Hematopoietic stem-cell transplantation may increase risk of fractures

1. In a retrospective review of over 7600 patients who previously underwent hematopoietic stem-cell transplantation, there was a significantly increased incidence of fractures compared to the United States general population.

Evidence Rating Level: 3 (Average)

Study Rundown: The use of hematopoietic stem-cell transplantation (HSCTs) has significantly improved survival in patients with multiple myeloma and other hematologic malignancies. Bone loss is a known sequelae of HSCT, potentially leading to pathological fractures contributing to significant disability and worsening quality of life. However, the current incidence and risk factors associated with fractures post-HSCT remains unclear. The purpose of this study was to evaluate the incidence of fractures in post-HSCT patients and to identify potential risk factors for fractures. A retrospective analysis of over 7600 patients that received HSCT was performed and the incidence of fractures in this population was compared to the general population of the United States (US). At the conclusion of the study, the authors found that the age- and sex-specific fracture incidences in the post-HSCT population was significant greater than those of the US general population. Significant risk factors for fracture included autologous HSCT and pre-morbid diagnosis of multiple myeloma and solid tumors. The results of this study support the use of early bone health assessment and preventative therapies to reduce bone loss for all patients undergoing HSCT. However, the study was limited by retrospective study design and the methodology utilizing billing codes to identify fractures. There was no distinction between differences in the types of fractures which may exaggerate the risk of morbid fractures in this patient population.

Click to read the study in JCO

Relevant Reading: Approach to the patient with transplantation-related bone loss

In-Depth [retrospective cohort]: This study was a retrospective cohort review of 7620 patients who underwent HSCT at the MD Anderson Cancer Center in the United States from 1997 to 2011. The primary end points were defined as first fracture, death, or last date of retrospective follow-up. Fracture occurrence was detected via billing code registration. Rates of fractures among these patients were compared to those of the US general population, which was estimated from the 1994 National Health Interview Survey (NHIS) and the 2004 National Hospital Discharge Survey (NHDS). After a median follow-up period of 85 months, 8% (n=602) of post-HSCT patients developed a fracture. The age- and sex-specific fracture incidences were significant higher in the post-HSCT population; specifically, the relative risk of fracture for women age 45-64 was approximately 8 times higher than the general population, and 7-9 times higher for men aged 45 to 64. Risk factors for developing fractures included autologous transplant (HR: 2.24; 95% CI: 1.88 to 2.66; p<0.001), and pre-morbid multiple myeloma (HR: 6.89; 95% CI: 5.76 to 8.24; p<0.001) and solid tumors (HR: 1.7; 95% CI: 1.24 to 2.32; p<0.001).

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