Antiresorptive Medications Prior to Stereotactic Body Radiotherapy for Spinal Metastasis are Associated with Reduced Incidence of Vertebral Body Compression Fracture

Palak P Patel; Edward P Esposito; Jiafeng Zhu; Xuguang Chen; Majid Khan; Lawrence Kleinberg; Daniel Lubelski; Nicholas Theodore; Sheng-Fu Larry Lo; Sang Hun Lee; Khaled Kebaish; Ali Bydon; Kristin J Redmond

doi:10.1177/21925682231156394

Antiresorptive Medications Prior to Stereotactic Body Radiotherapy for Spinal Metastasis are Associated with Reduced Incidence of Vertebral Body Compression Fracture

Global Spine J. 2023 Feb 7:21925682231156394. doi: 10.1177/21925682231156394. Online ahead of print.

Authors

Affiliations

¹ Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Baltimore, MD, USA.
² Department of Biostatistics, Johns Hopkins School of Public Health, Baltimore, MD, USA.
³ Department of Radiology, Thomas Jefferson University Sidney Kimmel Medical College, Philadelphia, PA, USA.
⁴ Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, MD, USA.
⁵ Department of Neurosurgery, Zucker School of Medicine at Hoftstra, Manhasset, NY, USA.
⁶ Department of Orthopedic Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA.

PMID: 36749660
DOI: 10.1177/21925682231156394

Abstract

Study design: Retrospective Cohort.

Objective: Antiresorptive drugs are often given to minimize fracture risk for bone metastases, but data regarding optimal time or ability to reduce stereotactic body radiotherapy (SBRT)-induced fracture risk is limited. This study examines the association between antiresorptive use surrounding spinal SBRT and vertebral compression fracture (VCF) incidence to provide information regarding effectiveness and optimal timing of use.

Methods: Patients treated with SBRT for spinal metastases at a single institution between 2009-2020 were included. Kaplan-Meier analysis was used to compare cumulative incidence of VCF for those taking antiresorptive drugs pre-SBRT, post-SBRT only, and none at all. Cox proportional hazards and Fine-Gray competing risk models were used to identify additional factors associated with VCF.

Results: Of the 234 patients (410 vertebrae) analyzed, 49 (20.9%) were taking bisphosphonates alone, 42 (17.9%) were taking denosumab alone, and 25 (10.7%) were taking both. Kaplan-Meier analysis revealed a statistically significant lower VCF incidence for patients initiating antiresorptive drugs before SBRT compared to those taking none at all (4% vs 12% at 1 year post-SBRT, P = .045; and 4% vs 23% at 2 years, P = .008). On multivariate analysis, denosumab duration (HR: .87, P = .378) or dose (HR: 1.00, P = .644) as well as bisphosphonate duration (HR: .98, P= .739) or dose (HR: .99, P= .741) did not have statistical significance on VCF incidence.

Conclusion: Initiating antiresorptive agents before SBRT may reduce the risk of treatment-induced VCF. Antiresorptive drugs are underutilized in patients with spine metastases and may represent a useful intervention to minimize toxicity and improve long-term outcomes.

Keywords: antiresorptive; spine metastases; stereotactic body radiotherapy; vertebral compression fracture.