Clinical Context

Even in remission, cancer can have negative effects on health. The authors of the current study describe how survivors of childhood cancer generally have lower levels of physical activity compared with their peers who do not have a history of cancer. Stolley and colleagues previously performed a systematic review to assess lifestyle habits among survivors of childhood cancer.^[1] Their results were published in the June 2010 issue of the Annals of Behavioral Medicine.

The researchers found 20 studies that addressed physical activity in survivors of childhood cancer. Most, but not all, studies found that cancer survivors had lower physical activity levels compared with individuals without a history of cancer. Most adolescents reported reducing physical activity after their diagnosis. Higher levels of physical activity among cancer survivors were associated with male sex, younger age, being White, and postsecondary education. Body mass index was inconsistently associated with physical activity among cancer survivors.

Motivating survivors of childhood cancer can be particularly challenging. The current study analyzes a novel program of motivational interviewing via text message for this outcome.

Study Synopsis and Perspective

Sending a text with a brief motivational intervention (MI) to parents of childhood cancer survivors substantially increased their child's physical activity level compared with control persons, and also reduced treatment-related late effects.

The findings come from a randomized trial of 161 children (median age, 12.4 years) who had recovered after leukemia, lymphoma, or brain tumors.

"Physical activity...is beneficial in preventing and attenuating many adverse late effects following pediatric cancer and treatment. However, most children who survive cancer do not participate in sufficient [physical activity] to obtain these health benefits," say the researchers, led by Ankie Tan Cheng, PhD, from the Chinese University of Hong Kong, Hong Kong, China.

"To our knowledge, [this study] was the first randomized clinical trial to use brief MI to motivate parents to encourage their children surviving cancer to engage in regular [physical activity]," the authors note.

The intervention "was effective in promoting regular physical activity in children who survived cancer," they add. It "can be integrated into pediatric survivorship care to attenuate cancer- and treatment-related adverse effects and improve QOL [quality of life] among the vulnerable pediatric oncology population."

The study was published online June 14 in JAMA Network Open.^[2]

A total of 161 children between 9 and 16 years of age who had survived cancer were randomly assigned, along with their parents, to the intervention group or the control group.

The primary outcome was the children's physical activity levels at 12-month follow-up, measured by the Chinese University of Hong Kong: Physical Activity Rating for Children and Youth score.

The intervention group underwent a 10-minute health advice session delivered by a nurse at the time of recruitment into the study. "The session highlighted the specific health benefits of regular [physical activity] for the children," the authors explain. "During each communication, parents were asked whether they had encouraged their child to perform regular [physical activity] in the past week," they add.

The brief intervention was delivered to parents typically not less than once a week and not more than 3 times a week during the first 6 months, after which minimal messaging was delivered to parents until study endpoint at 12 months.

Compared with the control group, the intervention group showed significantly greater increments in physical activity levels at 3, 6, and 12 months after study enrollment (P<.001 for all time endpoints). "Moderate to vigorous [physical activity] levels among participants in the intervention group increased by 72.8%, compared with 6.3% in controls during the 12-month study period," the team notes.

Secondary endpoints of the trial included treatment-related late effects. Cancer-related fatigue was significantly reduced (P=.003), and peak expiratory flow rate was significantly improved (P=.29). There were also improvements in left-hand grip strength (P=.04), right-hand grip strength (P=.02), and QOL (P=.04), although these did not reach statistical significance.

The intervention may have been effective because it simply alleviated parental concerns and misconceptions about their child's engagement in physical activity, the authors comment. They also note that family involvement is important in Chinese culture, in which children are encouraged to follow parental instructions and advice.

"The use of this technology enables direct, real-time, continuing professional counseling and support for parents; the rapid delivery of instant messaging provided a means of 2-way communication that was flexible, efficient and time-saving," Dr Cheung and colleagues conclude.

Family involvement is a key aspect of this study, comment Katie Devine, PhD, MPH, and Gary Kwok, PhD, both from the Rutgers Cancer Institute of New Jersey, New Brunswick, in an accompanying editorial.^[3]

"An important highlight of this intervention is the direct parent[al] involvement in the intervention," the editorialists write.

The intervention may help address specific concerns that parents might have about their children exercising, such as worrying about overtaxing their child and misconceptions about how exercise might make their child tired, rather than alleviating fatigue. "While there are barriers to implementing physical activity and exercise interventions with families following a cancer diagnosis, targeting the family unit may increase the chance of successful outcomes," the editorialists state.

Indeed, studies have shown that family support is a key factor in promoting physical activity among children and adolescents in the general population, as well as among childhood cancer survivors, the editorialists comment.

Furthermore, "instant messaging allows brief conversations to occur in parents' everyday life settings, offering support at times when needed, while minimizing participant burden," they add.

Limitations of the study include the potential for bias because physical activity was self-reported, although objective measures are difficult to collect and analyze. "This study suggested the utility of targeting parents to improve children's physical activity and the acceptability of using an instant messaging application to deliver personalized messages over time," Dr Devine and Dr Kwok comment.

"Future work should consider strategies for promoting family support for physical activity in different intervention contexts and measuring the pathways through which interventions improve outcomes," they suggest.

The authors and editorialists have disclosed no relevant financial relationships.

JAMA Netw Open. Published online June 14, 2022.

Clinical Implications

• A previous review found that most, but not all, studies found that survivors of childhood cancer had lower physical activity levels compared with individuals without a history of cancer. Higher levels of physical activity among cancer survivors were associated with being male, younger age, being White, and postsecondary education. Body mass index was inconsistently associated with physical activity among cancer survivors.
• A program of motivational interviewing using instant messaging to promote physical activity was associated with increased physical activity, improved grip strength, and less fatigue among survivors of childhood cancer enrolled in the current study.
• Implications for the healthcare team: The healthcare team should consider the use of technology, including instant messaging, to help patients and their support systems find value in healthy lifestyle choices such as physical activity.

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