ABSTRACT
As the effects of cancer and its treatment have long-lasting negative impacts on the health and quality of life of survivors, there is a need to explore new avenues to optimize long-term patient outcomes in pediatric oncology. Therefore, this scoping review aims to report on the state of the evidence on the use and effects of behavioural interventions targeting physical activity and diet behaviours in pediatric oncology. Fourteen quantitative studies were included. Studies evaluated a combination of two or three different modalities, including education (n=11), physical activity (n=6), psychosocial support or training (n=6), reward system (n=2) and adventure-based activities (n=1).  Overall, behavioural interventions in pediatric oncology appear beneficial; however, no conclusive evidence favouring specific interventions were identified.
INTRODUCTION
Progress in childhood cancer treatment, diagnosis and management have resulted in childhood cancer survival rates of over 80% in North America in the past decades [1, 2]. However, concurrent with this success comes an increased appreciation of the late effects resulting from the disease and its treatment that have been extensively described in the literature [3-5]. It is estimated that 62.3% of adult survivors of childhood cancer suffer from at least one chronic health condition, 27.5% have a severe or life-threatening condition [6] and 95% will have a significant health-related issue by the time they are 45 years of age [7].
For many cancer-related complications, behavioural modifications represent the primary method of risk modification available to survivors [8]. Although exercising, having a healthy diet, and adopting other healthy behaviours are beneficial for everyone, the importance of a healthy lifestyle is critical for pediatric cancer patients who are at increased risk of adverse health problems that could be potentially preventable. Lifestyle practices are well-recognized modifiable factors that contribute to lower the risk of cardiometabolic complications [9], one of the treatment-related long-term complication prevalent in this population [10, 11], and might increase the quality of life of survivors [12]. A review of social cognitive theory-based interventions in adult cancer survivors demonstrated promise in improving physical activity (PA) and diet behaviour [13]. Whereas interventions targeting one specific behaviour change such as exercise interventions have been the subject of reviews [14-17], there are currently no evidence-based recommendations to guide the promotion of more global behavioural intervention changes in the pediatric oncology population and little is known about complex health promotion interventions and their effectiveness.
Hence, the purpose of this scoping review is to report on the extent of what is known on the use of complex interventions or multimodal programs addressing PA and diet behaviour for children with cancer or childhood cancer survivors (CCS) and their reported findings. More specifically, the aims of this study are to examine the extent, range and nature of (1) the study populations, (2) the interventions or programs, and (3) the findings regarding the effects on health behaviours, patient outcomes, and clinical recommendations.
METHODS
The scoping review was conducted following the methodological framework by Arksey & O’Malley [18], with improved recommendations by Levac et al. [19] to examine and summarize the extent, range, and nature of complex interventions or multimodal programs targeting PA and/or nutrition as well as their findings in pediatric oncology. The adopted strategy involved searching for research evidence via electronic databases (Embase, CINAHL, Ovid MedLine, and PsychINFO), using snowballing technique of the reference lists of selected studies and hand searching of key journals. For the electronic databases search, no limit in publication dates was set and a combination of key words and MeSH terms were used based upon the identified core concepts of the research question. The search strategy for electronic databases was developed from the research question and definitions of key concepts with the help of a librarian. Materials in English and French were included.
Prior to study selection, inclusion and exclusion criteria were created. Then, two reviewers (CD and AB) independently screened the title and abstract of studies for inclusion. Disagreements were resolved by consensus. Studies were included for full-text review if they (i) included children with cancer or survivors of childhood cancer that were diagnosed before the age of 21, (ii) consisted of complex interventions or multimodal program, (iii) interventions targeted PA and/or nutrition. Behavioural complex interventions or programs were defined as broad interventions that are built from several interacting components that aim to change health behaviours and improve patient outcomes. The second level of screening involved reading the full text of each article, which was done by CD. AB was consulted as needed for further clarification of any ambiguities. Full-text review included all methodologies and excluded syntheses or reviews of existing evidence, theoretical and empirical articles, conference abstracts, and editorials. Multiple articles that provided results from the same study were grouped together for analyses. For intervention studies that had been preceded by published pilot studies, only the more recent version was discussed. A charting form was developed to retrieve the following data from the selected studies: authors, year of publication, study design, study population, sample size, intervention/program description, and findings (see Table 1).
In accordance with Levac et al. [19] and Colquhoun et al. [20] guidelines, we conducted a descriptive numerical and a thematic analysis. The descriptive numerical analysis focused on the characteristics of the studies (e.g. age of patients, program duration). We conducted a thematic analysis from the extracted data to answer our scoping review questions. Themes emerged around: (i) population addressed, (ii) type of interventions, (iii) patient outcomes, and (iv) clinical recommendations.
RESULTS