Treating Bone Metastasis

Video Transcript

Jane Meisel, MD, Winship Breast Oncologist. <br>Pond5. <br>AudioJungle.

[MUSIC PLAYING] JANE MEISEL: When we talk about bone metastases, what we mean is breast cancer that has spread usually through the bloodstream and set up shop in the bone and has basically kind of created a spot in the bone that often you can see on a scan and sometimes for patients, you can feel. They feel bone pain. In rare instances when it grows quickly or aggressively or has been there for a while, it can even lead to things like fracture. The most common bones that it spreads to are spine, hips, and ribs. So very rarely do we see it like in the bones in the lower extremities, for example, or the bones of the hand. So bone is one of the most common sites of spread of breast cancer when it spreads outside the breasts and surrounding lymph nodes. And it can often happen shortly after diagnosis, or it can happen years down the line. The goals of treatment of bony metastases from breast cancer include improving quality of life, so reducing pain, reducing the spread of cancer. So if you can keep it at bay and stop it from spreading to any other bones or worsening, where it already is. With bone metastases, I would say one of the unique things about that is that they can cause pain. So we do want to make sure that we manage pain optimally whether it's with medication, whether it's with focused radiation to a bone it's affected. And also, that we do things like preventing fracture. So often we'll co-manage these patients as oncologists, along with radiation oncologists, even orthopedic surgeons, to help make sure that we can control those situations adequately.

Many different treatments can help if your cancer has spread to bone, commonly called bone metastasis or bone "mets." Treatment can't cure bone metastasis, but it can relieve pain, help prevent complications, and improve your quality of life.

Doctors use two types of treatments for metastatic cancer in the bones. Systemic treatments can reach cancer cells throughout the body. Local treatments directly target the cancer in the bone.

The treatment you get will depend upon:

  • Where your cancer started, and the kind of primary tumor you have
  • Which bones the cancer has invaded
  • The extent of damage to the bones
  • Which types of treatment you already have had
  • Your overall health

Let your doctor know if your treatment isn't easing your pain and other symptoms. You may find that other approaches work better for you.

Chemotherapy

Chemotherapy is a common systemic treatment for bone metastasis. Your doctor will use a type of chemo that is effective against your primary tumor. So, if you have metastatic lung cancer, for example, your doctor will use drugs that are effective against lung cancer.

How it works. Anti-cancer drugs target and curb cancer growth. In most cases, you take chemo by mouth or through a vein (by IV). This can often shrink the tumors, which will ease your pain and help you feel better.

Possible side effects. Chemo can kill normal cells in addition to cancer cells. The side effects you might have will depend on:

  • The type and amount of drugs you take
  • The length of your treatment

Common side effects of chemotherapy include:

Your doctor can help you prevent or manage these. Most side effects go away once you stop treatment.

Hormone Therapy

Bisphosphonates

This group of drugs works best in cases where metastasis is weakening the bone.

How it works. You receive bisphosphonates by mouth or IV infusion every 3 to 4 weeks. These drugs help with bone metastasis by:

  • Slowing bone damage and reducing the risk of bone fractures
  • Easing bone pain
  • Reducing high levels of calcium in the blood

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Possible side effects. The most common ones include:

A rare and serious side effect is bone death (osteonecrosis) of the jaw. Ask your doctor about precautions to take before beginning this treatment. Osteonecrosis may cause:

  • Jaw bone pain, swelling, or numbness
  • Loss of gum tissue
  • Loose teeth
  • Infection

Another available treatment is denosumab (Prolia, Xgeva). It's given by injection and may work as well as or better than bisphosphonates to prevent fractures. But it also can cause osteonecrosis, as well as low calcium levels in the blood.

Radiopharmaceuticals

These drugs contain radioactive elements that target cancer cells. Doctors tend to use this systemic treatment when the metastasis is stimulating new bone growth. This is more common with prostate cancer.

If your cancer has spread to many bones, these drugs may be a better option than standard radiation, which uses a beam to aim radiation at each bone metastasis. However, sometimes doctors combine radiopharmaceuticals and standard radiation.

How it works. The doctor injects a single dose of the drug into a vein. It then travels to the areas of bone with cancer and gives off radiation to kill the cancer. This single dose may be effective against pain for several months. You can receive another treatment later.

Possible side effects. The most common ones include:

  • Infections
  • Bleeding
  • Temporary increase in pain (flare reaction)

Immunotherapy

This systemic treatment helps your immune system spot and more effectively kill cancer cells. Some methods of immunotherapy have been used for a while, and some are still experimental.

How it works. Immunotherapy works in one of two main ways:

  • It boosts your body's immune system to fight the cancer.
  • It uses a man-made version of proteins to kill cancer cells.

Examples of immunotherapy for cancer include:

  • Cytokines -- substances secreted by the immune system that have an effect on other cells
  • Monoclonal antibodies -- a class of antibodies made in the lab from a single population of cells
  • Tumor vaccines -- vaccines using a substance that prompts the immune system to respond to a tumor

Possible side effects. Side effects vary, depending upon the type of immunotherapy. They may include:

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Radiation Therapy

Radiation is a "local treatment" because it does not affect your entire body. It uses high-energy X-rays or particles to destroy or slow the growth of cancer cells in the bone. It helps most if you have only one or two bone metastases. You may receive it alone or combined with other types of treatment.

How it works. A machine focuses a beam of radiation on the bone metastasis. This treatment, called external beam radiation, lasts only a few minutes. You may receive radiation in one large dose or in smaller amounts over several treatments.

Possible side effects. Early, temporary side effects depend on the location being treated, but may include:

Surgery

Surgery can often help relieve bone metastasis symptoms.

How it works. If a bone is broken, surgery may help relieve pain quickly. Surgery can also help stabilize a weak bone to keep it from breaking. The surgeon may insert:

  • Screws
  • Rods
  • Pins
  • Plates
  • Cages

Possible side effects. These include the usual risks of any surgery, such as infection.

If surgery is not an option, your doctor may use a cast or splint, or inject bone cement to help you move better and relieve pain.

Ablation

With this local treatment, a needle or probe is put into the tumor to destroy it. Though used more often for other types of metastasis, ablation can help if you have a problem with one or two bone tumors.

How it works. Some methods of ablation use chemicals or alcohol to kill the tumor. Two common methods include:

  • Radiofrequency ablation (RFA). A needle delivers an electric current to heat the tumor.
  • Cryoablation. A probe is used to freeze the tumor.

Afterward, the doctor may fill the space created by ablation with bone cement to help stabilize the bone.

Possible side effects. This procedure is generally safe but may cause some temporary soreness, swelling, and bruising.

Nerve End Ablation

This noninvasive procedure uses ultrasound energy and imaging technology to provide pain relief by destroying nerve endings in the area of the tumor. Because there is no incision, and no probe is inserted, the procedure is typically done on an outpatient basis with a local anesthetic rather than general anesthesia. While complications are possible, they are rare.

How it works. A specialist uses imaging to target the specific area to be treated with ultrasound. Then, heat that's made when ultrasound penetrates the targeted tissue destroys nerve endings in the bone around the tumor. The destruction of nerve endings results in pain relief.

Possible side effects. Possible complications include skin burns and damage to heat-sensitive organs that are next to the treated area.

WebMD Medical Reference Reviewed by Laura J. Martin, MD on July 30, 2017

Sources

SOURCES:

American Cancer Society: "Bone Metastasis Overview;" "Immunotherapy;" and "Possible side effects of radiation therapy."

Dubey, A. The Internet Journal of Pain, Symptom Control and Palliative Care, 2010.

Society of Interventional Radiology: "Nonsurgical Treatments for Metastatic Cancer in Bones."

Catanel, A. Annals of Oncology, 2007.

Napoli, A. RadioGraphics, 2013.

BlueCross BlueShield of North Carolina: "Corporate Medical Policy: MRI-Guided Focused Ultrasound."

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