When Cancer Spreads to the Bone
Cancer occurs when cells in your body start growing and dividing faster than they are supposed to. At first, these cells may form into small clumps or tumors. But they can also spread to other parts of the body. If this occurs, you will be told you have “metastases,” “metastatic cancer,” or “stage 4 (IV)” cancer. The word “advanced” is also used to describe these cancers.
When cancer spreads to the bone, it’s called “bone metastases.” This doesn’t mean you now have bone cancer—you still have the same type of cancer you started with.
Watch our Facebook Live with Dr. Dawson who talks more about bone health and bone metastases.
Diagnosing Bone Metastases
Your doctor can find out if you have bone metastases through tests like bone scans, X-rays, CT scans, PET scans, and MRIs. These tests are painless.
Some cancers are more likely to spread to the bone than others. These include:
- breast cancer
- bladder cancer
- kidney cancer
- lung cancer
- prostate cancer
- thyroid cancer
When cancers spread, they can show up almost anywhere in the body. The most common sites for brain metastases are:
- hip bone (pelvis)
- ribs and skull
- upper leg bone (femur)
- upper arm bone (humerus)
People with cancer can live for years after learning they have bone metastases. This is one of the most common and treatable places for cancer to spread.
Important Point: Cancer can also start in the bone marrow. Cancers that start in the bone are different from cancers that spread to the bone.
Find information on cancer that starts in the bone: Bone Cancer
Find information on cancer that starts in the bone marrow: Multiple Myeloma
What is Bone?
Bone is living, growing tissue, made up of proteins and minerals. Your bones have two layers:
- Outer layer: cortical bone, which is very thick
- Inner layer: trabecular (truh-BEH-kyoo-ler) bone, which is very spongy
Inside the spongy bone is your bone marrow. It contains stem cells that can develop into white blood cells, red blood cells, or platelets.
The cells that make up the bones are always changing. Some cells, called osteoclasts (Os-tee-oh-klasts), break down bone. Other cells, called osteoblasts (Os-tee-oh-blasts), form new bone. Once cancer gets into your bones, it can keep these cells from working properly. This can cause your bones to become thin and weak and increase your risk for bone breaks.
How Healthy are Your Bones?
Your doctor may suggest you have a bone density test—called a DEXA scan test. The test uses low levels of X-rays to measure how much calcium and minerals are in the bones in your hip, wrist, and spine. The test is painless. The test results show if you have:
- Osteopenia (OS-tee-oh-PEE-nee-uh)—bone that is thinner than normal—or
- Osteoporosis (OS-tee-oh-puh-ROH-sis)—bone that has become so thin you are at higher risk of bone breaks.
The DEXA scan test gives your bone density as “score.” Here is what the score means:
- 0: bone mineral density is equal to that of a 30-year-old adult
- Between +1 and -1: bone mineral density is normal
- Between -1 and -2.5: bone mineral density is low (osteopenia)
- -2.5 or lower: bone mineral density is significantly low (osteoporosis)
You may also get a Fracture Risk Assessment Tool (FRAX) score when you get your DEXA bone density score. Your FRAX score is an estimate of how likely you are to break a bone in the next 10 years. Your score is based on your age, weight, gender, smoking history, alcohol use, and whether you have already had one or more broken bones. Your doctor will use the scores from these two tests to decide whether to recommend that you take a bone building drug.
Treating Bone Metastases & Pain
Bone metastases is one of the most common type of metastases. It is also one of the most treatable. The treatments your doctor recommends will be based on:
- Your symptoms
- Where the metastases are
- What other cancer treatments you are currently receiving
- What treatments you have previously received
Treatments for Bone Metastases
Chemotherapy: Used to kill cancer cells that may be anywhere in your body, including in your bone.
Hormone Therapy: If you have prostate cancer or you have breast cancer that estrogen and/or progesterone receptor positive (ER+/PR+), you may be treated with a hormone therapy. These therapies, taken as pills or injections, can help stop cancer cell growth in the bones and other parts of your body. The hormone therapies used to treat prostate cancer block testosterone. The hormone therapies used to treat breast cancer block estrogen.
Bone Building Drugs: These drugs help strengthen bone, slow bone metastases, and help reduce pain caused by bone metastases. Often given by IV (into the vein) or as injections under the skin, they include:
There are different types of bisphosphonates (bis-FOS-foh-nayts) available. The two most commonly used to treat bone metastases are zoledronate (Zometa®) and pamidronate (Aredia®).
The most common side effects are headache and muscle aches for up to three days after the injection. In rare cases, after more than five years of use, patients have developed a crack in the middle of their thigh bone. Another rare complication is osteonecrosis (bone death) of the jaw after having a tooth pulled. For this reason, you should have a dental exam before starting on a bisphosphonate.
Cancer cells can get bone cells to break down bone more quickly. Xgeva, which is given under the skin, can help stop this process. The most common side effects are shortness of breath, tiredness, weakness, nausea, diarrhea, low blood counts, back pain, swelling of the lower legs or hands, upper respiratory tract infection, pneumonia, rash, and headache. Like the bisphosphonates, in rare cases Xgeva can cause a crack in the thigh bone or osteonecrosis of the jaw.
Intravenous Radiation (also called radiopharmaceuticals or radionuclide therapy): These treatments use low levels of radioactive material that have a strong attraction to bones. They include:
- Radium-223 (Xofigo®)
- Stronium-89 Chloride Injection (Metastron®)
- Samarium sm 153 lexidronam (Quadramet®)
Used to treat men with prostate cancer that has spread to the bone. It may also help reduce pain caused by some bone metastases. Side effects can include damage to the bone marrow, which can lead to low blood cell counts.
Used to reduce bone pain caused by bone metastases.
Used to treat certain types of severe bone pain in patients with prostate, breast, or lung cancer that have spread to the bone.
Radiation: Radiation therapy can be directed to the specific sites of your bone metastases to slow cancer cell growth. It is also sometimes used to relieve pain.
Surgery: Your doctor may recommend surgery—possibly followed by radiation—if you have a bone that is weak or broken. Surgery may include:
- Orthopedic fixation, which uses metal plates, screws, and nails to stabilize bones that have become weak or are at risk of breaking.
- Bone cement to stabilize bones. The cement is injected into a bone that is broken or has been damaged by the bone metastases. This procedure can also help reduce pain.
- Repairing broken bone with metal plates, screws, and nails.
- Joint replacement to repair a broken bone or to reduce bone and joint pain.
Managing Bone Pain
People can live for years after they have told their cancer has spread (metastasized) to their bones. This is one of the most common and treatable places for cancer to spread. If you have bone metastases, it is important to:
Tell your doctor if you have any bone or joint pain. Bone metastases can be very painful. Your treatment may help to reduce your pain, but it may not get rid of it completely. You may also need other medicine or treatments for the pain itself. If you have bone pain, tell your health care team. You can ask about:
Getting a referral to a pain specialist or a palliative (PA-lee-uh-tiv) care specialist. Palliative or supportive care I used to treat pain or other symptoms caused by cancer and its treatments. Palliative care is not the same as hospice care, which is end-of-life care. You can ask for a referral to a palliative care specialist at any point during your cancer treatment.
Taking pain medication. Over-the-counter medication, like Tylenol®, Advil® or Motrin®, may be all you need. Talk to your doctor to be sure you are taking the right dose. Even though they don’t need a prescription, they can still cause harmful side effects. If these don’t help your pain, talk to your doctor about other types of pain medicine.
Taking steroids to decrease swelling that makes pain worse.
Using radiation to treat specific sites of bone pain.
Spinal Cord Compression
One of the most common places for bone metastases is the spine. It is important that your doctor watch spine metastases closely. If they grow too big, they can crush (or compress) your spinal cord, which can paralyze you and keep you from walking or moving ever again. Call your doctor or go the emergency room if you have these symptoms:
- Back pain that gets worse
- Back pain and leg pain at the same time
- Numbness in your arms, legs or belly
- Problems standing due to leg weakness
- Problems moving your legs
- Problems holding or keeping objects in your hands, due to arm weakness
- Los of control when you urinate (pee) or defecate (poop).
Treatment for spinal cord compression may include steroids, radiation, and/or surgery.
Cancer cells affect how your body builds bone. This can cause your bones to get thinner. It can also cause calcium to seep from the bones into your blood. If the calcium levels in your blood get too high, you can develop hypercalcemia (HY-per-kal-SEE-mee-uh), so it is important to treat it as early as possible. Be sure to let your doctor know if you:
- Are constipated
- Need to urinate (pee) more often than usual
- Feel tired often
- Are always thirsty and drinking more than usual
If the hypercalcemia gets worse and you become more dehydrated, you may also have muscle weakness or pain in your muscles and joints. Hypercalcemia can be dangerous if not treated. It can lead to confusion, a coma or kidney failure.
To prevent hypercalcemia, you can:
- Drink the right amount of fluids.
- Get enough salt in your diet.
- Control nausea and vomiting.
- Stay active by walking.
- Control fever.
- Stop taking drugs that can cause hypercalcemia or affect its treatment, when possible. Your health care team can tell you what drugs you may need to stop taking.
Changing the diet to decrease calcium will not lower the amount of calcium in the blood.
Living with Bone Metastases
A healthy diet, exercise, preventing falls, and taking the proper medicine can help you keep your bones as strong as possible, decrease pain, reduce your risk of broken bones, and improve your quality of life.
Some changes that can make a difference include:
- Not smoking—smoking makes bone loss happen faster.
- Limiting alcohol to one drink a day (for women) and or two (for men). Alcohol affects that cells that build new bone. Also, drinking increases the risk of falling.
- Eating a diet rich in calcium and vitamin D.
- Strengthening your bones with medication, supplements, and exercise.
- Taking steps to reduce your risk of falls and bone breaks.
Eating for Healthy Bones
Try to get your daily recommended levels of calcium and vitamin D from the food you eat. Good sources of calcium include:
- Low-fat dairy products, like yogurt
- Kale and other dark green, leafy vegetables
- Canned salmon or sardines with bones
- Calcium-fortified foods and drinks (orange juice is often fortified with calcium and vitamin D)
Talk to your health care provider about whether calcium and vitamin D supplements are right for you. Eat a well-balanced diet rich in calcium and vitamin D.
|Women ages 19 to 50||1,000 mg/day||600 IU|
|Men ages 19 to 70||1,000 mg/day||600 IU|
|Women ages 51 to 70||1,200 mg/day||600 IU|
|Women and Men 70+||1,200 mg/day||800 IU|
Exercise for Healthy Bones
Exercise is a key part of a healthy lifestyle that helps maintain bone density. Exercise also improves balance, which makes you less likely to fall. This, in turn, lowers your risk of breaking a bone.
You may not have as much energy or flexibility as you had before you developed bone metastases. Even so, you should try to move as much as you can. Whether you are starting to exercise for the first time or hoping to pick up where you left off, talk to your doctor about what types of exercises are okay or what you may need to change. For example, depending on where your bone metastases are, there may be limits on how much weight you should lift.
Here are some tips that can help you get started:
- Try to build up to exercising 30 minutes each day.
- Find things that feel good and safe to you—walking with friends, gardening, swimming, or gentle yoga.
- Try to add in some resistance exercises, like lifting weights and stretching with exercise bands. They build muscle strength, which can help your bones. They also help with balance, which can help prevent falls.
- When you feel sick, exercise only as much or as strenuously as you feel comfortable
- Allow yourself to exercise gently, slowly, and for short amounts of time.
- If you are extremely tired, try gentle, slow, and brief movements that are comfortable to you.
- If you have trouble sleeping, exercise during the day. It can help you to sleep better at night.
Thin bones are more likely to break if you fall. To help prevent falls, you can:
- Wear low-heeled shoes that fit well
- Get shoes with nonslip soles
- Check your home—move anything you could easily trip over (electrical cords) or slip on (rugs)
- Keep rooms brightly lit
- Put grab bars inside and outside your bath or shower (and ask for rooms that have them when you are staying at a hotel)
- Lower your mattress if it is hard for you to get out of bed
- Consider buying a pair of walking sticks, especially if walking or hiking is your favorite type of exercise
- Talk to your doctor about whether you should start a strength-training program. This could be a pool exercise program or involve using resistance from weights or bands.