Screening for Fracture Risk is Vital for Many Cancer Patients

Most cancers can spread to the bone. And if you’re at particularly high risk for bone metastasis ― or you’ve been told your cancer has already spread ― one of your next steps should be an evaluation of your skeletal system. It’s all about preventing a fracture, which could decrease your mobility and quality of life, delay your cancer care and even shorten survival.

“We have treatments for impending fracture, but many patients don’t reach me in time,” says Juan Pretell, M.D., chief of musculoskeletal oncology surgery at Baptist Health Miami Cancer Institute.

“Surgery after the fact is much more involved for the patient, and if a fracture occurs after they received radiation, the bone often doesn’t heal. We want to help patients before this happens.”

Juan Pretell, M.D., chief of musculoskeletal oncology surgery at Baptist Health Miami Cancer Institute

Dr. Pretell suggests speaking with your medical or radiation oncologist to get a referral to an orthopedic oncologist, a relatively rare specialist. “We need to raise the awareness of the importance of an evaluation. Ideally, I’d like to screen patients before other treatments, like radiation therapy, begin.”

Some 400,000 new cases of bone metastasis are diagnosed each year in the U.S., and the numbers are increasing as improved treatments for primary cancers are leading to longer survival, according to the American Cancer Society. Every cancer patient is at risk, but bone metastasis is most common in patients with prostate, breast, lung, thyroid and renal cancer. There is also a high incidence in multiple myeloma patients.

While the spine is frequently the site of metastasis, it’s the long bones in the extremities, Dr. Pretell’s area of expertise, that most often fracture. The femur and the humerus are particularly vulnerable, he says.

Before a fracture occurs, some patients experience bone pain, but many patients are asymptomatic. “It’s all the more reason for an evaluation,” says Dr. Pretell, who sees patients at Miami Cancer Institute’s Plantation office. “Many fractures are preventable.”

Today’s treatments include newer, less-invasive procedures to strengthen the bone, such as intramedullary devices, which involve the insertion of a balloon catheter through a tiny incision. Once the catheter reaches the canal of the compromised bone, a cement-like material is introduced and then exposed to blue light, which allows it to harden.

“For the upper extremities, it is amazing,” Dr. Pretell says. “Patients usually stay in the hospital one night for observation because of their fragile medical condition. If they were experiencing bone pain, their pain is controlled. Their functionality is improved. They heal very quickly.”

If a fracture has occurred and implants are necessary, Dr. Pretell says newer carbon-fiber options have numerous advantages over the more traditional metallic implants. In addition to being very lightweight, they improve the quality of images in X-rays, MRI and CT scans by preventing what’s known as artifact ― shadows or obstructions that metal can cause. Extremely sharp images are important for those facing radiation therapy and additional imaging studies.

Most of Dr. Pretell’s work is done to improve quality of life rather than to cure an already very advanced cancer, yet research continues to show a correlation between fracture prevention and extended survival. In a study of more than 14,000 patients with multiple myeloma, those who developed a fracture were twice as likely to die than those who did not have a fracture. Another study by Massachusetts General Hospital researchers found prophylactic stabilization of an impending fracture in long bones led to significantly longer survival in comparison with patients who had surgery after a fracture occurred.

“Because there are so few orthopedic oncologists, even some physicians don’t know we are available,” he says. “I would like to screen every high-risk patient to prevent further problems and to ensure they have a high quality of life.”