This information represents the views of the doctors and nurses serving on the American Cancer Society's Cancer Information Database Editorial Board. These views are based on their interpretation of studies published in medical journals, as well as their own professional experience.

The treatment information in this document is not official policy of the Society and is not intended as medical advice to replace the expertise and judgment of your cancer care team. It is intended to help you and your family make informed decisions, together with your doctor.

Your doctor may have reasons for suggesting a treatment plan different from these general treatment options. Don't hesitate to ask him or her questions about your treatment options.

Treatment options for people with bone metastases depend on where the primary cancer developed, which bones it has spread to, and whether any bones are severely weakened or broken. Other factors will also be considered, such as specific features of the cancer cells (in the case of breast cancer, for instance, whether they contain estrogen receptors), your general state of health, and which treatments you have already received.

Most doctors believe the most important treatment for bone metastases is treatment directed against the cancer. This is usually done with systemic therapies. Systemic therapies enter the bloodstream and can therefore reach cancer cells that have spread throughout the body. This is different from local therapies, which are directed at a single area. Systemic therapies include chemotherapy or hormone therapies, which are taken by mouth or injected.

There are also drugs called bisphosphonates that can help make diseased bones stronger and help prevent fractures. These drugs are used to supplement the chemotherapy or hormonal therapy for bone metastasis. If systemic therapy is successful, then the symptoms of the bone metastases will go away and new symptoms are not likely to develop soon.

Systemic Therapy

This section begins with a summary of the types of systemic treatments used for patients with metastatic cancers. For more detailed information about treating metastatic cancer that has spread from a specific type of primary cancer, please refer to our information on each cancer type. The information on metastatic cancer will be included in the sections on treatment of advanced cancer, stage IV cancer, or recurrent cancer. The second part of this section contains information that focuses specifically on treating bone metastases.

Chemotherapy: Chemotherapy uses anti-cancer drugs that are usually injected into a vein or taken by mouth. These drugs enter the bloodstream and can reach cancer that has spread. Chemotherapy is used as the main treatment for some metastatic cancers such as lymphomas and germ cell tumors of the ovaries, testicles, or placenta. In many cancers, chemotherapy can shrink tumors. This generally makes you feel better and reduces any pain you might have.

Chemotherapy drugs kill cancer cells but also damage some normal cells. Therefore, careful attention must be given to avoiding or reducing side effects. These depend on the type of drugs, the amount taken, and the length of treatment. Temporary side effects might include nausea and vomiting, loss of appetite, loss of hair, and mouth sores. Because chemotherapy can damage the blood-producing cells of your bone marrow, you may have low blood cell counts. Low blood cell counts can result in:

• an increased chance of infection (caused by a shortage of white blood cells);
• increased bleeding or bruising after minor cuts or injuries (caused by a shortage of blood platelets); and
• fatigue (caused by low red blood cell counts).

Most side effects go away once treatment is stopped. There are remedies to prevent or control many of the temporary side effects of chemotherapy. For example, drugs can prevent or reduce nausea and vomiting (these are called anti-emetic drugs).

For more information on chemotherapy, see Understanding Chemotherapy: A Guide for Patients and Families.

Hormone therapy: Estrogen, a hormone produced by the ovaries, promotes growth of some breast cancers, particularly those cancers where tests can detect estrogen receptors. Likewise, androgens, such as testosterone (produced by the testicles) promote growth of most prostate cancers. One of the main ways to treat breast and prostate cancer is to block these hormones. There are several types of hormone-blocking therapies.

One strategy is to remove the organs that produce hormones. Removing the ovaries in women with breast cancer or removing the testicles in men with prostate cancer are hormone therapy options. Drugs are another option. Postmenopausal women can be given aromatase inhibitors, which block the small amount of estrogen they normally produce.

More often, drugs can be given to keep hormones from being produced. This is a common approach to hormone therapy for prostate cancer. Other drugs can be given to prevent the hormones from affecting the cancer cells. For example, drugs such as tamoxifen block estrogen’s effects on breast cancers. Men can be given drugs such as luteinizing hormone-releasing hormone (LHRH), which block testosterone production and anti-androgens, which block the male hormone effects on prostate cancer. Side effects depend on the type of hormone treatments used. Use of tamoxifen, for example, may result in hot flashes, blood clots, loss of sex drive, and increased risk of uterine cancer.

Immunotherapy: Immunotherapy is a systemic therapy that helps a patient's immune system recognize and destroy cancer cells more effectively. Several types of immunotherapy are used to treat patients with metastatic cancer, including cytokines, monoclonal antibodies, and tumor vaccines. Most of these are still experimental.

These treatments are discussed in detail in American Cancer Society documents on immunotherapy and the specific types of cancer for which this approach is useful. For more information on immunotherapy, please see please see the American Cancer Society document, Immunotherapy.

Radiopharmaceuticals: Radiopharmaceuticals are a group of drugs that have radioactive elements. They are injected into a vein and settle in areas of bone that contain cancer. The radiation they give off kills the cancer cells and relieves some of the pain caused by bone metastases. Some of the radiopharmaceuticals that are most often used are strontium-89 (Metastron) and samarium-153 (Quadramet). Other radiopharmaceuticals, such as rhenium-186, rhenium-188, and tin- 17, are also being studied.

Radiopharmaceuticals are not used to treat early stage, localized cancer (cancer that has not spread) or for metastases to other organs of the body. They are only used for cancer that has spread from another site to the bone.

If cancer has spread to many bones, radiopharmaceuticals are much better than trying to aim external beam radiation at each affected bone. In some cases, radiopharmaceuticals may be combined with external beam radiation aimed at the most painful bone metastases (see section on Radiation Therapy ). Radiopharmaceuticals have the advantage over external beam radiation of being given in a single dose. This single treatment can reduce the pain for as long as 1 year. Re-treatment is possible when the pain returns, although usually the pain is not reduced for as long as it was with the first treatment.

These drugs work best when the metastases are osteoblastic. Osteoblastic means the cancer has stimulated the bone cells (osteoblasts) to form new areas of bone. These areas appear dense (white) on x-rays (as opposed to osteolytic lesions, which appear as dark areas or holes in the bones). Osteoblastic metastases occur most frequently in prostate cancer that has spread to bone. They are found less often in breast cancer that has spread to bone and even less often in most other cancers.

The major side effect of this treatment is a lowering of blood cell counts (white cells and platelets), which could place you at increased risk for infections or bleeding, especially if your counts are already low. Another possible side effect is a so-called flare reaction, in which the pain gets worse for a brief time before getting better.

Local Therapy

Radiation therapy: Radiation therapy uses high-energy rays or particles to destroy cancer cells or slow their rate of growth. Radiation therapy can be used to cure primary cancers that have not spread too far from their original site. When a cancer has metastasized to bones, radiation is used to relieve (palliate) symptoms. Radiation may prevent fractures once the bone has healed. If there is an impending risk of a bone fracture, radiation will not prevent it. Instead the bone must be stabilized with surgery (see below). If the bone is treated before it gets too weak, radiation therapy may help prevent later fractures.

The most common way to deliver radiation to a bone metastasis is to carefully focus a beam of radiation from a machine outside the body. This is known as external beam radiation. To reduce the risk of side effects, doctors carefully figure out the exact dose and aim the beam as accurately as they can to hit the target.

External beam radiation therapy: External beam radiation therapy for bone metastasis can be given as a large dose at one time, or in smaller amounts over 5 to 10 treatments. Most radiation oncologists (doctors who specialize in radiation therapy) prefer to give the radiation over several treatments. Both provide the same benefit in pain reduction and, when asked, most patients prefer the single-dose treatment. The advantage of the one-dose treatment is fewer trips for therapy and lower costs. The advantage of more treatments is that it reduces the number of patients who need re-treatment (because the pain has come back) from about 18% to around 9%.

Each external beam radiation treatment lasts only a few minutes. External beam radiation is an excellent option if you have 1 or 2 metastases that are causing symptoms. But if there are many metastases scattered throughout the body, treatment is more difficult. In rare cases, some patients can benefit from radiation therapy to either the entire upper or lower half of the body. A few weeks later, the other half of the body can be treated.

Although it is rarely used to treat bone metastases, another method of delivering radiation is to place (implant) metal rods or tiny pellets (sometimes called seeds) that contain radioactive materials in or near the cancer. This method is called internal radiation, interstitial radiation, or brachytherapy.

For more information on radiation therapy, please see the American Cancer Society document Understanding Radiation Therapy: A Guide for Patients and Families.

Radiofrequency ablation: Radiofrequency ablation involves use of a needle that carries electric current. The needle is placed into a particularly painful tumor that hasn’t improved with radiation therapy. The electric current that destroys the tumor and relieves pain is delivered through the needle. This is usually done while the patient is under anesthesia.

Surgery

Although surgery to remove a primary bone tumor (one that started in the bone) is often done with the intent to cure, the purpose of surgically treating bone metastasis is to relieve symptoms. Bone metastases can weaken bones, leading to breaks that tend to heal very poorly. An operation using a metal rod or external device to stabilize the bone can prevent some fractures and, if the bone is already broken, can rapidly relieve pain and help the patient return to usual activities.

If you can’t have surgery to reinforce a bone affected by metastasis (because of poor general state of health, other complications of the cancers, or side effects of other treatments), a cast may help stabilize leg bones to reduce pain and avoid the need to stay in bed.

Sometimes the cancer will spread to a bone in the spine. The cancer can grow enough to press against the spinal cord, causing spinal cord compression. If not treated immediately, this can lead to paralysis. Surgery can relieve the pressure on the spinal cord and prevent paralysis as well as help relieve the pain. Radiation therapy is another option. A recent study has found that surgery followed by radiation may be the best treatment.

Pain Medications for Bone Metastasis

There are effective and safe ways to treat pain caused by bone metastasis. In some cases, this may include treatments that kill the cancer cells (chemotherapy or radiation therapy), slow their growth (hormonal therapy), or reduce bone damage (bisphosphonates). If the treatment does not relieve your pain, you should not hesitate to ask for pain medicines.

You may not want to ask for or accept pain medicines such as opioids (morphine-like pain medicines) because you think you will become addicted or that the medicines will make you too sleepy to continue your usual activities. In reality, addiction rarely occurs, drowsiness can be controlled, and being free of pain can help you concentrate on the activities that are important to you.

If you are in pain and have been given prescription pain medicines, you should take them on a regular schedule. It works better to prevent the pain than to treat it once it starts. For more information on management of pain, please see Pain Control: A Guide for People With Cancer and Their Families.

Bisphosphonates: Bisphosphonates are a group of drugs routinely used to treat osteoporosis, a condition that weakens the bones. They have also proven useful in treating patients with cancer that has spread to the bones. Drugs in this category include alendronate, clodronate, etidronate, ibandronate, zoledronate, and pamidronate. Bisphosphonates are also used to treat patients with multiple myeloma, a cancer that starts in the bone marrow.

Bisphosphonates help reduce bone pain, slow down bone damage caused by the cancer, reduce high blood calcium levels (hypercalcemia), and lower the risk of broken bones. They are more effective when x-rays show the metastatic cancer is causing the bone to become thinner and weaker (osteolytic metastases). They are less effective in treating osteoblastic metastases (sclerosis).

Bisphosphonates may be taken by mouth or given through a vein. Because the digestive system does not absorb these drugs very well, and because they can cause irritation and ulcers in the esophagus, bisphosphonate treatment for bone metastasis usually is given intravenously, every 3 to 4 weeks. The most commonly used drug is zoledronate (Zometa^®). However ibandronate, which can also be given intravenously, may be as effective. Pamidronate is also commonly used used to treat bone metastases. Zoledronate has an advantage over pamidronate because it takes less time to inject. Studies have also suggested that zoledronate may reduce the risk of fracture somewhat better than pamidronate.

Clinical studies have reported the most common side effects of bisphosphonates to be fatigue, fever, nausea, vomiting, anemia (low red blood cell counts), and bone or joint pain. But the cancer or other drugs that the patients were taking may have caused many of these effects. Bisphosphonates may also cause arthritis-like joint pain and muscle pain. These can often be relieved or prevented with a mild pain reliever.

Recently, doctors have been reporting a very distressing side effect of damage to the jaw bones in patients receiving bisphosphonates. This side effect is called osteonecrosis. Patients complain of pain in the jaw, and examining doctors find that part of the bone of the upper or lower jaw has died. This can lead to loss of teeth in that area. Infections of the jaw bone may also develop. Doctors don’t know why this happens or how to prevent it. So far, the only treatment has been to stop the bisphosphonate treatment and try to surgically remove the damaged bone. The only factor that doctors have found that increases the risk of this problem is having jaw surgery or having a tooth removed. Such procedures should be avoided while taking these drugs.

One way to avoid these dental procedures is to maintain good oral hygiene by flossing, brushing, making sure that dentures fit properly, and having regular dental checkups. Any tooth or gum infections should be treated promptly. Dental fillings, root canal procedures, and tooth crowns do not seem to lead to osteonecrosis. Some oncologists recommend that patients have a dental checkup and have any tooth or jaw problems treated before they start taking bisphosphonates.