Comparing Osteoporosis Screening, Treatment Strategies in Postmenopausal Women

The need for effective osteoporosis screening tools and treatment strategies is high, as the current methods have a low sensitivity for determining postmenopausal women at risk for a major osteoporotic fracture, according to study results published in the Journal of Bone and Mineral Research.

Researchers compared the osteoporosis screening tools of the United States Preventive Services Task Force and Osteoporosis Canada, as well as the osteoporosis treatment strategies of the US National Osteoporosis Foundation and Canadian treatment strategies.

The US Preventive Service Task Force screening tool recommends women <65 years who have a 10-year risk for a major osteoporotic fracture higher than that of a “65-year-old white woman without major risk factors” receive a bone mineral density (BMD) test. The Osteoporosis Canada screening strategy recommends women <65 years receive a BMD test based on clinical risk factors, such as low body weight, fragility fracture, and high alcohol intake.

The National Osteoporosis Foundation treatment strategy uses the Fracture Risk Assessment Tool to determine treatment protocols for women who have a BMD T-score between -1 and -2.5. The Canadian treatment strategy uses a tool from the Canadian Association of Radiologists and Osteoporosis Canada to determine the need for treatment, taking into account age, femoral neck BMD, glucocorticoid use, and other clinical factors.

Study participants were pooled from the Women’s Health Initiative study. All participants completed demographic questionnaires, osteoporosis risk factors evaluations, and a complete history of prior fractures. BMD tests were completed on a subset of participants (n = 8134). During the 10-year follow-up, clinical and health information, including self-reported fractures, were collected from participants either annually or semi-annually. Of the 117,707 participants, the mean age was 62.7, mean body mass index was 27.8 kg/m², and 86% were white.

The US Preventive Service Task Force screening tool recommended 23.2% of participants for BMD testing and the Osteoporosis Canada screening tool recommended 52.5% of participants for BMD testing. Of the women who experienced a major osteoporotic fracture during the 10-year follow-up, the US Preventive Service Task Force screening tool identified 7% of women between the ages of 50 to 54 years and 50% between 60 to 64 years, while the Osteoporosis Canada screening tool identified 54% between the ages of 50 to 54 years and 61% between the ages of 60 to 64 years. The Osteoporosis Canada screening tool identified significantly more participants at risk in both age ranges (P <.001 for both). Although the positive predictive value was low for both screening tools (16% for the US Preventive Service Task Force and 14% for Osteoporosis Canada), the specificity for identifying participants for BMD testing was consistently higher for the US Preventive Service Task Force.

Of the women who experienced a major osteoporotic fracture during the 10-year follow-up, the National Osteoporosis Foundation treatment strategy identified a treatment need for 16% of participants between the ages of 50 to 64 years and 45% of participants ≥65 years, while the Canadian treatment strategy identified a treatment need for 3% of participants between the ages of 50 to 64 years and 21.3% of participants ≥65 years. The National Osteoporosis Foundation treatment strategy identified significantly more participants in both age ranges (P <.001 for both). Though both strategies were low in sensitivity, the National Osteoporosis Foundation had higher sensitivity than the Canadian strategy. However, the Canadian strategy had higher specificity.

Limitations to this study included questionnaire information limits, potentially inaccurate baseline fracture and medication reports, and uncertainty about pre-existing conditions.

Overall, the Osteoporosis Canada screening tool has higher sensitivity and lower specificity than the US Preventive Service Task Force for identifying individuals who experience a major osteoporotic fracture, and the National Osteoporosis Foundation treatment strategy has a higher sensitivity and lower specificity than the Canadian treatment strategy for identifying individuals who experience a major osteoporotic fracture. These results “highlight the difficulty in developing validated osteoporosis screening and treatment strategies that show acceptable performance in women age [50 to 64] years.”

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Reference

Crandall CJ, Larson J, Manson JE, et al. A comparison of U.S. and Canadian osteoporosis screening and treatment strategies in postmenopausal women [published online December 7, 2018]. J Bone Miner Res. doi:10.1002/jbmr.3636