Is the US Preventive Services Task Force ‘hurting men’ with its new osteoporosis recommendations? Here’s what you need to know

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Kevin Lomangino is the managing editor of He tweets as @KLomangino.

A Philadelphia Inquirer story takes issue with new guidelines on osteoporosis screening from the U.S. Preventive Services Task Force (USPSTF).

The headline says it all: “Updated osteoporosis screening guidelines cover only women. That could hurt men”

The implication is that men have been ignored in the task force’s latest evidence analysis, and that the omission “may reinforce” what the story later calls a “sexist view of the bone-weakening disease” that is “harmful to men.”

That’s quite an accusation. But does it hold up to scrutiny?

Contrary to the headline implication, the task force did perform a careful evaluation of the evidence on osteoporosis screening in men and issued the following recommendation:

The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for osteoporosis to prevent osteoporotic fractures in men. (I statement).

So it’s inaccurate to state that men aren’t “covered” by the new guidelines, and doubly so to imply that a lack of coverage promotes sexist notions about osteoporosis.

“The recommendation DOES cover men – the implication that men are ignored is simply wrong,” wrote Virginia Moyer, MD, former chair of the task force and contributor, in an email. “The recommendation statement makes it clear that the research needs to be done to provide evidence.”

Alex Krist, MD, vice chair of the USPSTF and professor of family medicine at Virginia Commonwealth University, says journalists and the public often misinterpret the “insufficient evidence” rating to be a recommendation against intervention — as seems to have happened here.

“The absence of evidence doesn’t mean an absence of benefit,” he said. “We’re not saying that men shouldn’t be screened. We’re not saying not to think about it. We’re saying that there’s insufficient evidence to say if we should screen them or not. Highlighting the lack of evidence is important so we can get the knowledge needed to take care of people better.”

Important gender differences

What about the Inquirer’s claim that men could be “hurt” by the new recommendation?

This view assumes that there’s an established benefit from finding and treating osteoporosis in men with bone-strengthening drugs — and that failing to endorse screening is somehow taking this benefit away from men and leading to harm.

The task force addresses this misconception head-on in its guidelines:

Although some treatments have been found to be effective in preventing fractures in postmenopausal women with osteoporosis, it cannot be assumed that they will be equally effective in men because the underlying biology of bones may differ in men due to differences in testosterone and estrogen levels.

Moreover, the task force explained that we don’t know what direct harms might occur from screening and treatment of men with osteoporosis drugs, since the “evidence on harms of drug therapies in men is very limited.”

The task force’s cogent explanation didn’t make it into the Inquirer’s imbalanced and incomplete piece. But the story did give a platform to industry-affiliated voices who advocate bone density testing for all men over the age of 70.

One such voice — Nelson Watts, MD — has received more than $300,000 from drugmakers since 2015, including companies such as Amgen that make drugs for osteoporosis. (And this impressive tally hasn’t yet been updated to include income from 2017 or 2018.)

The Inquirer didn’t disclose those payments. Nor did it feature anyone willing to push back against the claim, advanced by one source, who said a trial of osteoporosis drugs in men would be “‘a waste of money,’ because the circumstantial evidence that men would benefit is overwhelming.”

Research ‘a good investment’

That’s the same kind of logic that led to widespread adoption of hormone replacement therapy in postmenopausal women, a practice later shown in randomized controlled trials to increase the risk of stroke and breast cancer.

“When something is unproven it is never a waste to study it,” said Doug Campos-Outcalt, MD, a contributor. “The history of medicine is full of examples of things that looked obvious that turned out after study to be untrue.”

Krist also defended the need for evidence proving the benefits of treating patients based on screening.

“Before we subject large populations of patients to treatment, we should know if it’s more likely to help them than it is to hurt them,” he said. “It’s a good investment to do research to make sure we’re going to help them.”

A pattern of industry influence

The Inquirer isn’t alone in its promotion of this industry-friendly narrative. The New York Times has raised an alarm on multiple occasions about declining rates of osteoporosis screening in women and decreasing use of osteoporosis drugs. Those stories are stacked with sources who have undisclosed ties to drugmakers and who are affiliated with organizations that receive pharmaceutical funding. They make much of the drugs’ benefits, downplay serious harms, and blame media coverage of adverse effects for scaring people away from these drugs. Importantly, they lack perspective from independent experts who’ve raised questions about the value of expanded screening and who really benefits from it.

Even the World Health Organization has distanced itself from deceptive practices, advanced by industry-affiliated researchers, that are likely to increase the population eligible for screening and result in increased use of osteoporosis drugs.

This context calls for scrutiny of the voices calling for more medicine and better understanding of the USPSTF’s role in serving the public.

“The Task Force makes a public commitment to only making recommendations when evidence is sufficient,” Moyer said. “Blaming the Task Force for calling out the lack of evidence is putting the blame in the wrong place – it belongs squarely on Pharma and researchers for not producing the needed evidence.”

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Comments (1)

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Brad Flansbaum

June 29, 2018 at 8:24 am

More importantly, you do not address USPTFs recs for women. The group examines the evidence and harms and benefits: grade B. They are clear in their statement.
Yet, below and other past HNR posts cast skeptical light on available data.
Did USPTF get it wrong? The contrary positions need reconciling.