childhood cancer, hematological malignancies, brain tumors, CCS with mixed types of cancer |
Pain (1) | ↓ | [6] | ALL, osteosarcoma or Ewing’s sarcoma of the lower limb, hematological cancer, solid tumor, hematological disorders |
Body Weight/composition: | |||
Body Composition (3) | ↔ | [22,23] | Hematological cancer, brain tumors, CCS with mixed types of cancer |
Weak evidence | [24] | Hematological cancer | |
BMI (2) | ↔ | [5] | ALL |
↑ | [23] | CCS with mixed types of cancer | |
Activity/participation levels (6) | ↑ | [16,18,22,23] | ALL, hematological cancer, brain tumors, CCS with mixed types of cancer |
↔ | [5,20] | ALL, solid tumor survivors, brain tumor survivors, CCS with mixed types of cancer | |
Energy consumption (1) | ↔ | [18] | Brain tumors |
Psychosocial health indices (4) | ↑ | [6,18,20,23] | ALL, osteosarcoma or Ewing’s sarcoma of the lower limb, hematological cancer, solid tumor, brain tumors, hematological disorders, CCS with mixed types of cancer (solid tumor survivors, brain tumor survivors and others) |
HRQL (6) | ↑ | [5,6,18,19] | Hematological cancer (ALL and others), osteosarcoma or Ewing’s sarcoma of the lower limb, solid tumor, brain tumors, hematological disorders, hematopoietic stem cell transplantation |
↔ | [22,23] | Solid tumors, extracranial solid tumor, hematological cancer (ALL, AA, ALCL, AML, MPD), rhabdomyosarcoma, neuroblastoma, CCS with mixed types of cancer | |
Biochemical indicators (1) | ↔ | [20] | ALL, CCS with mixed types of cancer (solid tumor survivors, brain tumor survivors) |
Bone mineral density (3) | ↑ | [5,19,22] | ALL, hematological cancer, brain tumors |
Brain Volume/structure (2) | ↑ | [18,22] | Hematological cancer, brain tumors |
General health domain (1) | ↔ | [6] | ALL, osteosarcoma or Ewing’s sarcoma of the lower limb, hematological cancer, solid tumor, hematological disorders |
Cognitive function (1) | ↑ | [18] | Brain tumors |
Adverse effects (11) | No adverse effects | [5,6,16,19,20,22,23,24] | Hematological cancer (ALL, AML, AA, ALCL, MPD, lymphoma), solid tumors, osteosarcoma or Ewing’s sarcoma of the lower limb, hematological disorders, extracranial solid tumor, rhabdomyosarcoma, neuroblastoma, hematopoietic stem cell transplantation, CCS with mixed types of cancer (solid tumor survivors, brain tumor survivors) |
Some adverse effects | [8,17,22] | Hematological cancer (ALL and others), brain tumors, CCS with mixed types of cancer | |
Not reported | [15,18] | Brain tumors, cancer in general |
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Rapti, C.; Dinas, P.C.; Chryssanthopoulos, C.; Mila, A.; Philippou, A. Effects of Exercise and Physical Activity Levels on Childhood Cancer: An Umbrella Review. Healthcare 2023, 11, 820. https://doi.org/10.3390/healthcare11060820
Rapti C, Dinas PC, Chryssanthopoulos C, Mila A, Philippou A. Effects of Exercise and Physical Activity Levels on Childhood Cancer: An Umbrella Review. Healthcare. 2023; 11(6):820. https://doi.org/10.3390/healthcare11060820
Chicago/Turabian StyleRapti, Christina, Petros C. Dinas, Costas Chryssanthopoulos, Alexandra Mila, and Anastassios Philippou. 2023. "Effects of Exercise and Physical Activity Levels on Childhood Cancer: An Umbrella Review" Healthcare 11, no. 6: 820. https://doi.org/10.3390/healthcare11060820