Body Mass Index, Physical Activity, and Subsequent Neoplasm Risk Among Childhood Cancer Survivors

Importance High body mass index (BMI) and low physical activity levels are risk factors for adult-onset cancers. Limited data exist on their relationship with subsequent neoplasms among childhood cancer survivors. Objective To evaluate associations between time-varying BMI/physical activity and subsequent neoplasm risk among childhood cancer survivors. Design, Setting, and Participants This retrospective cohort analysis included 5-year childhood cancer survivors diagnosed younger than 21 years of age between 1970 and 1999, enrolled in the Childhood Cancer Survivor Study (CCSS), with follow-up through September 2019 at pediatric tertiary care hospitals in the US and Canada. The data analysis was performed between March 2021 and July 2024. Exposures Self-reported time-varying BMI and maximum reported physical activity (metabolic equivalent of task h/wk [MET-h/wk]) before any subsequent neoplasm development; first assessed at cohort entry and up to 6 times thereafter. Main Outcomes and Measures Cumulative incidence by physical activity level and relative rates (RRs) by physical activity and time-varying BMI categories, adjusted for demographic and clinical variables, were estimated for any, subtype (hematologic, solid organ, central nervous system [CNS], skin), and specific (breast, thyroid, colorectal, meningioma) subsequent neoplasms using piecewise exponential models. Results Of 25 658 enrolled CCSS participants, 22 716 had BMI data before subsequent neoplasm development and met eligibility criteria for this study (46.3% female; median [range] attained age, 33.7 [5.7-67.3 years]). Among 22 716 survivors, 2554 subsequent neoplasms occurred among 2156 individuals (56.7% female; median [range] age at subsequent neoplasm diagnosis, 37.4 [13.7-63.3] years). Survivors reporting lower physical activity had higher 30-year subsequent neoplasm cumulative incidence: 18.6% (95% CI, 17.0-20.3) for 0 MET-h/wk vs 10.9% (95% CI, 9.9-12.1) for 15-21 MET-h/wk. Obese BMI was associated with increased incidence rates of solid organ (RR, 1.22; 95% CI, 1.01-1.46), CNS (RR, 1.47; 95% CI, 1.12-1.95), and skin (RR, 1.30; 95% CI, 1.13-1.50) subsequent neoplasms. Higher physical activity (15-21 MET-h/wk) demonstrated a protective association for any (RR, 0.61; 95% CI, 0.53-0.71), solid organ (RR, 0.65; 95% CI, 0.52-0.83), CNS (RR, 0.50; 95% CI, 0.35-0.70), and skin (RR, 0.72; 95% CI, 0.60-0.86) subsequent neoplasms. BMI and physical activity were specifically associated with subsequent meningiomas and thyroid carcinomas, but not with breast or colorectal cancers, nor hematologic subsequent neoplasms. Conclusions and Relevance Among childhood cancer survivors in this cohort study, obesity was associated with an increased risk for multiple subsequent neoplasm types, while higher physical activity was associated with reduced subsequent neoplasm risk. Lifestyle interventions should be considered in future subsequent neoplasm prevention research.