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. This study compares the presentation, management, and outcomes of patients undergoing surgery for metastatic bone disease at Groote Schuur Hospital, South Africa (GS), and Karolinska University Hospital, Sweden (KS), 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 surgical treatment for a pathological fracture at GS or KS between 2018 and 2024 were included. The primary outcome was the proportion of patients treated for an unknown primary malignancy. Secondary outcomes included recently diagnosed cancer, indication for surgery, Eastern Cooperative Oncology Group (ECOG) performance status and survival. Results: A total of 362 patients were included (GS = 107; KS = 255). GS had a higher proportion with malignancy not yet diagnosed at surgery (13% vs 4%; p = 0.004) and with newly diagnosed cancer within two months (50% vs 25%; p < 0.001). GS patients were younger (median 60 vs 72 years; p < 0.001), more often female (p = 0.005), and more likely to have breast cancer (p = 0.001). They presented with fewer visceral metastases (25% vs 59%; p < 0.001) and better ECOG status (51% vs 16% with ECOG 0–1; p < 0.001). Prophylactic fixation was more common at GS, although surgical techniques were similar. Postoperative survival was comparable (p = 0.065), but GS had more long-term survivors (>2 years: 17% vs 3%; p < 0.001). Median survival from cancer diagnosis was shorter at GS (6 vs 13 months; p = 0.01). 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 was comparable. These findings underscore the need for earlier cancer detection and improved access to systemic therapy and postoperative care in resource-limited settings.