Physical Activity and Childhood Cancer: Present Status and Future Directions

Abstract

In children diagnosed with cancer, both physical and mental health are significantly impacted. Physical activity has emerged as a promising non-pharmacological intervention to improve both physical and psychosocial wellbeing, with growing evidence supporting its role in improving survivorship. Notably, pediatric patients who engage in regular physical activity demonstrate reduced all-cause mortality, particularly among female patients. Current research in physical activity and pediatric oncology aims to further improve mental and physical health, cardiac function, survival outcomes, and overall care. This paper provides an overview of the current state and future directions of the field, emphasizing the need for stronger evidence to support the integration of physical activity as a standard component of care. As the field advances, coordinated efforts among clinicians, researchers, and policy stakeholders will be critical to ensure equitable access to regular physical activity support for all pediatric cancer patients.

“The broader understanding of the benefits, safety, and feasibility of regular physical activity is as important as understanding the key barriers that might hinder children and adolescents in adhering to healthy behaviors.”

Introduction

Cancer is considered the second leading cause of death worldwide. ¹ Each year, nearly 10 500 children receive a diagnosis of cancer in the United States. ² Fortunately, the 5-year overall survival for childhood cancer in the United States has improved from 30% in the 1960s ³ to greater than 85% at the present time. ⁴ This remarkable progress is largely attributable to improved diagnostic modalities, better risk stratifications and advances in treatment regimens with novel targeted therapies. The National Cancer Institute has reported that there are about 495 739 childhood cancer survivors (CCS) in the United-States as of January 2020. ⁵ Nevertheless, with increased survival, therapy-related late effects are the primary cause of long-term morbidity and mortality for many survivors of childhood cancer. ⁶ The majority of survivors will have at least one late effect and in about 25% of them, these late effects can be severe or even life threatening. ⁷

Exposure to therapeutic agents during developmental phases when rapid and dramatic physiological and psychological changes are occurring -from infancy to early adulthood- can result in specific tissue or organ damage, and toxicities. ⁸ Often, toxicity-related damages that are subclinical or absent at the end of cancer therapy, can manifest later in the CCS's life with the demands of growth and aging. ⁹ Moreover, the development of late effects depends on several factors, including age at diagnosis, chemotherapy exposure, radiation therapy (dose of the radiation and the parts of the body that was exposed), and the severity of disease. ⁸ Moreover, age-related acquired comorbidities and unhealthy lifestyle-related behaviors can further worsen these late effects. ¹⁰ This is even more important because research has shown that CCS engage in low levels of physical activity both during and after therapy^11-13 and often lower than their siblings and healthy counterparts.^11,12

To give an example, exposure to cardiotoxic treatment modalities like anthracycline chemotherapy and chest radiation can lead to progressive and often irreversible damage to the developing hearts of young children diagnosed with cancer. ¹⁴ The free radicals released by anthracyclines can damage patients’ cardiac myocytes.^14,15 After 6 months of age, cardiac myocytes rarely proliferate and the principle mechanism to compensate for myocyte loss from anthracyclines therapy is for the surviving myocytes to hypertrophy even more than usual to maintain normal cardiac output. ¹⁵ The inability of the surviving myocytes to keep the pace with the demands placed on the heart by growth, pregnancy, aging and traditional modifiable cardiovascular risk factors contributes to the development of heart failure in CCS.^16,17 Engaging in regular physical activity has been shown to be beneficial to reduce cardiotoxicity in CCS, in addition to preventing chemotherapy-related cardiotoxicity among children diagnosed with cancer. ¹⁸ Evidence suggests that CCS who have a good cardiorespiratory fitness have improved markers of cardiovascular health, a decreased risk of cardiovascular disease, and a decreased risk of all-cause mortality compared to survivors who have a low cardiorespiratory fitness.^19-21

Radiation has also been associated with cardiac damage. Indeed, radiation to the chest at a young age can cause patchy myocardial necrosis and fibrosis based on the location and dose of radiation. ²² Radiation exposure affects the ability of the heart to grow and develop normally. ²³ Radiation-induced fibrosis can affect the coronary arteries, pericardium, cardiac valves and even the myocardial cells involved in conduction, all of which only worsen over time. ²³ As many as one in eight survivors of childhood cancer treated with anthracyclines and chest radiation will experience a life-threatening cardiovascular event by 30 years after their treatment of childhood cancer. ²⁴ Physical activity can improve childhood cancer patients’ cardiac prognosis. A report from the CCS Study, among adult survivors of childhood Hodgkin’s lymphoma who are at risk for coronary artery disease secondary to chest irradiation, revealed that vigorous intensity physical activity was associated with a lower risk of cardiovascular events, including coronary artery disease related events in a dose-dependent manner independent of cardiovascular risk profile and treatment. ²⁵

The field of physical activity and pediatric oncology has worked diligently to address these important issues regarding long-term health problems related to cancer treatments,^18,26,27 especially in the field of cardio-oncology. ¹⁸ In children diagnosed with cancer, both physical and mental health are affected. ²⁸ Regular physical activity has the benefits of improving physical and psychosocial wellbeing, in addition to extending the length of survivorship. ²⁷ Those who participate in post-treatment physical activity programs report positive outcomes (eg, improved health-related quality of life) that continue well beyond the end of the programs.^29-32 CCS who engage in increased physical activity over the course of 8 years show a reduction of 40% in their risk of death from any cause, compared to CCS who maintain low physical activity levels. ³³ Moreover, CCS who are physically active more than 3 days per week decrease their risk for all-cause mortality, with a lower risk of death among females, compared to those who are physically active less than 3 days per week. ³⁴

Ongoing efforts in the field of physical activity and pediatric oncology continue to be pursued to improve patients’ mental and physical health, cardiac health, as well as survival rates and care. Therefore, the aim of this paper is to provide an overview of the present status and future directions in physical activity and childhood cancer, from research and clinical standpoints.

Physical Activity in Oncology

Physical activity plays a key role in the regulation and development of multiple body systems. A wealth of scientific studies has demonstrated the impact of modifiable and preventable lifestyle-related behaviors, with physical inactivity emerging as a critical health outcome associated with higher mortality rates. ³⁵ In fact, half of all deaths in the United States can be attributed to preventable lifestyle-related behaviors, such as physical inactivity.^36,37

Having a physically active lifestyle, in contrast, is associated with significantly lower mortality rates.^38,39 The evidence is so strong that the World Health Organization reports that between 30% and 50% of cancer cases can be prevented by engaging in regular physical activity. ⁴⁰ Beyond its role in preventing chronic diseases (eg, cardiac diseases) and extending lifespan, engaging in regular physical activity also offers a multitude of physical and mental health benefits. ⁴¹ Age-specific physical activity guidelines have been developed to favor adequate lifestyle-related behaviors in children, adolescents, and adults. In the general population, the U.S. Physical Activity Guidelines recommend that children and adolescents engage in a minimum of 60 min of enjoyable moderate-to-vigorous intensity physical activity each day. ⁴¹ For adults, the recommendations include a minimum of 150 min per week of moderate intensity physical activity, with at least 2 days per week of muscle-strengthening activities. ⁴¹ These U.S. Physical Activity Guidelines serve as a foundation for building lifelong healthy behaviors that support physical health, quality of life and well-being. In essence, the key takeaway message from these guidelines is that people should be “avoiding inactivity”.

The evidence is robust and strengthens the importance of engaging in regular physical activity, as an integral part of each person’ daily routine. According to several agencies, such as the American College of Sports Medicine (ACSM),^42,43 the American Society of Clinical Oncology (ASCO) ⁴⁴ or the Children's Oncology Group (COG), ⁴⁵ physical inactivity is a public health problem and should be avoided at all costs.

Physical Activity During Active Treatments

The ACSM firmly advocates that physical activity is a form of medicine within the field of oncology. The importance of avoiding physical inactivity should start from the earliest stages of life, however, well before any cancer diagnosis occurs. Nevertheless, for children and adolescents who did not engage in regular physical activity prior to their cancer diagnosis, tailored support that considers their health, physical fitness and psychological status is even more crucial. Historical evidence underscores the safety and benefits of physical activity during active cancer treatments in pediatric patients.^46,47 In 2022, Morales et al. conducted a comprehensive historical overview of exercise and its relation to childhood cancer. ⁴⁷ Their research highlighted that the first study focusing on adolescents diagnosed with cancer undergoing treatment was published in 1999. These pioneering authors showed that an individual-planned 12-week physical activity intervention could significantly enhance peak oxygen uptake (VO₂peak) and mental health outcomes. ⁴⁸ Building on these findings, the field of physical activity and pediatric oncology continued to evolve, and in 2004, the first randomized controlled trial was published. ⁴⁹ The authors reported tangible improvements in ankle dorsiflexion active range of motion and knee extension strength among children diagnosed with acute lymphoblastic leukemia who were undergoing maintenance therapy. ⁴⁹ These improvements were achieved with 5 sessions of physical therapy and a home-based physical activity program, featuring ankle dorsiflexion stretching, lower extremity strengthening, and aerobic physical activity. ⁴⁹

Since the first studies in the field of physical activity and pediatric oncology, the peer reviewed literature has expanded, ranging from observational studies to rigorous randomized controlled trials, systematic reviews and meta-analyses. As of June 2025, a search of PubMed, using the following search terms (((cancer) OR (oncology)) AND ((child*) OR (adolescent*))) AND ((Exercise) OR (“physical activit*”)) nets a total of 6752 publications. Collectively, the research reinforces the following message: physical activity is a vital component of care and treatment for children and adolescents diagnosed with cancer. A multitude of published studies offers robust support of the benefits of physical activity during cancer treatments in children and adolescents diagnosed with cancer.^26,27,47,50 These studies emphasize the importance of integrating physical activity programs into the comprehensive care strategy for children and adolescent diagnosed with cancer. In particular, findings consistently show significant health effects in favour of physical activity interventions, compared to usual care. In fact, children and adolescents diagnosed with cancer who engage in regular physical activity during their cancer treatments report better physical health, psychosocial wellbeing, and quality of life.^{26,27,29-32,47,50} These benefits are maintained well beyond the end of the physical activity programs. These findings are supported by a Cochrane review dedicated to summarizing physical activity training interventions in children and adolescents diagnosed with cancer. ⁵⁰ Indeed, the review reported enhancements across various health-related outcomes, including patients’ cardiorespiratory fitness, body composition, flexibility, muscle endurance, muscle strength, health-related quality of life, and physical activity levels across the cancer continuum. ⁵⁰ This comprehensive work emphasizes, once again, the powerful effects of engaging in physical activity, strengthening its role as an indispensable component of care.

Therefore, it is imperative to recognize that children and adolescents diagnosed with cancer who are not engaging in regular physical activity are exposing themselves to higher risks of developing chronic diseases and unfavorable physical and psychosocial outcomes. In response to the growing body of evidence in the field of physical activity and pediatric oncology, the International Pediatric Oncology Exercise (iPOEG) guidelines were published in 2021.^26,27 These guidelines represent a momentous advancement in clinical research, supporting the emergency of integrating physical activity as standard of care and a central therapeutic strategy across the entire cancer continuum. The iPOEG guidelines provide a comprehensive framework to understand and implement physical activity programs that meet the unique needs of children and adolescents diagnosed with cancer. These guidelines recognize that physical activity programs have several benefits for children and adolescents’ health by managing and improving their long-term symptoms. They share a resounding international message that children and adolescents diagnosed with cancer who are receiving active treatments should integrate daily movement into their lives.

By encouraging regular physical activity, the iPOEG guidelines aim to improve patients’ long-term health-related quality of life, lifestyle-related behaviors, and encourage a more active future. Nevertheless, despite all the health benefits and advantages associated with physical activity in oncology, it remains a challenge to ensure that children and adolescents incorporate regular physical activity into their lives. The data shows that, on average, only half of children and adolescents diagnosed with cancer adhere to the recommended physical activity guidelines.^11,12 Alarming statistics from the American Association for Cancer Research (AACR) indicate that over 70% of these pediatric patients are significantly less likely to engage in regular physical activity, compared to their healthy peers. ¹³ This disparity in physical activity levels can impact their survivorship and have lasting consequences on their overall health-related quality of life and overall survival.

Physical Activity During Cancer Recovery

The importance of physical activity extends beyond its integration during treatments, as it remains vital during cancer recovery for children and adolescents diagnosed with cancer. Cancer therapy is associated with a vast spectrum of health-related complications (eg, organ dysfunction, second malignancies, chemotherapy-related cardiotoxicity, neurocognitive and psychological issues) that can significantly compromise the quality of life of CCS. Moreover, these long-term health complications, if left unaddressed, may even predispose them to early mortality.

In fact, CCS face an alarming sevenfold increase in the risk of dying from cardiovascular diseases compared to their peers in the general population, making cardiovascular diseases the leading cause of non-cancer-related mortality in this young population. ⁶ However, the current literature supports that CCS who engage in regular physical activity have a reduced risk of adverse cardiac outcomes, including improved markers of cardiovascular health, a decreased risk of obvious cardiovascular disease, and a decreased all-cause mortality risk compared to survivors who are not physically active. ⁵¹ These benefits extend even to those who have previously undergone cardiotoxic therapies, making physical activity a therapeutic choice of paramount importance for children and adolescents diagnosed with cancer. While the benefits of physical activity are well-established in adult cancer survivors to reduce the risk of cancer recurrence, ⁵² the need for stronger evidence pertaining to its impact on cancer survival and relapse in pediatric oncology remains a priority.

Over the demanding course of cancer treatment, children and adolescents diagnosed with cancer frequently adopt sedentary lifestyle behaviors due to extended hospital stays, disruptions in schooling and extracurricular activities (cultural and sports activities), and interruptions in social and peer relationships.^11,53-55 Regrettably, these sedentary patterns often persist into survivorship and amplify many of the chronic health problems (obesity, insulin resistance, cardiomyopathy, dyslipidemia, low bone mineral density, loss of lean muscle mass, peripheral neuropathy and altered psychosocial functioning) already associated with cancer therapy. Notably, low engagement in regular physical activity can exacerbate these chronic health problems.^56,57

Hence, childhood obesity emerges as a rising concern, particularly within the United States. A study focusing on obesity and overweight among CCS in the United States found that 13% of 7195 survivors were obese, with an additional 28% classified as overweight. ⁵⁸ Similarly, another study in Canada identified that one-third of 441 CCS were either obese or overweight. ⁵⁹ Although the prevalence of obesity among CCS is similar to the general population, sedentary obese survivors are at an increased risk for conditions like diabetes mellitus and insulin resistance, as corroborated by the St. Jude Lifetime Cohort Study. ⁶⁰ CCS also exhibit elevated levels of inflammatory biomarkers and adipokines (leptin and adiponectin), a significant elevation of high-sensitivity C-reactive protein (hsCRP) levels, and heightened susceptibility to symptoms of metabolic syndrome, including obesity, insulin resistance, glucose intolerance, hypertension, and dyslipidemia.^10,60 A study revealed that 32% of CCS met criteria for metabolic syndrome, compared to 18.3% in the general population of young adults. ⁶⁰

Therefore, physical activity during cancer recovery and survivorship is vital for children and adolescents diagnosed with cancer. Its impact extends far beyond the immediate effects on patients’ health-related outcomes. While physical activity may not reverse the damage caused by treatment, it has the power to prevent frailty and the accelerated aging process often seen in CCS. ⁶¹ Consequently, physical activity is an indispensable therapy to improve survival outcomes and should be recognized as a standard of care.

Long-Term Benefits of Physical Activity

The enduring battle against cancer and cancer recurrence is a long-term health issue that children and adolescents diagnosed with cancer are confronted with on a daily basis. physical activity plays an important role in improving their health after treatments. However, the long-term surveillance of CCS has unveiled a concerning trend in their physical activity levels. Indeed, a report from the National Health and Nutrition Examination Survey evidenced a significant decline in CCS’ physical activity levels, indicating a sedentary behavior state. ⁶² An observational cohort study has, however, reported that the levels of physical activity among CCS are similar to those observed in the general population. ⁶³ Nevertheless, CCS’ cardiorespiratory fitness level has been reported to be significantly lower when compared to their healthy peers. ⁶³ These findings prompt not only concerns, but a sense of urgency. These findings are accentuated by the fact that low levels of physical activity are associated with a lower cardiac health.^19,34 Moreover, an inactive lifestyle behavior has been associated with cardiovascular diseases in CCS. ⁶⁴ CCS’ health requires immediate attention and intervention, and physical activity can play a pivotal role. Therefore, researchers have formulated a compelling hypothesis that children and adolescents diagnosed with cancer may require a higher daily dose of physical activity compared to adults diagnosed with cancer. This would help guarantee their optimal development and better physical and mental health-related outcomes in CCS.

From the youngest age, physical activity should be part of daily life. It is during childhood that the chronic adaptations associated with physical activity hold the greatest potential for long-term efficacy and benefits, extending into adulthood. ⁶⁵ Physical activity during childhood is fundamental and is described as a key health behavior to prevent chronic diseases. ⁶⁶ It is important to understand, however, that children and adolescents who have undergone cancer treatments may have experienced disruptions to their healthy habits. Hence, CCS may need specific support to initiate lifestyle-related behavior changes toward engaging in more physical activity. Healthcare professionals and caregivers play a vital role in encouraging children and adolescents to move more every day. For CCS with lower physical activity levels, defined as less than 60 min of moderate-to-vigorous intensity physical activity per day every week, the need for support and guidance is particularly critical.

Published studies have consistently demonstrated the benefits of regular physical activity for CCS, including improvements in physical fitness and the prevention of late adverse effects related to treatment and treatment-related morbidity.^25,67 In 2021, a systematic review of randomized controlled trials that focused on physical activity interventions for CCS revealed that most of the included studies aimed to enhance physical activity levels and promote healthier behaviors, employing a variety of strategies to achieve these goals. ⁶⁸ Moreover, a cross-sectional study in CCS has highlighted that those with a high physical activity level exhibit a lower percentage of fat mass, reduced abdominal subcutaneous and visceral fat, greater lean body mass, and improved insulin sensitivity compared to survivors reporting lower levels of physical activity. ⁶⁹ Most recently, an umbrella review has emphasized the extensive benefits of physical activity for CCS. ⁷⁰ Reviews have shown the substantial long-term effects of physical activity on cardiorespiratory fitness, physical function, muscle strength, body composition, cognitive functioning, and health-related quality of life.^50,70 The literature not only highlights the positive impacts of physical activity on CCS’ physical and mental health, but also sheds light on the importance of tailored support and intervention strategies to improve survivors’ long-term health outcomes.

In oncology, physical activity programs need to be meticulously designed to provide essential support to patients by enhancing their health behavior in order to replace their unhealthy lifestyle habits or risky health behavior practices. One of the key challenges in promoting healthy behaviors is the design of programs tailored to CCS that will favor their adherence to physical activity post-cancer treatments. Researchers employ a multitude of strategies to favor healthy lifestyle behaviors in CCS.^71-77 For patients diagnosed with cancer, it has been reported that stimulating patients’ self-efficacy and belief that they can change their behavior is an important concept to initiate or motivate their behavior. ⁷⁸ In fact, research has consistently shown that individuals who have a sense of control over their behavior are more likely to engage in physical activity compared to those who do not have a sense of control.^79,80 This notion of control is reinforced in children and adolescents, as they often seek autonomy over their actions in a context where they want to have control of their behavior.

The literature shares undisputable evidence supporting the integration of physical activity into the care of CCS. It reinforces the imperative of incorporating lifestyle interventions, with physical activity programs, within survivorship programs.

Physical Activity as a Standard of Care

The recent report from the National Cancer Institute suggests that nearly 500 000 children and adolescents diagnosed with cancer are alive in the United States. ⁵ It is anticipated that at least 125 000 CCS (∼25% of them) will develop a condition secondary to their treatment that could be eliminated or attenuated by being regularly physically active.^7,27,45 In childhood cancer survivors, it has been reported that engaging in regular physical activity is associated with a lower prevalence of late adverse effects in health outcomes (metabolic health, cardiac health, cognitive health, and mental health).^20,21,81 Favorably, progress toward establishing physical activity as an integral aspect of care for children and adolescents diagnosed with cancer has been made. While a consensus designating exercise as medicine has not been reached, experts agree on the pressing need for more data and stronger evidence-based medicine. These are essential prerequisites before the formulation of guidelines on exercise prescription that can address specific cancer-related health outcomes; as are already in place for adults diagnosed with cancer. ⁴² The International Pediatric Oncology Exercise (iPOEG) guidelines emerge as the first recommendations for children and adolescents diagnosed with cancer,^26,27 setting a precedent for the integration of physical activity into pediatric oncology care.

Despite the low cost of physical activity intervention in oncology^77,82-84 and the compelling evidence supporting the benefits of physical activity in pediatric oncology, as outlined in this paper, children and adolescents diagnosed with cancer are not consistently referred to experts with specific training in exercise and oncology. These experts, such as exercise physiologists, certified exercise experts, and physical therapists play a crucial role in bridging the gap between the knowledge and implementation of physical activity programs in this unique population. Clinical efforts must be pursued and should focus on the patients and their family. Recognized as a multidisciplinary field, the physical activity and oncology field needs seamless collaborations between researchers and clinicians to optimize care throughout the entire survivorship continuum. ⁸⁵

In the perspective of establishing physical activity as a standard of care in pediatric oncology, it is essential to acknowledge and address two significant barriers that can pave the way for future adapted programs and their implementation. Children and adolescents diagnosed with cancer, whether they are undergoing active treatments or are post-cancer treatment, face daily life challenges related to their disease. Among these challenges, the common symptoms of fatigue and pain are prevalent issues. ⁸⁶ In CCS, cancer-related fatigue is defined as: “A common late effect of cancer and cancer treatments. It is characterized by a subjective, persistent, and multidimensional experience that differs from normal fatigue in the physical, emotional, and/or cognitive spheres. Cancer-related fatigue may have a variety of negative consequences including a reduced quality of life and level of functioning, a lack of vigor, work difficulties, relationship issues, and emotional distress.”. ⁸⁷ Importantly, this specific symptom cannot be alleviated only through rest or sleep. It can, however, be effectively managed with non-pharmacological interventions. physical activity has emerged as a key strategy. ⁸⁸ Nevertheless, a study reported that 50% of CCS are “simply too tired” to engage in physical activity, while 22% report that “pain prevents them from being active”. ⁵⁵ Indeed, pain is another common symptom faced by children and adolescents diagnosed with cancer. At some point in their journey, children and adolescents will experience cancer-related pain. In long-term survivors of childhood cancer, the prevalence of chronic pain can range from 11.0% to 43.9% across studies. ⁸⁹ And children and adolescents diagnosed with cancer who experience chronic pain will likely progress to adulthood with chronic pain. ⁹⁰ Pain is an important barrier that can limit adherence and engagement toward regular physical activity. The first study to explore the effects of physical activity on chronic pain in CCS is currently being performed by our team.^91,92

The integration of physical activity as a standard of care in pediatric oncology is only a matter of time. The broader understanding of the benefits, safety, and feasibility of regular physical activity is as important as understanding the key barriers that might hinder children and adolescents in adhering to healthy behaviors. By addressing these common barriers and implementing physical activity programs to overcome them, we not only pave the way for better outcomes in pediatric oncology but also empower children and adolescents diagnosed with cancer to take charge of their health and wellbeing, thus improving their overall quality of life.

Future Research and Clinical Directions

Interdisciplinary collaborations and partnerships in pediatric oncology are needed to mitigate the morbidities resulting from cancer therapy, the late effects of treatments, and the financial burden associated with survivorship. physical activity is the cornerstone to effectively manage and enhance the health-related outcomes of CCS. While considerable progress has been made, further efforts are necessary to strengthen the evidence necessary to solidify physical activity as a standard of care for this unique population. The future of physical activity in pediatric oncology could focus on several priority topics:

(a) A paramount priority is the development of novel strategies to prevent and mitigate the physical and psychosocial adverse effects associated with cancer therapies in CCS. This initiative should start by extending physical activity support during active cancer therapies. Toward this goal, physical activity programs should be safe, feasible and enjoyable. This approach aligns with the recent iPOEG guidelines, ²⁷ emphasizing the importance of providing physical activity support early in the cancer care journey. To achieve these objectives, it will be necessary to develop new screening and referral methods to ensure the accessibility of these programs for patients and their families. Furthermore, a multidisciplinary approach is vital to address the specific needs of patients and to overcome barriers, ultimately facilitating the adoption of a long-term healthy lifestyle.

(b) Another pivotal area of focus should be the education of healthcare providers. There is an essential need to favor the implementation of physical activity programs in pediatric oncology, and the education of healthcare providers on the benefits of physical activity is a first step toward this goal. The impact of physicians and healthcare providers on patients’ health behaviors is well documented within the field of pediatric oncology.^93,94 Nevertheless, physicians have recognized that they rarely engage in physical activity conversations with their patients during active treatments. ⁹⁵ A parallel observation in adult oncology emphasizes the lack of training in this domain, thus limiting their ability to recommend physical activity to their patients. ⁹⁶ In pediatric oncology, healthcare providers acknowledge that they need additional training to promote physical activity to effectively address barriers and to increase the quality of their physical activity conversations with young patients. ⁹⁷ Given that patients value physicians’ opinion, ⁹⁵ the training of physicians and healthcare providers is crucial to share accurate physical activity recommendations during regular clinic visits and routine delivery of care.

(c) Addressing cardiometabolic outcomes in CCS is another imperative research area. Indeed, CCS face a 2-fold increase in the risk of developing metabolic syndrome, with an astonishing 12.6-fold risk among those exposed to specific therapies, such as total body irradiation or abdominal radiation or cranial radiation.^60,98 It has been shown that CCS have elevated levels of inflammatory biomarkers and adipokines, including IL-6.^10,99 High levels of IL-6 have been characterized as a marker for metabolic disorder and cardiovascular disease. ¹⁰⁰ In breast cancer survivors, physical activity interventions have been shown to decrease the serum concentrations of IL-6, TNF-α, and IL-2. These markers are associated with metabolic disorders and cardiovascular diseases. ¹⁰¹ However, data specific to CCS is currently lacking, justifying the pressing need for studies exploring the impact of physical activity interventions on cardiometabolic outcomes in CCS.

(d) Accelerated aging and frailty in CCS is a pressing issue. Recent reports have shown that CCS encounter accelerated aging, characterized by a disproportionate loss of exercise capacity, cognitive decline, and early onset of chronic medical conditions. ¹⁰² This condition raises their risk of morbidity and results in a discrepancy between their chronological and physiological ages. Notably, over 10% of young adult survivors of childhood cancer exhibit a frailty phenotype.^61,102 This involves experiencing 3 or more of the following: low skeletal muscle mass, exhaustion, low energy expenditure, slowness, or weakness. In addition, 20% of survivors are categorized as prefrail.^61,102 physical activity can prevent accelerated aging and frailty in CCS. Comprehensive studies are required to strengthen the existing evidence and to explore the effect of physical activity on the biomarkers associated with aging.

(e) Studies focusing on parental and family involvement is another great area of interest. Traditionally, physical activity programs focus primarily on children and adolescents diagnosed with cancer and survivors. While a few have extended their scope to encompass patients and their families, there is a need to develop family-based physical activity interventions in pediatric oncology. Such interventions have potential of yielding promising benefits by educating the whole family on the adoption of healthy lifestyle habits, including regular physical activity and a healthy diet. As children often model their healthy and unhealthy behaviors after their parents, empowering families with essential knowledge on health behaviors can bring benefits to the entire family unit. It would also offer an opportunity for parents and children to be physically active together. Therefore, novel strategies need to be developed to facilitate the integration of parents and families into physical activity programs. For example, the “Stoplight diet for children” program provides a simple graphic visual guide to steer families toward healthy dietary habits. ¹⁰³ Future studies might also want to develop additional educational content for families of children and adolescents diagnoses with cancer, enhancing their overall wellbeing and quality of life.

Conclusion

To conclude, the evidence makes it clear that children and adolescents diagnosed with cancer benefit from engaging in regular physical activity, either during or after treatments. The evidence supports the safety, benefits, and feasibility of physical activity programs in pediatric oncology. And while it is indisputable that physical activity in pediatric oncology should be a standard of care, physical activity support is not always available to everyone. Patients from underrepresented populations (eg, non-Hispanic Blacks, Hispanics), patients with lower levels of education, and unemployed individuals typically have lower levels of leisure-time physical activity. ¹⁰⁴ The lack of safe space, time, and social support reinforces disparities among patients living with and beyond cancer. Therefore, interdisciplinary efforts are needed, and clinicians, researchers, and policy stakeholders need to work together to favor patients’ access to regular physical activity support, as a standard of care. Recent advances in research in the field of physical activity and pediatric oncology, in addition to the interest of healthcare providers in supporting the implementation of physical activity programs for their patients, are an encouraging perspective for these patients.