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Risk of Pelvic Fractures in Older Women Following Pelvic Irradiation
Nancy N. Baxter, MD, PhD;
Elizabeth B. Habermann, BS;
Joel E. Tepper, MD;
Sara B. Durham, MSc;
Beth A. Virnig, MPH, PhD
JAMA. 2005;294:2587-2593.
Context Pelvic fractures, including hip fractures, are a major source of morbidity and mortality in older women. Although therapeutic pelvic irradiation could increase the risk of such fractures, this effect has not been studied.
Objective To determine if women who undergo pelvic irradiation for pelvic malignancies (anal, cervical, or rectal cancers) have a higher rate of pelvic fracture than women with pelvic malignancies who do not undergo irradiation.
Design, Setting, and Participants We conducted a retrospective cohort study using Surveillance, Epidemiology, and End Results (SEER) cancer registry data linked to Medicare claims data. A total of 6428 women aged 65 years and older diagnosed with pelvic malignancies from 1986 through 1999 were included. We compared results for women who did (n = 2855) vs did not (n = 3573) undergo radiation therapy. To assess the influence of selection bias, we also evaluated the effect of irradiation on osteoporotic fractures in nonirradiated sites (arm and spine).
Main Outcome Measure We evaluated the effect of irradiation on the incidence of pelvic fractures over time, and adjusted for potential confounders using a proportional hazards model.
Results Women who underwent radiation therapy were more likely to have a pelvic fracture than women who did not undergo radiation therapy (cumulative 5-year fracture rate, 14.0% vs 7.5% in women with anal cancer, 8.2% vs 5.9% in women with cervical cancer, and 11.2% vs 8.7% in women with rectal cancer); the difference was statistically significant and most fractures (90%) were hip fractures. We controlled for potential confounders including age, race, cancer stage, and geographic location. The impact of irradiation varied by cancer site: treatment for anal cancer was associated with a higher risk of pelvic fractures (hazard ratio, 3.16; 95% confidence interval, 1.48-6.73); than for cervical cancer (hazard ratio, 1.66; 95% confidence interval, 1.06-2.59); or rectal cancer (hazard ratio, 1.65; 95% confidence interval, 1.33-2.05). No statistically significant difference was found in the rate of arm or spine fractures between the irradiated and nonirradiated groups (hazard ratio, 1.15; 95% confidence interval, 0.89-1.48).
Conclusions Pelvic irradiation substantially increases the risk of pelvic fractures in older women. Given the high baseline risk of pelvic fracture, this finding is of particular concern.
Author Affiliations: Division of Colon and Rectal Surgery, Department of Surgery, University of Minnesota, Minneapolis (Dr Baxter); Division of Health Services Research and Policy, University of Minnesota School of Public Health, Minneapolis (Mss Habermann, Durham, and Dr Virnig); University of Minnesota Comprehensive Cancer Center, Minneapolis (Drs Baxter and Virnig); Department of Radiation Oncology and the UNC/ Lineberger Comprehensive Cancer Center, University of North Carolina School of Medicine, Chapel Hill (Dr Tepper).
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