The USPSTF is hard to please

The July 20 edition of the Annals of Internal Medicine includes an update on screening for osteoporosis developed by the U.S. Preventive Services Task Force with the conclusion that, “Although methods to identify risk for osteoporotic fractures are available and medications to reduce fractures are effective, no trials directly evaluate screening effectiveness, harm, and intervals.”

The statements are true, but I question their relevance to clinical medicine.

Let’s start with harm from bone density screening. Unless the person having DXA accidentally falls off the table, I can think of no possible harm that can result from the minimal radiation exposure from DXA. What harms are the U.S. Preventive Services Task Force (USPSTF) looking for? (Note to the task force and Annals of Internal Medicine editorial staff — the official position of the International Society for Clinical Densitometry, of which I am a member, is that the preferred abbreviation is DXA, not DEXA.)

Screening intervals and effectiveness: It would be helpful for practitioners if the task force to let us know which screening programs (lipids, blood pressure and prostate-specific antigen to name a few) have definitive trials letting us know how often testing should be performed and how effective such screening are.

Yes, I am a "homer" when it comes to osteoporosis, but let me remind the task force of a few things that set apart the prevention of osteoporosis-related fractures:

No drug for prevention and treatment of osteoporosis related fractures has been FDA approved before a randomized, controlled, clinical trial has clearly demonstrated that fewer fractures occur in drug treated patients compared with placebo-treated controls. This is not the case for approved therapies for management of dyslipidemia or hypertension.
Vaccines aside, most preventive therapies other than those for osteoporosis require daily therapy, often several times per day and/or more than one drug. Conversely, osteoporosis therapies are available once-daily, once-weekly, once-quarterly, once every 6 months (the newly approved denosumab), or once annually.

There is an adage that “the best predictor of tomorrow’s (fragility) fracture is yesterday’s fracture." The peer-reviewed literature is replete with data from all over the globe pointing out how often patients with minimal trauma fractures are not recognized as having metabolic bone disease — most often osteoporosis. Of those whom recognized failure, to initiate effective therapy is also common.

If the USPSTF really wants to be helpful in reducing the personal and economic burden of disease, I suggest that, rather than pointing out the shortcomings of valuable screening programs to prevent disease, focus on optimizing effective intervention for those already affected by disease or already identified as having increased disease risk.