Osteoporosis Screening

Contents

1. From an age line to a measure of risk
2. Who is tested now
3. The question of men
4. How often, and what remains open

The bone density evaluations Candace Cooley has run and interpreted with DEXA technology sit at the center of a set of screening rules that a federal panel revised on January 17, 2011. On that date, NBC News reported, the U.S. Preventive Services Task Force announced that women 65 and older should be screened at least once for osteoporosis, and so should postmenopausal women younger than 65 who are at high risk.¹ Screening recommendations define who is tested and when, and this one was a revision. The previous advice, set in 2002, had also covered every woman 65 and older but beyond that only encouraged screening for high risk women aged 60 to 64. To justify widening it, the panel reviewed about a dozen studies published after 2002.¹

From an age line to a measure of risk

The 2011 change replaced a fixed age band with a judgment about risk. The task force chair, quoted by NBC News, put the logic simply: a younger woman whose bones, or whose fracture risk, resemble those of a 65 year old should be screened as if she were 65.¹ The same report recorded what the panel left out. It found too little evidence to recommend screening women of average risk more than once, and too little research in men to issue guidance for them at all. The chair also explained why bone screening can be spaced more widely than a test such as a mammogram: density is lost far more slowly than a cancer develops. The purpose, as he described it, is to find people at increased risk early enough that medicines can halt the loss of bone mass and prevent future fractures, since rebuilding bone once osteoporosis is established is difficult. The report also sorted the risks: low calcium intake, smoking, an inactive life and certain medicines can be changed, while being a woman, growing older, white or Asian descent, a chronic illness and a family history cannot.¹

The National Institute on Aging’s guidance still reflects that framework. It points women over 65 toward testing, along with younger women at greater risk, and notes that the task force does not recommend regular screening for men, though older men who break a bone easily are urged to raise testing with their doctor. It adds that clinicians may use questionnaires, physical examination and ultrasound to estimate who is likely to have low density or to break a bone.⁷

Figure

Who a bone density test is recommended for

1. 01
   Women 65 and olderTested regardless of other risk factors.
2. 02
   Men 70 and olderTested regardless of other risk factors.
3. 03
   A fracture after 50Anyone who has broken a bone after age 50.
4. 04
   Younger adults with risk factorsWomen 50 to 64 and men 50 to 69 with risks such as a family history of fracture, frequent falls or smoking.

Who is tested now

Professional and public health bodies have since published lists that reach further than the federal panel. The Bone Health and Osteoporosis Foundation’s list covers women 65 and older, men 70 and older, anyone who has broken a bone after age 50, and women 50 to 64 and men 50 to 69 who have risk factors such as a family history of fracture, frequent falls, vitamin D deficiency, smoking, malabsorption or certain medicines such as prednisone.³ The New York State Department of Health’s guide adds adults who have lost more than an inch and a half of height and adults over 50 with a condition or medicine linked to bone loss, and reserves testing for women before menopause, or for younger men, to rare cases. It frames the decision as a shared one with a clinician, beginning with an assessment of risk.⁵ MedlinePlus describes most women 65 and older as needing a scan because they are at high risk of losing density, and names the risks that can bring other women and men forward: very low body weight, a fracture after 50, a loss of half an inch or more of height within a year, a family history of osteoporosis, inactivity, too little calcium and vitamin D, and conditions such as diabetes or rheumatoid arthritis.⁶

Britain shows another design. The NHS does not begin from an age threshold; it recommends a scan for people whose risk is raised, including those with a broken bone after a minor fall, three months or more of oral glucocorticoids, early menopause or removal of the ovaries before 45 without hormone replacement, a body mass index under 21 after menopause, or gaps of more than a year between periods. It also notes that for some people over 75 the risk of a break is so high that treatment may begin without any scan. In the NHS account the scan is one input among several: family history and certain medicines also shape the estimate of risk, and all of them are meant to be weighed before a scan is ordered or treatment begins.⁴ In the United States, the Bone Health and Osteoporosis Foundation notes, most people need a referral from a clinician for the test, and the ideal facility has staff certified, or is itself accredited, by the International Society for Clinical Densitometry.³

Figure

Men screened in a veterans study, percent

• Usual care, screened2
• Bone health service, agreed to a scan49

The question of men

Screening of men is where the guidance divides. KFF Health News reports that the Endocrine Society and the American Society for Bone and Mineral Research advise screening men 50 and older who have a risk factor and all men over 70, while the American College of Physicians and the task force rate the evidence as insufficient, largely because studies in men have been too small or too short to show that treatment prevents fractures. The practical effect, the report says, is that many insurers will not pay to screen a man who has not yet broken a bone. A study it describes, among veterans aged 65 to 85, found that only 2 percent of those receiving usual care had been screened; when a nurse led bone health service offered testing, 49 percent agreed, and half of those tested had osteoporosis or osteopenia.² NBC News had recorded the same split in 2011, when the National Osteoporosis Foundation already advised screening every man 70 and older while the federal panel issued nothing for men.¹ Part of the reasoning for a later start is biological. The National Institute on Aging notes that men lose bone mass more slowly than women, and that by 65 or 70 the two sexes lose it at the same rate.⁷ An endocrinologist quoted by KFF Health News offers one plain marker for either sex: anyone who breaks a bone after 50 should have a scan.²

How often, and what remains open

Screening is not a single event. MedlinePlus ties the interval for central DEXA to risk: about every two years at high risk, every three to five years at moderate risk and every 10 to 15 years at low risk.⁶ The Bone Health and Osteoporosis Foundation says a test is often repeated one to two years after an osteoporosis medicine is started or changed, and after a similar gap for someone untreated who sits close to a treatment threshold.³ The New York State guide adds that one test describes present density only, so any loss has to be shown by a later comparison.⁵

The open question is the menopause transition. In the 2011 report, the president of the National Osteoporosis Foundation argued that no recommendation addressed women actually going through menopause, even though T scores fall from the year of menopause for about four years afterward, and called for research that could justify screening in that window.¹ That gap is the subject of bone and the menopause transition, and the numbers a scan produces are explained in T scores and Z scores. Whether and when a particular woman should be tested is a decision for her and her own clinician. The summary below sets the federal advice of 2002 and 2011 side by side.

Figure

Federal screening advice, 2002 and 2011

	2002 advice	2011 advice
Women 65 and older	Screen	Screen at least once
Younger women	High risk women aged 60 to 64 encouraged	Postmenopausal women under 65 at high risk
Basis for widening	Not applicable	About a dozen studies published since 2002
Men	No recommendation	No recommendation, evidence insufficient