JOURNAL OF BONE AND MINERAL RESEARCH Volume 5, Number 5, 1990 Mary Ann Liebert, Inc., Publishers
Editorial Guidelines for Osteoporosis Prophylaxis C. CONRAD JOHNSTON' and L. JOSEPH MELTON 1112
In a recent issue of the Journal of Bone and Mineral Research, Grisso and Turner") described the results of a survey of estrogen prescribing habits among various specialists in different practice settings. Although setting had some influence, clinical specialty largely dictated the proportion of postmenopausal women placed on estrogen replacement therapy (ERT) for prevention of osteoporosis, which varied from 45% among gynecologists to 15% among general internists and 14% among cardiologists. The authors were somewhat surprised by the low frequency of ERT use, especially since nonresponding physicians may have had even lower rates of use. However, an extensive review of the clinical uses of bone mass measurement conducted on behalf of the National Osteoporosis Foundation also found evidence for a low prevalence of ERT use.") Various studies seem to indicate that about a third of postmenopausal women are put on ERT but only about 15% of this group remain on therapy for 10 years or more. Because long-term use is needed to prevent osteoporosis-related fractures, this suggests that only 5% of postmenopausal women are so protected. Since long-term ERT is generally conceded to lower the frequency of osteoporosis-related f r a c t u r e ~ , ( ~it, ~is) of considerable interest to identify barriers to the use of that therapy. Although Grisso and Turner did not explore this issue in depth, they found that physicians' concerns about cancer risk and patient reluctance (which may also involve fear of cancer) were important considerations.('] Others have reached the same conclusions.~5~6~ This indicates that neither patients nor physicians are completely convinced of the efficacy of progestins in combating endometrial cancer associated with ERT, although gynecologists appear to be more confident on this point."' Lingering worries about an elevated risk of breast cancer may also play a role. Studies of this issue are contradictory but not sufficient to rule out a small increase in breast cancer risk, especially
with long-term ERT use,'8) and fears are exacerbated by the publicity afforded each new study that supports an association. 1 9 ) Also of note was the very low frequency of ERT use among cardiologists,") even though some of them recommended calcium and exercise for their postmenopausal patients in the absence of good evidence of efficacy for either of these in preventing fractures.('O1 This is especially surprising because of indications that ERT may substantially reduce the risk of coronary heart disease.'") It is important to obtain additional information about this apparent discrepancy and about the high frequency of perceived medical contraindications to ERT that Grisso and Turner found.") The latter observation reinforces the view that physicians in general may be uncertain about the specific indications and contraindications to this therapy, as well as its relative benefits and risks. The National Osteoporosis Foundation report provides initial guidance on the use of bone mass measurements to assess fracture risk in patients seen in clinical practice.(z' Although this information should be helpful in decisions about ERT therapy, the issue is not resolved. Additional research is needed to support detailed guidelines regarding the optimal technology and site for bone mass measurement, the specific level of bone mass at which intervention should be undertaken, the form of intervention that should be considered, and the duration and dose of indicated drugs. As Grisso and Turner make clear, however, attention must also be given to the practical problems of everyday patient management. Greater effort, for example, will be needed to quantify the risks and benefits of osteoporosis prophylaxis and convey this information in a meaningful way to patients and physicians alike. This will help assure that control measures achieve the greatest possible reduction in fracture risk in the community.
'Department of Medicine, Indiana University School of Medicine, Indianapolis, IN. 'Department of Health Sciences Research, Mayo Clinic, Rochester, MN.
423
424
JOHNSTON AND MELTON
ACKNOWLEDGMENTS Supported in part by research grants AR-27065 and AG-05793 from the National Institutes of Health, U.S. Public Health Service.
REFERENCES
6. 7.
8.
9. 1. Grisso JA, Baum CR, Turner BJ 1990 What do physicians in practice do to prevent osteoporosis? J Bone Min Res 5213-219. 2. Eddy DM, Johnston CC, Lindsay R, Melton LJ 1989 Clini- 10. cal indications for bone mass measurements. Report of the Scientific Advisory Committee of the National Osteoporosis 11. Foundation. J Bone Min Res 4(Suppl 2):l-28. 3. Dolan WD, Gifford RW Jr, Smith RJ, Beljan JR, Cooper T, Friedlander IR, Kastan MB, Moxley JH 111, Schmidt RTF, Skom JH, Snow JB Jr, Tupper CJ, Jones RJ (Council on Scientific Affairs) 1983 Estrogen replacement in the menopause. JAMA 249:359-361. 4. Consensus Conference 1984 Osteoporosis. JAMA 252:799802. 5. Elstein AS, Holzman GB, Ravitch MM, Metheny WA, Holmes MM, Hoppe RB, Rothert ML, Rovner DR 1986
Comparison of physicians’ decisions regarding estrogen replacement therapy for menopausal women and decisions derived from a decision analytic model. Am J Med 80:246-258. Ravnikar VA 1987 Compliance with hormone therapy. Am J Obstet Gynecol 156:1332-1334. American College of Obstetricians and Gynecologists Committee on Technical Bulletins 1988 Osteoporosis. ACOG Tech Bull 118:l-7. Barrett-Connor E 1989 Postmenopausal estrogen replacement and breast cancer. N Engl J Med 321:319-320. Bergkvist L, Adami H-0, Persson I, Hoover R, Schairer C 1989 The risk of breast cancer after estrogen and estrogenprogestin replacement. N Engl J Med 321:293-297. Osteoporosis. In: Health Promotion and Disability Prevention for the Second Fifty. Institute of Medicine. In press. Bush TL, Barrett-Connor E 1985 Noncontraceptive estrogen use and cardiovascular disease. Epidemiol Rev 7:80- 104.
Address reprint requests to: Dr. C . Conrad Johnston Department of Medicine Emerson Hall 421 545 Barnhill Drive Indianapolis, IN 46223
Editorial Guidelines for Osteoporosis Prophylaxis C. CONRAD JOHNSTON' and L. JOSEPH MELTON 1112
In a recent issue of the Journal of Bone and Mineral Research, Grisso and Turner") described the results of a survey of estrogen prescribing habits among various specialists in different practice settings. Although setting had some influence, clinical specialty largely dictated the proportion of postmenopausal women placed on estrogen replacement therapy (ERT) for prevention of osteoporosis, which varied from 45% among gynecologists to 15% among general internists and 14% among cardiologists. The authors were somewhat surprised by the low frequency of ERT use, especially since nonresponding physicians may have had even lower rates of use. However, an extensive review of the clinical uses of bone mass measurement conducted on behalf of the National Osteoporosis Foundation also found evidence for a low prevalence of ERT use.") Various studies seem to indicate that about a third of postmenopausal women are put on ERT but only about 15% of this group remain on therapy for 10 years or more. Because long-term use is needed to prevent osteoporosis-related fractures, this suggests that only 5% of postmenopausal women are so protected. Since long-term ERT is generally conceded to lower the frequency of osteoporosis-related f r a c t u r e ~ , ( ~it, ~is) of considerable interest to identify barriers to the use of that therapy. Although Grisso and Turner did not explore this issue in depth, they found that physicians' concerns about cancer risk and patient reluctance (which may also involve fear of cancer) were important considerations.('] Others have reached the same conclusions.~5~6~ This indicates that neither patients nor physicians are completely convinced of the efficacy of progestins in combating endometrial cancer associated with ERT, although gynecologists appear to be more confident on this point."' Lingering worries about an elevated risk of breast cancer may also play a role. Studies of this issue are contradictory but not sufficient to rule out a small increase in breast cancer risk, especially
with long-term ERT use,'8) and fears are exacerbated by the publicity afforded each new study that supports an association. 1 9 ) Also of note was the very low frequency of ERT use among cardiologists,") even though some of them recommended calcium and exercise for their postmenopausal patients in the absence of good evidence of efficacy for either of these in preventing fractures.('O1 This is especially surprising because of indications that ERT may substantially reduce the risk of coronary heart disease.'") It is important to obtain additional information about this apparent discrepancy and about the high frequency of perceived medical contraindications to ERT that Grisso and Turner found.") The latter observation reinforces the view that physicians in general may be uncertain about the specific indications and contraindications to this therapy, as well as its relative benefits and risks. The National Osteoporosis Foundation report provides initial guidance on the use of bone mass measurements to assess fracture risk in patients seen in clinical practice.(z' Although this information should be helpful in decisions about ERT therapy, the issue is not resolved. Additional research is needed to support detailed guidelines regarding the optimal technology and site for bone mass measurement, the specific level of bone mass at which intervention should be undertaken, the form of intervention that should be considered, and the duration and dose of indicated drugs. As Grisso and Turner make clear, however, attention must also be given to the practical problems of everyday patient management. Greater effort, for example, will be needed to quantify the risks and benefits of osteoporosis prophylaxis and convey this information in a meaningful way to patients and physicians alike. This will help assure that control measures achieve the greatest possible reduction in fracture risk in the community.
'Department of Medicine, Indiana University School of Medicine, Indianapolis, IN. 'Department of Health Sciences Research, Mayo Clinic, Rochester, MN.
423
424
JOHNSTON AND MELTON
ACKNOWLEDGMENTS Supported in part by research grants AR-27065 and AG-05793 from the National Institutes of Health, U.S. Public Health Service.
REFERENCES
6. 7.
8.
9. 1. Grisso JA, Baum CR, Turner BJ 1990 What do physicians in practice do to prevent osteoporosis? J Bone Min Res 5213-219. 2. Eddy DM, Johnston CC, Lindsay R, Melton LJ 1989 Clini- 10. cal indications for bone mass measurements. Report of the Scientific Advisory Committee of the National Osteoporosis 11. Foundation. J Bone Min Res 4(Suppl 2):l-28. 3. Dolan WD, Gifford RW Jr, Smith RJ, Beljan JR, Cooper T, Friedlander IR, Kastan MB, Moxley JH 111, Schmidt RTF, Skom JH, Snow JB Jr, Tupper CJ, Jones RJ (Council on Scientific Affairs) 1983 Estrogen replacement in the menopause. JAMA 249:359-361. 4. Consensus Conference 1984 Osteoporosis. JAMA 252:799802. 5. Elstein AS, Holzman GB, Ravitch MM, Metheny WA, Holmes MM, Hoppe RB, Rothert ML, Rovner DR 1986
Comparison of physicians’ decisions regarding estrogen replacement therapy for menopausal women and decisions derived from a decision analytic model. Am J Med 80:246-258. Ravnikar VA 1987 Compliance with hormone therapy. Am J Obstet Gynecol 156:1332-1334. American College of Obstetricians and Gynecologists Committee on Technical Bulletins 1988 Osteoporosis. ACOG Tech Bull 118:l-7. Barrett-Connor E 1989 Postmenopausal estrogen replacement and breast cancer. N Engl J Med 321:319-320. Bergkvist L, Adami H-0, Persson I, Hoover R, Schairer C 1989 The risk of breast cancer after estrogen and estrogenprogestin replacement. N Engl J Med 321:293-297. Osteoporosis. In: Health Promotion and Disability Prevention for the Second Fifty. Institute of Medicine. In press. Bush TL, Barrett-Connor E 1985 Noncontraceptive estrogen use and cardiovascular disease. Epidemiol Rev 7:80- 104.
Address reprint requests to: Dr. C . Conrad Johnston Department of Medicine Emerson Hall 421 545 Barnhill Drive Indianapolis, IN 46223
