This story is so well researched and written that it covers a lot of ground in a short amount of space. It summarizes decades of science related to bone health and left us wanting a closer look at some of the more recent evidence, particularly the study that sets the stage at the top of the story. Without any mention of costs, the potential harms of over-screening, or the quality of the evidence in that study or others, readers may be left with the impression that they should make sure to have a bone density screening at their next available opportunity. The story also should have clued readers in to the commercial motivations that may underlie a push for more osteoporosis screening in men.
This story emphasizes the fact that men who suffer fragility fractures — fractures not associated with trauma or following a fall from standing height or less — aren’t as likely to be assessed for osteoporosis as women in the same situation. The article goes on to nicely describe why this may matter and provides some patient examples. It also mentions that relevant expert groups recommend screening in all people over 50 with a potential fragility fracture. The problem here is that we don’t really know if following these recommendations will decrease the likelihood of men having future fractures. Experts think it will, but there is no real evidence to say this is in fact the case. It requires extrapolating from studies done in women, and while that may be a logical approach, it would be nice to see some acknowledgment of this evidence gap.
Why haven’t studies been done in men? That would be a great question for the experts quoted in this article. It is possible that it isn’t on the radar screen of specialists who care for these patients. Or it may be that such studies are hard to do, and that drug companies would prefer not to spend the money needed to perform them when their drugs are already approved and available. While the recommendations seem reasonable, there are many examples where expert opinion doesn’t hold up under the light of evidence. Demonstrating that men benefit from identifying and treating osteoporotic fractures would go a long way to convincing doctors to make screening a part of routine care.
There is not enough discussion of costs in the story The costs one needs to consider — in addition to the cost of the initial bone scan — are any treatment-related costs (e.g. drug therapy), as well as follow-up care, monitoring, etc. These would be offset by potential savings in terms of less need for future treatments for a new fracture. The story does mention that hip surgeries cost $25,000 or more, which may help explain why hospitals are not clamoring to set up screening programs for men to prevent fractures.
The story starts with the premise that screening for bone density is recommended by many health care organizations and that doing so will lead to fewer bone fractures and, in the case of hip fractures, perhaps reduce deaths in men whose health declines after a fracture. The story says that the study “found women were about three times as likely as men (53% versus 18%) to be tested using a bone-density scan.” But that doesn’t tell us the benefits of doing the scan. The assumption is that scanning everyone who comes in with a fracture for bone density will lead to health improvement. Some proof to back that up would have been nice. The closest the story comes to this is an anecdotal reference to Kaiser Permanente in Southern California, which apparently started a screening program in 1997 and, since then, “the rate of hip fractures at Kaiser is down 40%.”
To be clear, our understanding is that evidence supporting a fracture prevention benefit for screening in men doesn’t exist, so the best the story could have done would be to extrapolate from studies involving women. The story doesn’t go that far or acknowledge an evidence gap in this area. But that’s an omission we’ll penalize the story for below in the Evidence section, while ruling the Benefits description satisfactory.
There’s no explanation of the potential harms from unnecessary screening, the intervention that’s at the heart of this story. Unnecessary screening can produce false positive results that may lead to anxiety, unnecessary curtailing of activities, and needless treatment and follow-up that can cause harm. We acknowledge that the story does mention the harms from some specific bone density drugs. For example: “Bisphosphonates, sold under brand names such as Fosamax and Actonel, are highly effective. But because of some possible, rare side effects—an unusual type of fracture of the thigh bone and a deterioration of the jaw bone—the medication often isn’t prescribed for more than five years.” But we’d note that it isn’t clear how one should extrapolate data on potential harms seen in post-menopausal women to men.
The story could have gone a little deeper into the underlying evidence behind the push to get more men screened for bone density. The story says that 440 people were included in this most recent study. But the story does not say that these people were not put into separate groups with a control, were not monitored for several years, and were not randomized. Here’s how the researchers themselves describe what they did: “We retrospectively reviewed the medical records of ninety-five men and 344 women over the age of fifty years who were treated for a distal radial fracture at a single institution over a five-year period. We assessed whether the patients had received a dual x-ray absorptiometry (DXA) scan and osteoporosis treatment within six months following the injury.” That means that fewer than 100 men were included in this group. Of those, 17 were scanned, and nine were diagnosed with osteoporosis. That’s a pretty small number to start pushing new national protocols. That caveat and the fact that the study was a backward looking review of medical records should have been mentioned.
We also question the story’s failure to explore the evidence underlying the expert and society recommendations that it references to support the benefits of screening. Because fragility fractures are much less common in men than they are in women, they have not been studied in randomized trials in the same way that they have in women. The story never acknowledges this. The story could have simply stated that the evidence supporting these recommendations comes from expert opinion, and that there is a lack of studies in men that provide direct data to prove the benefits of screening and treatment in men.
There’s no disease mongering in the story. Instead, it provides some nice descriptions of bone health and bone health measurement to help put osteoporosis in context. “Bone tissue is always breaking down. When it isn’t replaced fast enough, bones become less dense and prone to breakage, even with a relatively minor fall or bump. Tests for osteoporosis include a bone-density scan, a type of X-ray of the hip, wrist or spine, and blood or urine tests to check calcium and vitamin D levels.”
To earn extra points here, the authors could have stated that screening asymptomatic older men for bone density, similar to women, is controversial. However, for individuals who have already had a fracture that may be due to osteoporosis, experts suggest that screening both men and women is warranted — although the data supporting this only comes from studies involving women.
The reporter sought out opinions from two clinicians not connected to the study, a patient, the Mayo Clinic, and the National Osteoporosis Foundation. But the story was not transparent about the relationships that these sources have with commercial interests. Dr. Amy Singer has disclosed significant financial ties to Amgen, which makes an osteoporosis drug. We’d also note that the National Osteoporosis Foundation receives funding from a “Corporate Advisory Roundtable” that includes makers of bone scanning machines and osteoporosis drugs. And the Foundation has previously been called out for its failure to educate consumers about the harms of bisphosphonate drugs when those problems were first coming to light. This context should make us wary of a push to screen more men for osteoporosis without evidence that it is beneficial. Is this drive totally about the patient or could there be a commercial motivation?
Ideally, we’d like to see some mention here of the option not to perform BMD testing, since there is no real evidence supporting this recommendation. But the story gets high marks for talking about a range of treatment options for osteoporosis and general bone health, and we applaud that. It’s rare to see a story try to pack in so much treatment information into one story, which is why we often ding stories in this part of the review.
It’s clear from the story that bone density screenings are common and done in a variety of ways.
What’s new here is the recent push to improve osteoporosis treatment in men, sparked in part by the study referenced in this story. The article is clear about this.
This story does not rely on any press release.[SJA: agree]