Debating the management of osteoporosis risk
CMAJ 1998;158:586
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In response to: A. Sovereign
This letter is typical of many received after the BC Study of Osteoporosis Risk suspended recruitment in January 1997. The study, cosponsored by the Osteoporosis Society of British Columbia, the British Columbia's Women's Hospital, the BC Hydro Foundation and industry, was designed to investigate the short-term effects of osteoporosis risk assessment on patient behaviour. Over the long term, the study was intended to relate any fractures that occurred to the results of the initial calcaneal ultrasonography and historical risk factors. The trial was considered particularly relevant in BC, where the provincial government has restricted the number of densitometry-testing sites to the 7 that existed in 1994.
The study sought to recruit 10 000 volunteers. Participants were to undergo osteoporosis risk assessment and receive advice on diet and lifestyle modification to reduce their risk of fracture. The risk assessment involved a questionnaire, and participants were informed of historical risk factors along with the results of calcaneal ultrasonography. No drugs or other diagnostic tests were discussed or recommended, and follow-up was by mailed questionnaire. In 10 months 6500 participants were recruited, and the response was universally positive.
In November 1996 a provincial agency, the BC Office of Health Technology Assessment, held a closed meeting to discuss its review of bone densitometry, a report that has never been made public. The office did not request any representation from or information about the BC study. In discussing the study, the office argued that bone densitometry (by dual-energy x-ray absorptiometry [DXA] or ultrasonography) was not a valid tool for risk assessment. In December 1996 and January 1997 a series of newspaper articles stated that fractures are a normal consequence of aging and that risk assessment is therefore unnecessary. Fearful of controversy, hospital administrators decided not to support further recruitment to the trial, although follow-up would be continued. BC residents have since expressed disappointment that their needs for information are not being met.
Over the past year many study participants have asked why people took issue with researching the outcome of osteoporosis risk assessment that promoted good diet, exercise and better lifestyle habits. They have asked whether the calcaneal ultrasound technology was inappropriate. With the passage of a year, we have seen European, US and Canadian osteoporosis societies endorse multifactorial risk assessment, including bone mass measurement (which can be done by calcaneal ultrasonography) — exactly the same process that was done in the BC study. The Food and Drug Administration has now approved the first calcaneal ultrasound instrument for use in the US. At a recent consensus meeting, the Osteoporosis Society of Canada endorsed the use of this instrument in settings such as those arranged for the BC Study of Osteoporosis Risk. Time has answered a lot of the questions raised by opponents of osteoporosis risk assessment.
What we now need are data from studies such as this one to guide us in implementing multifactorial osteoporosis risk assessment for improving patients' behaviour. Only through pioneering initiatives such as this one will we be able to stand up for our patients' right to acquire the personal health information they need to make important decisions about their future.
David Kendler, MD
Assistant Professor of Medicine
University of British Columbia
Vancouver, BC
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