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Risk factors for same-admission mortality after pathologic fracture secondary to metastatic cancer

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Abstract

Purpose

The skeleton is the third most common site of cancer metastases. Approximately 10 % of patients with bone metastases will develop a pathologic fracture, with significant associated morbidity and mortality. The purpose of this study was to identify risk factors for same-admission mortality after pathologic fractures secondary to metastatic cancer.

Methods

The Nationwide Inpatient Sample database was queried from 2002 to 2013 for hospitalized patients with diagnoses of pathologic fracture and a primary cancer at high risk for skeletal metastasis. Univariate and multivariate analyses were performed to determine risk factors associated with same-admission mortality after fracture.

Results

A total of 371,163 patients were identified. The spine was the most common site of pathologic fracture (68.0 %) followed by lower extremity (25.0 %) and upper extremity (8.7 %). The following factors were independently associated with increased mortality (p < 0.001): cancer of lung or unspecified location; fracture of upper or lower extremity; male gender; age ≥65; non-Medicare insurance; coexisting congestive heart failure, chronic pulmonary disease, renal failure, or liver disease; and postoperative surgical site infection, acute myocardial infarction, pulmonary embolism, or pneumonia. Closed reductions were associated (p < 0.001) with increased mortality while open or percutaneous surgical treatments were protective (p < 0.001) against mortality.

Conclusions

Pathologic fractures are a devastating consequence of metastatic bone disease, contributing significantly to morbidity and mortality. Numerous demographic and medical factors are associated with increased same-admission mortality. This data is useful for counseling patients with skeletal metastatic disease and should be taken into consideration when conducting routine skeletal surveillance in patients with metastatic cancer.

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References

  1. Bickels J, Dadia S, Lidar Z (2009) Surgical management of metastatic bone disease. J Bone Joint Surg Am 91:1503–1516. doi:10.2106/JBJS.H.00175

    Article  PubMed  Google Scholar 

  2. Piccioli A, Maccauro G, Rossi B, Scaramuzzo L, Frenos F, Capanna R (2010) Surgical treatment of pathologic fractures of humerus. Injury 41:1112–1116. doi:10.1016/j.injury.2010.08.015

    Article  PubMed  Google Scholar 

  3. Bhatt AD, Schuler JC, Boakye M, Woo SY (2013) Current and emerging concepts in non-invasive and minimally invasive management of spine metastasis. Cancer Treat Rev 39:142–152. doi:10.1016/j.ctrv.2012.08.002

    Article  PubMed  Google Scholar 

  4. Siegel RL, Miller KD, Jemal A (2015) Cancer statistics, 2015. CA Cancer J Clin 65:5–29. doi:10.3322/caac.21254

    Article  PubMed  Google Scholar 

  5. Schulman KL, Kohles J (2007) Economic burden of metastatic bone disease in the U.S. Cancer 109:2334–2342. doi:10.1002/cncr.22678

    Article  PubMed  Google Scholar 

  6. Niederhuber JE, Armitage JO, Doroshow JH, Kastan MB, Tepper JE, Abeloff MD (2014) Abeloff’s clinical oncology. Elsevier, Philadelphia

    Google Scholar 

  7. Coleman RE (2006) Clinical features of metastatic bone disease and risk of skeletal morbidity. Clin Cancer Res 12:6243s–6249s. doi:10.1158/1078-0432.CCR-06-0931

    Article  PubMed  Google Scholar 

  8. Coleman RE (2001) Metastatic bone disease: clinical features, pathophysiology and treatment strategies. Cancer Treat Rev 27:165–176. doi:10.1053/ctrv.2000.0210

    Article  CAS  PubMed  Google Scholar 

  9. Guise TA (2000) Molecular mechanisms of osteolytic bone metastases. Cancer 88:2892–2898

    Article  CAS  PubMed  Google Scholar 

  10. Guise TA, Yin JJ, Mohammad KS (2003) Role of endothelin-1 in osteoblastic bone metastases. Cancer 97:779–784. doi:10.1002/cncr.11129

    Article  PubMed  Google Scholar 

  11. Pugh J, Sherry HS, Futterman B, Frankel VH (1982) Biomechanics of pathologic fractures. Clin Orthop Relat Res:109–114

  12. Zickel RE (1998) Current concepts review. Treatment of metastatic adenocarcinoma of the pelvis and the extremities. J Bone Joint Surg Am 80:763–764

    Article  CAS  PubMed  Google Scholar 

  13. Gralow JR, Biermann JS, Farooki A, Fornier MN, Gagel RF, Kumar R, Litsas G, McKay R, Podoloff DA, Srinivas S, Van Poznak CH (2013) NCCN task force report: bone health in cancer care. J Natl Compr Cancer Netw 11(Suppl 3):S1–50 quiz S51

    Google Scholar 

  14. Bohm P, Huber J (2002) The surgical treatment of bony metastases of the spine and limbs. J Bone Joint Surg Br 84:521–529

    Article  CAS  PubMed  Google Scholar 

  15. Saad F, Lipton A, Cook R, Chen YM, Smith M, Coleman R (2007) Pathologic fractures correlate with reduced survival in patients with malignant bone disease. Cancer 110:1860–1867. doi:10.1002/cncr.22991

    Article  PubMed  Google Scholar 

  16. Hill T, D’Alessandro P, Murray K, Yates P (2015) Prognostic factors following pathological fractures. ANZ J Surg 85:159–163. doi:10.1111/ans.12830

    Article  PubMed  Google Scholar 

  17. Bauer HC, Wedin R (1995) Survival after surgery for spinal and extremity metastases. Prognostication in 241 patients. Acta Orthop Scand 66:143–146

    Article  CAS  PubMed  Google Scholar 

  18. Healthcare and Utilization Project (2011) HCUP Nationwide Inpatient Sample (NIS). Agency for Healthcare Research and Quality, Rockville www.hcup-us.ahrq.gov/home.jsp

    Google Scholar 

  19. Ulas A, Bilici A, Durnali A, Tokluoglu S, Akinci S, Silay K, Oksuzoglu B, Alkis N (2015) Risk factors for skeletal-related events (SREs) and factors affecting SRE-free survival for nonsmall cell lung cancer patients with bone metastases. Tumour Biol. doi:10.1007/s13277-015-3907-z

    Google Scholar 

  20. Delea T, Langer C, McKiernan J, Liss M, Edelsberg J, Brandman J, Sung J, Raut M, Oster G (2004) The cost of treatment of skeletal-related events in patients with bone metastases from lung cancer. Oncology 67:390–396. doi:10.1159/000082923

    Article  PubMed  Google Scholar 

  21. Bhattacharyya T, Iorio R, Healy WL (2002) Rate of and risk factors for acute inpatient mortality after orthopaedic surgery. J Bone Joint Surg Am 84-A:562–572

    Article  PubMed  Google Scholar 

  22. Maile MD, Engoren MC, Tremper KK, Jewell E, Kheterpal S (2014) Worsening preoperative heart failure is associated with mortality and noncardiac complications, but not myocardial infarction after noncardiac surgery: a retrospective cohort study. Anesth Analg 119:522–532. doi:10.1213/ANE.0000000000000116

    Article  PubMed  Google Scholar 

  23. Licker M, Schweizer A, Ellenberger C, Tschopp JM, Diaper J, Clergue F (2007) Perioperative medical management of patients with COPD. Int J Chron Obstruct Pulmon Dis 2:493–515

    PubMed  PubMed Central  Google Scholar 

  24. Teh SH, Nagorney DM, Stevens SR, Offord KP, Therneau TM, Plevak DJ, Talwalkar JA, Kim WR, Kamath PS (2007) Risk factors for mortality after surgery in patients with cirrhosis. Gastroenterology 132:1261–1269. doi:10.1053/j.gastro.2007.01.040

    Article  PubMed  Google Scholar 

  25. Mathew A, Devereaux PJ, O’Hare A, Tonelli M, Thiessen-Philbrook H, Nevis IF, Iansavichus AV, Garg AX (2008) Chronic kidney disease and postoperative mortality: a systematic review and meta-analysis. Kidney Int 73:1069–1081. doi:10.1038/ki.2008.29

    Article  CAS  PubMed  Google Scholar 

  26. Yavas O, Hayran M, Ozisik Y (2007) Factors affecting survival in breast cancer patients following bone metastasis. Tumori 93:580–586

    PubMed  Google Scholar 

  27. Niikura N, Liu J, Hayashi N, Palla SL, Tokuda Y, Hortobagyi GN, Ueno NT, Theriault RL (2011) Treatment outcome and prognostic factors for patients with bone-only metastases of breast cancer: a single-institution retrospective analysis. Oncologist 16:155–164. doi:10.1634/theoncologist.2010-0350

    Article  PubMed  PubMed Central  Google Scholar 

  28. Yong M, Jensen AO, Jacobsen JB, Norgaard M, Fryzek JP, Sorensen HT (2011) Survival in breast cancer patients with bone metastases and skeletal-related events: a population-based cohort study in Denmark (1999-2007. Breast Cancer Res Treat 129:495–503. doi:10.1007/s10549-011-1475-5

    Article  PubMed  Google Scholar 

  29. Piccioli A, Maccauro G, Spinelli MS, Biagini R, Rossi B (2015) Bone metastases of unknown origin: epidemiology and principles of management. J Orthop Traumatol 16:81–86. doi:10.1007/s10195-015-0344-0

    Article  PubMed  PubMed Central  Google Scholar 

  30. Harvey N, Ahlmann ER, Allison DC, Wang L, Menendez LR (2012) Endoprostheses last longer than intramedullary devices in proximal femur metastases. Clin Orthop Relat Res 470:684–691. doi:10.1007/s11999-011-2038-0

    Article  PubMed  Google Scholar 

  31. Sarahrudi K, Wolf H, Funovics P, Pajenda G, Hausmann JT, Vecsei V (2009) Surgical treatment of pathological fractures of the shaft of the humerus. J Trauma 66:789–794. doi:10.1097/TA.0b013e3181692132

    Article  PubMed  Google Scholar 

  32. Steinmetz MP, Mekhail A, Benzel EC (2001) Management of metastatic tumors of the spine: strategies and operative indications. Neurosurg Focus 11:e2

    Article  CAS  PubMed  Google Scholar 

  33. Patchell RA, Tibbs PA, Regine WF, Payne R, Saris S, Kryscio RJ, Mohiuddin M, Young B (2005) Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer: a randomised trial. Lancet 366:643–648. doi:10.1016/S0140-6736(05)66954-1

    Article  PubMed  Google Scholar 

  34. Morin S, Lix LM, Azimaee M, Metge C, Caetano P, Leslie WD (2011) Mortality rates after incident non-traumatic fractures in older men and women. Osteoporos Int 22:2439–2448. doi:10.1007/s00198-010-1480-2

    Article  CAS  PubMed  Google Scholar 

  35. Tokuhashi Y, Matsuzaki H, Oda H, Oshima M, Ryu J (2005) A revised scoring system for preoperative evaluation of metastatic spine tumor prognosis. Spine (Phila Pa 1976) 30:2186–2191

    Article  Google Scholar 

  36. Halpern MT, Ward EM, Pavluck AL, Schrag NM, Bian J, Chen AY (2008) Association of insurance status and ethnicity with cancer stage at diagnosis for 12 cancer sites: a retrospective analysis. Lancet Oncol 9:222–231. doi:10.1016/S1470-2045(08)70032-9

    Article  PubMed  Google Scholar 

  37. Ward E, Halpern M, Schrag N, Cokkinides V, DeSantis C, Bandi P, Siegel R, Stewart A, Jemal A (2008) Association of insurance with cancer care utilization and outcomes. CA Cancer J Clin 58:9–31. doi:10.3322/CA.2007.0011

    Article  PubMed  Google Scholar 

  38. Roetzheim RG, Pal N, Tennant C, Voti L, Ayanian JZ, Schwabe A, Krischer JP (1999) Effects of health insurance and race on early detection of cancer. J Natl Cancer Inst 91:1409–1415

    Article  CAS  PubMed  Google Scholar 

  39. Ward EM, Fedewa SA, Cokkinides V, Virgo K (2010) The association of insurance and stage at diagnosis among patients aged 55 to 74 years in the national cancer database. Cancer J 16:614–621. doi:10.1097/PPO.0b013e3181ff2aec

    Article  PubMed  Google Scholar 

  40. Haynes MA, Smedley BD, Institute of Medicine (U.S.). Committee on Cancer Research among Minorities and the Medically Underserved (1999) The unequal burden of cancer : an assessment of NIH research and programs for ethnic minorities and the medically underserved. National Academy Press, Washington

    Google Scholar 

  41. Zafar SY, Abernethy AP (2013) Financial toxicity, part I: a new name for a growing problem. Oncology (Williston Park) 27:80–81 149

    Google Scholar 

  42. Shankaran V, Jolly S, Blough D, Ramsey SD (2012) Risk factors for financial hardship in patients receiving adjuvant chemotherapy for colon cancer: a population-based exploratory analysis. J Clin Oncol 30:1608–1614. doi:10.1200/JCO.2011.37.9511

    Article  PubMed  Google Scholar 

  43. Bernard DS, Farr SL, Fang Z (2011) National estimates of out-of-pocket health care expenditure burdens among nonelderly adults with cancer: 2001 to 2008. J Clin Oncol 29:2821–2826. doi:10.1200/JCO.2010.33.0522

    Article  PubMed  PubMed Central  Google Scholar 

  44. Hanratty B, Holland P, Jacoby A, Whitehead M (2007) Financial stress and strain associated with terminal cancer—a review of the evidence. Palliat Med 21:595–607. doi:10.1177/0269216307082476

    Article  PubMed  Google Scholar 

  45. Nathan SS, Healey JH, Mellano D, Hoang B, Lewis I, Morris CD, Athanasian EA, Boland PJ (2005) Survival in patients operated on for pathologic fracture: implications for end-of-life orthopedic care. J Clin Oncol 23:6072–6082. doi:10.1200/JCO.2005.08.104

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Surgery, Division of Orthopaedics, University of Alabama at Birmingham, 1313 13th Street South, Birmingham, AL, 35205, USA

    Nicole K. Behnke, Dustin K. Baker, Shin Xu, Thomas E. Niemeier, Shawna L. Watson & Brent A. Ponce

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  1. Nicole K. Behnke
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  2. Dustin K. Baker
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Correspondence to Nicole K. Behnke.

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Behnke, N.K., Baker, D.K., Xu, S. et al. Risk factors for same-admission mortality after pathologic fracture secondary to metastatic cancer. Support Care Cancer 25, 513–521 (2017). https://doi.org/10.1007/s00520-016-3431-8

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  • DOI: https://doi.org/10.1007/s00520-016-3431-8

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