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Background: Experiencing the illness and death of a child is a traumatic experience for the parents and the child’s siblings. However, knowledge regarding effective grief interventions targeting the whole family is limited, including how to integrate age-appropriate support for siblings. Aim: We aimed to synthesize the empirical literature regarding grief interventions that target the whole family before and/or after the death of a child. Design: A scoping review following the Joanna Briggs Institute and Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines. Data sources: We searched PubMed, PsycINFO, Embase, CINAHL, and Scopus covering January 1998–May 2022. We included studies describing any type of structured intervention targeting the whole family (i.e. parents and siblings) before or/and after the death of a child (below 18 years), with pre-post assessments of grief-related symptoms in the family as an outcome. Results: After removal of duplicates, we screened the titles and abstracts of 4078 publications and identified 30 publications for full-text screening. None of the studies met the inclusion criteria. Most of the studies were excluded because they either did not target the whole family or did not target families who had lost a child below 18 years. Bereavement camps were a popular form of family intervention, but none were evaluated in a pre-post design. No grief interventions offering support pre-death were found. Conclusions: There is great need for research to improve bereavement outcomes for the entire family and to potentially integrate this in pediatric palliative care., Background: Experiencing the illness and death of a child is a traumatic experience for the parents and the child’s siblings. However, knowledge regarding effective grief interventions targeting the whole family is limited, including how to integrate age-appropriate support for siblings. Aim: We aimed to synthesize the empirical literature regarding grief interventions that target the whole family before and/or after the death of a child. Design: A scoping review following the Joanna Briggs Institute and Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines. Data sources: We searched PubMed, PsycINFO, Embase, CINAHL, and Scopus covering January 1998–May 2022. We included studies describing any type of structured intervention targeting the whole family (i.e. parents and siblings) before or/and after the death of a child (below 18 years), with pre-post assessments of grief-related symptoms in the family as an outcome. Results: After removal of duplicates, we screened the titles and abstracts of 4078 publications and identified 30 publications for full-text screening. None of the studies met the inclusion criteria. Most of the studies were excluded because they either did not target the whole family or did not target families who had lost a child below 18 years. Bereavement camps were a popular form of family intervention, but none were evaluated in a pre-post design. No grief interventions offering support pre-death were found. Conclusions: There is great need for research to improve bereavement outcomes for the entire family and to potentially integrate this in pediatric palliative care.

Background Parents who lose a child are at increased risk of impaired mental health, which may negatively affect their work ability. The aims of this study were to examine the risk for reduced labor market affiliation in parents who lost a child with cancer compared to a matched parent cohort, and factors associated with the bereaved parents’ labor market affiliation. Methods We conducted a nationwide population-based cohort study using Danish registry data. We followed bereaved parents (n = 1609) whose child died with cancer at age less than 30 during 1992–2020, and a matched, population-based sample of parents (n = 15,188) of children with no history of childhood cancer. Cox proportional hazard models and fractional logit models were performed separately for mothers and fathers. Results Cancer-bereaved mothers had an overall increased risk of long-term sick leave (hazard ratio [HR] = 1.62; 95% confidence interval [CI]: 1.48–1.77), unemployment (HR = 1.53; CI: 1.37–1.70), and lower odds of working in the first 2 years following the loss (odds ratio [OR] = 0.44; CI: 0.39–0.49), while bereaved fathers had lower odds of working (OR = 0.65; CI: 0.53–0.79), and increased risk of permanently reduced work ability (HR = 1.29; 95% CI: 1.01–1.66), compared to the matched cohort of parents of cancer-free children. Younger parental age, lower education, and being a single parent were identified as the main determinants of the bereaved parents’ reduced labor market affiliation. Conclusions Cancer-bereaved parents are at increased risk of reduced labor market affiliation, compared with a matched, population-based sample of parents. Certain groups of bereaved parents may be at particularly high risk, and targeted bereavement interventions are warranted., Background: Parents who lose a child are at increased risk of impaired mental health, which may negatively affect their work ability. The aims of this study were to examine the risk for reduced labor market affiliation in parents who lost a child with cancer compared to a matched parent cohort, and factors associated with the bereaved parents’ labor market affiliation. Methods: We conducted a nationwide population-based cohort study using Danish registry data. We followed bereaved parents (n = 1609) whose child died with cancer at age less than 30 during 1992–2020, and a matched, population-based sample of parents (n = 15,188) of children with no history of childhood cancer. Cox proportional hazard models and fractional logit models were performed separately for mothers and fathers. Results: Cancer-bereaved mothers had an overall increased risk of long-term sick leave (hazard ratio [HR] = 1.62; 95% confidence interval [CI]: 1.48–1.77), unemployment (HR = 1.53; CI: 1.37–1.70), and lower odds of working in the first 2 years following the loss (odds ratio [OR] = 0.44; CI: 0.39–0.49), while bereaved fathers had lower odds of working (OR = 0.65; CI: 0.53–0.79), and increased risk of permanently reduced work ability (HR = 1.29; 95% CI: 1.01–1.66), compared to the matched cohort of parents of cancer-free children. Younger parental age, lower education, and being a single parent were identified as the main determinants of the bereaved parents’ reduced labor market affiliation. Conclusions: Cancer-bereaved parents are at increased risk of reduced labor market affiliation, compared with a matched, population-based sample of parents. Certain groups of bereaved parents may be at particularly high risk, and targeted bereavement interventions are warranted.

Aim To explore the potential of a structured active play intervention to promote social and personal development in preschoolers during cancer treatment. Design A hermeneutic-phenomenological inspired explorative study. Methods Participant observations were conducted on 15 consecutively sampled children (aged 1–5 years) from April 2021 to April 2022. Observations were written as narrative scenic descriptions from field notes and were analysed inspired by hermeneutic-phenomenological analysis and using a thematic analysis structure. Results Observations were carried out during 67 group or individual structured active play sessions, resulting in 129 scenic descriptions. Observations of the children's emotional, verbal and bodily expressions and social interactions resulted in three main themes: (1) wanting to play, (2) gaining confidence in movement and (3) being part of a group. The findings showed how children, irrespective of age and the severity of their illness, wanted to play and expressed joy of movement. The children's daily physical state fluctuated and influenced their motivation to participate as well as their confidence in their physical abilities. Through structured active play and with support from their parents and healthcare professionals, the children had successful movement experiences and regained confidence in movement, supporting their personal development. Playing together with other children and accompanied by their parents, healthcare professionals supported the children's opportunities to practice social skills, such as turn-taking, waiting and taking charge. Familiarity, recognizability and fun were key motivational components for the children. Conclusion Participating in structured active play during treatment has the potential to promote personal and social development in preschoolers with cancer. Parents play a crucial role in supporting the participation of their children.

Background This study explores expectations for telepresence robots as a tool to reduce absence in education as school absence negatively influences children's academic advancement and psychosocial wellbeing. Design A qualitative semi-structured interview study. Method and population Using convenience sampling, we interviewed 11 children aged 8–17 years with cancer (n = 4), neuromuscular diseases (n = 3) or anxiety (n = 4) who had a high level of school absence (more than 15 days’ absence in a school year), and who had recently encountered a telepresence robot; and eight of their teachers. A thematical analysis and a deductive approach based on the theory of Technological frames were used. Results The children's and teachers' expectations of how telepresence robots could support them in reducing their school absence were identified and structured in three categories and five main themes: 1) Nature of technology: a) Learning, b) Sociality, c) Additional supportive resources; 2) Technology strategy: a) Flexible school day; 3) Technology in use: a) New workflows. Conclusion This study indicates that implementation requires additional resources from teachers. Children with disease-related school absence and their teachers expect telepresence robots to reconnect the children socially, by maintaining or creating new friendships, and academically, by fostering inclusion and reducing absence., Background: This study explores expectations for telepresence robots as a tool to reduce absence in education as school absence negatively influences children's academic advancement and psychosocial wellbeing. Design: A qualitative semi-structured interview study. Method and population: Using convenience sampling, we interviewed 11 children aged 8–17 years with cancer (n = 4), neuromuscular diseases (n = 3) or anxiety (n = 4) who had a high level of school absence (more than 15 days’ absence in a school year), and who had recently encountered a telepresence robot; and eight of their teachers. A thematical analysis and a deductive approach based on the theory of Technological frames were used. Results: The children's and teachers' expectations of how telepresence robots could support them in reducing their school absence were identified and structured in three categories and five main themes: 1) Nature of technology: a) Learning, b) Sociality, c) Additional supportive resources; 2) Technology strategy: a) Flexible school day; 3) Technology in use: a) New workflows. Conclusion: This study indicates that implementation requires additional resources from teachers. Children with disease-related school absence and their teachers expect telepresence robots to reconnect the children socially, by maintaining or creating new friendships, and academically, by fostering inclusion and reducing absence.

Children with cancer experience fragmented school attendance during treatment. Telepresence robots that connect them with school during treatment periods were explored through an intervention involving participant observation followed by semi-structured interviews from 2020–22 with children with cancer, their class teachers, and classmates. We used an abductive approach, inspired by the Agential Realism theory and Situational Analysis. The use of telepresence robots in education enables hospitalized children to actively participate in real-time social activities with their classmates. However, consistent monitoring is necessary to ensure the success of this integration process as the classmates can lose interest in providing support to a child with cancer., Children with cancer experience fragmented school attendance during treatment. Telepresence robots that connect them with school during treatment periods were explored through an intervention involving participant observation followed by semi-structured interviews from 2020–22 with children with cancer, their class teachers, and classmates. We used an abductive approach, inspired by the Agential Realism theory and Situational Analysis. The use of telepresence robots in education enables hospitalized children to actively participate in real-time social activities with their classmates. However, consistent monitoring is necessary to ensure the success of this integration process as the classmates can lose interest in providing support to a child with cancer.

Background: Physical activity (PA) may reduce risks of late effects in childhood cancer survivors, yet many have low activity levels. Using the WHO's International Classification of Functioning, Disability, and Health for Children and Youths (ICF-CY) as a conceptual framework, we aimed to identify perceived barriers and facilitators to PA in young survivors and their parents. Design/methods: We conducted individual, semi-structured interviews with 63 survivors, aged 9–18 years, ≥1-year off treatment, and 68 parents, recruited from three pediatric oncology departments in Norway and Denmark. Interviews were analyzed inductively using thematic analysis to identify barriers and facilitators to PA, which were mapped onto the ICF-CY model components; body function/structures, activities, participation, and environmental and personal factors. Results: Two-thirds of the survivors described how treatment-related impairments of bodily functions (e.g., fatigue, physical weakness, reduced lung capacity) caused physical limitations, reducing opportunities to participate in PA, especially team sports and school physical education. This resulted in a perceived ability gap between survivors and peers, reducing motivation for PA. These PA barriers were moderated by environmental factors that facilitated or further hindered PA participation (family, peer, and school support). Similarily, personal factors also facilitated (acceptance, motivation, goal setting) or hindered (anxiety, low motivation, and lack of trust) PA participation. Conclusion: Treatment-related long-term or late effects represented significant barriers to PA as their functional consequences reduced survivors’ capacities and capabilities to be active. Environmental and personal factors acting as facilitators or further barriers to PA were identified. Applying the ICF-CY framework in clinical practice could help to enable PA participation.

Childhood, adolescent, and young adult (CAYA) cancer survivors are at risk of developing late effects associated with their cancer and its treatment. Survivors’ engagement with recommended follow-up care to minimize these risks is suboptimal, with many barriers commonly reported. This scoping review aims to summarize the barriers to accessing follow-up care, using the dimensions of Levesque’s framework for accessing healthcare. We retrieved quantitative studies addressing barriers and facilitators to accessing survivorship care in CAYA survivors from PubMed, EMBASE and CINAHL. Data was categorized into the five healthcare access dimensions outlined in Levesque’s framework: i) approachability, ii) acceptability, iii) availability and accommodation, iv) affordability, and v) appropriateness. We identified 27 quantitative studies in our review. Commonly reported barriers to accessing care included a lack of survivor and provider knowledge of cancer survivorship, poor health beliefs, low personal salience to engage in follow-up care, high out-of-pocket costs and survivors living long distances from clinical services. Many studies reported increased barriers to care during the transition from paediatric to adult-oriented healthcare services, including a lack of developmentally appropriate services, lack of appointment reminders, and a poorly defined transition process. Healthcare-related self-efficacy was identified as an important facilitator to accessing follow-up care. The transition from pediatric to adult-oriented healthcare services is a challenging time for childhood, adolescent, and young adult cancer survivors. Optimizing CAYAs’ ability to access high-quality survivorship care thus requires careful consideration of the quality and acceptability of services, alongside financial and physical/practical barriers (eg distance from available services, appointment-booking mechanisms). Levesque’s model highlighted several areas where evidence is well established (eg fin, Childhood, adolescent, and young adult (CAYA) cancer survivors are at risk of developing late effects associated with their cancer and its treatment. Survivors' engagement with recommended follow-up care to minimize these risks is suboptimal, with many barriers commonly reported. This scoping review aims to summarize the barriers to accessing follow-up care, using the dimensions of Levesque's framework for accessing healthcare. We retrieved quantitative studies addressing barriers and facilitators to accessing survivorship care in CAYA survivors from PubMed, EMBASE and CINAHL. Data was categorized into the five healthcare access dimensions outlined in Levesque's framework: i) approachability, ii) acceptability, iii) availability and accommodation, iv) affordability, and v) appropriateness. We identified 27 quantitative studies in our review. Commonly reported barriers to accessing care included a lack of survivor and provider knowledge of cancer survivorship, poor health beliefs, low personal salience to engage in follow-up care, high out-of-pocket costs and survivors living long distances from clinical services. Many studies reported increased barriers to care during the transition from paediatric to adult-oriented healthcare services, including a lack of developmentally appropriate services, lack of appointment reminders, and a poorly defined transition process. Healthcare-related self-efficacy was identified as an important facilitator to accessing follow-up care. The transition from pediatric to adult-oriented healthcare services is a challenging time for childhood, adolescent, and young adult cancer survivors. Optimizing CAYAs' ability to access high-quality survivorship care thus requires careful consideration of the quality and acceptability of services, alongside financial and physical/practical barriers (eg distance from available services, appointment-booking mechanisms). Levesque's model highlighted several areas where evidence is well established (eg

Objective To synthesise qualitative literature on (1) the perceptions of patients with cancer of participating in an exercise intervention while undergoing chemotherapy and (2) to inform and guide professionals in oncology and haematology practice. Design A qualitative meta-synthesis based on Noblit and Hare’s seven-step meta-ethnography. Data sources Six electronic databases: Cochrane Central Register of Controlled Trials (CENTRAL), CINAHL, EMBASE, PubMed, SCI-Expanded—SSCI and Scopus (final search June 2022) were used to identify qualitative literature containing individual or focus group interviews. The transparency of reporting for each study was assessed using the Consolidated criteria for Reporting Qualitative research checklist. Results The search identified 5002 articles, 107 of which were selected for full-text review. Seventeen articles from five countries with patients undergoing chemotherapy during exercise interventions were included. Eleven articles were included in the meta-synthesis, which comprised 193 patients with various cancer diagnoses, disease stages, sexes and ages. Four main themes were identified: chemotherapy overpowers the body; exercise in battle with side effects; a break from gloomy thoughts; and a question of survivorship. Conclusions and implications The meta-synthesis emphasised that patients with cancer undergoing chemotherapy and simultaneously participating in exercise interventions may experience momentary relief from overwhelming side effects, even though full bodily recovery may be perceived as a distant prospect. The synthesis offers a sparse empirical basis for gaining insight into what patients experience existentially following exercise interventions. It is up to patients to independently apply the transfer value of exercise to their own existential circumstances., OBJECTIVE: To synthesise qualitative literature on (1) the perceptions of patients with cancer of participating in an exercise intervention while undergoing chemotherapy and (2) to inform and guide professionals in oncology and haematology practice.DESIGN: A qualitative meta-synthesis based on Noblit and Hare's seven-step meta-ethnography.DATA SOURCES: Six electronic databases: Cochrane Central Register of Controlled Trials (CENTRAL), CINAHL, EMBASE, PubMed, SCI-Expanded-SSCI and Scopus (final search June 2022) were used to identify qualitative literature containing individual or focus group interviews. The transparency of reporting for each study was assessed using the Consolidated criteria for Reporting Qualitative research checklist.RESULTS: The search identified 5002 articles, 107 of which were selected for full-text review. Seventeen articles from five countries with patients undergoing chemotherapy during exercise interventions were included. Eleven articles were included in the meta-synthesis, which comprised 193 patients with various cancer diagnoses, disease stages, sexes and ages. Four main themes were identified: chemotherapy overpowers the body; exercise in battle with side effects; a break from gloomy thoughts; and a question of survivorship.CONCLUSIONS AND IMPLICATIONS: The meta-synthesis emphasised that patients with cancer undergoing chemotherapy and simultaneously participating in exercise interventions may experience momentary relief from overwhelming side effects, even though full bodily recovery may be perceived as a distant prospect. The synthesis offers a sparse empirical basis for gaining insight into what patients experience existentially following exercise interventions. It is up to patients to independently apply the transfer value of exercise to their own existential circumstances.

Background: Many children and adolescents with incurable cancer and their families prefer to receive end-of-life care and to die at home. This implies a transition of care from hospital to home and presupposes the establishment of a well-functioning collaboration between the family and professionals across health care sectors. Aim: To identify and explore key elements of home-based end-of-life care collaboration for children with cancer, as experienced by their parents and grandparents and the hospital- and community-based professionals involved. Design: Descriptive qualitative multiple-case study. Data were collected by semi-structured interviews and written responses to open-ended questions, and analyzed inductively across cases using qualitative content analysis. Setting/participants: Cases comprised a criterion sample of five children (aged <18 years), who died of cancer at home. Cases were represented by the children’s bereaved parents (n = 8) and grandparents (n = 7), and community-based professionals (n = 16). Also, hospital-based professionals (n = 10) were interviewed about the children’s end-of-life care through group interviews. Results: We identified five main themes, describing key elements of the end-of-life collaboration: Establishing the collaboration, Bolstering family life, Elucidating organization and integration, Managing challenges, and Closing the collaboration. These themes all came under the overarching theme: A mutual trust-based collaboration. On this basis, we developed the “Home-Based Pediatric End-of-Life Care Model for Children with Cancer.” Conclusions: By highlighting key elements in the family-centered, intersectoral and interprofessional end-of-life care collaboration, our “Home-Based Pediatric End-of-Life Care Model for Children with Cancer” offers a framework for further optimization of home-based end-of-life care services for children with cancer and their families.

Child-centered communication in pediatric oncology can be challenging. We aimed to review communication interventions with children about cancer treatment and prognosis to identify potentially effective child-centered communication models and approaches. We updated a previous review on communication interventions in oncology and searched MEDLINE, Scopus, and PsychINFO for studies indexed between October 2019 up to October 2022. We further searched for ongoing studies on ClinicalTrials.gov. Communication interventions targeting pediatric oncology patients (below 18 years), with outcomes of communication, psychological symptoms or satisfaction in the target population were eligible. We identified 685 titles/abstracts, screened the full text of 34 studies and included only one published study and two ongoing studies. The published study tested a communication tool to help clinicians inform adolescents about treatment options and facilitate shared decision-making. No communication models were identified. We drew on knowledge from existing studies and guidelines to develop a new child-centered communication model.

Context: Although specialized pediatric palliative care (SPPC) teams increasingly provide home-based care, the evidence of its impact has not yet been systematically evaluated. Objectives: To examine the impact of home-based SPPC in children and adolescents with life-limiting conditions, regarding place of death, quality of life and symptom burden. Methods: We searched Medline, EMBASE, CINAHL, PsycINFO, the Cochrane Central Register of Controlled Trials, Web of Science and Scopus for studies comparing children and adolescents with life-limiting conditions receiving home-based SPPC with children and adolescents not receiving home-based SPPC, or studies reporting before-and-after measurements. We included studies that reported on place of death, quality of life and/or symptoms. Two authors independently screened the articles, extracted data, and assessed quality. Results were synthesized as a systematic narrative synthesis and meta-analysis, using a random-effects model. Results: We included five studies, which reported on 392 children and adolescents. Meta-analysis showed that receiving home-based SPPC was associated with a more than fourfold increased likelihood of home death (risk ratio 4.64, 95% confidence interval 3.06–7.04; 3 studies; n=296). Most studies reported improved quality of life and reduced symptom burden. The included studies were of low to moderate quality with a high risk of bias. Conclusion: This systematic review suggests that home-based SPPC is associated with increased likelihood of home death, and might be associated with improved quality of life and reduced symptom burden. The small number of studies and an overall high risk of bias, however, makes the overall strength of evidence low.

Objective: In this sub-study from the ‘PACCS’ study, we explored the psychosocial experiences of children and adolescents in everyday life post-cancer treatment and the possible factors that can moderate these experiences. Methods: This is a qualitative explorative study using semi-structured interviews with 43 childhood cancer survivors between the ages of nine and 18 from Norway and Denmark. We conducted a secondary thematic analysis using Malterud's systematic text condensation. Results: Two main themes were identified: ‘The post-treatment gap between expectations and reality’ comprised two subthemes: (1) lack of mastery and feeling different and (2) lack of understanding and acceptance. The second main theme, ‘Managing the gap’, comprised three subthemes: (1) information and knowledge, (2) adjustments and adaptions and (3) social support and openness. The findings reveal that the psychosocial challenges resulted from the remaining ability gap(s). Measures such as tailored information, school adjustments and social support were potential dynamic factors affecting the gap(s) positively or negatively. Psychosocial challenges post-treatment are experiences of lack of acceptance and understanding from others. Conclusion: To safeguard a positive transition back to everyday life, health care providers should support the survivors' psychosocial care, including getting back to school and re-entering social interactions.

Based on developing, implementing, and evaluating postgraduate interprofessional case-based learning, we have written these twelve tips for health education planners who wish to apply case-based learning in the clinical setting. Interprofessional case-based learning engages participants in a structured manner towards uncovering decisions processes and patterns of action that resemble the clinical reality in which various healthcare professionals handle multifaceted tasks related to the optimal patient treatment. Postgraduate interprofessional case-based learning has the potential to break down traditional hierarchical structures as interactions generate respectful behaviour. We present two models of case-based learning to assist in standardising, structuring, and systematising postgraduate interprofessional case-based learning. We have created 12 practical tips for the design, implementation, and evaluation of successful postgraduate interprofessional case-based learning integrated into the existing clinical setting.

Anti-cancer treatments, as well as cancer itself, reduce children’s cardiorespiratory fitness, muscle strength, and gross motor functions. Early rehabilitation programs, including physical activity for childhood cancer patients, can counteract these adverse effects. Previous studies of school-aged children (6–18 years old) indicate that physical activity, including aerobic and resistance training, is safe, feasible, and effective. The goal of structured physical activity rehabilitation for preschool children (1–5 years old) is to support gross motor development and opportunities to move freely in various ways. Specific rehabilitation for preschoolers diagnosed with cancer is needed to promote physical-, social-, and personal development. This paper introduces a conceptual model—The RePlay (Rehabilitation including structured active play) Model—for organizing physical rehabilitation sessions based on structured active play for preschoolers with cancer. The theory and empirically based model combine knowledge of early childhood development, play, physical activity and rehabilitation for children with cancer, and cancer treatment. With this model, we propose how to structure rehabilitation sessions, including goal-oriented, age-sensitive, fun movement activities that facilitate preschoolers to develop gross motor skills while enhancing their social and personal skills, through four core principles: (1) ritual practices, (2) reinforcement of movement through repetition, (3) development through appropriate challenge, and (4) adjusting activities to accommodate treatment-related side effects. This model holds promise for use with preschoolers diagnosed with cancer, as it is scalable and pragmatic and accounts for the children’s fluctuating physical capacity and daily wellbeing during cancer treatment.

Aims: This study explores experiences of childhood cancer survivors and their parents with a combined physical and social activity intervention during treatment, including how the survivors and their parents perceive physical activity post-treatment. Design: A process evaluation using semi-structured interviews. Methods: Using a criterion-sampling strategy, 18 Danish childhood cancer survivors (aged 11–18 years) and their parents were interviewed from September 2019 through May 2020. Data analysis used an inductive thematic approach focused on meaning. Results: Three themes emerged: (1) being physically active during hospitalization; (2) peers as motivators and (3) physical activity post-treatment. During hospitalization, daily motivation to do physical activity was dependent on the daily well-being, that is, presence of the side effects from the child's treatment. Healthy classmates provided distraction, reduced loneliness and promoted normality for those hospitalized. For most of the survivors, their healthy peers provided motivation for being physically active during treatment. When surplus energy was lacking, some survivors preferred doing physical activity alone with a professional. Those who were physically active in the hospital sustained being physically active post-treatment while their parents continued seeking advice about appropriate activity levels. Conclusion: Childhood cancer survivors and their parents benefited from the intervention which also provided guidance to remaining physically active post-treatment. This was particularly true for the participants with leukaemia. Impact: Healthcare professionals should support children with cancer to be physically active during hospitalization. Including social and physical components in their care plan and being aware of individual preferences is pivotal to improving the survivors' level of physical and social well-being during a

Background: Survivors of childhood cancer represent a growing population with a long life expectancy but high risks of treatment-induced morbidity and premature mortality. Regular physical activity (PA) may improve their long-term health; however, high-quality empirical knowledge is sparse. Objective: The Physical Activity and Fitness in Childhood Cancer Survivors (PACCS) study comprises 4 work packages (WPs) aiming for the objective determination of PA and self-reported health behavior, fatigue, and quality of life (WP 1); physical fitness determination (WP 2); the evaluation of barriers to and facilitators of PA (WP 1 and 3); and the feasibility testing of an intervention to increase PA and physical fitness (WP 4). Methods: The PACCS study will use a mixed methods design, combining patient-reported outcome measures and objective clinical and physiological assessments with qualitative data gathering methods. A total of 500 survivors of childhood cancer aged 9 to 18 years with ≥1 year after treatment completion will be recruited in follow-up care clinics in Norway, Denmark, Finland, Germany, and Switzerland. All participants will participate in WP 1, of which approximately 150, 40, and 30 will be recruited to WP 2, WP3, and WP 4, respectively. The reference material for WP 1 is available from existing studies, whereas WP 2 will recruit healthy controls. PA levels will be measured using ActiGraph accelerometers and self-reports. Validated questionnaires will be used to assess health behaviors, fatigue, and quality of life. Physical fitness will be measured by a cardiopulmonary exercise test, isometric muscle strength tests, and muscle power and endurance tests. Limiting factors will be identified via neurological, pulmonary, and cardiac evaluations and the assessment of body composition and muscle size. Semistructured, qualitative interviews, analyzed using systematic text condensation, will identify the perceived barriers to and facilitators of PA for survivors o

Background: Improved survival rates for children and adolescents diagnosed with cancer call for novel strategies for reducing short- and long-term treatment-related side effects. These include the physical and metabolic sequelae that are exacerbated by sedentary behavior and treatment-induced toxicities. We aim to investigate the effect of an integrative neuromuscular training intervention during the first 6 months of anti-cancer treatment primarily on muscle strength, and secondarily on exercise capacity, physical function, markers of metabolic syndrome, dysmetabolism, and health-related quality of life during and after ended treatment. Methods: One hundred and twenty-seven children and adolescents, newly diagnosed with malignant and benign neoplasia, aged 6–17 years, and treated with chemotherapy or radiation will be randomized to either the intervention or the control arm of the study. The intervention group will, in addition to usual care, be offered a combination of 6 months of supervised physical exercise (integrative neuromuscular training) and home-based exercise. The active control group will, in addition to usual care, receive information along an unsupervised written home-based training program. All participants, including parents, will receive information about the importance of physical exercise during the course of cancer treatment, at the start of treatment, and in 5 monthly sessions. The primary outcome is measured in terms of isometric quadriceps muscle strength. Secondary outcomes include muscle strength and endurance, markers of metabolic syndrome and dysmetabolism, exercise capacity, physical function and activity, days of hospitalization, and health-related quality of life. Assessment will be conducted at treatment initiation (baseline), at 3 and 6 months after inclusion, and 1 month and 1 year after ended treatment. The primary endpoint for lower-body muscle strength is at 6 months after treatment initiation. The effects of the intervention

Background: Socioeconomic differences in survival among children with acute lymphoblastic leukemia (ALL) have been reported in high-income countries and there is an unmet need for strategies to identify vulnerable patient subgroups. Reported differences in survival for children from families with different socioeconomic positions seem to arise when starting maintenance therapy. This could reflect reduced physician's compliance or family adherence to maintenance therapy. Methods: This nationwide cohort study with extensive monitoring of systemic methotrexate (MTX)/6-mercaptopurine (6MP) dosing and metabolite levels, retrospectively investigated 173 Danish children treated according to The Nordic Society for Pediatric Hematology and Oncology ALL2008 protocol from 2008 to 2016. Results: Significantly lower prescribed doses of MTX and 6MP were seen in the children in families with short parental education (short vs. medium vs. higher education: mMTX: 13.8, 16.2, and 18.6 mg/m2/week; p <.01; m6MP: 47.4, 64.9, and 66.1 mg/m2/day; p =.03) or parents unemployed/not in workforce (unemployed/not in workforce vs. mixed vs. at work: mMTX: 15.0, 19.9, and 17.2 mg/m2/week; p <.01; m6MP: 54.8, 72.0, and 65.1 mg/m2/day; p <.01). When assessing family adherence by analyzing MTX and 6MP metabolite levels, including per prescribed dose of MTX and 6MP, we found no significant differences by levels of parental education, affiliation to work market, or income (p >.05 for all comparisons). Conclusions: These results indicate that inferior physician compliance to protocol recommendations on drug dosage rather than families’ adherence to therapy may contribute to the association between socioeconomic position and cure rates in childhood ALL, although precise mechanisms remain to be explored.

Background: Children diagnosed with cancer experience muscle weakness and impaired physical function caused by treatment and related immobility. The situation forces them into a negative cycle of diminished participation in physical and leisure activities and isolation from peers; inhibiting the natural development of social and gross motor skills. This manuscript presents a protocol for a study that explores the effects of using structured active play to maintain preschoolers' age specific gross motor function and social and personal skills while undertaking intensive cancer treatment. Methods: The study is a two-arm, superiority randomized controlled trial with an intervention and a control group designed to evaluate the effects of a structured active play intervention on gross motor function. Gross motor subtests of the Peabody Developmental Motor Scales, Second Edition (PDMS-2) are used for measurement; with the primary end-point at 6 months post-treatment initiation. Eighty-four preschool children (aged 1–5 years), newly diagnosed with cancer at the Copenhagen University Hospital are randomly assigned to either an intervention or control group, using a 1:1 allocation. The intervention group receives a combined in-hospital and home-based program that includes structured active play activities, while the control group receives standard care, including physiotherapy. During hospital admission, the intervention group undertakes 45-min structured active play group sessions three times weekly, conducted by exercise professionals. Parents receive training and supervision to facilitate daily individual sessions outside of group sessions. Secondary study outcomes target the children's overall function level in everyday life, general physical performance, and health-related quality of life. As well, children's and parents' experiences within the intervention are explored and the children's social and personal development is observed. Di