Understanding Lung Cancer Metastases to Bone

Treatments and Prognosis for When Lung Cancer Spreads

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physician looking a an x-ray for evidence of bone metastases
What treatments are available for lung cancers that have spread to the bones?. mediaphoto/istock

Bone metastases from lung cancer (the spread of lung cancer to bones) are all too common with lung cancer, affecting 30 to 40 percent of people with advanced lung cancer. In fact, as survival rates for lung cancer are increasing, the number of people living with bone metastases is also increasing.

In addition to causing considerable pain and discomfort, bone metastases can result in fractures that interfere with daily activities and lessen your quality of life. What are the symptoms, treatments, and prognosis for lung cancer with bone metastases?

Overview

Lung cancer with bone metastases refers to lung cancer cells that spread to bone either through the bloodstream or through the lymphatics (vessels that carry infection-fighting cells through the body). Cancer metastatic to bone is different than bone cancer—cancers that originate in the bones and are made up of abnormal bone cells. Cancer metastatic to bone is made up of cells that originate in the primary cancer—in this case, the lungs. If this is confusing, you can learn more about how cancer spreads through the body.

What Bones Does Lung Cancer Spread To?

Lung cancer is the third most common form of cancer to spread to bones (after breast cancer and prostate cancer), and when metastases to bone are found without an obvious source, half of the time it is related to an underlying lung cancer. The most common bones to which lung cancer spreads include:

  • The spine (especially vertebrae in the chest and lower abdominal areas)
  • The pelvis
  • The upper bones of the arms and leg (the humerus and femur)

Lung cancer is also somewhat unique in that it can spread to bones in the hands and feet.

Symptoms

Pain is usually the first symptom of lung cancer with bone metastases. The pain may initially feel like a muscle pull or strain, but gradually worsens and can become severe. When bone metastases involve the arms and legs, pain is often worse with movement. Pain due to the spread of lung cancer to the spine is often worse at night and after resting in bed.

If bone metastases involve the spine, compression of the spinal cord due to the tumor may cause pain with walking and weakness or tingling in the legs. If spinal cause compression is severe in the lower spine (cauda equina syndrome), pain and weakness in the legs may occur along with the loss of bowel or bladder function. This is a medical emergency, and symptoms can become permanent without prompt treatment.

Sometimes the first symptom that lung cancer has spread to the bone is a fracture (pathological fracture) In this setting, cancer cells replace normal bone tissue, weakening it so it is more likely to break. These fractures may occur without any significant trauma (even rolling over in bed) and during normal daily activities.

Due to the breakdown of bone, which releases calcium, an elevated level of calcium in the blood (hypercalcemia) may cause confusion, nausea and vomiting, thirst, and muscle weakness.

Complications 

As noted above, bone metastases can cause several types of symptoms, many of which lower the quality of life for people living with lung cancer.

  • Pain - Pain related to bone metastases can be very severe, impairing quality of life. In addition, medications to treat the pain may result in further fatigue, as well as constipation.
  • Fractures - Fractures are, of course, often painful, but they reduce quality of life as well. Combined with cancer, decreased mobility due to a fracture increases the risk of developing blood clots and pulmonary emboli.
  • Spinal Cord Compression - In addition to causing symptoms, spinal cord compression is a medical emergency which can cause paralysis and loss of bowel and bladder control.
  • Hypercalcemia - In addition to causing the symptoms above, hypercalcemia in cancer patients is an emergency, and can result in abnormal heart rhythms, disorientation, and even death. Symptoms of hypercalcemia may include nausea and vomiting, increased thirst, decreased urination, muscle and joint aches, weakness, and confusion.
  • Extra Radiation, Surgery, and Medications - If radiation treatment, surgery or medications are used to treat complications of bone metastases, the side effects of these treatments are added to the side effects of the treatments used to treat cancer in the first place.
  • Missed Treatments - One complication that is not often appreciated, is how bone metastases may detract from other treatments for cancer. In this way, skeletal related events (such as fractures) can be part of a vicious circle in which cancer causes a problem (for example a fracture) which in turn is something which may limit the use of medications and surgery to treat cancer.

Diagnosis

Tests that are used to look for bone metastases may include:

  • Bone scans: Bone scans are used less frequently to look for bone metastases than in the past, and it can sometimes be difficult to distinguish cancer from other bone conditions.
  • PET scans: PET scans are very sensitive for detecting bone metastases, as they look for areas of active tumor growth in bone.
  • MRI scans
  • CT scans

Treatment

Treatment for lung cancer with bone metastases is primarily palliative—that is, it is meant to relieve symptoms, but not cure cancer. The primary goal of treatment is to reduce pain caused by the metastases and to treat or prevent fractures and other complications. That said, for people with only a few metastases (something termed oligometastatic), physicians may consider treating the metastases aggressively with the hope of long-term survival (see below).

Treatment options for bone metastases are listed below. Most important to keep in mind, however, is that a goal of treatment should be to relieve any pain or discomfort you are experiencing. Studies tell us that good pain relief is possible. That said, a few things can make sure this happens. It's important for people with cancer to realize that pain medications, when used as directed, rarely lead to addiction, and you will not reduce your chance of having pain relief in the future if you use pain medications now. It's also important to be your own advocate in your cancer care and to let your doctor know if you have any pain which is interfering with your quality of life.

Options for treatment include both systemic (throughout the body) and local (addressing the bone metastases alone) therapies. Let's look at each of these separately.

Systemic Treatment Options

General treatments for metastatic lung cancer, such as chemotherapy, targeted therapies, and immunotherapy, may reduce bone metastases. The first immunotherapy drug for lung cancer was approved in 2015, and now four such drugs are available for lung cancer. As a positive finding, a 2018 study found that the presence of bone metastases was an independent predictor that Opdivo (nivolumab) may be effective for the cancer.

Local Treatment Options

There are several options available for treating bone metastases in addition to whatever treatment you are undergoing for your cancer itself. These treatments may be used alone or in combination depending on the severity of your pain and the complications which could occur. Options include:

Pain medications - Both anti-inflammatory medications and narcotics, such as morphine, may be used to control pain from bone metastases.Here is more information on managing pain due to cancer.

Radiation Therapy- Radiation is the most common treatment used to lessen pain, prevent fractures, and relieve spinal cord compression from bone metastases. Most people get substantial pain relief from radiation therapy, and for many people, radiation can relieve their pain completely.

Surgery - Surgery is used primarily to stabilize bones if they fracture, or to prevent a fracture in a bone that is very weakened by cancer (impending fracture). Surgery may sometimes be used if the tumor is causing significant pressure on the spinal cord, such as with cauda equina syndrome.

Bone targeted therapies or bone-modifying therapies - You may hear your doctor speak about bone-modifying therapies. These therapies include both the use of bisphosphates (discussed next) and the use of denosumab).

Bisphosphonates - Bisphosphonates are medications that have been used to treat osteoporosis (thin bones), but may also help to prevent the breakdown of bone in people with bone metastases due to cancer. Medications used for people with lung cancer include Zometa (zoledronic acid) and Prolia (denosumab.)   

These medications are relatively safe, in rare instances they can cause a complication known as osteonecrosis of the jaw (the breakdown of bone in the jaw) and kidney damage. They may be used after a complication of bone metastases has occurred, or to prevent complications in the first place. Zometa and Prolia have a further advantage of having anticancer properties. Both Zometa and Prolia are given as intravenous therapies (IV) every three to four weeks for Zometa, or every two to four weeks with Prolia.

Denosumab - Denosumab is a human antibody that has been used with some success for people with breast and prostate cancers which have spread to bones. So far it's thought that it may decrease the complications, such as fractures, related to lung cancer which has spread to bones. It's also thought that it could have some effect on the cancer itself since it has anti-tumor properties. Denosumab is given as a subcuticular injection (just under the skin) every four weeks.

Radionuclide Treatment - Radionuclide treatment is an approach to treating bone metastases that has previously been used primarily for prostate and breast cancers. A review of a few trials done to date found that this treatment resulted in pain relief for 75 percent of people with lung cancer beginning one to five weeks after treatment and lasting up to six months. It's hoped that larger studies will evaluate the use of this method in the near future.

Clinical trialsClinical trials are in progress looking at better ways to treat bone metastases due to cancer.

Alternative Treatments - Researchers are also looking at complementary methods of treating bone pain due to metastatic cancer, and acupuncture may hold promise when used in addition to these other treatments.

Treatment of Solitary and Oligometastases

As noted above, in rare cases for people with a single or only a few metastases to bone from lung cancer, stereotactic radiation therapy (SBRT) may be considered. Thus far this has been done primarily for people with single or few metastases to the brain or liver.

Prognosis

The median survival—that is, the amount of time after which 50 percent of people are alive and 50 percent have passed away—is sadly less than six months for people with bone metastases from lung cancer. Survival is somewhat higher for women, those with adenocarcinoma, people with only one bone metastasis, and individuals who do not have any fractures. That said, some people have survived and done well for many years following a diagnosis of lung cancer with bone metastases.

A Word From Verywell on Bone Metastases From Lung Cancer

Learning that you have bone metastases from lung cancer is heartbreaking. It means that your cancer is stage 4 (metastatic) and is no longer curable. In addition, bone metastases can be very painful and affect your ability to get around. That said, treatments are improving. Treatments for metastatic cancer, such as chemotherapy, targeted therapies, and immunotherapy may help with bone metastases as well. In addition, bone metastases can be treated locally with options such as bone-modifying drugs (which may have anti-cancer effects) and radiation therapy. While the prognosis is poor overall, some people have lived many years with bone metastases from lung cancer.

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