Support group for cancer patients. Does it improve their physical and psychological wellbeing? A pilot study

Systematic self-reporting of patients’ symptoms: improving oncologic care and patients’ satisfaction

Background:

In recent years, there has been a growing interest to enhance patients’ symptom management during routine cancer care using patient-reported outcome measures. The goal of this study is to analyse patients’ responses to the Edmonton Symptom Assessment System (ESAS) to determine whether patient-reported outcomes could help characterise those patients with the highest supportive care needs and symptom burden in order to help provide targeted support for patients.

Methods:

In this study, we analysed ESAS questionnaire responses completed by patients as part of their routine care and considered part of patients’ standard of care. Statistical analyses were performed using the IBM SPSS Statistics version 26.0. Descriptive statistics are used to summarise patient demographics, disease characteristics and patient-reported symptom severity and prevalence.

Results:

The overall mean age is 65.2 ± 12.8 years comprising 43.8% male and 56.2% female patients. The five common primary disease sites are breast (26.2%), haematology (21.1%), gastrointestinal (15.3%), genitourinary (12.7%) and lung (12.0%) cancers. The mean severity for each symptom is all mild (score: 1–3). The three most common reported symptoms causing distress are tiredness, poor overall wellbeing and anxiety, and the least reported symptom is nausea.

Conclusions:

Systematic self-reporting of patients’ symptoms is important to improve symptom management, timely facilitation of appropriate intervention, patient experience, and patient and family satisfaction. The awareness of disease site, gender and age-related symptom variations should help in the design and provision of appropriate symptom-directed, tumour-specific and patient-focused interventions to meet patients’ immediate needs.

Assessment of Self-Efficacy as a Way to Help Identify Cancer Patients Who Might Benefit from Self-Help Group Attendance?

Participating in patient self-help groups is highly recommended to patients in cancer care. Yet, engagement is relatively rare. A total of 253 patients participated in our study conducted as a paper-and-pencil questionnaire. A binominal logistic regression, with interest in participation in self-help groups being the dependent variable, was run. General interest in self-help was high among the respondents. Female gender, higher age, higher education and low self-efficacy were found to significantly predict interest in self-help. Patients reported a lack of information provided by medical professionals. Self-efficacy as a predictor might contribute to characterizing patients who might benefit from self-help group participation.

Supportive care needs of multicultural patients with cancer in the United Arab Emirates

Despite the high prevalence of cancer in the Middle East, there is limited published data reporting the needs of cancer patients in this region of the world. The purpose of this study is to assess the unmet supportive care needs of oncology patients in the United Arab Emirates (UAE). From December 2014 to December 2016, a cross-sectional survey of cancer patients was conducted at a large tertiary care hospital and an oncology referral centre in the UAE, using a validated Arabic translation of the supportive care needs survey--short form (SCNS-SF34-A), assessing cancer-specific perceived needs across five domains: psychological, health system information, patient care and support, physical and daily living and sexuality. Chi-square test and Pearson's correlation coefficient were used to assess the association between variables. Participant responses were tabulated as mean ± standard error of the mean (SEM). The response rate was 78% (210/268). Five of the 10 items from the psychological domain constituted the 10 most prevalent unmet moderate or high needs, followed by physical and daily living needs (3.04 ± 0.029, p < 0.001), health system information (3.03 ± 0.02, p < 0.001), patient care and support (2.95 ± 0.24, p < 0.001), with low sexuality needs (1.79 ± 0.08, p < 0.001). Women had significantly higher psychological unmet needs. Cultural differences were noted only in the health system information domain. Improvements in mental health services, development of multidisciplinary cancer care teams, introduction of cancer support groups and fully engaging women in all treatment decisions are feasible and easy to implement interventions that can significantly improve the care and wellbeing of oncology patients in the UAE.

Development of a Comprehensive Questionnaire of Complementary and Alternative Medicine Use Among Cancer Patients and Survivors

The purpose of this study was to develop and pilot test a comprehensive measurement tool to quantify all aspects of complementary and alternative medicine (CAM) use among cancer survivors. Data are from 81 cancer patients and survivors with a mean age of 62 years and 77.2% women. CAMwas used by 63% of the sample. The most common CAM was regular exercise (50%), meditation (48.5%), and fresh fruit and vegetable juices (38.8%). The main motivations for using CAM were to boost the immune system and enhance quality of life. More than 65% had told a doctor they were using CAM. Reported benefits included feeling better, having more energy, and providing a distraction. The main sources of information were support groups (61.5%), books (50%), and friends (45.3%). Few participants used CAM to cure the cancer, and they had realistic expectations about benefits they may receive from using CAM. Further studies are needed with larger sample sizes to confirm whether findings can be generalized to the broader population of cancer patients and survivors.

Cancer-Related Fatigue, Version 2.2015

Cancer-related fatigue is defined as a distressing, persistent, subjective sense of physical, emotional, and/or cognitive tiredness or exhaustion related to cancer or cancer treatment that is not proportional to recent activity and interferes with usual functioning. It is one of the most common side effects in patients with cancer. Fatigue has been shown to be a consequence of active treatment, but it may also persist into posttreatment periods. Furthermore, difficulties in end-of-life care can be compounded by fatigue. The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Cancer-Related Fatigue provide guidance on screening for fatigue and recommendations for interventions based on the stage of treatment. Interventions may include education and counseling, general strategies for the management of fatigue, and specific nonpharmacologic and pharmacologic interventions. Fatigue is a frequently underreported complication in patients with cancer and, when reported, is responsible for reduced quality of life. Therefore, routine screening to identify fatigue is an important component in improving the quality of life for patients living with cancer.

Putting evidence into practice: an update of evidence-based interventions for cancer-related fatigue during and following treatment

Cancer-related fatigue (CRF) has deleterious effects on physical, social, cognitive, and vocational functioning, and causes emotional and spiritual distress for patients and their families; however, it remains under-recognized and undertreated. This article critically reviews and integrates the available empirical evidence supporting the efficacy of pharmacologic and nonpharmacologic treatment approaches to CRF, highlighting new evidence since 2007 and 2009 Putting Evidence Into Practice publications. Interventions that are recommended for practice or likely to be effective in improving fatigue outcomes include exercise; screening for treatable risk factors; management of concurrent symptoms; yoga; structured rehabilitation; Wisconsin ginseng; cognitive-behavioral therapies for insomnia, pain, and depression; mindfulness-based stress reduction; and psychoeducational interventions such as anticipatory guidance, psychosocial support, and energy conservation and activity management. This information can be applied to improve the management of CRF, inform health policy and program development, shape the design of clinical trials of new therapies for CRF, and drive basic and translational research.

Clinical pathway for the screening, assessment and management of anxiety and depression in adult cancer patients: Australian guidelines

PURPOSE

A clinical pathway for anxiety and depression in adult cancer patients was developed to guide best practice in Australia.

METHODS

The pathway was based on a rapid review of existing guidelines, systematic reviews and meta-analyses, stakeholder interviews, a Delphi process with 87 multidisciplinary stakeholders and input from a multidisciplinary advisory panel.

RESULTS

The pathway recommends formalized routine screening for anxiety and depression in patients with cancer at key points in the patient's journey. The Edmonton Symptom Assessment System or distress thermometer with problem checklist is recommended as brief screening tools, combined with a more detailed tool, such as the Hospital Anxiety and Depression Scale, to identify possible cases. A structured clinical interview will be required to confirm diagnosis. When anxiety or depression is identified, it is recommended that one person in a treating team takes responsibility for coordinating appropriate assessment, referral and follow-up (not necessarily carrying these out themselves). A stepped care model of intervention is proposed, beginning with the least intensive available that is still likely to provide significant health gain. The exact intervention, treatment length and follow-up timelines, as well as professionals involved, are provided as a guide only. Each service should identify their own referral network based on local resources and current service structure, as well as patient preference.

DISCUSSION

This clinical pathway will assist cancer services to design their own systems to detect and manage anxiety and depression in their patients, to improve the quality of care.

Predicting cancer patients' participation in support groups: a longitudinal study

OBJECTIVE

Few patients participate in cancer support groups despite their benefits. This study investigated the importance of Theory of Planned Behaviour variables in predicting group participation, relative to disease impact, existing support, coping and demographic variables.

METHODS

Longitudinal study of patients with colorectal, lung or prostate cancer recruited from a specialist oncology centre. Patients self-completed surveys at baseline and six-month follow up. Baseline measures included Theory of Planned Behaviour (TPB) variables, distress and control over cancer (IPQ-R), coping (Brief COPE), social support (MSPSS), health related quality of life (EORTC QLQ-C30) and readiness to participate (PAPM). Group participation and recommendations to participate were measured at follow up. Univariable and Random Forest analyses investigated predictors of baseline readiness to participate and participation by six-month follow up.

RESULTS

N=192 patients completed baseline questionnaires. N=13 participated in a group and N=59 did not by six-month follow up. Baseline readiness to participate was associated with inadequate support and positive views of support groups. Lower cognitive functioning, recommendations and readiness to participate predicted group participation by six-month follow up.

CONCLUSION AND PRACTICE IMPLICATIONS

Practitioners may facilitate group participation by promoting positive views of groups, recommending participation and focusing on patients experiencing greater disease impact and less existing support.

Effects of an educational intervention for managing fatigue in women with early stage breast cancer

PURPOSE

This randomized controlled trial of outpatients with breast cancer (stage I or II) evaluated the effects of a 3-week educational intervention on patient levels of fatigue.

METHODS

Norwegian outpatients were randomized into an intervention group (n = 79) and a control group (n = 81). Women with fatigue (>2.5 on a 0-10 numeric rating scale, NRS) completed the Fatigue Questionnaire (FQ) and the Lee Fatigue Scale (LFS) at baseline (after treatment) (T1), immediately after intervention (T2) and 3 months after intervention (T3).

RESULTS

The mean fatigue score (NRS) at study entry was 6.1 (SD 1.7) and 36% (n = 57) had a score ≥7. There were no statistically significant differences between the fatigue measures of women in the intervention and control group at T2 or T3 in the overall sample after the intervention. Using an NRS cut-off of 5, there was a borderline difference for women who scored <5 for chronic fatigue on FQ (p = 0.062) and a significant difference for energy on LFS (p = 0.042) where the women in the intervention group had less fatigue. Using an NRS cut-off score of 6, there was a borderline difference for women who scored <6 for fatigue on FQ (p = 0.062) and a significant difference for energy on LFS (p = 0.021) where women in the intervention group had more energy than those in the control group.

CONCLUSIONS

Further research is needed to identify psycho-educational interventions to reduce levels of fatigue and to tailor an intervention based on the level of fatigue. Fatigue measurements should be chosen more carefully.

A randomized controlled trial of support group intervention after breast cancer treatment: results on sick leave, health care utilization and health economy

BACKGROUND

More than 50% of breast cancer patients are diagnosed before the age of 65. Returning to work after treatment is, therefore, of interest for both the individual and society. The aim was to study the effect of support group intervention on sick leave and health care utilization in economic terms.

MATERIAL AND METHODS

Of 382 patients with newly diagnosed breast cancer, 191 + 191 patients were randomized to an intervention group or to a routine control group, respectively. The intervention group received support intervention on a residential basis for one week, followed by four days of follow-up two months later. The support intervention included informative-educational sections, relaxation training, mental visualization and non-verbal communication. Patients answered a questionnaire at baseline, two, six and 12 months about sick leave and health care utilization.

RESULTS

There was a trend towards longer sick leave and more health care utilization in the intervention group. The difference in total costs was statistically significantly higher in the intervention group after 12 months (p = 0.0036).

CONCLUSION

Costs to society were not reduced with intervention in its present form.

Identifying the informational and psychosocial needs of Chinese immigrant cancer patients: a focus group study

PURPOSE

The Chinese immigrant community faces multiple barriers to quality cancer care and cancer survivorship. Psychosocial interventions can positively impact quality of life, anxiety, and distress in cancer patients. In this study, we explored the informational and psychosocial needs of Chinese cancer patients to inform the development of culturally targeted support and survivorship interventions.

METHODS

We conducted four focus groups with a total of 28 Chinese cancer patients to elucidate their cancer informational and psychosocial needs. The groups were conducted using standard methodology and guided by community-based participatory research principles. Sessions were audio recorded, transcribed, and translated into English. The research team conducted the analysis.

RESULTS

Frequently occurring themes included (1) the need for accurate information on cancer and treatment options, (2) the role of language barriers in accessing cancer care, (3) the role of food in cancer and the need for nutritional information, and (4) the role of Chinese medicine in cancer treatment. Participants expressed significant dissatisfaction with the amount, reliability, and/or comprehensibility of available information.

CONCLUSIONS

Support groups and programs should be developed to address participants' needs for more information on cancer and its treatment. Programs should educate and empower patients on how to find further Chinese language information and resources and effectively communicate their questions and needs to providers in an interpreted encounter. System-level approaches should be implemented to ensure provision of interpretation services. Additionally, programs should incorporate the unique cultural needs of this population related to food/nutrition and Chinese medicine.

A randomised controlled trial of support group intervention after breast cancer treatment: results on anxiety and depression

BACKGROUND

Previous studies have demonstrated that between 20 and 30% of women treated for breast cancer have measurable signs of anxiety and depression compared with 6% in a population of healthy women. Depression has been proposed as a predictive factor for recurrence and survival. The aim of the present study was to evaluate if psychosocial support intervention could influence anxiety and depression during the first year after diagnosis.

MATERIAL AND METHODS

Newly diagnosed breast cancer patients were randomised between April 2002 and November 2007 and stratified by adjuvant chemotherapy. Of 382 eligible patients, 191 + 191 patients were randomised to intervention group or control group, respectively. Control patients were subjected to standard follow-up routines. The Intervention group had support intervention at the Foundation Lustgården Mälardalen. The rehabilitation lasted one week on a residential basis followed by four days of follow-up two months later. We used the Swedish version of the HAD scale with a cut-off value greater than 10 for clinical symptoms of depression and anxiety.

RESULTS

Support group intervention lowered anxiety over time (p < 0.001) but depression was unaffected (p = 0.610).

CONCLUSION

This prospective randomised trial of support group intervention in a large homogenous group of breast cancer women showed a statistically significant effect on lowering anxiety over time. No statistically significant effect of intervention could be seen on depression.

From Diagnosis to Death: A Case Study of Coping With Breast Cancer as Seen Through Online Discussion Group Messages

To understand the underlying psychosocial reactions against the unfolding of medical events that announce the disease progression, the objective of this analysis was to identify the patterns of online discussion group message themes in relation to the medical timeline of one woman's breast cancer trajectory. 202 messages posted by Darlene (our studied case) were analyzed by 2 independent coders using a grounded theory approach. The findings suggest that the pattern of messages was clearly correlated with distress-inducing events. The most frequent interaction theme was about building friendship with peers through communication of encouragement, validation, appreciation, and life sharing. Narratives of medical progression were constantly updated to identify similarities with peers. Family issues were increasingly raised at the end of life.

Pre-intervention distress moderates the efficacy of psychosocial treatment for cancer patients: a meta-analysis

This meta-analysis examined whether effects of psychosocial interventions on psychological distress in cancer patients are conditional upon pre-intervention distress levels. Published articles and unpublished dissertations between 1980 and 2005 were searched for interventions reporting the Hospital Anxiety and Depression Scale (HADS) or the Spielberger State-Trait Anxiety Inventory (STAI). Multilevel mixed-effects modeling was used to meta-analyze effect-sizes separately for the HADS (27 trials, 2,424 patients) and STAI (34 trials, 2,029 patients). Pre-intervention distress significantly moderated intervention effects, explaining up to 50% of the between-study effect-size variance: effects on anxiety and depression were generally negligible when pre-intervention distress was low and pronounced when it was high. These results could not be explained by differences in intervention type, setting, dose, and whether intervention was targeted at distressed patients. Psychosocial interventions may be most beneficial for cancer patients with elevated distress. Future research should identify which treatment components are most effective for these patients to facilitate optimal treatment tailoring and cost-effective health care.

Benefits from membership in cancer patient associations: relations to gender and involvement

Cancer patient associations report a growing number of members and increasing possibilities to influence health care, but knowledge about the members' views on the benefit of involvement is scarce. We therefore investigated how members (n = 1742) of Swedish patient associations for breast cancer and prostate cancer rate the benefit of membership for their physical and psychological well-being and social adjustment to cancer. Using a scoring scale, 2/3 of the members reported that membership had benefit for psychological well-being, whereas half of the members reported benefit for physical well-being and social adjustment. Individuals who had been actively involved in board work and/or contact person activities within the associations reported significantly more benefit for all three parameters. Gender differences were observed with men, represented by individuals affected by prostate cancer, reporting greater benefit for all three parameters, although especially evident for psychological well-being. Individuals who obtained membership within two years of diagnosis reported greater benefit for psychological well-being and social adjustment compared to those who became members later. In conclusion, members in patient associations for cancer report benefit particularly for their psychological well-being and actively involved members and men affected by prostate cancer perceive the greatest benefit from membership.

A review of the reliability and validity of the Edmonton Symptom Assessment System

BACKGROUND

Systematic symptom reporting by patients and the use of questionnaires such as the Edmonton Symptom Assessment System (ESAS) have potential to improve clinical encounters and patient satisfaction. We review findings from published studies of the ESAS to guide use of the system and to focus research.

METHODS

A systematic search for articles from 1991 through 2007 found thirty-nine peer-reviewed papers from 25 different institutions, thirty-three of which focused on patients with cancer. Observations, data, and statistics were collated according to relevance, reliability, validity, and responsiveness.

RESULTS

Findings apply predominantly to symptomatic palliative patients with advanced cancer who were no longer receiving active oncologic therapies. Uncertainty about summarizing findings arises from frequent modification of the ESAS (altered items, scales, and time periods). Overall, reliability is established for daily administration. Scores are skewed, with a floor effect, but the relative order of symptoms by mean scores is similar across studies. Emotional symptoms are poorly captured by the depression and anxiety items. An equally weighted summation of scores may estimate a construct of "physical symptom distress," which in turn is related to performance status, palliative goals, quality of life, and well-being.

CONCLUSIONS

The ESAS is reliable, but it has restricted validity, and its use requires a sound clinical process to help interpret scores and to give them an appropriate level of attention. Research priorities are to further develop the ESAS for assessing a greater number of important physical symptoms (and to target "physical symptom distress"), and to develop a similar instrument for emotional symptoms.

'Hands of Time': the experience of establishing a support group for people affected by mesothelioma

Expertise and management of mesothelioma are known to vary throughout the UK. The support needs of people with mesothelioma and their family members are poorly understood and poorly met. Support group participation can contribute to the supportive care of people with cancer and their family members by improving adaptation and reinforcing effective coping strategies. This paper describes the initial experience of establishing a support group for people affected by mesothelioma. The structure and process of developing and running the group are described and the challenges involved are discussed. The findings of a small evaluation of the group are presented.

Immune response, depression and fatigue in relation to support intervention in mammary cancer patients

GOAL OF WORK

To study the effect of support intervention on immune function in breast cancer patients.

MATERIALS AND METHODS

Breast cancer patients from an ongoing prospective randomised quality-of -life study were chosen for assaying immune functions in relation to a support-group intervention program running on a residential basis. Twenty-one women received adjuvant-combined radio-chemotherapy (CT-RT) and 20 women radiotherapy (RT). Eleven CT-RT and ten RT patients were randomised to support-group intervention, the rest served as controls. Immune tests for NK cells and NK-cell cytotoxicity, as well as lymphocyte subpopulations and response to antigen were performed before intervention, 2, 6, and 12 months later, in parallel to controls and healthy volunteers (n = 11). Depression, anxiety and fatigue were evaluated by the Hospital Anxiety and Depression (HAD) and the Norwegian Fatigue questionnaire. The density of NK cell receptors and in vitro quantitation of functional NK cytotoxicity against K562 cell line were evaluated. Four-colour flow cytometry was used to detect signal transduction molecules and cytokine expression. T-cell proliferate response to purified protein derivate (PPD) antigen was evaluated.

RESULTS

No significant immune effect of support intervention could be found. The immune variables were severely disarranged compared to healthy volunteers but showed a statistically significant improvement over time. The majority of patients suffered from fatigue but had low scores for depression and anxiety.

CONCLUSION

No effect on immune parameters could be detected from support intervention. The long-lasting immune suppression might override a putative effect of the intervention. Low depression scores may contribute to the absence of a detectable effect.

Quality-of-life impact of participation in a head and neck cancer support group

OBJECTIVE

To assess if participation by patients in a head and neck cancer support group improves perceived quality of life (QOL).

STUDY DESIGN AND SETTING

Subjects for this study included 47 patients at a tertiary Veterans Affairs Medical Center who were previously treated for head and neck cancer. This was a quasi-experimental, post-test study comparing the QOL of 24 patients who participated in a head and neck cancer support group with 23 patients who did not participate. The validated University of Michigan Head and Neck Quality of Life (HNQOL) instrument was used to evaluate head and neck cancer-related QOL.

RESULTS

Patients who participated in the head and neck cancer support group exhibited significantly better scores in the domains of eating, emotion, and pain as well as in the global bother and response to treatment questions of the HNQOL instrument compared with those patients who did not participate. Additional subgroup analysis comparing age, type of treatment, and length of time since cancer diagnosis suggests that these variables were less important predictors of QOL than was support group participation.

CONCLUSIONS

Our findings suggest that patient participation in a head and neck cancer support group is associated with improved QOL.

SIGNIFICANCE

Support groups may be beneficial in improving QOL after head and neck cancer treatment.

Influence of economic and demographic factors on quality of life in renal transplant recipients

BACKGROUND

The purpose of this study was to determine the influence of annual income, Medicare status, and demographic variables on the health-related quality of life (HQoL) of renal transplant recipients.

METHODS

A cross-sectional survey was mailed to 146 Georgia renal transplant recipients who had functional grafts. Data were collected using the SF-12 Health Survey (version 2), a demographics survey, and 2003 tax documents. One-way ANOVAs and Pearson's R correlations were used to examine relationships between annual income, Medicare status, demographic variables and SF-12 scores. Significant variables were included in stepwise multiple regression analyses.

RESULTS

Data from 130 participants (89% response rate) were collected. Recipients with no Medicare coverage had significantly higher scores on the Physical Functioning and Role Physical SF-12 scales (p = 0.005) compared to recipients with Medicare. Annual income was positively correlated with General Health (p < 0.05). Age and race were significant predictors of Vitality (p = 0.004) and Physical Component Summary (p < 0.001) scores. Age, race, and Medicare status were significant predictors of Physical Functioning and Role Physical scores (p < 0.001). Age, annual income, race, and years post-transplant were significant predictors of General Health score (p < 0.001). Age was the sole predictor of Bodily Pain score (p = 0.002), and marital status was the sole predictor of Social Functioning score (p = 0.005).

CONCLUSIONS

Interventions designed to offset financial barriers may be needed to bolster renal transplant recipients' HQoL.

Cancer-Related Fatigue

PURPOSE

Cancer-related fatigue contributes to negative outcomes relative to psychosocial and symptom distress, functional status, and quality of life, and yet it is often underdiagnosed and management is frequently suboptimal.

DESIGN

Systematic database searches were conducted, and primary research reports and meta-analyses of quantitative studies of interventions for fatigue published in English were identified and critically examined.

RESULTS

This paper reviews the etiology and evaluation of cancer-related fatigue and analyzes current empirical evidence supporting pharmacologic and nonpharmacologic techniques for its management.

DISCUSSION

A variety of pharmacologic and nonpharmacologic techniques to manage cancer-related fatigue have been studied, although most of the evidence is from single-arm pilot studies with small sample sizes, rather than from adequately powered, multicenter, randomized controlled trials. Continued research in ethnically and racially diverse samples is needed to identify the interventions that are most effective in specific cancer subpopulations and to develop and test interventions for fatigue at each phase in the illness trajectory.

Approaches to patient education: emphasizing the long-term value of compliance and persistence

Approximately 50% of patients with chronic disease do not obtain optimal clinical benefit from treatment because of poor compliance with medication regimens. Lack of compliance is associated with poor clinical outcomes, increased hospitalizations, lower quality of life, and higher overall healthcare costs. Although poor compliance and persistence are common across many disease states, they may be particularly poor in treatment for asymptomatic chronic diseases such as osteoporosis. Patient education has been demonstrated to significantly improve compliance with medication across a broad range of conditions and disease severities. In a study in which patients received educational materials, referral for bone densitometry, and physician consultation, 67% were compliant with treatment after 6 months. Patient satisfaction with treatment has been linked to compliance with therapy; by improving patient care through fulfilling expectations for physician visits and providing frequent feedback, the healthcare provider can dramatically improve compliance. Self-management programs focusing on day-to-day management of chronic diseases have been shown to significantly improve heath behaviors and health status. Regardless of the strategy used, attention must be directed to identifying the patients least likely to persist with treatment and to providing the education and support these patients need to adhere to osteoporosis therapy.