Screen Women 65 and Older for Osteoporosis, Says USPSTF

Final Recommendation Calls for Screening Some Younger At-risk Women, Not Men

July 02, 2018 12:03 pm News Staff – On June 26, The U.S. Preventive Services Task Force (USPSTF) posted a final recommendation statement and final evidence summary on screening for osteoporosis to prevent fractures.

Based on its review of the evidence, the USPSTF recommended screening for osteoporosis with bone measurement testing to prevent osteoporotic fractures in women 65 and older -- a "B" recommendation.

The task force also recommended screening for osteoporosis in postmenopausal women younger than 65 who are at increased risk of osteoporosis, as determined by a clinical risk assessment tool -- also a "B" recommendation.

"Without screening, most women won't know that they have osteoporosis until they have a fracture. Screening and treatment can help prevent these fractures," said USPSTF member Chien-Wen Tseng, M.D., M.P.H., M.S.E.E., in a news release. "Based on the evidence, we recommend screening for women over the age of 65 and younger women who have been through menopause and are at increased risk for osteoporosis."

The task force found insufficient evidence to assess the balance of benefits and harms of screening for osteoporosis to prevent osteoporotic fractures in men -- an "I" recommendation.

"While both men and women can develop osteoporosis, there's less evidence to know whether screening and current treatments prevent fractures in men without a history of fractures. More studies are needed that look at how well treatments work in men who have not had a fracture," said USPSTF Vice Chair Alex Krist, M.D., M.P.H., in the release.

The USPSTF said this final recommendation statement is consistent with the group's 2017 draft recommendation and 2011 final recommendation on screening for osteoporosis, which also found benefit in screening women 65 and older, as well as younger women at increased risk.

The AAFP agreed with that 2011 guidance at the time.

Story Highlights

This final recommendation statement is based on a systematic literature review that identified evidence published since the 2011 recommendation and that examined newer evidence on screening for and treating osteoporotic fractures in women and men. The review also sought evidence on risk assessment tools, screening intervals, and screening and treatment efficacy in various subgroups.

The task force defined the screening population as postmenopausal women and older men with no history of osteoporotic fractures and no known comorbid conditions or medication use associated with secondary osteoporosis. Adults younger than 40 were excluded.

The USPSTF said the only major change from 2011 is that the task force expanded its consideration of evidence related to fracture risk assessment, with or without bone mineral density (BMD) testing, for the final recommendation.

Additional Notes

After the USPSTF released its draft recommendation statement on this topic in November 2017, Jennifer Frost, M.D., medical director for the AAFP Health of the Public and Science Division, told AAFP News that although this recommendation is generally unchanged from the 2011 recommendation, the previous guidance defined its recommendation for younger women as pertaining to those "whose fracture risk is equal to or greater than that of a 65-year-old white woman who has no additional risk factors" -- a definition based on using the Fracture Risk Assessment (FRAX) tool developed from studying population-based cohorts in various parts of the world.

The final recommendation isn't tied specifically to FRAX, however, and discusses using other tools to determine risk, including the Simple Calculated Osteoporosis Risk Estimation, the Osteoporosis Risk Assessment Instrument, the Osteoporosis Index of Risk and the Osteoporosis Self-Assessment Tool, all of which have accuracy levels similar to that of the FRAX tool.

These tools have different thresholds to indicate increased risk, so the final recommendation's language was adjusted from the 2011 guidance to include them. The thresholds for the different tools are listed in the Other Considerations section of the final recommendation statement.

Common bone measurement tests used to screen for osteoporosis include central dual-energy X-ray absorptiometry (DXA) and quantitative ultrasound (QUS). DXA measures BMD at central sites (hip and lumbar spine) or peripheral sites (e.g., wrist, forearm and calcaneus). QUS evaluates peripheral sites and has similar accuracy in predicting fracture risk as DXA while avoiding the risk of radiation exposure, but it doesn't measure BMD.

And although age is the biggest risk factor associated with women's chance of developing osteoporosis, factors that put younger women at increased risk include menopausal status, low body weight, current tobacco use and excessive alcohol consumption, Frost said.

Also, related to the "I" statement for men, the AAFP has endorsed the American College of Physicians' guideline on treatment for osteoporosis, which recommends treatment with bisphosphonates in men with clinically identified (not screen-detected) osteoporosis, based on low-quality evidence.

Response to Public Comment

A draft version of the final recommendation statement was available for public comment on the USPSTF's website from Nov. 7 to Dec. 4, 2017.

In response to some commenters, the task force added information on the accuracy of certain clinical risk assessment tools to identify osteoporosis in women younger than 65 to the statement's Discussion section.

Additionally, the USPSTF clarified that adults with certain conditions that may increase their risk of falls and those using certain medications (such as aromatase inhibitors) that may increase their risk of fractures are excluded from this recommendation.

Other commenters said they were concerned that the task force didn't recommend screening for osteoporosis in men.

"Although the USPSTF agrees that prevention of osteoporotic fractures in men is an important public health issue, there is currently not enough evidence demonstrating that screening for and subsequent treatment of osteoporosis in men prevents primary fractures," the task force noted in its final recommendation statement.

The task force said studies that have evaluated screening and treatment in men have focused on populations that are out of the scope of this recommendation, such as men with a history of fractures or men taking medications that may cause secondary osteoporosis.

Finally, the USPSTF updated the final recommendation statement to include information from a recent trial that evaluated the direct effect of screening for osteoporosis on the incidence of fractures.

Up Next

The AAFP's Commission on Health of the Public and Science plans to review the USPSTF's final recommendation statement and evidence review and determine the Academy's stance on the recommendation.

Familydoctor.org: Osteoporosis