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.
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.
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.
The article did not discuss the costs of various management approaches. A simple statement about the costs of screening and the annual costs of bisphosphonates would have been useful.
The article provided adequate discussion of the relative benefits of the treatments and screening methods under discussion.
The article provided substantial information about potential side effects such as cancer of the esophagus and thigh fractures related to the use of bisphosphonates. However, it would have been useful for the article to also report the conclusion of the US Preventive Services Task Force that bisphosphonates are not consistently associated with serious adverse events.
The article provided accurate information on the quality of evidence supporting different management approaches.
The article did not engage in overt disease-mongering. However, it would have been useful if the article could have addressed the potential for disease-mongering among patients with osteopenia.
The article included commentary from several independent experts who provided useful insights. The article did not discuss potential conflicts of interest among these experts. However, the journalist’s hard work in soliciting a diversity of comments outweighs the lack of discussion of financial conflicts.
The article discussed multiple treatments: bisphosphonates, calcium, and vitamin D. It would have been useful to at least mention some other drug treatments that were discussed in the recent report of the US Preventive Services Task Force: estrogen replacement therapy, parathyroid hormone, and raloxifene.
All the screening, prevention, and treatment approaches described in this article are widely available and their availability doesn’t merit extensive discussion.
The article discussed management approaches to osteoporosis that are well established—though in some cases uNPRoven. Discussion of their novelty wasn’t necessary.
The article did not appear to rely on a news release.