Secondary (metastatic) breast cancer in the bone

When cancer that started in the breast has spread to the bones, it’s called secondary or metastatic breast cancer in the bone. 

Some people also refer to it as bone metastases or bone mets.

The bones most commonly affected are the: 

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

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.

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

The main symptoms of breast cancer that has spread to bone are: 

• Pain – particularly in the back, arms or legs, often described as ‘gnawing’ which occurs when resting or sleeping, and may get worse when lying down especially at night
• Fractures (breaks) 

Find out more about the symptoms of secondary breast cancer.

Other possible effects include: 

• Spinal cord compression  
• Low levels of blood cells, which can increase the risk of infection, anaemia, bruising and bleeding 
• Too much calcium in the blood  

Many people diagnosed with secondary breast cancer want to know how long they’ve got to live. 

Life expectancy is difficult to predict. Each person’s case is different. 

However, as treatments have improved, more and more people are living longer after their diagnosis.

Your treatment team can talk to you about the likely growth and spread (progression) of your secondary breast cancer. You may worry if their answers are vague, but it’s not possible to accurately predict how each person’s illness will respond to treatment. 

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

Treatment may include: 

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

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. 

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 can be given: 

• Into a vein (intravenously) 
• As a tablet or capsule (orally)

Intravenous (IV) bisphosphonates

Intravenous bisphosphonates can be given at your local hospital or sometimes hospice. 

• Disodium pamidronate (Aredia) is given over 90 minutes every 3 to 4 weeks 
• Ibandronic acid (Bondronat) is given over 15 minutes every 3 to 4 weeks 
• Zoledronic acid (Zometa) is given over at least 15 minutes every 3 to 4 weeks. Once you’ve had this treatment for around a year, you may be able to have it every 12 weeks instead 

Oral bisphosphonates 

Oral bisphosphonates are taken daily as either tablets or capsules.

Take them first thing in the morning on an empty stomach with water only.

Do not eat or drink anything (except the water) one hour before and up to one hour after taking your bisphosphonate. 

Stay sitting or standing for one hour after taking them to avoid irritating the oesophagus (gullet).

Oral bisphosphonates are:

• Ibandronic acid (Bondronat) 
• Disodium clodronate (Bonefos, Loron, Clasteon)  

Denosumab (Xgeva)

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

It’s usually given for as long as your treatment team feels you’re benefiting from it and any side effects can be managed.

Side effects of bisphosphonates and denosumab 

Flu-like symptoms 

Bisphosphonates and denosumab can cause joint and muscle pain, fatigue, shivering and fever. 

Low levels of calcium 

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

Calcium and vitamin D supplements are often prescribed to prevent calcium levels dropping too low.

Effects of IV bisphosphonates on the kidneys 

IV bisphosphonates can cause kidney damage, though not all bisphosphonates carry the same risk. Your doctor will check your kidney function before prescribing IV bisphosphonates. 

Osteonecrosis 

Osteonecrosis is a condition where a loss of blood flow to bone tissue causes the bone to die. It’s a less common but serious long-term side effect of bone-strengthening drugs.

It can affect the jaw, causing symptoms such as: 

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

Looking after your mouth, including your teeth and gums, can help reduce the risk. See your dentist for a check-up before starting bone-strengthening drugs. Any dental work should be done before you start bone-strengthening treatment. 

Less commonly osteonecrosis can affect the ear. 

If you have any ear pain, discharge from your ear or an ear infection while taking bone-strengthening drugs contact your treatment team.

Radiotherapy

External beam radiotherapy uses high energy x-rays to destroy cancer cells. A machine directs a beam of radiation to the area being treated. 
Radiotherapy may be used:

• To reduce pain and prevent further growth of cancer in the area affected
• After surgery to stabilise a weakened bone 

Radiotherapy carries on working after the treatment has finished, so you may not feel the benefits until a couple of weeks later.  

It’s not uncommon for pain to increase for a few days after radiotherapy. 

Radiotherapy is usually given as a single dose or as a number of doses over a few days. 

Giving more radiotherapy to the same area may be possible for some people depending on how much has been given in the past. 

There are different types of external beam radiotherapy. Some are able to 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 referred to as 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. 

Surgery is more likely 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.

Orthopaedic surgery, which involves the muscles and bones, may be considered either to treat a fracture or to try to stabilise a bone that has become weakened because of the cancer. 

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 to stabilise and strengthen them, and relieve pain. 

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

Kyphoplasty is a similar procedure. It uses a high-pressure balloon inside the vertebrae to make a space in which to put the cement, and sometimes to restore or increase the height of the vertebrae.

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 fracture.

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

Spinal cord compression

Spinal cord compression is a risk for people with secondary breast cancer that has spread to the spine.

It’s important to know who to contact at the hospital if you have any of the following symptoms at any time:

• Severe or unexplained back pain, which may also be felt around the front of the chest and belly
• Pain in the back which changes when you lie down, stand up or lift something
• Difficulty walking
• Numbness or pins and needles in the fingers, toes or bottom
• Problems controlling urine or bowel movements

Spinal cord compression is a medical emergency. It can have serious effects if not diagnosed quickly, so seek medical advice without delay to reduce the risk of any long-lasting effects.

It can happen when:

• A spinal bone (vertebra) 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. Some people may have surgery. A combination of all three treatments may also be used.

Too much calcium in the blood

Too much calcium in the blood (hypercalcaemia) can cause symptoms such as:

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

Hypercalcaemia is a medical emergency and can be serious if not diagnosed quickly. It’s important to know who to report these symptoms to if they occur, so check this with your treatment team.

To relieve symptoms you might be told to drink plenty of water. However, many people will need to be given fluids into a vein (intravenously) to help flush the calcium out of the 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 cause hypercalcaemia.

Fatigue

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

Find out more about managing fatigue in our guide (right).

Blood clots

People with breast cancer have a higher risk of blood clots.

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
• You can also call our free helpline, below