Who Manages Osteoporosis
Primary care physicians should take the lead role in osteoporosis management for most patients, particularly after initial diagnosis and during long-term follow-up care. 1
Primary Responsibility Framework
Primary care physicians (PCPs) are the central coordinators of osteoporosis care and should manage:
- Risk assessment using FRAX and other validated tools 1
- Ordering and interpreting bone mineral density (BMD) testing with DXA 2, 3
- Initiating and monitoring pharmacologic therapy 4
- Ensuring adequate calcium (1,000-1,200 mg/day) and vitamin D (800-1,000 IU/day) supplementation 2, 3
- Long-term monitoring with repeat DXA every 2 years 2, 3
The World Health Organization has specifically called for primary care to lead efforts in managing osteoporosis as a noncommunicable disease 4. Despite this clear mandate, a significant care gap persists, with many at-risk patients not being screened or treated 5.
Role of Specialists
Oncologists manage bone health during active cancer treatment, particularly for patients receiving treatments that affect bone density such as:
- Aromatase inhibitors in breast cancer 6, 1
- Androgen deprivation therapy in prostate cancer 6, 1
- GnRH agonists 3
- Chronic glucocorticoid therapy 3
Endocrinologists and rheumatologists should manage:
- Complex or treatment-resistant osteoporosis 1
- Secondary causes of bone loss 1
- Patients requiring anabolic agents (teriparatide, abaloparatide, romosozumab) for very high fracture risk 3
Orthopedic surgeons treat fragility fractures but should not be expected to manage the underlying osteoporosis—this responsibility rests with primary care 7, 8.
Transition of Care in Cancer Survivors
A critical handoff occurs as cancer survivors transition from oncology to primary care. 6, 1
- During active cancer treatment: Oncology team manages bone health 6, 1
- Early follow-up period: Shared responsibility with clear communication 6
- Long-term survivorship: Primary care assumes management 6, 1
A treatment summary and individualized care plan mandated by the American College of Surgeons Commission on Cancer must clearly identify the healthcare provider responsible for bone health. 6, 1 This prevents patients from falling through the cracks during care transitions.
Coordination Requirements
Effective osteoporosis management requires explicit coordination among all providers:
- Dental coordination: Dental screening must be performed before initiating bisphosphonates or denosumab to reduce osteonecrosis of the jaw (ONJ) risk 6, 1, 9
- Shared care plans: Clear designation of who orders DXA scans, prescribes medications, and monitors treatment response 1
- Communication protocols: Regular updates between oncologists, primary care, and specialists about treatment changes 6
Common Pitfalls in Care Coordination
The most significant barrier is the assumption that "someone else" is managing the patient's bone health. 7
- Orthopedic surgeons consistently believe primary care should manage post-fracture osteoporosis 7
- Primary care physicians may assume oncologists continue managing bone health after cancer treatment ends 6
- Result: Up to 80% of patients with fragility fractures receive no osteoporosis treatment 5
Cost concerns and medication adverse effects deter primary care physicians from treating, with 61% citing cost as the greatest barrier and 61% citing potential adverse effects 7. However, the cost of recurrent fractures far exceeds medication costs, and modern therapies have proven safety profiles 5.
Practical Implementation
Primary care should proactively screen all:
- Women ≥65 years 2, 3
- Postmenopausal women <65 years with risk factors 2, 3
- Men ≥70 years (using female reference database for diagnosis) 6, 2
- Any adult ≥50 years with prior fragility fracture 2
When specialist referral is warranted: