Intended for healthcare professionals

Clinical Review

Managing skeletal related events resulting from bone metastases

BMJ 2008; 337 doi: (Published 03 November 2008) Cite this as: BMJ 2008;337:a2041
  1. Anna N Wilkinson, general practitioner in oncology1,
  2. Raymond Viola, palliative care physician2, assistant professor2,
  3. Michael D Brundage, professor (oncology)3, community health and epidemiology principal investigator3
  1. 1Department of Oncology, Ottawa Hospital Cancer Centre, 503 Smyth Road, Ottawa, ON, Canada K1H 1C4
  2. 2Palliative Care Medicine Program, Department of Medicine, Queen’s University, 34 Barrie Street, Kingston, ON, Canada K7L 3J7
  3. 3Division of Cancer Care and Epidemiology, Queen’s Cancer Research Institute, Kingston, ON, Canada K7L 3N6
  1. Correspondence to: A N Wilkinson anwilkinson{at}
  • Accepted 3 September 2008

Summary points

  • Bone is an extremely common site of cancer metastases, and bone metastases frequently results in pain

  • Bone metastases can be detected on a bone scan, computed tomogram, and magnetic resonance imaging; plain x ray films will show abnormalities only when at least half of the bone is involved

  • Pathological fracture and spinal cord compression should always be ruled out

  • Treatment of metastatic bone pain should comprise analgesics, non-steroidal anti-inflammatory drugs, and bisphosphonates. Systemic chemotherapy, hormonal therapy, and surgery can play a role in some cases

  • Radiation therapy, as a single fraction, half body treatment, or as a systemic radiopharmaceutical, can provide effective pain relief with minimal side effects

Pain is one of the most common symptoms managed in a palliative setting, and over half of all metastatic cancers will be associated with pain originating from bone metastases. Breast, lung, and prostate cancers account for about 80% of all bone metastases.1 Management of bone pain is especially important in patients with prostate or breast cancer as these patients may survive for many years with metastatic disease. Primary care physicians are well suited to provide palliative care as their long term relationships with patients and their families can result in a more satisfactory experience for all involved.

All too often the management of bone pain from cancer metastases stops at opioids and non-steroidal anti-inflammatory drugs. Although specialists administer treatments such as radiation therapy and radiopharmaceuticals, family physicians must be aware of their role if they are to make appropriate referrals.

What problems can bone metastases cause?

Bone formation is a finely balanced process involving the continuous remodelling of bone through the activity of osteoclasts and osteoblasts. This dynamic process may be disrupted by the migration of cancer cells into bone, creating bone metastases. Metastatic lesions are intrinsically weaker than normal bone and can lead to multiple sequelae …

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