New USPSTF Draft Recommendations for Osteoporosis Screening

Nancy A. Melville

November 07, 2017

The US Preventive Services Task Force (USPSTF) has issued draft recommendations on screening for osteoporosis to prevent fractures that are similar to their previous guidelines in 2011, with some notable changes including suggestions to better identify women at risk under the age of 65.

The task force proposes routine screening for women aged 65 years and older and screening for postmenopausal women younger than 65 years who are at increased risk for osteoporosis, as determined by formal clinical risk assessment tools such as the Fracture Risk Assessment Tool (FRAX), the Osteoporosis Risk Assessment Instrument (ORAI), and others.

The USPSTF concludes, as it did in 2011, that evidence for the benefits of screening men for osteoporosis is still insufficient, noting the significantly lower prevalence of osteoporosis in men (4.3%) than in women (15.4%). For example, only when men reach age 80 years does the prevalence of osteoporosis in white men reach the rate in white women at age 65.

The draft recommendation, which is posted on the task force's website and open for public comment until December 4, rates the quality of evidence for the screening of women over age 65 and for at-risk women younger than age 65 as a "B," meaning the task force recommends the screening.

"Without screening, most women won't know that they have osteoporosis until they have a fracture," said task force member Alex H Krist, MD, MPH, professor of family medicine and population health at Virginia Commonwealth University in Richmond, and codirector of the Virginia Ambulatory Care Outcomes Research Network, in a USPSTF press statement.

"The task force found that screening for osteoporosis can help clinicians identify and treat the disease early to help prevent fractures."

Screening of Women Under 65 Is a Gray Area:  Proposal for 8.4% Cutoff

The fact that these new recommendations are consistent with the previous guideline from 2011 reflects the gray area surrounding routine screening for women under age 65 years, Dr Krist told Medscape Medical News.

"We still are recommending screening in younger postmenopausal women who are at risk, with a B recommendation saying the evidence is sufficient that benefits do seem to outweigh the harms," he noted.

"But where we need more evidence is in terms of what the threshold should be in assessing the risk in women under the age of 65. That remains a gap where we really don't know all the evidence."

Risk factors that should be considered in the decision about whether to screen women under age 65 include parental history of hip fracture, smoking, excess alcohol consumption, low body weight, and menopausal status, according to the draft recommendation.

If patients do have risk factors, the FRAX is a reasonable tool for assessing the 10-year risk for fracture. The new cutoff of an 8.4% risk for a major osteoporotic fracture in the next 10 years is just slightly lower than the previous cutoff of 9.3% in the 2011 recommendation.

As reported previously by Medscape Medical News, one study in 2014 concluded that three-quarters of women aged 50 to 64 years with osteoporosis were being missed with use of the 9.3% cutoff.

"Commonly used screening modalities such as USPSTF and other risk-based strategies do not seem to have the expected predictive performance," first author Xuezhi (Daniel) Jiang, MD, assistant professor of obstetrics and gynecology at the Sidney Kimmel Medical College of Thomas Jefferson University in Philadelphia, Pennsylvania, told Medscape Medical News at the time. In fact, "USPSTF has the poorest performance," he said.

That study showed that changing the FRAX cutoff from 9.3% to 4.7% improved the sensitivity to 92%; however, the number needed to scan to detect one case in 10 increased. "It may be time to revisit and redefine this FRAX-based threshold," Dr Jiang noted.

Commenting at the time, Lila Nachtigall, MD, professor of obstetrics and gynecology and head of the DXA unit at New York University–Langone Medical Center in New York City, echoed the concern: "The guidelines don't always make good medical practice. It's the under-65-year-old woman you're going to want to treat. If you wait till 65, then they've got broken bones."

FRAX Not Necessarily Best

In response to these prior concerns, Dr Krist said that the new proposed FRAX cutoff of 8.4% is considered a suggestion only, not a definitive cutoff, because of the limited evidence on the issue.

"We're trying to be clear that there is not a ton of evidence on the best way to categorize women under 65 who should get screening for bone-density testing — it's an area where we have limited data," he said.

Even the use of the FRAX tool itself is only a suggestion, he added.

"We're providing FRAX as an example of an assessment tool that you could use, but we actually don't have good data to say what is the best instrument for assessing risk or what is the exact right threshold," he explained.

"So, to some extent it is a clinical judgment and is something that we want doctors and patients to decide together based on various factors. It's not as simple as having one risk and you should go and do this.

"The other thing is that we're looking not just at the risk of osteoporosis — we're trying to prevent that whole pathway from osteoporosis to osteoporotic fractures, which is a little more complicated."

Other assessment tools that are considered by USPSTF to have accuracy similar to that of FRAX include the Simple Calculated Osteoporosis Risk Estimation (SCORE), the Osteoporosis Risk Assessment Instrument (ORAI), the Osteoporosis Index of Risk (OSIRIS), and the Osteoporosis Self-Assessment Tool (OST).

How Do Updated USPSTF Guidelines Compare With Other Guidelines?

The task force's recommendations for women are in line with those of such organizations as the National Osteoporosis Foundation, which in 2014 recommended bone-mineral density (BMD) testing in all women aged 65 years and older; in those aged 50 to 65 years, testing should be done according to their risk factors.

However, the National Osteoporosis Foundation also recommends screening for all men aged 70 years and older and men under age 70 who have risk factors for low bone mass.

The Endocrine Society also recommends screening in men older than 70 years and in any adults aged 50 and older with significant risk factors for osteoporosis or prior fracture.

The American Academy of Family Physicians recommends screening in women age 65 years and older and in younger women when the fracture risk is equal to or greater than that of a 65-year-old white woman. The American College of Obstetricians and Gynecologists in 2014 recommended BMD screening with dual-energy X-ray absorptiometry beginning at age 65 years in all women and selective screening of women under age 65 with risk factors or a history of adult fracture.

The American Association of Clinical Endocrinologists recommends evaluation of all women age 50 years and older for osteoporosis risk and consideration of BMD testing based on clinical fracture-risk profile.

The USPSTF also recently issued two separate draft recommendations on interventions to prevent falls and use of vitamin D, calcium, or combined supplementation for the primary prevention of fractures. Those recommendation statements are now being finalized.

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