Does the finding that the incidence of fractures is “compellingly higher” after hematopoietic stem cell transplantation mean that physicians counseling patients about transplant should feel compelled to discuss the fracture risks?

Huifang Linda Lu, MD, PhD, the corresponding author of the study finding that higher fracture rate, told The ASCO Post, “Physicians spend a significant amount of their time counseling patients about their underlying malignancy and treatment plan. In addition, risks of having the transplant and its long-term complications are also discussed. It is necessary to discuss the risk of bone loss with patients and urge them to take an active role in preventing fractures posttransplant.

Dr. Lu is Associate Professor, Rheumatology and Clinical Immunology at The University of Texas MD Anderson Cancer Center, Houston, where the study was conducted. Among 7,620 patients undergoing stem cell transplant from 1997 to 2011 at MD Anderson, 602 (8%) developed a fracture. This was significantly greater than the fracture rate of the U.S. general population for almost all subgroups, the researchers reported, with a “striking difference” of approximately eight times greater risk in females and seven to nine times greater risk in males aged 45 to 64.

The study identified several potential factors associated with a higher risk of fracture, such as a diagnosis of multiple myeloma, older age at transplantation, and having autologous rather than allogeneic transplantation. “However, there are many other potential risk factors that may have adverse effects on bone that need to be further investigated,” Dr. Lu stated. “Although our results did identify some potential risk factors we believe that maintenance of bone following [stem cell transplant] is a complex process and not completely understood, and hence, all patients undergoing a transplant should be considered at risk.”

Encourage Exercise, Discourage Smoking

The active role for patients in preventing bone loss and fractures should include physical exercise and fall prevention. Patients also should be encouraged to avoid tobacco and minimize excessive alcohol intake, which “some studies have shown to be independent risk factors for fractures,” Dr. Lu noted. In addition, avoiding excessive alcohol reduces risk of falls that could lead to fractures.

“Adequate intake of calcium, magnesium, and vitamin D is essential for general bone health. Hormone replacement therapy should be considered when appropriate,” Dr. Lu continued.

“There are pharmacologic interventions to prevent bone loss, but none can replace the importance of bone loss prevention by utilizing basic bone health measures such as calcium, vitamin D supplementation, weight-bearing exercise, and minimizing the use of bone-damaging medication as much as possible,” Dr. Lu added. “Pharmacologic interventions such as bisphosphonates are being used to prevent and treat bone loss following [stem cell transplant]; however, pharmacologic reagents carry their own risks.” ■

Disclosure: Dr. Lu reported no potential conflicts of interest.

Reference

1. Pundole XN, Barbo AG, Lin H, et al: Increased incidence of fractures in recipients of hematopoietic stem-cell transplantation. J Clin Oncol 33:1364-1370, 2015.