Availability and adaption of exercise programs in pediatric oncology during the COVID-19 pandemic and beyond: a nationwide follow-up survey of providers in Germany.

Background: The COVID-19 pandemic has presented major challenges to clinical practice and delivery of care programs throughout all health care systems. Exercise programs, that are implemented in most centers for pediatric oncology in Germany, are a relatively new care program however with high clinical impact and health benefits. Objective: The impact and consequences of the pandemic on the delivery and availability of exercise programs in Germany for pediatric cancer patients and survivors are unknown. A national survey analyzed restrictions, challenges and novel approaches of exercise program delivery and scientific research. Method: A two-stage online survey was distributed to providers of exercise programs (acute clinics, non-clinical institutions, rehabilitation facilities) via the established Network ActiveOncoKids. Data was collected during the pandemic in 2022 and 2023 using a combination of open and closed questions. Results: In total, n = 27 (response rate: 82%) and n = 17 (response rate: 63%) providers participated in the first and second survey, respectively. Findings pointed out restrictions in 85% of all exercise programs in 2020 and 2021, with slight reductions in 2022. During pandemic, restrictions with major impact arose within exercise offers during follow-up and declined gradually. Whereas restrictions within the setting of acute therapy had medium or minor impact but persisted beyond. Delivery of provided exercise programs necessitated adaptions, including digital methods, supervised interventions from a distance and change of locations. Discussion: The findings highlight the adaptability, the demand and the potential of exercise programs in pediatric oncology. We assume that exercise professionals have used the pandemic-related challenges to review and modify existing concepts and made adaptations according to local conditions and novel tools for the provision of exercise programs. Nevertheless, a conspicuous lack of exercise-related care has become evident in certain patients and survivors. Further expansion of programs is imperative to address and accommodate all pertinent needs.

How can current oncological datasets be adjusted to support the automated patient recruitment in clinical trials?

OBJECTIVES: This study aims to identify necessary adjustments required in existing oncological datasets to effectively support automated patient recruitment. METHODS: We extracted and categorized the inclusion and exclusion criteria from 115 oncological trials registered on ClinicalTrials.gov in 2022. These criteria were then compared with the content of the oBDS (Oncological Base Dataset version 3.0), Germany's legally mandated oncological data standard. RESULTS: The analysis revealed that 42.9% of generalized inclusion and exclusion criteria are typically present as data fields in the oBDS. On average, 54.6% of all criteria per trial were covered. Notably, certain criteria such as comorbidities, pregnancy status, and laboratory values frequently appeared in trial protocols but were absent in the oBDS. CONCLUSION: The omission of criteria, notably comorbidities, within the oBDS restricts its functionality to support trial recruitment. Addressing this limitation would enhance its overall effectiveness. Furthermore, the implications of these findings extend beyond Germany, suggesting potential relevance and applicability to oncological datasets globally.

Association of European Paediatric and Congenital Cardiology practical recommendations for surveillance and prevention of cardiac disease in childhood cancer survivors: the importance of physical activity and lifestyle changes From the Association of European Paediatric and Congenital Cardiology Working Group Sports Cardiology, Physical Activity and Prevention, Working Group Adult Congenital Heart Disease, Working Group Imaging and Working Group Heart Failure.

BACKGROUND: Childhood cancer survivors are at increased risk of developing cardiovascular diseases, presenting as the main causes of morbidity and mortality within this group. Besides the usual primary and secondary prevention in combination with screening during follow-up, the modifiable lifestyle factors of physical activity, nutrition, and body weight have not yet gained enough attention regarding potential cardiovascular risk reduction. OBJECTIVE: These practical recommendations aim to provide summarised information and practical implications to paediatricians and health professionals treating childhood cancer survivors to reduce the risk of cardiovascular late effects. METHODS: The content derives from either published guidelines or expert opinions from Association of European Paediatric and Congenital Cardiology working groups and is in accordance with current state-of-the-art. RESULTS: All usual methods of prevention and screening regarding the risk, monitoring, and treatment of occurring cardiovascular diseases are summarised. Additionally, modifiable lifestyle factors are explained, and clear practical implications are named. CONCLUSION: Modifiable lifestyle factors should definitely be considered as a cost-effective and complementary approach to already implemented follow-up care programs in cardio-oncology, which can be actively addressed by the survivors themselves. However, treating physicians are strongly encouraged to support survivors to develop and maintain a healthy lifestyle, including physical activity as one of the major influencing factors. This article summarises relevant background information and provides specific practical recommendations on how to advise survivors to increase their level of physical activity.

Effects of strength exercise interventions on activities of daily living, motor performance, and physical activity in children and adolescents with leukemia or non-Hodgkin lymphoma: Results from the randomized controlled ActiveADL Study.

Objectives: Pediatric patients with cancer experience impairments in muscle strength and physical activity (PA) that may reduce autonomy during hospitalization. To determine the effects of strength exercise interventions on the accomplishment of activities of daily living (ADLs), motor performance, and PA in children with leukemia or non-Hodgkin lymphoma, we randomly allocated patients (4-18 years) immediately after diagnosis into two exercise groups. Methods: The intervention group (IG; n = 21) received a specific strength training combined with a standard care exercise program, whereas the control group (CG; n = 20) was provided standard care exercise program without any targeted muscle strengthening. After the baseline visit, participants were followed-up three times until intensive treatment cessation. We assessed physical function limitations using the Activities Scale for Kids© (ASK) and Functional ADL Screen. Secondary outcomes were PA levels using accelerometer and motor performance as measured by MOON-test (motor performance in pediatric oncology-test). Results: In both groups, ADL accomplishment had significantly increased (p < 0.05). However, no significant between-group differences for ASK outcome were noted. Motor performance was reduced in all motor abilities. Conclusions: Both exercise interventions were effective to maintain ADLs and motor performance during intensive treatment. In comparison, regular strength exercise interventions in the course of therapy tended to be more beneficial with regards to muscular explosive and endurance strength.

Multidisciplinary Network ActiveOncoKids guidelines for providing movement and exercise in pediatric oncology: Consensus-based recommendations.

BACKGROUND: Pediatric cancer leads to reduced participation in exercise and only few patients comply with national physical activity recommendations. Physically inactive behavior hinders motor development and increases physical and psychological adverse effects of therapy and incidence of sequelae. Currently, there is neither nationwide coverage nor uniform level of knowledge regarding exercise promotion. The objective of the guideline is to facilitate qualified exercise interventions through standardized procedures in addition to regular physiotherapy and overall avoid physical inactivity in pediatric cancer patients. METHODS: This guideline addresses the multidisciplinary treatment team and informs physiotherapists and decision-makers in tertiary care hospitals and health insurance companies. The requirements of the Association of the Scientific Medical Societies in Germany were followed. Contents were based on best practice experience of experts, patient advocates, as well as on scientific evidence. RESULTS: The guideline includes 11 recommendations. Recommendations 1-4 declare the relevance of implementing exercise interventions and address general framework conditions. Recommendations 5-11 focus on the design of exercise programs, prevention and safety issues, relative contraindications for specific training loads, and options to overcome barriers to exercise. CONCLUSION: This guideline summarizes existing and established structures and evidence in the context of movement and exercise in pediatric oncology. It takes into consideration the rights, varying needs, and characteristics of children and adolescents as well as national and international experience in this field. In the future, relevant research gaps need to be addressed by high-quality intervention studies to provide the scientific background for a stronger evidence-based guideline.

A National Implementation Approach for Exercise as Usual Care in Pediatric and Adolescent Oncology: Network ActiveOncoKids.

The diagnosis of cancer as well as accompanying acute and late effects of treatment are influencing physical activity behavior of patients with childhood cancer and survivors. Research has shown that a pediatric cancer diagnosis is associated with impairments of physical performance, and function, as well as reduced physical, and psychosocial, health conditions. From an ethical perspective, lack of knowledge of health care providers, lack of physical activity promotion, and environmental, and structural barriers to physical activity restrict children's right to move and actively engage in physical activities. Network ActiveOncoKids is a German-wide initiative with the main goal of enabling children, adolescents, and young adults with exercise opportunities during and after cancer treatment. Since the network's foundation in 2012, Network ActiveOncoKids focuses on: (1) physical activity support for patients and families, (2) policy change to establish structures and guidelines, and (3) generating evidence through scientific projects. The purpose of this paper is to present an overview of Network ActiveOncoKids structure, aims, and projects. This topical review will highlight the network's structural development, research work, and implementation progress of exercise programs for patients with pediatric cancer and survivors, link international collaborations, and discuss future directions.

A Bout of High-Intensity Interval Training (HIIT) in Children and Adolescents during Acute Cancer Treatment-A Pilot Feasibility Study.

Low- and moderate-intensity exercise is safe and feasible during childhood cancer treatment. The feasibility of a bout of high-intensity interval training (HIIT) in this population has not been analyzed to date. Pediatric cancer patients aged between 6 and 18 years were selected based on clinical conditions to perform ten sets of 15 s HIIT (>90% of estimated maximal heart rate (HRmax)) and 1 min active recovery on a bicycle ergometer within the first three chemotherapy courses. We assessed safety and feasibility criteria and the following parameters: perceived exertion rate, heart rate, and lactate and adrenaline concentrations. Out of 212 eligible patients, 11 patients aged 13.9 ± 3.6 years (n = 7 ♂) with lymphoma, leukemia, rhabdomyosarcoma, nephroblastoma, and synovial sarcoma completed the bout of HIIT without serious adverse events. During exercise, patients reached a BORG value maxima of 16 ± 1.2, and their heart rates rose from 78 ± 17 beats per minute (bpm) at rest to 178 ± 12 bpm after exercise (90 ± 6% estimated HRmax). The power-to-weight ratio was 2 ± 0.5 W/kg (watt per kilogram). Blood lactate concentrations increased from 1.09 ± 0.50 mmol/L (millimole per liter) at rest to 5.05 ± 1.88 mmol/L post-exercise. Our preliminary data suggest that HIIT is applicable only in a small number of childhood cancer patients. Individually adapted exercise protocols for patients with multiple impairments are needed.

Analysis of self-reported activities of daily living, motor performance and physical activity among children and adolescents with cancer: Baseline data from a randomised controlled trial assessed shortly after diagnosis of leukaemia or non-Hodgkin lymphoma.

OBJECTIVE: Cancer diagnosis, treatment side effects and physical inactivity can lead to reduced muscle strength. Patients undergoing acute treatment experience many burdens that can restrict their mobility and autonomy, leading to limited independence and loss of resources to cope with everyday tasks. In this work, we analyse the status quo and potential influencing factors for the accomplishment of activities of daily living (ADLs) shortly after cancer diagnosis. METHODS: We recruited participants ages 4-18 years diagnosed with acute leukaemia or non-Hodgkin lymphoma. For the baseline analysis, we assessed (1) physical function limitations using the Activities Scale for Kids©, (2) exercise-related ADLs simulated with the Functional ADL Screen, (3) motor performance using the Motor Performance in Paediatric Oncology test and (4) physical activity (PA) level measured using an accelerometer. RESULTS: We conducted the baseline assessment 19.2 ± 12.6 days post-diagnosis in 41 patients. All participants reported functional limitations in ADLs and PA. Motor performance was reduced for all abilities. Cumulative steroid dose was negatively correlated with hand grip strength (r = -0.50, p = 0.009). CONCLUSION: Shortly after diagnosis of paediatric cancer, patients experience various physical impairments that can be counteracted with regular, instructed exercise interventions.

Physical and functional performance assessment in pediatric oncology: a systematic review.

BACKGROUND: Research indicates reduced physical performance from diagnosis into survivorship of pediatric cancer patients. However, there is no systematic information or guideline available on the methods to assess physical performance and function in this population. The purpose was to systematically compile and describe assessments of physical performance and function in patients and survivors of pediatric cancer, including cardiorespiratory fitness, muscle strength, speed, balance, flexibility, functional mobility, gait and motor performance test batteries. METHODS: We searched the databases PubMed, SPORTDiscus, and Cochrane Database and performed abstract and full-text selection of 2619 articles according to the Cochrane Handbook of Systematic Reviews. Information on patients characteristics, assessments, information on validity and reliability, and relevant references was extracted. RESULTS: In summary, 63 different assessments were found in 149 studies including 11639 participants. Most studies evaluated cardiorespiratory fitness and muscle strength with the majority conducted off treatment. Some outcomes (e.g. speed) and diagnoses (e.g. neuroblastoma) were severely underrepresented. With the exception of gait, leukemia patients represented the largest group of individuals tested. CONCLUSIONS: Insufficient data and patient heterogeneity complicate uniform recommendations for assessments. Our results support researchers and practitioners in selecting appropriate assessment to meet their specific research questions or individual daily practice needs. IMPACT: This systematic review includes 149 studies and provides a comprehensive summary of 63 assessments to evaluate cardiorespiratory fitness, muscle strength, speed, balance, flexibility, functional mobility, gait or motor performance test batteries in patients and survivors of pediatric cancer. We present the most studied fields within the pediatric cancer population, which are cardiorespiratory fitness and muscle strength, off treatment phase, and leukemia patients. We propose research priorities by identification of subgroups in terms of cancer type, phase of treatment, and outcome of interest that are underrepresented in studies currently available.

The international Pediatric Oncology Exercise Guidelines (iPOEG).

Physical activity (PA) and exercise are safe and beneficial for children and adolescents affected by cancer. Yet, this population is not active enough to receive benefits. PA guideline and recommendation statements can support individual behavior and practice change. The purpose of this project was to develop the international Pediatric Oncology Exercise Guidelines (iPOEG), comprised of guideline and recommendation statements, to promote PA among children and adolescents affected by cancer. Guideline development procedures, stakeholder engagement strategies, and the Delphi technique were used. Four online surveys were distributed to the iPOEG network (n = 9 core team members, n = 122 expert consensus committee members). Surveys included closed- and open-ended items informed by a literature synthesis and an in-person meeting. Responses were analyzed using descriptive statistics and content analysis. Consensus was defined as ≥ 80% agreement. Response rates to online surveys ranged from 82% to 91%. The iPOEG network agreed on four guideline and five recommendation statements, which highlight that movement is important for all children and adolescents affected by cancer. These statements are generic in nature as more research is still required to provide specific guidance on the frequency, intensity, time, and type of PA for this population. Nevertheless, the iPOEG statements represent available evidence and expert opinion, collectively suggesting that it is time for children and adolescents affected by cancer to move more.

Physical activity is safe and beneficial for children and adolescents affected by cancer. Yet, most are not active enough to receive benefits. Guideline and recommendation statements can help change individual behavior and practice. To develop such statements, guideline development procedures, stakeholder engagement strategies, and the Delphi technique were used. Four online surveys were distributed to an international network (n = 131 experts). Surveys asked closed- and open-ended questions informed by a literature synthesis and an in-person meeting. Findings from the online surveys resulted in the international Pediatric Oncology Exercise Guidelines statements, which highlight that it is time for children and adolescents affected by cancer to move more.

Advancing the Field of Pediatric Exercise Oncology: Research and Innovation Needs.

The field of pediatric exercise oncology explores the relationships between physical activity (PA), including exercise, and a range of outcomes among children and adolescents affected by cancer. Although PA is safe and beneficial for this population, several important gaps in knowledge and practice remain. In this article, we describe research and innovation needs that were developed with a team of international experts and relevant literature, a series of online surveys, and an in-person meeting. Addressing these needs will contribute valuable knowledge and practice outputs to advance this field, ultimately enabling a greater number of children and adolescents affected by cancer to realize the benefits of moving more.

Short-Term Consequences of Pediatric Anti-cancer Treatment Regarding Blood Pressure, Motor Performance, Physical Activity and Reintegration Into Sports Structures.

Background: Cardiovascular diseases in childhood cancer survivors are known late sequelae following treatment. Arterial stiffness, pulse wave velocity (PWV) and central systolic blood pressure (cSBP) are potential predictors to assess the status of cardiovascular health. Frequent inpatient stays and reduced physical activity (PA) during treatment can lead to noticeable impairments regarding motor skills and physical performance. The present study examined parameters of cardiovascular health, motor performance and the status of integration into sports structures shortly after cessation of treatment. Methods: A cross-sectional, monocentric study was conducted from April to June 2019. Participants (6-18 yrs, mixed cancer entities) during maintenance therapy and follow-up care were recruited. Peripheral and central systolic/diastolic blood pressure (pSBP, pDBP, cSBP) and PWV were assessed using the Mobil-O-Graph®. The MOON test (MOtor performance in pediatric ONcology) was used to scale motor performance. PA levels and status of integration into sports structures were assessed with a questionnaire referring to the KiGGS study. All measured data were compared to published reference values. Results: Forty participants (11.3 ± 3.8 years, 50% female) were recruited 1.6 ± 1.8 years post-treatment. PSBP (z-score: 0.87 ± 0.67, p = 0.003), pDBP (0.83 ± 1.94, p = 0.033) and cSBP (≥8 years: 0.60 ± 1.29, p = 0.011) were significantly increased compared to reference values. PWV was also elevated, but not significantly. Motor performance was reduced in almost all motor abilities. Thirty-six percent of the examined group did not participate in physical education at school to the full extent. Only 17% reported 1 hour of daily moderate-to-vigorous PA as recommended for children and adolescents by the World Health Organization. Half of the participants were active sports club members before treatment, but one third did not resume their former membership. Conclusion: Increased cardiovascular parameters and impaired motor performance shortly after cessation of treatment, physical inactivity, and low rates of integration into regular sports programs highlight the support needed. Young cancer patients should receive early support in coping with physical limitations preferably soon after diagnosis. Motor deficits could be reduced by applying targeted interventions. Furthermore, a regular sports therapy program during in- and outpatient care could increase engagement in PA to possibly counteract risk factors and improve cardiovascular health.

Exercise as a Potential Intervention to Modulate Cancer Outcomes in Children and Adults?

Exercise is recommended for the healthy population as it increases fitness and prevents diseases. Moreover, exercise is also applied as an adjunct therapy for patients with various chronic diseases including cancer. Childhood cancer is a rare, heterogeneous disease that differs from adult cancer. Improved therapeutic strategies have increased childhood cancer survival rates to above 80% in developed countries. Although this is higher than the average adult cancer survival rate of about 50%, therapy results often in substantial long-term side effects in childhood cancer survivors. Exercise in adult cancer patients has many beneficial effects and may slow down tumor progression and improve survival in some cancer types, suggesting that exercise may influence cancer cell behavior. In contrast to adults, there is not much data on general effects of exercise in children. Whilst it seems possible that exercise might delay cancer progression or improve survival in children as well, there is no reliable data yet to support this hypothesis. Depending on the type of cancer, animal studies of adult cancer types show that the exercise-induced increase of the catecholamines epinephrine and norepinephrine, have suppressive as well as promoting effects on cancer cells. The diverse effects of exercise in adult cancer patients require investigating whether these results can be achieved in children with cancer.

Feasibility and effects of a home-based intervention using activity trackers on achievement of individual goals, quality of life and motor performance in patients with paediatric cancer.

OBJECTIVES: Supervised exercise interventions during inpatient care are feasible. The objective was to evaluate the usability of activity trackers and centralised monitoring to conduct a home-based exercise intervention during cancer treatment. The primary endpoint and confirmatory analysis was achievement of individual goals for daily steps, compared (A) in the intervention group (IG) over time and (B) between the IG and control group (CG). Secondary endpoints included achievement of goals for active minutes and effects on motor performance and health-related quality of life (hrQoL). METHODS: Forty patients treated for paediatric cancer (14.7±3.9 years) were included. The IG received a 6-8 week intervention during acute treatment (T1) and a 2-week intervention in transition to aftercare (T2). The CG only received the intervention at T2. Baseline tests to assess motor performance and physical activity were conducted prior to every intervention. RESULTS: In the primary confirmatory analysis, the IG significantly improved achievement of individual step goals (p=0.04) whereas group analyses did not reveal significant differences. Achievement of active minutes remained low (p=0.23). IG scored higher in hrQoL than CG (p<0.01) and percentage of children scoring below normative value in strength tests was higher in CG. Of all participants, 94% rated the intervention as meaningful and 80% as motivational. CONCLUSIONS: Results of this study indicate that this intervention for home stays with centralised supervision is feasible and leads to increased achievement of individual step goals. Despite the positive effects on hrQoL, further strategies are needed to increase positive effects on motor performance.

Objectively measured versus self-reported physical activity in children and adolescents with cancer.

OBJECTIVE: Existing research recognizes low levels of physical activity in pediatric patients with cancer, but much uncertainty exists about their capability to self-reflect physical activity levels. The objective of this study was to compare results of subjective self-reports and objective accelerometers regarding levels of daily walking as well as moderate-to-vigorous physical activities. METHODS: Results of the objective assessment tool StepWatchTM Activity Monitor and self-reporting with a standardized questionnaire were compared in 28 children and adolescents during cancer treatment. RESULTS: The patients were 13.8±2.8 years of age and 3.4±2.0 months after cancer diagnosis. The Bland-Altman plots indicated a fairly symmetrical under- and over-estimation for daily minutes of walking with the limits of agreement ranging from -100.8 to 87.3 min (d = -6.7 min). Mean difference for moderate-to-vigorous physical activity was almost zero but limits of agreement are ranging from -126.8 to 126.9 min. The comparison for the days with at least 60 min of moderate-to-vigorous physical activity showed a marked difference with 3.0±2.6 self-reported days versus only 0.1±0.4 measured days. CONCLUSIONS: These findings suggest that physical activity in pediatric cancer patients should preferably be assessed with objective methods. Greater efforts are needed to implement supervised exercise interventions during treatment incorporating methods to improve self-reflection of physical activity.

One in Four Questioned Children Faces Problems Regarding Reintegration Into Physical Education at School After Treatment for Pediatric Cancer.

Resumption of physical activity and reintegration into social surroundings after treatment for pediatric cancer is of high importance to recover from the burden of disease and treatment and to positively influence long-term health outcomes. Eighty-three children who had completed intensive treatment for pediatric cancer were surveyed regarding their participation in physical education at school (PES). The results show a concerning low rate of participation, particularly in children treated for pediatric bone tumors, and associated barriers. Reported reasons for quitting PES seem to be conquerable by individual and entity-related support to enable participation according to the children's desire.

Motor Performance After Treatment for Pediatric Bone Tumors.

BACKGROUND: Reduced motor performance can negatively affect physical activity and social partake after childhood cancer. Especially in bone tumor patients, who are at risk of physical limitations due to surgical interventions, motor performance has not yet been sufficiently investigated. Therefore, this study aimed at assessing motor performance in pediatric bone tumor patients. PROCEDURE: Motor performance was measured within 2 years posttreatment using the MOON (test for MOtor performance in pediatric ONcology) test. This instrument enables quantitative data collection even in physically impaired patients for comparison with age-matched and sex-matched reference values. RESULTS: Twenty-one patients (13 male) ages 15.2±2.1 years (median: 15 y, 10 to 19 y) and 9.4±7.4 months posttreatment (median: 6 mo, 2 to 24 mo) were tested. Motor performance was slightly reduced in muscular endurance of the legs; significantly reduced in speed, flexibility, eye-hand coordination, and muscular explosive strength (P<0.001), whereas patients' hand grip strength and static balance were superior to the reference values. Follow-up duration, body mass index, and tumor localization apparently affected motor performance. CONCLUSIONS: These findings show serious reductions in motor performance within 2 years after bone tumor treatment and highlight the need for interventions to improve motor performance. The results should be used to advise and support patients to engage in suitable physical and sports activities.

Motor performance in children and adolescents with cancer at the end of acute treatment phase.

UNLABELLED: Reduced motor performance may particularly limit reintegration into normal life after cessation of treatment in pediatric cancer patients. This study aimed at analyzing motor performance at the end of the acute treatment phase and reveals potential risk factors for motor deficits. A childhood cancer population with different tumor entities was assessed with the MOON test, which allows for comparison with age- and gender-matched reference values of healthy children, at the end of the acute treatment phase. Forty-seven patients were tested at 7.0 ± 2.6 months after diagnosis. Significant reductions of motor performance affected muscular explosive strength (P < 0.001), handgrip strength (P < 0.001), muscular endurance of legs (P = 0.035), hand-eye coordination (P < 0.001), static balance (P = 0.003), speed (P = 0.012), and flexibility (P < 0.001). Loss of upper extremity coordination did not achieve statistical significance. Associations between single motor deficits and the tumor entity, age, body mass index, and inactivity during treatment were revealed, whereas no associations were found for gender and vincristine application. CONCLUSION: Overall, motor performance was low in the patient group studied. We recommend that individualized exercise interventions to attenuate motor deficits and promote physical activity are needed during cancer treatment in order to enhance motor performance and improve social participation during and after cancer therapy.

Experience of barriers and motivations for physical activities and exercise during treatment of pediatric patients with cancer.

BACKGROUND: Due to growing evidence about the value of exercise in pediatric cancer patients, the purpose of this study was to determine factors that influence participation in physical activities and exercise in children and adolescents during treatment. PROCEDURE: This cross-sectional qualitative study included 40 pediatric cancer patients during intensive treatment. Patients were recruited at the Department for Pediatric Hematology and Oncology, University Hospital of Muenster where a supervised exercise program has been implemented for hospital stays. The qualitative approach included semi-structured guideline interviews, transcription and coding based on grounded theory. Four major topics were discussed in the interviews: (1) values and beliefs, (2) barriers to exercise, (3) motivations to exercise, and (4) encouragement from parents and physicians. RESULTS: Patients reported mainly positive attitudes toward physical activities during treatment and the local exercise program was desired and valued as essential for engaging in exercise during in-patient stays. Identified barriers included physical, psychological, and organizational aspects. Motivational aspects were based on improvements in physical fitness and mental well-being. Parents' behavior related to physical activities of their children differed between being supportive, inhibiting, and inert. Few patients received information about exercise during treatment by their physicians. CONCLUSIONS: Interventions that aim at maintaining physical activities during treatment and eliminating exercise barriers are required due to the patients' positive attitudes and multiple motivations toward exercise. These interventions need to be supervised and should include health-counseling programs for patients, parents, and physicians to underline the importance of physical activities in childhood cancer patients.