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, also known as bone sarcoma, is rare. About 250 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 bones are one of the most common sites that cancer spreads to.

Signs and symptoms of bone cancer

The most common symptom of primary and secondary bone cancer is strong pain in the affected bone or joint. The pain gradually becomes constant and doesn’t improve with mild pain relievers such as paracetamol. It may be worse at night or during activity.

There are other symptoms of primary and secondary bone cancer apart from pain:

• swelling over the affected part of the bone
• stiffness or tenderness in the bone
• problems with moving around, for example an unexplained limp
• loss of feeling in the affected limb
• unexplained fractured bone
• unexplained weight loss
• tiredness
• 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 there are some things that can make it more likely to develop primary bone cancer. These are called risk factors and they 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 at a young age. Most people who have radiation therapy will not develop primary bone cancer.
• Other bone conditions – some people who have Paget’s disease of the bone, fibrous dysplasia or multiple enchondromas are at higher risk of developing primary bone cancer. Some studies also suggest that people who have had a soft tissue sarcoma have an increased risk of developing primary bone cancer.
• 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. Most bone cancers are not hereditary. 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. Often there is no clear reason for getting primary bone cancer. If you are worried about your risk factors, ask your doctor for advice.

Risk factors for secondary bone cancer

Secondary bone cancer is always caused by cancer cells spreading to the bone from somewhere else in the body.

It is not fully understood why some people develop secondary bone cancer and others don’t.

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
• x-ray – a scan that takes a two-dimensional picture of the inside of the body that can reveal bone damage or the creation of new bone
• bone scan – a small amount of radioactive dye is injected into a vein and a scan is then taken that allows doctors to see any abnormal changes in the bones
• 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 outer part of the affected bone for examination under a microscope.

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 in children and young adults 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 blade. Chondrosarcoma most often occurs in middle-aged and older people. 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 14% of bone cancers) – this cancer affects cells in the bone or soft tissue and is often associated with a large lump. 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

Grades

The grade of the cancer means how quickly a cancer might grow. In general, the lower the grade, the better the prognosis.

Knowing the grade also helps your healthcare team plan the most suitable treatment for you.

• Low grade – the cancer cells look similar to normal cells. They are usually slow-growing and less likely to spread.
• High grade – the cancer cells look very different from normal cells. 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.

Prognosis and survival rates

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 for primary bone cancer

Treatment for primary bone cancer will depend on the type of primary bone cancer, the location and size of the tumour, whether or not the cancer has spread and your age, fitness, general health and preferences.

Treatment for primary bone cancer usually includes:

• surgery
• chemotherapy
• radiation therapy, or
• a combination of these treatments.

Surgery

There are different types of surgery that depend on the location of the cancer. People with cancer in a limb (arm or leg) may have these surgical options:

• 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) – in some cases when it is not possible to remove all of the cancer without affecting the arm or leg too much, the limb is removed (amputated). After the area has healed you may be fitted for an artificial limb. This procedure is less common now, applying to about 1 in 10 people.

People with bone cancer in other parts of the body may have surgery to remove the affected part of the bone where possible.

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

Radiation therapy (also known as radiotherapy) uses a controlled dose of radiation, such as focused x-ray beams, to kill or damage cancer cells. It may be used for Ewing’s sarcoma:

• after surgery or chemotherapy to kill any remaining cancer cells
• to help control the cancer if it’s not possible to remove the tumour surgically
• 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.

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 starves cancer cells that need hormones to grow.

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 attack the cancer. The most common immunotherapy used to treat secondary bone cancer is checkpoint inhibitor drugs.

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.

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 2 options for bone-strengthening drug treatment:

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

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 caring cancer nurse.

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