What you need to know about metastatic breast cancer to the bone

1. What causes bone pain?
2. How are bone metastases diagnosed?
3. How are bone pain treated?

Bone pain in cancer patients is usually caused by cancer cells that have invaded the bone - these are called bone metastases. Bone pain is often the first sign of bone metastases, so tests are carried out to confirm this diagnosis. Treatment of bone injuries is aimed at reducing pain, reducing the risk of fractures, treating fractures, and preventing or slowing the development of additional bone complications.

What causes bone pain?

A common cause of bone pain is metastatic cancer. The spread of cancer from its original location to another part of the body is called metastasis. Bone metastases are not new or different cancers—they are made up of cancer cells from the primary cancer, such as breast, prostate, lung, kidney, or thyroid cancer cells, that have spread to the bone.

Cancer cells can spread, i.e. metastasize throughout the body and into the lymphatic system. Bones are one of the most common sites in the body to which cancer metastasizes. Bone metastases usually enter the bloodstream. Cancer cells detach from their original location and travel through blood vessels until they attach to the vessel wall of a small capillary network in bone tissue. Cancer can also spread to bone by direct growth from a nearby tumor, although this is much less common than spread through the bloodstream.

Pain in bone cancer occurs because the cancer disrupts the normal balance of cells in the bones, causing changes in the structure of the bone tissue. In healthy bone, there is a constant process of remodeling, i.e. destruction and restoration of bone tissue occurs. Cancer cells that have spread to the bone upset this balance between the work of osteoclasts (cells that break down bone) and osteoblasts (cells that form new bone), causing either less or increased bone formation. These disorders can either affect the periosteum (the tough membrane covering the bone, also called the bony film ) or stimulate the nerves in the bone, causing pain.

Management of patients with bone metastases and pain syndrome

When cancer cells metastasize, they can spread both locally and to other organs. It is not possible to predict exactly how cancer cells metastasize, but over the years, researchers have begun to note that certain types of tumors metastasize in a specific pattern, and their metastases are more often found only in certain areas. For unknown reasons, prostate cancer often affects bone tissue after spreading beyond the pelvis. Unlike bone cancer, which originates from bone tissue initially, bone metastases of prostate cancer are clusters of prostate cancer cells. Therefore, the same treatment that is used to treat prostate cancer (hormonal and chemotherapy) is also suitable for the treatment of bone metastases of prostate cancer.

But cancer cells in bones don't just sit there, they interact with bone tissue, often disrupting the normal growth and structure of the bone, making it more fragile. So, in addition to traditional methods of treating prostate cancer, a lot of attention should be paid to maintaining good bone health.

In general, treatment of patients with bone metastases has three main goals: directly combating cancer cells, combating possible complications caused by increased bone fragility, and, very importantly, relieving pain. Many men with bone metastases from prostate cancer experience pain. And if the pain is not stopped, it will take a lot of strength. The strength needed to fight the disease. This section provides an overview of the problems caused by bone metastases, methods of treating them and improving the quality of life of such patients.

Detection of bone metastases.

Since the prostate is located in the pelvic cavity, the pelvic bones and adjacent bones are the first to be affected by metastases. These include the pelvic bones, vertebrae, sacrum bones, and the upper parts of the femurs. In most cases, the appearance of pain in this area is the first sign of metastasis. Some patients experience constant pain in a specific location, while others experience pain of varying intensity in different areas. If the doctor suspects that the pain is a sign of the presence of metastases or believes that the risk of developing them is very high, then he may prescribe additional testing for you. The gold standard for diagnosing bone metastases is bone scintigraphy. In this test, a radioactive substance is injected into the body and deposited in the bones. As a result of the interaction of cancer cells and bone tissue, the processes of cell reproduction and death intensify in the latter, and the radioactive substance accumulates to a greater extent in such tissues, that is, around bone metastases.

Bone scintigraphy is a very sensitive method, which means it detects minute changes in the bones. But it is not very specific, which means that the method detects changes not only caused by bone metastases, but, for example, the consequences of past fractures, infections, arthritis, even hormonal therapy.

This is another reason why your doctor should be thoroughly familiar with your medical history. Such information will allow the doctor to reliably evaluate the results of scintigraphy, which will help determine the appropriateness of treatment. Even if the treatment is effective, it should be remembered that scintigraphy does not always reveal changes in the bones after treatment. Therefore, you can resort to other diagnostic methods, such as radiography, CT, MRI, to determine the effectiveness of treatment or to determine the appearance of new metastases.

Treatment of bone metastases.

There are several treatments for prostate cancer metastases to bone. Since the nature of their action is different, the attending physician may resort to several of them. Thus, the doctor tries to achieve the maximum effect of treatment. Before starting treatment for bone metastases, it is necessary to introduce some adjustments to your diet and lifestyle, which must first be discussed with your doctor. First of all, you need to take enough calcium and vitamin D, as well as exercise regularly. Even if the treatment is not entirely successful, such measures will help minimize the manifestations of osteoporosis and keep the bones themselves strong.

Patients experiencing bone pain are often treated with targeted doses of radiation aimed directly at the area where the metastasis is located. This will kill cancer cells and relieve pain. But the goals of such therapy are fundamentally different from those of primary treatment. And bone radiation for pain relief can be used regardless of what treatment the patient has already received for prostate cancer.

External beam radiation therapy uses X-rays to kill cancer cells in the bones. This treatment is sometimes called targeted irradiation; the procedure is planned in detail by a specialist so as not to damage surrounding tissues and organs. Also, sometimes the lower half of the body is irradiated, covering large areas.

Some other techniques use radiopharmaceuticals to combat metastases. These radioactive drugs, containing samarium (Quadramet) or strontium (Metastron), are injected intravenously and lodged in metastases, where their radioactivity kills cancer cells. Researchers have shown that the drug strontium is very effective in relieving pain when used immediately after a course of chemotherapy with doxorubicin (Adriamycin), which can be done by the attending physician. External beam radiation therapy and radiopharmaceutical therapy are called targeted treatments, which means that their effects are highly localized. There is also a group of drugs called bisphosphonates, which are used in systemic therapy to relieve pain and reduce the risk of complications caused by cancer metastases.

Under normal conditions, bone cells break down and divide in a constant proportion. Increased activity of osteoblasts, cells responsible for the formation of new bone cells, leads to bone growth; An increase in the activity of osteoclasts, which destroy bone cells, leads to increased porosity and fragility of the bone. Increased porosity and fragility of bones leads to an increased risk of fractures. Bisphosphonates are drugs designed to restore the balance between bone growth and destruction. Zoledronic acid (Zometa), a drug given intravenously, relieves pain and reduces the risk of bone complications. Another intravenous bisphosphonate, pamidronate (Aredia), is used less frequently because it is less effective. Most men experience flu-like symptoms after the first injections of zoledronic acid, such as weakness, nausea, vomiting, and pain, which subside after a few days. The drug may also cause some kidney problems. Therefore, before starting treatment, the necessary studies are carried out to determine the condition of the kidneys.

Also, if you are taking zoledronic acid, you should tell your dentist about this. Since taking the drug may cause some difficulties during dental procedures. Always remember that any doctor you contact must be informed about all your diseases and medications you are taking. There are also tablet forms of bisphosphonates. These include alendronate (Fosamax) and risedronate (Actonel), although they are mainly used in postmenopausal women or on hormone therapy to prevent osteoporosis.

Waiting for complications of bone metastases

Combating complications of metastases is one of the main goals of the treatment undertaken. Pathological fractures are bone fractures that are primarily the result of a disease. This happens, as already mentioned, due to the fact that metastases lead to increased bone fragility. Due to the characteristic location of prostate cancer metastases, the sacrum, pelvic bones, and femur are most often susceptible to pathological fractures. So, if you have had courses of hormonal therapy or any other reasons that previously weakened bone tissue, try to inform your doctor about them. You should also notify the doctor about all significant falls and bruises, which is also important. Surgery to stabilize the bones to reduce the risk of fractures is also likely.

In the long-term period, the most important complication of bone metastases is compression of the spinal cord. The spinal cord, starting at the base of the brain, runs within the vertebrae that make up the spine. The spinal cord is where most of the nerves that control movement and activity in the body originate. Therefore, damage to the spinal cord can lead to disability.

The vertebrae are located one on top of the other. Vertebrae weakened by metastases can flatten and shift, putting pressure on the spinal cord. Spinal cord compression that is not corrected can lead to serious consequences, possibly even paralysis. Therefore, if the possibility of compression is suspected, additional studies are carried out, for example, MRI, and a number of additional medications are prescribed.

Remember that the symptoms of spinal cord compression may not be pronounced and may be similar to other pathological conditions. This may be pain in the lumbar region, pain in the legs or weakness, problems with urination and defecation.

Since only the patient knows his body best, any discomfort or discomfort that arises should not be interpreted by him only as another side effect of the treatment. Any changes should be reported to your doctor.

Pain relief

Although pain often goes away with successful treatment of metastases using the above methods, sometimes patients need additional painkillers.

There are 3 basic rules that you should always remember: 1) Don't try to be a hero. Cancer pain can be quite significant. And there is no point in experiencing it stoically. Pain can take away valuable strength that you may need to fight the disease. And pain can be dealt with very effectively with the help of medications. 2) Pain relief can be achieved using quite simple methods. You should not expect that relief will come only when you are completely “pumped up” on drugs. The main goal of pain relief is to support the body. Sometimes oral medications are enough to make the pain go away. 3) Do not be afraid of becoming psychologically dependent on painkillers. The main reason why doctors try not to prescribe, and why patients do not take painkillers, is psychological dependence. But you need to understand the difference between addiction, physical dependence and stability.

Addiction is a psychological syndrome in which prolonged or increasing use of medications occurs regardless of negative psychological, physical or social consequences. In the case of cancer, taking medications is aimed at healing, a positive outcome.

With physical dependence, the body is not able to quickly cope with an abrupt cessation of taking the drug, and patients experience the so-called withdrawal syndrome. Therefore, withdrawal of any drug most often occurs with a gradual reduction in doses.

If you take the drug long enough, resistance may occur, in which the drug no longer has an effect. Gradually increasing the dose of medication may have a temporary effect, but most likely you will have to change the drug. Always keep your doctor informed about what pain medications you have already taken and what their effect was. If your doctor does not yet consider the need to take painkillers, consult with pain specialists. If the drugs do not work, even some minor surgical interventions are possible to eliminate the pain.

Remember that like any other medicine, painkillers have side effects. The most common of these is constipation. Constipation occurs so often that sometimes the question arises not if, but when it will appear. When taking painkillers, even in minute doses, it is necessary to reconsider your diet or even start taking laxatives.

Other side effects include nausea, vomiting, drowsiness, and confusion. Over time they may go away. The goal of pain relief is to preserve your strength to fight the disease. If something remains unclear, try to talk about it with your doctor.

Using materials from the site www.cancer-prostate.ru

How are bone metastases diagnosed?

Bone metastases are usually diagnosed by looking for the cause of bone pain. A fluoroscopy or a more complex procedure called a bone scan is done to find out whether the pain is caused by bone damage related to cancer. During a bone scan, a weakly radioactive substance is injected into a vein. It circulates throughout the body and also penetrates the bones. A high concentration of this radioactive substance on a bone scan image indicates the presence of cancer cells.

Bone pain can sometimes be difficult to distinguish from regular back pain or arthritis. Usually the pain caused by bone metastases is quite constant, even at night. They can get worse in various positions, such as standing (if the cancer cells are in a weight-bearing bone). If the pain continues for more than a week or two and does not seem to be getting better or resembling other pain you have had, you should definitely consult your doctor.

Bone metastases are usually located in the central part of the skeleton, although they can occur in any part of the skeletal system. Often bone metastases are found in the spine, pelvic bones, femur, ribs, humerus and skull; More than 90% of all bone metastases are found in these places.

Reasons for development

Like most malignancies, bone cancer does not have a specific cause. Today, hereditary predisposition is considered to be the most significant. Thus, Ewing's sarcoma most often develops in people with Paget's and Li-Fraumeni syndrome. In addition, the genetic linkage of bone cancer with retinoblastoma has been proven.

Predisposing risk factors include:

• external influence of negative factors - ionizing radiation, chemical carcinogens;
• presence of bad habits, especially smoking;
• some viral and iatrogenic diseases.

Painkillers

Bone pain caused by bone metastases can be treated with various medications. Although pain can be reduced in 90% of cancer patients, uncontrolled tumor-related pain is still a problem.

The World Health Organization (WHO) recommendations for reducing pain caused by a tumor indicate that the intensity of the patient's pain, which is assessed on a scale of 1 to 10 points, determines which type of pain medication to choose:

• Mild to moderate pain (1-3 points): Non-opioids are the first choice for mild to moderate pain. This group of medications includes, for example, paracetamol and nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen.
• Moderate to Severe Pain (4-6 points): Patients with moderate to severe pain who have not responded to first-level treatment should take pain medications that belong to the opioid class, i.e., narcotic analgesics. Medicines in this class can only be purchased with a doctor's prescription. Acetaminophen or NPS may be added.
• Severe pain (7-10 points): Patients with severe pain, as well as patients whose pain has not been relieved by previous treatment, should be prescribed a stronger opioid (a special prescription is required to obtain it). In some cases, it may be necessary to add non-opioid medications, such as aspirin, paracetamol, ibuprofen and other pain relievers.

Pain medications may have side effects such as drowsiness, constipation, dizziness, nausea, and vomiting. Relief from pain medications is short-lived and pain may return after a short time, so they are best taken when the pain first begins or on a regular basis.

Possible complications

A growing tumor and emerging metastatic sources are manifested by severe pain.
The symptom disrupts the usual order of life: the patient cannot fully sleep, eat, or move. Increasing painful sensations interfere with decision-making and daily work. Also, symptoms negatively affect the functioning of internal organs and systems. Modern medicine is able to keep pain under control in almost 100% of cases, which makes it possible to maintain a decent quality of life for cancer patients.

Bisphosphonates

A group of medications called bisphosphonates can effectively reduce bone loss that occurs from metastatic lesions, reduce the risk of fractures, and reduce pain. Bisphosphonates act by inhibiting bone resorption or destruction. Bone tissue is continuously exposed to two types of cells: osteoclasts, which destroy old bone cells, and osteoblasts, which restore it. In turn, cancer cells secrete various factors that stimulate osteoclast activity. Although the exact mechanism of action of bisphosphonates is not entirely clear, they are thought to inhibit and destroy cell-destructive osteoclasts, thereby reducing bone breakdown. Data from more than 30 clinical studies show that patients with bone metastases who were treated with bisphosphonates were less likely to have fractures, less likely to need radiation therapy, and less likely to have hypercalcemia (increased levels of calcium in the blood). Bisphosphonates have been shown in clinical studies to prevent or slow bone change and associated pain in patients. Most often, bone metastases occur with:

• Breast cancer
• Prostate cancer
• Lungs' cancer
• Myeloma
• Kidney carcinoma

Treatment methods in Medscan

The main goal of pain treatment is to achieve a lasting analgesic effect. There are several therapeutic stages, for each of which certain groups of drugs are used. They start with the least toxic ones, gradually choosing products with a large number of adverse reactions.

Principles of measures taken in the fight against pain:

1. An individual approach to the choice of pain medication should be taken into account.
2. It is necessary to follow the standard sequence of prescriptions, using drugs that have proven their effectiveness.
3. If sensitivity to the chosen medication decreases, a more powerful drug should be chosen.
4. At each stage, auxiliary agents can be added to the main pain reliever, including those affecting the central nervous system.
5. It is easier to prevent a symptom than to eliminate it. In this regard, the interval between taking painkillers depends on the duration of its effect. The medicine is taken until complaints arise.
6. The optimal forms of medicines are tablets or suppositories. Injection forms are chosen when other options are ineffective.

Medscan specialists in their practice use only international protocols with proven effectiveness. Individual treatment regimens involve the selection of original, highly effective drugs.

Radiation therapy

Radiation therapy is effective in reducing bone pain and the spread of cancer in the bone. Radiation therapy is especially effective when metastatic lesions are localized to only one area.

One type of radiation therapy is called radiodrug therapy. It involves injecting a radioactive substance, such as strontium-89, into a vein. This substance attaches to areas of the bone where there is cancer. Thus, by directing radiation directly to the affected areas of the bone, active cancer cells in the bone are destroyed and symptoms (pain) are reduced. Possible side effects of radiodrug therapy include a decrease in the number of blood cells (increased risk of bleeding) and, in rare cases, a risk of leukemia.

Diagnostic methods in Medscan

Choosing optimal analgesia requires understanding where the pain is located, how long it lasts, and its intensity. The doctor carefully interviews the patient and also offers to choose one of the options for a numerological rating scale and a visual analogue scale. A visual analogue scale (VAS) is a 10-cm ruler, on the reverse (non-graduated) side of which the patient is asked to mark a point corresponding to the level of pain. The left border of the line means “no pain”, the right border means “unbearable pain”. The ruler measures the gap between the “no pain” and the marked point. The Numerological Rating Scale (NRS) is a 10-centimeter ruler with numbers marked on it from 0 to 10, where 0 is “no pain” and 10 is “unbearable pain.” The patient marks a number from 0 to 10 corresponding to the intensity of his pain syndrome.

If a patient suffers from cognitive (mental) impairment, the patient’s behavior, facial expressions, and facial expressions help determine the severity of pain.

The Medscan Clinic has the necessary diagnostic equipment of an expert level. The experience of our specialists and modern laboratory and instrumental equipment will make a final diagnosis in the shortest possible time.

For bladder cancer

Pain from bladder cancer in men appears along with urination problems. Malignant neoplasm leads to an increase in the size of the bladder. The enlarged bladder is compressed between the pubic bone and the rectum - this causes a constant painful urge to urinate. Pain from bladder cancer radiates to the groin area, lumbosacral region, and suprapubic region. With the development of difficulties with defecation, pain appears in the rectal area - this indicates the spread of the process to the intestines. When a bladder tumor metastasizes, the bones of the pelvis and spine begin to ache, and problems with potency appear.

For bowel cancer

The intensity and frequency of pain in bowel cancer depends on the location of the tumor and the stage of cancer development. At the early stage of tumor development, severe tissue damage does not occur and there is no pain symptom. In some cases, there may be pain during bowel movements. At the second stage of development, the tumor spreads and may partially block the intestinal lumen - the pain becomes aching and constant. Often at this time, cancer is confused with gastritis, pancreatitis or colitis. The third stage is accompanied by the spread of the tumor and constant dull pain. During defecation, it may become cramping and sharp. In the last stage of the disease, severe acute pain is constantly present, which does not disappear after taking painkillers.

Headache

How does a headache hurt with brain cancer? What is a headache like with a brain tumor? – these questions concern not only oncology patients, but also loved ones who have to care for their relatives. Headache is the most common symptom of brain cancer. The headache can be diffuse, spreading throughout the head, or it can be concentrated in one place. Most often the pain appears at night or in the morning. The appearance of pain in the morning indicates the accumulation of fluid in the cranial cavity. As a result of damage to the blood vessels of the brain, the outflow of blood is disrupted, and edema develops, accompanied by a headache. The pain may intensify during rest; it can be pulsating, bursting, or pressing. The patient's body parts become numb, he feels dizzy, and epileptic seizures occur. At a late stage of tumor development, attacks of pain become excruciating and almost impossible to relieve.

Why does cancer cause severe pain?

Pain in stage 4 oncology is associated with extensive tissue damage by the tumor, during which nerves and pain receptors are damaged. And if in the early stages the degree of tissue damage is small, then as the tumor grows, the pain symptom intensifies. There are several types of cancer pain:

• nociceptive pain. The reflection of pain is unclear, since the abdominal organs have visceral innervation. Patients with damage to the abdominal organs cannot accurately explain where the source of pain is.
• neuropathic pain. It develops due to damage to nerve endings and plexuses by a cancerous tumor, as well as as a result of treatment with chemotherapy, due to damage to the peripheral nervous system, brain and spinal cord.
• psychogenic pain. The patient's stressful state can increase the perception of pain.

The oncology department of the Yusupov Hospital provides treatment for all types of malignant diseases. In a hospital inpatient unit, the patient undergoes diagnosis and treatment of the disease. The Yusupov Hospital includes a hospital and a rehabilitation department. After treatment, the patient will be able to constantly be in touch with the attending physician. You can sign up for a consultation by phone or through the feedback form on the website.

For breast cancer

Breast cancer is rarely accompanied by pain. At an early stage of development, breast cancer does not show symptoms, and tumor growth goes unnoticed. Unlike a cyst, which is very painful when palpated, a cancerous tumor is not painful when palpated. Pain is accompanied by one of the forms of aggressive cancer – diffuse infiltrative breast cancer. It occurs as chronic non-lactational mastitis, the mammary gland swells, the skin turns red, and pain appears. Pain in the nipples occurs with Paget's cancer.

For stomach cancer

Abdominal pain due to stomach cancer appears as the tumor develops; at an early stage, stomach cancer does not manifest itself in any way. The location of the primary tumor can be determined by time. If pain appears immediately after eating, the tumor is located near the esophagus. The appearance of pain after an hour indicates cancer of the fundus of the stomach, after one and a half to two hours - cancer of the pylorus. If the pain spreads to the shoulder, lower back, or radiates to the heart, this indicates the beginning of tumor metastasis. Back pain with stomach cancer is also an indicator of tumor metastasis. The course of the disease can pass without pain, or it can be accompanied by pain of varying intensity. The pain can be mild and aching, stabbing and sudden, pronounced, cutting. The pain may be accompanied by a feeling of fullness, be pressing, and constant. With stomach cancer, pain may not be associated with food intake, is present constantly, can be strong or weak, and causes a decrease in appetite.