Disparities in disease presentation and survival after pathological fracture surgery at a middle- and a high-income centre.

BACKGROUND

Cancer prevalence is rapidly increasing in low- and middle-income countries, where late diagnosis and limited healthcare resources contribute to poor outcomes. The aim of this study was to compare presentation patterns and survival outcomes between Groote Schuur Hospital (South Africa) and Karolinska University Hospital (Sweden) to highlight disparities between high- and middle-income healthcare settings. METHOD: This retrospective cohort study used data from the International Bone Metastasis Registry. Patients who underwent surgery for pathological fractures between 2018 and 2023 were included. The primary objective was to compare the proportion of patients presenting with malignancy not diagnosed prior to surgery between the two centres. Secondary outcomes included newly diagnosed malignancy within two months from surgery, indication for surgery, ECOG performance status, and survival.

RESULTS

A total of 362 patients were included; 107 from Groote Schuur Hospital (GS) and 255 from Karolinska University Hospital (KS). GS had a higher proportion of patients with malignancy not diagnosed prior to surgery (13% vs 4%; p = 0.004) and newly diagnosed malignancy within two months (50% vs 25%; p < 0.001). GS patients were younger, more often female, and more frequently had breast cancer. They had fewer visceral metastases and better ECOG performance status. Prophylactic fixation was more common at GS, while surgical techniques were similar. No statistically significant difference in postoperative survival from surgery was detected between centres (p = 0.065); however, median postoperative survival was longer at GS (13 months) compared with KS (6 months), and the proportion of long-term survivors (> 2 years) was higher at GS (17% vs 3%; p < 0.001). Median overall survival from cancer diagnosis was longer at KS (247 months) compared with GS (43 months; p < 0.001).

CONCLUSIONS

Patients at GS were more likely to present with previously undiagnosed or newly diagnosed malignancy, reflecting delayed detection and referral. They had better performance status, fewer visceral metastases, and more frequent prophylactic surgery. Despite similar surgical methods, postoperative survival did not differ significantly. These findings underscore the need for earlier cancer detection and improved access to systemic therapy in resource-limited settings.