Another use for the FRAX tool!

My patient is a 57-year-old woman with breast cancer that was diagnosed and successfully treated six years ago. Her oncologist appropriately checked her bone density as she started anastrozole (Arimidex, AstraZeneca) and found that her T-score was –2.8, ie, a pre-fracture diagnosis of osteoporosis. She was started on a bisphosphonate and completed five years of therapy.

The patient recently applied for long-term health care insurance and because of her history of breast cancer, was not overly surprised when her request was turned down. But that was not why she was turned down! The denial was because she had osteoporosis and was at increased risk of sustaining a fragility facture. She appealed and was offered insurance coverage for half the requested duration and at twice the premium.

Using the WHO fracture risk assessment (FRAX) tool, her 10-year probability of a major fracture at any skeletal site was 7.6% and for a hip fracture, it was 1.1%.

This is not really appropriate use of FRAX since the patient's T-score indicated that she should have been started on therapy, which did happen. FRAX should only be used for untreated patients and when the T-score would not automatically direct the treating physician to prescribe specific therapy. However, I will use this information as I write a letter to the insurance company strongly recommending that they quickly correct their error and allow her to purchase coverage without any disclaimers.

In fairness to the company — although I am not sure their behavior warrants fairness — the problem originates with us. Let me explain.

Cholesterol is an indicator of heart disease risk. If the level is elevated, the term hypercholesterolemia is used. If the patient with hypercholesterolemia has an acute myocardial infarction, we say the patient had a heart attack or an acute MI.

Bone density is an indicator of fragility fracture risk, and when the T-score is –2.5 or lower, the diagnostic label “osteoporosis” is placed on the patient. Should the patient subsequently sustain a fragility fracture, the term “severe osteoporosis” is used. That is analogous to using the term “severe hypercholesterolemia” when a patient with elevated cholesterol has an acute MI.

I doubt that the terminology in the bone field will change any time soon. But please keep in mind that osteoporosis diagnosed by DXA only is an assessment of risk for future fragility fracture, but the risk for future fracture is substantially greater if the patient has already sustained one or more fragility fractures, independent of the DXA data.