Finding Bone Metastases

Signs and symptoms of bone metastasis

Many of the symptoms listed here can also be caused by something other than the spread of cancer to the bones. Still, it’s very important for you to tell your cancer care team about any new symptoms you have. Finding and treating bone metastases early can help prevent problems later on.

Pain

Bone pain is often the first symptom of cancer that has spread to the bone. The pain may come and go at first. It tends to be worse at night and may get better with movement. Later on, it can become constant and may be worse during activity.

It’s important to tell your cancer care team about any new pain right away. If it’s coming from a bone, the bone might be so weakened that it will break. This can often be prevented if the bone metastasis is found early.

Fractures

Bones weakened from metastatic cancer can break or fracture. The fracture might happen with a fall or injury, but a weak bone can also break during everyday activities. These fractures often cause sudden, severe pain. The pain may keep you from moving.

The most common fractures are in the long bones of the arms and legs and the bones of the spine. Sudden pain in the middle of the back, for instance, is a common symptom of a bone in the spine breaking and collapsing from cancer.

Spinal cord compression

Cancer growth in the bones of the spine can press on the spinal cord. This is called spinal cord compression and is very serious. The spinal cord has nerves that allow you to move and feel what happens to your body. Some of these nerves also control other functions such as bowel and bladder control.

One of the very earliest symptoms of spinal cord compression is pain in the back or neck. Pressure on the spinal cord can also damage the nerves in the spinal cord, leading to symptoms like numbness and weakness in the area of the body below the tumor.

If a spinal cord compression isn’t treated right away, the person can become paralyzed. Most often this affects the legs (so that the person can’t walk) but if the tumor is pressing on the spinal cord in the neck, both the arms and the legs can be affected.

Sometimes the first symptom you may have of spinal cord pressure is trouble urinating because nerves from the spinal cord control the bladder. You may also feel more constipated (because nerves from the spine help you move your bowels).

High blood calcium levels

When cancer spreads to the bones, calcium from the bones can be released into the bloodstream. This can lead to high levels of calcium in the blood called hypercalcemia. This can cause problems such as constipation, nausea, loss of appetite, and extreme thirst. The high calcium also causes you to make more urine, leading to dehydration. It can make you feel very tired and weak, too. You may be sleepy or even confused. If hypercalcemia is not treated, you can even go into a coma.

Tests to find bone metastases

Bone metastases are sometimes found because they cause problems, but in some cases, they’re found before you have any symptoms. Lab tests and imaging tests (like x-rays or bone scans) are often used to see if and/or how far the cancer has spread. These tests may show bone metastases.

Imaging tests

Imaging tests create pictures of the inside of your body. They may be done before, during, and after cancer treatment for a number of reasons, including to help find out if cancer has spread (to the bones or any other part of the body).

X-rays

X-rays are often the first tests done if a person with cancer is having bone pain or other symptoms.

In osteolytic or lytic metastases, the cancer cells dissolve the bone, making part of it less dense. If the cancer has destroyed enough of the bone, these changes look like a darker hole in the gray-white bone seen on the x-ray.

Osteoblastic or blastic metastases cause an area of the bone to look denser or sclerotic. On x-rays, these changes show up as spots that are whiter than the bone around them.

Often, bone metastases have both lytic and blastic features.

X-rays can also show fractures (breaks) in bones that have been weakened by metastases.

Other imaging tests

Some of the other imaging tests that might be used include:

  • Bone scan
  • CT (computed tomography) scan
  • MRI (magnetic resonance imaging)
  • PET (positron emission tomography) scan

Many of the tests used to find bone metastases may have also been done when you were first diagnosed with cancer. You can learn more about these and other imaging tests your provider may want you to have in Imaging Tests.

Blood tests

When cancer spreads to the bones, certain substances that can be found by routine lab tests might be released into the blood. For example:

  • Calcium: Bone metastases can dissolve the bones, leading to a high blood calcium level (called hypercalcemia). Problems other than bone metastases can cause high calcium levels, but if a person with cancer has a high blood calcium level, tests are often done to look for bone metastases. 
  • Alkaline phosphatase: When the bones dissolve, the levels of alkaline phosphatase or ALP may increase. Alkaline phosphatase is also made by the liver, so high ALP levels can mean liver problems. (They don’t always mean bone metastases.)

Urine tests

Several substances can be released into urine when bone is damaged. One substance that can be measured is called N-telopeptide.

Biopsies used to find bone metastases

In most cases, cancer is diagnosed by removing a small piece of body tissue and looking at it under a microscope. This procedure is called a biopsy.

If you’ve been diagnosed with cancer or have had cancer in the past, your doctor may be able to tell if you have bone metastasis based on the results of imaging tests such as a bone scan.

If any of your blood test results also suggest bone metastasis, this makes the diagnosis even more certain. In this case, your doctor might not need to do a biopsy. But if it’s not clear from tests if the cancer has spread to the bones, your doctor might take a sample from the changed bone to find out if it’s cancer.

CT scans may be used to guide a biopsy needle into a suspected area of bone metastasis deep in the body. You stay on the CT scanning table while a doctor guides the needle through your skin and toward the changed area. CT scans are repeated until the needle has reached the right place. A tiny piece of tissue is then taken out and checked in the lab to see if there are cancer cells in it.

What should you ask your doctor about bone metastasis?

It’s important to have open and honest talks with your doctor. Your doctor and the rest of your cancer care team want to answer all of your questions and help you make decisions that are best for you. It may help to have a family member and or a friend with you during these talks. Take notes or ask if you can record the conversation.

Here are some questions you might want to ask:

  • How do you know that this is the same cancer I had before and not a new cancer?
  • Which bones has the cancer spread to?
  • Which treatments do you recommend, and why?
  • What’s the goal of treatment? To cure the cancer? Help me live longer? Relieve or prevent some of the symptoms of the cancer?
  • What are my chances of treatment working?
  • Are there any problems I might notice that you need to know about right away?
  • How would treatment affect my daily activities?
  • What treatment options do I have for relieving bone pain or other symptoms?
  • What can I do to help prevent broken bones?
  • What would we do if a bone breaks?
  • Are there clinical trials that may be right for me?
  • Will my insurance cover treatment? How much will I have to pay?
  • What will happen next?
  • How do I get help after hours or on weekends?

The American Cancer Society medical and editorial content team
Our team is made up of doctors and master’s-prepared nurses with deep knowledge of cancer care as well as journalists, editors, and translators with extensive experience in medical writing.

Chow E, Finkelstein JA, Sahgal A, Coleman RE. Metastatic cancer to the bone. In: DeVita VT, Lawrence TS, Rosenberg SA, eds. DeVita, Hellman, and Rosenberg’s Cancer: Principles & Practice of Oncology. 9th ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2011: 2192-2204.

Coleman RE, Holen I. Bone metastasis. In: Niederhuber JE, Armitage JO, Doroshow JH, Kastan MB, Tepper JE, eds. Abeloff’s Clinical Oncology. 5th ed. Philadelphia, Pa: Elsevier; 2014: 739-763.

Oliver TB, Bhat R, Kellett CF, Adamson DJ. Diagnosis and management of bone metastases. J R Coll Physicians Edinb. 2011;41(4):330-8.

Last Medical Review: December 15, 2016 Last Revised: December 15, 2016

American Cancer Society medical information is copyrighted material. For reprint requests, please see our Content Usage Policy.