When Cancer Spreads to the Bone: Surgery for Metastatic Bone Disease
Last updated Thursday, December 13, 2007
AboutBasics of metastatic bone disease Edited By: Jason S. Weisstein,
M.D, MPH
Metastatic bone disease is a serious condition in which cancer has
migrated from another part of the body, such as the lung, breast,
prostate, thyroid, or kidney into one or more bones of the skeleton.
Metastatic bone disease is not the same as cancer that originates in
the bone, such as sarcoma. As a consequence, treating metastatic cancer
that has gone to the bones is different than treating cancers that
originate in the bones. Any kind of cancer can spread to the bone, but
the most common are cancers of the kidney, thyroid, lung, breast, and
prostate.Immediate medical attention Any new bone or joint pain should be taken very seriously in a patient
who has a history of cancer, even if the cancer appeared to be in
complete remission many years ago. Metastatic bone disease is heralded
by onset of pain, usually in the arm, leg, back, or pelvis. Sometimes
patients don’t know they have cancer until it spreads to the bone and
causes enough pain that they seek medical attention. The physician then
needs to find the original location of the cancer elsewhere in the body.Facts and myths Treating metastatic bone disease may not increase the length of time a
patient lives, but frequently can increase the patient's quality of
life. Radiation is used for pain control. Radiation doesn’t
restore the integrity of the bone, and the patient may continue to be
susceptible to fractures. Surgery can sometimes help protect the bone
and make it easier for the patient to move around. The reduction of
pain and the restoration of some activities, like walking, can improve
a patient’s overall quality of life. Some people also believe
that surgery should not be performed if the patient has only a short
while to live. On the other hand, some patients think surgery is worth
enduring if it gives them even a few more months of a more active, less
painful, life. The ultimate decision on what treatments to undergo is
individualized on a patient-to-patient basis.Prognosis The appearance of metastatic bone disease is very serious and can
worsen a patient’s overall prognosis. Left untreated, it has a severe
effect on the remaining quality of life. A patient can become
profoundly hypercalcemic (have very high levels of calcium in the
blood), which can be dangerous. When too much calcium is released into
the bloodstream, the patient can become prone to gastrointestinal
symptoms, psychiatric symptoms such as delusions, and kidney stones. If
the cancer spreads from the bones to the lungs, the consequences can be
fatal. In a few patients whose initial treatment was successful,
metastatic bone disease can be a chronic problem. The patient may, for
example, have an isolated problem in a leg bone, get it treated, and
live several years before the disease reappears in the spine or arm.Lethality How lethal metastatic bone disease is depends on the patient’s original
type of cancer and how much the cancer has spread. Widespread
metastatic bone disease has a poor prognosis. However, the outlook may
be better for those patients who have just one or two spots in their
bones. Patients may find some peace of mind from knowing that not all
patients with metastatic bone disease have a grim future. Medication
and surgery can help keep the symptoms of the disease at bay and help
permit a good level of activity.Pain Pain is usually what prompts the patient to seek medical attention.
Rarely is metastatic bone disease an incidental finding during a
routine exam. Patients usually describe the pain as body aches that
occur during the night, and feel like a bad toothache.Debilitation How debilitating metastatic bone disease is varies from person to
person, depending on which part of the skeleton is affected. For
example, a metastasis that appears in the right arm of a left-handed
person causes less trouble than if the patient were right handed.Comfort Metastatic bone disease will cause some degree of discomfort. The
amount will vary from person to person. Radiation treatment,
medications, surgery, and other pain management techniques can often
make the patient more comfortable. Patients should let their doctors
and nurses know if they are in pain, where it hurts, how severe it is,
and how the pain is affecting their daily lives. Their doctors and
nurses can then find ways to try to reduce the pain. More can be done
today to lower the musculoskeletal pain from cancer than was available
in the past.Curability While treatment may improve the patient’s comfort and function, reduce
pain, and prevent additional suffering from fractures, treatment is
rarely curative.Fertility and pregnancy Metastatic bone disease has no effect on fertility. However, because
metastatic bone disease usually doesn’t occur until after age 40, most
women who develop metastatic bone disease are no longer in their prime
childbearing years.Independence Metastatic bone
disease may lessen independence in a significant number of, but not all,
patients. Some patients with metastatic bone disease have chronic pain that
requires treatment with sedating medications. Those whose bones are affected in
the lower part of the body may have difficulty walking. If the bones in the
arms are affected, patients may have problems carrying out the daily activities
of living, such as cooking, writing, cleaning, shopping, and personal
care. Patients will likely have to stop
working. Some will need to use a wheelchair to get around. Because of their
restricted range of movement, and if they are taking narcotics to curb their
pain, some patients will not be able to drive.
The loss of independence may be especially
difficult for cancer patients who felt they have gotten their daily life back
and have been disease-free from cancer for 10 or 20 years, only to have their
activities curtailed by pain and bone deterioration. However, surgery or
radiation might be able to reduce the pain to the point where narcotics are not
needed, and might be able to reduce other disabilities from the disease.Mobility The limitations that
metastatic bone disease places on mobility depends on which bones have the
disease, how many bones are involved, and how much area of each bone is
damaged, and the severity of the damage. Patients should check with their
doctor to see if treatment can help restore some of their lost mobility or
reduce their risk of fractures.Daily activities Whether metastatic
bone disease alters activities of daily living depends on where in the skeleton
the disease is occurring. For example, metastasis in the arm bones or in the
upper backbone may limit the ability to do housework, work at a computer, use
hand tools, or do lifting. In addition, a patient’s energy for accomplishing
tasks may be low, especially while he or she is receiving radiation.Energy As with many other
forms of cancer, metastatic bone disease is often accompanied by fatigue. In
addition, the narcotics to treat pain are often sedating. Radiation and
chemotherapy can also cause fatigue, and patients often suffer from sleep
problems, including being woken up by pain. This loss of nighttime sleep can
lead to daytime drowsiness. Depression may also make it hard to get up the
energy to do things. Some forms of cancer can cause anemia and its resulting
tiredness. Some causes of fatigue, such as depression, anxiety, insomnia, and
anemia, can be addressed to reduce its impact.Diet There are no specific
diets, dietary restrictions, or requirements for people who have metastatic
bone disease.Relationships A person who has
metastatic bone disease may need more practical help, because the disease might
have significant impact on his or her independence and mobility. A patient will
likely have repeated visits to the doctor, which will take up a sizeable amount
of time, especially if the patient lives in a rural town and must travel a long
distance for treatment. Sometimes receiving cancer treatment, or caring for a
relative with metastatic bone disease, can seem burdensome at times. For
example, radiation therapy often requires several weeks of daily treatments at
the hospital or clinic. If the patient already has stresses in his or her life,
or has had difficult interpersonal relationships before the disease occurred,
these may become worse because of the demands of living with cancer. On the
other hand, sometimes the appearance of a serious disease can change people’s
outlooks in such a way that family, friendships, and other personal
relationships become more important and stronger.Other impacts Metastatic bone
disease is not contagious, nor is it disfiguring.
One of the impacts of the disease is that some
patients will have metal surgical hardware placed in their body to treat a
fracture or a bone about to fracture.Incidence Metastatic bone
disease is more likely to occur in patients with a history of lung cancer,
breast cancer, or prostate cancer. It is less likely to occur from cancers of
the gastrointestinal system, such as colon cancer, stomach cancer, or
pancreatic cancer. It is equally common in men and in women.Acquisition Metastatic bone
disease occurs when cancer cells from another area of the body –the breast, the
lung, or other organ – travel through the blood stream and attach themselves to
bone. There are factors circulating in the blood stream that give cancer cells
a predilection for setting up shop in bone. The skeleton is highly
vascularized, that is, a lot of blood vessels feed into it. Living bone is not
in the dry, unchanging state seen in the skeletons displayed in high school
biology classes. Instead it is constantly remodeling itself. Its dynamic
nature, with a lot of cell turnover, makes bone susceptible to invasion by
cancer cells from elsewhere in the body.Genetics enetics plays a role
in a person’s risk of developing the original cancer in another part of the
body. For example, certain genes put women at risk for breast cancer, some
forms of breast cancer run in families, and breast cancer is more likely than
some other forms of cancer to spread to the bone. However, metastatic bone
cancer doesn’t run in families, and as yet no genes have been discovered that
either place people at risk for metastatic bone cancer or protect them from it.
Metastatic bone disease is usually a consequence of not being able to
completely destroy the original cancer or the result of chemotherapy that
failed or that was not fully effective.Communicability Metastatic bone
cancer is not contagious. It cannot be spread from person to person.Lifestyle risk factors Certain behaviors,
life factors, and habits can put people at greater risk for the kinds of
cancers that might lead to metastatic bone disease, but not at greater risk for
metastatic bone disease itself. For example, smokers are more likely to get
lung cancer. Women who are obese or childless are at greater risk for breast
cancer.Injury & trauma risk factors There is no evidence
that injury or trauma leads to metastatic bone cancer.Prevention The only way to
prevent metastatic bone disease is through good control of the cancer that
originated elsewhere in the body.Anatomy Metastatic bone
disease is more likely to affect the parts of the skeleton that have a lot of
red bone marrow. Examples are the bones in the hip, spine, and other bones near
the midsection of the body. However, tumors can spread to any bone in the body.Initial symptoms Metastatic bone
disease is signaled by the appearance of a new musculoskeletal pain that
doesn’t go away, especially in a person who has had cancer. The pain may be
mistaken for any number of things: a muscle injury or strain, or the patient
may think he or she has unknowingly bumped the arm or leg, or slept in the
wrong position. The pain may feel as if it is coming directly from the bones or
joints, or the pain may feel as if it is coming from another location, like the
muscles. It can also appear as a new pain in someone who has cancer elsewhere
in the body, but who is unaware that he or she has cancer.
Any new musculoskeletal pain in a person who has
had cancer should be taken very seriously and imaged appropriately by a
radiologist. An image as simple as an X-ray may tell whether that patient has
metastatic bone disease.Symptoms The major symptom of
metastatic bone disease is musculoskeletal pain.
On an X-ray, a spot may be seen on a bone. Some
forms of metastatic bone disease will cause bone deformity, others may cause
parts of the bone to disappear. Either way, the quality of the affected bone is
poor. Women who have breast cancer or who already have osteoporosis (bone loss
from another cause) may be more badly affected.Progression Typically if
metastatic bone disease is not treated, the symptoms will worsen.
The patient may begin to have mobility problems,
such as difficulty walking. If the backbone is affected, the patient may feel
as if a nerve in the back is pinched, or feel pain shooting down the leg, or
have other signs that the spinal cord is being compressed. Paralysis can occur
if this is left untreated. The patient may suffer one or more broken bones
after a slight fall or seemingly minor injury, because bones with metastasis
are fragile.
However, if metastatic bone disease is treated,
the patient may see a remarkable diminution of pain, a lowered risk of
fractures, and a restoration of function. The treatment will not prolong life,
but it may make the quality of life better.
The speed of progression of metastatic bone
disease depends on the type of cancer that has spread to the bones, and on the
individual patient. It is difficult to predict how quickly or slowly the
disease will progress.Secondary effects Some of the secondary
effects of metastatic bone disease are hypercalcemia (a problematic increase of
calcium in the blood stream); anemia (a reduction in red blood cells);
sedation, mental cloudiness, and other effects of narcotics; and an increased
risk of falls and bone fractures.Conditions with similar symptoms Metastatic bone
disease may initially be confused with pain from a muscle ache or sprain, when
the real problem is skeletal from cancer, not muscular from an injury. Delays
made from writing off the symptoms as being do to a muscle injury can
profoundly impact the patient’s quality of life.Causes The underlying cause
of metastatic bone disease is the spread of cancer from another organ or
another type of tissue into the bone. The bone is an ideal environment for
cancer cells to take hold and grow, because of factors in the circulating blood
that allow cancer to adhere to the bone. The sheer amount of blood volume that
passes through the bone increases the odds that the bones will be readily
exposed to cancer cells traveling in the blood. While people usually think of
cancer as being a disease of a particular site, such as the breast or the
thyroid, it is actually thought to be a more systemic disease of the body, and
can often be found in the blood stream. Cancer patients are given chemotherapy
to remove cancer from the blood stream after surgery and radiation therapy have
been performed to remove or destroy the original tumor.Effects Metastatic bone
cancer can weaken or destroy bone tissue. This releases calcium into the blood
stream, and also damages the ability of bone marrow to manufacture enough
healthy, new blood cells. The affected bones might also fracture easily. The burden of cancer in the body, as well as
the indirect effects of cancer in the bone, such as causing high levels of
calcium and low blood cell counts, can become so great that the patient’s life
is threatened.Diagnosis Cancer patients who
are experiencing new pain that suggests the cancer may have spread to the bone,
or new patients who have symptoms that suggest they may have an advanced stage
of cancer that has not yet been diagnosed, may have images taken to see if
cancer is appearing in their bones. Radiographic magnetic resonance imaging
(MRI) may be ordered if X-rays are inconclusive. MRI creates detailed
anatomical pictures of the patient’s bones and soft tissues. The images are
then examined to see if there is cancer in the bone, and if so, how much damage
it has done. A patient might also have a bone scan to screen the entire
skeleton for any possible cancer.Diagnostic tests Metastatic bone
disease is generally diagnosed through imaging procedures, such as X-rays, MRI,
or CT scans, to produce clear pictures of the bones to see if and how they are
affected by cancer. In addition, the levels of calcium in the blood might also
be measured through a blood test, and other tests, such as looking at the blood
sample to see if the patient has anemia, might also be performed. These blood
tests do not diagnose metastatic bone disease, but are used to check for
conditions that might accompany the disease.Effects The imaging tests are
not painful. Patients need to hold fairly still for the technician to obtain a
clear image. A few patients are troubled by the confined space and the noise of
the magnetic resonance imaging machine. Such patients should tell their
physician or the imaging technician if they have a fear of closed spaces, to
get advice on how to manage this feeling during the imaging.
Much of the pain of diagnosis is emotional
distress, as the patient deals with uncertainty and with the possibility that
their cancer may have spread to the bone. Facing the possibility of metastatic
bone disease can be a big emotional blow to someone who has been free from
cancer for up to ten or 15 years, and who thought the cancer was potentially
cured. How people find ways to come to terms with this situation varies from
person to person.Health care team If the patient’s
personal physician or oncologist suspects metastatic bone disease, they may
conduct some preliminary exams and testing, and then refer the patient to a
medical center or cancer treatment center. At a major medical center, the
patient’s team will usually be made up of an internal medicine specialist, a
medical oncologist, a radiation oncologist, a pain specialist, and an
orthopaedic surgeon, as well as nurses, technicians, and patient care
coordinators. Cancer care centers that
are part of major medical centers and cancer research institutions are ideal
set ups for optimal care of metastatic bone disease because all specialties
that treat cancer are represented, they work together as a team, and have
experience in treating metastatic bone disease.Finding a doctor People who are
suspected of having metastatic bone disease can be referred by their physician
to a regional cancer treatment center, to a major medical center, or to an
alliance of medical institutions that have joined together to diagnose and
treat cancer patients. In many cases, patients can also refer themselves or a
friend or family member to one of these centers. People can call a medical
center, a cancer research institution, or an institution specializing in cancer
care to learn if they have a special expertise in treating metastatic bone
disease. Patients should be careful to look at the qualifications and
reputation of any institution before becoming a patient of that center, and
especially check the institution’s expertise in treating metastatic bone
disease.Treatment Patients usually
receive some combination of surgical, medical, and radiation treatment for
metastatic bone disease. While this treatment is not curative, it may help
improve the patient’s quality of life by reducing pain, making it easier to
move around, and preventing or fixing bone fractures.
Surgical treatment usually consists of implants
of metal rods or plates to stabilize fractured bone or bone about to fracture.
Surgery may also sometimes be performed to reduce compression on the spinal
cord, if that is occurring and is causing pain, numbness, loss of bowel or
bladder control, or difficulty walking or using the arms.
Radiation therapy is directed at killing the
cancer locally and at improving localized pain control in affected parts of the
body.
Medical treatment may include different forms of
chemotherapy. A class of drugs called bisphosphonates act by decreasing bone
destruction and thereby reducing pain. This class of drugs is similar to those
used to treat osteoporosis, a form of non-cancerous bone loss common in
postmenopausal women or in younger adults who diet and exercise in the extreme.
Patients will also receive medications to boost their comfort, such as
narcotics or other pain treatments.
Surgery usually needs to be performed only once,
radiation therapy usually takes a number of treatment sessions over several weeks,
and medication of some sort usually continues for the rest of the patient’s
life. After treatment, many patients go back to their regular lifestyle, and
their primary-care doctor or oncologist at home manages their medications for
them. At the UW and the Seattle Cancer Care Alliance, and at many other widely
respected cancer treatment centers, every effort is made to keep the patient’s
primary care physician and local oncologist informed on their patient’s
clinical course.Self-management Any cancer patient
should see their doctor early on if they are experiencing new pain, and not
wait to schedule an appointment. Patients should keep their diagnostic and
treatment appointments, and follow the course of treatment he or she has agreed
upon with his or her cancer treatment team. Patients should take their
medications as prescribed, or report intolerable medication side effects to
their physician and not simply stop taking the medication without consulting a
doctor or pharmacist.Health care team Health professionals
involved in treating or managing metastatic bone disease may include medical
oncologists, radiation oncologists, radiologists, orthopedic surgeons,
hospitalists, pharmacists, nurses, rehabilitation medicine specialists,
physical therapists, social workers, and others as needed for the patient’s
individual concerns. The patient’s primary-care physician will also continue to
be involved in the patient’s care before and after treatment at a specialized
medical center, and may be consulted during the course of specialized
treatment.Pain and fatigue Radiation therapy can
usually help reduce localized pain. Surgery can sometimes help prevent or
reduce pain from fractures or stabilize bones that are at risk for fracture.
Medications, such as narcotics, can also help in pain reduction. If anemia is a
cause of fatigue, it can sometimes be treated. Adequate pain control can often
prevent or relieve sleep problems and the daytime fatigue that results from
repeated nighttime awakenings. Comfort items, such as a favorite chair; soft,
easy fitting clothing; and a good mattress and pillows, can help to promote
rest by reducing pressure on achy parts of the body.Diet No, diet has not yet
been shown to help treat metastatic bone disease. Nonetheless, appropriate
calcium and vitamin D supplementation can help maintain a healthy skeleton.Exercise and therapy Exercise can increase
overall well being and keep bones healthy, but it should not be attempted until
after the bones have received appropriate treatment and the patient has checked
with his or her doctor before starting an exercise routine.Medications Patients may be given
various forms of chemotherapy for the recurrence of their cancer. They may also
receive medications similar to those given for osteoporosis (bone loss) to
improve the quality of their bone tissue. They can also be given medications,
such as narcotics, to control their pain. Other medications, such as treatments
for anemia, may be prescribed as necessary to control other conditions that may
accompany or occur coincidentally with metastatic bone disease.Surgery While not curative,
surgery can help prevent or manage some of the problems associated with
metastatic bone disease, and can prevent the bone from fracturing (breaking) or
treat the fracture if it already has occurred. Rods, plates, joint
replacements, and some types of cementing treatments may be employed surgically
to strengthen weak bones or to prevent or fix fractures.Joint aspiration Neither joint
aspiration nor injection is used in the management of metastatic bone disease.Splints or braces In selected cases, if
a bone is broken or if a patient elects not to have bone surgery, splints or
braces may be employed.Alternative remedies Alternative remedies
for metastatic bone disease are directed at increasing patient comfort, not at
treatment or cure. Some patients may try non-medical modalities or non-Western
medical therapies in addition to their medical treatment to improve their sense
of well being. These may include acupuncture, herbs, massage, and meditation.
Some patients believe in the metaphysical nature of certain places to help them
feel better. Patients should tell their physician about any herbal medicines
they plan to take, because some may interact unfavorably with their other
treatments. Some patients find that complementary, non-medical modalities such
as meditation can be helpful, but it is very important also to seek
conventional treatment for metastatic bone disease.Long-term management There needs to be
continual monitoring of the original cancer that now has spread to the bone.
Any musculoskeletal complaints from a patient need to be taken seriously by the
patient and his or her physician. Depending on the type of cancer, many
patients with metastatic bone disease will be on chronic medication management.Unproven remedies People need to
realize that the treatment of metastatic bone disease is not curative. Many
people think that if their bone disease is cared for, then they are cured. This
is not true. Some patients also have a fear of radiation treatment, but today
radiation therapy has evolved so the side effects are fewer and those that do
occur are managed more effectively than they were 20 or 30 years agoStrategies for coping Having a good social
support system is critical. Maintaining strong lines of communication with
health-care workers is also helpful. If a patient feels depressed or anxious,
he or she should consider seeking assistance from a social worker, hospital or
clinic chaplain, psychologist, or psychiatrist, depending on the patient’s
personal preferences for a counselor and his or her psychological needs.Asking for help Patients have
different preferences for the kind of help that would be useful to them, as is
also the case with their family members. Some patients and their families find
it useful to talk about coping with the disease with the physician who is
treating them, or with other health care personnel such as nurses or social
workers or psychologists. Others prefer to talk with a general medical chaplain
trained or one who is trained in counseling cancer patients. Some patients
receive support through members of fraternal, social or other organizations to
which they belong. There are also support groups offered through local chapters
of the American Cancer Society or through various hospitals.Work Most people who
develop metastatic bone disease are elderly and retired, or are not working
because of the severity of their illness.Family and friends It is important for
people who have metastatic bone disease to have a good support system in place,
or to seek out a support group. Having others who can help can sometimes
provide respite to family members or close friends who are the primary
caregivers for the patient. Caring for a relative or friend who has metastatic
bone cancer can be especially challenging for those living in rural areas,
because of the distance needed to travel for medical appointments or for others
to visit them to offer support. The subject of useful support for caregivers is
one that needs more attention from health-care professional and from community
service organizations.Adaptive aids Canes, braces,
walkers may be of use under some circumstances, but the goal of most treatment
plans is to try to return patients to a level where they don’t need assistive
devices or aids. This doesn’t always work out every time, but it is the goal of
treatment.Stress Patient should feel free to ask lots of
questions of their physicians. They shouldn’t leave the clinic until all of
their questions are answered. They might want to have a friend or family member
along on doctor’s visits to record their conversations with their physician,
because their anxiety is likely to be high and as such they may forget much of
what is said. Physicians or other health professionals may know of support
groups that can act as an outlet for patients or their family members to share
their anxieties or experiences with other cancer patients or family members of
cancer patients.Resources Patients can obtain
information by calling their local chapter or the national office of the
American Cancer Society. There are also libraries or patient information rooms
at most cancer hospitals. Patients can also go to trusted Web sites, but should
be aware that there is a lot of anecdotal information on the Web that may not
conform to the general standards of care.Condition research Unfortunately,
nationally there has not been sufficient research attention given to the
problem of metastatic cancer generally. However, more studies are beginning to
emerge.Pharmaceutical research Drugs aimed at
treating bone loss and bone pain are the most recent development. There is also
research to develop new narcotics and better pain control with fewer side
effects.Non-surgical research There are no major
research studies under way at the University
of Washington in
lifestyle issues or other non-medical, non-surgical contributors to metastatic
bone disease.
Surgical research There is research
under way to develop optimal devices for stabilizing bones that have been
weakened by cancer.Cellular, genetics, or tissue research There is new research
aimed at understanding why cancer spreads to the bone and how cancer cells
destroy tissue after they reach the bone. There are lots of different cellular
factors that may play a role in how cancer cells attach to the bone and
disintegrate the bone. If scientists can find out how the disease begins in the
bone, perhaps they can develop ways to decrease the ability of cancer cells to
attach to the bone to prevent metastatic bone disease.Surgery for Metastatic Bone Disease at the University of Washington If you are interested in making an appointment to discuss this procedure, you can request an appointment using our online referrals website. To request a referral online, please click here. You can also call 206-598-4288 (outside the Seattle area: 800-440-3280) to make an appointment.
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