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Overview of Therapeutic Approaches for Adult Patients With Bone Metastasis From Solid Tumors

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There are numerous cancer treatment therapies for individuals with bone metastasis. The article describes them further in detail.

Medically reviewed by

Dr. Anuj Gupta

Published At April 26, 2023
Reviewed AtApril 26, 2023

Introduction:

The progressive approaches in cancer treatment have improved patient survival with advanced-stage cancers. As a result, it is often fatal due to bone metastases. Skeletal-related events, like pathological fractures and spinal paralysis, impair the quality of life. An early diagnosis and a preventive approach are required to avoid such serious skeletal-related events impairing the quality of life and survival. It is essential to start a bone management program along with cancer treatment to prevent complications of bone metastasis. Additionally, a multidisciplinary approach is required to focus on the management of bone metastases and involve a team of oncology specialists, radiotherapy, palliative care, nuclear medicine, radiology, physiatrists, and orthopedics. The focus should be on preventing complications arising from bone metastases and reducing morbidity, hospitalization, and costs associated with advanced-stage cancers.

What Is Bone Metastasis?

Metastasis is the spread of cancer cells to other body parts, and bone is one of the common sites of metastasis. Bone metastasis leads to morbidity in patients with advanced-stage malignant diseases. The advancements in cancer treatments, such as immune checkpoint inhibitors, and the development of molecular-targeted agents have improved the survival rate of people with advanced-stage cancers. Thus prolonging the clinical courses of individuals due to bone metastases. On the other hand, morbidities, such as spinal paralysis and pathological fractures, cause impaired daily life activities and quality of life and affect the prognosis because of deterioration of the patient's condition and discontinuation of treatment for the primary disease.

What Are the Supportive Therapies?

Painkillers:

Most cancer patients with bone metastases suffer from bone pain.Initially, nonopioid analgesic drugs, and nonsteroidal anti-inflammatory drugs (NSAIDs), were used for mild to moderate pain. However, if the pain is not relieved, these painkillers may be used in combination with an opioid. For moderate or severe cancer pain, opioids are the most common painkillers because they are effective for all types of cancer pain. In addition, most cancer patients with metastatic bone disease get adequate pain relief with opioids.

Osteoclasts Inhibitors:

Osteoclast inhibitors are used for treating metastatic bone disease in patients with solid tumors. Osteoclast inhibitors slow down the progression of skeletal metastases. Additionally, they also have a medium painkiller effect. However, the painkiller effect of all of these inhibitors is limited, and they are not recommended as first-line therapy to treat painful bone metastases.

Exercise:

People with bone metastases should be encouraged to engage in some form of physical activity. Studies have found that regular physical activity or exercise improves physical function and reduces the side effects related to treatment and cancer-related fatigue.

Anti-cancer Therapy:

Chemotherapy and hormone therapy may reduce pain by decreasing the tumor bulk or by altering the pain signaling pathways. Systemic therapy plays a major role in the treatment of prostate cancer with bone metastases. However, pain relief is usually not quickly achieved, and patients may find it difficult to tolerate chemotherapy. Chemotherapy may also cause painful side effects or complicated side effects, limiting the effective administered dose that can be administered. New drugs have fewer side effects and may be more tolerable. However, they are not associated with immediate pain relief.

What Are the Local Therapies?

Radiation Therapy:

External beam radiation therapy (EBRT) is a standard treatment option for symptomatic skeletal metastases, leading to 50 to 80 percent of pain reduction. Certain individuals with multiple bone metastases have pain that is not easily managed by local radiation. in such conditions, there are two options: hemibody radiation and bone-targeted radiopharmaceutical therapy. Hemibody radiation can provide quick pain relief at multiple sites of symptomatic bone metastases. It has been replaced for conditions such as advanced prostate cancer by bone-targeted radiopharmaceuticals, which cause pain relief and is associated with less toxicity.

Bone-targeted Radiopharmaceutical Therapy:

Bone-targeted radiopharmaceutical therapy is indicated in conditions like refractory bone pain despite painkillers, a positive bone scan, a life expectancy of more than three months, and no chemotherapy or bisphosphonate six weeks before treatment. Contraindications of bone-targeted radiopharmaceutical therapy include acute spinal cord compression, acute or chronic renal failure, pregnancy, breastfeeding, and myelosuppression (a condition that refers to a decrease in the production of blood cells in the bone marrow).

Surgical Management:

Surgical management of bone metastases is usually for lesions involving fractures. However, surgery might also be required for spine metastases causing mechanical instability or epidural spinal cord compression. Most patients without complete fractures or evidence of epidural spinal cord compression do not require surgery for bone metastasis. However, for individuals with advanced cancer with a bone lesion beyond the primary site, the entire resection of the metastasis may lead to tumor control, provide pain relief, and could prolong patient survival. However, curative removal is rare for bone metastasis, except for individuals with sternal involvement or isolated spine. For individuals with long bone or spinal metastases, postoperative radiation is generally given after surgical stabilization to promote bone healing, decrease pain, improve functionality, and reduce the risk for further fracture or fixation loss by treating the metastasis.

Ablation:

Thermal ablation is an essential therapeutic option for individuals with persistent pain in a few skeletal sites after radiation therapy and does not require surgery or re-radiation. The various ablation therapies, including cryoablation, radiofrequency ablation, and focused ultrasound, are effective treatments for reducing symptomatic skeletal metastases. During thermal ablation to vertebral metastasis, the treatment should be aimed at least 10 mm (millimeters) away from a neural structure to prevent neurological complications. Thermal ablation contraindications include the following:

  1. The inability of the individual to tolerate the level of anesthesia required to perform the procedure.

  2. Uncorrectable bleeding.

  3. Inaccessibility of the target lesion from a percutaneous approach.

The relative contraindications include the following:

  1. Widespread skeletal metastases.

  2. Active infection, or tumor located to an adjacent critical anatomical structure that cannot be displaced or precisely monitored to allow safe ablation.

Conclusion:

Bone is one of the recurrent sites of cancer metastasis. Prostate and breast cancer are responsible for the majority of bone metastases. The overall incidence of bone metastasis is unknown. Bone metastases lead to pathologic fractures, severe pain, impaired mobility, spinal cord compression, hypercalcemia, and bone marrow aplasia. In addition, bone metastases cause serious fatalities, such as pathological fractures and spinal paralysis, that hampers the quality of everyday life. The treatment strategies for bone metastases should be planned in such a way as to keep in mind the health status, prognosis, and social background of the individuals. Multidisciplinary approaches focusing on managing bone metastases should include specialists supporting comprehensive healthcare and treating individuals.

Frequently Asked Questions

1.

Does the Spread of Bone Metastases Happen Rapidly?

In some cases, bone metastases may develop relatively slowly, allowing for effective management and treatment options. However, in other instances, they can progress more rapidly, leading to increased complications and challenges in treatment. Patients with a cancer diagnosis must work closely with their healthcare team to promptly monitor and address any potential bone metastases, as early detection and intervention can significantly impact the course of the disease.

2.

Is There a Cure for Cancer When It Has Metastasized to the Bones?

A cure for cancer that has metastasized to the bones is often challenging. The presence of bone metastases typically indicates an advanced stage of cancer. At this stage, the primary goal of treatment is usually to manage the disease, alleviate symptoms, and extend the patient's life while maintaining the best possible quality of life. While some individuals may experience long-term remission or a complete cure with aggressive treatment approaches, such outcomes are less common for metastatic bone cancer. Treatment plans usually involve a combination of radiation, chemotherapy, targeted therapies, and palliative care to control the cancer and improve the patient's comfort.

3.

Can Chemotherapy Halt the Progression of Metastasis?

Chemotherapy can be effective in slowing down the progression of metastasis in some cases. While chemotherapy may not always cure metastatic cancer, it can help manage the disease, reduce tumor size, alleviate symptoms, and improve the patient's quality of life. The effectiveness of chemotherapy can vary depending on the type and stage of cancer and individual factors, so patients need to discuss their treatment options and expectations with their oncologist to make informed decisions about their care.

4.

Is It Possible for Chemotherapy to Provide a Cure for Metastatic Bone Cancer?

The potential for chemotherapy to cure metastatic bone cancer depends on several factors. While chemotherapy can be a crucial component of treatment, its primary goal is typically to manage the cancer, slow its progression, relieve symptoms, and improve the patient's quality of life. Achieving a complete cure at this stage is challenging but not impossible, and it may depend on the type of cancer, its response to chemotherapy, and the patient's overall health. Treatment plans often involve a combination of therapies tailored to the individual's specific condition and needs.

5.

What Is the Life Expectancy with Bone Metastasis?

The life expectancy of someone with bone metastasis varies widely depending on several factors. Some individuals may live for many years with bone metastasis, especially when the cancer responds well to treatment and remains stable. Others, unfortunately, may face a more limited life expectancy, mainly if the cancer is aggressive and resistant to therapy. Patients need to have open and honest discussions with their healthcare team to understand their prognosis and to explore available treatment options that can potentially extend their lives and improve their quality of life.
 

6.

Which Organ Typically Experiences Metastasis First?

The organ that typically experiences metastasis first can vary depending on the type of cancer. However, the liver is a common site for metastasis due to its filtering and processing of blood from various parts of the body. Lung and bone metastases are also relatively common. The specific organ affected first can provide important information about the primary cancer's behavior and stage. 

7.

How Would One Describe the Sensation of Pain from Metastases?

The pain sensation from metastases can vary widely depending on factors such as the location of metastatic lesions and the individual's pain threshold. Metastatic cancer often leads to bone pain, manifesting as a dull ache, throbbing, or sharp discomfort. Nerve compression by metastatic growths can cause shooting or radiating pain. Additionally, cancer-related pain can be accompanied by other symptoms like inflammation, swelling, and tenderness. Effective pain management is a crucial aspect of cancer care, and patients should communicate their pain experiences with their healthcare team to develop a tailored pain management plan that may include medications, radiation therapy, or other interventions to improve their comfort and quality of life.

8.

Does Prostate Cancer Tend to Metastasize to the Bones Initially?

Yes, prostate cancer has a propensity to metastasize to the bones initially in some cases. The bones, particularly the spine, hips, and pelvis, are common sites for metastasis in advanced prostate cancer. This occurrence is often due to the affinity of prostate cancer cells for bone tissue. Early detection and appropriate management are essential in addressing bone metastasis in prostate cancer to improve patient outcomes and quality of life. Patients with prostate cancer should work closely with their healthcare team to monitor and manage any signs of bone metastasis.

9.

Is Bone the Most Frequent Location for Metastasis?

Bone is indeed one of the most common sites for metastasis. Many types of cancer, including breast, prostate, lung, and kidney, tend to spread to the bones. The bones provide a favorable environment for cancer cells to thrive, with their rich blood supply and supportive tissue. It leads to bone pain, fractures, and spinal cord compression, making them a significant concern in advanced cancer. While bone metastases can be challenging to cure, they can often be managed and treated to improve the quality of life.

10.

Are Survival Chances Favorable for Individuals with Bone Metastases?

Survival chances for individuals with bone metastases vary depending on several factors, including the effectiveness of treatments and the patient's overall health. While bone metastases indicate an advanced stage of cancer and may not always be curable, they can often be managed and treated to alleviate symptoms. Advances in cancer treatments, like targeted therapies and immunotherapies, have improved the outlook for some patients with bone metastases. Individuals with this condition must consult their healthcare team to develop a personalized treatment plan.

11.

Does Bone Metastasis Result in Neuropathic Pain?

Yes, bone metastasis can lead to neuropathic pain in some cases. Neuropathic pain is caused by damage or compression of nerves. When cancer spreads to the bones, it leads to neuropathic pain. This type of pain is complex and may require specialized pain management techniques, such as nerve blocks or medications specifically designed to target neuropathic pain. Patients experiencing neuropathic pain from bone metastasis should discuss their symptoms with their healthcare team to explore appropriate treatment options for pain relief and improved quality of life.

12.

How Can You Manage Pain from Metastatic Bone Involvement?

Pain management for metastatic bone involvement typically involves a multifaceted approach tailored to the individual's needs. Treatments may include pain-relieving medications, such as opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), or medications specifically targeting neuropathic pain. Radiation therapy can be used to treat. Additionally, Bisphosphonates and Denosumab are drugs that can help to strengthen bones with metastatic bone disease. Treatment includes physical therapy, complementary therapies, and psychological support to enhance their well-being while dealing with metastatic bone pain.

13.

What Is the Most Effective Pain Relief Medication for Bone Pain?

The best pain medication for bone pain depends on various factors, including the individual's specific pain levels, the underlying cause (such as cancer-related bone metastasis), and overall health. Pain management strategies may involve opioids like morphine or oxycodone for severe pain, non-opioid analgesics like Acetaminophen or NSAIDs for mild to moderate pain, and adjuvant medications targeting neuropathic pain, such as gabapentin or pregabalin. The appropriate medication selection should be made in consultation with a healthcare provider to improve their quality of life.

14.

What Are the Latest Advancements in Treating Bone Metastasis?

The newest treatments for bone metastasis continue to evolve with ongoing research and advancements in cancer care. Some of the latest approaches include targeted therapies that focus on specific molecular markers in cancer cells, immunotherapies that harness the immune system to combat cancer, and radiopharmaceuticals that deliver radiation directly to bone metastases. Additionally, advancements in pain management techniques, such as nerve ablation and minimally invasive surgical procedures, improve the quality of life for patients. Patients with bone metastasis should discuss these emerging options with their oncologists to determine the most suitable and up-to-date treatment plan for their specific condition.

15.

What Distinguishes Bone Metastasis from Skeletal Involvement?

The difference between bone metastasis and skeletal involvement lies in the extent and nature of their impact. Bone metastasis refers explicitly to the spread of cancer cells. This involves active cancer cells in the bones, leading to pain, fractures, and other complications. On the other hand, skeletal involvement is a broader term encompassing various bone conditions related to cancer but does not necessarily involve active cancer cells. It includes bone metastasis and conditions like osteoporosis, bone loss, or bone damage resulting from the cancer's effects on bone density and structure.
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Dr. Anuj Gupta
Dr. Anuj Gupta

Spine Surgery

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