Secondary (metastatic) breast cancer in the bone

Secondary breast cancer in the bone occurs when cancer that started in the breast spreads to the bone.

The cells that have spread to the bone are breast cancer cells. It’s not the same as having cancer that starts in the bone (bone cancer).

Breast cancer cells can spread to the bone through the lymphatic system or the blood.

The bone is the most common site of secondary breast cancer. The bones most commonly affected are the:

• Spine 
• Ribs 
• Skull 
• Pelvis 
• Upper bones of the arms and legs

You may have several symptoms. It’s important to report any new or ongoing symptoms to your treatment team, however minor they seem.

The main symptoms of secondary breast cancer in the bone are: 

• Pain in your bones, often described as "gnawing". This occurs when resting or sleeping, and may get worse when lying down (especially at night) or when doing specific movements
• Fractures (breaks) that happen without injury 

Other possible effects include:

• Spinal cord compression which can cause back pain, difficulty walking, numbness, loss of bladder or bowel control and, if not treated, can lead to paralysis 
• Low levels of blood cells, which can increase the risk of infection, anaemia, bruising and bleeding
• Too much calcium in the blood, which can cause symptoms such as feeling sick (nausea) and being sick (vomiting), fatigue, passing large amounts of urine, confusion and being very thirsty

Find out more about the symptoms of secondary breast cancer.

If you’ve been told you have secondary breast cancer in the bone, you may want to know how long you have to live.

Life expectancy is difficult to predict. Each person’s case is different, and no 2 cancers progress or respond to treatment in the same way. 

However, as treatments have improved, more and more people are living much longer after a diagnosis of secondary breast cancer. 

Your treatment team can talk to you about how your secondary breast cancer may progress. 

You may worry if their answers are vague, but it’s very difficult to accurately predict how each person’s cancer will respond to treatment.

When breast cancer spreads to the bone, it can be treated but cannot be cured.

Treatment aims to control and slow down the spread of the cancer, relieve symptoms and give you the best quality of life for as long as possible.

Treatment may include: 

• Pain relief 
• Bone-strengthening therapy
• Hormone (endocrine) therapy 
• Targeted therapies
• Immunotherapy
• Chemotherapy 
• Radiotherapy
• Surgery 

You may have these treatments on their own or in combination.

Bone-strengthening therapy

Bisphosphonates and denosumab are drugs that strengthen existing bone and reduce damage caused by cancer. They work in slightly different ways.

Bisphosphonates

Bisphosphonates slow down or prevent loss of bone tissue while allowing new bone to be produced.

The most commonly used bisphosphonate drug is zoledronic acid (Zometa).

Zoledronic acid is given into a vein (intravenously) over at least 15 minutes every 3 to 4 weeks. 

You will have zoledronic acid as an outpatient at your local hospital. This can also be done at a local hospice.

You’ll have a blood test before starting zoledronic acid.

Once you’ve had this treatment for around 1 year, you may be able to have it every 12 weeks instead.

You’ll usually have zoledronic acid for as long as your treatment team feels you’re benefiting from it and any side effects are manageable. 

Denosumab (Xgeva)

Denosumab is a targeted therapy that reduces bone loss.

Denosumab is given as an injection under the skin (subcutaneously) usually once every 4 weeks.

Once you’ve had this treatment for a certain amount of time, your treatment team may recommend having it every 12 weeks instead.

You’ll usually have denosumab for as long as your treatment team feels you’re benefiting from it and any side effects are manageable.  

Side effects of bisphosphonates and denosumab 

Like any treatment, bisphosphonates and denosumab can cause side effects. Everyone reacts differently to drugs and some people have more side effects than others. These side effects can usually be managed and those described here will not affect everyone.

Side effects vary between the different bone-strengthening drugs, but they are usually mild.

If you’re worried about any side effects, regardless of whether they’re listed here, talk to your treatment team.

Flu-like symptoms 

Bisphosphonates and denosumab can cause flu-like symptoms such as:

• Joint and muscle pain
• Fatigue
• Shivering
• Fever

Low levels of calcium 

Bisphosphonates and denosumab can cause calcium levels in the blood to drop too low. This is known as hypocalcaemia.

Early symptoms include tingling around the mouth and lips and in the hands and feet.

You may be prescribed calcium and vitamin D supplements with bisphosphonates and denosumab to prevent your calcium levels dropping too low.

Eating a well-balanced diet, including foods that contain calcium and vitamin D, can also help.

Kidney changes 

Zoledronic acid can cause kidney problems. Your doctor will check your kidney function before prescribing it.

Denosumab does not cause kidney problems.

Osteonecrosis 

Some bone-strengthening drugs can cause some of the jawbone to lose its blood supply and die. This is called osteonecrosis of the jaw (ONJ).

Your treatment team will recommend you see a dentist before starting bone-strengthening drugs.

If you do not have a dentist or you’re having difficulty registering with one, let your treatment team know.

You may be given a dental alert card. You should show this to a dentist if you develop any symptoms of ONJ, including:

• Jaw pain 
• Loose teeth 
• Swelling, redness or ulcers on the gums 

Let your treatment team know straight away if you have any of these symptoms.

ONJ is hard to treat, so trying to prevent it is very important. Good dental hygiene can help reduce the risk of developing ONJ. This includes brushing your teeth and flossing, making sure dentures fit well, and having regular dental check-ups.

There’s also evidence that people who smoke are at more risk of developing ONJ. Speak to your treatment team or GP if you need support with stopping smoking.

It’s not clear how long the risk of ONJ continues once treatment is completed.

In rare cases, osteonecrosis can affect the ear. If you have any ear pain, discharge from your ear, or an ear infection while taking bone-strengthening drugs, let your treatment team know.

Fracture

Although rare, bone-strengthening drugs can cause the large bone in the upper leg (femur) to fracture. It’s not fully understood why this happens.

If you have pain in your thigh, hip or groin, let your treatment team know.  

Hormone therapy 

Some breast cancers use the hormone oestrogen in the body to help them to grow. These are known as oestrogen receptor positive or ER-positive breast cancers.

Hormone therapies block or stop the effect of oestrogen on breast cancer cells. Different hormone therapy drugs do this in different ways.

Targeted therapies

This group of drugs blocks the growth and spread of cancer. They target and interfere with processes in the cells that help cancer grow.

The type of targeted therapy you have will depend on the features of your cancer.

Chemotherapy

Chemotherapy destroys cancer cells by affecting their ability to divide and grow.

A number of chemotherapy drugs are used to treat secondary breast cancer. These drugs may be given alone or in combination with targeted therapies.

The drugs you’re offered will depend on many things, including any chemotherapy you’ve had in the past and how long ago you had it.

Radiotherapy 

Radiotherapy uses high energy x-rays to destroy cancer cells.

External beam radiotherapy is commonly used to treat secondary breast cancer in the bone. It aims to:

• Reduce pain and prevent further growth of cancer in the affected area 
• Stabilise a weakened bone after surgery 

There are different types of external beam radiotherapy.

Some deliver high doses of radiation very precisely to a single or limited number of secondary cancers in the bone. This minimises the damage to the surrounding healthy tissue.

You may hear these types of radiotherapy called stereotactic radiotherapy, CyberKnife, stereotactic ablative radiotherapy (SABR) or high dose conformal radiotherapy.

The type of radiotherapy you have will depend on your situation. Your treatment team can tell you if it may be suitable for you.

Surgery 

Although it will not cure secondary breast cancer in the bone, occasionally surgery may be part of a treatment plan.

You’re more likely to have surgery if the area of cancer in the bone is very small, can be easily accessed by the surgeon, and there’s no other secondary breast cancer elsewhere in the body.

When breast cancer spreads to the bones it can make them weak and more likely to break (fracture). Orthopaedic surgery involves the muscles and bones. It may be considered either to treat a fracture or to try to stabilise a bone that has become weakened.

Sometimes surgery is a treatment option for spinal cord compression. This type of surgery is called decompression surgery.

Spinal procedures 

If cancer is causing severe back pain and damage to the bones in the spine, you may be able to have an injection of bone cement into the bones. This will stabilise and strengthen the bones and may also relieve pain.

This is called a vertebroplasty. It’s done in the x-ray department. It takes about an hour, and you can usually go home later that day.

A kyphoplasty is a similar procedure. It uses a high-pressure balloon inside the vertebrae to make a space to put the cement into. It can also be used to restore or increase the height of the vertebrae.

Many people with secondary breast cancer in the bone feel well. However, symptoms can affect your quality of life if they are not controlled.

Pain

There are a number of effective treatments for pain caused by secondary breast cancer in the bone, including pain relief and radiotherapy.

Find out more about pain control and secondary breast cancer.

Bone weakening and fracture

Secondary breast cancer in the bone may mean the affected bones are weakened, which can increase the risk of a break (fracture).

If a bone has fractured you may need surgery to try to repair the fracture. You may have radiotherapy after the surgery. You may also be given drug treatment to stop this happening in the future.

Spinal cord compression

You may be at risk of spinal cord compression if your breast cancer has spread to your spine.

The spinal cord is a bundle of nerves that runs from the brain to the lower back. It’s protected by the bones of the spine (vertebrae).

Spinal cord compression can happen when:

• A spinal bone (vertebrae) collapses and puts pressure on the spinal cord
• Cancer grows in or near the spine, putting pressure on the spinal cord

Spinal cord compression is usually treated with radiotherapy and steroids. It can also be treated with surgery. Or you may have a combination of all 3 treatments.

You can find an alert card at the back of our Secondary breast cancer in the bone booklet. You can hand this to any healthcare professional you see if you believe you have symptoms of spinal cord compression.

Too much calcium in the blood 

Secondary breast cancer in the bone can cause calcium to be released into the bloodstream. Too much calcium in the blood is called hypercalcaemia.

Hypercalcaemia can be serious if it’s not diagnosed quickly.

It’s important to know who to report the following symptoms to if they occur, so check this with your treatment team:

• Fatigue
• Nausea and vomiting
• Loss of appetite 
• Constipation 
• Loss of concentration 
• Drowsiness
• Being very thirsty
• Passing large amounts of urine 
• Weakness
• Confusion 

Your specialist will examine you. You will usually need a blood test to check your calcium levels.

You might be told to drink plenty of water to help your symptoms. However, you may need to be given fluids into a vein (intravenously) to help flush the calcium out of your body.

If you’re not already having bone-strengthening drugs, your treatment team will prescribe these.

Eating foods that contain calcium or taking prescribed calcium supplements does not usually cause hypercalcaemia.

You will have blood tests to check your calcium levels during treatment.

Extreme tiredness (cancer-related fatigue)

Cancer-related fatigue is one of the most common symptoms of secondary breast cancer.

Find out more about managing fatigue. 

Blood clots

People with breast cancer have a higher risk of blood clots such as a deep vein thrombosis (DVT).

If you have a DVT, there’s a risk part of the blood clot could break away and travel to the lung. This is known as a pulmonary embolism (PE). 

Blood clots can be life-threatening and should be treated quickly.

Support for living with secondary breast cancer

Everyone’s experience of being diagnosed with secondary breast cancer is different, and people cope in their own way.

For many people, uncertainty can be the hardest part of living with secondary breast cancer.

You may find it helpful to talk to someone else who’s had a diagnosis of secondary breast cancer:

• Chat to other people living with secondary breast cancer on our online forum
• Find out about Living with Secondary Breast Cancer Online - please see below

We also have information for anyone caring for someone with secondary breast cancer.

You can also call our free helpline, below