Bone cancer

Bones

A typical healthy adult has over 200 bones.

Bones:

• support and protect internal organs
• are attached to muscles to allow movement
• contain bone marrow (which produces and stores new blood cells)
• store protein, minerals and nutrients, such as calcium.

Primary and secondary bone cancer

Bone cancer can develop as either a primary cancer, meaning that the cancer started in the bones, or a secondary cancer, meaning that the cancer started somewhere else and spread to the bones.

Primary bone cancer is rare. About 270 Australians are diagnosed with primary bone cancer each year. It affects people of all ages but is most often seen in people aged 10 to 25 years and over 50 years.

Secondary bone cancer is much more common than primary bone cancer in Australia and is more common in adults than children. The bone is one of the most common places cancer may spread to, along with the lymph nodes, liver, lungs and brain.

Signs and symptoms of bone cancer

The most common symptom of primary and secondary bone cancer is pain in the affected bone or joint that doesn’t improve with mild pain medicines such as paracetamol. You might have this pain most of the time, and it may be worse at night or during activity.

• Other symptoms can include: swelling over the affected part of the bone
• stiffness or tenderness in the bone
• problems with moving around(e.g. walking with a limp)loss of feeling in the affected arm or leg (limb)
• bone that breaks for no reason
• fractures
• high calcium levels in the blood (hypercalcaemia)
• pressure on the nerves in the spine (spinal cord compression)
• low levels of blood cells.

Not everyone with these symptoms has bone cancer. If you have any of these symptoms or are worried, always see your doctor.

Risk factors for primary bone cancer

The causes of most bone cancers are unknown, but factors that may increase the risk include:

• Previous radiation therapy (also known as radiotherapy) – radiation therapy to treat cancer increases the risk of developing primary bone cancer. The risk is higher for people who have high doses of radiation therapy have been given in childhood. Most people who have radiation therapy will not develop primary bone cancer.
• Other bone conditions – some people who have benign bone conditions, such as Paget’s disease of the bone, are at higher risk.
• Genetic factors – some inherited conditions such as Li-Fraumeni syndrome increase the risk of bone cancer. People with a strong family history of certain types of cancer are also at risk. Ask for a referral to a family cancer clinic for more information. Some people develop bone cancer due to genetic changes that happen during their lifetime, rather than inheriting a faulty gene.

Having these risk factors doesn’t mean you will develop primary bone cancer. If you are worried about your risk factors, ask your doctor for advice.

Tests for bone cancer

Your doctor will do some tests to check for primary or secondary bone cancer:

• blood tests – to check your general health, calcium levels and possibly a specific blood test called an alkaline phosphatase (ALP) test
• x-ray – a scan that takes a two-dimensional picture of the inside of the body that can reveal bone damage, fractures or the creation of new bone
• bone scan – a small amount of radioactive dye is injected into a vein; it collects in the bone and any abnormal changes are found by a special camera and computer
• computed tomography (CT) scan – a scan that uses x-rays to take a three-dimensional picture of the inside of the body
• magnetic resonance imaging (MRI) scan – a scan that uses magnetism and radio waves to take pictures of the inside of the body
• positron emission tomography (PET) scan – a small amount of radioactive glucose solution is injected into a vein and a scan is then taken and any cancerous areas on the scan will be highlighted
• bone biopsy – some cells and tissues are removed from the affected bone for examination under a microscope to check for cancer cells.

Types of primary bone cancer

There are more than 30 types of primary bone cancer. These are the most common types:

• Osteosarcoma (about 35% of bone cancers) – bone cancer that starts in the cells that grow in bone tissue. It usually affects the arms, legs and pelvis but can occur in any bone. Osteosarcoma occurs most often in teenagers with growing bones and older people in their 70s and 80s. Most are high-grade tumours.
• Chondrosarcoma (about 30% of bone cancers) – bone cancer that starts in the cells that grow cartilage. It usually affects the bones in the upper arms and legs, pelvis, ribs and shoulder blades. Chondrosarcoma most often occurs in adults aged over 40. It’s a slow-growing form of cancer that rarely spreads to other parts of the body, and most are low-grade tumours.
• Ewing’s sarcoma (about 15% of bone cancers) – this cancer affects cells in the bone or soft tissue that multiply rapidly. It usually affects the pelvis, legs, ribs, spine and upper arms. Ewing’s sarcoma is more common in children and young adults, and are all high-grade tumours.

Types of secondary bone cancer

Any type of cancer can spread to the bone, causing secondary bone cancer. There are 2 main types of secondary bone cancer:

• Osteolytic – where bone is broken down by the cancer cells without being replaced by new bone. Holes, also called lytic lesions, might form in the bone, which increases the risk of a break or fracture.
• Osteoblastic – where new bone cells form abnormally in some areas. These areas are called osteoblastic (or sclerotic) lesions and even though they are very hard (dense), they make the bone weak and deformed.

Most people with secondary bone cancer develop either osteolytic or osteoblastic changes but some people have both.

Stages and grades

The test results will help show where the cancer is and if it has spread. This is called staging. Knowing the stage helps your doctors plan your treatment.

Grades

Grading describes how quickly a cancer might grow. In general, the lower the grade, the better the outlook

• Low grade – the cancer cells look like normal cells. They usually grow slowly and are less likely to spread.
• High grade – the cancer cells look very abnormal. They grow quickly and are more likely to spread.

Stages for primary bone cancer

Many cancers are staged using a system that divides them into 4 stages, but bone cancer is different. It is usually divided into localised or advanced. Ask your doctor to explain the stage of cancer to you.

• Localised – The cancer contains low-grade cells; found in the bone in which it started. It can be removed by surgery (resectable) or not removed completely (non-resectable).
• Advanced (metastatic) – The cancer is any grade and has spread to other parts of the body (for example the lungs).

Stages for secondary bone cancer

Secondary bone cancer is when cancer cells have spread from another part of the body to the bones. Because the cancer has spread from its original location, doctors classify secondary bone cancer as advanced or stage 4 cancer.

If you have been diagnosed with bone cancer you can speak to your doctor or nurse for more information about the stage of your cancer and the primary cancer type

Prognosis

When someone is diagnosed with bone cancer, their doctor will give them a ‘prognosis’. A prognosis is the doctor’s opinion of how likely the cancer will spread and the chances of getting better. A prognosis depends on the type and stage of cancer, as well as the person’s age and general health.

If you have bone cancer, your doctor will talk to you about your individual situation when working out your prognosis. Every person’s experience is different, and there is support available to you.

Treatment

The treatment of bone cancer is complex and requires specialist care. Research shows that having treatment at a specialist treatment centre means better recovery and longer survival.

Treatment will depend on:

• the type of primary bone cancer
• the location and size of the tumour
• whether or not the cancer has spread
• your age, fitness and general health.

Treatment for primary bone cancer

Primary bone cancer is usually treated by surgery, chemotherapy or radiation therapy, or a combination of those.

The aim is to control the cancer and maintain the use of the affected area of the body.

Many people who are treated for bone cancer go into complete remission (when there is no evidence of active cancer).

Surgery

The type of operation you have will depend on where the cancer is in the body.

• Limb-sparing surgery – to remove the cancer but save the limb. The surgeon will remove the affected part of the bone and may also take out some surrounding bone and muscle to remove as much of the cancer as possible, and to reduce the chance of the cancer coming back. The bone that is removed is replaced with a metal implant or a bone graft.
• Surgery to remove the limb (also known as amputation) – for about 1 in 10 people, the only way to remove the cancer completely is to remove the limb (amputation). This procedure is less common now because techniques used for limb-sparing surgery have improved. However, amputation may be needed in certain situations.
• Pelvis – when possible, the cancer is removed along with some healthy tissue around it (wide local excision). Some people may need to have a bone graft or a metal implant to rebuild the bone.
• Jaw or cheek bone (mandible or maxilla) – the surgeon will remove the affected bone. Bone from other parts of the body may be used to replace the affected bone. Some people may need to have chemotherapy or radiation therapy.
• Spine or skull – If surgery isn’t possible, a combination of radiation therapy and chemotherapy may be used.

Chemotherapy

This treatment uses drugs to destroy or slow the growth of cancer cells, while causing the least possible damage to healthy cells. Chemotherapy may be given for high-grade osteosarcoma and Ewing’s sarcoma:

• before surgery, to shrink the size of the tumour and make it easier to remove
• after surgery or radiation therapy to kill any remaining cancer cells
• as palliative treatment, to help stop the growth of an advanced cancer or control the symptoms.

Radiation therapy

This treatment uses targeted radiation to kill or damage cancer cells. The radiation is usually in the form of x-ray beams. Radiation therapy may be used:

• for Ewing sarcoma after surgery or chemotherapy to kill any remaining cancer cells
• as an alternative treatment to surgery if a wide local excision is not possible as palliative treatment, to stop the growth of an advanced cancer or control the symptoms.

Treatment for secondary bone cancer

The aim of treatment for secondary bone cancer is to control or shrink the cancer and relieve symptoms. This is called palliative treatment and may make you feel better.

Your treatment options will depend on:

• the type of primary cancer, if it is known
• the treatment you have already had
• how many bones are affected by cancer
• whether the cancer has spread to other parts of the body
• your symptoms and general health.

You may have treatment that affects the body as a whole (systemic) or focuses on a particular bone (local). Systemic treatments include hormone therapy, chemotherapy, targeted therapy, immunotherapy and bone-strengthening drugs. Local therapies include radiation therapy and surgery. Treatments can be given on their own or in combination.

Radiation therapy

Also known as radiotherapy, radiation therapy uses targeted radiation to kill or damage cancer cells. The radiation is usually in the form of x-ray beams. Radiation therapy is often used to reduce pain in the bone. It is usually given from outside the body and is aimed at the particular bone causing pain.

Chemotherapy

Chemotherapy uses drugs to kill or slow the growth of cancer cell, while causing the least possible damage to healthy cells.

Targeted therapy

Targeted therapy uses drugs that attack certain features – genes or proteins – in the cancer cells to stop the cancer growing and spreading. The type of drugs you have will depend on the primary cancer.

Immunotherapy

Immunotherapy works by using the body’s own immune system to fight cancer. The most common immunotherapy used to treat secondary bone cancer is checkpoint inhibitor drugs.

Hormone therapy

Hormone therapy may be used to treat breast or prostate cancer that has spread to the bone. The aim of this treatment is to lower the levels of hormones in the body or stop hormones reaching cancer cells. This can help to slow down the growth and spread of the cancer.

Surgery

Cancer can weaken bones and cause fractures. Surgery using metal rods or prostheses can be used to stabilise a fracture, or to strengthen bones which are at risk of fracturing. Surgery may also be used if the cancer is pressing on the spinal cord and causing weakness in the arms or legs.

Bone-strengthening drugs

Your doctor may prescribe medicines to help strengthen your bones, reduce bone pain and control high calcium levels in the blood. There are two options for bone-strengthening drug treatment:

• bisphosphonates – a group of drugs that can be given as an injection into a vein (intravenously) or as a tablet (orally)
• denosumab – given as an injection under the skin (subcutaneously).

Clinical trials

Over the years, clinical trials have improved treatments and led to better outcomes for people diagnosed with cancer.

Talk with your doctor about the latest clinical trials and whether you’re a suitable candidate.

You can also search for cancer trials available in Victoria through the Victorian Cancer Trials Link.

Side effects of treatment for bone cancer

All cancer treatments can have side effects. Your treatment team will discuss these with you before you start treatment. Talk to your doctor or nurse about any side effects you are experiencing.

Some side effects can be upsetting and difficult, but there is help if you need it. Call Cancer Council Tel: 13 11 20 or contact cancer support to speak with a qualified professional.

Living with advanced cancer

Advanced cancer usually means cancer that is unlikely to be cured. Some people can live for many months or years with advanced cancer. During this time palliative care services can help.

Most people continue to have treatment for advanced cancer as part of palliative care, as it helps manage the cancer and improve their day-to-day lives. Many people think that palliative care is for people who are dying but palliative care is for any stage of advanced cancer. There are doctors, nurses and others who specialise in palliative care.

Treatment may include chemotherapy, radiation therapy or another type of treatment. It can help in these ways:

• slow down how fast the cancer is growing
• shrink the cancer
• help you to live more comfortably by managing symptoms, like pain.

Treatment depends on:

• where the cancer started
• how far it has spread
• your general health
• your preferences and what you want to do.

Ask your doctor about treatment and palliative care services that may help you.

Support for carers, family and friends

Caring for someone with cancer can be difficult sometimes. If you are caring for someone with bone cancer, these organisations can help:

• Cancer Council Tel. 13 11 20
• CanTeen Tel. 1800 835 932
• Carer Gateway Tel. 1800 422 737
• Carers Australia Tel. 1800 514 845

Where to get help

• Your GP (doctor)
• Your treatment team
• Cancer Council Victoria
  • Information and support line Tel. 13 11 20 (or 13 14 50 for an interpreter)
  • Primary bone cancer
  • Secondary bone cancer
  • Sarcoma (bone and soft tissue tumours)
  • Cancer Council Victoria, My Cancer Guide - Find support services that are right for you.
• CanTeen Tel. 1800 835 932
• Nurse-on-Call Tel. 1300 606 024