Survivors of childhood cancer in developed nations are an exponentially growing population, with a substantial risk of long-term morbidity or premature mortality because of cancer treatment.1,2 As well as the risk of cancer recurrence and secondary cancers, which is significantly higher than population norms, the risk of late effects from anticancer treatment manifest as numerous chronic diseases including endocrine, cardiac, musculoskeletal, neurosensory, and renal disorders.1,3,4 Survivors of childhood cancer are estimated to be 10 times more likely to experience chronic diseases than their counterparts.5 Despite this, cancer is treated as an acute condition, with little integration with community health and primary care systems.6, 7, 8 Consequently, cancer services around the world are grappling with how to best care for the growing number of young cancer survivors in need of support, while constrained by ever-rising pressures on resources.9,10

Although the existing medical model of surveillance for cancer recurrence is supported by evidence-based guidelines and recommendations,3,7,11 the focus on disease neglects the psychological and social effects of cancer and cancer treatment in young people at a vulnerable age. Research highlights that 50% to 80% of young cancer survivors do not attend long-term follow-up,12,13 suggesting that services do not meet needs. Moreover, this model neglects the role of health behaviors, which are modifiable and amenable to intervention, in reducing the risk of both second cancers and chronic disease. As young people have a long time to live with the consequences of cancer, it is imperative to identify effective ways to resource and provide holistic survivorship care.14 Alternative models are proposed such as the inclusion of primary care physicians15 and community-based services that address broader aspects of physical, social, and psychological health, advocating for self-management.16,17 However, there is scant evidence to inform service development of such models and little understanding of what outcomes to evaluate to determine the effects of survivorship care. Without such evidence, it remains unclear who, what, when, where, and why services should be provided to the growing number of survivors of childhood cancer.14

To inform the development of a community-based model of cancer survivorship care, understanding the relationships between potential outcomes can help determine appropriate targets for intervention and evaluation.18 We previously explored the relationship between health self-efficacy, persistent symptoms, and quality of life in a pilot study of survivors of childhood cancer and identified that (1) an average of nine symptoms were experienced at moderate or higher intensity, (2) high symptom burden was associated with a lower overall quality of life, and (3) self-efficacy and quality of life were positively correlated (Fig. 1).19 These findings can be contextualized within Bandura's social-cognitive theory.20 This theory posits the dynamic and reciprocal influence between behaviors, the environment, and personal/cognitive factors, highlighting the importance of health behaviors. As such, we further hypothesize that health self-efficacy, an amenable determinant of health and lifestyle behaviors,21 has the potential to positively influence long-term health outcomes in childhood cancer survivors, making it a suitable target for future interventional studies and, subsequently, services.

Building on our previous work, in this secondary analysis of our pilot study, we include analysis of modifiable health behavior variables. Our primary aim was to assess the feasibility of study measures to inform a larger interventional study. This is important to ensure measures and processes are acceptable and appropriate to the target population.22 The secondary aims were to explore the reciprocal relationship between modifiable health behaviors and health self-efficacy, quality of life, and persistent symptoms in childhood cancer survivors (Fig. 1). Understanding these relationships would then inform the development of interventions to be delivered in the community-based model of cancer survivorship care and subsequent evaluation in a larger trial.