Cervical Cancer Survivors Faced Years of Pelvic Pain After Radiation-Related Fractures, Israeli Study Finds

Key Takeaways

• An Israeli study of 153 patients treated with chemotherapy and radiation for cervical cancer found that 18 patients (11.8%) developed imaging-confirmed pelvic insufficiency fractures.
• Most fractures were diagnosed within two years of treatment, with a median time to diagnosis of 9.5 months.
• Fifteen of the 18 patients with fractures experienced symptoms. Their median observed duration of symptoms was 37 months, and none had documented complete symptom resolution during follow-up.
• Most fractures involved the sacrum, a bone at the base of the spine. New pelvic, sacral, or lower-back pain after cervical cancer treatment may warrant investigation.
• The researchers did not identify reliable clinical or radiation-dose predictors of fractures, but the small number of cases limited their ability to detect risk factors.

Introduction

Pelvic insufficiency fractures following cervical cancer radiation treatment can cause prolonged pain. An Israeli study found that some affected survivors experienced symptoms for years.

Radiation therapy is an important part of treatment for many patients with cervical cancer. However, an Israeli study has identified a potentially prolonged complication that can affect survivors months or years after their cancer treatment ends.

Researchers found that nearly 12% of patients treated with chemotherapy and radiation developed fractures in weakened pelvic bones. Most affected patients experienced pain, and some continued to report symptoms for several years.

The study, published October 23, 2026, in The Oncologist, examined medical records from 153 cervical cancer patients treated at Sheba Medical Center in Israel.

Of the 18 patients who developed pelvic insufficiency fractures, 15 experienced symptoms requiring specialized pain-management care. None of those symptomatic patients had documented complete symptom resolution during the available follow-up.

The findings draw attention to an aspect of cancer survivorship that can receive less attention than the treatment itself: the long-term effects of radiation on bone health, mobility, and daily functioning.

They do not mean that radiation should be avoided. Chemoradiotherapy remains an essential treatment for many patients with cervical cancer. Instead, the research points to the importance of recognizing and managing complications that may emerge after treatment.

What the Study Examined

The researchers conducted a retrospective study using medical records from patients treated for nonmetastatic cervical cancer at Sheba Medical Center between 2018 and 2024.

All 153 patients received chemotherapy alongside pelvic radiation therapy. Most also received brachytherapy, a treatment that delivers radiation close to or inside the tumor.

The median age at the start of treatment was 53 years, with patients ranging from 21 to 81 years old. The median follow-up period was 41.4 months.

Researchers reviewed treatment records, radiation-dose measurements, imaging studies, and subsequent clinical care.

Their primary objective was to determine how often pelvic insufficiency fractures were diagnosed and how long after treatment they appeared.

They also examined whether patient characteristics or radiation exposure could help predict who would develop a fracture.

Unlike studies focused mainly on fracture incidence, this investigation placed particular emphasis on what happened afterward, including pain, specialist referrals, treatments, and symptom persistence (Saad et al., 2026).

What Is a Pelvic Insufficiency Fracture?

A pelvic insufficiency fracture occurs when ordinary physical stress causes a break in bone that has become structurally weakened.

Unlike a typical traumatic fracture, it may develop without a fall or major injury.

Radiation can contribute to bone weakening through changes in blood supply and bone remodeling. Other factors, including osteoporosis, menopause-related bone loss, and underlying skeletal health, may also influence risk.

In cervical cancer survivors, these fractures commonly affect the sacrum, the triangular bone at the base of the spine that connects with the pelvis.

Symptoms can include pelvic pain, lower-back pain, and difficulty with movement.

Because these symptoms can have several causes, imaging may be needed to distinguish an insufficiency fracture from cancer recurrence or other treatment-related complications.

What Researchers Found

Nearly 12% of Patients Developed Pelvic Fractures

Among the 153 patients, 18 developed pelvic insufficiency fractures confirmed by MRI, PET-CT, or both.

That represents 11.8% of the study population, or approximately one in nine patients.

The researchers also calculated an estimated 24-month fracture probability of 11.4% using a time-to-event analysis.

These figures describe different statistical measures. The 11.8% is the observed proportion of patients diagnosed during follow-up, while the 11.4% estimate accounts for the timing of fracture diagnoses and available follow-up.

The median time from completion of chemoradiotherapy to fracture diagnosis was 9.5 months, although diagnoses ranged from four to 65 months afterward.

Most fractures were identified within the first two years after treatment.

This suggests that the early survivorship period is particularly important for evaluating new pelvic symptoms, while recognizing that fractures can also be diagnosed later.

Most Fractures Involved the Sacrum

Sixteen of the 18 patients with fractures, or 89%, had sacral involvement.

Some fractures were confined to the sacrum, while others also involved nearby pelvic structures.

The researchers identified fractures using imaging findings rather than symptoms alone.

Of the 18 patients, 10 were diagnosed using PET-CT, three using MRI, and five using both imaging methods.

This distinction matters because pelvic pain after cancer treatment does not necessarily indicate a fracture. Other possible explanations include nerve injury, soft-tissue changes, degenerative conditions, or recurrent disease.

Most Affected Patients Experienced Pain

Fifteen of the 18 patients with fractures, or 83%, experienced symptoms.

The remaining three patients had fractures detected incidentally during imaging and remained asymptomatic during follow-up.

All 15 symptomatic patients were referred to specialized pain-management services.

Their care included different combinations of medications, rehabilitation, interventional pain procedures, and other supportive treatments.

Among the 18 patients with fractures:

No symptomatic patient had documented complete symptom resolution during the available follow-up.

This does not establish that the symptoms were permanent. Some patients may have improved after their last recorded assessment.

It also does not prove that all ongoing pain was caused by an unhealed fracture. The researchers acknowledged that radiation-related tissue changes, nerve pain, and other musculoskeletal problems could have contributed.

Symptoms Were Documented for a Median of 37 Months

Among symptomatic patients, the median observed duration of symptoms was 37 months.

The recorded durations ranged from 4.2 to 94.5 months.

This was one of the study’s most concerning findings because it indicates that pain and related symptoms could remain part of survivorship care for years.

However, the 37-month figure requires careful interpretation.

It represents the duration over which symptoms were documented in the available records, not the average time required for a fracture to heal or for pain to disappear.

Because many patients were still symptomatic at their last assessment, the study could not establish the eventual time to recovery.

Could Researchers Predict Who Would Develop a Fracture?

The investigators examined several possible risk factors, including age, menopausal status, radiation treatment fields, and radiation doses delivered to pelvic and sacral bones.

They did not identify statistically significant predictors in their time-to-event regression analyses.

However, that finding should not be interpreted as evidence that these factors have no effect.

Only 18 patients developed fractures, leaving the study with limited statistical power to detect associations.

The researchers also lacked consistent information about important aspects of skeletal health, including bone mineral density, osteoporosis status, vitamin D levels, and some hormonal treatments.

One radiation-dose comparison produced an unexpected result. The median sacral mean dose was 36.0 Gy among patients who developed fractures and 36.9 Gy among those who did not (p = 0.043).

Although that difference was statistically significant in the unadjusted comparison, sacral mean dose was not significantly associated with fracture development in the subsequent Cox regression analysis (hazard ratio, 0.98; 95% confidence interval, 0.93–1.04; p = 0.57).

These results do not establish that receiving a lower radiation dose increases fracture risk.

The researchers concluded that fracture development is likely influenced by multiple interacting factors rather than a single easily identifiable characteristic.

How the Findings Compare With Earlier Research

Pelvic insufficiency fractures after radiation therapy are not a newly discovered complication.

Previous research has reported widely varying rates, partly because studies differ in patient populations, imaging schedules, follow-up duration, and definitions of fracture.

A 2020 meta-analysis involving 3,929 patients across 21 studies estimated that 14% developed pelvic insufficiency fractures after radiation therapy for gynecologic cancers.

Approximately 61% of patients with fractures had symptoms.

The sacrum and sacroiliac region were among the most commonly affected locations (Sapienza et al., 2020).

The 11.8% fracture proportion in the Israeli study is broadly consistent with that earlier estimate.

However, the Israeli cohort had a higher proportion of symptomatic fractures: 83%, compared with approximately 61% in the earlier meta-analysis.

That difference does not necessarily mean the Israeli patients experienced more severe radiation-related injury.

The researchers explained that their imaging practices may have contributed.

Patients with new pain were more likely to undergo targeted imaging, while some fractures that caused no symptoms may have remained undetected.

The newer study’s contribution is its detailed examination of long-term symptoms and the supportive care required after fracture diagnosis.

What the Results May Mean for Cervical Cancer Survivors

Persistent Pelvic Pain Should Not Automatically Be Dismissed

Pain after cervical cancer treatment can have many causes.

This study provides evidence that pelvic insufficiency fractures are one possible explanation, particularly when pain develops in the sacrum, pelvis, or lower back after chemoradiotherapy.

The authors emphasized the importance of considering this diagnosis when evaluating new symptoms.

That does not mean every survivor with pelvic pain needs the same imaging test or that pain should automatically be attributed to radiation-related bone injury.

Clinical assessment remains important because recurrent cancer, nerve-related problems, and other conditions may require different investigations and treatments.

For survivors, the practical message is to report new or persistent pelvic pain to their oncology team rather than assuming it is an unavoidable consequence of treatment.

Bone Health May Deserve More Attention During Survivorship

The researchers proposed incorporating bone-health assessments into follow-up care, particularly for patients with risk factors for skeletal weakness.

Potential areas of assessment include osteoporosis, bone mineral density, menopausal status, and other factors affecting bone strength.

However, the study did not test whether a specific screening program or preventive medication reduces fracture risk.

Its proposed care framework is intended to guide future research and clinical discussion, not serve as a validated treatment protocol.

Managing Pain Remains a Challenge

Patients with symptomatic fractures received individualized supportive care.

Some received non-opioid pain medications, while others required opioids, interventional pain procedures, rehabilitation, cannabis, or hyperbaric oxygen therapy.

The study did not randomly assign these treatments or compare their effectiveness.

It therefore cannot establish which intervention works best or whether any particular treatment shortened symptom duration.

The authors called for prospective research using standardized pain scores, mobility assessments, and patient-reported outcomes to better evaluate treatment strategies.

Limitations

The study has several important limitations.

First, it was retrospective and conducted at a single Israeli medical center. Its results may not represent all cervical cancer survivors, particularly those receiving different radiation techniques or follow-up care.

Second, the study included only 18 fracture events. This substantially limited its ability to identify reliable risk factors.

Third, imaging was performed according to clinical need rather than a uniform research schedule.

Patients with symptoms may have been more likely to receive imaging, potentially increasing the detection of painful fractures while missing fractures that caused no symptoms.

Fourth, information about baseline skeletal health was incomplete. The researchers could not fully assess the contribution of osteoporosis, vitamin D status, or changes in bone density over time.

Fifth, pain and functional outcomes were extracted from clinical records rather than measured using standardized questionnaires.

This makes it difficult to compare symptom severity across patients or determine exactly how much improvement occurred.

Finally, the researchers treated death as a censoring event in their Kaplan-Meier analysis rather than accounting for it as a competing event. They acknowledged that this approach could overestimate fracture probability.

The study also lacked a comparison group treated without radiation, so it cannot isolate the effects of radiation from every other contributor to bone weakness.

Final Thoughts

The Israeli study identified pelvic insufficiency fractures in 18 of 153 patients treated with chemoradiotherapy for cervical cancer.

Most fractures appeared within two years of treatment and involved the sacrum.

The most significant finding was the prolonged burden among patients who developed symptoms. All 15 symptomatic patients required specialized pain-management care, and none had documented complete symptom resolution during follow-up.

These observations do not establish that every patient’s pain was caused entirely by the fracture or that symptoms would never resolve.

They do, however, demonstrate why long-term cancer care must address more than whether the disease has returned.

For cervical cancer survivors, new or persistent pelvic pain deserves clinical attention, particularly after pelvic radiation therapy.

Further studies are needed to determine which patients face the greatest fracture risk and which preventive and supportive treatments can improve their long-term outcomes.

Funding and Disclosures

The authors reported that the study received no external funding.

They declared no conflicts of interest relevant to the research.

The study was approved by the institutional review board of Sheba Medical Center. Because it involved retrospective analysis of existing medical records, the requirement for individual informed consent was waived.

References

Saad, A., Goldstein, J., Atamneh, R., Helpman, L., Shapira, R., Berner, O., Morag, O., Jacobi, O., Oren, D., Abu-Toamih Atamni, H. J., Mordechai, R., Goor Aryeh, I., Taylor, A., Peleg Hasson, S., & Felder, S. (2026). Pelvic insufficiency fractures after chemoradiotherapy for cervical cancer: Incidence, long-term outcomes, and survivorship management. The Oncologist. Advance online publication. https://doi.org/10.1093/oncolo/oyag427

Sapienza, L. G., Salcedo, M. P., Ning, M. S., Jhingran, A., Klopp, A. H., Calsavara, V. F., Schmeler, K. M., Leite Gomes, M. J., de Freitas Carvalho, E., & Baiocchi, G. (2020). Pelvic insufficiency fractures after external beam radiation therapy for gynecologic cancers: A meta-analysis and meta-regression of 3929 patients. International Journal of Radiation Oncology, Biology, Physics, 106(3), 475–484. https://doi.org/10.1016/j.ijrobp.2019.09.012