Physical activity and fitness among pediatric cancer survivors: a meta-analysis of observational studies



The number of pediatric cancer survivors has increased dramatically over recent decades. Prior studies involving pediatric cancer survivors have reported reduced physical activity and fitness levels. Thus, the aim of this meta-analysis was to synthesize previous findings on physical activity and fitness levels of pediatric cancer survivors, who had completed cancer treatment and are in complete remission compared with age-matched, non-athletic healthy controls with no history of cancer diagnosis.


Three electronic databases (PubMed, Web of Science, and EBSCO) were searched using a combination of 24 terms. Observational studies examining the post-treatment physical activity and/or fitness levels of pediatric cancer survivors compared with that of non-cancer controls and published in peer-reviewed, English-language journals before August 22, 2018 were eligible. Random-effect models were used in Comprehensive Meta-Analysis software for effect-size estimations of eight studies for physical activity and eight for fitness.


The studies included a total sample of 2628; 1413 pediatric cancer survivors and 1215 non-cancer controls. Both physical activity and fitness were significantly lower in childhood cancer survivors than in non-cancer controls (g = − 0.889; 95% confidence interval [CI] = − 1.648 − 0.130; p = 0.022) and (g = − 1.435; 95% CI = − 2.615 − 0.225; p = 0.017), respectively, with high heterogeneity.


Pediatric cancer sequelae and its treatment may limit participation in physical activity and fitness activities by survivors of pediatric cancer. Accentuating the need to incorporate physical activity and fitness into treatment protocols and post-treatment recommendations may improve pediatric cancer survivors’ health and well-being.

This is a preview of subscription content, log in to check access.

Fig. 1
Fig. 2
Fig. 3


  1. 1.

    Ward E, Desantis C, Robbins A, Kohler B, Jemal A (2014) Childhood and adolescent cancer statistics, 2014. CA Cancer J Clin 64(2):83–103.

    Article  PubMed  Google Scholar 

  2. 2.

    Robison LL, Hudson MM (2014) Survivors of childhood and adolescent cancer: life-long risks and responsibilities. Nat Rev Cancer 14(1):61–70.

    CAS  Article  PubMed  Google Scholar 

  3. 3.

    Siegel RL, Miller KD, Jemal A (2017) Cancer statistics, 2017. CA Cancer J Clin 67(1):7–30

    Article  Google Scholar 

  4. 4.

    Key Statistics for Childhood Cancers. American Cancer Society. Accessed 26 July 2018

  5. 5.

    Hewitt ME, Weiner SL, Simone JV (2003) Childhood cancer survivorship: improving care and quality of life. National Academies Press, Washington, D.C.

    Google Scholar 

  6. 6.

    Phillips SM, Padgett LS, Leisenring WM, Stratton KK, Bishop K, Krull KR, Alfano CM, Gibson TM, de Moor JS, Hartigan DB, Armstrong GT, Robison LL, Rowland JH, Oeffinger KC, Mariotto AB (2015) Survivors of childhood cancer in the United States: prevalence and burden of morbidity. Cancer Epidemiol Biomark Prev 24(4):653–663.

    Article  Google Scholar 

  7. 7.

    Armstrong GT, Liu Q, Yasui Y, Huang S, Ness KK, Leisenring W, Hudson MM, Donaldson SS, King AA, Stovall M, Krull KR, Robison LL, Packer RJ (2009) Long-term outcomes among adult survivors of childhood central nervous system malignancies in the childhood cancer survivor study. JNCI J Natl Cancer Instit 101(13):946–958.

    Article  Google Scholar 

  8. 8.

    Armstrong GT, Kawashima T, Leisenring W, Stratton K, Stovall M, Hudson MM, Sklar CA, Robison LL, Oeffinger KC (2014) Aging and risk of severe, disabling, life-threatening, and fatal events in the childhood cancer survivor study. J Clin Oncol 32(12):1218–1227.

    Article  PubMed  PubMed Central  Google Scholar 

  9. 9.

    Bleyer WA, Barr RD, Ries LAG, Whelan J, Ferrari A (2017) Cancer in adolescents and young adults. Springer, Cham

    Google Scholar 

  10. 10.

    Nottage KA, Ness KK, Li C, Srivastava D, Robison LL, Hudson MM (2014) Metabolic syndrome and cardiovascular risk among long-term survivors of acute lymphoblastic leukaemia - from the St. Jude Lifetime Cohort. Br J Haematol 165(3):364–374.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  11. 11.

    Waas MV, Neggers SJ, Lelij A-JVD, Pieters R, Heuvel-Eibrink MMVD (2010) The metabolic syndrome in adult survivors of childhood cancer, a review. J Pediatr Hematol Oncol 32(3):171–179.

    Article  PubMed  Google Scholar 

  12. 12.

    Zhang FF, Saltzman E, Must A, Parsons SK (2012) Do childhood cancer survivors meet the diet and physical activity guidelines? A review of guidelines and literature. Int J Child Health Nutr 1(1):44–58.

    Article  PubMed  PubMed Central  Google Scholar 

  13. 13.

    Stolley MR, Restrepo J, Sharp LK (2010) Diet and physical activity in childhood cancer survivors: a review of the literature. Ann Behav Med 39(3):232–249.

    Article  PubMed  PubMed Central  Google Scholar 

  14. 14.

    Bogg TF, Shaw PJ, Cohn RJ et al (2015) Physical activity and screen-time of childhood haematopoietic stem cell transplant survivors. Acta Paediatr 104(10).

  15. 15.

    Jansen H, Postma A, Stolk RP, Kamps WA (2009) Acute lymphoblastic leukemia and obesity: increased energy intake or decreased physical activity? Support Care Cancer 17(1):103–106.

    CAS  Article  PubMed  Google Scholar 

  16. 16.

    Fuemmeler BF, Pendzich MK, Clark K, Lovelady C, Rosoff P, Blatt J, Demark-Wahnefried W (2013) Diet, physical activity, and body composition changes during the first year of treatment for childhood acute leukemia and lymphoma. J Pediatr Hematol Oncol 35(6):437–443.

    Article  PubMed  PubMed Central  Google Scholar 

  17. 17.

    Brussel MV, Takken T, Net JVD et al (2006) Physical function and fitness in long-term survivors of childhood leukaemia. Pediatr Rehabil 9(3):267–274.

    Article  PubMed  Google Scholar 

  18. 18.

    Yelton L, Forbis S (2016) Influences and barriers on physical activity in pediatric oncology patients. Front Pediatr 4:131.

    Article  PubMed  PubMed Central  Google Scholar 

  19. 19.

    Götte M, Kesting S, Winter C, Rosenbaum D, Boos J (2014) Experience of barriers and motivations for physical activities and exercise during treatment of pediatric patients with cancer. Pediatr Blood Cancer 61(9):1632–1637.

    Article  PubMed  Google Scholar 

  20. 20.

    Huang T-T, Ness KK (2011) Exercise interventions in children with cancer: a review. Int J Pediatr 2011:1–11.

    Article  Google Scholar 

  21. 21.

    Gilliam MB, Schwebel DC (2013) Physical activity in child and adolescent cancer survivors: a review. Health Psychol Rev 7(1):92–110.

    Article  PubMed  PubMed Central  Google Scholar 

  22. 22.

    Batra A, Kumari M, Paul R, Patekar M, Dhawan D, Bakhshi S (2016) Quality of life assessment in retinoblastoma: a cross-sectional study of 122 survivors from India. Pediatr Blood Cancer 63(2):313–317.

    Article  PubMed  Google Scholar 

  23. 23.

    Cochrane Consumers and Communication Review Group (2015) Data extraction template for included studies London. The Cochrane Collaboration, UK

    Google Scholar 

  24. 24.

    Borenstein M, Hedges LV, Higgins JP, Rothstein HR (2010) A basic introduction to fixed-effect and random-effects models for meta-analysis. Res Synth Methods 1(2):97–111.

    Article  Google Scholar 

  25. 25.

    Rothstein HR, Sutton AJ, Borenstein M (2006) Publication bias in meta-analysis. Publication Bias in Meta-Analysis, pp 1–7.

  26. 26.

    Ross WL, Le A, Zheng DJ et al (2018) Physical activity barriers, preferences, and beliefs in childhood cancer patients. Support Care Cancer 26(7):2177–2184.

    Article  PubMed  Google Scholar 

  27. 27.

    Bansal M, Sharma KK, Vatsa M, Bakhshi S (2013) Comparison of health-related quality of life of children during maintenance therapy with acute lymphoblastic leukemia versus siblings and healthy children in India. Leuk Lymphoma 54(5):1036–1041.

    Article  PubMed  Google Scholar 

  28. 28.

    Beulertz J, Bloch W, Prokop A, Rustler V, Fitzen C, Herich L, Streckmann F, Baumann FT (2016) Limitations in ankle dorsiflexion range of motion, gait, and walking efficiency in childhood cancer survivors. Cancer Nurs 39(2):117–124.

    Article  PubMed  Google Scholar 

  29. 29.

    Bianco A, Patti A, Thomas E, Palma R, Maggio MC, Paoli A, Palma A (2014) Evaluation of fitness levels of children with a diagnosis of acute leukemia and lymphoma after completion of chemotherapy and autologous hematopoietic stem cell transplantation. Cancer Med 3(2):385–389.

    Article  PubMed  PubMed Central  Google Scholar 

  30. 30.

    Caro ED, Fioredda F, Calevo MG et al (2006) Exercise capacity in apparently healthy survivors of cancer. Arch Dis Child 91(1):47–51.

    Article  PubMed  Google Scholar 

  31. 31.

    Hoffman MC, Mulrooney DA, Steinberger J, Lee J, Baker KS, Ness KK (2013) Deficits in physical function among young childhood cancer survivors. J Clin Oncol 31(22):2799–2805.

    Article  PubMed  PubMed Central  Google Scholar 

  32. 32.

    Jenney MEM, Faragher EB, Jones PHM, Woodcock A (1995) Lung function and exercise capacity in survivors of childhood leukaemia. Med Pediatr Oncol 24(4):222–230.

    CAS  Article  Google Scholar 

  33. 33.

    Kobayashi K, Nakagami-Yamaguchi E, Hayakawa A, Adachi S, Hara J, Tokimasa S, Ohta H, Hashii Y, Rikiishi T, Sawada M, Kuriyama K, Kohdera U, Kamibeppu K, Kawasaki H, Oda M, Hori H (2017) Health-related quality of life in Japanese children with acute lymphoblastic leukemia during and after chemotherapy. Pediatr Int 59(2):145–153.

    Article  PubMed  Google Scholar 

  34. 34.

    Wright M, Bryans A, Gray K, Skinner L, Verhoeve A (2013) Physical activity in adolescents following treatment for cancer: influencing factors. Leuk Res Treat 2013:1–7.

    Article  Google Scholar 

  35. 35.

    Norris JM, Moules NJ, Pelletier G, Culos-Reed SN (2010) Families of young pediatric cancer survivors: a cross-sectional survey examining physical activity behavior and health-related quality of life. J Pediatr Oncol Nurs 27(4):196–208.

    Article  PubMed  Google Scholar 

  36. 36.

    Nuss SL, Wilson ME (2007) Health-related quality of life following hematopoietic stem cell transplant during childhood. J Pediatr Oncol Nurs 24(2):106–115.

    Article  PubMed  Google Scholar 

  37. 37.

    Polgreen LE, Petryk A, Dietz AC et al (2012) Modifiable risk factors associated with bone deficits in childhood cancer survivors. BMC Pediatr 12(1).

  38. 38.

    Schulte F, Wurz A, Reynolds K, Strother D, Dewey D (2016) Quality of life in survivors of pediatric cancer and their siblings: the consensus between parent-proxy and self-reports. Pediatr Blood Cancer 63(4):677–683.

    Article  PubMed  Google Scholar 

  39. 39.

    Slater ME, Ross JA, Kelly AS, Dengel DR, Hodges JS, Sinaiko AR, Moran A, Lee J, Perkins JL, Chow LS, Baker KS, Steinberger J (2015) Physical activity and cardiovascular risk factors in childhood cancer survivors. Pediatr Blood Cancer 62(2):305–310.

    Article  PubMed  Google Scholar 

  40. 40.

    Warner JT, Bell W, Webb DKH (1998) Daily energy expenditure and physical activity in survivors of childhood malignancy. Pediatr Res 43:607–613

    CAS  Article  Google Scholar 

  41. 41.

    Sterne JAC, Sutton AJ, Ioannidis JPA et al (2011) Recommendations for examining and interpreting funnel plot asymmetry in meta-analyses of randomized controlled trials. BMJ 343(jul22 1):d4002–d4002.

    Article  PubMed  Google Scholar 

  42. 42.

    Dietz AC, Chen Y, Yasui Y, Ness KK, Hagood JS, Chow EJ, Stovall M, Neglia JP, Oeffinger KC, Mertens AC, Robison LL, Armstrong GT, Mulrooney DA (2016) Risk and impact of pulmonary complications in survivors of childhood cancer: a report from the Childhood Cancer Survivor Study (CCSS). Cancer 122(23):3687–3696.

    Article  PubMed  PubMed Central  Google Scholar 

  43. 43.

    Huang T-T, Hudson MM, Stokes DC, Krasin MJ, Spunt SL, Ness KK (2011) Pulmonary outcomes in survivors of childhood Cancer. Chest 140(4):881–901.

    Article  PubMed  PubMed Central  Google Scholar 

  44. 44.

    Wilson C, Gawade P, Ness K (2015) Impairments that influence physical function among survivors of childhood cancer. Children 2(1):1–36.

    Article  PubMed  PubMed Central  Google Scholar 

  45. 45.

    Lipshultz SE, Adams MJ, Colan SD, Constine LS, Herman EH, Hsu DT, Hudson MM, Kremer LC, Landy DC, Miller TL, Oeffinger KC, Rosenthal DN, Sable CA, Sallan SE, Singh GK, Steinberger J, Cochran TR, Wilkinson JD, American Heart Association Congenital Heart Defects Committee of the Council on Cardiovascular Disease in the Young, Council on Basic Cardiovascular Sciences, Council on Cardiovascular and Stroke Nursing, Council on Cardiovascular Radiolo (2013) Long-term cardiovascular toxicity in children, adolescents, and young adults who receive cancer therapy: pathophysiology, course, monitoring, management, prevention, and research directions: a scientific statement from the American Heart Association. Circulation 128(17):1927–1955.

    Article  PubMed  Google Scholar 

  46. 46.

    Mulrooney DA, Yeazel MW, Kawashima T, Mertens AC, Mitby P, Stovall M, Donaldson SS, Green DM, Sklar CA, Robison LL, Leisenring WM (2009) Cardiac outcomes in a cohort of adult survivors of childhood and adolescent cancer: retrospective analysis of the Childhood Cancer Survivor Study cohort. BMJ 339:b4606.

    Article  PubMed  PubMed Central  Google Scholar 

  47. 47.

    Dalen ECV, Pal HJVD, Kok WE, Caron HN, Kremer LC (2006) Clinical heart failure in a cohort of children treated with anthracyclines: a long-term follow-up study. Eur J Cancer 42(18):3191–3198.

    CAS  Article  PubMed  Google Scholar 

  48. 48.

    Pal HJVD, Dalen ECV, Kremer LC, Bakker PJ, Leeuwen FEV (2005) Risk of morbidity and mortality from cardiovascular disease following radiotherapy for childhood cancer: a systematic review. Cancer Treat Rev 31(3):173–185.

    Article  PubMed  Google Scholar 

  49. 49.

    Ginsberg JP, Goodman P, Leisenring W, Ness KK, Meyers PA, Wolden SL, Smith SM, Stovall M, Hammond S, Robison LL, Oeffinger KC (2010) Long-term survivors of childhood Ewing sarcoma: report from the Childhood Cancer Survivor Study. JNCI J Natl Cancer Instit 102(16):1272–1283.

    Article  Google Scholar 

  50. 50.

    Fromm M, Littman P, Raney RB, Nelson L, Handler S, Diamond G, Stanley C (1986) Late effects after treatment of twenty children with soft tissue sarcomas of the head and neck. Experience at a single institution with a review of the literature. Cancer 57(10):2070–2076.<2070::aid-cncr2820571032>;2-g

    CAS  Article  PubMed  Google Scholar 

  51. 51.

    Fiorillo A, Migliorati R, Vassallo P, Canale G, Tranfa F, Fariello I, de Chiara C, D’Amore R, Muto P, Bonavolontà G (1999) Radiation late effects in children treated for orbital rhabdomyosarcoma. Radiother Oncol 53(2):143–148.

    CAS  Article  PubMed  Google Scholar 

  52. 52.

    Raney RB, Anderson JR, Kollath J, Vassilopoulou-Sellin R, Klein MJ, Heyn R, Glicksman AS, Wharam M, Crist WM, Maurer HM, from the Intergroup Rhabdomyosarcoma Study Group (IRSG) (2000) Late effects of therapy in 94 patients with localized rhabdomyosarcoma of the orbit: report from the Intergroup Rhabdomyosarcoma Study (IRS)-III, 1984-1991. Med Pediatr Oncol 34(6):413–420.<413::aid-mpo6>;2-4

    CAS  Article  PubMed  Google Scholar 

  53. 53.

    Craft A (1997) Long-term results from the first UKCCSG Ewings tumour study (ET-1). Eur J Cancer 33(7):1061–1069.

    CAS  Article  PubMed  Google Scholar 

  54. 54.

    Raney RB, Asmar L, Vassilopoulou-Sellin R, Klein MJ, Donaldson SS, Green J, Heyn R, Wharam M, Glicksman AS, Gehan EA, Anderson J, Maurer HM, for the IRS Group of the Children’s Cancer Group and the Pediatric Oncology Group (1999) Late complications of therapy in 213 children with localized, nonorbital soft-tissue sarcoma of the head and neck: a descriptive report from the Intergroup Rhabdomyosarcoma Studies (IRS)-II and - III. Med Pediatr Oncol 33(4):362–371.<362::aid-mpo4>;2-i

    CAS  Article  PubMed  Google Scholar 

  55. 55.

    Paulino AC (2004) Late effects of radiotherapy for pediatric extremity sarcomas. Int J Radiat Oncol Biol Phys 60(1):265–274.

    Article  PubMed  Google Scholar 

  56. 56.

    Kawai A, Lin PP, Boland PJ, Athanasian EA, Healey JH (1999) Relationship between magnitude of resection, complication, and prosthetic survival after prosthetic knee reconstructions for distal femoral tumors. J Surg Oncol 70(2):109–115.<109::aid-jso9>;2-x

    CAS  Article  PubMed  Google Scholar 

  57. 57.

    McNeely ML, Campbell KL, Rowe BH, Klassen TP, Mackey JR, Courneya KS (2006) Effects of exercise on breast cancer patients and survivors: a systematic review and meta-analysis. CMAJ 175(1):34–41.

    Article  PubMed  PubMed Central  Google Scholar 

  58. 58.

    Speck RM, Courneya KS, Mâsse LC, Duval S, Schmitz KH (2010) An update of controlled physical activity trials in cancer survivors: a systematic review and meta-analysis. J Cancer Surviv 4(2):87–100.

    Article  PubMed  Google Scholar 

  59. 59.

    Fitness: can exercise lengthen survival in patients with cancer? Effects of Menarche and Menopause on Breast Cancer Risk: Meta-analysis Findings - The ASCO Post. Accessed 7 Oct 2018

  60. 60.

    Schmid D, Leitzmann MF (2014) Association between physical activity and mortality among breast cancer and colorectal cancer survivors: a systematic review and meta-analysis. Ann Oncol 25(7):1293–1311.

    CAS  Article  PubMed  Google Scholar 

  61. 61.

    Wolin KY, Ruiz JR, Tuchman H, Lucia A (2010) Exercise in adult and pediatric hematological cancer survivors: an intervention review. Leukemia 24(6):1113–1120.

    CAS  Article  PubMed  Google Scholar 

  62. 62.

    Moyer-Mileur LJ, Ransdell L, Bruggers CS (2009) Fitness of children with standard-risk acute lymphoblastic leukemia during maintenance therapy. J Pediatr Hematol Oncol 31(4):259–266.

    Article  PubMed  Google Scholar 

  63. 63.

    Juan AFS, Fleck SJ, Chamorro-Viña C et al (2007) Early-phase adaptations to intrahospital training in strength and functional mobility of children with leukemia. J Strength Cond Res 21(1):173–177.

    Article  Google Scholar 

  64. 64.

    Shore S, Shepard R (2001) Immune responses to exercise in children treated for cancer. Rehab Oncol 19(2):32.

    Article  Google Scholar 

  65. 65.

    Philip EJ, Coups EJ, Feinstein MB, Park BJ, Wilson DJ, Ostroff JS (2015) Patient-provider discussion of physical activity among early-stage lung cancer survivors. Psycho-oncology 24(3):359–362.

    Article  PubMed  Google Scholar 

  66. 66.

    Orrow G, Kinmonth A-L, Sanderson S, Sutton S (2012) Effectiveness of physical activity promotion based in primary care: systematic review and meta-analysis of randomised controlled trials. BMJ 344(mar26 1).

  67. 67.

    Cox CL, Montgomery M, Oeffinger KC, Leisenring W, Zeltzer L, Whitton JA, Mertens AC, Hudson MM, Robison LL (2009) Promoting physical activity in childhood cancer survivors: targets for intervention. Cancer 115(3):642–654.

    Article  PubMed  PubMed Central  Google Scholar 

  68. 68.

    Ungar N, Wiskemann J, Weißmann M, Knoll A, Steindorf K, Sieverding M (2016) Social support and social control in the context of cancer patients’ exercise: a pilot study. Health Psychol Open 3(2):205510291668099.

    Article  Google Scholar 

  69. 69.

    Pinto BM, Trunzo JJ (2005) Health behaviors during and after a cancer diagnosis. Cancer 104(S11):2614–2623.

    Article  PubMed  Google Scholar 

  70. 70.

    Coleman S, Berg CJ, Thompson NJ (2014) Social support, nutrition intake, and physical activity in cancer survivors. Am J Health Behav 38(3):414–419.

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Author information



Corresponding author

Correspondence to Godfred O. Antwi.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material


(DOCX 17 kb)


(DOCX 24 kb)


(DOCX 17 kb)

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Antwi, G.O., Jayawardene, W., Lohrmann, D.K. et al. Physical activity and fitness among pediatric cancer survivors: a meta-analysis of observational studies. Support Care Cancer 27, 3183–3194 (2019).

Download citation


  • Physical activity
  • Fitness
  • Pediatric cancer survivors