Photo Credit: Shidlovski

FRAX has been validated for fracture risk assessment for patients with cancer, with HRs indicating an association between FRAX scores and fracture risk.

The Fracture Risk Assessment Tool (FRAX) is widely used to estimate the 10-year probability of major osteoporotic fractures (MOFs) and hip fractures in the general population; however, its effectiveness in patients with cancer has been unclear, according to a study conducted by Carrie Ye, MD, MPH, and colleagues.

The study, published in JAMA Oncology, aimed to evaluate the predictive performance of FRAX in people with cancer. The study included 9,877 people with cancer and 45,877 without. These cohorts had FRAX scores calculated and adjusted for bone mineral density (BMD), focusing on predicting incident fractures.

Patients with cancer had higher rates of MOFs (14.5 vs 12.9 per 1000 person-years) and hip fractures (4.2 vs 3.5 per 1,000 person-years) compared to those without cancer. FRAX with BMD demonstrated strong predictive power in the cancer cohort, with calibration slopes of 1.03 for MOFs and 0.97 for hip fractures. The HRs indicated a significant association between FRAX scores and fracture risk.

Physician’s Weekly (PW) spoke with Dr. Ye to learn more.

PW: How well does FRAX with BMD predict fractures in those with cancer?

Carrie Ye, MD, MPH: It seems to predict major osteoporosis fractures and hip fractures just as well in patients with cancer as in the general population. We do see that fracture risk is probably higher in patients with cancer, even after adjusting for baseline FRAX score and bone mineral density. However, we’re still seeing such good calibration from FRAX prediction because patients with cancer don’t tend to live as long as patients without cancer, and they don’t have as many years of opportunity fractures. That counterbalances an increased fracture risk, so we still have almost perfect calibration for fracture prediction over the long term.

How can the findings be applied in the clinic for survivors?

Until now, we haven’t had a truly validated fracture prediction tool across a wide range of cancers. When you want to predict someone’s future fracture risk, for deciding if they should be on preventative treatment or actual osteoporosis treatment, we didn’t know if the traditional tools worked in the cancer population; now, we do. A clinician can confidently use the FRAX tool to predict fracture risk and use that to decide on treatment.

What else should clinicians consider when using FRAX?

There are certainly risk factors for fractures that are not included in the FRAX tool. Fragility, fall risk, and multiple previous fractures should be considered. A patient who’s had multiple vertebral fractures is at higher risk for future fractures than someone who’s had one wrist fracture, but FRAX doesn’t distinguish between the type or number of fractures.

Those are important considerations when looking at a patient where those additional risk factors may not be accounted for. We’ve also done some studies looking at the validation of the FRAX tool with certain cancer medications. For some cancers, respectively, FRAX still seems to hold up, but that same validation hasn’t necessarily been done in all sorts of cancer treatments. Additional factors in terms of cancer therapies should also be considered.

What are potential challenges in implementing this tool?

Bone marrow density certainly adds to the accuracy of fracture prediction, as shown in our study; however, we realize that not everybody has access to timely bone marrow density scans. And so, even without bone mineral density, FRAX performs decently well at predicting future fracture risk. Just because someone doesn’t have bone marrow density results certainly isn’t a reason not to do some fracture risk prediction or assessment fracture risk assessment because you can certainly get a lot of information on someone’s future fracture risk from their clinical information without bone marrow density results. The other thing is I think some patients may not understand the importance of getting a DEXA scan—especially during their other cancer therapies. Patients might be overwhelmed and think this is just another potentially unnecessary test. Counseling by their care team to explain why patients with cancer are at a higher risk for fractures and why it’s so important to do assessments of their bone health and hopefully prevent fractures is important.

Some patients might also need help understanding the implications of fractures. We’ve done studies to show that even in patients with cancer, having a fracture reduces survival. Many studies have shown that fractures can reduce quality of life and contribute to morbidity. Good counseling on the importance of bone health and fracture prevention can also help get more bone mineral density scans done.

Do you have any last thoughts?

There is a huge gap in the treatment of osteoporosis in general, and that gap is even larger in patients with cancer. In our study, we show that patients with cancer who have had a prior fracture are about half as likely to be on osteoporosis medication, and we already know in the general population that the treatment rates are low for osteoporosis. I think the emphasis should be on fracture prevention and bone health assessment. The tool you use and what you treat with is secondary, so long as you’re thinking about it and counseling, that’s what is important.