To the editors of the Pan African Medical Journal
Decreased bone mineral density (BMD) is attributed to reducing bone mass index with
architectural distortion, resulting in fractures [1]. Following adjuvant chemotherapy,
cancer patients are more likely to develop osteopenia and osteoporosis, which affects
two-thirds of males, more than half of premenopausal women, and approximately one-fifth
of postmenopausal women [2]. Cancer therapy-induced bone loss is a leading cause of
secondary osteoporosis, which results in bone fragility, increased fracture risk,
decreased quality of life, and increased mortality [2]. Recent clinical guidelines
recommend evaluating BMD in high-risk patients [3]. In Saudi Arabia, published data
scarce on the impact of chemotherapy on bone loss among cancer survivors in the literature
[4]. We report the prevalence of osteoporosis and osteopenia and their associated
factors in cancer patients managed within the cancer center of King Khalid Hospital
in Najran, Saudi Arabia between February 2021 and March 2022. 39 adult chemotherapy
cancer, were interviewed. Using a Dual-energy X-ray absorptiometry (DXA) scan, the
BMD of the lumbar spine and femur neck were evaluated. Univariate analysis was performed
to determine the risk factors of osteoporosis and osteopenia with other variables.
The patients' mean age was 60.15 ± 12.26 years. The majority of patients (53.8%) were
aged between (60-69) years old, and most of them (64.1%) were female. The main primary
diagnosis was breast cancer in 14 (35.9%) patients. Osteopenia, osteoporosis, and
normal BMD were found in 7(17.9%), 28(71.8%), and 4 (10.3%) patients, respectively.
Most of the patients (43.6%) had a low serum concentration of 25-hydroxycholecalciferol
(25-vitamin D) ≤ 20 (ng/ml). Univariate analysis showed no relation between osteopenia
or osteoporosis with gender, type of cancer, hormone therapy, length of hormone therapy
or chemotherapy, history of bone pain, and metastatic stage (p >0.05). Osteoporosis
and osteopenia were significantly more frequent in older patients, patients receiving
chemotherapy, and patients with lower serum levels of vitamin D (p = 0.04, 0.05, and
0.005, respectively) (Table 1).
Table 1
comparison between osteopenia, osteoporosis, and normal bone health status with other
factors
Variables
Subgroup
Total N (%)
Osteopenia N (%) and Mean (SD) 7(17.9)
Osteoporosis N (%) and Mean (SD) 28(71.8)
Normal N (%) and Mean (SD) 4(10.3)
P-value*
Age (year)
-
60.15 ± 12.26
55.71 ± 4.11
62.29 ± 12.73
53.00 ± 16.00
0.213
Age group (year)
<60
12(30.8)
5(41.7)
6(50.0)
1(8.3)
0.044
≥60
27(69.2)
2(7.4)
22(81.5)
3(11.1)
Gender
Male
14 (35.9)
1(7.1)
10(71.4)
3(21.4)
0.139
Female
25 (64.1)
6(24.0)
18(72.0)
1(4.0)
Primary diagnosis
Breast cancer
14(35.9)
2(14.3)
11(78.6)
1(7.1)
0.218
Prostate cancer
10(25.6)
1(10.0)
6(60.0)
3(30.0)
Other
15 (38.5)
4(26.7)
11(73.3)
0(0.0)
History of bone pain
Yes
18(46.2)
2(11.1)
14(77.8)
2(11.1)
0.597
No
21(53.8)
5(23.8)
14(66.7)
2(9.5)
Chemotherapy use
Yes
26(66.7)
4(15.4)
21(80.8)
1(3.8)
0.05
No
13(33.3)
3(23.1)
7(53.8)
3(23.1)
Duration of chemotherapy
≥ 5years
9(23.1)
2(22.2)
6(66.7)
1(11.1)
0.522
4-2 years
6(15.4)
1(16.7)
5(83.3)
0(0.0)
≤ 1 year
11(28.2)
1(9.1)
10(90.9)
0(0.0)
Hormone therapy use
Yes
25(64.1)
4(16.0)
17(68.0)
4(16.0)
0.372
No
14(35.9)
3(21.4)
11(78.6)
0(0.0)
Duration of hormone therapy
≥ 5years
4(10.3)
1(25.0)
2(50.0)
1(25.0)
0.268
4-2 years
12(30.8)
2(16.7)
7(58.3)
3(25.0)
≤ 1 year
9(23.1)
1(11.1)
8(88.9)
0(0.0)
Serum Vit D level
<20 (ng/ml)
17(43.6)
1(5.9)
16(94.1)
0(0.0)
0.005
20-30 (ng/ml)
10(25.6)
4(40.0)
6(60.0)
0(0.0)
≥ 30 (ng/ml)
12(30.8)
2(16.7)
6(50.0)
4(33.3)
Bone scan
No bone metastasis
24(61.5)
4(16.7)
17(70.8)
3(12.5)
1.000
Bone metastasis
15(38.5)
3(20.0)
11(73.3)
1(6.7)
Aware of jaw necrosis
Yes
10(25.6)
3(30.0)
7(70.0)
0(0.0)
0.292
No
29(74.4)
4(13.8)
21(72.4)
4(13.8)
*
P-values < 0.05 were considered significant
Al Amri et al. reported a higher trend of osteopenia and osteoporosis in patients
aged 50 years old or younger [4]. Another study found a higher prevalence of osteoporosis
among older cancer survivors, as seen in our patients [5]. Various factors that may
influence BMD in cancer patients were reported in different studies. For instance,
in Reuss-Borst's study, age, body weight, menopausal state, and hormonal replacement
therapy (HRT) in women and body weight in men have shown a significant association
with the prevalence of osteoporosis [6]. Choi et al. showed a higher prevalence of
osteoporosis among older age, female gender, and lower monthly income cancer survivors.
Additionally, being underweight and inadequate calcium consumption in male cancer
survivors were associated with osteoporosis [5]. In our analysis, older age, chemotherapy
use, and low level of vitamin D were significantly associated with the prevalence
of osteoporosis and osteopenia. However, other risk factors, including hormone therapy,
duration of chemotherapy, and metastatic status, were not statistically significant.
We explained that the small sample size and the short follow-up period limited us
from making a robust statistical analysis. Therefore, a multicentric study is recommended.
Chemotherapy-associated bone loss in premenopausal women may be due to premature ovarian
failure or, possibly, through estrogen-independent mechanisms. However, the more substantial
bone loss was attributed to hormonal therapy due to its direct impact on osteogenesis
and a longer administration time. Findings that are consistent with our results [7].
Pharmacological interventions for bone loss are recommended for patients with high
risk and insufficient dietary intake, which include vitamin D supplementation (1000-2000
IU daily) and calcium supplementation (1000 mg daily) [8]. The addition of antiresorptive
therapy should be recommended for patients with a baseline T score of -2.0 or patients
with two or more clinical risk factors for fracture [9]. In our patients, instead
of vitamin D, denosumab and calcium were administrated to all patients.
The current study had several limitations. Firstly, a retrospective nature, monocentric,
and a small number of participants limited us from making a robust statistical analysis.
Second, the incidence of osteopenia and osteoporosis was determined based DEXA scan
and may be subject to misclassification. Finally, factors such as physical activity,
economic status, comorbidity conditions, and diet, which may influence osteopenia
and osteoporosis status, are not included.
Conclusion
Bone loss due to cancer treatment is a significant potential adverse side effect.
Those at risk of treatment-related bone loss should be identified using effective
screening procedures, and therapy should be offered if risk factors are found. Our
study found that osteoporosis and osteopenia were more common in older patients, patients
under chemotherapy, and those with low levels of serum vitamin D.