- Finding Bone Metastases
- Signs and symptoms of bone metastasis
- Tests to find bone metastases
- Biopsies used to find bone metastases
- What should you ask your doctor about bone metastasis?
- Symptoms of Bone Metastasis
- The most common symptom of bone metastasis is pain. Other symptoms are bone fractures, spinal code compression and anemia.
- Bone Fracture
- Spinal Cord Compression
- Other Symptoms
- At the U-M Rogel Cancer Center, treatment of bone metastasis takes place in the clinic where the originating cancer is treated. For example, if prostate cancer has metastasized into the bone, it is treated in the Urologic Oncology Clinic. Call the Cancer AnswerLine at 1-800-865-1125 for help finding the clinic you need. NOTE: Cancers of the spine are treated by our Spine Oncology Program.
- What is bone cancer?
- How do doctors diagnose bone cancer?
- What does bone cancer feel like?
- All About Bone Metastases
- Painful hip fractures strike breast cancer survivors
- What Happens When Metastatic Breast Cancer Spreads to Your Bones
- Signs That Breast Cancer Has Spread to the Bone
- Getting Back on Track: How Bone Metastases Are Treated
- Secondary (metastatic) breast cancer in the bone
- 10. Support for living with secondary breast cancer
- Metastatic breast cancer
- Symptoms of metastatic breast cancer
- Treatment options for metastatic breast cancer
- Supportive care for metastatic breast cancer
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.
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.
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 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 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.
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.)
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?
Symptoms of Bone Metastasis
The most common symptom of bone metastasis is pain. Other symptoms are bone fractures, spinal code compression and anemia.
Pain is usually the first symptom patients notice. It’s most often felt at the site of the metastasis, which is referred to as localized pain. There are also cases where patients experience pain in areas surrounding the metastasis.
Depending upon the location of the metastasis, the pain may vary. Bone metastasis patients often describe the pain as gradually increasing over a period of time and becoming more severe. Patients with metastases to the spinal cord often have pain or discomfort that is worse at night or with bed rest. However, those patients with lesions involving the long bones, such as the arms and legs, have pain with activity or movement. In this case, some relief is usually achieved with rest.
It is important for you to know that not all pain means metastasis. Your doctor may be able to help you to tell the difference between bone metastasis pain and normal aches and pains or pains from other sources. It is important to talk with your doctor about any pain or discomfort that you may be having.
Too much force or stress on a bone will lead to fracture. A fracture is a medical term used to describe a broken or cracked bone. Bone metastases can weaken your bones and put you at risk for fractures. Not all patients will fracture bones, but it is important to be aware of that possibility. Impending fractures describe those bones that are about to break. If found early, your doctor may be able to treat the bone to keep it from breaking.
Bone metastasis patients need to remember that their bones are frailer, and they may need to be more careful when performing daily tasks. Although regular exercise is generally helpful, it is important to ask your doctor if you should change or stop doing certain activities.
Spinal Cord Compression
If the secondary tumor is located in the spinal area, it can result in spinal cord compression. Spinal cord compression occurs when the tumor squeezes the spinal cord. This can lead to back pain or make walking painful and difficult. Other symptoms might include numbness and weakness in the legs, problems with the bowels or bladder, or numbness in the abdominal area.
Patients can experience a number of other symptoms if bone metastases affect the bone marrow, which usually occurs in those who have received extensive chemotherapy or radiation therapy. If your level of red blood cells drops, you might become anemic and have symptoms of fatigue, weakness, and shortness of breath. Patients whose white blood cells are affected may be more likely to have infections, which could cause fevers, chills, fatigue, or pain. Lastly, if your platelet count is low, you may have abnormal bleeding. The symptoms vary depending upon the type of blood cell affected.
Continue learning about bone metastasis:
- What is bone metastasis?
- Bone cancer and other bone disorders
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What is bone cancer?
Cancer can be found in bone for two different reasons. One kind of cancer in bone actually originates in that bone. This is true bone cancer, or primary bone cancer. An example of primary bone cancer is an osteosarcoma. Cancer can also involve bone when it originates in another organ and then spreads to involve bone. This is call metastatic or secondary bone cancer. Common causes of metastatic bone cancer are lung, breast, and prostate cancer. We name the cancer problem by its place of origin. For example, a man with prostate cancer which later spreads into his bones has not developed true “bone cancer.” He now has metastatic prostate cancer in his bones. That is treated differently than metastatic lung cancer in bone.
How do doctors diagnose bone cancer?
Whether the cancer in bone is primary or metastatic, the early symptoms vary from no symptoms at all to severe bone pain. It is very common for cancer in bone to not cause any symptoms. This form of cancer can only be detected using imaging tests, such as X-ray tests, computerized tomography (CT scan), or magnetic resonance imaging (MRI). For some cancers doctors will use a general screening method to search all bones for cancer using X-ray screening or nuclear medicine bone scan to find cancer in bone that is not causing symptoms.
What does bone cancer feel like?
Cancer in bone can cause intermittent or progressively severe localized bone pain where the cancer is in the bone. The bone pain is described as aching, throbbing, stabbing, and excruciating. This can lead to insomnia, loss of appetite, and inability to carry out normal daily activities.
Sometimes cancer in bone weakens the bone to such a degree that it leads to breaking of the bone (bone fracture). This can cause severe bone pain and loss of function of the affected area of the body. Occasionally, bone fracture is the initial symptom of a bone cancer.
The bones are the most common place where metastatic breast cancer cells tend to go. For more than half of women who develop stage IV breast cancer, the bones are the first site of metastasis. Although breast cancer can spread to any bone, the most common sites are the ribs, spine, pelvis, and long bones in the arms and legs.
A sudden, noticeable new pain is the most common symptom of cancer that has spread to the bone. It may come and go at first, but over time it can become constant. It can be hard to tell the difference between bone metastasis pain and pain due to arthritis or an exercise strain. If the pain feels just as bad or even worse when you rest or lie down, that can be a sign of a problem. Don’t wait to get it checked out; if it is bone metastasis, prompt treatment can prevent a fracture down the road. If you develop a skeletal-related event or SRE as a complication of bone metastasis, symptoms can include:
- Sudden severe pain and the inability to move, which can be a sign of fracture.
- Pain in the back or neck; numbness or weakness in an area of the body; or difficulty passing urine or having bowel movements. All can indicate a spinal cord compression, in which a fractured vertebra presses on the nerves in the spinal cord that control various bodily functions.
- Fatigue, weakness, nausea, loss of appetite, and/or dehydration, which all can indicate very high levels of calcium in the blood due to bone breakdown.
To diagnose bone metastasis, your doctor usually will order one or more imaging tests. Examples include:
- bone scan
- CT scan
- PET scan
You can read more about each of these tests in our Screening and Testing section.
Your doctor also might order a blood test to check for high levels of calcium or alkaline phosphatase (ALP), another substance that can be elevated due to bone metastasis.
In some cases, a biopsy is needed to confirm the diagnosis. With the aid of CT scans, your doctor can guide a small needle into the suspicious area and remove a sample of tissue to be examined in the lab. If the metastatic breast cancer started as an earlier-stage breast cancer, you can ask whether the cancer cells should be tested for characteristics such as hormone receptors and HER2 receptors in case they are different from the primary breast cancer.
The most common treatments for metastatic breast cancer in any location (bone, brain, lung, or liver) are systemic medications, which treat cancer throughout the entire body. Systemic medications include chemotherapy, hormonal therapy, targeted therapies, and bone-strengthening medication. Often, bone metastases can be stabilized and managed for long periods of time.
Local treatments — therapies directed specifically to the new locations of the breast cancer — aren’t usually the first choice for metastases. Still, local treatments are recommended under certain circumstances. Local treatments include surgery and radiation therapy.
Learn more at Bone Metastasis: Local Treatments.
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Last modified on June 20, 2019 at 11:44 AM
All About Bone Metastases
What are bone metastases?
Bone metastases, also called “bone mets,” occur when cancer cells break off from a primary tumor that is somewhere else in the body. These cells travel through the bloodstream or lymph system to a part of the bone and become metastatic cancer cells. This is different than a primary bone tumor, which starts in the bone. When metastatic cancer cells reach the bones, they release substances that turn on either osteoclasts or osteoblasts. Osteoclasts lead to breakdown of bone without new bone being made, which weakens the bones. Osteoblasts lead to new bone being made without the breakdown of old bone first, which makes the bones abnormally hard.
Let’s use an example to better understand metastases: a lung cancer is first formed in the lung tissue, but tumor cells can break off from the original mass and travel through the bloodstream or lymph system. These cells can make their way to other areas of the body, including the bone. This spreading of the tumor is known as “metastasis.” When a lung cancer metastasizes to the bone, this “bone cancer” is actually made up of lung cancer cells. If a pathologist looked at these cells under a microscope, they would look like lung cancer cells. It is important to understand the difference between primary bone tumors and bone metastases because they are treated differently.
Metastases can occur in any bone in the body, but are most often found in bones near the center of the body. The spine is the most common site of bone metastasis. Other common sites are the pelvis (hip), upper leg bone (femur), upper arm bone (humerus), ribs, and the skull. The lesions are referred to as either osteolytic or osteoblastic lesions, depending on the effect of the cancer cells on the bone.
The cancers most likely to metastasize to the bone are breast, prostate, lung, thyroid, and kidney. More than 2 out of 3 primary breast and prostate cancers metastasize to the bone before any other site. About 1 out of 3 primary lung, thyroid, and kidney cancers will spread to the bones.
Signs, Symptoms, and Diagnosis
The most common signs of bone metastases are pain, fracture (broken bone), spinal cord compression, and a high calcium blood level. Your provider will monitor you closely during treatment of your primary cancer for these signs and symptoms. You should notify your provider if you start to experience any symptoms of bone metastases.
Bone pain is usually the first symptom of bone metastases. The pain usually starts intermittently (comes and goes), is worse at night, and is usually relieved with movement. It may progressively worsen and become constant. There are many medications that can be used to treat the pain.
Bone metastases can weaken bones and even result in fractures (breaks). Fractures that are the result of bone metastases are called “pathologic” fractures. The fractures could be caused by trauma, but if the bone is weak enough, it can break just by doing an everyday activity.
Cancer that has spread to the spine can cause pressure on the spinal cord, which is called spinal cord compression. Signs of spinal cord compression include new or worsening pain in the back or neck, numbness and weakness in the body below the tumor and difficulty walking. Spinal cord compression can lead to nerve damage and even paralysis if not treated promptly.
Some bone metastases can cause calcium to leak from the bones into the bloodstream. This can lead to high calcium levels (hypercalcemia) in the blood. Hypercalcemia can cause constipation, nausea, loss of appetite, extreme thirst, frequent urination, dehydration, fatigue, and in very serious cases confusion and even coma.
Imaging studies such as a bone scan, x-rays, CT scan, PET, or MRI, may be used to diagnose bone metastases, depending on the particular situation. You may also have blood tests drawn to check your calcium level or to check for tumor markers. A high calcium level or an elevated tumor marker level may indicate that cancer has spread to the bones. If there is a bone lesion found but it is unclear what it is, your provider may suggest a biopsy. A biopsy is a procedure that removes parts of a tumor or areas of bone that may be affected by cancer cells. A pathologist then views this sample under a microscope to determine what type of cells make up the tumor. The type of biopsy used depends on where the tumor is located.
Treating bone metastases is important because treatment can improve symptoms and quality of life. Treatment options depend on the type of cancer, the location and extent of the metastases, and the patient’s overall health. Most providers believe the most important treatment for bone metastases is treatment directed against the primary cancer (the original cancer).
The two general types of treatment for bone metastasis are systemic (affecting your whole body) or local (treatment is directed at a specific area). Systemic therapies enter the bloodstream, either through a pill taken by mouth or a medication injected directly into a vein (IV, intravenously), and can reach cancer cells that have spread throughout the body. The treatments directed at only the metastases are called local treatments. Each therapy may be given alone or may be given in combination with another therapy depending on the situation. Each therapy is detailed below:
Medical therapies, including chemotherapy, targeted therapy, immunotherapy, and hormone therapy, are known as systemic therapies because they can travel throughout the body to kill cancer cells. Because metastatic cancer cells have broken off from the original tumor and are somewhere else inside the body, chemotherapy has a chance of reaching them and killing them.
A group of medications called bisphosphonates can help make diseased bones stronger and can help prevent fractures. Bisphosphonates may be used along with other therapies for bone metastasis. This class of medication is often prescribed as treatment for osteoporosis (a form of bone thinning not related to cancer). Bisphosphonates can help bones affected by cancer by allowing them to hold on to calcium, making them stronger. This slows down bone damage caused by the cancer, reduces high blood calcium levels (hypercalcemia), and decreases the risk of fracture. Bisphosphonates are more effective for lytic (weakening) than blastic (thickening/hardening) types of metastases. The bisphosphonates used as treatment for bone metastasis are given intravenously. The most commonly used bisphosphonates are zoledronate (Zometa®) and pamidronate (Aredia®). Possible side effects include tiredness, nausea, vomiting, lack of appetite, low blood calcium levels, and a rare side effect called osteonecrosis of the jaw (ONJ).
The medication denosumab (Xgeva®) may be used to prevent further bone damage from cancer cells. This medication works a little differently – it is a type of targeted therapy (monoclonal antibody). It works by targeting a specific protein that is necessary for bone destruction to occur. By targeting this protein, called RANKL, denosumab inhibits the breakdown of bone and, in turn, reduces the chance of developing a fracture in the affected bone. This medication has side effects similar to the bisphosphonates, though it has a higher likelihood of causing low blood calcium, so patients are asked to take calcium and vitamin D supplements while on this treatment.
Another form of systemic treatment is radionuclide therapy. A radionuclide is an element that is radioactive. The medication is given intravenously (IV, into a vein) and deposits itself into the areas of bone that contain cancer. The radiation is given off over a period of time, killing the cancer cells and alleviating pain. The treatment is given once, but the effect can last for several months. Samarium and strontium are the most used radionuclides for bone metastases, but radium may also be used.
Radionuclides are more effective for “blastic” metastases, those that stimulate bone growth. Prostate cancer metastases are often blastic. Most metastases from other types of cancers are “lytic,” meaning they break down bone. These are not treated with radionuclides. This treatment can initially cause pain to get worse before it gets better. A main side effect is low blood counts, so it is used with caution in people with low counts. In addition, your care team will provide education about necessary precautions for your family members because the radiation is present for days to weeks.
Radiation therapy is the use of high energy x-rays that are delivered to the areas of metastases. These x-rays are similar to those used for diagnostic x-rays, but they are of a much higher energy. The high energy of x-rays in radiation therapy results in damage to the DNA of cells. Cancer cells divide faster than healthy cells, so their DNA is more likely to be damaged than that of normal cells. Additionally, cancer cells have a harder time repairing damaged DNA compared to normal cells, so cancer cells are killed more easily by radiation. Radiation therapy exploits this difference to treat cancers by killing cancer cells while killing fewer cells in normal, healthy tissue.
Radiation is frequently offered when patients have bone pain from a metastasis that is not relieved with pain medication. The goal of the treatment is to reduce pain. Most patients will experience at least partial improvements in their pain quite quickly; however, it can be a few weeks after treatment before maximum pain relief is achieved.
Ablation is a technique in which a needle is placed directly into the tumor. This needle is used to introduce heat, cold, or a chemical into the tumor to destroy cancer cells. The two commonly used types of ablation are radiofrequency ablation and cryoablation. Radiofrequency ablation introduces an electric current into the tumor which produces heat to destroy the tumor. This is typically done under general anesthesia. Cryoablation freezes the tumor and kills cancer cells.
In some cases, and after some treatments, a bone may need to be strengthened or stabilized. This can be done using a quick-setting cement or glue. A procedure called kyphoplasty or vertebroplasty is used to treat fractures of the spine. This involves the injection of cement to stabilize the bone. These can be used alone to stabilize a bone and manage pain or can be used with other treatments such as radiation or radiofrequency ablation.
Surgery can be used to relieve symptoms, such as pain, and to stabilize the bone or bones. Surgical rods, screws, pins, plates, and cages can be used to stabilize bones and prevent or treat fractured bones.
Clinical trials are designed to determine the value of specific treatments. Trials are often designed to treat a certain stage of cancer, either as the first form of treatment offered, or as an option for treatment after other treatments have failed to work. They can be used to evaluate medications or treatments to prevent cancer, detect it earlier, or help manage side effects. Clinical trials are extremely important in furthering our knowledge of this disease. It is through clinical trials that we know what we do today, and many exciting new therapies are currently being tested. Talk to your provider about participating in clinical trials in your area. You can also explore currently open clinical trials using the OncoLink Clinical Trials Matching Service.
Resources For More Information
American Cancer Society
Provides information and resources for patients and caregivers.
Painful hip fractures strike breast cancer survivors
Results of the study are published in the February 2011 issue of Clinical Cancer Research.
Hip fractures are rare in people under 70. Yet, Northwestern Medicine physician Beatrice Edwards, M.D., found that several breast cancer survivors in their early 50s were coming to her for treatment of hip fractures.
Edwards is director of the Bone Health and Osteoporosis program and associate professor of medicine and of orthopaedic surgery at Northwestern University Feinberg School of Medicine. She also is a physician at Northwestern Memorial Hospital and a member of the Robert H. Lurie Comprehensive Cancer Center of Northwestern University.
Researchers studied six of these women over one year and assessed the type of breast cancer they had, the treatment they underwent and a hip fracture’s effect on quality of life, said Edwards, lead author of the study.
“One year after the fracture the women still reported difficulty with climbing stairs, shopping and heavy housekeeping,” Edwards said. “Their health care costs may increase and their fractures contribute to losing some independence.”
Edwards was surprised to find that the majority of the women did not have osteoporosis, but did have lower than normal bone mineral density (osteopenia). This suggests that rapid change in bone architecture from chemotherapy, early menopause and adjuvant therapy may not be evident on bone mineral density test, Edwards said.
The women had early-stage breast cancer and received treatment including lumpectomy, radiation therapy and chemotherapy with cytoxan and adriamycin one to four years before the fracture occurred. They were all perimenopausal at the time of the fracture.
Four of the six women had breast cancer that grew in response to estrogen and received aromatase inhibitors (AIs) as part of their cancer therapy to block their bodies from making estrogen. Recent studies have linked AIs with possible bone loss in women.
Edwards’ team also reviewed reports from the FDA’s adverse event reporting system and other databases and found that AIs were the most common drug class associated with hip fractures.
“Although the majority of women with breast cancer can expect to be fully cured from the disease, the prevention of cancer treatment-induced bone loss is important to consider in cancer survival,” Edwards said. “More research needs to be done before treatment guidelines are changed, but greater awareness of the adverse effects of certain breast cancer drugs is needed.”
Edwards said the next step is for researchers to conduct a clinical trial and give bone density screenings to women before they enter breast cancer chemotherapy. High-risk patients would be flagged and given preventive bone loss therapy and monitored for premature hip fractures.
“The pain and suffering and hospital stays and higher health costs associated with these hip fractures might be prevented through early intervention,” Edwards said.
What Happens When Metastatic Breast Cancer Spreads to Your Bones
When breast cancer spreads beyond the breast, one of the most common places it goes is the bones (it may also spread to the lungs, liver, or brain). Bone metastases, also known as “bone mets,” occur in roughly 70 percent of women with metastatic breast cancer and are often the first sign that the cancer has returned, says Alissa Huston Porter, MD, a breast cancer oncologist and associate professor of medicine at the James P. Wilmot Cancer Institute at the University of Rochester. While breast cancer can metastasize to any bone in the body, it most commonly spreads to the spine, pelvis, ribs, and long bones of the arms and legs (humerus and femur).
Typically, bone pain is the first sign that cancer has spread to the bone. In some cases, however, bone metastases cause little or no symptoms, and it takes a routine scan or fracture from a minor fall or injury to uncover the bone cancer. “A fracture is one of the worst case scenarios, and one we try to avoid,” says Dr. Huston.
While these secondary cancers in the bone are difficult to cure, many new and advanced treatments are available to lessen the symptoms and lengthen a person’s life. What’s more, finding and treating bone metastases early on can be critical in preventing problems later.
Signs That Breast Cancer Has Spread to the Bone
“Most aches and pains aren’t cancer,” stresses Huston. “But it’s important to keep an open and honest dialogue with your doctor about any unusual or persistent discomfort you may be having. He or she can determine if getting images is appropriate to rule out bone metastasis.” Here are the symptoms of bone metastasis to look out for:
- Bone pain Pain is the most common symptom of bone metastasis. The pain may come and go at first, be worse at night, and feel better with movement. Later on, it may become constant and worsen during physical activity, according to the American Cancer Society (ACS). It’s important to tell your cancer care team about any new, unexplained pain that doesn’t resolve with rest, says Huston. If the pain is due to a tumor in the bone, that bone may be weak and at risk of fracture, which can be prevented if the metastasis is found and treated early.
- Broken bones Because metastases can eat away areas of bone or stimulate abnormal bone growth, they can cause the bones to be weak and unstable, making them more likely to fracture. The most common sites of fracture are the spine and the long bones of the arms and legs, notes Huston. A fracture can happen from a fall, trauma, or, if a bone is significantly weakened, everyday activities. Alert your doctor immediately if you experience sudden, severe bone pain, as this can be a sign of a fracture.
- Spinal cord compression When cancer spreads to the bones of the spine, it can squeeze or press on the spinal cord. This can cause weakness in the legs, numbness in the belly or legs (or elsewhere in the body), difficulty urinating, and constipation, says Huston. If you have any of these symptoms, you should tell a doctor or nurse right away. Left untreated, spinal cord compression can lead to paralysis.
- Extreme thirst, loss of appetite, and sluggishness These are signs of hypercalcemia, or high levels of calcium in the blood, cautions the ACS. Bone metastases can cause a release of calcium into the bloodstream that, if left untreated, can lead to coma. If you experience these symptoms, alert your medical team right away.
If you report any of the above symptoms to your doctor, he or she may want to do a thorough physical exam, blood tests, and a bone scan to check for bone metastasis. Depending on the results and where or how severe the bone pain is, he or she may also order an X-ray, PET scan, or CT scan. In some cases, a tissue biopsy is also done to confirm the diagnosis.
Getting Back on Track: How Bone Metastases Are Treated
Oncologists have a range of tools that can help alleviate the pain and discomfort of bone metastases as well as treat the cancer itself, including:
- Systemic cancer treatment Addressing the underlying breast cancer is the most important step in the treatment of bone metastases, says Huston. Depending on the type of tumor, this may include chemotherapy, hormone therapy, or targeted medications.
- Bone-modifying medications Bisphosphonates — a class of drugs used to prevent and treat bone loss — such as zoledronic acid are very effective in reducing pain and lowering the risk of fracture and further bone metastases, Huston says. They are also used to bring blood calcium levels down quickly. Denosumab, a medication that prevents the breakdown of bone, can also be effective in treating bone metastases.
- Surgery Surgery may be recommended to remove most of the tumor or stabilize the bone to prevent or manage a fracture. If a bone is very weak or a fracture seems imminent, an orthopedic surgeon may insert a rod or pin to stabilize the bone. Spinal fractures are sometimes treated with an outpatient procedure called vertebroplasty, in which bone cement is injected into a collapsed vertebra to build it back up and improve back pain.
- Radiation Radiation therapy, which uses high-energy ionizing radiation to hurt or destroy cancer cells, may be used to help prevent fractures and treat spinal cord compression to help alleviate symptoms of pain or numbness, says Huston.
- Pain medications These can include narcotics and NSAIDs (nonsteroidal anti-inflammatory drugs) like ibuprofen, which blocks the production of prostaglandins, substances that the body releases in response to illness or injury.
Other ways to effectively manage pain and discomfort from bone metastases include using hot and cold compresses; practicing relaxation methods like meditation, physical therapy, or yoga; and doing other gentle forms of exercise. Ask your health care team about programs that can help keep you safely active. “Strong muscles protect bones,” stresses Huston, “and being active makes you feel better both physically and psychologically.”
Secondary (metastatic) breast cancer in the bone
- pain, redness/discolouration, heat and swelling of the calf, leg or thigh
- swelling, redness or tenderness where a central line is inserted to give chemotherapy, for example in the arm, chest area or up into the neck
- shortness of breath
- tightness in the chest
- unexplained cough (may cough up blood)
Find out more about blood clots.
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10. Support for living with secondary breast cancer
Everyone’s experience of being diagnosed with secondary breast cancer is different, and people cope in their own way.
For many people, uncertainty can be the hardest part of living with secondary breast cancer.
You may find it helpful to talk to someone else who’s had a diagnosis of secondary breast cancer.
- Chat to other people living with secondary breast cancer on our online Forum.
- Meet other women with a secondary diagnosis and get information and support at a Living with Secondary Breast Cancer meet-up.
- Live Chat is a weekly private chat room where you can talk about whatever is on your mind.
You can also call Breast Cancer Now’s Helpline free on 0808 800 6000.
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Metastatic breast cancer
Metastatic breast cancer, also known as stage IV or advanced breast cancer, is breast cancer that has metastasized, or spread, to other organs in the body. Metastases from breast cancer may be found in lymph nodes in the armpit, or they can travel anywhere in the body. Common sites include distant organs like the lung, liver, bone and brain. Even after an original tumor is removed, microscopic tumor cells may remain in the body, which allows the cancer to return and spread.
Patients may initially be diagnosed with metastatic disease, or they may develop metastases months or years after their initial treatment. The risk of breast cancer returning and metastasizing varies from person to person and depends greatly on the biology of the tumor and the stage at the time of the original diagnosis.
Learn more about metastatic cancer
Symptoms of metastatic breast cancer
The symptoms of metastatic breast cancer may vary depending on where in the body the cancer has spread. For example:
- If the breast or chest wall is affected, symptoms may include pain, nipple discharge, or a lump or thickening in the breast or underarm.
- If the cancer has spread to bones, symptoms may include pain, fractures or decreased alertness due to high calcium levels.
- If the cancer has spread to the lungs, symptoms may include shortness of breath, difficulty breathing, coughing, chest pain or fatigue.
- If the cancer has spread to the liver, symptoms may include nausea, fatigue, swelling of the feet and hands or yellowing skin.
- If cancer has spread to the central nervous system, which includes the brain or spinal cord, symptoms may include pain, memory loss, headache, blurred or double vision, difficulty with and/or movement or seizures.
Learn more about the symptoms of breast cancer
Treatment options for metastatic breast cancer
Treatment for metastatic breast cancer includes many of the same treatments as other stages of breast cancer:
- Hormone therapy
- Radiation therapy
- Targeted therapy
These treatments may be given alone or in combination. Some patients with metastatic breast cancer may also be eligible to participate in a clinical trial
Learn more about treatments for breast cancer
Supportive care for metastatic breast cancer
To help our patients maintain quality of life after a metastatic breast cancer diagnosis, our team of breast cancer experts may offer supportive care services to help manage side effects of the disease and its treatments. These may include:
- Pain management
- Nutrition therapy
- Naturopathic support
- Mind-body medicine
- Spiritual support
Learn more about integrative care
Next topic: What are molecular types of breast cancer?