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Bone Metastases and Metastatic Breast Cancer

Read our blog, I Wish I Had Known about Falls as a Breast Cancer Survivor.

Metastatic breast cancer

Metastatic breast cancer (also called stage IV or advanced breast cancer) is the most advanced stage of breast cancer. It’s not a specific type of breast cancer.

Metastatic breast cancer is breast cancer that has spread beyond the breast and nearby lymph nodes to other parts of the body (most often the bones, lungs, liver or brain).

For some people, metastatic breast cancer only spreads to one part of the body. For other people, the cancer spreads to multiple parts of the body over time. For others, the cancer is found in multiple parts of the body when they are first diagnosed.

Learn about treatment for metastatic breast cancer.

Bone metastases

The bones are one of the most common sites of breast cancer metastases. Metastatic breast cancer that has spread to the bones is called bone metastases.

Bone metastases are not bone cancers. Although the cancer is in the bones, it’s still breast cancer. Bone metastases are treated with breast cancer drugs, not bone cancer drugs.

The following is a 3D interactive model showing metastatic breast cancer (stage IV) with one area of bone metastasis.

When can bone metastases occur?

Bone metastases may be present when metastatic breast cancer is first diagnosed, or the cancer may spread to the bones later.

The bones are the first site of metastases for almost half of women diagnosed with metastatic breast cancer [85]. For many of these women, the bones will be the only site of metastases [85].

Bone metastases and hormone receptor status

For people with estrogen receptor-positive metastatic breast cancer, the bones are the most common site of metastases.

For people with estrogen receptor-negative metastatic breast cancer, the lungs and liver are the most common sites of metastases.

Bone metastases and quality of life

Watch our MBC Impact Series, Ask Your Quality of Life Questions.

As treatment for metastatic breast cancer improves, so does survival. With people living longer with metastatic breast cancer, it’s even more important to prevent and treat any side effects of bone metastases. These side effects can greatly impact quality of life.

Bone metastases and bone problems

People with bone metastases are at risk of serious bone complications such as bone fractures (breaks), spinal cord compression and bone pain.

Bone complications are a concern for people with bone metastases. They can cause pain and may lead to loss of mobility, impacting quality of life. Bone complications can also decrease survival [85]. With the use of bone-strengthening drugs, bone complications are not common [86].

Bone-strengthening drugs for people with bone metastases

Bone metastases can damage your bones. Medications to strengthen and protect your bones (bone-strengthening drugs) reduce this damage. They have greatly improved the treatment of bone metastases.

There are 2 types of bone-strengthening drugs:

  • Bisphosphonates (zoledronic acid (Zometa) or pamidronate (Aredia))
  • RANK ligand (RANKL) inhibitor (denosumab (Xgeva))

If you have bone metastases, your treatment plan will include a bisphosphonate or denosumab [4]. Talk with your health care provider about which drug is right for you.

Benefits of bone-strengthening drugs

For people with bone metastases, the use of bisphosphonates or denosumab can [86]:

  • Lower the risk of fractures related to bone metastases
  • Help reduce pain caused by bone metastases
  • Prevent complications of cancer in the bones such as hypercalcemia (high levels of calcium in the blood that can weaken bones, cause kidney stones and can lead to heart problems)
  • Reduce the need for surgery to repair bone fractures related to bone metastases
  • Reduce the need for radiation therapy to treat bone pain
  • Prevent progression of bone metastases that could lead to a fracture

Learn about bisphosphonates in early breast cancer treatment.

How are bone-strengthening drugs given?

Bone-strengthening drugs

Pamidronate (Aredia)

Zoledronic acid (Zometa)

Denosumab (Xgeva)

How is it given?

Given through an IV

Given through an IV

Given by injection under the skin

How often is it given?

Every 3-4 weeks or every 12 weeks

Every 12 weeks

Every 4 weeks

Side effects of bone-strengthening drugs

Bone, joint or muscle pain

In some people, bisphosphonates and denosumab can cause bone, joint or muscle pain [87]. This type of pain usually only lasts for 1-2 days and is most common with the first treatment.

Osteonecrosis of the jaw

In rare cases, with either bisphosphonates or denosumab, a disorder called osteonecrosis of the jaw may occur [4,86-88]. This is mostly a concern for people who take frequent doses of one of these drugs for long periods of time, and for those who have other oral health concerns such as smoking or tooth decay.

It’s recommended you have a dental exam and take care of any dental work before starting treatment with bisphosphonates or denosumab [4].

Talk with your oncologist before getting any dental work while you’re on bone-strengthening therapy. Also, tell your dentist you are on these medications.

Reducing the pain of bone metastases

Bone-strengthening drugs can reduce pain from bone metastases, but they aren’t the only treatment option for bone pain [89]. Bone pain should also be treated with standard pain management methods.

Medications for mild bone pain

Bone pain often responds to heat, or to mild pain relievers such as ibuprofen (Advil or Motrin), naproxen (Aleve or Naprosyn) or acetaminophen (Tylenol).

Although you can get these medications without a prescription, check with your health care provider before taking them. For example, if you have (or are expected to have) a low platelet count, or your kidneys are not functioning normally, or you have heart failure, your health care provider may advise you not to take ibuprofen or naproxen.

Learn more about these medications in metastatic breast cancer care.

Medications for more severe bone pain

Tramadol or opioids, such as morphine or oxycodone, can be added if the ibuprofen, naproxen or acetaminophen alone don’t relieve the pain.

All of these drugs can cause constipation, so you may need to make some changes in your diet or take medications to promote regular bowel movements. For example, your health care provider may recommend increasing your liquid intake (warm or hot liquids may be helpful) and eating high-fiber foods, such as fruits and vegetables to manage constipation.

Other side effects of these drugs include sleepiness and nausea. These usually go away after about a week. If they don’t, tell your health care provider. These side effects can be treated.

If you’re prescribed opioid medications, your health care provider will carefully monitor the amount prescribed so you don’t take too much. People may worry about taking opioid medications, fearing side effects or addiction. However, when used as prescribed, these drugs can offer a great deal of pain relief.

Learn more about opioids and other pain medications, their side effects and fear of addition.

Radiation therapy or surgery for bone pain

Radiation therapy to the bone can relieve pain at the site of the tumor(s) and prevent fractures. Even very short courses of radiation therapy, with treatments given for 1-5 days, can relieve the pain of bone metastases.

Orthopedic surgery may be used to prevent or repair bone fractures.

Chemotherapy or hormone therapy for bone pain

Drug therapies that control metastatic breast cancer throughout the body can also help treat the pain caused by bone metastases. For example, chemotherapy or hormone therapy can relieve bone pain by shrinking the cancer so it doesn’t press upon the spine or other bones.

Learn more about managing pain related to metastatic breast cancer.

Treatment guidelines for metastatic breast cancer

Although the exact treatment for metastatic breast cancer varies from person to person, guidelines help make sure high-quality care is given. These guidelines are based on the latest research and agreement among experts.

The National Comprehensive Cancer Network (NCCN) and the American Society of Clinical Oncology (ASCO) are respected organizations that regularly review and update their guidelines.

In addition, the National Cancer Institute (NCI) has treatment overviews.

Talk with your health care team about which treatment guidelines they follow.

Updated 03/22/24