USPSTF guidelines may miss osteoporosis in at-risk younger postmenopausal women

National guidelines for osteoporosis screening may miss postmenopausal women ages 50 to 64 years destined to suffer a fracture, according to a new study. The report, based on analysis of data from the Women’s Health Initiative (WHI), compared guidelines from the United States Preventive Services Task Force (USPSTF), the Osteoporosis Self-Assessment Tool (OST) and the Simple Calculated Osteoporosis Risk Estimate (SCORE) and found them “no better than chance alone in discriminating women who did and did not have subsequent fractures.”

The USPSTF guidelines recommend screening in women younger than 65 years only when they have a 10-year predicted risk of major osteoporotic fracture (MOF) of at least 9.3%, using the Fracture Risk Assessment Tool (FRAX). Weight and age are the factors considered by OST whereas screening with SCORE is based on race, rheumatoid arthritis history, history of nontraumatic fracture, age, prior estrogen history, and weight.

The 62,492 women in the WHI cohort were ages 50 to 64 years and not taking medication for osteoporosis and the data were from 40 clinical centers nationwide.

In the study led by investigators from the University of California, the overall sensitivity of the guidelines for identification of women with incident MOF ranged from 25.8% to 39.8%, specificity ranged from 60.7% to 65.8%, and area under the curve values ranged from 0.52 to 0.56. Sensitivity of the USPSTF guidelines ranged from 4.7% (3.3– 6.0) among women ages 50 to 54 years to 37.3% (35.4–39.1) for women ages 60 to 64 years.  Using the SCORE screening, sensitivity ranged from 18.5% (16.0 – 21.0) among women ages 50 to 54 years to 57.6% (55.7 – 59.5) in those ages 60 to 64 years. Sensitivities for the OST ranged from 22.9% (20.1 – 25.6) in women ages 50 to 54 years to 48.1% (46.2 – 50.1) in those ages 60 to 64 years.

Study limitations included the fact that the WHI cohort did not constitute a population sample, which could mean that the cohort was healthier than women found in clinical practice. In addition, the FRAX risk estimates do not account for secondary causes of osteoporosis, although those causes are uncommon in healthy, younger postmenopausal women. No information was available for the circumstance of the fractures in the cohort.

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The investigators concluded that the current USPSTF screening guidelines were unable to identify most women ages 50 to 64 years. They believe that these results highlight the need to evaluate alternate strategies to better target younger, postmenopausal women who are at risk.

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