Bone Density Screening, Treatment and Fracture Rates in Allogeneic Hematopoietic Cell Transplant Patients

Bone mineral density (BMD) loss and fractures are a known cause of increased morbidity post allogeneic hematopoietic cell transplant (allo-HCT). Guidelines for post-transplant BMD screening have been established since 2012. Dual X-ray Absorptiometry (DEXA) and FRAX risk scores are used to identify patients with osteoporosis, osteopenia and increased risk of fractures. In September 2019 our survivorship program implemented a new BMD management care path (Figures 1 and 2). Pre-transplant DEXA screening was added with new guidelines on treatment for those with increased risk of bone fractures.We performed a retrospective chart review of allo-HCT patients at Cleveland Clinic who were transplanted from September 2016 to March 2022 with at least one year of follow-up. DEXA screening pre- and post-transplant, treatment and fractures post-transplant were compared to before and after the care path was initiated. Treatment was guided by the National Osteoporosis Foundation recommendations (T-score or -2.5 or less, T-score -1 to -2.4 and a 10- year probability of hip fracture >= 3% or any major fracture >= 20% as calculated by FRAX).We identified 248 patients who survived at least 1-year post-HCT from 2016-2022, 143 prior to Sept 2019 (cohort 1) and 105 after Sept 2019 (cohort 2). Pre-transplant DEXA screening went from 0% to 97%, and 1-year screening from 77% to 46%. First screening for patients ≥2-year post transplant increased from 17.2% to 30.6% with 27.3% of patients in cohort 1 having 2 or more DEXA scans post-transplant versus 7% in cohort 2. Thirty-two (25%) patients in cohort 1 met criteria for treatment and 28 (21.9%) of those were treated, in comparison to 30 (41.7%) patients in cohort 2 meeting criteria and 22 (30.6%) of those were treated. Patients in cohort 1 had a 26% fracture rate after transplant while only 1.3% suffered fractures in cohort 2. Stable or better T-score and FRAX score were noted in 18.8% of cohort 1 versus 11% in cohort 2.Since implementation of BMD care path, we have demonstrated increased screening prior to transplant, increased treatment of low BMD and decreased fractures. Post-transplant screening was unexpectedly lower. This may, in part, be due to longer-follow up period of cohort 1. Long-term follow-up will continue to be necessary to evaluate the impact of BMD screening and treatment on the overall morbidity and mortality of allo-HCT patients.