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Background Leukaemia is the most common cancer in children with 800 diagnoses per year in England. To survive, children need strong treatments like chemotherapy and steroids given usually through clinical trials. The current trial used by the NHS is called ALLTogether. Fifty percent of children become obese during treatment due to increased hunger, cravings for junk foods and lack of physical activity. Obesity raises the chance of cancer relapse by 31%, makes treatment side-effects worse and makes it harder to kill off leukaemia cells, which affects how well children do during treatment, as indicated by minimal residual disease, a key predictor of prognosis.
Aims and Objectives This study (called BREVARY) aims to see if we can successfully provide personalised diet and physical activity with behaviour support for children and young people with leukaemia who are being treated with the ALLTogether trial. It will help us figure out if we can perform a bigger study, if this programme could reduce obesity and side-effects and improve survival and wellbeing.
How it will be done We plan to randomly assign participants to one of three groups; one group will get both a diet and physical activity plan, another will get only a diet plan, and the last group will receive standard care. This will take place in Hospital Infantil Universitario Nino Jesus, Madrid and Bristol Royal Hospital for Children and Southwest England NHS-sites. The diet and exercise plans will be created in partnership with the children and their families and delivered online or during regular hospital visits. The diet will follow healthy eating guidelines, consider personal food preferences (including cultural and religious needs), treatment side-effects and personal finances. Assessments of fitness and strength will be taken to plan personalised activities. During the study, the following data will also be collected: weight, height, body fat, diet, biomarkers, microbiome, muscle strength and wellbeing at three different times. "One to one" interviews will be conducted at the end to obtain feedback on their experiences with BREVARY.
This study aims to find out if children and their families/carers are willing to participate in BREVARY, if enough people sign up and stay until the end and if our interventions and health measurements are appropriate.
Potential Impact The results will help determine if a larger study can be performed, if changes are needed and what the cost will be. The study will be disseminated through networks, targeting underserved communities, healthcare professionals and affected families using accessible platforms to spread the word.
The international randomised controlled trial registry shows that no lifestyle intervention (diet, physical activity with integrated counselling) has been performed in the UK. The IDEAL trial performed in the USA demonstrated that diet with energy intake restriction and physical activity was feasible and significantly improved Minimal Residual Disease (MRD) in children diagnosed with Acute lymphoblastic leukaemia (CYP_ALL) and treated with National Cancer Institute/Rome high-risk B-ALL protocol during induction. ALLTogether is similar and will for the first time provide an excellent platform to prevent obesity in CYP_ALL.
Obesity associated relapse is attributed to adipocyte-mediated chemo-resistance, which occurs in CYP_ALL with higher fat mass and leads to more persistent MRD. MRD is a marker of leukaemic cells and the strongest predictor of prognosis including both remission and relapse. Therefore, obesity is identified as a prognostic factor for relapse (measured by MRD) and it is associated with increased morbidity and mortality, and poorer wellbeing.
Only two dietary feasibility interventions have investigated CYP_ALL differing in the type (diet alone vs. diet and physical activity) and the length of intervention (1 - 6 months). Both showed improvements in diet quality, high participation (>70%) and 56 - 82% adherence. Indeed, the IDEAL trial also showed improvements in MRD and body composition, making it suitable to base BREVARY's design. Consensus exists regarding using patient-centre interventions in clinical settings; like the Individualised Macronutrient Meal-Equivalent Menu (Menus). This approach reduces food associated stress, anxiety and financial costs, while empowering patients and their families/carers, thus improving adherence. It has been shown to be successful in adults with breast cancer and provides a validated approach to CYP_ALL.
A systematic review showed that individualised physical activity combining fitness and strength mitigated complications in CYP_ALL. However, it was difficult to draw firm conclusions because evidence were limited by sample sizes, adherence was seldom reported and study designs were heterogenous differing in length (1 - 30 months), exercise type and intensity and assessed outcomes (e.g. cardiorespiratory fitness, strength and wellbeing). Six trials are underway including all cancers with interventions being either individualised ("as able" and play-based exercise for children aged <5 years) or employing generic exercise prescriptions with intensity "as able". They are investigating fitness, strength and wellbeing; however, none have incorporated dietary assessment or intervention.
4. Research proposal
Aim
Investigate the feasibility of conducting a randomised controlled trial (RCT) to prevent obesity in CYP_ALL and treated with ALLTogether.
The hypothesis is that BREVARY will reduce obesity rates, improve clinical outcomes by reducing side-effects and relapse and improving CYP_ALL and their families/carers' quality of life. BREVARY will establish if a multi-site RCT is feasible and acceptable to families and clinical teams, examine recruitment and data collection strategies, and assess candidate outcomes.
BREVARY comprises three workstreams (WS):
WS1: Implementing a RCT of BREVARY for 3 months involving newly diagnosed CYP_ALL treated with ALLTogether in SW England NHS-sites and Hospital Infantil Universitario Nino Jesus Madrid WS2: Process evaluation of BREVARY RCT examining feasibility and maintenance of intervention (3 months intervention, maintenance at 6 months) WS3: Assessment of feasibility of progression to a definitive trial, including setting trial parameters
Objectives
Project plan
WS1: Implementing BREVARY
Study design BREVARY is phase 2 of Medical Research Council framework for complex interventions. Development and identification of the complex intervention (phase 1) was performed based on the IDEAL pilot-trial. BREVARY was designed in consultation with NIHR Nutrition and Cancer and PPI, reviewed by NIHR RSS and is supported by ALLTogether sponsors (UK and Spain).
Feasibility three-arm non-blinded parallel RCT with integrated quantitative and qualitative measures. Quantitative measures will be performed at baseline, end of induction (4 - 6 weeks) and during consolidation treatment (3 months weeks) and a follow up at 6 months. Qualitative measures will be performed at the end of BREVARY in a sample subgroup. The three-arms include combined diet and physical activity, diet only and standard care.
Recruitment Recruitment will be conducted by researchers. Inclusion criteria
Eligible participants will be randomised using computer-generated restricted (nutritional status, age and sex) randomisation procedure in 1:1:1 ratio.
BREVARY Intervention (table 1)
Twenty % energy deficit and equicaloric intervention will be applied to those classified as overweight/obese and healthy weight respectively by diet (- 20%).
Researchers will deliver weekly one-to-one supervised sessions during induction and fortnightly during consolidation (total 8 sessions) online/home or at routine appointments. Physical activity intervention will include two additional sessions supervised non-consecutive sessions as tolerated. Both designed following PPI preferences.
Dietary intervention Menus based on Eatwell guide in the UK and Food and Agriculture Organisation in Spain will be used. Menus consists of prescribing 7 interchangeable meal options matched in energy and macronutrients requirements to reduce participants meal planning burden. It accounts for side-effects, psycho-social factors and religious, cultural, personal (and PPI) preferences. Nutritics® will be used to create Menus and estimate nutrients.
CYP_ALL referred to Dietetics will receive the intervention post-Dietetic discharged to avoid interference with nutritional support.
Physical activity intervention Individualised plans will be prescribed based on fitness and clinical condition. The programme will start at enrolment unless contraindicated. Sessions will include a combination of aerobic, balance and resistance exercise based on individual fitness and strength, age and clinical history as well as individual preferences and available equipment.
Standard care CYP_ALL will receive usual care (described in "The problem"). Counselling sessions for CYP_ALL and families/carers (all groups) Counselling sessions were requested by PPI and are recommended for motivation and adherence in long-term clinical interventions.
Two online/home (or at routine appointments) one-to-one sessions will be delivered. Sessions will be designed by all co-applicants, reviewed by our clinical psychologist and delivered by the researchers with PPI CoA support and focusing on:
(i) Diet and physical activity benefits (ii) Behaviour and autonomy (iii) Difficulties encountered and how to address them (iv) Motivation Data collection (all groups)
Health Electronic Records (HER) will be accessed to collect demographics (CYP_ALL sex, ethnicity and age), socio-economics (parents' relationship status, siblings, employment status, education level, income and housing status), clinical (diagnosis, treatments, side-effects, hospital admissions), routine biomarkers (MRD, immunoglobulins, full blood count, total cholesterol, high density lipoprotein and low density lipoprotein and glucose) and other biomarkers (leptin and adiponectin) and stool samples (microbiome). Participants' postcodes will be linked to the Indices of Multiple Deprivation.
Based on the IDEAL trial, feasibility and acceptability and PPI feedback, the following outcome measures will be taken at baseline, 4 - 6 weeks, 3 months and a follow up at 6 months (to assess intervention sustainability - no intervention from 3 - 6 months).
We will determine primary and secondary candidate outcome measures for future trial based on performance of selected measures.
Candidate primary outcome measures for definitive trial
Analysis CONSORT flow diagram will be used to report participant flow and descriptive statistics for demographics, clinical and socio-economic data with overall data and stratified by arm. Appropriate distribution or frequencies will be used (count/percentages, mean/SD and median/IQR). IBM_SPSS statistics® will be used for analysis and a Statistical Analysis Plan will be signed-off prior to any analysis taking place.
WS2: Process evaluation The process evaluation assesses how implementation of BREVARY is achieved, influenced by contextual factors including randomisation and trial design, and quality of implementation and acceptability. The following stakeholders will be included: Parents/carers whose CYP_ALL partake in BREVARY, CYP_ALL able to understand the questions and communicate an answer and researchers plus NHS-staff directly involved in implementing BREVARY. RE-AIM (http://www.re-aim.org/) based on reach, effectiveness, adoption, implementation and maintenance will be used.
Semi-structured one-to-one online (or at routine appointment) interviews will be conducted to a subgroup (n = 15) with equal representation from each arm to explore enjoyment:
Analysis Quantitative survey data will be analysed using descriptive statistics. Free text responses will be analysed using thematic analysis and audio recordings will be transcribed, anonymised and data analysed using thematic analysis in Nvivo®.
Fidelity: Intervention delivery (usage statistics), receipt (usage statistics and interviews) and enactment (interviews, questionnaires and measurements) as well as repeated engagement (usage statistics and counselling sessions) will be conducted separately. Findings will be integrated following a triangulation protocol to assess whether data agree (convergence), complement one another (complementary), or contradict each other (dissonance).
WS3: Progression criteria and definitive RCT design
Results from WS1 and WS2 will be reviewed by all co-applicants. A trial will be regarded feasible if the following criteria are met:
Progression criteria and definitive RCT design
Health economics Within-trial economic and resource use analysis based on complex intervention protocols will be used. This reduces participants' burden and meets PPI feedback.
The within-trial analysis will investigate the cost-effectiveness of each arm. The primary within-trial analysis used in the full trial will be a cost-utility-analysis (CUA), which estimates the incremental cost per quality adjusted life (QALY) of each arm. QALY will be generated via measurement of utility values using PedsQL-cancer and Parents PedQL-Cancer instrument mapped to the EQ-5D.
The resource use analysis will be estimated using HER. Data (e.g. admissions, medication) will be collected by researchers. A cost-consequences framework will be used to describe resources used and benefits gained from the intervention without developing a full cost-effectiveness estimate.
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| Label | Type | Description | Intervention Names |
|---|---|---|---|
| Diet | Experimental | Individualised Dietary Intervention |
|
| Diet and Physical Activity | Experimental | Individualised Dietary and Physical Activity Intervention |
|
| Standard Care | No Intervention | No intervention - this is standard care |
| Name | Type | Description | Arm Group Labels | Other Names |
|---|---|---|---|---|
| Diet | Behavioral | Individualised dietary intervention |
| |
| Diet and physical activity |
| Measure | Description | Time Frame |
|---|---|---|
| Minimal Residual Disease | Candidate Primary Outcome (feasibility study). Hospital own's laboratory assay | initial assessment, day 29, day 50 and day 78 |
| Muscle and fat mass | Candidate primary outcome, Multifrequency BIA FFM and FM percentage Impedance Reactant | Initial assessment, at 29 days, at 3 months, at 6 months |
| Body Mass Index Z score | Candidate Primary Outcome Calculated from weight and height (weight/height^2) WHO BMI Z score (scale score) Z-Score Range Nutritional Status < -3 SD: Severe undernutrition (Severely underweight, stunted, or wasted)
| initial assessment, at day 29, at 3 months and at 6 months |
| Quality of Life | Candidate Primary outcome (Quality of Life: PedQL-Cancer Module questionnaire) The PedsQL-Cancer Module includes multiple subscales that address specific areas of functioning and challenges related to cancer, such as: Pain and hurt, Nausea, Procedural anxiety, Treatment anxiety, Worry, Cognitive problems, Perceived physical appearance, Communication. To calculate scores, the items are reverse scored and linearly transformed to a Original Response Reverse Score (Transformed Score) 0 = Never 100
Scores are reverse, thus higher scores indicate better health-related quality of life or fewer reported problems. Mean scores are calculated for each subscale by summing the item scores and dividing by the number of items answered. If more than 50% of the items in a subscale are missing, the subscale score is not computed. | initial assessment, at 3 months and at 6 months |
| Parent's quality of life |
| Measure | Description | Time Frame |
|---|---|---|
| Leptin | Candidate secondary outcomes for future RCT: leptin (abcam assay) | Initial assessment, at day 29, at 3 months and at 6 months |
| Food group indicators and nutrient intake | Candidate Secondary Outcome for RCT multiple pass 24-hour recall Food groups (Eatwell Guide and A healthy eating index score (HEI)) Macronutrients and micronutrients (analysed in Nutritics) compared to UK Dietary Recommended Daily Intake (DRVs 1991, SANC 2011) and Spanish Ingestas Nutricionales de Referencia (AESAN 2019) |
| Measure | Description | Time Frame |
|---|---|---|
| Characterisation of gut microbiome: Diversity | Outcome from 16sRNA sequencing: alpha and beta bacteria. | At 0, day 29, 3 months and 6 months |
| Gut microbiome: Relative abundance | Relative abundances (comparison between groups: alpha and beta bacteria) |
Inclusion Criteria:
Exclusion Criteria:
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| Name | Role | Phone | Extension | |
|---|---|---|---|---|
| Raquel Revuelta Iniesta, PhD | Contact | 0044 07715303535 | r.revuelta-iniesta@exeter.ac.uk | |
| Raquel Fiuza Luces, PhD | Contact | 0034 658961509 | r.revuelta-iniesta@exeter.ac.uk |
| Name | Affiliation | Role |
|---|---|---|
| Raquel Revuelta Iniesta, PhD | University of Exeter | Study Chair |
| Carmen Fiuza Luces, PhD | Hospital 12 de Octubre Research Institute | Study Chair |
| Raquel Revuelta Iniesta, PhD |
| Facility | Status | City | State | ZIP | Country | Contacts |
|---|---|---|---|---|---|---|
| Hospital Infantil Universitario Nino Jesus | Madrid | Madrid | 28009 | Spain |
| PubMed Identifier | Type | Citation | Retractions |
|---|---|---|---|
| 24715604 | Background | Khan KA, Petrou S, Rivero-Arias O, Walters SJ, Boyle SE. Mapping EQ-5D utility scores from the PedsQL generic core scales. Pharmacoeconomics. 2014 Jul;32(7):693-706. doi: 10.1007/s40273-014-0153-y. | |
| 20851841 | Background | O'Cathain A, Murphy E, Nicholl J. Three techniques for integrating data in mixed methods studies. BMJ. 2010 Sep 17;341:c4587. doi: 10.1136/bmj.c4587. No abstract available. |
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| ID | Type | URL | Comment |
|---|---|---|---|
| Protocol and ethics can be shared on request | View IPD |
Given the sensitive nature of hospital patient data and the feasibility focus of your study, sharing individual participant data does not align with ethical guidelines, data protection regulations, and the consent provided by participants.
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Intervention: online or in hospital Diet: weekly one-to-one sessions for 4 weeks, then fortnightly (8 sessions total). Menus follow Eatwell guide/Food and Agriculture Organization with 20% energy deficit for overweight/obese and equicaloric for healthy weight.
Physical activity: one-to-one supervised sessions with two-three supervised non-consecutive sessions as tolerated and prescribed based on individual assessment.
Standard care: diet and physical activity information. Two counselling sessions (psychology) for motivation and adherence.
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It is not possible to mask the intervention - as it is diet and physical activity, diet alone or standard care
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| Behavioral |
Obesity prevention: Diet, Diet and physical activity and standard care |
|
Parents PedQL-Cancer he PedsQL Cancer Module - Parent Proxy Report is a specialized tool designed to assess health-related quality of life (HRQoL) in children and adolescents with cancer, based on the parent's perception. The Parent PedsQL Cancer Module includes the following subscales tailored to cancer-related challenges: Pain and Hurt, Nausea, Procedural Anxiety, Treatment Anxiety, Worry, Cognitive Problems, Perceived Physical Appearance, Communication To calculate scores, the items are reverse scored and linearly transformed to a 0-100 scale: 0 = 100; 1 = 75; 2 = 50; 3 = 25; 4 = 0 Higher scores indicate better health-related quality of life or fewer reported problems. |
| Initial assessment, at 3 months and at 6 months |
| Feasibility: Participation rate | The proportion of the target population that actually participates in the intervention measured in frequencies | Baseline, time 0 |
| Feasibility: Representativeness | The degree to which the participants reflect the broader population intended to benefit from the intervention. Outcome measure in percentages | At 0, day 29, 3 months and 6 months |
| Feasibility: Accessibility | Evaluates whether the intervention is accessible to all segments of the target population, including those who are typically underrepresented. Outcome measure in percentage | At 0, day 29, 3 months and 6 months |
| Feasibility: Barriers to participation | Identifies factors that prevent individuals from engaging with the intervention, such as lack of awareness, logistical issues, or cultural barriers. Outcome: qualitative | At 0, day 29, 3 months and 6 months |
| Feasibility: Effectiveness | The trial will be regarded feasible if the following criteria are met:
| At 0, day 29, 3 months and 6 months |
| Feasibility: Adoption | Settings: the proportion of settings that agree to implement the intervention. Outcome measured in percentage. | At 0, day 29, 3 months and 6 months |
| Feasibility: staff/provider adoption | The proportion and characteristics of researchers and healthcare staff who choose to deliver the intervention. Outcome in percentages | At 0, day 29, 3 months and 6 months |
| Feasibility: Barriers and facilitators: Qualitative | Identifies factors that help or hinder the willingness of organisations and individuals to adopt the intervention (e.g., cost, training requirements, organisational culture). Outcome: quaitative | At 0, day 29, 3 months and 6 months |
| Feasibility: Fidelity | Fidelity scores ranging from 0 to 100 (e.g., percentage of protocol elements followed) where 0 is nothing was followed and 100 everything was followed as originally planned. | At 0, day 29, 3 months and 6 months |
| Cost-effectiveness | Cost-utility analysis to evaluate the economic value of different interventions (or arms) by comparing their costs to their outcomes. This is based on quality-adjusted life in years. QALY will be generated via measurement of utility values using PedsQL-cancer and Parents PedQL-Cancer instrument mapped to the EQ-5D. Outcome: scale in pounds and euros. Total cost of control, cost of diet alone and cost of diet and physical activity | At 0, 3 months and 6 months |
| Initial assessment, at day 29, at 3 months and at 6 months |
| Physical activity levels min/day | Candidate secondary outcome for RCT GENEActiv accelerometers (min/day) 5 week days, 2 weekend days (minimum recorded 10 hours) | Initial assessment, at 3 months and at 6 months |
| Handgrip strength | Candidate secondary outcome for RCT hand-held hydraulic dynamometer | Initial assessment, at day 29, at 3 months and at 6 months |
| Fitness | 15-foot walk | Initial assessment, at day 29, at 3 months and at 6 months |
| Side-effects | Candidate Secondary Outcome for RCT: treatment side-effects, intervention arms side-effects, hospital admissions (and length), changes in treatment regime (ALLTogether) | Throughout the study (0 - 3 months), then again at 6 months |
| Gut microbiome composition | Characterisation of gut microbiome composition: α- and β-diversity, relative abundances (comparison between groups) 16sRNA sequencing | Initial assessment and 3 months |
| Adiponectin | Candidate secondary outcome for RCT, Abcam assay | Initial assessment, at day 29, at 3 months and at 6 months |
| Insulin | Candidate secondary outcome for RCT, Oxford Biosyste ELISA | Initial assessment, at day 29, at 3 months and at 6 months |
| Immunoglobulin A (IgA) | IgA (hospital owns assays) | Initial assessment, at day 29, at 3 months and at 6 months |
| Immunoglobulin G (IgG) | IgG - hospital own's laboratory | Initial assessment, at day 29, at 3 months and at 6 months |
| Immunoglobulin M (IgM) | IgM (hospital own's assay) | Initial assessment, at day 29, at 3 months and at 6 months |
| Total Cholesterol | Total Cholesterol (TCh) - hospital owns assay | Initial assessment, at day 29, at 3 months and at 6 months |
| High Density Lipoprotein (HDL) | HDL (hospital own's assay) | Initial assessment, at day 29, at 3 months and at 6 months |
| Low Density Lipoprotein (LDL) | LDL (hospital's own assay) | Initial assessment, at day 29, at 3 months and at 6 months |
| Triglycerides (TGA) | TGA (hospital's own assay) | Initial assessment, at day 29, at 3 months and at 6 months |
| Glucose | Glucose (hospital's own assay) | Initial assessment, at day 29, at 3 months and at 6 months |
| C-Reactive Protein (CRP) | Standard Sensitivity CRP, hospital's own assay. | Initial assessment, at day 29, at 3 months and at 6 months |
| At 0, day 29, 3 months and 6 months |
| University of Exeter |
| Study Director |
| University Hospitals Bristol & Weston NHS Trust | Bristol | Somerset | BS1 3NU | United Kingdom |
|
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| 25349177 | Background | Orgel E, Tucci J, Alhushki W, Malvar J, Sposto R, Fu CH, Freyer DR, Abdel-Azim H, Mittelman SD. Obesity is associated with residual leukemia following induction therapy for childhood B-precursor acute lymphoblastic leukemia. Blood. 2014 Dec 18;124(26):3932-8. doi: 10.1182/blood-2014-08-595389. Epub 2014 Oct 27. |
| 25752883 | Background | Brinksma A, Sanderman R, Roodbol PF, Sulkers E, Burgerhof JG, de Bont ES, Tissing WJ. Malnutrition is associated with worse health-related quality of life in children with cancer. Support Care Cancer. 2015 Oct;23(10):3043-52. doi: 10.1007/s00520-015-2674-0. Epub 2015 Mar 10. |
| 38185902 | Background | Lovell AL, Gardiner B, Henry L, Bate JM, Brougham MFH, Iniesta RR. The evolution of nutritional care in children and young people with acute lymphoblastic leukaemia: a narrative review. J Hum Nutr Diet. 2025 Feb;38(1):e13273. doi: 10.1111/jhn.13273. Epub 2024 Jan 7. |
| 32580035 | Background | Coombs A, Schilperoort H, Sargent B. The effect of exercise and motor interventions on physical activity and motor outcomes during and after medical intervention for children and adolescents with acute lymphoblastic leukemia: A systematic review. Crit Rev Oncol Hematol. 2020 Aug;152:103004. doi: 10.1016/j.critrevonc.2020.103004. Epub 2020 May 27. |
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Information will be shared following ethical approval on relevant websites |
| ID | Term |
|---|---|
| D009043 | Motor Activity |
| D009765 | Obesity |
| D054198 | Precursor Cell Lymphoblastic Leukemia-Lymphoma |
| ID | Term |
|---|---|
| D001519 | Behavior |
| D050177 | Overweight |
| D044343 | Overnutrition |
| D009748 | Nutrition Disorders |
| D009750 | Nutritional and Metabolic Diseases |
| D001835 | Body Weight |
| D012816 | Signs and Symptoms |
| D013568 | Pathological Conditions, Signs and Symptoms |
| D007945 | Leukemia, Lymphoid |
| D007938 | Leukemia |
| D009370 | Neoplasms by Histologic Type |
| D009369 | Neoplasms |
| D006402 | Hematologic Diseases |
| D006425 | Hemic and Lymphatic Diseases |
| D008232 | Lymphoproliferative Disorders |
| D008206 | Lymphatic Diseases |
| D007160 | Immunoproliferative Disorders |
| D007154 | Immune System Diseases |
Not provided
Not provided
| ID | Term |
|---|---|
| D004032 | Diet |
| D015444 | Exercise |
| ID | Term |
|---|---|
| D009747 | Nutritional Physiological Phenomena |
| D000066888 | Diet, Food, and Nutrition |
| D010829 | Physiological Phenomena |
| D009043 | Motor Activity |
| D009068 | Movement |
| D009142 | Musculoskeletal Physiological Phenomena |
| D055687 | Musculoskeletal and Neural Physiological Phenomena |
Not provided
Not provided