New U.S. guideline would expand bone density testing

Under a new set of guidelines proposed by an influential U.S. panel, more women would be eligible for bone density tests to detect the bone-thinning disease osteoporosis.

The draft guidelines by the U.S. Preventive Services Task Force (USPSTF), sponsored by the U.S. government’s Agency for Healthcare Research and Quality, call for all women to be screened for osteoporosis starting at age 65. Women who are deemed to have higher risks could start earlier, at any age.

The group’s last guidelines, in 2002, had the same recommendations for all women 65 and older, but said that high-risk women should not begin screening until age 60. The new draft is based on a review of evidence, published in the Annals of Internal Medicine, since the previous guidelines were issued.

About 10 million people in the U.S. over the age of 50 have osteoporosis, according to the National Institutes of Health, most of them women. More than three times as many women are at risk of the disease.

The disease, which typically begins after menopause, increases the risk of broken bones, the most dangerous of which are broken hips, and may cost the health care system as much as $18 billion per year.

It’s unclear how many additional women will now fit the screening criteria, task force chair Dr. Ned Calonge told Reuters Health. “The good news,” he said, is that it’s the minority of women between 50 and 64 who will be at high risk.

“What physicians should do is not pull out the DXA machine,” Calonge said, referring to the device usually used for bone mineral density tests, “but calculate clinical risk factors” in women under 65.

Such scans cost a few hundred dollars each, with DXA machines costing up to $85,000.

Ultrasound, which is cheaper and does not involve radiation, has also been shown to effectively predict fractures, and is also commonly used. However, most diagnostic criteria refer to DXA measurements.

In the new draft, the USPSTF does not recommend testing men for the disease, saying there is not enough evidence to show a benefit. The National Institutes of Health estimates that about 2 million men in the U.S. have osteoporosis, accounting for about one fifth of cases overall.

For women, the draft guidelines are similar to those of the American Congress of Obstetricians and Gynecologists, and also to those of the National Osteoporosis Foundation.

The osteoporosis organization recommends all women be screened starting at age 65, and that doctors use World Health Organization criteria - also used by the USPSTF - to determine if a woman is at higher risk before 65. Such criteria take into account other health conditions, a history of broken bones, and drugs people are taking.

The foundation does, however, recommend that all men be screened starting at the age of 70.

That difference just reflects “different ways of dealing with uncertainty,” Calonge said. “Men do get osteoporosis and osteoporotic fractures. But we don’t feel there’s enough evidence.”

Dr. Mone Zaidi, an osteoporosis researcher at the Mount Sinai School of Medicine in New York, said that while the new draft guidelines are a step in the right direction because they broaden screening criteria, and are appropriate for men, they do not go far enough.

“What we really need to do is capture women much earlier than menopause,” Zaidi, professor of medicine and director of Mount Sinai’s Bone Program, told Reuters Health. “A woman starts losing bone at a maximal rate within two years of menopause.”

Zaidi cited advances in treatment since the USPSTF’s 2002 guidelines. Osteoporosis is typically treated with drugs called bisphosphonates such as Fosamax, Boniva, Reclast, and Actonel.

Such drugs have come under scrutiny by the Food and Drug Administration (FDA) for increasing the risk of heart disease and certain fractures, but the FDA has said it found no such links after reviewing the data.

Evista is also used to treat osteoporosis, although it has been shown to increase the risk of blood clots, according to the USPSTF. Estrogen, which is also sometimes prescribed to prevent fractures, can increase the risk of stroke, heart disease, and breast cancer.

Still, given the availability of safe treatments, “it doesn’t make any clinical or common sense to me to wait until they’ve lost enough to be at a high enough risk or qualify under the old osteoporosis criteria,” Zaidi said.

“In the field, if you go and talk to any ob-gyn, they do a bone density test at menopause,” Zaidi said. “The task force is far behind.”

Calonge, who works at the Colorado Department of Public Health and Environment in Denver, acknowledged that doctors go beyond the evidence in practice all the time.

“From the standpoint of being a clinician, I understand that,” he said. “I think it’s important to know what the evidence supports, and know when you’re exceeding the evidence, and that’s a good time for a frank discussion with your patients.”


The release of these draft guidelines mark a change in how the USPSTF will put forth its recommendations, Calonge told Reuters Health. In the past, they simply released final versions of their recommendations, but they have been quietly working on ways to release drafts for public comment, before the guidelines were final.

For one month, the draft will be available for comment on the group’s website at Based on the feedback, the group may change its recommendations.

“We’ve decided that since the miscommunication and the reaction to the breast cancer screening guidelines, that we wanted to accelerate the process,” Calonge said, referring to mammography recommendations released last November that were met with controversy.

The 2002 osteoporosis screening recommendations remain in force until the new ones are finalized, Calonge said. “We’re not recommending clinicians use this recommendation until final release.”

SOURCE: Annals of Internal Medicine, July 5, 2010.

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