Treating Bone Metastases
Treatment options for people with bone metastases depend on many things:
- What kind of primary cancer you have
- Which bones (and how many) the cancer has spread to
- Whether any bones have been weakened or broken
- Which treatments you have already had
- Your symptoms
- Your general state of health
Treatments can often shrink or slow the growth of bone metastases and can help with any symptoms they are causing. But they usually do not make the metastases go away completely.
Systemic (which go through the whole body) and local (treat cancer in the bone) treatments are the 2 main types of treatment for bone metastases. Depending on the extent and location of the cancer, one or both of these types of treatment may be used.
Systemic treatments for bone metastases
Systemic treatments affect the whole body. In many cases, especially if the cancer has spread to many bones, systemic treatments are used because they can reach cancer cells that have spread throughout the body.
Systemic therapies include chemotherapy, hormone therapy, or other medicines that are taken by mouth or injected into the blood. These treatments are not aimed specifically at bone metastases, but they often help treat them. Other systemic treatments, such as radiopharmaceuticals and bisphosphonates, are aimed more specifically at cancer that has reached the bones. Sometimes both of these types of treatments are used at the same time.
Chemotherapy (chemo) uses anti-cancer drugs injected into a vein or taken by mouth. These drugs enter the bloodstream and can reach cancer that has spread. Chemo is used as the main treatment for many types of metastatic cancer. Chemo can often shrink tumors, which can reduce pain and help you feel better, but it doesn’t make them go away and stay away. It’s sometimes used with local treatments such as radiation.
Chemo drugs kill cancer cells but also damage some normal cells, which causes side effects. Side effects depend on the type of drugs, the amount taken, and the length of treatment. Some common chemo side effects include:
- Nausea and vomiting
- Loss of appetite
- Hair loss
- Mouth sores
- Increased chance of infection (from a shortage of white blood cells)
- Bleeding or bruising (from a shortage of platelets)
- Feeling weak, short of breath, or tired (from too few red blood cells)
If you’ll be getting chemo, ask your cancer care team about the drugs being used and what side effects to expect. Most side effects go away once treatment is stopped.
Be sure to tell your doctor or nurse if you do have side effects, as there are often ways to help with them. For example, drugs can be given to prevent or reduce nausea and vomiting.
To learn more about chemo, see the Chemotherapy section of our website.
Hormones in the body drive the growth of some common cancers. For example, the female hormone estrogen promotes growth of some breast and uterus cancers. Likewise, male hormones (androgens such as testosterone) promote growth of most prostate cancers. One of the main ways to treat some of these cancers is to stop certain hormones from affecting the cancer cells. This might be done by lowering hormone levels and/or by blocking the hormone’s action at the cancer cell.
Side effects of hormone treatments depend on the type of treatment used. A common side effect for many of these treatments is hot flashes. Drugs that lower testosterone levels can lead to anemia, weight gain, loss of sex drive, breast development, weak bones, and other effects. Drugs that lower estrogen levels can lead to weak bones and body aches.
Targeted therapy drugs are designed to go after the cancer cells’ inner workings – the programming that sets them apart from normal, healthy cells. These drugs tend to have different side effects from standard chemo drugs.
Targeted therapy can be combined with other treatments, including chemo and hormone therapy. For some types of cancer, like kidney cancer, they are used alone as the main treatment for advanced disease.
To learn more about targeted therapy drugs used for a certain type of cancer, see our information on that type of cancer. General information about targeted therapy and its side effects can be found in Targeted Therapy.
Immunotherapy is a systemic therapy that boosts the body’s immune system or uses man-made versions of immune system proteins to kill cancer cells. Several types of immunotherapy are used to treat patients with metastatic cancer.
For more information about immunotherapy for a certain cancer, see our information on that cancer (such as Prostate Cancer, Melanoma Skin Cancer, or Kidney Cancer). More on how immunotherapy works can be found in Immunotherapy.
Radiopharmaceuticals are a group of drugs that carry radioactive elements. These drugs are injected into a vein and settle in areas of bone with active turnover (like those containing cancer spread). Once there, the radiation they give off kills cancer cells.
If cancer has spread to many bones, radiopharmaceuticals work 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 “Radiation therapy”)
Some of the radiopharmaceuticals approved for use in the United States include:
- Strontium-89 (Metastron®)
- Samarium-153 (Quadramet®)
- Radium-223 (Xofigo®)
Treatment with a radiopharmaceutical can often reduce pain from bone metastases for several months. Re-treatment is possible when the pain returns, although the pain might not be reduced for as long as it was with the first treatment.
These drugs work best when the metastases are blastic, meaning the cancer has stimulated certain bone cells (osteoblasts) to form new areas of bone.
The major side effect of this treatment is lower blood cell counts (mainly white cells and platelets), which could put you at increased risk for infections or bleeding. This is more of a problem if your counts are already low before treatment. Another possible side effect is a so-called “flare reaction,” in which the pain gets worse for a short time before it gets better.
Bisphosphonates (bis-FAHS-fun-ATES) are a group of drugs that may be used to treat cancer that has spread to the bones. These drugs work by slowing down the action of osteoclasts. These bone cells normally dissolve small bits of bones to help remodel them and keep them strong. But osteoclasts are often overactive when cancer spreads to the bones, which can cause problems.
Bisphosphonates can help with cancer that has spread to the bones by:
- Reducing bone pain
- Slowing down bone damage caused by the cancer
- Reducing high blood calcium levels (hypercalcemia)
- Lowering the risk of broken bones
Bisphosphonates tend to work better when x-rays show the metastatic cancer is thinning and weakening the bone (lytic metastases). They don’t work as well for treating blastic metastases, where the bones become denser.
The most common side effects of bisphosphonates are fatigue, fever, nausea, vomiting, anemia (a low red blood cell count), and bone or joint pain. But other drugs or the cancer itself can cause many of these effects, too. These drugs can lower calcium levels, so they can’t be given to someone whose calcium levels are already low. Bisphosphonates can cause kidney damage and often can’t be given to people with poor kidney function.
Medication-related osteonecrosis of the jaw
A rare but very serious side effect of bisphosphonates is osteonecrosis (OS-tee-o-nuh-CROW-sis) of the jaw or ONJ. In ONJ, part of the jaw bone loses its blood supply and dies. This can lead to tooth loss and infections or open sores of the jaw bone that won’t heal and are hard to treat.
ONJ is very hard to treat and prevention is very important. ONJ sometimes seems to be triggered by having a tooth pulled while on a bisphosphonate. Many cancer doctors advise patients to get a dental check-up and have any tooth or jaw problems treated before they start taking a bisphosphonate. Maintaining good oral hygiene by flossing and brushing, making sure that dentures fit properly, and having regular dental check-ups might also help prevent ONJ.
Denosumab is another drug that can help when cancer spreads to bone. Like the bisphosphonates, this drug keeps osteoclasts from being turned on, but it does so in a different way, by blocking a substance called RANKL.
Common side effects include nausea, diarrhea, and feeling weak or tired. Like the bisphosphonates, denosumab can cause osteonecrosis of the jaw (ONJ), so doctors recommend taking the same precautions (such as having tooth and jaw problems treated before starting the drug). Unlike the bisphosphonates, this drug is safe to give to patients with kidney problems.
Local treatments for bone metastases
Local treatments, including radiation therapy, surgery and other techniques, are directed at a single area instead of at the entire body.
Local treatments can be useful if the cancer has spread to only one bone, or if there are areas of cancer spread that are worse than others and need to be treated right away. These treatments can help relieve pain or other symptoms caused by one or a few bone metastases.
Sometimes, local treatments such as surgery are used to stabilize a bone that’s in danger of breaking because it’s been weakened by cancer. It’s much easier to keep a damaged bone from breaking than to try and fix it after it has broken.
External radiation therapy
Radiation therapy uses high-energy rays or particles to destroy cancer cells or slow their growth. When a cancer has spread to a small number of spots in bones, radiation can be used to help relieve symptoms such as pain. If the bone is treated with radiation before it gets too weak, it may also help prevent a later fracture.
The most common way to give radiation for bone metastasis is to focus a beam of radiation from a machine outside the body. This is called external beam radiation. Special types of external beam radiation therapy are able to focus the radiation more precisely to lower some side effects. These include 3D-conformal radiation and intensity modulated radiation therapy. See our radiation therapy information to learn more.
Radiation therapy for bone metastasis can be given as 1 or 2 large doses or in smaller amounts over 5 to 10 treatments that result in a somewhat larger total dose. Both schedules give the same degree of pain relief. The major advantage of the 1- or 2-dose treatment is that fewer trips are needed for treatment. The advantage of more treatments is that patients are less likely to need re-treatment because of the pain coming back.
Stereotactic body radiation therapy (SBRT): This is a special kind of external beam radiation that gives high doses of radiation therapy very precisely. Instead of giving small doses of radiation each day for several weeks, SBRT gives very focused beams of high-dose radiation on one or a few days. Several beams are aimed at the tumor from different angles. To focus the radiation precisely, the person is put in a specially designed body frame for each treatment. Like other forms of external radiation, the treatment itself is painless.
Common side effects of radiation therapy include
- Extreme tiredness (fatigue)
- Loss of appetite
- Skin changes where the radiation passes through, which can range from redness to blistering and peeling
- Low blood counts
Other side effects depend on what area is treated. For example, radiation to the pelvis can lead to diarrhea because the intestines can be affected.
Putting a needle or probe right into a tumor and using heat, cold, or a chemical to destroy it is called ablation. It may be used if only 1 or 2 bone tumors are causing problems.
Radiofrequency ablation (RFA) is a common type. It uses a needle that carries an electric current. The tip of the needle is put into the bone tumor. CT scans may be used to be sure the needle is in the right place. Electric current sent through the needle heats the tumor to destroy it. RFA is usually done while the patient is under general anesthesia (deeply asleep and not able to feel pain).
In another type of ablation, called cryoablation, a very cold probe is put into the tumor to freeze it, killing the cancer cells. Other methods use alcohol to kill the cells or other ways to heat the tumor (such as laser-induced interstitial thermotherapy). After the cancer tissue is destroyed, the space left behind may be filled with bone cement. (See below.)
Another option to strengthen and/or stabilize a bone is to use injections of quick-setting bone cement or glue called PMMA (polymethyl methacrylate).
When PMMA is injected into a spinal bone it’s called vertebroplasty (VUR-tuh-bro-PLASS-tee) or kyphoplasty (KI-foe-PLASS-tee). This helps stabilize the bone and relieves pain in most people. Vertebroplasty often reduces pain right away and can be done in an outpatient setting.
When the bone cement is injected to strengthen bones other than the spine, it’s called cementoplasty (suh-MEN-toe PLASS-tee). Sometimes, it’s used along with surgery, radiation, radiofrequency ablation, or other treatments.
Surgery used to treat a bone metastasis is done to relieve symptoms and/or stabilize the bone to prevent fractures (breaks).
Bone metastases can weaken bones, leading to fractures that tend to heal very poorly. An operation can be done to place screws, rods, pins, plates, cages or other devices to make the bone more stable the bone and help prevent fractures. If the bone is already broken, surgery can often relieve pain quickly and help the patient return to their usual activities.
Sometimes a person can’t have surgery because of poor general health, other complications of the cancer, or side effects of other treatments. If doctors can’t surgically reinforce a bone that has metastasis, a cast or splint may help stabilize it to reduce pain so the person can move around.
Thinking about taking part in a clinical trial
Clinical trials are carefully controlled research studies that are done to get a closer look at promising new treatments or procedures. Clinical trials are one way to get state-of-the art cancer treatment. In some cases, they may be the only way to get access to newer treatments. They are also the best way for doctors to learn better methods to treat cancer. Still, they are not right for everyone.
If you would like to learn more about clinical trials that might be right for you, start by asking your doctor if your clinic or hospital conducts clinical trials. You can also call our clinical trials matching service at 1-800-303-5691 for a list of studies that meet your medical needs, or see Clinical Trials to learn more.
Considering complementary and alternative methods
You may hear about alternative or complementary methods that your doctor hasn’t mentioned to treat your cancer or relieve symptoms. These methods can include vitamins, herbs, and special diets, or other methods such as acupuncture or massage, to name a few.
Complementary methods refer to treatments that are used along with your regular medical care. Alternative treatments are used instead of a doctor’s medical treatment. Although some of these methods might be helpful in relieving symptoms or helping you feel better, many have not been proven to work. Some might even be dangerous.
Be sure to talk to your cancer care team about any method you are thinking about using. They can help you learn what is known (or not known) about the method, which can help you make an informed decision. See Complementary and Alternative Medicine to learn more.
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Last Medical Review: 05/02/2016
Last Revised: 05/02/2016