Cancer Survivors Face Heightened Risk of Bone Fractures

Erika Rees-Punia, PhD, MPH

Survivors of cancer, particularly those diagnosed or who had received chemotherapy within the past 5 years, were at an increased risk of bone fractures compared to their counterparts without cancer, according to new research from the American Cancer Society.

An analysis of data from more than 90,000 participants from the Cancer Prevention Study-II Nutrition cohort and Medicare claims data from 1997-2017, results of the study indicated cancer survivors who were diagnosed 1 to less than 5 years earlier with advanced stage cancer had a more than doubling in risk of fractures compared to their counterparts without a history of cancer, but part of this risk was mediated by increased physical activity.

“These findings are important as the number of cancer survivors living in the United States is projected to rise to 26.1 million by 2040. Research like this seeks ways for cancer survivors to have a better quality of life after their diagnosis,” said lead investigator Erika Rees-Punia, PhD, MPH, a senior principal scientist in behavioral and epidemiology research at the American Cancer Society, in a statement. “Fractures of the pelvis and vertebrae are more than just broken bones – they are serious and costly.”

As the population ages and the number of cancer survivors continues to grow, concern over the long-term prognosis of cancer survivors, including risk of fracture, has grown as well. Recognizing this concern, Rees-Punia and a team of colleagues from the American Cancer Society sought to further examine the topic to provide clinicians with guidance on fracture prevention in this patient population. With this in mind, investigators designed the current study as an analysis of data from the Cancer Prevention Study II (CPS-II).A prospective study assessing cancer mortality launched by the American Cancer Society in 1982, CPS-II contained a subset of participants who were invited to join a nutrition cohort within the study in 1992. This nutrition cohort completed a survey in 1992 and biennial questionnaires beginning in 1997. From the cohort, 92,431 participants were identified for inclusion in the current study. This cohort had a mean age of 69.4 (SD, 6.0) years, 56% were female, 97.9% were White, and 14% (n=12,943) experienced a frailty-related bone fracture.

For the purpose of analysis, multivariable Cox proportional hazards regression was used to assess risk of pelvic, radial, vertebral, and total frailty-related fractures, which were considered the primary outcomes of interest for the investigators’ analysis. Investigators pointed out their analysis included data recorded from 1999-2017, with analyses occurring from July 15, 2021-May 3, 2022. Investigators also pointed out cancer history, some since diagnosis, and stage at cancer diagnosis served as the exposures of interest for their analyses.

Upon analysis, results indicated cancer survivors who were diagnosed 1 to less than 5 years earlier with advanced sage cancer had a more than doubling in fracture risk compared to those without a history of cancer (HR, 2.11 [95% CI, 1.75-2.58]). Further analysis suggested the increased risk in cancer survivors with recent advanced staff cancer compared to their counterparts without cancer was mostly driven by increased risk of vertebral (HR, 2.46 [95% CI, 1.93-3.13]) and pelvic (HR, 2.46 [95% CI, 1.84-3.29]) fractures.

Compared to those who did not receive chemotherapy, survivors who received chemotherapy were more likely to experience a frailty-related bone fracture. Investigators noted this association was stronger within 5 years of diagnosis than it was more than 5 years after diagnosis (HR, 1.22 [95% CI, 0.99-1.51]). Additionally, investigators highlighted that the risk of fracture was lower among those who were physically active survivors 5 years or more removed from diagnosis, but this did not reach statistical significance (HR, 0.76 [95% CI, 0.54-1.07]). Investigators also highlighted the finding that current smoking was significantly associated with higher risk of fracture (HR, 2.27 [95% CI, 1.51-3.33]).

“We hope our findings will inform clinical guidance on fracture prevention, which could incorporate physical activity with exercise cancer professionals and smoking cessation programs, to improve quality of life after a cancer diagnosis,” Rees-Punia added.

This study, “Fracture Risk Among Older Cancer Survivors Compared With Older Adults Without a History of Cancer,” was published in JAMA Oncology.