Monthly Archives: December 2012

UPDATE: WHAT’S THE PROBLEM WITH BONE DENSOMETRY AT ALL AGES AND SEXES??

neil.burman@gmail.com

WHAT’S THE PROBLEM WITH BONE DENSOMETRY?

Answer: none provided it is safely and economically measured and safely and economically corrected at all ages from small children to dotage. It is so cheap and easy to halve  the fracture risk and rate in all, and thus save vast suffering, costs and especially deaths.

A spinal surgeon laments as we all do  the poor correlation between dual xray bone density analysis DXA and fracture risk.
The simple answer is that bone density is not the top risk factor for fractures,

The chief risk for fractures in the aging is falls and fragility ie global health balance  including agility-co-ordination, balance, and strength- muscle mass.

As this column has previously detailed, DXA is valuable for looking at risk areas in the hip or a vertebra;
but just as screening X-ray mammography overdiagnoses clinically relevant breast cancer,   trunkal DXA measurement  increasingly overreads bone density  as we age because of false densification- vascular calcification overlying hips and spine, and progressive collapse wedging of vertebrae.

That’s why,  as  this column has previously referenced,  QUS -quantified ultrasound – done mostly at the heelbone, has become the international gold standard for monitoring global fracture risk, since that bone measured in its long axis  is generally free of overlying vascular calcification and collapse wedging. It is recommended by  international bodies, many leading universities from Cape Town to Cambridge to Scotland, Japan and USA. .

There is generally  good  correlation between true DXA measurement at hip and spine, and heel QUS measurement.
And QUS lacks the cumulative radiation risks of DXA.
That’s why QUS bone density  is increasingly recommended from childhood, for monitoring and thus simple prevention of frailty   – thus avoiding  the mushrooming  fracture and frailty risk in later life

http://www.ncbi.nlm.nih.gov/pubmed/22878531 Osteoporos Int. 2012 Aug  Quantitative ultrasound and fracture risk prediction in non-osteoporotic men and women as defined by WHO criteria.Chan ea  Garvan Institute of Medical Research,Sydney,  Australia.

http://www.ncbi.nlm.nih.gov/pubmed/22037972 Osteoporos Int. 2012 Jan:143-53.Quantitative ultrasound of  heel and fracture risk. Moayyeri ea .University Cambridge  UK. Metanalysis: 21 studies with 55,164 women and 13,742 men were included  with a total follow-up of 279,124 person-years. All QUS parameters were associated with risk of different fracture:  1 SD decrease in BMD associated with almost doubling of  hip fracture risk.  (RR by BUA  1.69, SOS was 1.96). There was marked heterogeneity among studies on hip and any clinical fractures but no evidence of publication bias amongst them. Different validated devices predicted fracture risks with similar performance; with  similar performance in men and women. This study confirms that heel QUS, using validated devices, predicts risk of different fracture outcomes in elderly men and women.

Oct 30, 2010.

FRAILTY FRACTURES- OSTEOPOROSIS- ARE ALSO COMMON- AND EASILY PREVENTED-  IN AGING MEN

The just-published Champ study of osteoporosis in men over 70yrs in Australia shows the high risk for older men as well: 25% had vertebral fractures, but only 77% of the men with fractures had even osteopenia let alone osteoporosis on DXA screening. and this does not factor in the overreading by DXA at the spine and hip owing to the high prevalence of both calcinosis and vertebral collapse. And abysmally few of the men were taking realistic preventatives.

The study bears out:

that frailty,  usually from aging  – is the chief risk factor for non-violent fractures;

and  the low sensitivity of especially  DXA screening, never mind the folly of waiting for fractures or dementia or worse before doing safe lowcost (QUS bone risk) screening as one incentive to starting multipreventative supplements.

As the GIOS Project in Spain yet again confirms, simple  diagnosis and safe  treatment of those at risk of non-violent fractures is scandalously neglected.

And it does not require costly risky high technology – xray screening  bisphosphonates or strontium ranelate..

Like doctors, men are far more resistant than even women to heeding warning to start screening and supplements early enough.

The  CHAMP  study again highlights the importance of asymptomatic middleaged men never mind women having periodic no-xray ultrasound quantitative bone strength scans  routinely as the gold standard so as to prompt them to take the appropriate blend of the fewscore supplements effective against both frailty fractures as well as the associated lipid- diabetes- vascular -respiratory- dementia- cancer diseases.

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question: WHAT IS THE PROBLEM WITH MAMMOGRAMS?

A: THERE IS NO PROBLEM PROVIDED THEY ARE APPROPRIATE.

update 20/12/12      Dr Giske Ursin of the Norwegian Cancer Registry has just published   thoughts on collaboration – not anger for and against risky xray mammography – needed to move the field forward on avoiding breast cancer, to defend the integrity of women’s breasts. http://www.ncbi.nlm.nih.gov/pubmed/23234258 

this column has previously reviewed mammography screening  https://healthspanlife.wordpress.com/2011/11/06/negligent-promotion-of-screening-xray-mammography-as-saving-lives/

and   https://healthspanlife.wordpress.com/2011/10/16/the-evidence-against-xray-screening-mammography-grows-after-20-years/

A new paper – from the USA National Cancer Institute no less- writes about the fraud of alarmist marketing of cancer screening/treatment. http://www.nejm.org/doi/full/10.1056/NEJMp1209407

Another new paper, from Wisconsin University,   What Is the Optimal Threshold at Which to Recommend Breast Biopsy? notes that with an annual incidence of breast biopsy  of 0.626% there (ie about 6 per 1000 women of the ~18 000 screened over 5 years ),  1 in 4 biopsied  ie about 0.15% of those screened will be proven to have some degree of (pre)cancer..  They confirm the 2% risk threshold at which radiologists recommend biopsy.   http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3492229/

Of well women, perhaps <1 in 20 justify screening breast imaging except in those women with relevant anxieties ie the worried well.

But screening xray mammography often uncovers clinically silent ie preclinical breast cancer which otherwise might never cause problems in lifetime; and such irradiation and crushing may activate and  spread dormant precancer cells.
Just as cardiograms are electrical-, echo- or angio- images of the heart, mammograms MGMs are widely different technology images of the breasts.

But unlike heart disease, no living imaging technique diagnoses with certainty cancer that is not already clinically pretty obvious.

The breast carcinogenic radiation risks from X-rays have been known for a century and yet it’s heavy usage is often inappropriate, profit-driven.

When patient’s history and  physical  exam suffice to exclude significant risk of breast cancer with practical certainty, it is unnecessary to crush, irradiate, needle or cut. Low risk women expose themselves to a greater risk with lower-dose  screening X-ray MGMs and more invasive costly tests. For the common “silent” cancers (e.g. prostate/breast), statistics do not support that routine invasive screening of the apparently healthy saves lives.

As with all technology, many ‘grams – imaging methods – have evolved for the breasts. Like the infants they are built to nourish, breasts are extremely sensitive to irradiation. The lower the X-ray dose, the worse the subtle genetic damage that may occur – even decades later. We know this from follow-up consultations with women with initially healthy breasts >15 years earlier who had repeated xray mammograms, versus their sisters who had xray mammograms only when suspicions arose; and from controlled laboratory experiments on rodents and human breast cells.

Objective statistical analyses since the Canadian breast X-ray screening trial more than 20 years ago, show no benefit, but show instead an increasing risk of more breast cancer, more breast surgery and more premature deaths in well women repeatedly xrayed. .

ALTERNATIVE BREAST SCANS available include no-touch photographic thermo-mammography, gentle ultrasound;

and gentle mechanical tactile imaging (MTI), which may be  better than xray or ultrasound MGM show early warning signs such as thickening of tissue and lumps. These signs may be reversed with diet, supplements and lifestyle changes.

From international studies and  local experience, MTI (e.g. Sure Touch Mammography) has become the best at outpatients, to document the physical exam findings with three-dimensional characteristics mapped.. With this simple process, perhaps  < 1 in 30 healthy women may need referral for ultrasound, and perhaps < 1 in 100 cases justify biopsy, and as the Wisconsin study shows, <1 in 1000 found to have significant breast cancer. It has been validated as at least as effective as (if not better than) other breast imaging  in studies in USA, England, China and India.
MTI is recommended by CANSA, which says that from 2005 data    about 1:29 women will be diagnosed in their lifetime with breast cancer. .

Studies confirm the obvious, that the more experts with vested interests (in XRMGM and breast cancer management) who draw up Guidelines, the more likely that Panel is to encourage mass XRMGM and intervention. So instead of perhaps 1 in 30 woman justifying breast imaging, the Breast Disease Industry – including the USA Breast Cancer Association the Industry funds – wants every woman X-ray screened regularly ideally from age 40years for the rest of their lives. But despite rage from the $8billion a year USA breast screening industry, Authorities have steadily cut back the age of starting mass screening XRMGM from age 40 to 50 years and to every 2nd or 3rd years.

No preclinical imaging diagnoses cancer. The only sure diagnosis is lump excision histology – if not multiple biopsies with their risk of needle spread.

Talk about unsubtle seduction. This year – despite massive financial (including stock-market) and marketing pressure- even mammography wine and food parties at USA radiology centers  to persuade women to submit   http://online.wsj.com/article/SB126325763413725559.html  -two books  never mind a flood of scientific journal papers have just  been published questioning routine xray mammography of the well:

Dr Peter Gotzsche and the Danish Cochrane epidemiology team have published the evidence from all over the world – from at least 14 countries- against universal XRMGM for all, against the myth of the benefits and safety of regular xray mammography.. http://www.dailymail.co.uk/health/article-2120750/The-expert-branded-woman-hater-saying-breast-cancer-screening-ruins-lives.html   and 

The Big Squeeze: A Social and Political History of the Controversial (XRAY) Mammogram (Culture and Politics of Health Care Work) by radiologist Dr Handel Reynolds 2012 http://handelreynoldsmd.com/the_big_squeeze_history_mammography.html