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  3. Diagnosis and referral of adults with suspected bony metastases
Practice Practice Pointer

Diagnosis and referral of adults with suspected bony metastases

BMJ 2021; 372 doi: https://doi.org/10.1136/bmj.n98 (Published 25 January 2021) Cite this as: BMJ 2021;372:n98
  1. Samantha Downie, orthopaedic clinical research fellow1,
  2. Elizabeth Bryden, general practitioner2,
  3. Fergus Perks, consultant radiologist3,
  4. A Hamish RW Simpson, professor of orthopaedics and trauma1
  1. 1University of Edinburgh, Edinburgh, UK
  2. 2NHS Greater Glasgow & Clyde, Glasgow, UK
  3. 3NHS Lothian, Edinburgh, UK
  1. Correspondence to S Downie Samantha.Downie3{at}nhs.scot

What you need to know

  • Red flag symptoms for cancer related bone pain include severe progressive pain that is worse on movement or at night, inability to bear weight, signs of hypercalcaemia, and pain on direct palpation

  • Metastases may not show up on radiographs until 50-70% of the bone has been destroyed, so initial radiographs may be normal

  • Mirels’ score can be used to predict risk of fracture based on metastasis location, size, radiographic appearance, and pain

  • Prophylactic fixation (before a pathological fracture occurs) leads to better outcomes in terms of pain relief, hospital stay, and function

  • Surgery can relieve pain, improve function, and maximise independence, and is usually of benefit even if prognosis is poor

Of the 44 million people worldwide who are living with treated cancer, 30-80% will experience bone metastases.12345 Metastatic bone disease (MBD) can lead to pain, loss of function, and pathological (low energy) fractures.67

Patients can present to any specialty, and half of those with a first recurrence present to primary care.8 Initial diagnosis can be difficult as lesions may not be visible on radiographs until 50-70% of bone has been destroyed.9 Early treatment can reduce the need for surgery and improve outcomes101112; therefore, a high degree of suspicion is essential when assessing cancer patients with new bone pain.

Despite evidence that outcomes are better when we operate to stabilise bony lesions before they break, more than half of patients are not referred for surgery until they have sustained a pathological fracture.41314

Guidelines from the British Orthopaedic Oncology Society for good practice in metastatic bone disease were published in 201512 and called for targeted guidance for oncology and primary care to ensure that patients who could benefit from surgery were referred to their …

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