Fall-Related Injuries in Older Adult Cancer Survivors : A Decade of Racial Disparities

doi:10.21203/rs.3.rs-4979156/v1

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Fall-Related Injuries in Older Adult Cancer Survivors : A Decade of Racial Disparities

https://doi.org/10.21203/rs.3.rs-4979156/v1

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Background: As the population ages and the number of cancer survivors in the USA continues to rise, fall-related injuries are becoming an increasingly critical public health issue. The purpose of this study is to assess the incidence and prevalence of fall-related injuries among older adult cancer survivors, with a particular focus on identifying and understanding racial disparities in fall risk between Black and White cohorts.

Methods: A retrospective cohort study using data from 19,370 older adult cancer survivors aged 65 and above, extracted from the TriNetX network at Virginia Commonwealth University Health System (VCUHS). The study spanned from January 1, 2013, to December 31, 2023. Demographic information, including age, sex, race, and ethnicity, as well as ICD-10 codes for cancer history and fall-related injuries, were analyzed. Incidence rates were calculated as cases per person-day.

Results: The study found that 7% of the cancer survivors experienced a new fall-related injury, with a prevalence rate of 8% over the study period. The incidence rate was calculated at 0.00005432 cases per person-day. Black or African American survivors exhibited a higher fall risk (4.915%) compared to their White counterparts (4.048%), with a statistically significant risk difference of 0.867% (95% CI: 0.199% to 1.534%).

Discussion

The findings of this study are consistent with existing literature that highlights the increased fall risk among older adult cancer survivors. The observed racial disparities in fall-related injuries underscore the need for targeted interventions that address the specific challenges faced by minority populations. The study's large sample size and comprehensive dataset strengthen the generalizability of the results, although the reliance on automated ICD-10 coding presents a potential limitation in data accuracy.

Conclusions

This study reveals significant racial disparities in fall-related injuries among older adult cancer survivors, particularly between Black and White individuals. The findings suggest the need for culturally sensitive and equitable healthcare strategies to improve the quality of life for all cancer survivors.

Fall-related injuries are a critical public health issue that disproportionately affects cancer survivors, who often experience unique physical and functional declines due to their disease and its treatments¹. Over the last decade, advancements in cancer care have significantly improved survival rates, leading to an increasing population of cancer survivors who may face long-term health challenges, including an elevated risk of falls^2,3. Fall risk is influenced by factors such as muscle weakness, neuropathy, and bone fragility, often exacerbated by cancer treatments like chemotherapy, radiation, or surgery⁴.

Studies indicate that cancer survivors, regardless of cancer type, face a higher risk of falls compared to the general population, with rates as high as 60% in some cohorts ⁵. Demographic variables significantly impact the risk of falls⁶. Research shows that minority cancer survivors may experience higher fall rates due to disparities in access to care, quality of treatment, and the subsequent management of side effects, which directly contribute to fall risk ⁷. For example, African American and Hispanic cancer survivors might receive less comprehensive follow-up care, potentially leading to unmanaged side effects such as neuropathy or muscle weakness, both of which elevate the risk of falls⁸.

Moreover, socioeconomic factors linked to different racial and ethnic groups further influence the risk and consequences of falls. These factors include variations in living conditions, such as housing quality and neighborhood walkability, both of which are essential for ensuring safe mobility, particularly for individuals weakened by cancer treatments⁹.

In addition to racial and socioeconomic disparities, gender differences can be a significant variable affecting fall-related injury rates¹⁰. Women generally experiencing a higher incidence of falls among breast cancer survivors, where estrogen-lowering therapies contribute to decreased bone density, increasing the risk of fragility fractures¹¹. However, men are not exempt from these risks, as male survivors, particularly those treated for prostate cancer with androgen-deprivation therapies, face similar issues of bone demineralization and muscle weakness. This underscores the need for targeted fall prevention strategies across genders ¹².

The purpose of this study is to assess the incidence and prevalence of fall-related injuries among older adult cancer survivors over a decade, with a specific focus on understanding the demographic factors, including age, sex, race, and ethnicity, that contribute to fall risk. Additionally, the study aims to identify and quantify racial disparities in fall incidence, particularly between Black and White cancer survivor cohorts, to inform targeted prevention strategies and address the observed disparities in fall risk within this vulnerable population.

Study Design and Population. This retrospective cohort study utilizes a dataset of 19,370 older adults aged 65 years and above, specifically focusing on Black and White cancer survivors who have experienced falls, as identified through their medical records. The study period spans from January 1, 2013, to December 31, 2023.

Data Collection. Data were extracted from the electronic health records (EHRs) available through the TriNetX network at Virginia Commonwealth University Health System (VCUHS). The dataset includes detailed demographic information (age, sex, race, and ethnicity), diagnosis codes (ICD-10) related to survivors who had malignant cancers, and records of fall-related injuries, specifically identifying cases where patients arrived at the emergency room (ER) with injuries classified as severe or related to older adult falls.

The EHR data encompasses comprehensive patient records, capturing a wide range of clinical variables essential for robust epidemiological analysis. Diagnosis codes were based on the International Classification of Diseases, 10th Revision (ICD-10), ensuring standardized and accurate identification of medical conditions. Data extraction was facilitated by the informatics team at Virginia Commonwealth University's (VCU). Kenneth and Dianne Wright Center for Clinical and Translational Research. Their support ensured the accuracy and completeness of the dataset, enabling detailed analysis of patient outcomes.

The observational informatics program at VCUHS provided secure access to the TriNetX database, adhering to stringent data governance protocols designed to protect patient privacy and comply with regulatory standards. This program ensured that all data handling processes met ethical and legal requirements, guaranteeing the integrity and confidentiality of patient information.

Statistical Analysis. Our analysis was conducted on the TriNetX platform. We employed descriptive statistics to summarize the demographic characteristics of the study population. Continuous variables such as age were expressed as means and standard deviations, while categorical variables including sex, race, and ethnicity were reported as frequencies and percentages. Incidence rates were calculated as the number of new cases per person-day, providing a measure of the risk of developing fall-related injuries among the study population.

Software and Tools. Data analysis was conducted using the analytical tools available within the TriNetX network. These tools facilitated the processing and analysis of large datasets, enabling comprehensive statistical evaluations and visualizations.

The study encompassed 19,370 cancer survivors over a decade, aged between 65 and 89 years. The mean age of participants was 79 years, with a standard deviation of 8 years, highlighting the predominantly older adult cohort at heightened risk of fall-related injuries. The demographic breakdown (Table 1) revealed a slight male predominance with 51.17% males (n = 9,911) and 48.83% females (n = 9,459), with no participants categorized under unknown sex.

In terms of racial composition, 72.69% of the participants were White (n = 14,096), while 27.31% were Black or African American (n = 5,285), reflecting significant racial diversity within the study group. Ethnicity data showed that 0.72% were Hispanic or Latino (n = 140), 98.25% were not Hispanic or Latino (n = 19,037), and 1.03% had unknown ethnicity (n = 193).

Table 1

Descriptive Analysis of Demographic of Cancer Survivor
Variable	Category	N = 19,370	%=100
Sex	Female	9,459	48.83%
	Male	9,911	51.21%
	Unknown	0	0.00%
Race	White	14,096	72.69%
	Black or African American	5,285	27.31%
Ethnicity	Hispanic or Latino	140	0.72%
	Not Hispanic or Latino	19,037	98.25%
	Unknown Ethnicity	193	1.03%

Incidence and Prevalence of Fall-Related Injuries Among Cancer Survivors Aged 65 and Above, Stratified by Age, Sex, Race, and Ethnicity (2013–2023)

The study conducted over a decade reveals significant findings regarding fall-related injuries among older adult cancer survivors. In Table 2. The incidence proportion stands at 0.07005254, indicating that about 7% of the population experienced a new fall-related injury. The prevalence rate was slightly higher at 0.07919075, suggesting that nearly 8% of the survivors had fall-related injuries at any point in the given time frame. Additionally, the incidence rate measured as cases per person-day was 0.00005432, underscoring a continuous risk and occurrence of new fall injuries among this demographic.

The study delineates clear trends in the incidence and prevalence of fall-related injuries among cancer survivors, with noticeable differences across age groups. For those aged 65–69 years, the incidence proportion stood at 0.0627, with a prevalence of 0.0712 and an incidence rate of approximately 4.80 cases per person-day. As age increased, so did the incidence and prevalence rates; the group aged 80–84 exhibited the highest figures, with an incidence proportion of 0.1102, prevalence of 0.1285, and an incidence rate of 9.32 cases per person-day, indicating a heightened vulnerability among the oldest subsets of the population.

Transitioning from age to sex-related differences, the data show that males had a slightly higher incidence rate at 5.67 cases per person-day compared to females, who had a rate of 5.19 cases per person-day. Despite this, females exhibited a higher prevalence rate of 0.0797, suggesting that while fewer females may experience falls, those who do fall tend to do so repeatedly. This contrast highlights the nuanced differences in fall dynamics between genders.

In terms of race, Black or African American survivors exhibited both higher incidence proportions and prevalence rates (0.0759 and 0.0896, respectively) compared to their White counterparts, who showed incidence proportions and prevalence rates of 0.0687 and 0.0753, respectively. This disparity may reflect underlying socio-economic and healthcare access differences that affect recovery and preventive care availability.

Ethnic differences further accentuate disparities, with Hispanic or Latino survivors experiencing the highest incidence rate at 0.156 cases per person-day, significantly outpacing their Non-Hispanic or Latino peers who recorded an incidence rate of 5.45 cases per person-day. This stark contrast may be influenced by cultural, linguistic, and systemic barriers that affect health outcomes and access to preventive measures. Conversely, individuals of unknown ethnicity had the lowest figures in all categories, indicating potential issues in data capture or healthcare engagement.

Table 2

Incidence and Prevalence of Fall-Related Injuries Among Cancer Survivors Aged 65 and Above, Stratified by Age, Sex, Race, and Ethnicity (2013–2023)
Variable	Category	Incidence Proportion	Prevalence	Incidence Rate (cases/person-day)
Overall		0.07005254	0.07919075	5.431524E-5
Age Group	65–69	0.06269593	0.071207434	4.7957765E-5
	70–74	0.07633588	0.08712121	5.8963567E-5
	75–79	0.102564104	0.11167513	8.054279E-5
	80–84	0.11020408	0.12851405	9.3233975E-5
Sex	Female	0.068509616	0.07966706	5.186841E-5
	Male	0.071428575	0.07874016	5.6736822E-5
Race	Black or African American	0.07592191	0.08955224	5.542092E-5
	White	0.0686901	0.07533704	5.4506472E-5
Ethnicity	Hispanic or Latino	0.07692308	0.07692308	1.5581421E-4
	Not Hispanic or Latino	0.07070707	0.079458505	5.4530123E-5
	Unknown Ethnicity	0.055555556	0.055555556	4.8480382E-5

Comparative Analysis of Fall Incidence Between Black and White Cancer Survivor Cohorts

Table 3 provided statistical data compares the incidence of falls between Black and White cancer survivor cohorts. Within the Black Cancer Survivor cohort, which includes 5,290 patients, 260 patients experienced falls, resulting in a fall risk of 4.915%. Conversely, the White Cancer Survivor cohort, encompassing 14,080 patients, documented 570 falls, corresponding to a risk of 4.048%. The risk difference between the cohorts is 0.867% (95% CI: 0.199–1.534%), indicating a statistically significant higher risk of falls among Black cancer survivors compared to their White counterparts. The risk ratio and odds ratio are 1.214 (95% CI: 1.052 to 1.401) and 1.225 (95% CI: 1.054 to 1.424), respectively, suggesting the likelihood of falls is about 21–22% higher in the Black cohort. The statistical significance of these findings is confirmed with a p-value of 0.0080, highlighting a notable disparity in fall incidence between the two groups.

Table 3

Measures of Association for Fall Incidence in Cancer Survivor Cohorts
Cohort	Patients in Cohort	Patients with Outcome	Risk	Risk Difference	95% CI of Risk Difference	Z-Value	P-Value	Risk Ratio	95% CI of Risk Ratio	Odds Ratio	95% CI of Odds Ratio
Black Cancer Survivor Cohort	5,290	260	4.915%	0.867%	(0.199%, 1.534%)	2.654	0.0080	1.214	(1.052, 1.401)	1.225	(1.054, 1.424)
White Cancer Survivor Cohort	14,080	570	4.048%	0.867%	(0.199%, 1.534%)	2.654	0.0080	1.214	(1.052, 1.401)	1.225	(1.054, 1.424)

This study provides a comprehensive analysis of fall-related injuries among older adult cancer survivors, emphasizing the significant disparities that exist across different demographic groups, particularly between Black and White cancer survivors. The study’s demographic analysis highlights that the majority of the 19,370 cancer survivors were older adults. The slight male predominance and significant racial diversity within the cohort, particularly with 27.31% being Black or African American and most of them are non-Hispanic.

Our finding that approximately 7% of the cancer survivor population experienced a new fall-related injury aligns with the literature, which consistently reports higher fall rates among older adults with cancer compared to the general population. This elevated risk is largely attributed to the long-term effects of cancer treatments, such as chemotherapy-induced peripheral neuropathy and radiation-induced bone density loss, which significantly impair balance and mobility ^13,14. The literature also supports our observation that fall risk increases with age, particularly in individuals over 80 years old, who experience the highest incidence rates of fall-related injuries. This trend is well-documented and reflects the cumulative effects of aging and cancer treatment on physical health¹⁵.

Regarding racial disparities, our study found that Black or African American cancer survivors had higher incidence and prevalence rates of falls compared to their White counterparts. This finding is corroborated by previous research indicating that minority groups, particularly African Americans, often experience worse health outcomes, including higher fall rates, due to a combination of socio-economic factors, reduced access to healthcare, and differences in the quality of care received^16–19. Investigating further into the health challenges faced by the Black or African American community reveals significant disparities in cancer outcomes and related health risks, including fall-related injuries. Our study contributes to this understanding by demonstrating that Black cancer survivors experience a notably higher risk of falls compared to their White counterparts, with a fall risk difference of 0.867%. This finding is consistent with broader research that highlights the disproportionate burden of poorer health outcomes and increased vulnerability to injuries among Black individuals, often linked to systemic socio-economic factors and unequal access to healthcare^21,22.

However, the literature also notes some variability in fall rates among different racial groups, suggesting that other factors, such as cultural practices and community support, may influence fall risk ¹⁴. The higher incidence of falls related injury rate among Hispanic or Latino cancer survivors observed in our study is consistent with findings that suggest cultural and systemic barriers may limit access to fall prevention resources and adequate follow-up care for this group ^10,20.

Strengths

One of the primary strengths of this study lies in its large sample size, encompassing 19,370 older adult cancer survivors, which enhances the generalizability of the findings across this vulnerable population. The use of a comprehensive dataset from the TriNetX network at Virginia Commonwealth University Health System (VCUHS) allowed for detailed demographic analysis, providing insights into the incidence and prevalence of fall-related injuries stratified by age, sex, race, and ethnicity. The inclusion of ICD-10 codes to identify specific cancer types and fall-related injuries ensures a high level of accuracy in capturing relevant clinical outcomes, further strengthening the validity of the study's findings. Additionally, the decade-long study period provides a robust temporal framework to observe trends and shifts in fall risk, making the results more reliable and reflective of long-term patterns.

Limitations

While the inclusion of ICD-10 codes to identify specific cancer types and fall-related injuries enhances the accuracy of capturing relevant clinical outcomes, there is a limitation in that these codes are sometimes assigned automatically to patients, which may lead to potential misclassification or inaccuracies in the data. The reliance on automated coding systems for assigning ICD-10 codes may introduce variability in data quality, potentially impacting the study’s findings. Such variability could lead to misclassification or inaccuracies in identifying specific cancer types and fall-related injuries. Moreover, while the decade-long study period offers a comprehensive temporal framework, it may also reflect changes in coding practices or healthcare delivery over time. These factors could influence the observed trends, necessitating a careful and cautious interpretation of the results.

Our study highlights significant disparities in fall-related injuries among older adult cancer survivors, particularly between Black and White individuals. The findings emphasize the need for targeted interventions that address the unique risks associated with aging, race, and cancer treatment. Despite the limitations related to automated ICD-10 coding and potential shifts in healthcare practices over the decade, the study provides valuable insights into the persistent challenges faced by this vulnerable population. These results underscore the importance of developing culturally sensitive and equitable healthcare strategies to mitigate fall risk and improve outcomes for all cancer survivors.

VCUHS: Virginia Commonwealth University Health System
ICD-10: International Classification of Diseases, 10th Revision
EHR: Electronic Health Records

Clinical Trial Number: Not applicable

Ethics Approval and Consent to Participate

Ethical approval for this study was obtained from the Institutional Review Board (IRB) at Virginia Commonwealth University, classified as a non-human subject submission to ensure adherence to ethical guidelines and patient confidentiality. As this study involved retrospective analysis of de-identified data, patient consent was not required.

Consent for Publication: Not applicable.

Availability of Data and Materials; The datasets generated and/or analyzed during the current study were extracted from the TriNetX database. These datasets are available from the corresponding author on reasonable request, subject to privacy and ethical restrictions.

Competing Interests: The authors declare that they have no competing interests.

Funding: This work was supported by the C. Kenneth and Dianne Wright Center for Clinical and Translational Research at Virginia Commonwealth University under the Clinical and Translational Science Award (CTSA) Grant number UM1TR004360.

Authors' Contributions

Asmaa Namoos, MD, MPH, PhD: Conceptualized the study, led the data analysis, and drafted the manuscript.

Nicholas Thomson, PhD: Provided methodological support and critical revisions to the manuscript.

Vanessa Sheppard, PhD: Assisted in the interpretation of the results and contributed to the manuscript's writing.

Michel Aboutanos, MPH, MD: Supervised the study, contributed to the study design, and reviewed the manuscript for intellectual content.

All authors have read and approved the final manuscript.

Acknowledgements

We extend our gratitude to the informatics team at Virginia Commonwealth University's (VCU) C. Kenneth and Dianne Wright Center for Clinical and Translational Research, especially Dr. Tamas Gal and his team members Evan French and Patrick Shi, for their invaluable support in data extraction through the TriNetX platform.

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No competing interests reported.

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You are reading this latest preprint version

Fall-Related Injuries in Older Adult Cancer Survivors : A Decade of Racial Disparities

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Version 1

Abstract

Background

Methods

Results

Comparative Analysis of Fall Incidence Between Black and White Cancer Survivor Cohorts

Discussion

Conclusion

Abbreviations

Declarations

References

Additional Declarations

Status:

Version 1