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If prostate cancer spreads to other parts of the body, it nearly always goes to the bones first. Bone metastasis can be painful and can cause other problems, such as fractures (breaks), spinal cord compression (an area of cancer is pressing on the spinal cord), or high blood calcium levels, which can be dangerous or even life threatening.
If the cancer has grown outside the prostate, preventing or slowing the spread of the cancer to the bones is a major goal of treatment. If the cancer has already reached the bones, controlling or relieving pain and other complications is also a very important part of treatment.
Bisphosphonates are drugs that work by slowing down bone cells called osteoclasts. These cells normally break down the hard mineral structure of bones to help keep them healthy. Osteoclasts often become overactive when prostate cancer spreads to the bones, which can cause problems. Bisphosphonates can be used:
Zoledronic acid (Zometa) is a commonly used bisphosphonate for prostate cancer. This drug is given as an intravenous (IV) injection, usually either once every 3 or 4 weeks, or once every 12 weeks. Men given this drug are advised to take a supplement containing calcium and vitamin D to prevent problems with low calcium levels.
Sometimes other bisphosphonates are used to treat prostate cancer that has spread to bone.
Bisphosphonates can have side effects, including flu-like symptoms and bone or joint pain. They can also cause kidney problems, so patients with poor kidney function might not be able to be treated with these medicines.
A rare but very serious side effect of these drugs is osteonecrosis of the jaw (ONJ). With this condition, part of the jaw bone loses its blood supply and dies. This can lead to tooth loss and infections of the jaw bone that are hard to treat. Some people develop ONJ when dental work is done during treatment. Many times men are advised to have a dental checkup 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 checkups may also help prevent ONJ.
Denosumab (Xgeva) is another drug that can help when prostate cancer spreads to bone. Like the bisphosphonates, denosumab also blocks osteoclasts, but it does so in a different way. This drug can be used:
This drug is injected under the skin every 4 weeks. Men given this drug are often advised to take a supplement containing calcium and vitamin D to prevent problems with low calcium levels.
Common side effects include nausea, diarrhea, and feeling weak or tired. Like the bisphosphonates, denosumab can also cause ONJ, so doctors recommend taking the same precautions (such as having teeth and jaw problems treated before starting the drug).
Some studies suggest that corticosteroid drugs (such as prednisone and dexamethasone) can help relieve bone pain in some men. They also can help lower PSA levels. These drugs are often already a part of prostate cancer treatment that has spread.
Radiation therapy can help reduce bone pain, especially if the pain is limited to one or only a few areas of bone. Radiation can be aimed at tumors on the spine, which can help relieve pressure on the spinal cord in some cases, and prevent paralysis. Radiation therapy may also help relieve other symptoms by shrinking tumors in other parts of the body.
Radiopharmaceuticals are drugs that contain radioactive elements. They are injected into a vein and settle in areas of damaged bones (like those containing cancer spread). Once there, they give off radiation that kills cancer cells. These drugs can be used to treat prostate cancer that has spread to many bones. Unlike external beam radiation, these drugs can reach all the affected bones at the same time.
The radiopharmaceuticals that can be used to treat prostate cancer spread to bone include:
All of these drugs can help relieve pain caused by bone metastases. Radium-223 has also been shown to help men who have prostate cancer spread only to their bones (as opposed to spread to other organs such as the lungs) to live longer. For these men, radium-223 may be an early part of treatment.
The major side effect of these drugs is a decrease in blood cell counts, which could increase risks for infections or bleeding, especially if your counts are already low. Other side effects have also been seen, so ask your doctor what you can expect.
Kyphoplasty is a minor surgery to stabilize a painful collapsed bone in a spine weakened by prostate cancer. During this procedure a small incision is made in the middle of the back and a balloon is placed into the weak spinal bone. The balloon is first filled with air and then a cement-like mixture (which will harden) to stabilize the bone and spine.
When properly prescribed, pain medicines are very effective. Pain medicines work best when they’re taken on a regular schedule. They don’t work as well if they’re only used when the pain becomes severe.
If you have bone pain from prostate cancer, it’s very important that it's treated. This can help you feel better and let you focus on the things that are most important to you. Don’t hesitate to discuss pain, other symptoms, or any quality of life concerns with your cancer care team. Pain and most other symptoms of prostate cancer can often be treated.
To learn more about pain, how to talk to your cancer care team about it, and the different ways to manage it, see Cancer Pain.
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National Cancer Institute. Physician Data Query (PDQ). Prostate Cancer Treatment – Health Professional Version. 2019. Accessed at https://www.cancer.gov/types/prostate/hp/prostate-treatment-pdq. On April 9, 2019.
National Comprehensive Cancer Network (NCCN). Practice Guidelines in Oncology: Prostate Cancer. Version 1.2019. Accessed at https://www.nccn.org/professionals/physician_gls/pdf/prostate.pdf on April 9, 2019.
Nelson WG, Antonarakis ES, Carter HB, DeMarzo AM, DeWeese TL, et al. Chapter 81: Prostate Cancer. In: Niederhuber JE, Armitage JO, Doroshow JH, Kastan MB, Tepper JE, eds. Abeloff’s Clinical Oncology. 6th ed. Philadelphia, Pa: Elsevier; 2020.
Sartor AO and DiBiase. Bone metastases in advanced prostate cancer: Management. UpToDate website. https://www.uptodate.com/contents/bone-metastases-in-advanced-prostate-cancer-management. Updated March 28, 2019. Accessed April 5, 2019.
Smith MR, Saad F, Coleman R, Shore N, Fizazi K, Tombal B, et al. Denosumab and bone-metastasis-free survival in men with castration-resistant prostate cancer: results of a phase 3, randomised, placebo-controlled trial. Lancet. 2012;379:39-46.
Zelefsky MJ, Morris MJ, and Eastham JA. Chapter 70: Cancer of the Prostate. In: DeVita VT, Lawrence TS, Rosenberg SA, eds. DeVita, Hellman, and Rosenberg’s Cancer: Principles and Practice of Oncology. 11th ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2019.
Last Revised: August 1, 2019