Cancer Of The Bone

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Introduction

Introduction

Primary bone cancer is a rare type of cancer that begins in the bones. Around 550 new cases are diagnosed each year in the UK.

This is a separate condition from secondary bone cancer, which is cancer that spreads to the bones after developing in another part of the body.

These pages only refer to primary bone cancer. The Macmillan Cancer Support website has more information about secondary bone cancer.

Signs and symptoms of bone cancer

Bone cancer can affect any bone, but most cases develop in the long bones of the legs or upper arms.

The main symptoms include:

  • persistent bone pain that gets worse over time and continues into the night
  • swelling and redness (inflammation) over a bone, which can make movement difficult if the affected bone is near a joint
  • a noticeable lump over a bone
  • a weak bone that breaks (fractures) more easily than normal

If you or your child are experiencing persistent, severe or worsening bone pain, visit your GP. While it's highly unlikely to be the result of bone cancer, it does require further investigation.

Read more about the symptoms of bone cancer.

Types of bone cancer

Some of the main types of bone cancer are:

  • osteosarcoma - the most common type, which mostly affects children and young adults under 20
  • Ewing sarcoma - which most commonly affects people aged between 10 and 20
  • chondrosarcoma - which tends to affect adults aged over 40

Young people can be affected because the rapid growth spurts that occur during puberty may make bone tumours develop.

The above types of bone cancer affect different types of cell. The treatment and outlook will depend on the type of bone cancer you have.

What causes bone cancer?

In most cases, it's not known why a person develops bone cancer.

You're more at risk of developing it if you:

  • have had previous exposure to radiation during radiotherapy
  • have a condition known as Paget's disease of the bone - however, only a very small number of people with Paget's disease will actually develop bone cancer
  • have a rare genetic condition called Li-Fraumeni syndrome - people with this condition have a faulty version of a gene that normally helps stop the growth of cancerous cells

Read more about the causes of bone cancer.

How bone cancer is treated

Treatment for bone cancer depends on the type of bone cancer you have and how far it has spread.

Most people have a combination of:

  • surgery to remove the section of cancerous bone - it's often possible to reconstruct or replace the bone that's been removed, but amputation is sometimes necessary
  • chemotherapy - treatment with powerful cancer-killing medication
  • radiotherapy - where radiation is used to destroy cancerous cells

In some cases of osteosarcoma, a medication called mifamurtide may also be recommended.

Read more about treating bone cancer.

Outlook

The outlook for bone cancer depends on factors such as your age, the type of bone cancer you have, how far the cancer has spread (the stage), and how likely it is to spread further (the grade).

Generally, bone cancer is much easier to cure in otherwise healthy people whose cancer hasn't spread.

Overall, around 6 in every 10 people with bone cancer will live for at least 5 years from the time of their diagnosis, and many of these may be cured completely.

For more detailed statistics broken down by the different types of bone cancer, see the page on statistics and outlook for bone cancer on the Cancer Research UK website.

Symptoms of bone cancer

Symptoms of bone cancer

Bone pain is the most common symptom of bone cancer. Some people experience other symptoms as well.

Bone pain

Pain caused by bone cancer usually begins with a feeling of tenderness in the affected bone. This gradually progresses to a persistent ache or ache that comes and goes, which continues at night and when resting.

Any bone can be affected, although bone cancer most often develops in the long bones of the legs or upper arms.

The pain can sometimes be wrongly mistaken for arthritis in adults and growing pains in children and teenagers.

Other symptoms

Some people also experience swelling and redness (inflammation) or notice a lump on or around the affected bone. If the bone is near a joint, the swelling may make it difficult to use the joint.

In some cases, the cancer can weaken a bone, causing it to break (fracture) easily after a minor injury or fall.

Less common symptoms can include:

When to seek medical advice

See your GP if you or your child experiences persistent, severe or worsening bone pain, or if you're worried about any of the symptoms mentioned above.

While it's highly unlikely that your symptoms are caused by cancer, it's best to be sure by getting a proper diagnosis. Read more about diagnosing bone cancer.

Causes of bone cancer

Causes of bone cancer

Cancer occurs when the cells in a certain area of your body divide and multiply too rapidly. This produces a lump of tissue known as a tumour.

The exact reason why this happens is often not known, but certain things can increase your chance of developing the condition, including:

These risk factors are described in more detail below.

Radiotherapy treatment

Previous exposure to high doses of radiation during radiotherapy may cause cancerous changes in your bone cells at a later stage, although this risk is thought to be small.

Bone conditions

Some non-cancerous (benign) conditions affecting the bones may increase your chances of developing bone cancer, although the risk is still small.

In particular, a condition called Paget's disease of the bone can increase the risk of bone cancer in people over 50-60 years of age.

Rarer conditions that cause tumours to grow in your bones, such as Ollier's disease, can also increase your risk of bone cancer.

Genetic conditions

A rare genetic condition called Li-Fraumeni syndrome can increase your risk of developing bone cancer, as well as several other types of cancer.

People with this condition have a faulty version of a gene that usually helps stop the growth of tumours in the body.

Other conditions

People who had a rare type of eye cancer called retinoblastoma as a child may be more likely to develop bone cancer, because the same inherited faulty gene can be responsible for both conditions.

Research has also found that babies born with an umbilical hernia are three times more likely to develop a type of bone cancer called Ewing sarcoma, although the risk is still very small.

Diagnosing bone cancer

Diagnosing bone cancer

If you're experiencing bone pain, your GP will ask about your symptoms and examine the affected area, before deciding whether you need to have any further tests.

They will look for any swelling or lumps, and ask if you have problems moving the affected area. They may ask about the type of pain you experience - whether it's constant or comes and goes, and whether anything makes it worse.

After being examined, you may be referred for an X-ray of the affected area to look for any problems in the bones. If the X-ray shows abnormal areas, you'll be referred to an orthopaedic surgeon (a specialist in bone conditions) or bone cancer specialist for a further assessment.

Some of the tests you may have to help diagnose and assess bone cancer are described below.

X-rays

An X-ray is a procedure where radiation is used to produce images of the inside of the body. It's a particularly effective way of looking at bones.

X-rays can often detect damage to the bones caused by cancer, or new bone that's growing because of cancer. They can also determine whether your symptoms are caused by something else, such as a broken bone (fracture).

If an X-ray suggests you may have bone cancer, you should be referred to a specialist centre with expertise in diagnosing and treating the condition. As bone cancer is rare, there are a small number of specialist centres, so you may have to travel outside your local area for advice and treatment.

Biopsy

The most definitive way of diagnosing bone cancer is to take a sample of affected bone and send it to a laboratory for testing. This is known as a biopsy.

A biopsy can determine exactly what type of bone cancer you have and what grade it is (see below).

A biopsy can be carried out in two ways:

  • A core needle biopsy is performed under anaesthetic (depending on where the bone is located, this could be a local anaesthetic or general anaesthetic). A thin needle is inserted into the bone and used to remove a sample of tissue.
  • An open biopsy is performed under a general anaesthetic. The surgeon makes an incision in the affected bone to remove a sample of tissue.

You may need to have an open biopsy if the results of a core needle biopsy are inconclusive.

Further tests

If the results of the biopsy confirm or suggest bone cancer, it's likely you'll have further tests to assess how far the cancer has spread. These tests are described below.

MRI scan

magnetic resonance imaging (MRI) scan uses a strong magnetic field and radio waves to produce detailed pictures of the bones and soft tissues.

An MRI scan is an effective way of assessing the size and spread of any cancerous tumour in or around the bones.

CT scan

computerised tomography (CT) scan involves taking a series of X-rays and using a computer to reassemble them into a detailed three-dimensional (3-D) image of your body.

CT scans are often used to check if the cancer has spread to your lungs. Chest X-rays may also be taken for this purpose.

Bone scans

A bone scan can give more detailed information about the inside of your bones than an X-ray. During a bone scan, a small amount of radioactive material is injected into your veins.

Abnormal areas of bone will absorb the material at a faster rate than normal bone and will show up as "hot spots" on the scan.

Bone marrow biopsy

If you have a type of bone cancer called Ewing sarcoma, you may have a test called a bone marrow biopsy to check if the cancer has spread to the bone marrow (the tissue inside your bones).

During the test, a needle is inserted into your bone to remove a sample of your bone marrow. This may be done under either local or general anaesthetic.

Staging and grading

Once these tests have been completed, it should be possible to tell you what stage and grade the bone cancer is. Staging is a description of how far a cancer has spread and grading is a description of how quickly the cancer is likely to spread in the future.

A widely used staging system for bone cancer in the UK uses three main stages:

  • Stage 1 - the cancer is low-grade and has not spread beyond the bone
  • Stage 2 - the cancer has still not spread beyond the bone, but is a high-grade
  • Stage 3  - the cancer has spread into other parts of the body, such as the lungs

Most cases of stage 1 bone cancer and some stage 2 bone cancers have a good chance of being cured. Unfortunately, stage 3 bone cancer is more difficult to cure, although treatment can relieve symptoms and slow the spread of the cancer.

Coping with a diagnosis

Being told you have bone cancer can be a distressing and frightening experience. Receiving that type of news can be upsetting at any age, but can be particularly difficult if you are still in your teenage years, or if you're a parent of a child who has just been told they have bone cancer.

These types of feelings can cause considerable stress and anxiety, which in some cases can trigger depression. If you think you may be depressed, your GP may be a good person to talk to about support and possibly treatment.

You may also find it useful to contact the Bone Cancer Research Trust, which is the UK's leading charity for people affected by bone cancer, if you need more information. If you're a teenager you may want to contact the Teenage Cancer Trust, which is a charity for teenagers and young adults affected by cancer. 

Read more about coping with a cancer diagnosis.

Treating bone cancer

Treating bone cancer

Treatment for bone cancer depends on the type of bone cancer you have, how far it has spread and your general health. The main treatments are surgery, chemotherapy and radiotherapy.

Your treatment plan

Your treatment should be managed by a specialist centre with experience in treating bone cancer, where you'll be cared for by a team of different healthcare professionals known as a multi-disciplinary team (MDT).

Members of the MDT will include an orthopaedic surgeon (a surgeon who specialises in bone and joint surgery), a clinical oncologist (a specialist in the non-surgical treatment of cancer) and a specialist cancer nurse, among others.

Your MDT will recommend what they think is the best treatment for you, but the final decision will be yours.

Your recommended treatment plan may include a combination of:

  • surgery to remove the section of cancerous bone - it's often possible to reconstruct or replace the bone that's been removed, although amputation is occasionally necessary
  • chemotherapy - treatment with powerful cancer-killing medication
  • radiotherapy - where radiation is used to destroy cancerous cells

In some cases, a medication called mifamurtide may be recommended as well.

Surgery

Surgery to remove the cancerous area of bone is an important part of treatment for bone cancer, although it's often combined with the other treatments mentioned below.

Nowadays, it's usually possible to avoid removing an affected body part completely (known as limb-sparing surgery), although up to 1 in every 10 people may need to have a limb permanently removed (amputation).

Limb-sparing surgery

Limb-sparing surgery is usually possible when the cancer has not spread beyond the bone, and the bone can be reconstructed.

The most common type of limb-sparing surgery involves removing the section of affected bone and some of the surrounding tissue (in case any cancerous cells have spread into the tissue).

The removed section of bone may then be replaced with a metal implant called a prosthesis or a piece of bone from elsewhere in your body (bone graft).

If the cancer is near a joint, such as the knee, it may be possible to remove the joint and replace it with an artificial one. Read more about knee joint replacement and hip joint replacement.

Amputation

Amputation may be necessary if limb-sparing surgery is not possible or has not worked well. For example, it may be necessary if:

  • the cancer has spread beyond the bone into major blood vessels or nerves
  • you developed an infection after limb-sparing surgery and the prosthesis or bone graft had to be removed 
  • the cancer has developed in a part of the body where limb-sparing surgery is not technically possible, such as the ankle

Your care team will understand the shock and fear that you, or your child, may be feeling if an amputation is needed and should be able to provide you with counselling and other support. In some cases, your care team may be able to introduce you to someone who has already had an amputation.

After an amputation, most people use an artificial limb to replace the limb that's removed. These limbs are now very advanced and convenient to use. For example, people with an artificial leg are often able to walk, run and play sport, and have an excellent quality of life.

Recovering from surgery

After limb-sparing surgery or an amputation, you'll need help to return to normal life. This is known as rehabilitation.

Rehabilitation will usually involve physiotherapy sessions, where you carry out exercises to help regain proper function in the treated body part, and occupational therapy, where you're taught skills to help you cope with day-to-day activities.

After an amputation, you may be referred to a local limb centre for advice, support and rehabilitation treatment. Read more about living with an amputation.

Chemotherapy

There are four ways chemotherapy can be used to treat bone cancer. It can be used:

  • before surgery, to shrink the tumour and make surgery easier
  • in combination with radiotherapy before surgery (chemoradiation) - this approach works particularly well in the treatment of Ewing sarcoma
  • after surgery, to prevent the cancer returning
  • to control symptoms in cases where a cure is not possible (known as palliative chemotherapy)

Chemotherapy for bone cancer involves taking a combination of different medications that are usually delivered via a drip into your vein, or into a line inserted into a bigger blood vessel.

The treatment is usually given in cycles. A cycle involves taking the chemotherapy medication for several days, then having a break for a few weeks to allow your body to recover from the effects of the treatment. The number of cycles you need will depend on the type and grade of your bone cancer.

Side effects

Chemotherapy can damage healthy cells as well as cancerous cells, which means it often causes a number of side effects.

Common side effects of chemotherapy include:

Most side effects associated with chemotherapy should resolve once your treatment has finished. However, there is a risk you will be permanently infertile. Your care team will provide more detailed information about the specific risk to your fertility.

Read more about the side effects of chemotherapy.

Radiotherapy

As with chemotherapy, radiotherapy can be used before and after surgery to treat bone cancer, or used to control the symptoms and slow the spread of cancer when a cure is not possible.

Radiotherapy for bone cancer involves beams of radiation being directed at the cancerous section of bone by an external machine.

This is normally given in daily sessions, five days a week, with each session lasting a few minutes. The whole course of treatment will usually last a few weeks.

Side effects

The radiation you're exposed to during radiotherapy will mostly be focused on the cancerous cells, but healthy cells nearby can also be damaged. This can lead to side effects such as:

  • reddening and irritation of the skin (this can feel much like sunburn)
  • joint pain in the part of the body that is being treated
  • feeling sick
  • hair loss in the body part being treated
  • tiredness

These side effects will pass once the radiotherapy has been completed, although feelings of tiredness may persist for several weeks.

Read more about the side effects of radiotherapy.

Mifamurtide

For people with a type of bone cancer called osteosarcoma, a medication called mifamurtide may be used alongside the treatments described above.

Mifamurtide is an immune macrophage stimulant. This means it works by encouraging the immune system to produce specialised cells that kill cancerous cells.

It's normally recommended for young people with high-grade osteosarcomas and is given after surgery, in combination with chemotherapy, to help prevent the cancer returning.  

Mifamurtide is slowly pumped into one of your veins over the course of an hour (known as infusion). The recommended course of treatment is usually twice a week for 12 weeks, and then once a week for a further 24 weeks.

Side effects

Mifamurtide can cause a wide range of side effects. These can include:

  • nausea and vomiting 
  • diarrhoea or constipation
  • headache 
  • dizziness
  • loss of appetite
  • tiredness and weakness

It's unclear whether it's safe to take mifamurtide during pregnancy, so as a precaution it's important to use an effective method of contraception if you're a sexually active woman. You will need to tell your MDT as soon as possible if you think you're pregnant, and you should avoid breastfeeding while taking mifamurtide.

Follow-up

Once your treatment has finished, you'll need to attend regular follow-up appointments to check the cancer hasn't returned.

You'll be asked to attend frequent appointments in the first two years after treatment has finished - possibly every three months. These will become less frequent as the years go on.

Contact your specialist or GP if you develop symptoms of bone cancer again and think the cancer may have come back.

'It never crossed my mind that I might not survive'

'It never crossed my mind that I might not survive'

Carol Starkey, from Bromsgrove, Worcs, was diagnosed with bone cancer in her shoulder just three weeks after she started university.  

"It was February 2006 when I first noticed the aches in my right shoulder. I thought it was a pulled muscle and I expected it to sort itself out, but it didn't. The ache would wake me up at night and I could feel it when I was driving.

"I went to my GP, who thought I was studying too hard and that it might be repetitive strain injury (RSI) from using my computer. He told me to take painkillers. The pain didn't stop and, after a holiday to Sicily, I went back to see him. He sent me for physio, thinking it might be tendonitis. I also had ultrasound and acupuncture, but the pain still didn't go away.

"Then one day, when I was getting out of a swimming pool, my right arm completely gave way. It was really painful and I lost all power in it for about a half an hour.

"My GP gave me a cortisone injection, which he said would keep me pain-free for two weeks, which was exactly what I wanted. I was off to Honduras for an expedition that involved walking, backpacking and scuba diving. I coped, but I couldn't sleep as I was in constant pain, and I didn't have the strength in my arm to lift anything. 

"The GP then referred me to a specialist, who said I should have a further course of cortisone. A few weeks later I felt my shoulder pop, which was followed by the most excruciating pain. For the first time, I saw a big bulge on the front of my shoulder, which I thought meant it was dislocated. I went straight to A&E.

"I had an X-ray, which showed two fractures of the humerus (the bone in the upper arm). The doctor told me it needed further investigation and referred me to the Royal Orthopaedic Hospital in Birmingham.

"After several scans, X-rays and a biopsy, the doctor showed me the X-ray of the lump on my shoulder. When he mentioned the word cancer, it came as a complete bombshell. I'd had no inkling, as I'd never even heard of bone cancer. 

"I wasn't upset by the thought of treatment. Nor was I bothered about losing my hair. I was upset by the fact I wouldn't be able to do water sports in the future. It never crossed my mind that I might not survive.

"Although it had taken eight months to get a diagnosis, the treatment began just over a week later. I went to the Young Person's Unit at the Queen Elizabeth Hospital, Birmingham. It was brilliant and it made so much difference to be with people of my own age. I was very grateful for that.

"I had six cycles of chemotherapy, which meant three weeks in hospital followed by two weeks at home for each cycle. I was very sick at first and spent a lot of time in hospital. It took over my whole life.

"The tumour did shrink, but not by as much as the doctors would have liked, so I had to have radiotherapy. After the second cycle of chemotherapy, in January 2007, I had surgery. In a three-hour operation, they removed 20cm of my humerus and replaced it with a metal artificial bone. 

"It was difficult at first - I needed a sling for six weeks and my arm was quite weak. It was hard to chop food and to write, but the physio and practising has helped a lot. Now I can cook most of the things I used to be able to.

"I have got back into some sports, too. I can swim breaststroke and have begun driving powerboats and canoeing again. We do a lot of walking as a family and I've been able to do that again. My fitness came back quite quickly. Sadly, I will never be able to do contact sport, because there's too much danger of the prosthesis getting dislodged.

"My advice to a young person who suspects they might have bone cancer is to think of seeking a second opinion if your pain is not being taken seriously. Also, don't get discouraged by the treatment. The first few weeks of chemotherapy are the worst. After that, it gets better."