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Younger women at risk of losing bone mass and bone quality are now officially one group who should be screened for osteoporosis with bone density scans, according to updated U.S. Preventive Services Task Force (USPSTF) recommendations.

Women age 65 years and older keep their B recommendation for screening with bone density testing, whereas another B was given to younger women who are postmenopausal and at increased risk of osteoporosis based on a number of formal clinical risk assessment tools, including the Fracture Risk Assessment Tool (FRAX) and the Osteoporosis Self-Assessment Screening Tool (OST).

For men, however, the insufficient evidence of the associated benefits and harms of screening yielded the same I recommendation as before, Susan Curry, PhD, of University of Iowa in Iowa City, and colleagues of the USPSTF wrote in a recommendation statement published in the.

The USPSTF recommendation statement in 2011 formally gave B and I ratings to for osteoporosis screening only in older women and men, respectively.

Now, the updated document is based on a systematic review of 168 reports showing that the accuracy of bone density tests to identify osteoporosis varied widely (area under the curve [AUC] 0.32-0.89). From this USPSTF-commissioned report, it was also determined that the pooled accuracy of clinical risk assessments for identifying osteoporosis was in the AUC 0.65-0.76 range in women and 0.76-0.80 in men, reported a group led by Meera Viswanathan, PhD, of RTI International at Research Triangle Park, N.C., in the same journal.

"In 2011, the USPSTF endorsed FRAX to identify candidates for screening among women age 50 to 64 years," recalled Jane Cauley, DrPH, of University of Pittsburgh, in an accompanying . "Specifically, the 2011 guidelines recommended BMD [bone mineral density] testing for women age 50 to 64 years whose 10-year predicted risk of major osteoporotic fractures using FRAX was equivalent to that of a 65-year old white woman with no other FRAX risk factors (9.3%)."

A change was needed after a study showed that this USPSTF strategy was modestly better than chance alone and inferior to other tools in identifying women age 50-64 years who need BMD testing, Cauley suggested, calling the updated recommendations "timely" in light of higher-than-predicted hip fractures rates recently in the U.S.

"Screening for high-risk patients who may benefit from therapy is important because prevention of fractures in these individuals is possible, given the armamentaria of effective therapies," according to Cauley.

However, the B rating for osteoporosis screening in younger women at risk wasn't received well by Margaret Gourlay, MD, MPH, of the University of Carolina at Chapel Hill.

"The B recommendation for routine osteoporosis screening in all women 65 years or older has been an enduring and evidence-based feature of the USPSTF recommendations since 2002. Unfortunately, the B recommendation for a two-step strategy of risk-factor assessment before bone-density testing in postmenopausal women younger than 65 years does not match existing evidence," she wrote in a editorial.

For one, there is no evidence that women starting osteoporosis therapy earlier, at 50-59 years of age, derive any more benefit from the extra years of treatment, she said.

The evidence for two-step osteoporosis screening in women younger than 65 years would be better characterized by an I statement saying that the evidence is insufficient to determine the balance between benefits and harms, Gourlay emphasized, citing overtreatment and poor resource utilization as potential risks when it comes to this population.

"As the United States spends more dollars to achieve worse health care outcomes than other industrialized countries, the worst mistakes we can make are to underuse an effective screening protocol that has been made unnecessarily complex, or overuse a prescreening step that adds uncertain value," she said.

In the future, studies should focus more on men and report on fracture outcomes rather than BMD, the USPSTF group urged.

"More studies are also needed that evaluate the direct effect of screening for osteoporosis (either with BMD or clinical risk assessment tools) on fracture outcomes. Additional research is needed to determine whether clinical risk assessment tools alone (without BMD) could help identify patients at risk of fractures and help guide decisions to initiate medications to prevent fractures," according to Curry and colleagues.