Bone metastases mean that cancer cells from another organ, most often the breast or prostate, and also the lung or kidney, have reached the bones; bone is the most common place cancer spreads to, and this is not bone cancer [1, 2]. Bone metastases rarely go away completely, but they can often be controlled for years; in breast and prostate cancer, survival with them is usually measured in years [2, 12]. Pain can be eased with radiotherapy and medicines, and medicines such as zoledronic acid and denosumab help prevent fractures and other complications [2, 6].
Key points
- Bone metastases are not bone cancer: breast cancer that has reached the bones is "metastatic breast cancer" and is treated like breast cancer [1].
- Pain and fractures are common signs [1]; a high blood calcium level and pressure on the spinal cord are other important complications [12].
- Weakness or numbness in the legs, or problems controlling your bladder or bowels, may be a sign that cancer is pressing on the spinal cord; this is an emergency. For new or worsening back pain, contact your treatment team within 24 hours [4].
- Radiotherapy eases bone pain in most patients, and a single session often works as well as several [6].
- Zoledronic acid or denosumab make bones stronger; have a dental check before starting [9, 10].
- In breast and prostate cancer, many people live for years with bone metastases [2, 12].
What are bone metastases? Are they the same as bone cancer?
Bone is the most common place that many cancers, especially breast cancer and prostate cancer, spread to [2]. Cancer cells reach the bone through the blood and sometimes stay dormant there for years; later they may start growing again and damage the bone [1, 2]. This damage can cause pain, fractures and difficulty with everyday activities [2].
Cancers that most often spread to the bones [1, 2]:
- Breast cancer and prostate cancer
- Lung cancer and kidney cancer
- Thyroid, bladder and womb cancer, and melanoma
Multiple myeloma, a cancer of the bone marrow, also usually affects the bones, and many of the treatments on this page are used for it too [2]. Read: symptoms of multiple myeloma
Bone metastases are different from cancer of the bone itself, a cancer that starts in the bone's own cells. Under the microscope, the cells of a metastasis look like the original cancer, which is why the disease keeps that name and is treated like it [1]. Cancer reaching the bones usually means stage 4 cancer [1]. Read more: What is metastasis?, cancer that has spread to the liver and How fast does cancer grow?
Bone metastasis symptoms
Bone metastases do not always cause symptoms and are sometimes found on a scan [1]. When they do, these are the most common [1, 12]:
- Bone pain: pain that persists, gradually gets worse or wakes you at night [4, 12].
- A fracture after a minor knock or even without any injury, because the bone has been weakened [1, 12].
- A high blood calcium level: loss of appetite, nausea and vomiting, constipation, thirst and passing a lot of urine, tiredness and drowsiness, and in severe cases confusion [11].
- Pressure on the spinal cord or nerve roots: back pain with weakness or numbness in the legs; read the next section [4, 12].
Most bone pain and back pain have a simple cause; but if you have or have had cancer, tell your doctor about any new pain.
Spinal bone metastases: take back pain seriously
If cancer reaches the bones of the spine (vertebrae) and the tumour grows, it may press on the spinal cord; this is called "spinal cord compression". It is an emergency: the UK national guideline recommends contacting the cancer team immediately and having an MRI scan of the spine within 24 hours [4].
In someone who has or has had cancer, these features of back pain are possible signs that cancer has spread to the spine [4]:
- Severe, unrelenting back pain, or pain that gets worse day by day
- Pain that gets worse when standing, sitting or moving
- Pain that gets worse when coughing, sneezing or straining to open your bowels
- Pain at night that disturbs your sleep
- Tenderness at one spot on the spine when pressed
And these are possible signs of spinal cord compression [4]:
- Weakness in an arm or leg, or difficulty walking
- Numbness, pins and needles or loss of feeling
- Pain that shoots like a belt around the body or along an arm or leg
- Problems controlling your bladder or bowels
When should I call my doctor?
Go to the emergency department now or call your local emergency number if you have or have had cancer and [4]:
- an arm or leg has become weak or numb, or walking has become difficult
- you have lost control of your bladder or bowels
Contact your treatment team within 24 hours if you have new or worsening back pain, especially pain that gets worse with coughing or sneezing or keeps you awake at night [4].
Contact your treatment team the same day if you have thirst and are passing a lot of urine, nausea and vomiting, new constipation, drowsiness or confusion; your blood calcium may have risen [11].
Also tell your doctor the same day if bone pain suddenly becomes severe, you cannot put weight on a leg or arm, or your pain is not controlled by your current medicines. Read more: Cancer pain can be treated: do not put up with it
Can bone metastases be treated?
Treating the cancer itself
Hormone therapy, chemotherapy, targeted therapy or immunotherapy, depending on the type of the original cancer, control the cancer throughout the body, including in the bones [2]. Read: hormone receptor positive breast cancer and prostate cancer that has spread
Radiotherapy for pain
Radiotherapy to a painful bone eases the pain in most patients: about 6 in 10 people have less pain, and about 2 in 10 have their pain go away completely [6]. A single session of radiotherapy for pain works as well as several; it is just more common to need the treatment repeated later after a single session [5, 6]. Read: What is radiotherapy?
Bone-strengthening medicines
Surgery
Pain medicines and palliative care
Do not put up with pain; take your pain medicines on time and get help from a palliative care team [2]. Read: cancer pain
Zoledronic acid and denosumab: how they are given and what to know
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Before starting: a dental check
These medicines can damage the jawbone (osteonecrosis of the jaw); the risk is higher with longer use and with tooth extraction or poor oral hygiene [10]. Before starting, have a dentist examine your mouth and complete any dental treatment you need; during treatment, keep your mouth clean and avoid tooth extractions and dental surgery if possible [9, 10].
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How is zoledronic acid given?
As a drip into a vein over at least 15 minutes, usually every 3 to 4 weeks [9]. In a large study, giving it every 12 weeks prevented fractures and other complications as well as every 4 weeks; your doctor decides the right interval [8]. A creatinine blood test (kidney function) is needed before each dose, and the dose is lowered if the kidneys are weak [9].
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How is denosumab given?
As an injection under the skin of the upper arm, thigh or belly every 4 weeks, given by a nurse or doctor [10]. Denosumab can lower the blood calcium level, especially in the first weeks and in people with weak kidneys, so blood calcium is checked [10]. Do not stop this medicine on your own; after it has been stopped, fractures of several vertebrae have been reported [10].
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Side effects to know about
For up to 3 days after a zoledronic acid infusion, some people have a fever, tiredness, bone or muscle pain and a flu-like feeling, which usually settles within a few days [9]. If you have jaw pain, toothache, a gum infection or ulcer, or a sore in your mouth that is slow to heal, tell your doctor [10]. Read more: denosumab
Are bone metastases fatal? Life expectancy with cancer in the bones
Bone metastases are a serious illness, but people can usually live with them for a long time. The outlook depends above all on the type of the original cancer: in breast and prostate cancer, survival with bone metastases is usually measured in years, whereas in lung cancer it is often shorter [12]. Whether the cancer is only in the bones or has also reached other organs matters too [12].
For comparison, in the United States, 5 years after a diagnosis of cancer that has spread (to the bones or elsewhere), about 4 in 10 men with prostate cancer, about 3 in 10 women with breast cancer and about 1 in 10 people with lung cancer are alive [3]. These figures are averages for thousands of patients, do not yet include the newest treatments and cannot predict one person's future. Read more: How long do people with cancer live?, Can breast cancer be cured? and Can prostate cancer be cured?
Frequently asked questions
Can bone metastases be cured?
How many radiotherapy sessions are needed for bone pain?
How long should zoledronic acid be given for?
How are bone metastases diagnosed?
With imaging. For the spine, MRI is the main test, and if you have signs of spinal cord compression it should be done within 24 hours [4]. Your doctor may also ask for other scans, such as a bone scan, CT scan or PET scan, and sometimes a biopsy. Read: What is a PET scan? and What is a biopsy?
Can I walk and exercise with bone metastases?
Before you start exercising or a new activity, ask your doctor which bones are at risk of breaking and which movements are suitable and safe for you. Read: exercise during cancer treatment
What does high blood calcium mean in cancer?
Out of every 10 people with cancer, 1 to 3 develop a high blood calcium level at some point; mostly because of a substance made by the tumour itself, and less often because of bone damage [11]. Its symptoms are loss of appetite, nausea, vomiting, constipation, thirst and passing a lot of urine, and confusion, and it is treated with fluids through a drip and medicines such as zoledronic acid [9, 11].
Radiotherapy, spinal cord compression and bone-modifying agents (for doctors)
For physicians
Palliative radiotherapy (ASTRO 2024). RT is recommended for pain from bone metastases and for spine metastases with or without spinal cord or cauda equina compression. Recommended conventional RT regimens: 8 Gy in 1 fraction, 20 Gy in 5, 24 Gy in 6 or 30 Gy in 10 fractions; for cord compression in patients ineligible for surgery: 8 Gy/1, 16 Gy/2, 20 Gy/5 or 30 Gy/10. In cord compression, surgery with postoperative RT is conditionally recommended over RT alone, and dexamethasone is recommended; postoperative RT is recommended after surgery for nonspine metastases; SBRT is conditionally recommended over conventional RT in selected patients with good performance status, no need for surgery and no neurological symptoms or signs [5].
Single versus multiple fractions. In a meta-analysis of 29 trials, the overall pain response was 61% with a single fraction versus 62% with multiple fractions, and complete response 23% versus 24%; retreatment was more frequent after a single fraction (20% versus 8%; P<0.01), with no difference in pathological fracture, cord compression at the treated site or acute toxicity [6]. In SCORAD (686 patients with spinal cord or cauda equina compression; 44% prostate cancer), ambulatory status at week 8 was 69.3% with single-fraction 8 Gy versus 72.7% with 20 Gy in 5 fractions (difference 3.5 percentage points in favour of multiple fractions; lower bound of the one-sided CI 11.5 percentage points against a noninferiority margin of 11; P for noninferiority 0.06); 12-week survival 50% versus 55% [7].
NICE NG234. Symptoms or signs of cord compression: contact the MSCC coordinator immediately and perform whole-spine MRI as soon as possible (always within 24 hours); pain with features of spinal metastases without neurological symptoms: seek advice within 24 hours and MRI within 1 week. With neurological symptoms or signs, oral dexamethasone 16 mg as soon as possible, then 16 mg daily until surgery or RT, then a gradual reduction. Urgent radiotherapy (within 24 hours) for MSCC not suitable for surgery, using 8 Gy in a single fraction unless at high risk of side effects; for spinal metastases with non-mechanical pain without MSCC, also 8 Gy in a single fraction [4].
Bone-modifying agents. Zoledronic acid for bone metastases from solid tumours and multiple myeloma: 4 mg IV infusion over no less than 15 minutes every 3 to 4 weeks for CrCl above 60 mL/min; dose for CrCl 50 to 60: 3.5, 40 to 49: 3.3 and 30 to 39: 3.0 mg; creatinine before each dose and withhold for renal deterioration (increase of 0.5 mg/dL with normal baseline creatinine or 1 mg/dL with abnormal baseline) until creatinine returns to within 10% of baseline; oral calcium 500 mg and vitamin D 400 IU daily; optimal duration unknown [9]. In CALGB 70604 (1822 patients with breast cancer, prostate cancer or myeloma), skeletal-related events within 2 years occurred in 29.5% with 4-weekly and 28.6% with 12-weekly dosing (P<0.001 for noninferiority), with no difference in pain, osteonecrosis of the jaw or renal dysfunction [8]. Denosumab: 120 mg subcutaneously every 4 weeks; correct hypocalcaemia before starting and monitor calcium, especially in the first weeks (higher risk with CrCl below 30 or dialysis); on discontinuation, assess the risk of multiple vertebral fractures [10]. In randomised trials in advanced cancer, a major skeletal event occurred on average every 3 to 6 months [12]. Hypercalcaemia occurs in 10% to 30% of patients with cancer; about 80% is mediated by PTHrP and about 20% is due to bone metastases [11]. More detail in the lessons bone-modifying agents in cancer and oncological emergencies.
Scientific evidence
Scientific evidence
3 itemsEffect of Single-Fraction vs Multifraction Radiotherapy on Ambulatory Status Among Patients With Spinal Canal Compression From Metastatic Cancer: The SCORAD Randomized Clinical Trial
Treatment of multiple myeloma-related bone disease: recommendations from the Bone Working Group of the International Myeloma Working Group
Denosumab versus zoledronic acid in bone disease treatment of newly diagnosed multiple myeloma: an international, double-blind, double-dummy, randomised, controlled, phase 3 study
Related cancer types
Related questions
References
12 referencesShow all references, 2 with a study cardClose the reference list
Numbers in the text, such as [1], refer to these sources. Sources with a “Study card” button are summarised in the site’s evidence library.
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- 3Cancer statistics, 2026
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- 7Effect of Single-Fraction vs Multifraction Radiotherapy on Ambulatory Status Among Patients With Spinal Canal Compression From Metastatic Cancer: The SCORAD Randomized Clinical Trial
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