Reference Materials

Reference Materials 2020-05-19T07:28:34-06:00

Insight Medical Imaging refers to Osteoporosis Canada’s 2010 Clinical Practice Guidelines and the Canadian Association of Radiologists 2013 Technical Standards for reporting 10 year fracture risk, Osteoporosis, and dexa scan results. These recommendations are merely guidelines, not rules, and ultimate procedure judgement resides with referring physician’s based on family history and unique circumstances presented in each case.

Bone Mineral Density Diagnostic Categories
Patient GroupCategory NameT-Score ValueZ-Score Value
50 Years and olderNormal>= -1.0
Low bone mass
Between -1 and -2.5
Osteoporosis<= -2.5
49 years and youngerWithin expected range for age> -2.0
Below expected range for age<= -2.0
For Adults 50 years and older:

Diagnostic category is determined using the lowest T-score for the lumbar spine, total hip, femoral neck, 33% radius, and total body.

For Adults 18 to 49 years old:

Diagnostic category is determined using the lowest Z-score for the lumbar spine, total hip, femoral neck, 33% radius, and total body.

For Adolescents 17 years and younger:

Diagnostic category is determined using the lowest adjusted Z-spine for the lumbar spine and total body. Z-scores require adjustment for one of more of height, weight, body mass index, bone area, bone age, pubertal stage, and lean body mass.

Determining a 10-year Absolute Fracture Risk
  1. Determine patient’s gender and identify row closest to patients age.
  2. Determine fracture risk category by using the femoral neck T-score.
  3. If your patient’s age is between rows, infer the T-score thresholds.
    1. If either the fragility fracture history or glucocorticoid history are positive, bump the patient in to the next highest risk category.
    2. Fracture risk is high regardless of the CAROC result if:
      1. Both fragility fracture history after age 40 years and glucocorticoid history are positive
      2. Glucocorticoid history is considered positive if prednisone or prednisone equivalents was in use at a dose > 7.5 mg/day for more than 90 days in the previous 12 months
      3. Patient’s with hypoadrenalism on replacement glucocorticoids should not be considered to have a positive glucocorticoid history for fracture risk evaluation regardless of the dose.
      4. There has been a fragility hip, vertebral, or more than two fragility fractures after age 40
  4. If the fracture risk category is low after the previous steps, the lumbar spine T-score is considered.

If the lumbar spine T-score is <-2.5, risk is increased to moderate

CAROC 10 Year Fracture Risk for Women (2010)
Femoral Neck T-Score
Age (Years)Low Risk (<10%)Moderate Risk (10% - 20%)High Risk (>10%)
50Greater than -2.5-2.5 to -3.8Less than -3.8
55Greater than -2.5-2.5 to -3.8Less than -3.8
60Greater than -2.3-2.3 to -3.7Less than -3.7
65Greater than -1.9-1.9 to -3.5Less than -3.5
70Greater than -1.7-1.7 to -3.2Less than -3.2
75Greater than -1.2-1.2 to -2.9Less than -2.9
80Greater than -0.5-0.5 to -2.6Less than -2.6
85Greater than +0.1+0.1 to -2.2Less than -2.2
CAROC 10 Year Fracture Risk for Men (2010)

Femoral Neck T-Score
Age (Years)Low Risk (<10%)Moderate Risk (10% - 20%)High Risk (>10%)
50Greater than -2.5-2.5 to -3.9Less than -3.9
55Greater than -2.5-2.5 to -3.9Less than -3.9
60Greater than -2.5-2.5 to -3.7Less than -3.7
65Greater than -2.4-2.4 to -3.7Less than -3.7
70Greater than -2.3-2.3 to -3.7Less than -3.7
75Greater than -2.3-2.3 to -3.8Less than -3.8
80Greater than -2.1-2.1 to -3.8Less than -3.8
85Greater than -2.0-2.0 to -3.8Less than -3.8

For an additional representation of the diagnosis process to determine a patient’s 10-year absolute fracture risk, please refer to Appendix 5, page 17, of Osteoporosis Canada’s step by step guide.

  1. Siminoski, K., O’Keeffe, M., Brown, JP., Burrell, S., Coupland, D., Dumont, M., … Levesque, J. (2013). CAR Technical Standards for Bone Mineral Densitometry Reporting. Retrieved from
  2. Papaioannou, A et al. (2010).  2010 Clinical Practice Guidelines for the Diagnosis and Management of Osteoporosis in Canada. Retrieved from

Insight Medical Imaging follows the Canadian Association of Radiologists (CAR) practice guidelines and technical standards for breast imaging and intervention. The CAR committee encourages a consensus-based approach for performing and interpreting breast imaging, interventional procedures, and best practice guidelines. The guidelines educate practitioners, radiologists, and technologists so there is a consistent understanding for what is considered best practice in the industry. These guidelines are not binding for practitioners, but rather evidence-informed principles of practice intended to generate a higher quality of radiological care for patients. The guidelines are in accordance with those published by the Canadian and American Cancer Societies, the National Comprehensive Cancer Network, American College of Radiology, and shared across the Alberta Society of Radiologists (ASR) and 2013 Alberta Toward Optimized Practice (TOP) screening recommendations.

Car and TOP Breast Cancer Mammography Screening Recommendations for Asymptomatic Women

39 Years & Under: Screening is not recommended because the incidence of breast cancer is low in this age group and there is no evidence for mortality reduction. [2]

40-49 Years: Health care providers must discuss the benefits and risks of screening in this age group. The ideal interval for this age group is less clear as there are a number of factors that can influence screening results such as breast density. Additionally, sojourn time and rapid tumor growth in younger women suggest shorter interval screening is ideal; the recommended screening interval is one year. [1][4]

50-74 Years: Mammography screening in this group has shown significant evidence of mortality reduction. Routine screening is recommended every two years (biennial). When compared to annual screenings in this age group, biennial screening preserves 80% of the benefit and has shown almost 50% fewer false positive results. [5]

75 Years & Older: women in this age group are at an increased risk for developing breast cancer, however the correlation between scanning and its benefits are not as significant. Health care providers should consider individual health factors when deciding whether to continue screening, however we encourage our patients to continue screening intervals for the rest of their life. The recommended interval for healthy patients is every two years (biennial).

*The Canadian Association of Radiologists (CAR) recommends 50-74 and 75+ age groups consider screening on an annual or biennial basis (one to two years). [6]

High Risk Population – Intensive Screening Exceptions
  • Women who have one or two first degree relatives (sister, mother, daughter) with invasive breast cancer, exhibit symptoms, but do not meet the criteria for Medical Genetics referral, qualify for more intense screening measures.

-Talk to your doctor, but a baseline recommendation starts with annual screening mammography or breast ultrasound scans, starting 5-10 years younger than the youngest case in the family. (generally no earlier than age 25 and no later than age 40)

-Annual clinical breast examination starting at age 25.

  • Women with a breast biopsy showing atypical hyperplasia or lobular carcinoma in situ and following surgical management to rule out invasive carcinoma.

-Annual mammography.

-Annual clinical breast examination.

  • Women with a history of chest wall radiation at age 30 or younger.

-Annual mammography, breast ultrasound and breast screening MRI starting 5-10 years after radiation exposure. (no earlier than age 25 and no later than age 40)

-Annual Clinical breast examination.

Breast Imaging Reporting and Data System (BI-RADS) Assessment Categories

BI-RADS 0: Mammography: Incomplete*
Ultrasound and MRI: Incomplete*
*Need additional imaging evaluation and/or prior mammograms for comparison*
BI-RADS 1: Negative
BI-RADS 2: Benign
BI-RADS 3: Probably Benign
BI-RADS 4: Suspicious – 4A – Low suspicion for malignancy
4B – Moderate suspicion for malignancy
4C – High suspicion for malignancy
BI-RADS 5: Highly suggestive of malignancy
BI-RADS 6: Known biopsy-proven malignancy

  1. Buist DSM, Porter PL, Lehman C, Taplin SH, White E. (2004). Oct 6; 96(19):1432–40. Factors contributing to mammography failure in women aged 40-49 years. J. Natl. Cancer Inst.  
  2. Canadian Task Force on Preventive Health Care, Tonelli M, Gorber S, Joffres M, Dickinson J, Singh H, et al. (2011). Nov 22; 183(17):1991–2001. Recommendations on screening for breast cancer in average-risk women aged 40–74 years. CMAJ.
  3. D’Orsi CJ, Sickles EA, Mendelson EB, Morris EA, et al. (2013) ACR BI-RADS® Atlas, Breast Imaging Reporting and Data System. Reston, VA, American College of Radiology. Retrieved from
  4. Duffy SW, Chen HH, Tabar L, Fagerberg G, Paci E. (1996). Dec; 25(6):1139–45.  Sojourn time, sensitivity and positive predictive value of mammography screening for breast cancer in women aged 40-49. Int J Epidemiol.
  5. Mandelblatt JS, Cronin KA, Bailey S, Berry DA, De Koning HJ, Draisma G, et al. (2009). Nov 17; 151(10):738–47. Effects of mammography screening under different screening schedules: model estimates of potential benefits and harms. Ann. Intern. Med.
  6. Shiela, C., Aldis, A., Causer, P., Crystal P., Mesurolle, B., Mundt, Y., Panu, N., … Wadden, N. (2016). CAR Practice Guidelines and Technical Standards for Breast Imaging and Intervention. Retrieved from
2012 Canadian Association of Radiologists Diagnostic Imaging Referral Guidelines

The 2012 CAR guidelines are based on expert opinion or case studies, intended to assist physicians in the decision-making process regarding appropriate imaging studies for specific cases. These evidence-informed guidelines are not intended to restrict or diminish the freedom of practising physicians to order imaging studies for their patients for whom they have the ultimate responsibility. Furthermore, discussion between the radiologist and referring physician must always take precedence and is encouraged by all industry professionals at Insight Medical Imaging.

CAR referral Guides (PDF format)

Section A: Central nervous system

Section B: Head and neck

Section C: Spine

Section D: Musculoskeletal system

Section E: Cardiovascular

Section F: Thoracic

Section G: Gastrointestinal system

Section H: Urological, adrenal and genitourinary systems

Section I: Obstetrics and gynaecology

Section J: Trauma

Section K: Cancer

Section L: Pediatrics

Section M: Breast Disease

For more information visit the Canadian Association of Radiologists website.