Older Cancer Survivors Face Increased Risk for Bone Fracture

Megan Brooks

November 10, 2022

Older cancer survivors, especially those diagnosed within 5 years or who underwent chemotherapy, have significantly higher risks for pelvic and vertebral fractures than older adults without a history of cancer, a new study found.

About 1 in 7 cancer survivors experienced a frailty-related bone fracture, with several factors — including a more recent cancer diagnosis, distant metastases, chemotherapy use, and smoking — associated with a higher risk.

"Fractures of the pelvis and vertebrae are more than just broken bones — they are serious and costly," first author Erika Rees-Punia, PhD, MPH, senior principal scientist, epidemiology and behavioral research, American Cancer Society, Atlanta, Georgia, said in a statement.

And with the number of cancer survivors in the United States projected to rise to 26 million by 2040, understanding fracture incidence and prevention strategies in this population is particularly important, Rees-Punia added.

The study was published online November 3 in JAMA Oncology.

Although prior studies have found an increased risk for bone fractures in cancer survivors, important gaps in the research remain, such as what factors can heighten or attenuate fracture risk.

To investigate, the study team analyzed longitudinal data for 92,431 mostly White older adults (mean age 69 at baseline; 56% women) from the Cancer Prevention Study II Nutrition Cohort.

Among the participants, 12,943 (14%) experienced a frailty-related bone fracture during follow-up.

Compared with adults with no history of cancer, cancer survivors diagnosed within 5 years with an advanced stage cancer had more than a twofold higher fracture risk (hazard ratio [HR], 2.12), driven largely by vertebral and pelvic fractures (HR, 2.46 for both).

Compared with cancer survivors who did not receive chemotherapy, those who did were also more likely to suffer a fracture. This association was stronger within 5 years of diagnosis (HR, 1.31), but still suggestive after that time (HR, 1.22; 95% CI, 0.99 - 1.51).

As for mitigation strategies, current smoking was significantly associated with a higher risk for fracture (HR, 2.27).

In addition, physical activity appeared to lower the risk for fracture, although not significantly so (HR, 0.76; 95% CI, 0.54-1.07). However, in an earlier study, she and her colleagues showed that long-term cancer survivors who met guidelines for physical activity had a significantly lower risk for frailty-related fractures than those who exercised less.

"We hope our findings will inform clinical guidance on fracture prevention, which could incorporate physical activity regimens and smoking cessation programs to improve quality of life after a cancer diagnosis," Rees-Punia said.

Reached for comment, Jonas Sokolof, DO, noted that "many chemotherapeutic agents can have a direct detrimental effect on the musculoskeletal system and lead to subsequent fractures."

Compounding the problem, said Sokolof, is that older adults may already have a suboptimal baseline in terms of musculoskeletal health.

"This further supports what we do in rehabilitation medicine, which is to optimize physical function and quality of life throughout the entire cancer care continuum," Sokolof, director of oncological rehabilitation at NYU Langone Health in New York City, told Medscape Medical News.

Sokolof also noted that the mindset about the importance of physical activity during chemotherapy is shifting. In the past, the mantra was to take it easy and rest, but "there's movement now to implement exercise early on in the cancer care continuum and get patients on an exercise regimen as they undergo treatment, because we know that it works like a medicine," he said. "We have good randomized controlled data that shows exercise can actually improve cancer-related health outcomes, including osteoporosis and fractures."

This study was funded by the intramural research program at the American Cancer Society. Rees-Punia and Sokolof report no relevant financial relationships.

JAMA Oncol. Published online November 3, 2022. Abstract

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