SECONDARY BONE CANCER

( By JASCAP )

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Treatment

Treatment for secondary bone cancer

Treating the cancer
Relieving symptoms

Types of treatment used
Giving consent
Second opinion

Treating the cancer

A number of different types of treatment can be used to treat people with secondary bone cancer. The treatment you have will depend on:

which bone is affected
where the cancer first started (the primary cancer)
how damaged and weakened the bone is
how the cancer is affecting you Ė the symptoms you have.

The aim of treatment for a secondary bone cancer is to:

relieve any symptoms and make you more comfortable
reduce the number of cancer cells
lower the risk of developing a bone fracture
reduce the risk of developing a high calcium level in the blood (hypercalcaemia).

Relieving symptoms

Apart from painkillers and other pain relieving drugs, the main treatment used to relieve symptoms is radiotherapy. Radiotherapy may be given by a machine (similar to an x ray machine) as external beam radiotherapy, or as a radioisotope. A radioisotope is a radioactive liquid, usually given as an injection or by a drip into a vein.

Bisphosphonates (bone strengthening drugs) may be used to reduce the risk of fracture or hypercalcaemia, and to relieve pain.

Types of treatment used

The type of treatment you have depends on where your cancer started. This is because the secondary cancer cells in the bone have come from where the primary cancer is and will usually respond to the same type of treatment as the primary cancer.

To treat the cancer you may be offered:

chemotherapy
hormonal therapy

a combination of hormonal therapy and chemotherapy.

Giving consent

Before you have any treatment, your doctor will explain the aims of the treatment to you. You will usually be asked to sign a form saying that you give your permission (consent) for the hospital staff to give you the treatment. No medical treatment can be given without your consent. Before you are asked to sign the form you should have been given full information about:

the type and extent of the treatment you are advised to have
the advantages and disadvantages of the treatment
any other treatments that may be available
any significant risks or side effects of the treatment.

If you donít understand what you have been told, let the staff know straight away so that they can explain it again. Some cancer treatments are complex, so itís not unusual for people to need repeated explanations.

Itís often a good idea to have a friend or relative with you when the treatment is explained. This can help you remember the discussion more fully.

Patients often feel that hospital staff are too busy to answer their questions, but itís important for you to be aware of how the treatment is likely to affect you. The staff should be willing to make time for you to ask questions. You can always ask for more time to decide about the treatment if you feel that you canít make a decision when itís first explained to you.

You are also free to choose not to have the treatment. The staff can explain what may happen if you donít have it. It is important to tell a doctor or your nurse if you decide not to have treatment, so that they can record your decision in your medical notes. You do not have to give a reason for not wanting to have treatment, but it can be helpful to let the staff know your concerns so that they can give you the best advice.

Second opinion

Usually a number of cancer specialists work together as a team and they use national treatment guidelines to decide on the most suitable treatment for a patient. Even so, you may want to have another medical opinion. Either your specialist, or your GP, should be willing to refer you to another specialist for a second opinion, if you feel it will be helpful.

Getting a second opinion may cause a delay in the start of your treatment, so you and your doctor need to be confident that it will give you useful information. If you do go for a second opinion, it may be a good idea to take a friend or relative with you, and have a list of questions ready so that you can make sure your concerns are covered during the discussion.

Radiotherapy for secondary bone cancer

External beam radiotherapy
Radioisotopes

External beam radiotherapy

Radiotherapy is the use of high-energy rays to destroy cancer cells, while doing as little harm as possible to normal cells. It is the most common type of treatment for secondary bone cancer as it is very effective for relieving symptoms such as pain or swelling.

Radiotherapy can be given in different ways. Sometimes a single dose is given. This has the advantage that you will only need to make one visit to the radiotherapy department. Sometimes your treatment may be divided into a number of sessions. Each session is known as a fraction.

Positioning the radiotherapy machine

The way in which your treatment is given will depend on the type of cancer and its position in the body. Your doctor will discuss your treatment with you beforehand and answer any questions that you have.

Radiotherapy is normally given to the area of the bone affected by the cancer. However, if the cancer is in several areas of bone it may be necessary to give radiotherapy to a larger area. This may be referred to as hemibody irradiation, which means treating half the body.

It usually takes from 7Ė10 days for the radiotherapy to start reducing the pain and it may take up to six weeks before you feel the full effect. You may notice that the pain becomes slightly worse before getting better. During this time it is important to continue taking the painkillers prescribed by your doctors. As the pain improves, it may be possible to reduce the amount of painkillers you are taking. Itís a good idea to discuss this with your doctor or nurse before adjusting the dose.

Side effects

Usually this type of radiotherapy causes very few side effects. However, treating bones in certain areas of the body, such as the ribs or the spine, may cause some sickness for a day or so after the treatment. This can usually be prevented by taking anti sickness tablets.

Our booklet on radiotherapy discusses the treatment and how to cope with the side effects.

Radioisotopes

Radioisotopes are mildly radioactive substances. Some radioisotopes are taken up (absorbed) by bone and they are sometimes used to treat secondary cancers in the bone. The radioisotope is usually given as a liquid injected into a vein, usually in the arm.

The radioisotope travels through the bloodstream to the bones, where it gives a dose of radiotherapy to the areas affected by the cancer cells. This can help to reduce pain, often within a few days, but sometimes it will take a few weeks to start working.

The advantage of radioisotope treatment is that all the bones in the body affected by cancer will be treated. This makes it an ideal treatment if a number of your bones are affected. However, it is only suitable for treating secondary cancers (secondaries) from certain types of primary cancer.

For instance:

An injection of strontium89 may be used to treat secondaries from cancer of the prostate or breast.

Secondaries from cancer of the thyroid may be treated with iodine131.

Strontium89 A single injection is given through a small tube (a cannula) inserted into a vein. People are normally given the injection as an outpatient. Pain caused by the cancer is normally reduced several weeks after the injection. In most people the pain relief lasts for several months. The treatment is sometimes repeated if the pain comes back. After the injection of strontium, it is safe to be with other people, including children. However, your urine and blood will be very slightly radioactive for about seven days afterwards. You will be given advice to follow to reduce any risk to others.

Iodine131 is given as a treatment for bone secondaries from thyroid cancer. The iodine is given as a capsule that is swallowed, or as an odourless and colourless drink. If the iodine is used as a treatment for other types of cancer, or if itís attached to another chemical, it is likely to be given as a drip (intravenously) over a period of up to one hour.

The radioactivity in iodine131 breaks down slowly and you will need to stay in hospital in a single room for a few days. When the radioactivity reduces to a safe enough level to allow you to mix with other people you can go home.

You may need to take some special precautions for a short time after going home, such as avoiding spillages of urine. The hospital staff will explain these to you.

Side effects

Radioisotopes such as strontium89 can temporarily reduce the number of normal red and white blood cells produced by the bone marrow. When the number of white blood cells is low, youíre more likely to get an infection. If necessary, youíll be given antibiotics to treat any infection. If the number of red blood cells is low (anaemia), you may get tired easily. If the number of red blood cells is very low you may be given a blood transfusion.

Tumour flare may occur Ė this is swelling around the tumour area in the days following treatment. It can cause a temporary increase in pain and tenderness and you may need to take painkillers for a few days.

Hormonal therapy for secondary bone cancer

Hormonal therapies are often used to treat secondary cancers in the bone which have spread from primary cancers in the breast or prostate gland. Hormones are substances that occur naturally in the body. They control the activity and growth of normal cells. However, certain hormones can also affect the growth of breast cancer or prostate cancer cells.

Hormonal therapies work by lowering the levels of particular hormones in the body, or by preventing hormones from being taken up by the cancer cells. This can slow down or stop the growth of the cancer cells in the bone. Hormonal therapies can shrink the cancer and reduce, or get rid of, symptoms such as bone pain.

There are many different types of hormonal therapy and they work in slightly different ways. Sometimes two different types of hormonal therapy may be given together. Hormonal therapy is given as tablets or injections.

Side effects

Hormonal therapy can cause side effects for some people, including hot flushes and sweats in both men and women. Although the effects can be mild for many people, for others they may be quite severe. It's important to discuss the possible effects with your doctor before you start treatment. We have information on all the commonly used hormonal drugs.

Our factsheets on menopausal symptoms, and on hormonal symptoms in men have information about reducing hot flushes and sweats.

Chemotherapy for secondary bone cancer

Chemotherapy is the use of anti-cancer (cytotoxic) drugs to destroy cancer cells. They work by disrupting the growth of cancer cells.

Whether chemotherapy can be used, and the type of drugs used, will depend on where the cancer started in the body. For example, if you have cancer of the breast that has spread to the bones, you will have the chemotherapy drugs which treat breast cancer cells.

How chemotherapy is given
Benefits and disadvantages

How chemotherapy is given

The drugs may be given by injection into a vein (intravenously) or as tablets. Chemotherapy is usually given as a course of several treatments, each treatment lasting from a few hours to a few days. This is followed by a rest period of a few weeks, which allows your body to recover from any side effects. The number of treatments you have will be planned in advance, but may be altered depending on how well the chemotherapy works.

Usually, chemotherapy is given as an outpatient. Occasionally a short stay in hospital may be necessary.

Benefits and disadvantages

Many people are frightened about the idea of having chemotherapy because of the potential side effects that can occur. Chemotherapy can cause side effects but these will depend on the drugs used. Any side effects can usually be well controlled with medicines that your doctor can prescribe.

Chemotherapy for secondary bone cancer is designed to try and shrink the secondaries, to improve symptoms and quality of life, and to extend life if possible. For some people the chemotherapy will help to shrink the cancer leading to a reduction in the symptoms. However, for other people the chemotherapy will not have any effect on the cancer and they will have the side effects of the treatment with little benefit.

Making decisions about treatment in these circumstances is always difficult. You may need to discuss the possible benefits and disadvantages in detail with your doctor, before you decide whether you wish to have chemotherapy. If you choose not to have chemotherapy, you can still be given other treatments to control any symptoms that you have.

Our booklet on chemotherapy discusses the treatment and its side effects in detail. Factsheets about individual drugs and their particular side effects are also available.

Surgery for secondary bone cancer

Very occasionally, if tests show that only one area of bone has cancer in it, the affected area may be removed under general anaesthetic. The bone is then strengthened with a metal pin or replaced with a false part (prosthesis).

If a secondary tumour is near to a joint Ė such as the hip, knee or shoulder Ė the joint and the area of bone containing the tumour are usually both removed. The joint is then replaced with an artificial hip, knee or shoulder (prosthesis). If surgery is a possible option for you, your doctor will explain about the operation and answer any questions you may have.

Treating weakened bones resulting from secondary bone cancer

Bones can sometimes be weakened by secondary cancers in them. If this happens they can sometimes be strengthened or repaired.

Weak thigh or arm bones
Weak hip or shoulder joints
Percutaneous cementoplasty

Weak thigh or arm bones

Sometimes an x-ray shows that a secondary cancer has weakened a long bone such as the thigh bone (femur) or upper arm bone (humerus). If thereís a risk of the bone breaking, you may need an operation to strengthen it and prevent a break from happening.

A metal pin or a locking nail (a nail with screws at each end) can be put down the middle of the weakened bone. This secures and strengthens the bone, holding it firm so that it wonít break. The operation is carried out under a general anaesthetic. The pin or nail can stay in permanently to continually protect the bone. Whether this operation is appropriate for you will depend on which bone is affected by your secondary cancer.

You may need to stay in hospital for up to a couple of weeks after the operation to recover fully, but most people are able to start walking a couple of days after surgery. A physiotherapist may give you exercises to do to help you move your leg more easily.

Sometimes the weakness caused by the secondary bone cancer leads to a crack or a fracture in the bone before a strengthening operation has been done. If this happens, it may still be possible to mend the bone. Your doctor or specialist nurse will discuss this with you.

Weak hip or shoulder joints

If secondary cancer has caused a lot of damage to your hip or shoulder joint then you may need to have an operation to replace the joint. You will need to stay in hospital for around three to five days and will have physiotherapy afterwards to help you get used to the new joint.

You may have radiotherapy before and/or after your operation to try to destroy any cancer cells left in the area and help the bone to repair itself.

Percutaneous cementoplasty

A newer technique to strengthen a weakened bone involves injections of a bone cement. The doctor puts a needle through the skin and, using x-rays or CT scanning to guide the way, injects the cement into the weakened bone. The operation is carried out either under a general anaesthetic or after you have been given a sedative to make you feel drowsy. This technique can be used to treat bones in the arm or leg, and can sometimes be used when a tumour is affecting the spine, when it is known as vertebroplasty.

Percutaneous cementoplasty is mainly used after other treatments to strengthen the bone have been tried. Your doctor can discuss whether it would be appropriate for you. Percutaneous cementoplasty can also help to relieve bone pain.

Treating spinal cord compression resulting from secondary bone cancer

A common place for a secondary bone cancer to occur is the spine. This often causes back pain. If this affects you, your doctors will make sure you have painkillers to relieve any discomfort.

Less often, the cancer can cause pressure on the nerves in the spine. This is known as spinal cord compression and can cause symptoms, such as:

weakness in the legs
numbness or pins and needles in your toes or fingers
strange sensations
problems passing urine
constipation or problems controlling your bowels.

If you develop any of these symptoms it's important to let your doctor know as soon as possible. If you have spinal cord compression, treatment is needed straight away to relieve the pressure and prevent permanent damage to the nerves.

High doses of steroids are used to reduce the swelling and pressure around the spine. This is often followed by radiotherapy to shrink the cancer and reduce the pressure. Sometimes surgery may be used to relieve pain and strengthen the spine. The dose of steroids will be gradually reduced after the radiotherapy or surgery.

We have separate information about steroids and their possible side effects. We also have information on spinal cord compression.

Treating pain resulting from secondary bone cancer

Pain is the most common symptom of secondary bone cancer. There are different types of pain which may need different treatments. Different types of painkiller are available to treat all levels of pain and these are usually very effective. They may be given alone or alongside radiotherapy. The medical staff will discuss your pain with you. It's important to let them know if it's not controlled.

You may need to try a few different painkillers before you find one that is effective for you. Sometimes you may need to take a combination of painkillers to get the right level of pain control. You might also need to take painkillers temporarily while having other treatment. For example, it may take two to three weeks for radiotherapy to relieve the pain caused by secondary bone cancer, so youíll need to take painkillers during this time.

You may be prescribed other drugs, such as non-steroidal anti-inflammatory drugs (NSAIDs) or bisphosphonates to help relieve your pain, or be given other treatments, such as cementoplasty.

If you are having trouble sleeping, your doctor may prescribe a mild sleeping tablet for you. Other general ways of relaxing and helping to reduce your pain include:

listening to relaxation tapes or CDs
applying heat and gentle massage to painful areas
a long soak in a warm bath.

If your pain isnít controlled at any time, itís important to let your doctor or specialist palliative care nurse know as soon as possible. Palliative care nurses (sometimes called Macmillan nurses) can visit you Ė they are specialists in advising on pain and symptom control and giving emotional support.

You can ask your doctor to refer you to a specialist in palliative medicine. This is a doctor who is expert in treating symptoms such as pain.

You may find it helpful to read our booklets on controlling cancer pain and symptoms of cancer.

Research is continually going on to find new drugs, different ways of giving drugs, and new techniques to control pain for people with secondary cancer in the bone.

Bisphosphonates for secondary bone cancer

Bisphosphonates are drugs commonly used to treat secondary cancer in the bones.

There are two different types of cells found in bone Ė osteoclasts and osteoblasts. Osteoclasts destroy the old bone and osteoblasts deposit new minerals and build new bone. Cancer cells which have spread to the bone produce chemicals that change the activity of these cells, upsetting the normal balance. The osteoclasts (the cells that destroy old bone) become overactive and this commonly causes small holes in the bone.

Bisphosphonates are drugs that restrict the action of the osteoclasts. They are not a treatment for the cancer itself but may help to reduce the breakdown of the bone. This can reduce the risk of fracture, hypercalcaemia and spinal cord compression, and reduce discomfort. Your doctor may recommend that you have treatment with bisphosphonates to treat bone-pain, prevent broken bones and reduce the need for radiotherapy treatment. Bisphosphonates are also commonly used to treat high blood calcium levels.

Bisphosphonates may be given into a vein through a drip (intravenously) in the outpatient department, every 3Ė4 weeks. Some bisphosphonates can be taken as tablets, which must be taken on an empty stomach at least half an hour before food. You canít eat or drink for six hours (usually overnight) before taking some of the tablets and they should be taken when you are sitting or standing, not lying down. Your doctor, nurse or the pharmacist will explain how you should take your tablets.

Treating hypercalcaemia resulting from secondary bone cancer

If you have secondary cancer cells in the bone, this may release calcium into the blood. High levels of calcium in the blood (hypercalcaemia) can make you feel sick (nauseous), drowsy, confused and unwell. It can also cause constipation. You may need to spend a few days in hospital for treatment to reduce the calcium levels.

Your doctor or nurse may ask you to drink lots of liquids. You are also likely to have a drip (intravenous infusion) of fluids into a vein in your arm. This will increase the fluid/liquid content of your blood, and encourage your kidneys to get rid of the calcium from your body in the urine.

Your doctor will also give you medicines, such as bisphosphonates, to reduce the level of calcium in the bloodstream. These may be given through a drip over a few hours, although some bisphosphonate treatments only take 15 minutes. This treatment can be repeated if the calcium levels rise again. You should feel much better within a couple of days.

Bisphosphonates can also be taken as tablets, which may be used to maintain normal levels of calcium in the blood.

Managing the effects of secondary bone cancer treatment on the bone marrow

The bone marrow is the spongy material in the centre of some of our bones which produces blood cells. If you have secondary cancer in the bone, this may affect how the bone marrow works and may lower the number of cells in your blood. If you have a low level of red blood cells (anaemia) you may be breathless and get tired more easily. Low levels of white blood cells may make you more likely to get an infection, and a low platelet count will increase the risk of bruising and bleeding.

It may be possible to raise the number of red blood cells in your blood by giving you a blood transfusion. This may need to be repeated. Less commonly, platelet transfusions may also be given. Antibiotics can be given to treat any infection.

Newer treatments for secondary bone cancer

A number of new treatments are being tested for secondary bone cancer. These treatments may not be widely available. If your doctor thinks a newer treatment may be helpful for you, they can refer you to a specialist hospital where the treatment is being given. You may have to travel a long way to a specialist hospital.

Radiofrequency ablation

Radiofrequency ablation (RFA) uses heat to destroy cancer cells. It can help to relieve pain that hasnít responded to radiotherapy and is usually only used to treat small secondary bone tumours.

A doctor places a needle into the bone tumour. This is usually done using a CT scanner to make sure the needle is in the right place. Radiowaves are then passed down the needle into the tumour to heat, and so destroy, the cancer cells.

There are very few side effects with this treatment although it is quite common for people to have some pain or discomfort and to feel tired. You usually need to stay in hospital overnight with this treatment.

Embolization

Embolization involves injecting a drug directly into the secondary bone cancer. The drug causes the blood vessels in the tumour to block, which starves the tumour of nutrients and oxygen. This can cause it to shrink and can help to relieve pain and spinal cord compression.

Embolization is mainly used to treat secondary bone tumours in people who had primary kidney (renal) cancer and some types of thyroid cancer. The treatment can be repeated if necessary.

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