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Response to Reviewers Comments
In the following, the reviewers’ comments have been reproduced. Our responses follow each
comment. We have responded to all reviewer comments. Please note:
 Any text cited directly from the revised manuscript appears in quotation marks.
 Any additions or changes to the revised manuscript in response to reviewer
comments have been underlined here and in the marked manuscript.
Reviewer A
Comments to the author:
Positive comments (strengths):
This commentary is certainly very relevant and has important implication in improving
guidelines in advocating physical activities in cancer patients. Very good evidence is provided to
support the claims. The article flows very well.
Thank you for your review of our work and positive comments.
Major comments:
In the introduction please briefly comment on common types of cancers in adolescents.
This information has been added to the introduction and can be found on lines 14-16:
“Lymphomas, leukemias, germ cell tumours, central nervous system tumours, and
melanomas are the most prevalent cancers diagnosed in those individuals aged 15-19
years [1, 2].”
Line 17: Please provide a source for the definition of cancer survivor.
A citation has been added to support the definition of cancer survivor used, see lines 1720: “To assist this growing population of adolescent cancer survivors, (i.e., adolescents
who have been diagnosed with cancer, from the time of diagnosis onward; [5]), it is
important to recognize the unique challenges they may face.”
Line 23-24: Please provide examples of "serious, disabling, and/or life-threatening condition"
Examples of serious, disabling, and/or life-threatening conditions have been included. See
lines 39-42. It now reads: “In addition, it is estimated that 95% of young cancer survivors
will develop at least one chronic health condition by the age of 45 years, and 80% will
develop a serious, disabling, and/or life-threatening condition (e.g., pulmonary, cardiac,
organ dysfunctions, neurocognitive impairment) as a result of their treatments [11].”
Line 41: The use of the pronoun “we” was previously referring to the author’s work. Using this
pronoun in this context again causes confusion because this sentence is not an opinion but it
consists of cited facts.
Thank you for bringing this to our attention. The use of the pronoun “we” has been
removed. See lines 75-77. The section now reads: “Despite this, it is noted that adolescent
cancer survivors want information about physical activity [24], and are motived to make
positive lifestyle changes [25].”
Minor comments:
Line 14: Please add the word "cancer" between "in" and "treatment"
The word “cancer” has been added, lines 13-14: “Progress in cancer treatment protocols
offer hope for the 7,500 newly diagnosed adolescents living in North America each year
[1, 2].”
Line 23: Please provide statistics on what percentage of young cancer survivors make it to the
age of 45 to put things in perspective.
While we agree that providing a statistics indicating the percentage of young cancer
survivors who make it to 45 would be useful, unfortunately we could not find any published
data on this. At present, there are only data available for the 5-year survival rates. We
have added a statement (and citations) in the introduction for these rates. Please see lines
16-17: “Fortunately, recent survival estimates show that 80% will live for at least 5 years
after their cancer is diagnosed [3, 4].”
Line 24: Please briefly comment on the type of treatments applicable to adolescent cancer
patients
We have included the common treatments beforehand. Please see lines 35-37: “Indeed,
many adolescent cancer survivors experience a host of adverse physical (e.g., impaired
muscular strength, reduced aerobic capacity, fatigue, pain), psychological/emotional (e.g.,
increased anxiety, depression, fear of recurrence, mood disturbances), and social side
effects (e.g., social isolation, poor peer relations, failure to achieve independence) as a
result of their treatment regimens (which may include a combination of surgery,
chemotherapy, radiation, and/or hematopoietic stem cell transplant) [8-10].”
Line 37: Use the citation without “(e.g.)”
We have removed the “e.g.” in the citation.
Line 38: Does "treatment" in this case refer to surgery, chemotherapy, radiation or all three?
The word “treatment” in this case refers to all possible treatments. We have revised this
section. See lines 55-58: “In our own work, we advocate for the use of physical activity as
a self-management strategy to help adolescent cancer survivors address the negative side
effects associated with the disease and its treatments, as well as help them enhance their
health and quality of life throughout survivorship.”
Together, with the information we have provided regarding treatments earlier in the
introduction, we hope we have adequately addressed your comment. Please see lines 3537: “…as a result of their treatment regimens (which may include a combination of
surgery, chemotherapy, radiation, and/or hematopoietic stem cell transplant) [8-10].”
Line 39: For the "recent study", please indicate the geographical setting (Canada, North America,
etc.)
We have specified the geographical setting (i.e., America), lines 69-71: “In fact, a recent
study found that 65% of child and adolescent cancer survivors living in America were not
meeting guidelines that recommend they do at least 60 minutes of physical activity daily
[20].”
Line 55: Citation is needed at the end of the sentence. Also, please indicate whether this is
happening in Canada or elsewhere.
Lines 94-95, a citation and geographical location have been added: “Unfortunately, many
adolescent cancer survivors living in North America are not receiving such
counselling/advice [24, 29].”
Line 68: Since reviewers don't have access to the cited article, did the authors only used
controlled trials in their systematic review?
We reviewed randomized controlled trials and controlled clinical trials. This information
has been added to the manuscript, lines 122-125: “For example, we have synthesized the
best available evidence from randomized controlled trials and controlled clinical trials
exploring the effects of physical activity on health and quality of life outcomes with
adolescent cancer survivors.”
Line 84: Please Omit the sentence with the website address.
The sentence was removed.
Reviewer B
Comments to the author:
Positive comments (strengths):
Interesting topic. Great point that cancer survivors are often in front of MDs so this is the prime
time for counselling on physical activity.
Thank you for your review of our work and positive comments.
Major comments:
Starting at line 67, you talk about how you've synthesized evidence from controlled trials and
that "these findings will be published", but then you don't really talk about what you found. It
would be a perfect opportunity, here, to explain what your recommendations are, in conjunction
with the University of Calgary and CSEP. You talk about people summarizing guidelines, so
why not add a paragraph or two on the findings? More should be added about what you've found,
and your recommendations, since you seem to be heavily invested in the topic; your opinion is
valuable.
We have taken this comment into consideration and have expanded this section to discuss
briefly the main findings from our review. Please see lines 125-132: “In our review, one
randomized controlled trial and three controlled clinical trials met our inclusion criteria,
which points to the lack of literature in this area. Consequently, we are unable to
determine whether physical activity has an effect on health and quality of life for
adolescent cancer survivors given the very limited data and methodological limitations of
the reviewed studies. Despite this, the studies included in our review found physical
activity to be both safe and feasible. These findings are important as they may alleviate any
concerns healthcare providers may have about the potential harm of physical activity
during and after treatment for adolescent cancer survivors.”
As well, at the end of this section, we expanded on our recommendations, in conjunction
with the University of Calgary, the American College of Sports Medicine, and CSEP. See
lines 155-168: “Considering the current body of knowledge on the benefits of physical
activity for cancer survivors and existing physical activity guidelines and resources, it is
clear that adolescent cancer survivors can and should be engaging in physical activity.
Special consideration should be taken with survivors on- and off-treatment, including
carefully considering contraindications and comorbidities that could interfere with the
ability of cancer survivors to perform physical activity (e.g., avascular necrosis,
pulmonary disease, neurological problems, general performance limitations; [40, 36]).
Further, healthcare providers should take into account adolescents’ past physical activity
patterns, current levels of physical fitness, and activity preferences when recommending
physical activity. They should also consider referring their patients to physical activity
specialists (preferably specialists who have received training in cancer rehabilitation) [3639]. Moving forward, the goal is to ensure healthcare providers use existing and emergent
information and resources as tools for making physical activity recommendations for their
patients, and incorporate physical activity counselling into routine preventive and
rehabilitative cancer care.”
Minor comments:
Might want to add in a comparison between non-cancer survivors and their compliance with
physical activity. I wouldn't be surprised if it was around 65% as well. It would be an interesting
comparison.
Thank you for this suggestion. We have provided data from a recent review exploring
physical activity rates in adult survivors of child or adolescent cancers as compared to
non-cancer controls within the same studies (note: there are no studies comparing
adolescent cancer survivors and non-cancer controls). See lines 71-73: “As well, a recent
review suggests adult survivors of child or adolescent cancers were less active than noncancer controls [21].” However, we do not feel it is appropriate to compare compliance
rates of separate studies because different physical activity measures are used in studies
with cancer survivors and non-cancer controls, which do not allow for direct comparisons.
Reviewer C
Comments to the author:
Positive comments (strengths):
Overall, the manuscript is clearly formatted lending to reader comprehension and clarity. Points
of discussion are organized in a way that tells a story (again ensuring the reader is captivated
from beginning to end). Finally, (since submitted as a commentary) it is good to see the author(s)
draw from personal experience/opinion when discussing current plans for knowledge translation.
Thank you for your review of our work and positive comments.
Major comments:
Line 23-25: Elaborate on these health conditions (i.e. how might these be avoided/controlled by
regular exercise?)
Because we explain the benefits associated with physical activity on some of the health
conditions faced by adolescent cancer survivors in the Physical Activity as a SelfManagement Strategy section, we have chose not to elaborate on these here to avoid
repetition and because of word limit. Nonetheless, as per your suggestion below, we have
elaborated on the benefits, lines 58-65: “Our focus on physical activity is based on the
mounting evidence that physical activity can improve physical (e.g., muscular strength,
aerobic fitness, fatigue, cancer-specific concerns), psychological (e.g., quality of life,
depression, anxiety, self-esteem), and social health (e.g., social support, social isolation)
among cancer survivors across the lifespan [14, 15]. It is also based on evidence that
physical activity may help to reduce the risk of several health conditions, such as cancer
recurrence, co-morbidities (e.g., obesity, cardiovascular disease, second cancers, organ
dysfunctions, neurocognitive impairment), and premature [15-18].”
Line 26: Premature death due to cancer re-emergence? Treatment side-effects? Clarify.
We have clarified this and it now reads: “As well, cancer survivors are 8.4 times more
likely to die five years after their diagnosis compared to their healthy peers mostly because
of recurrence and disease progression (57.5% of deaths) [12]. Subsequent cancers (18.6%
of deaths) and diseases of the circulatory (6.9% of deaths) and respiratory systems (2.6%
of deaths) are also contributors to mortality [12].” Lines 43-47.
Section "Physical activity as a Self-Management Strategy": elaborate on what benefits regular
exercise may convey to an adolescent cancer survivor
We have elaborated on the benefits regular physical activity may confer. Please see lines
58-65: “Our focus on physical activity is based on the mounting evidence that physical
activity can improve physical (e.g., muscular strength, aerobic fitness, fatigue, cancerspecific concerns), psychological (e.g., quality of life, depression, anxiety, self-esteem),
and social health (e.g., social support, social isolation) among cancer survivors across the
lifespan [14, 15]. It is also based on evidence that physical activity may help to reduce the
risk of several health conditions, such as cancer recurrence, co-morbidities (e.g., obesity,
cardiovascular disease, second cancers, organ dysfunctions, neurocognitive impairment),
and premature mortality [15-18].”
Section "Healthcare providers as physical activity advocates": This point of discussion focuses
on the close interactions between adolescent individuals and their healthcare providers.
However, supporting argument as to why necessary counselling is insufficient/lacking refers
directly to adult cancer populations. While believable in terms of information presented, the tie
between adult and adolescent cancer survivors is lacking.
Thank you for bringing this to our attention. In the revised manuscript we have highlighted
the role of healthcare providers for adolescents specifically. Please see lines 82-94:
“Given adolescent cancer survivors experience close contact with their healthcare team
during treatment and into survivorship, healthcare providers are in a key position to
influence their patients’ lifestyle behaviours through counselling. For instance, by
conveying information about the importance of physical activity and prescribing it during
clinic visits, adolescent cancer survivors may be more inclined to participate in it. Based
on a recent systematic review, physical activity counselling effectively enhanced physical
activity participation [26]. Although this conclusion is based on studies conducted with
disease-free sedentary youth and adults [26], it points to the potential value of physical
activity counselling in the cancer setting. Moreover, emerging research performed with
adult cancer populations has found that physical activity counselling led by healthcare
providers is effective at increasing participation [27]. Considering that as many as 75% of
adolescents agree with the statement “If my doctor told me to exercise I would do so”
[28], physical activity counselling is likely to be effective in this population as well.”
Additionally, we have added information to the paragraph outlining key barriers to
physical activity counselling in pediatric cancer populations. Please see 100-102:”In a
similar vein, key barriers to physical activity counselling in pediatric cancer populations
include a lack of knowledge and resources, as well as a belief that patients do not adhere
to physical activity recommendations [31].”
Presumably these populations (adolescent vs. adult) differ in terms of appropriate approaches to
counselling and knowledge translation. Perhaps elaborate on these differences (if present), and
how they may be approached by healthcare practitioners in order to "flesh out" this section.
There are too few studies on this topic to determine if adolescents and adults differ in
terms of their responses to counselling and knowledge translation initiatives. Thus,
elaborating on these differences would be purely speculative. That said, based on your
comment, we have added a paragraph outlining age-appropriate recommendations for
counselling. Please see lines 107-117: “Recent recommendations by the National
Comprehensive Cancer Network urge healthcare providers to give physical activity
information to their adolescent and young adult cancer patients [32]. However, there are
special age-appropriate considerations that should be taken into account. In recognition of
adolescents’ growing desire to be independent from their parents, every effort should be
made to ensure that physical activity counselling is delivered to adolescent cancer
survivors in a manner that is supportive, rather than controlling [33, 34]. Specifically,
efforts should be made to counsel adolescent cancer survivors in a respectful, positive,
non-judgemental way, and frame it as what they can do, versus what they cannot do [33,
34]. Further, while some adolescents may be accompanied by their parents/guardians,
care should be taken to give information directly to adolescents [35], so as to ensure that
they feel more involved and in control of their care.”
Section "Translating the Evidence: Plans for Action and Existing Resources": Line 66-67, Which
groups are responsible for these projects, and what approaches are being taken? Citations?
We have added the citations. Please see lines 120-122: “To ensure healthcare providers
have the knowledge needed to provide regular physical activity counselling to their
patients, several groups are undertaking knowledge synthesis and resource development
projects to ensure that knowledge is translated into practice [36-39].”
Following discussion (Lines 76-94) is well written, but could be alluded to in more detail in this
sections' intro paragraph in order to better introduce the reader to the work that has currently
been done.
We have provided examples of the types of projects being undertaken in the introductory
paragraph of this section. Please see lines 120-122: “To ensure healthcare providers have
the knowledge needed to provide regular physical activity counselling to their patients,
several groups are undertaking knowledge synthesis and resource development projects to
ensure that knowledge is translated into practice [36-39].”
Section "Translating the Evidence: Plans for Action and Existing Resources": Line 68-70,
provided synopsis of these findings (i.e. How do they provide evidence for the benefits of
physical activity)
We have added information regarding our findings, and how they provide evidence for
physical activity in adolescents, as well as lend themselves to promoting physical activity
in this population. Please see lines 125-132: “In our review, one randomized controlled
trial and three controlled clinical trials met our inclusion criteria, which points to the lack
of literature in this area. Consequently, we are unable to determine whether physical
activity has an effect on health and quality of life for adolescent cancer survivors given the
very limited data and methodological limitations of the reviewed studies. Despite this, the
studies included in our review found physical activity to be both safe and feasible. These
findings are important as they may alleviate concerns healthcare providers have about the
potential harm of physical activity during and after treatment for adolescent cancer
survivors.”
Section "Translating the Evidence: Plans for Action and Existing Resources": Line 90-91, Have
referral systems proven successful in providing cancer survivors with accurate and safe exercise
advice, and how long have such systems been in place? Do problems, either due to patient non-
compliance or avoidance of such systems by healthcare professionals, exist, and how may these
be addressed?
While this is an excellent comment/question, addressing it is outside of the scope of this
manuscript. Further, there is a general lack of referral systems or referral for physical
activity for cancer survivors (unlike other clinical populations such as those with
cardiovascular diseases). Thus, it is not possible to answer your questions at this time.
Remaining questions to be (possibly) addressed:
How can a regular exercise regime be modified to suit an adolescence cancer survivor,
considering the barriers these individuals face? Perhaps outline these "barriers" to better prove to
the reader that this knowledge translation to cancer survivors is more challenging than that to the
regular healthy person.
Physical activity programs can be modified to suit an adolescent cancer survivor
(considering their barriers). This modification/tailoring must be done on an individualized
basis and is outside of the scope of our commentary. That said, in an effort to address the
latter part of your question/comment regarding the unique barriers adolescents may face
and special considerations that need to be taken into account when working with this
population, we have added information to the Introduction and Physical Activity as a SelfManagement Strategy sections.
Please see lines 22-31: “Adolescence is a complex life stage with developmental demands
that differ from those experienced during childhood and adulthood. Significant physical
(e.g., changing body weight, shape, and height, undergoing sexual maturation), cognitive
(e.g., developing capacity for higher-level thinking and mature decision-making),
psychological/emotional (e.g., creating a coherent sense of self, learning to cope with
stress and manage emotions), and social challenges and changes (e.g., establishing greater
independence from parents/guardians, strengthening bonds with peers, developing a social
identity) characterize this phase in life [6]. As such, a diagnosis of cancer during
adolescence, may be particularly damaging as it can interrupt boys and girls’ healthy
development and thwart their ability to cope with physical, cognitive,
psychological/emotional, and social challenges [7].”
Further, please see lines 73-75: “These low rates may be due to the additional cancerrelated barriers to physical activity experienced by adolescent cancer survivors, such as
short- and long-term side effects, physical deconditioning, and overprotective attitudes of
caregivers [22, 23].”
Minor comments:
Minor grammatical errors:
Line 5-6: "Despite the known benefits of physical activity, the majority of young cancer
survivors not meeting recommended guidelines."
The word “are” has been added to this sentence, lines 4-5: “Despite its critical
importance, the majority of young cancer survivors are not meeting recommended physical
activity guidelines.”
Line 50-51: "in healthcare settings enhanced physical activity participation disease-free
sedentary youth and adults"
This section has been re-worked and as a result, is no longer worded as such. Please see
lines 86-89: “Based on a recent systematic review, physical activity counselling may
effectively enhance physical activity participation [26]. Although this conclusion is based
on studies conducted with disease-free sedentary youth and adults [26], it points to the
potential value of physical activity counselling in the cancer setting.”