reproducible research chapter 4: central tendency … · dipak das (u conn)-- wine researcher...
TRANSCRIPT
REPRODUCIBLE RESEARCH&
CHAPTER 4: CENTRAL TENDENCY AND DISPERSION
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Wa! Street JournalDecember 2, 2011
“Reproducibility of scientific results and data is essentially the gold standard of the foundation of all modern research.”
--Gautam Naik (WSJ)
Reproducible Research“The goal of reproducible research is to tie specific instructions to data analysis and experimental data so that scholarship can be recreated, better understood and verified.”
CRAN Task View: Reproducible Research
Victoria Stodden, PhD, MLS Keith Baggerly, PhD
February 11, 2011 December 2, 2011
(V. Stodden, Computing in Science & Engineering, 2009)
Only 2 of the 18 articles on microarray expression gene profiling published in Nature Genetics from 2005-2006 were reproducible.
Reasons Not to Share
(Victoria Stodden)
Reasons To Share
(Victoria Stodden)
ScandalsClimategate (Climatic Research Unit email controversy)-- Eight committees investigated the allegations and published reports including many email exchanges involving Michael Mann, Director of Penn State’s Earth System Science Center.
Dipak Das (U Conn)-- Wine researcher accused of fraud in 26 articles.
Geoffrey Chang (Scripps Research Institute)--“unintentional” mistakes led to the retraction of 3 Science papers and 1 PNAS paper.
Jan Hendrik Schön (previously at Bell Labs)-- made-up data led to the retraction of 9 Science papers, 7 Nature papers, 6 Physical Review papers, 4 Applied Physics Letters papers, 2 Advanced Materials papers, and 8 other journal articles were flagged.
...journals should demand that authors submit sufficient detail for the independent assessment of their paper’s conclusions. We recommend that all primary data are backed up with adequate documentation and sample annotation; all primary data sources, such as database accessions or URL links, are presented; and all scripts and software source codes are supplied, with instructions. Analytical (non-scriptable) protocols should be described step by step, and the research protocol, including any plans for research and analysis, should be provided. Files containing such information could be stored as supplements by the journal.
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H1N1Of the 566 people who are known to have contacted H1N1, 322 have died. (~60% kill rate)
The virus consists of 8 pieces of RNA (~10 genes) that replicated independent of each other. There’s no built in error-correction.
Some random mutation might just bring back a major flu pandemic like the 1918 flu pandemic--“we better investigate”.
Dutch virologist Ron Fouchier altered the H1N1 genome in two places supposedly allowing the virus to pass from ferret to ferret.
He was blocked from publishing his results.
Back in 2005, researchers at Mount Sinai reconstructed the 1918 influenza virus from formalin-fixed autopsy material and frozen lung tissue from an Alaskan influenza victim.
Front Page of the NY TimesJuly 8, 2011
Other Potti Retractions:-NEJM-JAMA-PNAS-JCO-The Lancet Oncology-PLOS ONE-Blood
Data is Publicly Available
Drug Response: NCI-60 sensitivity/resistancehttp://dtp.nci.nih.gov/docs/cancer/cancer_data.html
Training Data: NCI-60 triplicate Affy expression arrayhttp://dtp.nci.nih.gov/mtargets/download.html
Testing Data: 24 breast cancer patients (published in Cheng et al (2003), Lancet)
The Drama...Potti et al get the wrong gene signatures, off-by-one gene lists, made up data, switch-up sensitive/resistant labels
Clinical trials initiated at Duke (2007) and Moffitt (2008) -- completely bogus design
Baggerly & Coombes publish their findings in the Annals of Applied Statistics (2009)
Duke launches internal investigation; suspends three trials
Trials resume because treatments are all standard of care therapies (six different chemotherapy drugs)
The Drama (continued)Duke’s internal review report was kept confidential (but provided to NCI).
The Cancer Letter uses the Freedom of Information Act to obtain a redacted version from the NCI.
NCI stops one trial, has no control over the others.
The Cancer Letter reports Potti falsified his CV (claiming he was a Rhodes scholar)
Duke terminates all related trials; Potti resigns (was fired)
Duke is now dealing with the ramifications of its cover-up.
document markup language and document preparation system
Created by Leslie Lamport (built upon the TeX system developed by Donald Knuth)
It is not WYSIWYG
It is free, open, and powerful (just like R).
SweaveSweave allows S (“R”) to be weaved inside a markup language (like LaTeX).
Reproducible ReportsMAdCAm1, VCAM1, NKX2-31
Arthur Berg
November 12, 2011
1Analysis provided for Wei Yu, PhD (correspondence) and Zhenwu Lin, PhD
/Users/ab/Documents/communications/wei/2011-11-09 wei/stat-report-2011-11-09.Rnw
MAdCAm1, VCAM1, NKX2-31
Arthur Berg
November 12, 2011
1Analysis provided for Wei Yu, PhD (correspondence) and Zhenwu Lin, PhD
/Users/ab/Documents/communications/wei/2011-11-09 wei/stat-report-2011-11-09.Rnw
Contents
1 Analysis 2
1.1 MAdCAm1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
1.1.1 Two-Sample . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
1.1.2 Di�erences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
1.1.3 Quotients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
1.2 VCAM1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
1.2.1 Two-Sample . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
1.2.2 Di�erences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
1.2.3 Quotients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
1.3 NKX2-3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
1.3.1 Two-Sample . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
1.3.2 Di�erences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
1.3.3 Quotients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
A The Data 19
Arthur Berg, PhD Page 6 October 5, 2011
3.2 Covariate analysisvar3b
23 Variables 1324 Observationsid
n missing unique Mean .05 .10 .25 .50 .75
1324 0 1323 41700415 21630153 21630309 35630056 50630030 51630209
.90 .95
54630034 54630099
lowest : 15630005 15630009 15630011 18630004 18630007
highest: 54630162 54630163 54630164 54630165 54630166
cc n missing unique1305 19 2
case (710, 54%), control (595, 46%)
gendern missing unique
1305 19 2
female (567, 43%), male (738, 57%)
agen missing unique Mean .05 .10 .25 .50 .75 .90 .95
1305 19 61 65.41 46 51 58 65 74 80 84
lowest : 19 24 27 28 33, highest: 88 89 90 94 98
race n missing unique1305 19 6
asian black multi-racial native american other white
Frequency 2 36 4 2 1 1260
% 0 3 0 0 0 97
smoken missing unique1305 19 3
ex-smoker (557, 43%), never (605, 46%), smoker (143, 11%)
packyearsn missing unique Mean .05 .10 .25 .50 .75 .90 .95
1305 19 249 112.2 0.0 0.0 0.0 1.2 25.0 56.0 76.2
lowest : 0.00 0.05 0.10 0.15 0.20
highest: 8998.20 9498.10 9998.00 15996.80 21995.60
kcaln missing unique Mean .05 .10 .25 .50 .75 .90 .95
1140 184 1140 1951 729.1 882.5 1218.9 1722.0 2297.7 3215.6 3874.0
lowest : 175.2 190.3 201.9 227.8 244.6
highest: 8980.5 8996.7 10954.6 12144.4 14260.4
Proteinn missing unique Mean .05 .10 .25 .50 .75 .90 .95
1140 184 1094 72.5 26.19 31.72 45.53 64.81 90.58 119.21 142.44
lowest : 4.72 6.54 8.44 9.31 10.01
highest: 273.53 275.58 305.39 322.68 496.87
TotalFatn missing unique Mean .05 .10 .25 .50 .75 .90 .95
1140 184 1081 72.81 23.21 28.74 42.97 64.75 90.88 124.79 150.17
lowest : 2.66 6.05 6.87 6.99 7.05
highest: 311.37 321.07 345.60 415.59 637.43
3.17 rs2248733
countAA 558AT 214TT 14NA 93
HWE p-value: 0.2050813
AA AT TTcase 215 89 6
control 343 125 8
fisher test p-value: 0.7127 (n=786)
‰2-based p-value for snp rs2248733 from logistic regressionwith covariates age, sex, and cig: 0.45 (n=762)female: 0.2071 (n=321)male: 0.7472 (n=441)adenocarcinoma: 0.7906 (n=569)sequamous cell carcinoma: 0.007446 (n=520)light smokers: 0.3278 (n=275)heavy smokers: 0.4912 (n=268)
3.18 rs12988520
countCC 233AC 431AA 169NA 46
HWE p-value: 0.2371508
CC AC AAcase 97 181 62
control 136 250 107
fisher test p-value: 0.4808 (n=833)
‰2-based p-value for snp rs12988520 from logistic regres-sion with covariates age, sex, and cig: 0.655 (n=808)female: 0.715 (n=345)male: 0.8732 (n=463)adenocarcinoma: 0.903 (n=595)sequamous cell carcinoma: 0.8183 (n=539)light smokers: 0.8936 (n=289)heavy smokers: 0.6435 (n=292)
3.19 rs7608713
countGG 467AG 310AA 55NA 47
HWE p-value: 0.7139378
GG AG AAcase 201 119 20
control 266 191 35
fisher test p-value: 0.3436 (n=832)
‰2-based p-value for snp rs7608713 from logistic regressionwith covariates age, sex, and cig: 0.3905 (n=808)female: 0.241 (n=344)male: 0.0476 (n=464)adenocarcinoma: 0.3225 (n=596)sequamous cell carcinoma: 0.08445 (n=539)light smokers: 0.4317 (n=291)heavy smokers: 0.3275 (n=290)
3.20 rs7578153
countCC 789TC 44TT 4NA 42
HWE p-value: 0.0002462722
CC TC TTcase 331 12 0
control 458 32 4
fisher test p-value: 0.03749 (n=837)
‰2-based p-value for snp rs7578153 from logistic regressionwith covariates age, sex, and cig: 0.2328 (n=811)female: 0.0318 (n=345)male: 0.0101 (n=466)adenocarcinoma: 0.5587 (n=596)sequamous cell carcinoma: 0.3141 (n=539)light smokers: 0.5532 (n=291)heavy smokers: 0.4467 (n=292)
7
4.2 overall (with covariates)
glmrs4663333 0.0113rs7564935 0.0791
rs17868323 0.0873rs28969678 0.0891rs17868322 0.0963rs11695770 0.0999rs6725478 0.1004
rs17863762 0.1125rs6759892 0.1381rs1500482 0.1436
4.3 female (with covariates)
femalers10929251 0.0115rs7578153 0.0318rs6747843 0.0411rs4663333 0.0492rs887829 0.1060
rs4148325 0.1077rs12474980 0.1143rs1875263 0.1213
rs11891311 0.1228rs10210058 0.1331
4.4 male (with covariates)
malers7578153 0.0101
rs11695770 0.0237rs2741029 0.0453rs7608713 0.0476rs2070959 0.0636
rs17868323 0.0672rs10189426 0.0773rs1500482 0.0892rs2602373 0.0972
rs17863762 0.1004
4.5 adenocarcinoma (with covariates)
adenors17868322 0.0162rs17864678 0.0701rs11888492 0.0711rs2302538 0.1295rs4663333 0.1387rs7586006 0.1404
rs10189426 0.1549rs1817154 0.1560
rs17868337 0.1941rs11695770 0.1998
4.6 sequamous cell carcinoma (with co-variates)
seqrs2248733 0.0074
rs10929251 0.0083rs17863773 0.0276rs10221563 0.0414rs4663333 0.0637
rs12474980 0.0805rs7608713 0.0844rs1604144 0.0953rs7564935 0.1154
rs10189426 0.1371
4.7 light smokers (with covariates)
lightrs7569014 0.0251rs3771342 0.0347
rs17863762 0.0376rs10929251 0.1010rs1604144 0.1322rs4663333 0.1405
rs12474980 0.1436rs17862859 0.1487rs28898590 0.1535rs28969678 0.1540
23
Arthur Berg, PhD Page 25 November 14, 2011
no yes
12
34
5
obs. mean median s.d. min. max.
469 3.187 3.1 0.76 1.1 5.3
For cc = no
obs. mean median s.d. min. max.
388 3.17 3.1 0.778 1.1 5.3
For cc = yes
obs. mean median s.d. min. max.
81 3.265 3.3 0.674 1.7 4.9
t-test p-value: 0.262Mann-Whitney p-value: 0.3
peak (minimum)
Estimate Std. Error z value Pr(>|z|)(Intercept) 2.5878 0.4330 5.98 0.0000
x -0.3754 0.1483 -2.53 0.0113
●●
●
●
no yes
12
34
5
Recurrence (§ Labs)
Arthur Berg, PhD Page 25 November 14, 2011
no yes
12
34
5
obs. mean median s.d. min. max.
469 3.187 3.1 0.76 1.1 5.3
For cc = no
obs. mean median s.d. min. max.
388 3.17 3.1 0.778 1.1 5.3
For cc = yes
obs. mean median s.d. min. max.
81 3.265 3.3 0.674 1.7 4.9
t-test p-value: 0.262Mann-Whitney p-value: 0.3
peak (minimum)
Estimate Std. Error z value Pr(>|z|)(Intercept) 2.5878 0.4330 5.98 0.0000
x -0.3754 0.1483 -2.53 0.0113
●●
●
●
no yes
12
34
5
Recurrence (§ Labs)
With the limited data size, variable selection is rather sensitive, but no variable is particularly significant in this analysis.Note that it is expected that the inclusion of covariates would decrease the variation explained by the genetics, whichthen reduces the significance of the genetic e�ect. With large sample sizes and only a couple of covariates, these changein e�ect is typically very small, but with small sample sizes and many covariates, this e�ect can be significantly larger.
2 Results
The following are the covariate-adjusted results, adjusting for smoking status, location, behavior, and sex.
p-value snp name gene name0.001923 rs6927210 U60.003754 rs13361189 IRGM0.011122 rs4958847 IRGM0.047845 rs2241880 ATG16L10.055233 rs2522057 IBD5
Table 1: Top SNPs – covariate adjusted
If the behavior variable is removed as a covariate, the follow results are yielded:
p-value snp name gene name0.003207 rs13361189 IRGM0.008045 rs4958847 IRGM0.017559 rs12704036 U70.018937 rs6927210 U60.026161 rs3024505 IL.10
Table 2: Top SNPs – covariate adjusted without the behavior variable
3 Session Info
• R version 2.11.1 (2010-05-31), x86_64-apple-darwin9.8.0
• Locale: C
• Base packages: base, datasets, grDevices, graphics, methods, stats, utils
• Other packages: xtable 1.5-6
2
T h e n e w e ngl a nd j o u r na l o f m e dic i n e
n engl j med 366;3 nejm.org january 19, 2012 225
original article
Bone-Density Testing Interval and Transition to Osteoporosis in Older Women
Margaret L. Gourlay, M.D., M.P.H., Jason P. Fine, Sc.D., John S. Preisser, Ph.D., Ryan C. May, Ph.D., Chenxi Li, Ph.D., Li-Yung Lui, M.S., David F. Ransohoff, M.D.,
Jane A. Cauley, Dr.P.H., and Kristine E. Ensrud, M.D., M.P.H., for the Study of Osteoporotic Fractures Research Group
From the Departments of Family Medi-cine (M.L.G.), Biostatistics ( J.P.F., J.S.P., R.C.M.), and Medicine (D.F.R.) and the North Carolina Translational and Clinical Sciences Institute (C.L.), University of North Carolina, Chapel Hill; the Research Institute, California Pacific Medical Cen-ter, San Francisco (L.-Y.L.); the Depart-ment of Epidemiology, University of Pittsburgh, Pittsburgh (J.A.C.); and the Department of Medicine and Division of Epidemiology, University of Minnesota, and the Department of Medicine, Minne-apolis Veterans Affairs Health Care Sys-tem (K.E.E.) — both in Minneapolis. Ad-dress reprint requests to Dr. Gourlay at the University of North Carolina–Chapel Hill, Aycock Bldg., Manning Dr., Chapel Hill, NC 27599-7595, or at [email protected].
N Engl J Med 2012;366:225-33.Copyright © 2012 Massachusetts Medical Society.
A BS TR AC T
BackgroundAlthough bone mineral density (BMD) testing to screen for osteoporosis (BMD T score, !2.50 or lower) is recommended for women 65 years of age or older, there are few data to guide decisions about the interval between BMD tests.
MethodsWe studied 4957 women, 67 years of age or older, with normal BMD (T score at the femoral neck and total hip, !1.00 or higher) or osteopenia (T score, !1.01 to !2.49) and with no history of hip or clinical vertebral fracture or of treatment for osteopo-rosis, followed prospectively for up to 15 years. The BMD testing interval was defined as the estimated time for 10% of women to make the transition to osteoporosis before having a hip or clinical vertebral fracture, with adjustment for estrogen use and clinical risk factors. Transitions from normal BMD and from three subgroups of osteopenia (mild, moderate, and advanced) were analyzed with the use of paramet-ric cumulative incidence models. Incident hip and clinical vertebral fractures and initiation of treatment with bisphosphonates, calcitonin, or raloxifene were treated as competing risks.
ResultsThe estimated BMD testing interval was 16.8 years (95% confidence interval [CI], 11.5 to 24.6) for women with normal BMD, 17.3 years (95% CI, 13.9 to 21.5) for women with mild osteopenia, 4.7 years (95% CI, 4.2 to 5.2) for women with moderate os-teopenia, and 1.1 years (95% CI, 1.0 to 1.3) for women with advanced osteopenia.
ConclusionsOur data indicate that osteoporosis would develop in less than 10% of older, post-menopausal women during rescreening intervals of approximately 15 years for wom-en with normal bone density or mild osteopenia, 5 years for women with moderate osteopenia, and 1 year for women with advanced osteopenia. (Funded by the Na-tional Institutes of Health.)
The New England Journal of Medicine Downloaded from nejm.org at PENN STATE UNIVERSITY on January 19, 2012. For personal use only. No other uses without permission.
Copyright © 2012 Massachusetts Medical Society. All rights reserved.
T h e n e w e ngl a nd j o u r na l o f m e dic i n e
n engl j med 366;3 nejm.org january 19, 2012 225
original article
Bone-Density Testing Interval and Transition to Osteoporosis in Older Women
Margaret L. Gourlay, M.D., M.P.H., Jason P. Fine, Sc.D., John S. Preisser, Ph.D., Ryan C. May, Ph.D., Chenxi Li, Ph.D., Li-Yung Lui, M.S., David F. Ransohoff, M.D.,
Jane A. Cauley, Dr.P.H., and Kristine E. Ensrud, M.D., M.P.H., for the Study of Osteoporotic Fractures Research Group
From the Departments of Family Medi-cine (M.L.G.), Biostatistics ( J.P.F., J.S.P., R.C.M.), and Medicine (D.F.R.) and the North Carolina Translational and Clinical Sciences Institute (C.L.), University of North Carolina, Chapel Hill; the Research Institute, California Pacific Medical Cen-ter, San Francisco (L.-Y.L.); the Depart-ment of Epidemiology, University of Pittsburgh, Pittsburgh (J.A.C.); and the Department of Medicine and Division of Epidemiology, University of Minnesota, and the Department of Medicine, Minne-apolis Veterans Affairs Health Care Sys-tem (K.E.E.) — both in Minneapolis. Ad-dress reprint requests to Dr. Gourlay at the University of North Carolina–Chapel Hill, Aycock Bldg., Manning Dr., Chapel Hill, NC 27599-7595, or at [email protected].
N Engl J Med 2012;366:225-33.Copyright © 2012 Massachusetts Medical Society.
A BS TR AC T
BackgroundAlthough bone mineral density (BMD) testing to screen for osteoporosis (BMD T score, !2.50 or lower) is recommended for women 65 years of age or older, there are few data to guide decisions about the interval between BMD tests.
MethodsWe studied 4957 women, 67 years of age or older, with normal BMD (T score at the femoral neck and total hip, !1.00 or higher) or osteopenia (T score, !1.01 to !2.49) and with no history of hip or clinical vertebral fracture or of treatment for osteopo-rosis, followed prospectively for up to 15 years. The BMD testing interval was defined as the estimated time for 10% of women to make the transition to osteoporosis before having a hip or clinical vertebral fracture, with adjustment for estrogen use and clinical risk factors. Transitions from normal BMD and from three subgroups of osteopenia (mild, moderate, and advanced) were analyzed with the use of paramet-ric cumulative incidence models. Incident hip and clinical vertebral fractures and initiation of treatment with bisphosphonates, calcitonin, or raloxifene were treated as competing risks.
ResultsThe estimated BMD testing interval was 16.8 years (95% confidence interval [CI], 11.5 to 24.6) for women with normal BMD, 17.3 years (95% CI, 13.9 to 21.5) for women with mild osteopenia, 4.7 years (95% CI, 4.2 to 5.2) for women with moderate os-teopenia, and 1.1 years (95% CI, 1.0 to 1.3) for women with advanced osteopenia.
ConclusionsOur data indicate that osteoporosis would develop in less than 10% of older, post-menopausal women during rescreening intervals of approximately 15 years for wom-en with normal bone density or mild osteopenia, 5 years for women with moderate osteopenia, and 1 year for women with advanced osteopenia. (Funded by the Na-tional Institutes of Health.)
The New England Journal of Medicine Downloaded from nejm.org at PENN STATE UNIVERSITY on January 19, 2012. For personal use only. No other uses without permission.
Copyright © 2012 Massachusetts Medical Society. All rights reserved.
T h e n e w e ngl a nd j o u r na l o f m e dic i n e
n engl j med 366;3 nejm.org january 19, 2012230
sis in which we used the secondary definition of osteoporosis, based on the BMD at the femoral neck alone, the covariate-adjusted times for 10% of women to make the transition to osteoporosis were 1.0 years for women with advanced osteo-penia, 4.7 years for those with moderate osteope-nia, and more than 15 years for those with mild osteopenia or normal BMD. Although these es-timates were similar to the estimates in the pri-mary analysis (which was based on the BMD at the total hip or femoral neck) for women with osteopenia, the time estimate in this sensitivity analysis for women with normal BMD was more than twice as long as that in the primary analy-sis, and it was much longer than the maximum follow-up time of 15 years.
A total of 121 women (2.4%) had a hip or clini-cal vertebral fracture before the transition to os-teoporosis, as defined by WHO diagnostic criteria, or before the receipt of treatment for osteoporosis. The adjusted estimated time for 2% of women to have a hip or clinical vertebral fracture was more than 15 years for women with normal BMD or mild osteopenia, and approximately 5 years for those with moderate or advanced osteopenia. Complete results of the sensitivity analyses are presented in the Supplementary Appendix.
Discussion
We conducted a study of rates of transition to osteoporosis in order to help clinicians decide on BMD testing intervals for older women with nor-mal BMD or osteopenia at the initial assessment. Our results suggest that the baseline T score is the most important determinant of a BMD testing interval. During the 15-year study period, less than 1% of women with T scores indicating normal BMD and 5% of women with T scores indicating mild osteopenia at their first assessment made the transition to osteoporosis, with an estimated testing interval of about 15 years for 10% of wom-en in each of these groups to make the transition. This finding suggests that if BMD testing is de-ferred for 15 years among women with T scores greater than !1.50, there is a low likelihood of a transition to osteoporosis during that period. We found that 10% of women with moderate osteo-penia and 10% of women with advanced osteope-nia made the transition to osteoporosis in 5 years and 1 year, respectively. Although clinical risk fac-tors had a minimal effect on the time estimates as a whole, a significant trend for age supported shorter testing intervals as women age. The esti-mated time for only 2% of women to make the
Normal BMDT score, !1.00 or higher(N=1255)
Mild osteopeniaT score, !1.01 to !1.49(N=1386)
Moderate osteopeniaT score, !1.50 to !1.99(N=1478)
Advanced osteopeniaT score, !2.00 to !2.49(N=1351)
Cum
ulat
ive
Inci
denc
e of
Ost
eopo
rosi
s(%
)
100
80
90
70
60
40
30
10
50
20
00 2 4 6 8 10 12 14 16 18
Years since Baseline Study Visit
Figure 2. Unadjusted Cumulative Incidence of Osteoporosis According to Baseline T-Score Range.
The proportion of women who had a transition to osteoporosis is shown as a function of time. The cumulative inci-dence curves were estimated by means of parametric cumulative incidence models for interval-censored data. The dashed horizontal line marks the 10% threshold for the transition to osteoporosis; where this line intersects each cu-mulative incidence curve, a vertical dashed line to the x axis marks the estimated testing interval. The analysis of wom-en with osteopenia at baseline is based on three T-score groups and included the 513 women who made the transition from normal BMD to osteopenia and had at least one subsequent examination with BMD recorded.
The New England Journal of Medicine Downloaded from nejm.org at PENN STATE UNIVERSITY on January 19, 2012. For personal use only. No other uses without permission.
Copyright © 2012 Massachusetts Medical Society. All rights reserved.
T h e n e w e ngl a nd j o u r na l o f m e dic i n e
n engl j med 366;3 nejm.org january 19, 2012 225
original article
Bone-Density Testing Interval and Transition to Osteoporosis in Older Women
Margaret L. Gourlay, M.D., M.P.H., Jason P. Fine, Sc.D., John S. Preisser, Ph.D., Ryan C. May, Ph.D., Chenxi Li, Ph.D., Li-Yung Lui, M.S., David F. Ransohoff, M.D.,
Jane A. Cauley, Dr.P.H., and Kristine E. Ensrud, M.D., M.P.H., for the Study of Osteoporotic Fractures Research Group
From the Departments of Family Medi-cine (M.L.G.), Biostatistics ( J.P.F., J.S.P., R.C.M.), and Medicine (D.F.R.) and the North Carolina Translational and Clinical Sciences Institute (C.L.), University of North Carolina, Chapel Hill; the Research Institute, California Pacific Medical Cen-ter, San Francisco (L.-Y.L.); the Depart-ment of Epidemiology, University of Pittsburgh, Pittsburgh (J.A.C.); and the Department of Medicine and Division of Epidemiology, University of Minnesota, and the Department of Medicine, Minne-apolis Veterans Affairs Health Care Sys-tem (K.E.E.) — both in Minneapolis. Ad-dress reprint requests to Dr. Gourlay at the University of North Carolina–Chapel Hill, Aycock Bldg., Manning Dr., Chapel Hill, NC 27599-7595, or at [email protected].
N Engl J Med 2012;366:225-33.Copyright © 2012 Massachusetts Medical Society.
A BS TR AC T
BackgroundAlthough bone mineral density (BMD) testing to screen for osteoporosis (BMD T score, !2.50 or lower) is recommended for women 65 years of age or older, there are few data to guide decisions about the interval between BMD tests.
MethodsWe studied 4957 women, 67 years of age or older, with normal BMD (T score at the femoral neck and total hip, !1.00 or higher) or osteopenia (T score, !1.01 to !2.49) and with no history of hip or clinical vertebral fracture or of treatment for osteopo-rosis, followed prospectively for up to 15 years. The BMD testing interval was defined as the estimated time for 10% of women to make the transition to osteoporosis before having a hip or clinical vertebral fracture, with adjustment for estrogen use and clinical risk factors. Transitions from normal BMD and from three subgroups of osteopenia (mild, moderate, and advanced) were analyzed with the use of paramet-ric cumulative incidence models. Incident hip and clinical vertebral fractures and initiation of treatment with bisphosphonates, calcitonin, or raloxifene were treated as competing risks.
ResultsThe estimated BMD testing interval was 16.8 years (95% confidence interval [CI], 11.5 to 24.6) for women with normal BMD, 17.3 years (95% CI, 13.9 to 21.5) for women with mild osteopenia, 4.7 years (95% CI, 4.2 to 5.2) for women with moderate os-teopenia, and 1.1 years (95% CI, 1.0 to 1.3) for women with advanced osteopenia.
ConclusionsOur data indicate that osteoporosis would develop in less than 10% of older, post-menopausal women during rescreening intervals of approximately 15 years for wom-en with normal bone density or mild osteopenia, 5 years for women with moderate osteopenia, and 1 year for women with advanced osteopenia. (Funded by the Na-tional Institutes of Health.)
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sis in which we used the secondary definition of osteoporosis, based on the BMD at the femoral neck alone, the covariate-adjusted times for 10% of women to make the transition to osteoporosis were 1.0 years for women with advanced osteo-penia, 4.7 years for those with moderate osteope-nia, and more than 15 years for those with mild osteopenia or normal BMD. Although these es-timates were similar to the estimates in the pri-mary analysis (which was based on the BMD at the total hip or femoral neck) for women with osteopenia, the time estimate in this sensitivity analysis for women with normal BMD was more than twice as long as that in the primary analy-sis, and it was much longer than the maximum follow-up time of 15 years.
A total of 121 women (2.4%) had a hip or clini-cal vertebral fracture before the transition to os-teoporosis, as defined by WHO diagnostic criteria, or before the receipt of treatment for osteoporosis. The adjusted estimated time for 2% of women to have a hip or clinical vertebral fracture was more than 15 years for women with normal BMD or mild osteopenia, and approximately 5 years for those with moderate or advanced osteopenia. Complete results of the sensitivity analyses are presented in the Supplementary Appendix.
Discussion
We conducted a study of rates of transition to osteoporosis in order to help clinicians decide on BMD testing intervals for older women with nor-mal BMD or osteopenia at the initial assessment. Our results suggest that the baseline T score is the most important determinant of a BMD testing interval. During the 15-year study period, less than 1% of women with T scores indicating normal BMD and 5% of women with T scores indicating mild osteopenia at their first assessment made the transition to osteoporosis, with an estimated testing interval of about 15 years for 10% of wom-en in each of these groups to make the transition. This finding suggests that if BMD testing is de-ferred for 15 years among women with T scores greater than !1.50, there is a low likelihood of a transition to osteoporosis during that period. We found that 10% of women with moderate osteo-penia and 10% of women with advanced osteope-nia made the transition to osteoporosis in 5 years and 1 year, respectively. Although clinical risk fac-tors had a minimal effect on the time estimates as a whole, a significant trend for age supported shorter testing intervals as women age. The esti-mated time for only 2% of women to make the
Normal BMDT score, !1.00 or higher(N=1255)
Mild osteopeniaT score, !1.01 to !1.49(N=1386)
Moderate osteopeniaT score, !1.50 to !1.99(N=1478)
Advanced osteopeniaT score, !2.00 to !2.49(N=1351)
Cum
ulat
ive
Inci
denc
e of
Ost
eopo
rosi
s(%
)
100
80
90
70
60
40
30
10
50
20
00 2 4 6 8 10 12 14 16 18
Years since Baseline Study Visit
Figure 2. Unadjusted Cumulative Incidence of Osteoporosis According to Baseline T-Score Range.
The proportion of women who had a transition to osteoporosis is shown as a function of time. The cumulative inci-dence curves were estimated by means of parametric cumulative incidence models for interval-censored data. The dashed horizontal line marks the 10% threshold for the transition to osteoporosis; where this line intersects each cu-mulative incidence curve, a vertical dashed line to the x axis marks the estimated testing interval. The analysis of wom-en with osteopenia at baseline is based on three T-score groups and included the 513 women who made the transition from normal BMD to osteopenia and had at least one subsequent examination with BMD recorded.
The New England Journal of Medicine Downloaded from nejm.org at PENN STATE UNIVERSITY on January 19, 2012. For personal use only. No other uses without permission.
Copyright © 2012 Massachusetts Medical Society. All rights reserved.
T h e n e w e ngl a nd j o u r na l o f m e dic i n e
n engl j med 366;3 nejm.org january 19, 2012230
sis in which we used the secondary definition of osteoporosis, based on the BMD at the femoral neck alone, the covariate-adjusted times for 10% of women to make the transition to osteoporosis were 1.0 years for women with advanced osteo-penia, 4.7 years for those with moderate osteope-nia, and more than 15 years for those with mild osteopenia or normal BMD. Although these es-timates were similar to the estimates in the pri-mary analysis (which was based on the BMD at the total hip or femoral neck) for women with osteopenia, the time estimate in this sensitivity analysis for women with normal BMD was more than twice as long as that in the primary analy-sis, and it was much longer than the maximum follow-up time of 15 years.
A total of 121 women (2.4%) had a hip or clini-cal vertebral fracture before the transition to os-teoporosis, as defined by WHO diagnostic criteria, or before the receipt of treatment for osteoporosis. The adjusted estimated time for 2% of women to have a hip or clinical vertebral fracture was more than 15 years for women with normal BMD or mild osteopenia, and approximately 5 years for those with moderate or advanced osteopenia. Complete results of the sensitivity analyses are presented in the Supplementary Appendix.
Discussion
We conducted a study of rates of transition to osteoporosis in order to help clinicians decide on BMD testing intervals for older women with nor-mal BMD or osteopenia at the initial assessment. Our results suggest that the baseline T score is the most important determinant of a BMD testing interval. During the 15-year study period, less than 1% of women with T scores indicating normal BMD and 5% of women with T scores indicating mild osteopenia at their first assessment made the transition to osteoporosis, with an estimated testing interval of about 15 years for 10% of wom-en in each of these groups to make the transition. This finding suggests that if BMD testing is de-ferred for 15 years among women with T scores greater than !1.50, there is a low likelihood of a transition to osteoporosis during that period. We found that 10% of women with moderate osteo-penia and 10% of women with advanced osteope-nia made the transition to osteoporosis in 5 years and 1 year, respectively. Although clinical risk fac-tors had a minimal effect on the time estimates as a whole, a significant trend for age supported shorter testing intervals as women age. The esti-mated time for only 2% of women to make the
Normal BMDT score, !1.00 or higher(N=1255)
Mild osteopeniaT score, !1.01 to !1.49(N=1386)
Moderate osteopeniaT score, !1.50 to !1.99(N=1478)
Advanced osteopeniaT score, !2.00 to !2.49(N=1351)
Cum
ulat
ive
Inci
denc
e of
Ost
eopo
rosi
s(%
)
100
80
90
70
60
40
30
10
50
20
00 2 4 6 8 10 12 14 16 18
Years since Baseline Study Visit
Figure 2. Unadjusted Cumulative Incidence of Osteoporosis According to Baseline T-Score Range.
The proportion of women who had a transition to osteoporosis is shown as a function of time. The cumulative inci-dence curves were estimated by means of parametric cumulative incidence models for interval-censored data. The dashed horizontal line marks the 10% threshold for the transition to osteoporosis; where this line intersects each cu-mulative incidence curve, a vertical dashed line to the x axis marks the estimated testing interval. The analysis of wom-en with osteopenia at baseline is based on three T-score groups and included the 513 women who made the transition from normal BMD to osteopenia and had at least one subsequent examination with BMD recorded.
The New England Journal of Medicine Downloaded from nejm.org at PENN STATE UNIVERSITY on January 19, 2012. For personal use only. No other uses without permission.
Copyright © 2012 Massachusetts Medical Society. All rights reserved.