Copyright © 2007 by The Journal of Bone and Joint Surgery, Inc.
Commentary & Perspective
Commentary & Perspective by
Laura Lowe Tosi, MD*,
Children's Hospital Medical Center, Washington, D.C.
Posted April 2007
The article by Skedros et al. in this issue of The Journal raises awareness of a
critical and generally underrecognized issue—namely, that osteoporosis is not
just a woman's disease1. Men are at high risk for osteoporosis and
its sequela, fragility fracture. Moreover, Skedros and colleagues advocate
using the simple-to-use Osteoporosis Self-Assessment Screening Tool (OST)2 to screen both male and female patients.
Historically, most clinicians have not been concerned about the
risk of osteoporosis or bone fracture in men. They have been complacent because,
compared with women, men achieve higher peak bone mass, have slower rates of
bone loss during aging, do not become hypogonadal, fall less frequently, and
have shorter life expectancies. But clinicians have failed to recognize that men
who have passed the age of sixty-five or seventy years of age begin to lose
bone mass at the same rate as women do; in addition, if a man does have
osteoporosis, his risk of having a secondary medical condition that contributes
to bone loss is 40% to 60%3.
The risk of osteoporosis for both men and women is too high,
and the consequences are unacceptable. As the average life span of both men and
women increases, we need to ensure that all seniors remain healthy and
independent for as long as possible.
Unfortunately, we don't yet know a lot about what influences
bone health in men, because most research has been focused on women. But what
we do know is worrisome. For example, the lifetime risk for the occurrence of a
hip fracture at fifty years of age is indeed substantially lower for men than
for women (6% to 11% and 17% to 22%, respectively)4,5. However, a
man who does fracture a hip is, on the average, younger than a woman who fractures a hip, and he also has more
comorbidities and is at a higher risk of sustaining a refracture6.
That's not the end of the tale. Of the approximately 90,000
men who are sixty-five years of age or older and who suffer a hip fracture in
any one year, one in three will die within the first year after fracture6,7.
That means that, in the United States, more men die of hip fracture each year
than of prostate cancer8.
And if a man who is sixty-five years of age or older sustains
a hip fracture and survives, he will achieve a lower level of postfracture
function than would a woman under similar circumstances6. He will be
much less likely to receive preventive care9. Fragility fractures
may be less common in men than in women, but woe unto the man who suffers one!
The dearth of information about osteoporosis in men has serious
public policy implications. The nursery rhyme that begins, "For want of a nail,
a shoe was lost," describes the osteoporosis story. Because so little research
has been done in men, there are no evidence-based guidelines for osteoporosis
prevention, diagnosis, and treatment in men. Existing guidelines have been
based on the accumulated data from the prevention and treatment of osteoporosis
in white women10.
Furthermore, because of the lack of evidence-based
guidelines, osteoporosis screening for men is not approved for reimbursement by
the Centers for Medicare and Medicaid Services (CMS) under many circumstances.
CMS pays for bone-density testing only for an estrogen-deficient woman who has
been clinically identified as being at risk for the development of osteoporosis;
for an individual with radiographically demonstrated vertebral abnormalities
indicative of osteoporosis, low bone mass, or vertebral fracture; for an
individual who is receiving long-term glucocorticoid (steroid) therapy; for an
individual with primary hyperparathyroidism; or for an individual being
monitored to assess the response to or efficacy of a Food and Drug
Administration-approved osteoporosis drug therapy11. A review of the
new CMS 2007 Physician Voluntary Reporting Program Measure Specifications
indicates that, although bone-density measurement is urged after a fracture in all patients, such testing is encouraged
as a screening tool only in women who
are older than sixty-five years12.
The OST holds great promise, but its potential cannot be realized
if public policy and CMS reimbursement guidelines remain behind the curve. As
an orthopaedic surgeon, I concur with Skedros et al. that the OST should be
applied to women who are older than forty-five years and to men who are older
than fifty-five years; however, it is not clear that health insurers will
agree.
Fortunately, help is on the way. The National Institutes of
Health (NIH) is wrapping up "Mr. OS," its seven-year, multi-site study of more
than 5700 men, age sixty-five years or older13. The purpose of the
study is to determine whether fracture risk in men is related to bone mass as
it is in women. The study is also looking at the role of other potential risk
factors (e.g., bone structure, lifestyle, and tendency to fall) on bone mass
and fracture rates in men. When these data are analyzed, it will be possible to
develop an evidence-based guideline for men that can drive the public policy
and reimbursement agenda.
As we evaluate the results of the NIH study, however, we will
need to remember one ironic outcome of the National Osteoporosis Risk
Assessment (NORA) study: most women who suffered a fragility fracture in that
study did not, in fact, have osteoporosis14. In other words, there
is more to bone quality than bone density. Bone quality research has the
potential to improve the quality of life of millions of Americans. It must become
a federal research priority.
In the meantime, as orthopaedic surgeons, we must do what we
can to ensure optimum bone health in our older patients. Because of lack of
training, many orthopaedic surgeons are reluctant to take on the
responsibilities of diagnosing secondary causes of osteoporosis and providing
pharmacotherapy. However, all orthopaedic surgeons are qualified—and should
feel obligated—to discuss bone health with their patients. Osteoporosis
prevention needs to be a patient-education priority. We need to ensure that the
public is better informed of the importance of getting enough dietary calcium
and vitamin D as well as regular exercise.
Skedros et al. have given us a remarkable tool. With only a
calculator and measurements of age and weight (data required by the Joint
Commission on Accreditation of Healthcare Organizations), we can alert some of
our most vulnerable patients (and their primary care physicians) of a major
health risk. We owe it to America's seniors to begin.
*The author did not receive any outside funding or grants in support of their research for or preparation of this work. The author or a member of her immediate family received, in any one year, payments or other benefits of less than $10,000 or a commitment or agreement to provide such benefits from a commercial entity (Merck, for lectures on fragility fractures). Also, a commercial entity (Merck, for a research grant unrelated to this work) paid or directed in any one year, or agreed to pay or direct, benefits in excess of $10,000 to a research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of her immediate family, is affiliated or associated.
References
1. National Osteoporosis Foundation. America's bone health (prevalence report): the state of osteoporosis and low bone mass in our nation. Osteoporosis and low bone mass - males. Accessed 2007 Mar 9.
2. Koh LK, Sedrine WB, Torralba TP, Kung A, Fujiwara S, Chan SP, Huang QR, Rajatanavin R, Tsai KS, Park HM, Reginster JY. Osteoporosis Self-Assessment Tool for Asians (OSTA) Research Group. A simple tool to identify Asian women at increased risk of osteoporosis. Osteoporos Int. 2001;12:699-705.
3. Seeman E. Osteoporosis in men: epidemiology, pathophysiology, and treatment possibilities. Am J Med. 1993;95:22S-8S.
4. Melton LJ 3rd, Atkinson EJ, O'Connor MK, O'Fallon WM, Riggs BL. Bone density and fracture risk in men. J Bone Miner Res. 1998;13:1915-23.
5. Oden A, Dawson A, Dere W, Johnell O, Jonsson B, Kanis JA. Lifetime risk of hip fractures is underestimated. Osteoporos Int. 1998;8:599-603.
6. Orwig DL, Chan J, Magaziner J. Hip fracture and its consequences: differences between men and women. Orthop Clin North Am. 2006;37:611-22.
7. DeFrances CJ, Podgornik MN. 2004 National hospital discharge survey. In: Advance data from vital and health statistics. No. 371. Hyattsville, MD: National Center for Health Statistics; 2006 May 4. Accessed 2007 Mar 9.
8. American Cancer Society. Cancer facts and figures 2006. Accessed 2007 Mar 12.
9. Kiebzak GM, Beinart GA, Perser K, Ambrose CG, Siff SJ, Heggeness MH. Undertreatment of osteoporosis in men with hip fracture. Arch Intern Med. 2002;162:2217-22.
10. National Osteoporosis Foundation. Physician's guide to prevention and treatment of osteoporosis. Washington, DC: National Osteoporosis Foundation; 2003.
11. National Osteoporosis Foundation. Reimbursement of bone mineral density tests. Accessed 2007 Mar 12.
12. Centers for Medicare and Medicaid Services. 2007 Physician Voluntary Reporting Program Measure Specifications. Accessed 2007 Mar 12.
13. National Institutes on Health. Word on Health. Men can get osteoporosis too. Accessed 2007 Mar 12.
14. Siris ES, Miller PD, Barrett-Connor E, Faulkner KG, Wehren LE, Abbott TA, Berger ML, Santora AC, Sherwood LM. Identification and fracture outcomes of undiagnosed low bone mineral density in postmenopausal women: results from the National Osteoporosis Risk Assessment. JAMA. 2001;286:2815-22.
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