Doctors study osteoporosis screening and treatment choices to lessen risk of fractures

Our Review Summary

The scientific evidence in this area seems to be changing by the month—and those at potential risk of fractures need to stay informed about key developments. The Boston Globe article clearly gave women and men enough information to at least start a discussion with their doctors about these issues.

Many news stories on osteoporosis simply parrot the opinions of experts and present them as the last word on the subject. This article avoided that trap, clearly distinguishing the proven from uNPRoven, and opinion from fact.

It accurately observed that there is no conclusive evidence regarding the indications for, and the timing of, bone density screening. It hammered home the key point that rigorous scientific trials have not yet proven that screening prevents fractures.

The article identified the substantial uncertainties regarding the use of both calcium and vitamin D in the prevention of osteoporosis. It discussed the potential of hugely popular medications such as Fosamax and Boniva to prevent fractures—as well as to cause serious side effects such as cancer of the esophagus and pathological fractures of the thigh bone.

It there is a shortcoming in this article, it might be the way it presents medical decision-making in this area. At a couple of junctures, the story came close to endorsing traditional “doctor knows best” paternalistic decision-making.

 “In the absence of clear guidelines, many physicians make their own judgment calls,” the story suggested at one point. “Physicians face a tough choice when it comes to frail patient with brittle bones,” the story speculated at another.  Yet in medical encounters it is (or should be) the patient who is the ultimate decision-maker.

Only in the last paragraph did the article acknowledge the modern paradigm of shared decision-making, where informed patients make therapeutic decisions based on their values, goals and tolerance for risk.

In areas of medical uncertainty, it is the role of the healthcare provider to help patients make the right decision—not to dictate the therapeutic approach.

 

Why This Matters

Osteoporosis is both a serious and controversial condition. As much as 50% of the U.S. population older than 50 will be at risk for osteoporotic fractures over the course of their lifetimes, according to a recent report from the U.S. Preventive Services Task Force. This could translate into 12 million people with osteoporosis by 2012, according to this panel.

Fractures can lead to functional disability, chronic pain, and high levels of medical utilization. All types of osteoporotic fractures are associated with elevated death rates.

There is a general sense in medicine that osteoporosis is under-detected and inadequately treated. Yet, as the Preventive Services Task Force pointed out, the indications for screening aren’t clear. And the Task Force couldn’t find a single well-designed study that clearly documented the risks and benefits of screening.

There is controversy about how to define the population at risk of developing osteoporotic fractures. Should this be confined to those with very low bone density, with or without other risk factors? Or should medicine also target those with osteopenia—modestly reduced bone density? The expansion of osteoporosis screening and treatment into the population with osteopenia has led to charges of medicalization and disease mongering. 

So given the aging of the general population, coming up with better evidence on the prevention, screening and treatment of osteoporosis is a key public health issue.