1. What is secondary breast cancer in the bone?
2. What’s my prognosis (outlook)?
3. Newly diagnosed or worried about a symptom?
4. The bones
5. How is secondary breast cancer in the bone treated?
6. Secondary breast cancer in the bone marrow
7. Palliative and supportive care
8. How to manage the symptoms of secondary breast cancer in the bone
9. Blood clots
10. Support for living with secondary breast cancer

1. What is secondary breast cancer in the bone?

Breast cancer that has spread to the bones is known as secondary or metastatic breast cancer in the bone. Some people also refer to it as bone metastases or bone mets.

Secondary breast cancer occurs when breast cancer cells spread from the primary (first) cancer in the breast to other parts of the body. This may happen through the blood or lymphatic system.

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

Sometimes secondary breast cancer can affect the bone marrow.

Secondary breast cancer in the bone is not the same as having cancer that starts in the bone. The cancer cells that have spread to the bone are breast cancer cells.

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2. What’s my prognosis (outlook)?

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.

After a diagnosis of secondary breast cancer, many people want to know how long they’ve got to live. As treatments have improved, more and more people are living longer after a diagnosis of secondary breast cancer. However, life expectancy is difficult to predict as each person’s case is different and no two cancers are the same.

Your specialist can talk to you about the likely progression of your secondary breast cancer. You may worry if their answers are vague, but it isn’t possible to accurately predict how each person’s illness will respond to treatment.

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3. Newly diagnosed or worried about a symptom?

In the days or weeks after a diagnosis of secondary breast cancer, you may feel in turmoil and find it hard to think clearly.

You can read our information for people newly diagnosed with secondary breast cancer, including where to find support.

If you haven’t been diagnosed but are worried about a symptom, find out more about the signs and symptoms of secondary breast cancer.

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4. The bones

To understand some of the symptoms of secondary breast cancer in the bone, it may help to know more about bones.

Bone contains two main types of living cells:

  • osteoclasts destroy and remove small amounts of old or damaged bone
  • osteoblasts help build up new bone

This process continues throughout life to keep the skeleton healthy and strong.

When breast cancer cells spread to the bone, chemicals are produced that disrupt this process. The osteoclasts can become overactive, causing more bone to be broken down than is being replaced. This can lead to some of the symptoms of secondary breast cancer in the bone.    

Areas of secondary cancer in the bone may be described as:

  • osteolytic – the cancer causes breakdown or thinning of the bone
  • osteoblastic – the cancer increases the production of rigid, thick bone

Often areas of secondary breast cancer have both of these.

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5. How is secondary breast cancer in the bone treated?

Treatment for secondary breast cancer in the bone aims to relieve symptoms such as pain, maintain and improve mobility and strengthen the bones, as well as slow down the growth of the cancer.

Treatments can be given alone or in combination.

When making decisions about how best to treat you, your specialist team will consider factors such as:

  • how extensive the cancer is in the bones
  • whether the cancer has spread to other organs
  • any symptoms you have
  • what treatment you’ve had in the past
  • the features of the cancer
  • whether you have been through the menopause
  • your general health

Your specialist should discuss any recommendations for treatment with you and take into account your wishes. They will talk with you about your options, explain what the aims of treatment will be and help you weigh up the potential benefits against the possible side effects.

Bone-strengthening therapy

Bisphophonates and denosumab are drugs that work in slightly different ways to strengthen existing bone and reduce the damage caused by cancer.

They also help control the level of calcium in the blood so that it doesn’t become too high.

Bisphosphonates

Bisphosphonates slow bone breakdown while allowing new bone to be produced as normal.

Bisphosphonates can be given:

  • into a vein (intravenously)
  • as a tablet or capsule (orally)

Both oral and intravenous treatments are effective and your specialist will recommend whichever is most appropriate for you.

Intravenous (IV) bisphosphonates
Intravenous bisphosphonates can be given at your local hospital or sometimes hospice. Usually you’ll need some blood tests before the treatment is given. This includes a test to check your kidney function and the levels of calcium in your blood.

Disodium pamidronate (Aredia) is given over 90 minutes, every three to four weeks.

Ibandronic acid (Bondronat) is given over 15–60 minutes, every three to four weeks.

Zoledronic acid (Zometa) is given over 15–30 minutes, every three to four 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, ideally first thing in the morning on an empty stomach with water only.

They can’t be absorbed when there’s food or calcium-containing liquid, such as milk, in the stomach. This means you shouldn’t eat or drink anything one hour before and up to one hour after taking your bisphosphonate. You may be told to stay sitting or standing for one hour after taking them to avoid any irritation to the oesophagus (gullet).

Ibandronic acid (Bondronat) is given as tablets.

Disodium clodronate (Bonefos, Loron, Clasteon) can be given as either a tablet or capsule.  

Denosumab (Xgeva)

Denosumab is a targeted (biological) therapy specifically for secondary breast cancer in the bone. It’s given as an injection under the skin (subcutaneous) usually once every four weeks.

Denosumab reduces bone loss, making complications of secondary breast cancer in the bone less likely to happen. Denosumab works by attaching to a substance called RANKL, which is involved in causing bone to be broken down.

It’s usually given for as long as the secondary cancer in the bone is under control.

Side effects of bisphosphonates and denosumab

Everyone reacts differently to drugs and some people have more side effects than others. Side effects vary between the different bone-strengthening drugs, but are usually mild.

If you’re concerned about any side effects, regardless of whether they’re listed here, talk to your specialist team as they may be able to help you manage them.

Flu-like symptoms
Bisphosphonates and denosumab can cause flu-like symptoms, such as joint and muscle pain, fatigue, shivering and fever.

Low levels of calcium
Bisphosphonates and denosumab can cause the 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.

Calcium and vitamin D supplements are often prescribed with bisphosphonates and denosumab to prevent calcium levels in your blood dropping too low. Vitamin D helps your body absorb calcium.

Blood tests will be done before you start denosumab to check your levels of calcium and vitamin D.

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.

Denosumab doesn’t cause kidney damage.

Osteonecrosis 
Osteonecrosis is a condition where there is a loss of blood flow to bone tissue, which causes the bone to die. It is an uncommon but serious long-term side effect of bone-strengthening drugs. It can affect the jaw and more rarely the ear.

If it affects the jaw it is known as osteonecrosis of the jaw or ONJ. The lower jaw is more commonly affected.

Symptoms include:

  • persistent jaw pain
  • loose teeth
  • swelling, redness or ulcers on the gums

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

See your dentist for a check-up before starting treatment with bone-strengthening drugs. Tell your dentist that you’ll be taking a bone-strengthening drug as they can cause problems such as infection and delayed healing following dental surgery.

Speak to your specialist if your dentist recommends any dental treatment.

Osteonecrosis can also affect the ear. If you have any ear pain, discharge from your ear or an ear infection while taking bone-strengthening drugs contact your specialist.

Fracture
Although rare, bone-strengthening drugs can cause fractures. It’s not fully understood why this happens, but it’s more likely in people who have been on them for a long time.

Fractures can happen with little or no trauma. If you experience any persistent thigh, hip or groin pain, contact your specialist team so you can be assessed.

Pregnancy

Taking bisphosphonates or denosumab while pregnant may have a harmful effect on a developing baby. Some women can still become pregnant even if their periods are irregular or have stopped, so effective barrier contraception such as a condom should be used.

Hormone (endocrine) therapy

Hormone therapy is used to treat breast cancers that are oestrogen receptor positive (ER+).

Tissue from your primary breast cancer will usually have been tested to see if it is ER+.  However, in some people the oestrogen receptors change during the development of the secondary breast cancer. Because of this, your doctor may discuss taking a sample of bone (or another area of secondary breast cancer) to retest for hormone receptors.

Targeted (biological) therapies

Targeted therapies are a group of drugs that block the growth and spread of cancer. They target and interfere with processes in the cells that cause cancer to grow.

The most widely used targeted therapies are suitable for people whose cancer is HER2 positive

There are various tests to measure HER2 levels, which will usually have been done using tissue from your primary breast cancer. However, in some people the HER2 levels change during the development of the secondary breast cancer. Because of this, your doctor may discuss doing a biopsy of the secondary breast cancer to retest for HER2.

The most common targeted therapy used for HER2 positive breast cancer is trastuzumab (Herceptin).

Chemotherapy

Chemotherapy is treatment that destroys cancer cells using anticancer drugs.

A number of chemotherapy drugs are used to treat secondary breast cancer. These drugs may be given alone or in combination. The drugs you’re offered will depend on many factors, including any chemotherapy you had in the past and how long ago it was.

Radiotherapy

Radiotherapy is very commonly used to treat secondary breast cancer in the bone.

Radiotherapy uses high energy x-rays to destroy cancer cells. It aims to reduce pain and prevent further growth of cancer in the area affected. It can also be used 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 to have an increase in pain after radiotherapy for one or two days.

Radiotherapy is usually given as a single dose or divided into a number of doses over a few days. It’s usually given only once to an affected area. Giving more radiotherapy to the same area may be possible for some people depending on how much has been given in the past.

Stereotactic radiotherapy

Stereotactic radiotherapy is a very precise radiotherapy treatment that may be considered for some people with a single or limited number of secondary cancers in the bone.

The treatment allows high doses of radiation to be delivered with extreme accuracy and minimal damage to the surrounding tissue.

Stereotactic radiotherapy may also be called CyberKnife, which is the name of the radiotherapy machine. Stereotactic radiotherapy is a specialist treatment and is not widely available. Your specialist team can tell you if it may be suitable for you.

Radioisotopes

This is another way of giving radiotherapy, although it’s rarely used for secondary breast cancer in the bone and is usually available only as part of a clinical trial.

A radioisotope is given in a liquid form as an injection into a vein. The radioisotope travels through the bloodstream and delivers radiotherapy to the bones affected by the cancer cells. It’s sometimes useful when there are several areas of cancer throughout the body.

Surgery

When breast cancer spreads to the bones it can make them weak and more likely to fracture. 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.

Vertebroplasty

If the secondary breast 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.

Availability of treatments

Some treatments for secondary breast cancer may not be routinely available in the NHS. You may still be able to access these treatments in other ways.

Macmillan Cancer Support has information about what you can do if a treatment isn’t available.

It can be frustrating and distressing if a treatment you and your cancer specialist feel could benefit you isn’t routinely available. For help and advice about accessing a treatment, you can speak to your specialist team. You can call our Helpline on 0808 800 6000 to talk through your concerns.

Clinical trials

Many breast cancer trials look at new treatments or different ways of giving existing treatments, such as surgical techniques, hormone therapy, chemotherapy, targeted therapies or radiotherapy.

Your specialist may talk with you about a clinical trial, or if you’re interested in taking part in clinical research you can ask them if you’re eligible for a trial.

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6. Secondary breast cancer in the bone marrow

In some cases secondary breast cancer affects how the bone marrow works.

Bone marrow is a spongy material found in the hollow part of bones. It makes blood cells (white blood cells, red blood cells and platelets) to replace those which are naturally used up in the body.

Secondary breast cancer in the bone marrow may cause low levels of red blood cells, white blood cells and platelets and can lead to anaemia, increased risk of infection and bruising or bleeding.

A blood test and a bone marrow biopsy may be needed to confirm a diagnosis.

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7. Palliative and supportive care

Palliative and supportive care focuses on symptom control and support. It’s an extremely important part of the care and treatment for many people with secondary breast cancer and can significantly improve quality of life for them and their families.  

People often think of palliative care as being associated with end-of-life treatment. However, many people value having it at any stage of their illness, alongside their medical treatment, to help prevent and relieve symptoms such as pain or fatigue. It can also help with the emotional, social and spiritual effects of secondary breast cancer.

You can be referred by your specialist team, GP or breast care nurse depending on your situation. Some people may be able to refer themselves.

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8. How to manage the symptoms of secondary breast cancer in the bone

Pain

Secondary breast cancer in the bone can cause pain in or near the affected area, though not all areas of secondary breast cancer will cause pain.

Pain may come and go, and can range from mild to severe. It may feel like a dull ache or a burning or stabbing pain. You may find that the pain is persistent, is worse at certain times such as at night, or that certain movements affect it.

Pain can affect your mobility and quality of life, but most pain can be relieved or controlled.

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

It’s very important that your pain is assessed regularly by your nurse or doctor to make sure it remains under control.

Bone weakening and fracture

Secondary breast cancer in the bone may mean that the affected bones are weakened, which can increase the risk of fracture. This is called a pathological fracture, which means the break in the bone is due to disease and not caused by an accident.

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.

Spinal cord compression

Spinal cord compression is a risk for people with secondary breast cancer in the bone that has spread to the spine. It can happen when:

  • a vertebra (spinal bone) collapses and puts pressure on the spinal cord
  • cancer grows in or near the spine, putting pressure on the spinal cord

The spinal cord is a bundle of nerves that runs from the brain to the lower back, and is protected by the vertebrae.

Symptoms can include:

  • 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

It’s important to know who to contact at the hospital if you have any of these symptoms at any time. Spinal cord compression can have serious effects if not diagnosed quickly, so seek medical advice without delay to reduce the risk of any long-lasting effects.

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.

Hypercalcaemia (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 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 can be serious if not diagnosed quickly, so seek medical advice if you have any of these symptoms. Your doctor will examine you and will usually request a blood test to check your calcium levels.

To relieve your 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 doctor will prescribe these.

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

Fatigue

Cancer-related fatigue (extreme tiredness) is one of the most common symptoms experienced by people with secondary cancer.

Find out more about fatigue and how to manage it.

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9. Blood clots

People with breast cancer have a higher risk of blood clots. Their risk is higher because of the cancer itself and some treatments for breast cancer.

You may be at risk of a blood clot forming known as a deep vein thrombosis (DVT). People with a DVT are at risk of developing a pulmonary embolism. This is when part of the blood clot breaks away and travels to the lung.

Blood clots can be harmful but are treatable so it’s important to report symptoms as soon as possible.

If you experience any of the following symptoms contact your local A&E department, GP or specialist team straight away:

  • pain, redness/discolouration, heat and swelling of the calf, leg or thigh
  • swelling, redness or tenderness where a central line is inserted to give chemotherapy, for example in the arm, chest area or up into the neck
  • shortness of breath
  • tightness in the chest
  • unexplained cough (may cough up blood)

Find out more about blood clots.

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10. 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.
  • Meet other women with a secondary diagnosis and get information and support at a Living with Secondary Breast Cancer meet-up.
  • Live Chat is a weekly private chat room where you can talk about whatever’s on your mind.

You can also call Breast Cancer Care’s Helpline free on 0808 800 6000.

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Last reviewed: February 2018
Next planned review begins 2020

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