What experts say about the use of absolute risk and RLFP for Osteoporosis risk estimation.

        I.            Parfitt, A .M. and Johnston, C. C., Jr. Bone Mass and Bone Turnover. Osteoporosis 1996, S.E. Papapoulas, Editor. Elsvier Science B.V.

"Bone mass measurements at various sites by various methods indicate the likelihood of fracture for the next several years, depending on the duration of prospective observation. Ideally, the risk would be integrated over a person.s expected life span. This integrated risk has been referred to as remaining lifetime fracture probability or RLFP.

A reduction in RLFP is the objective of therapeutic intervention, and the magnitude of reduction in RLFP is the benefit that has to be weighed against the total cost, social and economic, of the intervention."

     II.            Miller, P. D., Bonnick, S. L., Johnston, C. C., et al. The Challenges of Peripheral Bone Density Testing. Journal of Clinical Densitometry, 1998; 3:211 . 217.

"As a consequence, T-scores measured by various techniques from the different manufacturers within a given patient may differ because the T-score is being derived from different reference population."

"A complimentary approach to this diagnostic dilemma would be to shift from solely using bone mass as a diagnostic tool and emphasize its use as a fracture risk assessment tool. This paradigm shift would reduce the confusion surrounding the different diagnostic classifications. Absolute fracture risk would be directly related to the bone mineral content (or ultrasound equivalent) or more preferably to a universal standardized BMD, not dependent on the variability of the young normal reference population BMD or its SD. Absolute fracture risk differences between skeletal sites within an individual are likely to be small. In the postmenopausal population, absolute fracture risk from a single site using any technique would be predictive of global fracture risk, since discordance using BMD is reduced by removing the variance in the SD of the young reference population."

   III.            Wasnich, R. D. Consensus and the T-Score Fallacy. Clinical Rheumatology, 1997; 16:337-339.

"There is a final and fatal flaw in the use of T-scores. Our data have shown that the relationship of bone density to absolute fracture risk among men is virtually identical to that in women. In other words,  a given bone density level in a man relates to the same, absolute fracture incidence rate as it would in a woman (after adjustment for other risk factors). Therefore, it is only logical that female reference values would have to be used in calculating male T-scores in order to have the same meaning in terms of absolute fracture risk."

  IV.            Miller, P. D., Bonnick, S. L., Rosen, C. J., et al. Clinical Utility of Bone Mass Measurements in Adults. Consensus of an International Panel Seminars in Arthritis and Rheumatism, 1996; 5:361-372.

"A young adult does not have the same current (5 year) fracture risk as an elderly individual, despite equal levels of reduced bone mineral density, because of the independent effect of age on increasing fracture risk. However, because a younger individual.s years of exposure to low and declining bone mass is longer than that of an elderly patient, the remaining lifetime fracture probability (RLFP) is greater in the younger patient with no intervention. The RLFP is based on the patient.s known age and current bone mass and is dependent on variable rates of bone loss and life expectancy. A gradient-risk chart based on age, bone mass, and duration of exposure to low bone mass, will allow the clinician to make clinical decisions and estimate the expected benefit of recommended interventions in terms of fracture reduction."

     V.            Bonnick, S. L. Bone Densitometry in Clinical Practice, 1998. Humana Press.

"RLFP is one of the most concrete and easily understood modalities for expressing future fracture risk." . . . "RLFP is based on a statistical model. When the RLFP model is applied to the U.S. population, the estimates of vertebral and nonvertebral fracture incidence are comparable to actual observations of fracture incidence. This observation provides an external validation of the theory and application of RLFP."