Children and adolescents
Improved cardiopulmonary and muscular fitness
Improved bone health
Improved cardiovascular and metabolic health biomarkers
Reduced symptoms of depression
Lower risk of early death
Lower risk of coronary artery disease
Lower risk of stroke
Lower risk of hypertension
Lower risk of type 2 diabetes
Lower risk of metabolic syndrome
Lower risk of colon and breast cancer
Improved cardiopulmonary and muscular fitness
Improved bone density
Improved blood lipid profile
Weight loss and prevention of weight gain
Reduced symptoms of depression
Minimum physical activity requirements to achieve health benefits
Level of intensity
Children and adolescents
150 min moderate-intensity aerobic activity each week
75 min vigorous-intensity aerobic activity each week
60 min or more daily moderate to vigorous-intensity aerobic activity
Activities should be age appropriate, varied, and enjoyable
Individual participating in the activity can talk but not sing during the activity
Energy expenditure is 3–5.9 times the amount of energy expended at rest
At least 10 min intervals of activity spread throughout the week
Muscle strengthening activities 2 or more days each week. Work all major muscle groups (legs, hips, back, abdomen, chest, shoulders, and arms) in sets of 8–12 repetitions
Muscle strengthening and weight-bearing activities that produce force on the bones at least 3 days each week as part of the 60 min per day of physical activity
Work all the major muscle groups of the body
Individual participating in the activity cannot say more than a few words without pausing for a breath
Energy expenditure is 6 or more times the amount of energy expended at rest
Health-care providers should encourage survivors to participate in physical activity as recommended by the CDC guidelines. The risk of developing many of the late effects of childhood cancer therapy can be decreased through regular exercise including cardiovascular disease, diabetes, obesity, stroke, decreased bone mineral density, and some second malignant neoplasms. Existing late effects may also be ameliorated through participation in adequate physical activity. Bone strengthening activities are especially important for child and adolescent survivors at risk for low BMD since the greatest increase in bone mass occurs just before and during puberty and peak bone mass is obtained by the end of adolescence . Participation in regular weight-bearing exercise during adolescent growth can significantly increase bone mineral content [24, 25].
126.96.36.199 Physical Activity: Special Considerations
The Children’s Oncology Group (COG) Long-Term Follow-Up Guidelines recommend that survivors who received anthracycline chemotherapy and/or chest radiation should be counseled to avoid intense isometric exercise as this has been reported to precipitate cardiac events in survivors. Aerobic exercise and high repetition lifting of light weights are generally thought to be safe in this population, although this has not been studied prospectively due to obvious difficulties with study design. Survivors who choose to participate in strenuous activity or competitive sports should discuss their personal risk with a health-care provider and receive ongoing monitoring by a cardiologist .
Survivors who had limb-sparing surgery should discuss limitations on physical activity with their orthopedic surgeon. High levels of physical activity may damage the endoprosthesis . However, regular participation in approved exercise should be encouraged to prevent functional limitation and decreased bone mineral density .
Survivors who have undergone nephrectomy should protect their single kidney during physical activity by staying well hydrated . Survivors with a single kidney should be encouraged to discuss their kidney status with a health-care provider before participation in contact sports or recreational activities. Caution should be taken to avoid bicycle handlebar injuries. A kidney guard may be worn during activities with an increased risk for renal injury. Survivors should wear a medical alert bracelet or carry a card in their wallet indicating that they have a single kidney.
The CDC recommends all individuals to wear a helmet when participating in sports that carry a risk of traumatic brain injury. Survivors should be counseled to wear a fitted and well-maintained helmet when riding a bike, skateboard, or scooter; playing a contact sport such as football or hockey; using in-line skates; horseback riding; skiing or snowboarding; and batting/running bases in baseball or softball .
A healthy diet can reduce the risk of major chronic health conditions such as heart disease, diabetes, osteoporosis, and cancer. The US Department of Health and Human Services (HHS) and the US Department of Agriculture (USDA) jointly publish Dietary Guidelines every 5 years, including the most recent edition: Dietary Guidelines for Americans, 2010 . While these goals are intended for the general population, they are especially relevant for childhood cancer survivors.
188.8.131.52 Diet: Weight Management
Weight management is a well-documented challenge for survivors of childhood cancer. This includes both being underweight and being obese. Dietary Guidelines for Americans, 2010 provides basic information readily available to all that can serve as a foundation for dietary health promotion. When available, individualized dietary recommendations from a registered dietician can help minimize the many risk factors associated with obesity or being underweight in the childhood cancer survivor.
Dietary Guidelines for Americans, 2010 has three major goals that can assist in preventing and/or treating obesity:
Balance calories with physical activity to manage weight
Consume more of certain foods and nutrients such as fruits, vegetables, whole grains, fat-free and low-fat dairy products, and seafood
Consume fewer foods with sodium (salt), saturated fats, trans fats, cholesterol, added sugars, and refined grains
The USDA recommends using a Daily Food Plan to optimize food consumption and caloric intake that promotes a healthy weight. A Daily Food Plan summarizes what and how much to eat within a specific calorie allowance that is based on age, sex, height, weight, and physical activity level . The five recommended food groups are fruit, vegetables, grains, protein, and dairy. For the 2,000 calorie per day level, recommended intakes include 2 cups fruit, 2.5 cups vegetables, 6 oz grains, 5.5 oz protein foods, and 3 cups dairy . Just as an exercise scientist or physical therapist can create a personalized exercise regimen or physical activity plan, a registered dietician can create a personalized nutrition plan that can best help the survivor manage their weight.
184.108.40.206 Diet: Hypertension
Like obesity, hypertension is a significant risk factor for heart disease, but can be modified with dietary changes. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) calls for an aggressive approach to treating hypertension including lifestyle modifications with an emphasis on dietary changes before the initiation of drug therapy. The JNC 7 recommends adopting an eating plan that is rich in fruits, vegetables, and low-fat dairy products with reduced content of saturated and total fat . These dietary modifications have been shown to reduce systolic blood pressure by 8–14 mmHg [32, 33]. Blood pressure classifications are summarized in Table 24.3.
Classification of blood pressure (BP) ranges for adults
Systolic BP (mmHg)
Diastolic BP (mmHg)
Stage 1 hypertension
Stage 2 hypertension
An appropriate dietary plan should serve as the mainstay of heart health promotion, along with weight loss and physical activity.
220.127.116.11 Diet: Bone Health
Appropriate amounts of dietary calcium and vitamin D are necessary to maintain proper levels of calcium and bone mass. Physiological vitamin D also comes from synthesis in the skin through sunlight exposure. In 2010, the Institute of Medicine (IOM) was commissioned to assess the current data on health outcomes associated with calcium and vitamin D . Their exhaustive review of the evidence determined that calcium and vitamin D have a role in bone health but not in other health conditions. It was concluded that Americans are receiving adequate amounts of both calcium and vitamin D. Additionally, the IOM report indicated that too much of these nutrients may be harmful. The recommended amounts of intake for the general population were based on age and assumed minimal sun exposure. Recommended dietary intake for calcium and vitamin D are summarized in Table 24.4.
Recommended dietary allowance (RDA) for calcium and vitamin D
Calcium RDA (mg)
Vitamin D (IU)
It has been hypothesized that in addition to treatment-related risk factors, sedentary lifestyle and inflammation may play a role in bone deficits in childhood cancer survivors . While lifestyle changes are possible, appropriate dietary guidelines should be followed for calcium and vitamin D supplementation to optimize bone health.
Evidence-based guidelines now exist for calcium and vitamin D supplementation. Given the concern for low BMD in both child and adult survivors of childhood cancer, it is prudent to use the IOM recommendations (see Table 24.4 above) regarding calcium and vitamin D as a foundation for supplementation therapy. It is advisable to consult with a registered dietician or endocrinologist for the optimal calcium and vitamin D doses needed by the childhood cancer survivor based on the individual risk for poor bone health. Special attention must be paid to women on hormonal therapy as that also can affect bone health. In conjunction with the appropriate physical activity regimen, such supplementation can maintain optimal bone health and help prevent low BMD and its serious sequelae such as ON.
24.3 Health-Risk Behaviors
A key component of survivor health promotion is minimizing health-risk behaviors. Research indicates that childhood cancer survivors participate in health-risk behaviors at rates similar to their healthy peers. These include tobacco and alcohol use, substance abuse, inadequate sun protection, unsafe sexual practices, poor adherence to general recommendations for diet/exercise, and injury prevention [34–41]. This may not provide survivors with adequate risk reduction given their increased likelihood of chronic health conditions and adverse health outcomes . Some survivors have reported a perception of being more vulnerable to health problems and needing to protect their health [34–42]. Providers must leverage this sentiment to empower survivors with the education and medical assistance needed to promote health-protective behaviors. Behavioral change is a challenge, as factors other than health perceptions are involved, but survivor behaviors can directly determine several health outcomes that must be addressed as part of comprehensive survivorship care [35–43].
Tobacco use is the leading cause of preventable illness and death in the United States [36–44]. More than 600,000 middle school students and three million high school students smoke cigarettes [37–45]. In the CCSS, 28 % reported ever smoking with 17 % being current smokers . Adolescent survivors had rates of tobacco use similar to their cancer-free siblings [35, 38–45]. This is still concerning as survivors used tobacco at higher rates than expected given their increased risk of cardiac and pulmonary complications [35, 39–46]. When compared to the general population, survivors of childhood cancer were, in fact, more likely to report being a current smoker than their noncancer peer controls [35, 40–47]. In countries outside the United States, tobacco use among survivors has varied. For example, in Great Britain, the prevalence of smoking among adult survivors of childhood cancer is substantially less overall than that in the general population [35, 40, 42–48]. Given the multiple risks associated with tobacco use, survivorship care should routinely screen for its use and have accessible smoking cessation resources readily available [35, 40, 43–49]. Multiple options exist for smoking cessation, but interventions designed to build self-efficacy may be specifically beneficial for this population [35, 40, 44–50]. Data from the CCSS showed that >69 % of survivors studied engaged in two or more other health-risk behaviors . Reducing other risk behaviors might also encourage survivors to quit smoking .
24.3.2 Substance Abuse
According to the Centers for Disease Control and Prevention’s (CDC) 2011 Youth Risk Behavior Surveillance System (YRBSS), 38.7 % of US high school students had at least one alcoholic drink in the 30 days prior to being surveyed, and 39.9 % had used marijuana one or more times during their life . Varying reports exist on the prevalence of alcohol and drug use by survivors of childhood cancer. Some reports have found no significant difference between survivors and their peers in regard to alcohol use . There is still great concern, however, as the rate of alcohol use in long-term survivors was higher than expected given the increased risk of cardiac and pulmonary sequelae . Another study reported that adult survivors of childhood cancer have decreased alcohol consumption compared to their peers . This trend was also seen in a British cohort of childhood cancer survivors . Illicit drugs that have a stimulatory effect on the cardiovascular system may also pose significant health risks. Therefore, survivors at risk for cardiac long-term complications should be specifically counseled regarding the dangers of any drug use that may be associated with cardiac side effects, such as cocaine use or methamphetamine abuse and smoking risk factors with marijuana.
Evidence-based interventions are needed to address substance abuse among survivors. The multiorgan damage associated with excessive alcohol consumption can quickly compound the risks of potential cardiac, pulmonary, hepatic, and endocrine complications for the childhood cancer survivor. Interventions specific to the childhood cancer survivor are currently under investigation and many show promise [54, 55]. If substance abuse is suspected by a survivorship provider, a quick and definitive referral to an addiction specialist is necessary for further evaluation and treatment.
24.3.3 Sun Safety
Inadequate sun protection is a health-risk behavior that can have serious consequences for the cancer survivor. The risk of skin cancer as a second malignant neoplasm is especially relevant for those who received radiation therapy for their primary malignancy. The CDC recommends that all people take precautions against sun exposure every day of the year, especially during midday hours. This is the time period when ultraviolet (UV) rays are strongest and can do the most damage. UV rays are not blocked by clouds and can damage unprotected skin in as little as 15 min . The CDC recommends the following sun protection (Table 24.5).
CDC recommendations for sun protection 
Seek shade, especially during midday hours
Avoid tanning beds and sunlamps
Cover up with clothing to protect exposed skin
Use UVA and UVB sunscreen
Wear a hat with a wide brim to shade the face, head, ears, and neck
Use sunscreen with protective factor (SPF) 15 or higher
In a study of 75 adolescent survivors of childhood cancer, nonadherence to sun protection was the single most common health-risk behavior reported . An educational intervention for these survivors was found to be efficacious in improving short-term self-reported sun safety practices . Nevertheless, sun protection behaviors are difficult to instill in survivors, as in the general population. Even in a group of primary melanoma survivors, the rates of sun protection were no higher than the estimates for the general population . Survivors should also be cautioned about the use of tanning beds which also increases the risk of skin cancer.
24.3.4 Injury Prevention
Single kidney health guidelines have been reviewed in the Physical Activity: Special Considerations section of this chapter. The use of a helmet when engaging in physical activities that involve movement at high speeds may prevent head injury. The CDC YBRSS found that 87.5 % of youth who had ridden a bicycle in the last year prior to the survey reported not wearing a helmet . As with the general population, age-appropriate preventive medicine and anticipatory guidance should be communicated to all childhood cancer survivors. This involves reviewing seat belt guidelines, especially when survivors approach the legal driving age. Seat belt laws vary, but most states mandate the use of seat belts for drivers and front seat passengers, while many require that all passengers wear seat belts when riding in a passenger vehicle. This anticipatory guidance is critical as 7.7 % of youth surveyed for the YBRSS rarely or never wore a seat belt when riding in a car driven by someone else . Distracted driving should also be included as a risk-taking behavior that should be avoided by survivors. It is now estimated that 33 % of youth text or email while driving a car .
24.3.5 STI Prevention
It is imperative that all survivors understand their risks for sexually transmitted infections (STIs). Young people in the United States account for nearly half of all new STIs, yet they represent only 25 % of the sexually active population . Consequently, a sexual history should be obtained on all adolescent and young adult survivors of childhood cancer as part of routine survivorship health promotion. In the CCSS cohort, survivors were more likely than their siblings to report being tested for human immunodeficiency virus (HIV) . Furthermore, providers must dispel any survivor misconception that infertility is protective against contracting STIs. Another opportunity for survivor health promotion includes anticipatory guidance regarding human papillomavirus (HPV) infections . A recent study found that the rate of HPV vaccination among female pediatric cancer survivors was not appreciably different than that seen in the general population . Unsafe sexual practices and their associated significant health risks must be addressed as part of childhood cancer survivor health promotion.