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FRAX – It's Not a Dirty Word
Abstract & Commentary
By Alison Edelman, MD, MPH, Associate Professor, Assistant Director of the Family Planning Fellowship, Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, is Associate Editor for OB/GYN Clinical Alert.
Dr. Edelman is a implanon trainer for Schering Plough.
Synopsis: The U.S. Preventive Services Task Force has updated its guidelines for osteoporosis screening. For women who do not clearly meet eligibility criteria for screening, an easy-to-use and accessible tool is available to aid clinicians in identifying those who need screening.
Source: U.S. Preventive Services Task Force. Screening for osteoporosis: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2011;154:356-364.
This publication is an update on osteoporosis screening from the 2002 U.S. Preventive Services Task Force (USPSTF) recommendation.1 The USPSTF now recommends that all women age 65 and older receive screening for osteoporosis. In women younger than age 65, osteoporosis screening should be performed if their risk is equivalent to a 65-year-old woman. To determine screening eligibility for these women, a free online screening tool called FRAX (see below for more details) is available. The screening test most commonly used in clinical practice and in outcomes research is the dual-energy x-ray absorptiometry (DXA). There remains a lack of evidence regarding the best screening interval for women whose initial test is negative but a minimum of at least 2 years is needed to reliably demonstrate a change in bone mineral density due to the precision capabilities of the DXA. Unlike the recent USPSTF recommendation regarding breast cancer screening, these recommendations are very similar to those of the American Congress of Obstetricians and Gynecologists (ACOG).2
Clinicians and even the public understand that a hip fracture in the elderly is a game changer, if not the "beginning of the end" since more than a quarter will die within 12 months.3 Less significant fractures also can cause serious morbidity through chronic pain and immobility. Yet, osteoporosis andmore importantlyosteoporotic-related fractures are preventable; very little if no harm is associated with screening and treating. The USPSTF has performed an updated review of the evidence regarding screening.1 The USPSTF recommendation states that all women age 65 and older should receive screening for osteoporosis and women younger than this age should undergo screening if their risk is equivalent to a 65-year-old woman. There is no upper age limit to stop screening, and it is recommended that clinicians individualize to a patient's remaining lifespan and the potential benefit from treatment, which takes approximately 1.5 to 2 years to achieve.4
Pray tell, how do you know if a woman under age 65 is at higher risk and needs screening? An online, easy to use, FREE tool is available to help with this question. FRAX or Fracture Risk Assessment5 (I have no idea where the X comes from) has been designed in collaboration with a number of international entities to help determine a person's 10-year fracture risk using easily available clinical information including: BMI, race, age, parental and personal fracture history, and smoking and alcohol use. Depending on certain risk factors, women as young as 50 might qualify for screening1 (for example, a 50-year-old woman who smokes, drinks, is thin, and has a parental fracture history, or simply, a 55-year-old woman who has a parental fracture history). It is important to make sure to use the correct country designation when logging in to the site as the tool is calibrated for certain populations. Try it out at www.shef.ac.uk/FRAX/ and add it to your Internet "favorites" file. There also are apps for smart phones.
Unfortunately, there remain some unanswered questions that the USPSTF cannot address as the evidence is lacking. This includes routine screening for men. I realize that if you are reading this commentary you probably don't care about screening men but you may be male yourself and then it's one less screening test you need to worry about unless you also have a risk similar to a 65-year-old woman! Additionally, there is no clear guidance regarding when to repeat DXA testing in a woman whose initial testing was normal. Data do exist showing that the screening interval with DXA testing should be no less than 2 years as the modality does not have the precision to demonstrate a change in less time, but it may be that the interval should be longer than 2 years.
There may be some of you still grumbling about why the USPSTF recommendations for mammography are so different from ACOG.6 Take a sigh of relief as the USPSTF update is very similar to what is already recommended by ACOG to screen women age 65 or older or postmenopausal women younger than age 65 with 1 or more risk factors.2