Despite research suggesting cancer survivors often improve dietary behaviors following diagnosis, concern remains regarding the fact that survivors of childhood cancer are at an increased risk for bone-related morbidity, and many do not meet behavioral recommendations for promoting healthy bone development [5
]. Compounding this problem is that the evidence-base for behavioral interventions targeting bone health behaviors among adolescent survivors of childhood cancer remains scarce [20
]. Our study examined the immediate efficacy of the Survivor Health and Resilience Education (SHARE) Program, a health-promoting multiple behavior change counseling intervention for adolescent survivors of childhood cancer, on improving their bone health behaviors. To our knowledge, this is among the first studies to do so in this special population. The findings indicate that the group-based intervention was efficacious in improving self-reported milk consumption frequency, calcium supplementation, and dietary calcium intake at 1-month follow-up. The results point to potentially fruitful areas of future research.
An interim evaluation of SHARE indicated intervention participants found the group-based format to be relevant, understandable, beneficial, and acceptable [22
]. Our findings add to the evidence supporting the program’s approach, suggesting it is not only well-received within the target population, but that it also represents an efficacious approach to bone health behavior improvement. Nevertheless, practical factors limited participation by some teens. Those who lived farther away from the intervention site were more difficult to engage, possibly due to travel and other logistical barriers [22
]. Indeed, recent research suggests cancer survivors may readily accept distance-based approaches to behavioral intervention, further reducing barriers to in-person engagement [12
In order to expand the reach and impact of such interventions within this population, additional work examining strategies to lower barriers among teens is warranted, especially those teens that were more difficult to reach in SHARE [12
]. For instance, intervention approaches applying interactive communication technologies, such as the Internet and wireless mobile technology, could improve program reach and impact [22
]. Additional intervention approaches that reduce barriers to participation, such as offering the intervention in multiple geographic locations within the community, may also improve program reach.
After accounting for change in theoretical predictors of bone health and baseline dietary calcium intake, dietary calcium intake was significantly greater 1-month post-intervention among intervention participants, compared with control participants. Though we did not use an objective measure of bone health (i.e., bone density scan) to examine bone health outcomes, it is unlikely that short-term changes in bone density would be observable. However, our findings do suggest the intervention appears promising in moving participants toward that direction. Peak bone density is typically achieved at levels of daily calcium intake between 1200 – 1500 mg in children [18
]; participants in the intervention were, on average, within this critical range at 1-month post-intervention. In addition, dietary protein and calcium have been found to interact to affect bone density: when both protein and calcium are consumed at recommended levels, a positive net impact on bone density has been observed among young adult females [38
]. Milk contains both protein and calcium, and the fact that the intervention improved calcium supplementation and increased milk consumption may lead to such effects if sustained over time [38
While we are only able to draw conclusions regarding immediate post-intervention behavior change, prior work suggests long-term outcomes among cancer survivors are achievable [11
]. Among young survivors, there is evidence suggesting health behavior interventions can produce sustained outcomes up to 12-months [39
], and that young survivors are interested in improving their diets, physical activity levels, and lifestyle-related risk factors [12
]. Whether or not a full complement of such changes is possible or durable in the long-term remains to be seen.
Ensuring that cancer survivors receive optimum risk-based medical care is critical to prevent cancer late-effect morbidities among survivors [3
]. Optimum risk-based care entails systematic planning for lifelong screening, surveillance, and prevention of cancer late-effects among survivors of childhood cancer that considers risks based on previous cancer type, cancer therapy, genetic predispositions, lifestyle behaviors, and comorbid conditions [5
]. Encouraging a healthy lifestyle among survivors of pediatric cancer is essential to optimum risk-based care and prevention [3
]. Moreover, it is important that risk-based care addresses individual-level survivor-related factors, including knowledge, self-efficacy, and motivation necessary to engage in a healthy lifestyle and address behavioral factors contributing to cancer late-effects [3
These issues are central to SHARE’s intervention approach, which includes directed health behavior changes that could be integrated into optimum risk-based care for survivors of pediatric malignancies. The ideal time at which to deliver health behavior interventions among cancer survivors has not been firmly established [3
]. However, age-appropriate recommendations and approaches should be integrated across the continuum of cancer care to encourage young survivors to take increasing responsibility for their health and healthcare. Future research is needed to examine how health behavior interventions such as the SHARE Program can be best integrated into long-term care to achieve this purpose.
Our findings should be interpreted in light of important study limitations, including the sample size and homogeneity, the immediate follow-up period, self-report methods of assessment, and limited reach. In particular, the fact that we relied on self-reported measures of bone health behavior, some of which were developed for this research and were not previously well-established psychometrically, is an important limitation. Future work can improve on this by including more diverse, randomly-selected samples to address generalizability of findings, and utilizing multi-dimensional, multi-modal assessments to strengthen study measures. In addition, research is needed to establish the reliability and validity of self-reported behavioral assessments for milk consumption frequency and calcium supplementation used in this study. Our cursory observation associating it with 24-hour recall calcium consumption data is encouraging, but limited. Research is also needed over longer follow-up periods to examine the durability of the intervention. Objective measures of bone density (i.e., bone density scans) may be important to pursue, along with more systematic comparisons among active treatment components (i.e., education, behavioral counseling, calcium supplementation) to discern those with maximal effect. Finally, research exploring alternative intervention modalities that address barriers to participation within this population appears warranted.
The limitations of this small-scale study notwithstanding, the findings suggest the multi-component, manualized SHARE Program intervention was efficacious in producing short-term improvements in milk consumption frequency, calcium supplementation, and dietary calcium intake at 1-month follow-up among pediatric cancer survivors. Health behavior and health education interventions appear useful in promoting good bone health habits among young cancer survivors, possibly preventing and controlling the onset of osteoporosis and related late-effects.