Baseline Bone Mineral Density Testing Research Articles

CO209 Association between Baseline Bone Mineral Density Testing and the Risk of Fractures in Men Initiating Androgen Deprivation Therapy: Population-Based Study

Androgen deprivation therapy (ADT) is a staple of advanced prostate cancer (PCa) treatment, however several side-effects are associated with its long-term use. Notably, loss of bone mineral density (BMD) is accelerated which increases fracture risk. Although guidelines recommend BMD testing when initiating ADT to properly assess baseline fracture risk, there is scarce data to support this recommendation in the PCa patient population. The objective was to examine the association between baseline BMD testing (bBMDT) and the risk of fractures in men initiating ADT for PCa.

Screening of Corticosteroid-Induced Osteoporosis in Patients with Immune Thrombocytopenia or Warm Autoimmune Hemolytic Anemia in the Outpatient Setting

Introduction:Corticosteroids (CS) are the standard first line treatment for immune thrombocytopenia (ITP) and warm autoimmune hemolytic anemia (WAIHA). Current guidelines advise against long-term CS (LTCS) use to minimize associated toxicities. Despite these guidelines, a number of patients remain on LTCS. For example, in a retrospective study of 53 patients with WAIHA, the mean duration of CS therapy was 15 months (mo) with 20% of patients with CS-induced diabetes, 10% with worsening of pre-existing diabetes, 10% with osteoporosis (OP) with fracture, and 4% with osteonecrosis of the femoral head (Roumier 2014).It is our observation that our hematology clinic patients may benefit from the application of guidelines for the prevention of CS-induced OP. The 2017 American College of Rheumatology (ACR) guidelines for prevention and treatment of CS-induced OP include a baseline clinical fracture risk assessment within 6 mo of the start of LTCS therapy (≥3 mo) followed by age and risk-adapted OP screening (Buckley 2017). Adults <40 years old (yo) with OP risk factors or prior OP fracture should undergo baseline bone mineral density (BMD) testing within 6 months of the start of CS therapy. For patients ≥40 yo, the Fracture Risk Assessment Tool (FRAX) with CS dose correction and BMD testing should be done within 6 mo of the start of CS therapy. With no similar national hematology guidelines, we applied 2017 American College of Rheumatology (ACR) guidelines for the prevention of CS-induced OP to our hematology clinic patients. The aim of the study was to improve screening for CS-induced OP in patients with ITP or WAIHA.Methods:We retrospectively identified patients with ITP or WAIHA by ICD-10 codes who were seen in the hematology clinic at LAC+USC Medical Center, Los Angeles, CA, from October 1, 2020 to March 31, 2021. The electronic medical record (EMR) was reviewed for demographic data and to confirm diagnosis. The relevant clinical history including CS dose/duration, common adverse events (AEs) from LTCS use, and BMD screening with a dual-energy X-ray absorptiometry (DEXA) scan. The patients were assessed for whether they underwent appropriate screening for CS-induced OP based on ACR guidelines.Results:Of the 2256 patient encounters in the hematology clinic during the 6-mo study period, 54 patients were identified with either ITP and/or WAIHA. The median age was 49 yo (range: 21-87), 74% were female (40/54) and 85.2% (46/54) were Hispanic. Of these 54 patients, 46 patients had prior or current CS therapy with either prednisone or dexamethasone. The most common AEs associated with CS included: weight gain (34.8%, 16/54), hypertriglyceridemia (34.8%, 16/54), worsening of diabetes (7.4%, 4/54), and worsening hypertension (3.7%, 2/54). Of the 15 patients <40 yo, 7 received LTCS therapy for ≥3 months and 42.9% (3/7) underwent screening with a DEXA scan. 1 had a normal BMD, 1 had osteopenia and 1 had OP. Of the 39 patients ≥40 years, 14 had received LTCS therapy for ≥3 months and 14.3% (2/14) had a screening DEXA scan; both demonstrated osteopenia. 2 patients with <3 months of CS therapy underwent screening - 1 for CS use, which showed osteopenia and one for age-appropriate screening of OP, which also showed osteopenia. Of the 6 patients with osteopenia or OP, 83.3% (5/6) were on vitamin D and calcium supplementation prior to screening. After diagnosis of osteopenia, one patient was not started on vitamin D and calcium supplementation. Bisphosphate therapy was initiated after diagnosis of OP in 1 patient.Conclusions:The majority of patients with ITP or WAIHA seen in our hematology clinic who were treated with LTCS ≥3 months did not receive a screening DEXA scan for OP as recommended by ACR guidelines. With this baseline data, we propose a quality improvement initiative in our clinic to ensure that all patients on LTCS are assessed for OP risk. Planned interventions include resident/fellow education, creation of a handout of the ACR guidelines posted in clinic, implementation of clinical fracture risk reassessment at baseline and every 12 months with BMD as indicated, and implementation of an EMR template to ensure uniform documentation. More broadly, our findings serve as a reminder of the importance for monitoring CS duration and suggest a need for a structured approach to monitoring for short and long-term toxicities of CS for the field of hematology. The creation of hematology-specific guidelines may be beneficial in this effort. DisclosuresPiatek: Apellis: Research Funding; Alexion: Consultancy, Research Funding; Rigel: Consultancy, Research Funding; Dova: Consultancy, Speakers Bureau.

Contemporary analysis of bone mineral density in men initiating androgen deprivation therapy for prostate cancer.

38 Background: Androgen deprivation therapy (ADT) is a cornerstone of advanced prostate cancer (PCa) treatment, however several side-effects are associated with its long-term use. Notably, loss of bone mineral density (BMD) is accelerated which increases fracture risk. Guidelines recommend BMD testing when initiating ADT to properly assess baseline fracture risk. The objective was to examine the proportion of BMD testing in men initiating long-term ADT in Quebec. Methods: The cohort consists of men extracted from Quebec public healthcare insurance administrative databases who were diagnosed with PCa from 2001-2012 and treated by ADT for at least one continuous year. The primary study outcome was the receipt of baseline BMD testing (defined as a BMD test identified in the period from 6 months prior to and up to 12 months after ADT initiation). Multivariable generalized linear mixed with a logit link was performed to identify variables associated with baseline BMD testing accounting for physician clustering. Results: We identified 7,069 patients, of which 887 (12.6%) underwent baseline BMD testing. Baseline BMD testing varied by year of ADT initiation, from 7.7% in 2001-2003 to 12.3% in 2013-2012. Following multivariable analyses, later years of ADT initiation (2004-2006, 2007-2009, 2010-2012, 2013-2015) remained associated with higher odds of baseline BMD testing compared to the earlier years (2001-2003) (ORs ranging from 1.43-1.88; p &lt; 0.001). Conversely, age &gt; 80 (OR 0.73; 95% CI 0.57-0.94; p = 0.001), greater Charlson comorbidity score (OR 0.51; 95%CI 0.34-0.75; p = 0.001), and rural residence (OR 0.60; 95%CI 0.48-0.75; p &lt; 0.001) were associated with lower odds of baseline BMD testing. Conclusions: In our study population, rates of baseline BMD testing in men initiating ADT are low, although the rates increased over the course of the study period. Potential gaps identified in baseline BMD testing include older, more comorbid patients, and rural residence. Additional efforts emphasizing the importance of BMD testing in PCa guidelines may be needed.

Bone Density Screening in Postmenopausal Women With Early-Stage Breast Cancer Treated With Aromatase Inhibitors.

In postmenopausal women with breast cancer treated with aromatase inhibitors (AIs), most expert panels advise baseline bone mineral density testing with a dual-energy x-ray absorptiometry (DXA) scan repeated every 1 to 2 years. How often this recommendation is followed is unclear. We performed a retrospective analysis of women with stage I to III breast cancer who started AI therapy from January 1, 2008, to December 31, 2010, with follow-up through December 31, 2012, by using the SEER-Medicare database. Selection criteria included AI use for ≥ 6 months and no recent osteoporosis diagnosis or bisphosphonate use. We used multivariable logistic regression to investigate associations between patient characteristics and receipt of a baseline DXA scan. In patients who continued AI treatment, we assessed rates of follow-up scans. In the sample of 2,409 patients (median age, 74 years), 51.0% received a baseline DXA scan. Demographic characteristics associated with the absence of a baseline DXA scan were older age (85 to 94 years v 67 to 69 years; odds ratio [OR], 0.62; 95% CI, 0.42 to 0.92) and black v white race (OR, 0.68; 95% CI, 0.47 to 0.97). Among patients who underwent a baseline DXA scan and continued AI for 3 years, 28.0% had a repeat DXA scan within 2 years and 65.9% within 3 years. In aggregate, of the 1,164 patients who continued with AI treatment for 3 years, only 34.5% had both a baseline and at least one DXA scan during the 3-year follow-up period. The majority of older Medicare beneficiaries with breast cancer treated with AIs do not undergo appropriate bone mineral density evaluation.

Bone Health and Bone-targeted Therapies for Prostate Cancer: a Programme in Evidence-based Care — Cancer Care Ontario Clinical Practice Guideline

AimsTo make recommendations with respect to bone health and bone-targeted therapies in men with prostate cancer. Materials and methodsA systematic review was carried out by searching MEDLINE, EMBASE and the Cochrane Library from inception to January 2016. Systematic reviews and randomised-controlled trials were considered for inclusion if they involved therapies directed at improving bone health or outcomes such as skeletal-related events, pain and quality of life in patients with prostate cancer either with or without metastases to bone. Therapies included medications, supplements or lifestyle modifications alone or in combination and were compared with placebo, no treatment or other agents. Disease-targeted agents such as androgen receptor-targeted and chemotherapeutic agents were excluded. Recommendations were reviewed by internal and external review groups. ResultsIn men with prostate cancer receiving androgen deprivation therapy, baseline bone mineral density testing is encouraged. Denosumab should be considered for reducing the risk of fracture in men on androgen deprivation therapy with an increased fracture risk. Bisphosphonates were effective in improving bone mineral density, but the effect on fracture was inconclusive. No medication is recommended to prevent the development of first bone metastasis. Denosumab and zoledronic acid are recommended for preventing or delaying skeletal-related events in men with metastatic castration-resistant prostate cancer. Radium-223 is recommended for reducing symptomatic skeletal events and prolonging survival in men with symptomatic metastatic castration-resistant prostate cancer. ConclusionsThe recommendations represent a current standard of care that is feasible to implement, with outcomes valued by clinicians and patients.

Bone Mineral Density Testing Disparities Among Patients With Breast Cancer Prescribed Aromatase Inhibitors.

Aromatase inhibitors (AIs) are standard adjuvant therapy for postmenopausal women with early-stage, estrogen receptor-positive breast cancer. We designed our study to determine whether women initiating adjuvant therapy with an AI underwent baseline bone mineral density testing, as well as what factors predicted adherence with testing guidelines. Medicare Parts A, B, and D claims were used to identify a cohort of women aged 67 years and older with incident breast cancer in 2006 and 2007 who started AI therapy. Medicare claims provided information about bone density testing, as well as demographic and other treatment data through 2012. We also ascertained which patients were treated with bisphosphonates and studied the relationship of bisphosphonate therapy with bone density testing. Approximately two-thirds of patients had baseline bone density testing. Older age, comorbidity, low income, and black race were associated with lower rates of baseline bone density testing. Testing rates decreased substantially with increasing age from 73% for women aged 67 to 70 years to 51% for those 85 years of age and older (adjusted odds ratio for not being tested, 2.48 [Cl, 2.17-2.82]). The proportion of women who had neither bone density testing nor bisphosphonate therapy increased with age as well. Despite the importance of age as a risk factor for fractures, older women starting treatment with AIs for treatment of breast cancer are less likely to undergo recommended bone density assessment.

Understanding Referral Patterns for Bone Mineral Density Testing among Family Physicians: A Qualitative Descriptive Study.

Introduction. Evidence of inappropriate bone mineral density (BMD) testing has been identified in terms of overtesting in low risk women and undertesting among patients at high risk. In light of these phenomena, the objective of this study was to understand the referral patterns for BMD testing among Ontario's family physicians (FPs). Methods. A qualitative descriptive approach was adopted. Twenty-two FPs took part in a semi-structured interview lasting approximately 30 minutes. An inductive thematic analysis was performed on the transcribed data in order to understand the referral patterns for BMD testing. Results. We identified a lack of clarity about screening for osteoporosis with a tendency for baseline BMD testing in healthy, postmenopausal women and a lack of clarity on the appropriate age for screening for men in particular. A lack of clarity on appropriate intervals for follow-up testing was also described. Conclusions. These findings lend support to what has been documented at the population level suggesting a tendency among FPs to refer menopausal women (at low risk). Emphasis on referral of high-risk groups as well as men and further clarification and education on the appropriate intervals for follow-up testing is warranted.

Baseline bone mineral density testing among breast cancer patients prescribed aromatase inhibitors (AIs).

6642 Background: Because of the adverse effects of AI’s on bone mineral density (BMD) and fracture risk, current guidelines recommend baseline BMD testing when initiating adjuvant AI’s. Methods: We used a validated breast cancer algorithm of Medicare claims to identify older US female breast cancer patients starting adjuvant AI therapy and to examine baseline BMD testing rates. The cohort included all US non-HMO Medicare D-enrolled women age ≥67 years who initiated AI therapy within one year after a 2006-2007 initial breast cancer surgery. Women receiving IV bisphosphonates consistent with metastatic breast cancer treatment (interval &lt;90 days)were excluded. We examined BMD testing between 24 months prior and 6 months after AI initiation, adjusting for demographic and fracture risk factors, and comparing to a duration-adjusted testing rate for a 5% random sample of all cancer-free women enrolled in Medicare in 2008. Results: A majority of the cancer cohort (67.7%) had baseline BMD testing. This was substantially higher than the 2008 BMD testing rate for the non-cancer sample (15.4%, which translates into a 38.5% 30-month rate). Women of higher age and co-morbidity, as well as women of black race or lower income were less likely to be tested (see Table). Empiric use of oral bisphosphonates increased slightly with age, but this did not fully account for the testing differences by age. Conclusions: Although baseline BMD testing is high among women initiating AIs, approximately one-third do not receive guideline-recommended testing. Furthermore, those with greater risk fracture risk based on age and higher co-morbidity are less likely to have appropriate bone care. [Table: see text]

Does osteoporosis therapy invalidate FRAX for fracture prediction?

Ten-year fracture risk assessment with the fracture risk assessment system (FRAX) is increasingly used to guide treatment decisions. Osteoporosis pharmacotherapy reduces fracture risk, but the effect is greater than can be explained from the increase in bone mineral density (BMD). Whether this invalidates fracture predictions with FRAX is uncertain. A total of 35,764 women (age ≥50 years) and baseline BMD testing (1996–2007) had FRAX probabilities retroactively calculated. A provincial pharmacy database was used to identify osteoporosis medication use. Women were categorized as untreated, current high adherence users [medication possession ratio (MPR) ≥0.80 in the year after BMD testing], current low adherence users (MPR <0.80), and past users. Fractures outcomes to 10 years were established form a population-based health data repository. FRAX and femoral neck BMD alone stratified major osteoporotic and hip fracture risk within untreated and each treated subgroup (all p-values <0.001) with similar area under the receiver operating characteristic curve. In untreated and each treated subgroup, a stepwise gradient in observed 10-year major osteoporotic and hip fracture incidence was found as a function of the predicted probability tertile (all p-values <0.001 for linear trend). Concordance (calibration) plots for major osteoporotic fractures and hip fractures showed good agreement between the predicted and observed 10-year fracture incidence in untreated women and each treated subgroup. Only in the highest risk tertile of women highly adherent to at least 5 years of bisphosphonate use was observed hip fracture risk significantly less than predicted, though major osteoporotic fracture risk was similar to predicted. In summary, this work suggests that the FRAX tool can be used to predict fracture probability in women currently or previously treated for osteoporosis. Although FRAX should not be used to assess the reduction in fracture risk in individuals on treatment, it may still have value for guiding the need for continued treatment or treatment withdrawal

A clinical decision rule to enhance targeted bone mineral density testing in healthy mid-life women

The rates of bone mineral density testing for osteoporosis among healthy mid-life women are high, although their osteoporosis or fracture risk is low. To reduce unnecessary testing, we created and evaluated a tool to guide bone density testing based on the woman's age, weight, fracture history, and menopausal status. This study aims to improve case finding of mid-life women with low bone mass on bone mineral density (BMD) assessment. Among healthy women aged 40-60 years having their first BMD test, osteoporosis risk factors were assessed by questionnaire and BMD by dual-energy X-ray absorptiometry. The combination of risk factors that best discriminated women with/without low bone mass (T-score ≤ -2.0) was determined from the logistic regression model area under the curve (AUC) and internally validated using bootstrapping. Using the model odds ratios, a clinical prediction rule was created and its discriminative properties assessed and compared with that of the osteoporosis self-assessment tool (OST). Sensitivity analyses examined results for pre-/peri- and post-menopausal women, separately. Of 1,664 women referred for baseline BMD testing, 433 with conditions known to be associated with bone loss were excluded. Of 1,231 eligible women, 944 (77%) participated and 87 (9.2%) had low bone mass (35 pre-/peri- and 52 post-menopausal). Four risk factors for low bone mass were identified and incorporated into a clinical prediction rule. Selecting women for BMD testing with weight of ≤70 kg or any two of age >51, years' post-menopause of ≥1, and history of fragility fracture after age 40 was associated with 93% sensitivity to identify women with low bone mass, compared with 47% sensitivity for an OST score of ≤1 (AUC 0.75 versus OST AUC 0.69, p = 0.04). Results restricted to post-menopausal women were similar. Among healthy mid-life women receiving a baseline BMD test, few had low bone mass, supporting the need for guidance about testing. A prediction rule with four risk factors had improved sensitivity over the OST. Further validation is warranted.

Time since prior fracture is a risk modifier for 10-year osteoporotic fractures

The objective of this study was to assess the importance of time since prior fracture as a risk factor for future osteoporotic fractures and how it affects 10-year fracture rates. We identified 39,991 women 45 years of age or older undergoing baseline bone mineral density (BMD) testing (1990-2007) from a regional database that contains dual-energy X-ray absorptiometry (DXA) results for Manitoba, Canada. Health service records were used to identify nontrauma ICD-9-CM fracture codes preceding DXA, grouped as "major" fractures (n = 5178; hip, spine, forearm, and humerus) or "minor" fractures (n = 3479; ribs, sternum, pelvis, trunk, clavicle, scapula, patella, tibia/fibula, and ankle). Time since prior fracture was coded in years as less than 1, 1 to 5, 5 to 10, and more than 10. Incident fractures (ie, hip, spine, forearm, and humerus) after BMD testing were identified (mean follow-up 4.2 years, maximum 10 years) and studied in Cox proportional-hazards models adjusted for age, BMD T-score, and other covariates. After BMD testing, n = 1749 (4.4%) women experienced an incident fracture. Prior major fracture was a strong risk factor for incident fracture, greatest risk in the first year [hazard ratio (HR) 1.90, 95% confidence interval (CI) 1.60-2.25], declining by more than 10 years (HR 1.62, 95% CI 1.25-2.10). Prior minor fracture was a weaker risk factor, greatest in the first year (HR 1.45, 95% CI 1.13-1.87) and no longer significant by 1 to 5 years. Major and minor fractures both showed a time-dependent decline in importance as risk factors. In conclusion, time since prior fracture modifies future fracture risk, but prior fractures of the hip, spine, forearm, and humerus remain strong risk factors even 10 years later. Fracture risk assessment should emphasize the importance of prior fractures at these sites.

Simplified 10-Year Absolute Fracture Risk Assessment: A Comparison of Men and Women

A simplified (semiquantitative) approach developed by the Canadian Association of Radiologists and Osteoporosis Canada (denoted as CAROC) for absolute fracture risk assessment incorporates age, sex, prior fragility fracture, and systemic corticosteroid use, together with bone mineral density (BMD) to define absolute fracture risk. The CAROC system has been shown to predict fracture rates in women referred for clinical BMD testing, but it is uncertain how this system performs in routine clinical practice in men who are much less likely to undergo BMD testing with potential for referral biases. Thirty-six thousand seven hundred and thirty women and 2873 men aged 50 yr or older at the time of baseline BMD testing were identified in a database containing all clinical dual-energy X-ray absorptiometry test results for the Province of Manitoba, Canada. Population-based health service records from 1987 to 2008 were assessed for fracture codes and medication use. Fracture risk under the CAROC model was categorized as low (<10%), moderate (10–20%), or high (>20%). Ten-year fracture risk estimated by the Kaplan-Meier method showed the same gradient in observed fracture risk for men and women. Despite evidence of greater referral bias in men resulting in a higher rate of clinical risk factors, the performance of the prediction algorithm was not affected.

Factors predicting osteoporosis treatment initiation in a regionally based cohort

Osteoporosis treatment initiation was assessed during the year after baseline BMD testing in 8,689 previously untreated women. Treatment initiation increased progressively as BMD T-scores decreased, but there was a gradient response rather than step increases at conventional T-score intervention thresholds. Bone mineral density (BMD) testing is used to identify those at high fracture risk and guide osteoporosis treatment (OTx) initiation. Clinical guidelines have used the World Health Organization T-score diagnostic cutoffs as thresholds for treatment intervention. Our objective was to assess whether OTx initiation tracks these T-score cutoffs. Eight thousand six hundred and eighty-nine women age > or = 50 years who had not been dispensed any OTx medication in the year prior to baseline BMD were identified from a regionally based database in the Province of Manitoba, Canada, and OTx initiation rates were analyzed. Forty-four percent of women were dispensed OTx in the year after BMD. OTx initiation increased progressively as BMD T-scores decreased (8.2% normal, 41.0% osteopenic, 78.5% osteoporotic, p-for-trend < 0.0001). There was a gradient response to OTx initiation, rather than step increases at conventional T-score intervention thresholds. BMD was strongly associated with OTx (p < 0.0001) while age, weight, and fracture in the last year were not. Physicians rely heavily on BMD T-score to decide on OTx initiation. Although guidelines suggest using clinical risk factors to guide decision making, we did not see evidence of this. More explicit methods of reporting fracture risk may help physicians select patients who are likely to derive the largest benefit from OTx.

High bone mineral density is associated with high body mass index

High BMD is an infrequent finding. In this retrospective cohort study of women 50 years and older, we documented a strong association between high BMD and high BMI. High bone mineral density (BMD) has been associated with genetic disorders and a variety of dietary, endocrine, metabolic, infectious and neoplastic diseases that in many cases warrant medical attention. Since body mass index (BMI) is closely correlated with BMD, we sought to explore the relationship between these two parameters in older women. We conducted a retrospective clinical cohort study of 16,500 women 50 years and older who underwent baseline BMD testing between May 1998 and October 2002. Mean T-scores and Z-scores, and the proportions of women with high BMD (T-score +2.5 or greater, Z-score +2.0 or greater), were assessed according to BMI category. Higher BMI category was associated with higher mean T-scores and Z-scores at all sites (P < 0.001). The proportion of women with high BMD increased with each BMI category (P for trend <0.05). In women with a lumbar spine T-score of +2.5 or more, 43.5% were obese with BMI > 30 kg/m(2) (55.6% for the femoral neck and 73.1% for the total hip). For women with a lumbar spine Z-score of +2.0 or more, 37.2% were obese (42.0% for the femoral neck and 50.9% for the total hip). There was no evidence of a paradoxical increase in fracture rates in women with high BMD. High BMD is closely associated with elevated BMI in women. This should be taken into consideration prior to initiating extensive investigations for rare pathologies.

Weight and body mass index predict bone mineral density and fractures in women aged 40 to 59 years

Weight and body mass index are associated with low bone mineral density and fractures in older women. This retrospective cohort study confirms a similar relationship in women aged 40 to 59 years. Risk factors for the prediction of osteoporosis and fractures have been less thoroughly studied in younger women. We evaluated the associations between weight, body mass index (BMI), the Osteoporosis Self-Assessment Tool (OST), bone mineral density (BMD) and fracture risk in women aged 40 to 59 years. Using administrative health management databases, we conducted a retrospective cohort study in 8,254 women aged 40-59 years who had baseline BMD testing. Linear regression and Cox proportional multivariate models were created to examine the associations with weight, BMI, OST, BMD, and subsequent fractures throughout a 3.3-year follow-up. Body weight, BMI, and OST had a similar overall performance in their ability to classify women with femoral neck T-score < or = -2.5. Throughout 27,256 person years of observation, 225 women experienced one or more fractures. After adjustment for age, prevalent fractures, and use of corticosteroids, each standard deviation decrease in weight was associated with a 19% increase in the risk of incident fracture (95% CI: 1.01-1.35). Femoral neck BMD and the presence of prevalent fractures were also associated with the risk of incident fractures. Low weight and BMI predict osteoporosis and are associated with increased fracture risk in younger women. The negative impact of low body weight on bone health should be more widely recognized.

A pilot study of bone density loss in menopausal women treated with chemotherapy for cancer

To estimate the incidence and severity of bone loss in menopausal women diagnosed with cancer who receive treatment with chemotherapy. Also, to evaluate the use of bone loss prevention agents in this population. A total of 25 postmenopausal women with newly diagnosed cancers who received chemotherapy for a minimum of six cycles were enrolled in this pilot study. All subjects underwent baseline bone mineral density (BMD) testing of the lumber spine (LS), left hip (LH), and femoral neck (FN). Of the 25 women, 22 also underwent follow-up BMD testing at 6 months. The median age of the subjects was 61 years (range 41-76 years) and the median age of menopause was 50 years (range 34-55 years). Of the 25 subjects, 9 used at least 1 g oral calcium daily, 4 used alendronate, 2 used raloxifene, and 1 used oral estrogen. The mean BMDs (g/cm2) with standard deviation above or below the mean for young adult women at baseline were: LS 0.996 (-0.5 SD), LH 0.876 (-0.5 SD), and FN 0.760 (-0.7 SD). The following values were obtained at 6 months: LS 0.965 (P<0.001), LH 0.847 (P<0.001), and FN 0.739 (P=0.009). Menopausal women diagnosed with cancer appear to have a high incidence of baseline bone loss, with significant additional loss during treatment. Use of agents for prevention/treatment of bone loss in this group is infrequent. A prospective, controlled analysis is indicated to determine the optimal utility of bone densitometry testing and osteoporosis prevention strategies in this population.

The validity of decision rules for selecting women with primary osteoporosis for bone mineral density testing.

The purpose of this study was to determine the validity of the Osteoporosis Risk Assessment Instrument (ORAI), Osteoporosis Self-Assessment Tool (OST) chart and equation, and a criterion based on body weight for identifying women with asymptomatic primary osteoporosis. Prospective recruitment and chart abstractions from family practices of three University affiliated hospitals were completed for women aged 45 years or more with baseline bone mineral density (BMD) testing results by dual energy X-ray absorptiometry. Those taking bone active medication other than hormone therapy, with prior fragility fracture or with risk factors for secondary osteoporosis were excluded. Women were categorized as being normal, osteopenic or osteoporotic by lowest BMD T-score at either the femoral neck or lumbar spine (L1-L4). Sensitivity, specificity and area under the receiver operating characteristic (ROC) curve to identify those with osteoporosis were determined for each decision rule. The positive predictive value (PPV) for detecting osteoporosis after using a second cut point to convert each decision rule into a risk index (low, moderate or high risk) was also determined. The sensitivity of the decision rules to identify women with osteoporosis ranged from 92% to 95% and specificity from 35% to 46%. The area under the ROC curves were significantly better for the ORAI (0.80), OST chart (0.82) and OST equation (0.82) compared with the body weight criterion (0.73). PPV for detecting osteoporosis ranged from 30% to 58% among women deemed at high risk. These data confirm the validity of the ORAI, the OST chart and the OST equation as screening tools for BMD testing. Further evidence is required to confirm the validity of the body weight criterion.