Towards Closing the Care Gap in Bone Health in Gynaecological Oncology

Abstract

Loss of bone mineral density (BMD) resulting in osteopaenia, or osteoporosis is relatively common in women, particularly postmenopausal women. Women with gynaecological malignancies are at particular risk due to the effect of cancer treatment-induced bone loss (CTIBL). Researchers have demonstrated care-gaps in relation to CTIBL in other oncological settings, and while the deleterious effects of gynaecological cancer-treatments on bone health have long been proved, there are no studies assessing the provision of care in this area. In addition, there is a paucity of guidance from national and international professional bodies in gynaecological oncology in relation to the prevention, detection, or care of CTIBL. I hypothesised that a similar care-gap exists for women with gynaecological cancer. I aimed to identify if appropriate attention was given to bone health during follow-up by gynaecological oncology tertiary carers. I aimed also to gain insights into the attitudes and practices of these tertiary carers in relation to bone health. The objective of my studies was to identify means of improving the provision of bone health-related survivorship care for women with gynaecological cancers. Following identification of low rates of referral for the recommended DXA quantification of baseline BMD in this cohort, and the difficulties in access to DXA in the public health system Ireland, I undertook an evaluation of the opportunistic use of staging CT scans in the assessment of BMD in the gynaecological oncology setting. To these ends, I conducted a retrospective, observational cohort study of attention to bone health in the follow-up of gynaecological cancers over a 5-year period at a tertiary referral centre. I also carried out a written (online) cross-sectional survey of clinicians working within gynaecological oncology in the UK and Ireland. Finally, I conducted a cross sectional correlation study of the pilot introduction of use of staging CT scans to evaluate bone mineral density in gynaecological oncology. This is the first study to evaluate the opportunistic use of CT in this setting. My research demonstrated suboptimal attention to bone health during follow-up of women with gynaecological cancers at a tertiary referral centre, with over half of women in the highest-risk categories not undergoing any BMD quantification. I found that tertiary carers have wide-ranging practices and views in relation to care provision in this area. In particular there was division and diversity of opinion regarding who should take responsibility for bone health, a finding which increases the risk of a care-gap and calls for improved co-ordination of survivorship care. Finally, I demonstrated good diagnostic accuracy of CT in assessment of BMD and suggested a role for its opportunistic use in gynaecological oncology. These are clinically meaningful results that can aid service provision and could lead to an improvement in the provision of bone health-related survivorship care for women living with and beyond gynaecological cancers.