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Cancer Medicine :: Bone Cancer

Bone Cancer

Treatment Options

This section outlines treatments that are the standard of care (the best proven treatments available) for this specific type of cancer. When making treatment plan decisions, patients are also encouraged to consider clinical trials as an option. A clinical trial is a research study to test a new treatment to evaluate whether it is safe, effective, and possibly better than standard treatment. Your doctor can help you review all treatment options. 

Treatment overview

In cancer care, different types of doctors often work together to create a patient’s overall treatment plan that combines different types of treatments. This is called a multidisciplinary team.

                                                

Descriptions of the most common treatment options for bone cancer are listed below. Treatment options and recommendations depend on several factors, including the type and stage of cancer, possible side effects, and the patient’s preferences and overall health. 

For a low-grade tumor, the primary treatment is surgery. The goal of surgery is to remove the tumor and a margin of healthy bone or tissue around the tumor to make sure all of the cancer cells are gone.

For a high-grade tumor, oncologists (doctors who specializes in the care and treatment of people with cancer) often use a combination of treatments, including surgery, chemotherapy, and radiation therapy.

Surgery

Surgery is the removal of the tumor and surrounding tissue during an operation.

A surgical oncologist is a doctor who specializes in treating cancer using surgery. Surgery for bone cancer often involves a wide excision of the tumor. A wide excision means that the tumor is removed along with a margin of normal tissue around it in all directions.

If the tumor is in an arm or leg, limb-sparing techniques are used whenever possible. However, amputation (removal) of the arm or leg with the tumor may be needed depending on the tumor’s size or location.

Wide excision surgical techniques have reduced the number of amputations performed for patients with bone cancer. About 75% to 80% of patients can be treated with conservative (limb-sparing) surgery compared with amputation. These surgeries often require prostheses, such as metal plates or bone from other parts of the body, to replace the missing bone and provide strength to the remaining bone. This is called reconstructive surgery. Surgeons use soft tissue, such as muscle, to cover the reconstruction area. The tissue helps with healing and reduces the risk of infection.

For some patients, amputation may offer the best option. These include patients whose cancer is located where it cannot be completely removed by surgery, patients who cannot undergo reconstruction, or when the surgical area cannot be fully covered with soft tissue.

Children with bone cancer may require amputation more often than adults since their bones grow more. To avoid amputation, some children can be fitted for expandable joint prostheses that adjust as the skeleton grows. These prostheses require multiple operations to adjust bone length as the child grows.

It’s important to remember that the operation that results in the most useful and strongest limb may be different from the one that gives the most normal appearance. If amputation is needed, rehabilitation that includes physical therapy can help maximize the patient’s physical functioning. Rehabilitation can also help a person cope with the social and emotional effects of losing a limb. 

Chemotherapy

Chemotherapy is the use of drugs to kill cancer cells, usually by stopping the cancer cells’ ability to grow and divide. Systemic chemotherapy is delivered through the bloodstream to reach cancer cells throughout the body. Chemotherapy is given by a medical oncologist, a doctor who specializes in treating cancer with medication. A chemotherapy regimen (schedule) usually consists of a specific number of cycles given over a set period of time. A patient may receive one drug at a time or combinations of different drugs at the same time. Chemotherapy for bone cancer can usually be given as an outpatient treatment, which is treatment that can be given at a clinic or doctor’s office instead of requiring the patient to be admitted to a hospital.

Surgery alone is not usually enough treatment for patients with some bone cancers, particularly osteosarcoma. These cancers sometimes recur as distant metastases (most often in the lungs) that were most likely very small (only able to be seen with a microscope) when the person was diagnosed. The use of chemotherapy has increased survival rates for people with some types of bone cancer. In addition, chemotherapy is often useful for treating cancer that has visibly spread at the time of diagnosis.

Fast-growing bone cancer may be treated first with chemotherapy before surgery. This often reduces the size of the primary tumor and may destroy tiny areas of metastasis if some of the cancer cells have spread to other areas.

Chemotherapy that is given before surgery is called preoperative chemotherapy, neoadjuvant chemotherapy, or induction chemotherapy. For most high-grade tumors, the oncologist gives chemotherapy for three to four cycles before surgery to shrink the primary tumor and make it easier to remove. Chemotherapy before surgery may also improve survival, since it kills cancer cells that have spread from the original tumor. The tumor’s response to chemotherapy, evaluated with a microscope after the primary tumor has been removed, can be used to better determine the prognosis.

After the patient has recovered from surgery, the patient may receive additional chemotherapy to kill any remaining tumor cells. This is called postoperative or adjuvant chemotherapy. The use of chemotherapy to shrink the tumor before surgery combined with chemotherapy after surgery has saved many lives and many patients’ limbs.

Some common chemotherapy drugs given to patients with bone cancer are ifosfamide (Cyfos, Ifex, Ifosfamidum), methotrexate (multiple brand names), cyclophosphamide (Cytoxan, Clafen, Neosar), etoposide (Toposar, VePesid), cisplatin (Platinol), doxorubicin (Adriamycin), and dactinomycin (Cosmegen, Lyovac Cosmegen).

In particular, chemotherapy is very effective for Ewing sarcoma. Some drugs used to treat Ewing sarcoma are vincristine (Vincasar), dactinomycin, cyclophosphamide, doxorubicin, ifosfamide, and etoposide.

The side effects of chemotherapy depend on the individual and the dose used, but they can include fatigue, risk of infection, nausea and vomiting, loss of appetite, and diarrhea. These side effects usually go away once treatment is finished.

The medications used to treat cancer are continually being evaluated. Talking with your doctor is often the best way to learn about the medications prescribed for you, their purpose, and their potential side effects or interactions with other medications. 

Radiation therapy

Radiation therapy is the use of high-energy x-rays or other particles to kill cancer cells. A doctor who specializes in giving radiation therapy to treat cancer is a radiation oncologist. The most common type of radiation treatment is called external-beam radiation therapy, which is radiation given from a machine outside the body. When radiation treatment is given using implants, it is called internal radiation therapy or brachytherapy. A radiation therapy regimen (schedule) usually consists of a specific number of treatments given over a set period of time.

For bone cancer, radiation therapy is most often used for patients who have a tumor that cannot be removed by surgery. Radiation therapy may also be done before surgery to shrink the tumor, or it may be done after surgery to kill any cancer cells remaining after surgery. Radiation therapy makes it possible to do less extensive surgery, often preserving the arm or leg. Radiation therapy may also be used to relieve pain for people as part of palliative care .

For patients with Ewing sarcoma, radiation therapy may be combined with chemotherapy and surgery. However, oncologists have had good results in recent years using surgery for Ewing sarcoma, with or without radiation therapy. Ewing sarcoma that starts in a bone that cannot be surgically removed is treated with chemotherapy and radiation therapy.

Side effects from radiation therapy may include fatigue, mild skin reactions, upset stomach, and loose bowel movements. Most side effects go away soon after treatment is finished. 

Palliative/supportive care

Cancer and its treatment often cause side effects. In addition to treatment to slow, stop, or eliminate the cancer, an important part of cancer care is relieving a person’s symptoms and side effects. This approach is called palliative or supportive care, and it includes supporting the patient with his or her physical, emotional, and social needs.

Palliative care can help a person at any stage of illness. People often receive treatment for the cancer and treatment to ease side effects at the same time. In fact, patients who receive both often have less severe symptoms, better quality of life, and report they are more satisfied with treatment.

Before treatment begins, talk with your health care team about the possible side effects of your specific treatment plan and supportive care options. And during and after treatment, be sure to tell your doctor or another health care team member if you are experiencing a problem, so it is addressed as quickly as possible. 

Recurrent bone cancer

A remission is when cancer cannot be detected in the body and there are no symptoms. This may also be called “no evidence of disease” or NED. 

A remission can be temporary or permanent. This uncertainty leads to many survivors feeling worried or anxious that the cancer will come back. While many remissions are permanent, it’s important to talk with your doctor about the possibility of the cancer returning. Understanding the risk of recurrence and the treatment options may help you feel more prepared if the cancer does return. 

If the cancer does return after the original treatment, it is called recurrent cancer. It may come back in the same place (called a local recurrence), nearby (regional recurrence), or in another place (distant recurrence).

When this occurs, a cycle of testing will begin again to learn as much as possible about the recurrence. After testing is done, you and your doctor will talk about your treatment options. Often the treatment plan will include the therapies described above (such as surgery, chemotherapy, and radiation therapy) but may be used in a different combination or given at a different pace. Your doctor may also suggest clinical trials that are studying new ways to treat this type of recurrent cancer.

People with recurrent cancer often experience emotions such as disbelief or fear. Patients are encouraged to talk with their health care team about these feelings and ask about support services to help them cope. 

Metastatic bone cancer

If cancer has spread to another location in the body, it is called metastatic cancer. Patients with this diagnosis are encouraged to talk with doctors who are experienced in treating this stage of cancer because there can be different opinions about the best treatment plan. 

Your health care team may recommend a treatment plan that includes a combination of surgery, chemotherapy, and radiation therapy. Supportive care will also be important to help relieve symptoms and side effects.

For many patients, a diagnosis of metastatic cancer can be very stressful and, at times, difficult to bear. Patients and their families are encouraged to talk about the way they are feeling with doctors, nurses, social workers, or other members of the health care team. It may also be helpful to talk with other patients, including through a support group.

If treatment fails

Recovery from cancer is not always possible. If treatment is not successful, the disease may be called advanced or terminal cancer.

This diagnosis is stressful, and this is difficult to discuss for many people. However, it is important to have open and honest conversations with your doctor and health care team to express your feelings, preferences, and concerns. The health care team is there to help, and many team members have special skills, experience, and knowledge to support patients and their families. Making sure a person is physically comfortable and free from pain is extremely important.

Palliative care given toward the end of a person’s life is called hospice care. You and your family are encouraged to think about where you would be most comfortable: at home, in the hospital, or in a hospice environment. Nursing care and special equipment can make staying at home a workable alternative for many families.

Coping with Side Effects

Fear of treatment side effects is common after a diagnosis of cancer, but it may help to know that preventing and controlling side effects is a major focus of your health care team. This is called palliative or supportive care, and it is an important part of the overall treatment plan, regardless of the stage of disease.

Common side effects from each treatment option for bone cancer are described in detail within the Treatment section.  Side effects depend on a variety of factors, including the cancer’s stage, the length and dosage of treatment(s), and your overall health.

Before treatment begins, talk with your doctor about possible side effects of each type of treatment you will be receiving. Ask which side effects are most likely to happen, when they are likely to occur, and what can be done to prevent or relieve them. And, ask about the level of caregiving you may need during treatment and recovery, as family members and friends often play an important role in the care of a person with bone cancer. 

In addition to physical side effects, there may be psychosocial (emotional and social) effects as well. Patients and their families are encouraged to share their feelings with a member of their health care team who can help with coping strategies. 

During and after treatment, be sure to tell the health care team about the side effects you experience, even if you feel they are not serious. Sometimes, side effects can last beyond the treatment period, called a long-term side effect. A side effect that occurs months or years after treatment is called a late effect. Treatment of both types of effects is an important part of survivorship care. 

After Treatment

After treatment for bone cancer ends, talk with your doctor about developing a follow-up care plan. This plan may include regular physical examinations and/or medical tests to monitor your recovery for the coming months and years. For bone cancer, follow-up care typically includes general physical examinations, blood tests, and imaging studies (such as a bone scan, CT scan, or x-rays) to check for signs that the cancer has come back. Tell your doctor about any new symptoms, such as swelling or bone pain, because they may be signs that the cancer has come back or signs of another medical condition.

Patients who have surgery for bone cancer, particularly amputation, often need physical therapy and other types of rehabilitative therapies. Follow-up care should also address the patient’s quality of life, including social and emotional concerns, especially if amputation was necessary. 

People recovering from bone cancer are encouraged to follow established guidelines for good health, such as maintaining a healthy weight, not smoking, eating a balanced diet, and having recommended cancer screening tests. Talk with your doctor to develop a plan that is best for your needs. For bone cancer survivors who smoke, quitting smoking may help recovery and reduce the risk of cancer recurrence. 

Moderate exercise can help you rebuild your strength and energy level. Talk with your doctor about helping you create an appropriate exercise plan based upon your needs, physical abilities, and fitness level.

Latest Research

Doctors are working to learn more about bone cancer, ways to prevent it, how to best treat it, and how to provide the best care to people diagnosed with this disease. The following areas of research may include new options for patients through clinical trials. Always talk with your doctor about the diagnostic and treatment options best for you.

Intraoperative radiation therapy. Clinical trials are evaluating the usefulness of radiation therapy given inside the body during surgery for some Ewing tumors. This is called intraoperative radiation therapy or internal radiation therapy.

Myeloablative therapy. A supplement to the treatment options for Ewing tumors is myeloablative therapy with stem cell support. Myeloablative therapy, an intense regimen of chemotherapy, destroys all cells that are dividing rapidly. This includes cancer cells but also some normal cells. Stem cells are cells that create all other types of cells in the body. They may be given to the patient after myeloablative therapy to boost the patient’s recovery.

Targeted therapy. Targeted therapy is a treatment that targets the cancer’s specific genes, proteins, or the tissue environment that contributes to cancer growth and survival. This type of treatment blocks the growth and spread of cancer cells while limiting damage to normal cells.

A type of targeted therapy being looked at for bone cancers, as well as other types of sarcoma, is called insulin-like growth factor receptor (IGFR) inhibitors. The IGFR is an important growth protein for sarcomas. Blocking its activity may be an important new way to improve sarcoma treatment. Early results look promising, but the clinical trials are still ongoing. Some research suggests that combining an IGFR inhibitor with other targeted therapies, such as an mTOR inhibitor, may be a more effective treatment. An mTOR inhibitor blocks the protein mTOR, which is another growth protein for sarcomas. 

Supportive care. Clinical trials are underway to find better ways of reducing symptoms and side effects of current bone cancer treatments in order to improve patients’ comfort and quality of life.

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