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Chemoradiotherapy raises risk of thoracic vertebral fracture

JAMA Network Open
Reuters Health - 14/09/2020 - Chemoradiotherapy for esophageal cancer increases the risk of thoracic vertebral fractures, researchers in Japan report.

"Decreasing the vertebral (radiation) dose using advanced radiotherapy techniques may reduce the incidence of vertebral fractures in patients with thoracic malignancy after chemoradiotherapy," Dr. Katsuyuki Sakanaka of Kyoto University Graduate School of Medicine told Reuters Health by email. "Early intervention for osteoporosis in this population may reduce the risk of vertebral fractures."

Radiotherapy for malignant neoplasms has been associated with an increased incidence of vertebral fractures, but previous studies of this association have been flawed, according to Dr. Sakanaka and colleagues.

The researchers compared the incidence of vertebral fractures in patients with thoracic esophageal cancer treated by chemoradiotherapy versus those treated with endoscopy or surgery using their institutional database of patients who had visited their cancer center.

During a median observation time of around 40 months, 16.8% (20/119) of patients in the chemoradiotherapy group developed thoracic vertebral fractures, compared with 4.1% (8/196) of patients who did not receive chemoradiotherapy.

The 36-month incidence of thoracic vertebral fractures was 12.3% in the chemoradiotherapy group and 3.5% in the non-chemoradiotherapy group, the researchers report in JAMA Network Open.

After adjusting for age, sex and history of vertebral or hip fractures, chemoradiotherapy was associated with more than a three-fold increase in the risk of thoracic vertebral fractures (P=0.009).

The incidence of a thoracic vertebral fracture increased 19% for each 5-Gy increase of mean thoracic vertebral radiation dose and was 3.15-fold higher in women than in men.

"Patients with other thoracic malignancies probably suffer the risk of vertebral fractures after chemoradiotherapy," Dr. Sakanaka said.

The "authors of this study describe patients having primary tumors treated with a total radiation dose of 60 Gy, which is significantly higher than our national guidelines recommend based on failures of dose-escalation studies to show meaningful improvements and actually showing survival detriment," write Dr. Cristina DeCesaris and Dr. Avani D. Rao of the University of Maryland Marlene and Stewart Greenebaum Cancer Center, in Baltimore, in a linked editorial.

"This study once again highlights the inherent risk of bone density changes resulting from chemoradiotherapy, warranting counseling specific to this treatment-related toxic effect," they note.

"Because advanced radiation modalities are increasingly used, physicians will have the capability to deliver highly conformal plans and may have the ability to significantly decrease radiation exposure to the vertebral bodies, if it is an established planning goal," they add.

By Will Boggs MD

SOURCE: https://bit.ly/2Z7nhp2 and https://bit.ly/3gZBOcD JAMA Network Open, online September 1, 2020.

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