Osteoporosis Screening Recommendations

January 18, 2011 — The US Preventive Services Task Force (USPSTF) issued a B recommendation to routinely screen for osteoporosis in women 65 years of age or older and in younger women at comparable or greater fracture risk to that of a 65-year-old white woman with no additional risk factors. Current evidence was found to be insufficient to make a recommendation for or against screening men at this time (I statement).
This update to the 2002 USPSTF osteoporosis screening recommendation was published online January 17 in the Annals of Internal Medicine and is the first final recommendation statement to be published since the USPSTF implemented a new process for recommendation statements in July 2010. In this process, all draft recommendation statements are posted for public comment on the USPSTF Web site, as this draft was from July 6 to August 3, 2010, before being issued in final form.
"One half of all postmenopausal women will have an osteoporosis-related fracture during their lifetime, including 25% who will develop a vertebral deformity and 15% who will suffer a hip fracture," write USPSTF Chair Ned Calonge, MD, MPH, from the Colorado Trust in Denver, and colleagues. "Osteoporotic fractures, particularly hip fractures, are associated with chronic pain and disability, loss of independence, worsened quality of life, and increased mortality. Although hip fractures occur less commonly in men than in women, more than one third of men who sustain a hip fracture will die within 1 year."
Approximately 12 million Americans older than 50 years are expected to have osteoporosis by 2012. In addition to female sex and white race/ethnicity, other risk factors for osteoporosis include smoking, alcohol intake, low body mass, and parental history of fractures. To estimate 10-year risks for fractures, the USPSTF used the FRAX tool because it relies on easily obtainable clinical information, it was extensively validated in 2 large US cohorts, and it is freely accessible by clinicians and by the public.
Because the risk for fractures continues to rise with increasing age, the USPSTF did not specify an age limit at which screening should no longer be performed. When deciding whether to screen patients with significant morbidity, however, clinicians should consider the remaining lifespan.
The updated recommendations were based on a USPSTF assessment of available evidence on the diagnostic accuracy of instruments to determine osteoporosis and fracture risk, the utility of dual-energy x-ray absorptiometry (DXA) and peripheral bone measurement tests in predicting fractures, the potential harms of osteoporosis screening, and the potential benefits and harms of pharmacotherapy for osteoporosis in women and in men.
In terms of detecting osteoporosis, the USPSTF found convincing evidence that bone measurement tests such as DXA of the hip and lumbar spine and quantitative ultrasound of the calcaneus predict short-term risk for osteoporotic fractures in women, as well as in men. Evidence is adequate that clinical risk assessment instruments are only modestly predictive for low bone density or for fractures.
To date, no controlled studies have assessed whether screening for osteoporosis offers any benefits in terms of detection and early treatment, such as lower fracture rates or fracture-related morbidity or mortality.
Available evidence is convincing that drug treatment lowers the risk for fractures in postmenopausal women who have no previous osteoporotic fractures. The USPSTF determined that the magnitude of benefit of treating screening-detected osteoporosis is at least moderate in women 65 years of age or older, and in younger women whose fracture risk is at least as great as that of a 65-year-old white woman with no additional risk factors.
Treatment options include sufficient intake of calcium and vitamin D and weight-bearing exercise. Several drugs have been approved by the US Food and Drug Administration to prevent fractures, including bisphosphonates, parathyroid hormone, raloxifene, and estrogen.
"The choice of therapy should be an individual one based on the patient's clinical situation and the tradeoff between benefits and harms," the statement authors write. "Clinicians should provide patient education on how to use drug therapies to minimize side effects."
Because of the absence of randomized trials of primary fracture prevention in men who have osteoporosis, evidence was deemed inadequate to determine whether pharmacotherapy lowers fracture risk in men with no history of osteoporotic fractures.
Since publication of the 2002 USPSTF osteoporosis screening recommendation, the USPSTF has found no new studies evaluating harms of screening for osteoporosis in men or in women. DXA screening is associated with opportunity costs; namely, the time and effort expended by patients and by the healthcare system.
The specific agent used determines the potential harms of drug therapies for osteoporosis. For bisphosphonates, which are the most commonly prescribed treatments for osteoporosis, the USPSTF found adequate evidence that the harms are no greater than small. For estrogen and selective estrogen receptor modulators, however, the USPSTF found convincing evidence that the harms are small to moderate.
"The USPSTF concludes that for women ages 65 years and older, and for younger women whose fracture risk is equal to or greater than that of a 65-year-old white woman who has no additional risk factors, there is moderate certainty that the net benefit of screening for osteoporosis using DXA is at least moderate," the statement authors write. "The USPSTF concludes that for men, evidence of the benefits of screening for osteoporosis is lacking, and the balance of benefits and harms cannot be determined."