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Level II – Osteoporosis Screening

Level II Services: Preventive services for which clinicians and care systems should assess the need. These services should be recommended to each patient as they have value, but less than those in Level I.

The USPSTF recommendation is endorsed by the ICSI Preventive Services work group.
Grade of Recommendation and Level of Certainty as Evaluated by USPSTF
  1. “Screening for osteoporosis in women age 65 years or older and in 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.”
  2. “The current evidence is insufficient to assess the balance of benefits and harms of screening for osteoporosis in men.”
(USPSTF Last Revised 2011)
Grade of Recommendation:
  1. B
  2. I Statement

Level of Certainty:

  1. Moderate
  2. Insufficient
“Benefits:
No controlled studies have evaluated the effect of screening for osteoporosis on fracture rates or fracture-related morbidity or mortality.
In postmenopausal women who have no previous osteoporotic fractures, the USPSTF found convincing evidence that drug therapies reduce the risk for fractures. In women age 65 years or older and in 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, the USPSTF judged that the benefit of treating screening-detected osteoporosis is at least moderate.
Because of the lack of relevant studies, the USPSTF found inadequate evidence that drug therapies reduce the risk for fractures in men who have no previous osteoporotic fractures. The USPSTF identified the absence of randomized trials of primary fracture prevention in men who have osteoporosis as a critical gap in the evidence.
Harms:
The USPSTF found no new studies that described harms of screening for osteoporosis in men or women. Screening with DXA is associated with opportunity costs (time and effort required by patients and the health care system). Harms of drug therapies for osteoporosis depend on the specific medication used. The USPSTF found adequate evidence that the harms of bisphosphonates, the most commonly prescribed therapies, are no greater than small. Convincing evidence indicates that the harms of estrogen and selective estrogen receptor modulators are small to moderate.
Benefits-Harms Assessment:
The USPSTF concludes that for women age 65 years or older and 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 by using DXA is at least moderate.
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.
Clinical considerations:
This guideline addresses screening for women who have not had osteoporotic fractures, often called "fragility" or "low-impact" fractures. Woman with a diagnosis of secondary osteoporosis or conditions strongly associated with this diagnosis, e.g., chronic glucocorticoid therapy, are excluded.
The USPSTF commissioned a systematic review of the evidence for osteoporosis screening. The comments below are largely derived from this review (Nelson, 2010).
  1. There is convincing evidence that bone measurement tests predict short-term risk for osteoporotic fractures in women and men.
  2. No controlled studies have evaluated the effect of screening for osteoporosis on fracture rates or fracture-related morbidity or mortality.
  3. Adequate evidence indicates that clinical risk-assessment instruments (FRAX, OST and others) have only modest predictive value for low bone density or fractures. The USPSTF derived the 9.3% value from using the FRAX tool to determine the fracture risk of an average 65-year-old white woman without other risk factors.
  4. Current diagnostic and treatment criteria for osteoporosis rely on DXA measurements only; criteria for quantitative ultrasonography have not been defined. For this reason, bone mineral density (BMD) by dual-energy x-ray absorptiometry (DXA) of the hip and lumbar spine is generally considered the preferred test. Quantitative ultrasonography of the calcaneus is as effective as DXA in predicting fractures of the femoral neck, hip and spine and has some advantages – the absence of radiation exposure, portability and lower cost.
For further information on testing and treatment for osteoporosis, plus primary prevention of osteoporosis (diet, exercise, vitamin D and other issues), see the ICSI Diagnosis and Treatment of Osteoporosis guideline.
Evidence for effectiveness:
Clinical considerations: Testing intervals – for women whose initial screening test demonstrates adequate bone mass density, there is currently no recommendation regarding optimal interval to rescreen. But a recent study suggests a reasonable framework for considering follow-up testing intervals, although further research is needed to confirm these findings in larger and diverse populations. In this large prospective study (women ≥ age 67 years; 99% white), the initial screening DXA scan results were placed in four groups (normal and three subgroups of osteopenia).
The study results identified how long it took 10% of women in each group to progress to osteoporosis and suggested the following rescreening intervals (table below) (Gourlay, 2012 [Moderate Quality Evidence). The ICSI guideline work group elected to suggest a more conservative range of 10-15 years while awaiting further validation of these findings.
Initial Screen DXA Result: Approx. interval for retesting:
Normal BMD (T-score -1 or higher) 15 years
Mild Osteopenia (T-score -1.01 to -1.49) 15 years
Moderate Osteopenia (T-score -1.50 to -1.99) 5 years
Advanced Osteopenia (T-score -2.00 to -2.49) 1 year
If a woman's fracture risk assessment changes for reasons beyond aging, such as chronic use of glucocorticoids or occurrence of a fragility fracture, then sooner retesting would be a consideration (Gourlay, 2012 [Moderate Quality Evidence]).
Regarding use of questionnaire tools to assess fracture risk – according to the USPSTF recommendation, clinicians and health care systems should assess fracture risk in women under age 65 years, as women with a significantly increased risk (> 9.3% in the next 10 years) should also be offered osteoporosis screening with DEXA or quantitave calcaneal ultrasonography (Strong Recommendation) (U.S. Preventive Services Task Force, 2011).
The USPSTF supporting “Clinical Considerations” information indicates that fracture risk can be estimated using validated clinical risk-assessment instruments (Nelson, 2010), and the FRAX tool is specifically mentioned as a suitable tool.
Of note is a recent study (Crandall, 2014) that suggests that the FRAX tool may be significantly inferior in sensitivity (but mildly superior regarding specificity) to other simple questionnaire tools such as the Osteoporosis Self-Assessment Tool (OST) and the Simple Calculated Osteoporosis Risk Estimate (SCORE). In this study, data was examined from 5165 Women’s Health Initiative participants ages 50-64 years. Using the USPSTF goal of identifying women < 65 years old whose major fracture risk is ≥ 9.3% calculated without BMD, the researchers compared the FRAX to OST (score < 2) and SCORE (score > 7) strategies. The researchers “assessed sensitivity, specificity, and area under the receiver operating characteristic curve (AUC) to discriminate between those with and without femoral neck (FN) T-score ≤ -2.5. Sensitivity, specificity, and AUC for identifying FN T-score ≤ -2.5 were 34.1%, 85.8%, and 0.60 for USPSTF (FRAX), 74.0%, 70.8%, and 0.72 for SCORE, and 79.8%, 66.3%, and 0.73 for OST. The USPSTF strategy identified about 1/3rd of women ages 50-64 with FN T-scores ≤ -2.5. Among women ages 50-64 years, the USPSTF strategy was modestly better than chance alone and inferior to conventional SCORE and OST strategies in discriminating between women with and without FN T-score ≤ -2.5.” Further research needs to be done, but these findings suggest that it is important to be aware of the strengths and weakness of the various tools available.”
Relevant Resources:
http://www.uspreventiveservicestaskforce.org/uspstf10/osteoporosis/osteors.htm
Related guideline
ICSI Prevention and Treatment of Osteoporosis guideline
ICSI Work Group Supplement:
  • Osteoporosis screening with dual-energy x-ray absorptiometry (DXA) of the hip and lumbar spine (or with quantitative ultrasonography of the calcaneus) should be offered to women over age 65 years (U.S. Preventive Services Task Force, 2011).
  • Clinicians and health care systems should assess fracture risk in postmenopausal women under age 65 years; women with a significantly increased risk (> 9.3% in the next 10 years) should also be offered osteoporosis screening (U.S. Preventive Services Task Force, 2011). Fracture risk can be estimated using validated clinical risk-assessment instruments such as the FRAX, OST, SCORE and others (Nelson, 2010).
  • The frequency of screening is uncertain, but there is emerging evidence that most women over age 67 years with normal or only mildly osteopenic bone density on DXA may reasonably wait 10-15 years before repeat testing (Gourlay, 2012; Hillier, 2007).