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Unlocking the Key to Long-term Health For Cancer Survivors

August 30, 2023

According to the American Childhood Cancer Organization, approximately 1 in 285 children in the US will be diagnosed with cancer before their 20th birthday. St. Jude Children's Research Hospital reports that approximately 80% of these children will become long-term cancer survivors, and almost 500,000 long-term survivors of childhood cancer currently live in the US. That is a large group of pediatric patients!  And these patients are at increased risk for a variety of conditions that affect physical and mental health, including cardiovascular disease, diabetes, anxiety, depression, low bone density, and secondary cancers.

Physical activity mitigates risk for many of these issues1 and therefore assessment and promotion of healthy levels of activity are particularly important in young cancer survivors. Although the potential benefits of activity in this population are clear, the levels of activity are not.  To date, there has been a paucity of data looking at activity levels in this population, but “Physical Activity Among Adolescent Cancer Survivors: the PACCS study,” published in this month’s issue of Pediatrics reveals some compelling insights into this topic (10.1542/peds.2023-061778). In this study, Dr. Grydeland and her co-authors examined accelerometry data to assess daily levels of physical activity and sedentary time in 432 adolescent survivors of childhood cancer in northern and central Europe. They then looked at this data in 2 different ways:

  1. Activity patterns were compared between the cancer survivor cohort and a large age- and sex-matched reference group of European children and adolescents. Look for these results in Figures 3A-F. You will note that many activity patterns are similar to those previously described in general adolescent populations:2 activity levels decrease (and sedentary levels increase) with age; higher BMI correlates with lower activity; and activity levels in females are lower than males. However, as starkly demonstrated in Figures 3A and B, activity levels in male survivors are lower than the reference group, but there is no discernible difference between female survivors and the reference group. This is an interesting distinction.  While the reason for this is unclear, it is not necessarily reassuring since only 29% of the reference group met current physical activity recommendations!
  2. Activity patterns were sorted based upon cancer type. These findings are nicely summarized in Figure 2 in the study, and demonstrate the heterogeneity of this population, with survivors of central nervous system (CNS) tumors showing significantly less physical activity and more sedentary time than survivors of leukemia or lymphoma.

Although this study was performed in Europe, the activity patterns of the reference group in this study replicate those found in the general adolescent population in the,US,2 and therefore it is reasonable to predict that these findings in cancer survivors would be similar in the US as well. Unfortunately, the low activity levels described in this study represent a lost opportunity to enhance the well-being of this increasingly large pediatric cohort.

So, what is a pediatrician to do?  Recognize the potential barriers to physical activity in this population, particularly in survivors of CNS tumors. The discussion in this article outlines the unique vulnerabilities of this population, and some may need additional support to achieve healthy levels of activity.

  1. Physical therapy may be helpful (consider the following ICD-10 codes if applicable to support the referral and reimbursement: M62.81 (muscle weakness); R53.81 (deconditioning); or R68.89 (exercise intolerance).
  2. Parents/caregivers of patients with Individualized Educational Plans may specifically request a physical education assessment from their child’s school.
  3. In childhood cancer survivors, treatment-related decreases in strength, energy and lung capacity may reduce motivation and capacity for physical activity.3 Advise families that the benefits of physical activity are not all or nothing. Getting just a little more active can make a significant difference in their physical and mental well-being, even if they are not fully achieving the recommended 60 minutes per day.
  4. Encourage families to seek activities that are fun for all. Don’t think of this as exercise, but rather as active ways to play!


  1. Dimitri P, Joshi K, Jones N; Moving Medicine for Children Working Group. Moving more: physical activity and its positive effects on long term conditions in children and young people. Arch Dis Child. 2020 Nov;105(11):1035-1040. doi: 10.1136/archdischild-2019-318017. Epub 2020 Mar 20. PMID: 32198161.
  2. Centers for Disease Control and Prevention (CDC). 1991-2021 High School Youth Risk Behavior Survey Data.
    Available at Accessed on August 25, 2023.
  3. Larsen EH, Mellblom AV, Larsen MH, et al. Perceived barriers and facilitators to physical activity in childhood cancer survivors and their parents: A large-scale interview study from the International PACCS Study. Pediatr Blood Cancer. Jan 2023;70(1):e30056. doi:10.1002/pbc.30056
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