Insufficiency fractures in postmenopausal gynaecological patients receiving pelvic radiotherapy treatment – can we prevent them by optimising bone health?

Results

Current data to support prevention of radiation-induced insufficiency fractures (IF) is limited. Pelvic IF secondary to radiotherapy treatment in gynaecological cancer patients are observed in up to 45% of patients; with a median time to development of 6–20 months. In 43–77% of patients these can cause significant pain and reduce quality of life. We hypothesise that in addition to the use of sophisticated radiotherapy techniques to reduce the exposure of bone to radiation (both volume and dose reduction – Ramlov et al (2017)),² addressing bone health will lead to a further reduction in the incidence of IF. Most patients are postmenopausal at the time of radiotherapy; we assess their bone health based upon dual energy X-ray absorptiometry (DXA) result and clinical risk factors. We also address their calcium and vitamin D status. Bisphosphonate therapy and appropriate calcium and vitamin D supplementation is considered if:

• T score <-2 irrespective of other risk factors

• T score of -1.5 to -2 plus one additional risk factor (see table)

A dental assessment is recommended in all patients prior to commencing a bisphosphonate. If oral therapy is not tolerated we would consider intravenous bisphosphonates or denosumab. We repeat the DXA scan at 2 years aiming to give a total 3–5 years of treatment.

1. Age >65 years

2. Low BMI (<20 kg/m²)

3. Family history of hip fracture

4. Personal history of fragility fracture (particularly if after age 50 years)

5. Oral corticosteroid use for >6 months

6. Smoking history