Pelvic Insufficiency Fractures After Chemoradiotherapy for Cervical Cancer: Incidence, Long-Term Outcomes, and Survivorship Management
Akram Saad, Jeffrey Goldstein, Ronza Atamneh, Limor Helpman, Ronnie Shapira, Omer Berner, Ofir Morag, Oded Jacobi, Dana Oren, Hanifa J Abu-Toamih Atamni, Reut Mordechai, Itay Goor Aryeh, Alexandra Taylor, Shira Peleg Hasson, Shira FelderAbstract
Background
Pelvic insufficiency fractures, a late complication of chemoradiotherapy for cervical cancer, can cause pain and functional impairment. Although most studies have reported incidence rates and risk factors, few have examined clinical presentation, long-term symptom burden, or the impact on survivorship.
Methods
We conducted a retrospective study of patients with cervical cancer treated with chemoradiotherapy from 2018 to 2024. We extracted clinical characteristics, treatment details, dosimetric parameters, imaging studies documenting pelvic insufficiency fractures, and clinical outcomes from the electronic medical record. We used the Kaplan–Meier method to estimate the probability of pelvic insufficiency fractures and univariate Cox regression to assess clinical and dosimetric factors associated with their development.
Results
The cohort comprised 153 patients (median follow-up: 41.4 months). After chemoradiotherapy, 18 patients (11.8%) developed radiologically confirmed pelvic insufficiency fractures (median time to diagnosis: 9.5 months; probability of pelvic insufficiency fracture at 24 months: 11.4%). PET-CT and/or MRI showed that most pelvic insufficiency fractures involved the sacrum. No statistically significant clinical or dosimetric predictors of pelvic insufficiency fractures were identified. All symptomatic patients (n = 15, 83%) required referral to pain-management services (median observed duration of symptoms: 37 months). No symptomatic patient achieved documented complete symptom resolution during the available follow-up.
Conclusions
Most pelvic insufficiency fractures presented with new-onset pelvic or sacral pain within two years of completing chemoradiotherapy. The lack of clinical or dosimetric predictors suggests a multifactorial etiology of fracture risk. Persistent pain, despite multimodal supportive care, led to long-term morbidity. These findings underscore the need for prospective studies to develop evidence-based preventive strategies, survivorship assessments, and management pathways.