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Bone Mets From Breast Cancer

Why Does My Provider Need To Test The Metastatic Tumor

Dr. Julie Gralow on Treating Breast Cancer Bone Metastases

Your care team will test the metastases to figure out the biology of the tumor, which can help guide your treatment plan. Providers may test tumors for:

  • Hormone receptor status: If the cancer is hormone receptor-positive, hormonal therapy may be your first treatment.
  • HER2 status: Human epidermal growth factor receptor 2 is a protein that is overexpressed on some breast cancer cells. HER2-positive cancer responds to specific HER2-targeted therapies.
  • PIK3CA gene mutation: If a tumor is hormone receptor-positive and HER2-negative, your provider may test for this gene mutation. Specific targeted therapies can be used to treat tumors with this mutation.
  • PD-L1 status: Tumors that are hormone receptive-negative and HER2-negative may be tested for PD-L1 status. If the PD-L1 test is positive, you may be recommended to receive a combination of immunotherapy and chemotherapy.

How Is Metastatic Breast Cancer In Bones Diagnosed

Your doctor will likely start with a discussion of your symptoms and a physical examination.

Diagnostic testing may include blood tests to find out if your blood has too much calcium or alkaline phosphatase , either of which can be elevated because of bone metastasis. But this can also be due to other conditions. Blood tests alone cant confirm metastatic breast cancer in bones or pinpoint the location.

Sometimes, an X-ray can reveal bone metastasis. But other times, your doctor may order one or more of the following imaging tests to look for signs that cancer has reached bone:

Breast cancer isnt a single disease, but a group of diseases. So, treatment is personalized to reflect your:

  • specific type of breast cancer
  • extent of metastasis
  • age and overall health

Bone Metastases And Bone Problems

People with bone metastases are at risk of serious bone complications such as bone fractures , spinal cord compression and bone pain.

Bone complications are a concern for people with bone metastases as they can cause pain and may lead to loss of mobility, impacting quality of life. Bone complications can also decrease survival . With the use of bone-strengthening drugs, bone complications are not common .

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How Is Metastatic Breast Cancer Diagnosed

If you have symptoms of metastatic breast cancer, your provider may recommend tests including:

  • Blood tests, including complete blood count and comprehensive metabolic panel.
  • Imaging studies, including MRI, CT, bone scan and PET.
  • Bronchoscopy, which uses a scope to look inside your lungs this can be done if there is a concerning spot in the lungs.
  • Biopsy to remove tissue from a suspicious area and analyze it.
  • A tap to remove fluid from an area with symptoms. For example, pleural tap removes fluid from the lung area. Spinal tap removes fluid from the spinal cord area.

Survival Rates Of Bone Metastases

Patient with breast cancer and bone metastasis. A. CT scans at baseline ...

Survival rates for people with bone metastases vary greatly by cancer type and stage. Your general health condition and the type of treatment you received for the primary cancer are additional factors.

Discuss your particular situation with your doctor. Remember that survival rates are averages gathered from large numbers of people. Also, survival data may reflect statistics from a period before the most recent treatment advances.

A large-scale 2017 study of the 10 most common cancers with bone metastasis found:

  • Lung cancer had the lowest 1-year survival rate after bone metastasis .
  • Breast cancer had the highest 1-year survival rate after bone metastasis .
  • Having metastases in bone and also in other sites was found to decrease the survival rate.

Here are some typical figures from a 2018 study of common cancers and bone metastasis:

Type of cancer

Youre likely to have a combination of therapies that may include:

  • radiation to slow metastasis growth and reduce pain
  • chemotherapy to kill cancer cells and reduce tumor size
  • hormone therapy to reduce the hormones known to be involved with breast and prostate cancer
  • painkillers and steroids for pain relief
  • drugs that specifically target bones
  • surgery if necessary to stabilize your bone, fix a break, and help with pain
  • physical therapy to strengthen your muscles and help you with mobility
  • extreme heat or cold that targets cancer cells and may relieve pain

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Physiological States That Exacerbate Osteolysis

While not directly responsible for osteolysis in metastatic breast cancer disease, there are physiological parameters that can amplify the degree of bone loss. Clinical studies of newly diagnosed breast cancer patients have revealed that high bone turnover correlates with a higher risk of skeletal complications . For post-menopausal women, high bone turnover may be caused by estrogen deficiency. Estrogen profoundly affects bone remodeling by suppressing production of RANKL while increasing production of OPG. Estrogen also increases osteoblast pro-collagen synthesis and decreases osteoblast apoptosis . In addition, production of inflammatory cytokines is suppressed by estrogen . Estrogen has also been shown to promote osteoclast apoptosis and inhibit activation of mature osteoclasts. Unfortunately, some of the therapies used for breast cancer patients may exacerbate the problem. For example, the use of aromatase inhibitors increases the risk for osteoporosis. Chemotherapy may bring about ovarian failure and premature menopause .

Association Between Pain And Bone Metastasis Characteristics

Based on the 767 patients with available information on both type of bone metastasis and pain status at BOM diagnosis, we found that pain was significantly associated with bone metastasis type = 10.79 p = .0045). Patients with lytic bone metastases had a significantly higher odds of pain than patients with blastic/sclerotic metastases = 10.78 p = .001 Table ). Among patients with available pain status and number of bone metastases , patients with multiple bone metastases at time of BOM diagnosis had 37% increased odds of having pain compared with patients with single bone metastasis = 4.62 p = .0316). The overall effect of location of bone metastases on pain trended toward statistical significance = 4.92 p = .0853), with higher odds of pain in patients with both axial and appendicular metastases versus those with pain confined to the axial skeleton = 4.49 p = .0340).

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Types Of Bone Metastases

Normally your bones are constantly changing. New bone tissue is being formed and old bone tissue is breaking down into minerals that circulate in your blood. This process is called remodeling.

Cancer cells upset the normal process of bone remodeling, causing bones to become weak or too dense, depending on the type of bone cells affected.

Your bone metastases may be:

  • osteoblastic, if there are too many new bone cells
  • osteolytic, if too much bone is destroyed

In some cases, your bones may have both types of metastases.

Overall Survival By Bone Metastasis Characteristics

New bone-in technique tests therapies for breast cancer metastasis

OS of this BOM population is described in our previous manuscript, which details survival differences in these patients with BOM with respect to tumor subtype .

OS from distant disease did not differ significantly by bone metastasis type = 4.53 p = .10) or pain at BOM diagnosis = 1.75 p = .19). However, using other characteristics available at time of BOM diagnosis, we found OS differences between several unique BOM subgroups. Patients with a single metastasis versus multiple bone metastases at time of BOM diagnosis had improved OS from distant disease diagnosis = 34.76 p< .0001). Median survival for patients with a single bone metastasis was 7.54 years compared with 4.80 years for patients with multiple bone metastases .

Overall survival from first metastasis diagnosis by number of bone metastases among patients with breast cancer and boneonly metastases .

OS from distant disease diagnosis also differed by location of bone metastases at time of BOM diagnosis = 31.75 p< .0001), with poorer OS in patients with metastases in both the axial and appendicular skeleton compared with patients with appendicularonly or axialonly metastases. Median OS from distant disease diagnosis was 6.78 years for appendicularonly bone metastases, 5.62 years for axialonly bone metastases, and 4.58 years for both appendicular and axial bone metastases .

Number of metastases .

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What Are The Symptoms Of Bone Metastasis In Breast Cancer

All three doctors say that new, progressive pain in your bones or joints is the most common symptom of metastatic breast cancer in bones. “I always tell patients to inform me if there’s pain that’s not getting better,” says Dr. Tsarwhas. This can sometimes be confused with arthritis or other pre-existing chronic pain issues, he says, which is why it’s important for breast cancer patients to be proactive about any new pain they encounter.

New fractures or unexplained fractures can also be a sign of bone metastasis, Dr. Tsarwhas adds. Cancer can weaken bones and make them break more easily. “New lumps or bumps in the lymph node area…could be a sign of recurrent breast cancer as well,” he says.

A person with metastatic breast cancer in their bones may also experience more general cancer symptoms, such as fatigue, lack of appetite, and extreme, unexplained weight loss.

What Is Metastatic Breast Cancer

Metastatic breast cancer is the most advanced stage of breast cancer. Breast cancer develops when abnormal cells in the breast start to divide uncontrollably. A tumor is a mass or collection of these abnormal cells.

Metastasis refers to cancer cells that have spread to a new area of the body. In metastatic breast cancer, cells may spread to the:

Healthcare providers name cancer based on its primary origin. That means breast cancer that spreads to other body parts is still considered breast cancer. The cancer cells are still breast cancer cells. Your care team will use breast cancer therapies, even if the cancer cells are in other areas.

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Demographic And Clinicopathological Features

This retrospective cohort study consists of 554,585 breast cancer patients with recorded bone metastasis event and intact ER/PR information, among which 19,439 patients were confirmed with developing bone metastasis and 10,447 patients with bone-only metastasis and valid survival time . In order to investigate the differences in the incidence of bone metastasis across the four HR status breast cancers, the numbers and percentage of bone metastatic events were outlined . Bone metastasis is most likely to develop in ER-positive/PR-negative breast cancers than in other subgroups, while the incidence of bone metastasis is similar between ER-positive/PR-positive and ER-negative/PR-negative breast cancers. Thereafter, to exclude the potential influence of other concurrent metastases, including brain, liver, or lung metastasis, we outlined the demographic and clinicopathological features of the 10,447 breast cancer patients with sole bone metastasis, which was included into the subsequent survival analysis . Among the cohort, 71.9% , 16.3% , 0.7% , and 11.1% of the bone metastatic breast cancer patients had ER-positive/PR-positive, ER-positive/PR-negative, ER-negative/PR-positive, and ER-negative/PR-negative primary tumors, respectively.

Figure 1 Flowchart of the cohort selection.

Table 1 Bone metastasis incidence in breast cancer patients stratified by hormone receptor status.

Bone Metastasis Characterization At Time Of Bom Diagnosis

Bone metastasis

In our sample of 1,445 patients with BOM, 808 had available information regarding type of bone metastasis at BOM diagnosis: 389 had lytic bone metastases, 270 had sclerotic/blastic metastases, and 149 had mixed bone metastases. At time of BOM diagnosis, 290 patients were found to have a single bone metastasis, whereas 1,141 patients had multiple bone metastases . Regarding the location of bone metastases at BOM diagnosis, 511 patients had bone metastases only in the axial skeleton, 153 patients had bone metastases only in the appendicular skeleton, and 770 patients had bone metastases in both the axial and appendicular skeleton . The majority of patients with a single bone metastasis had metastasis to the spine followed by metastasis to the pelvis , sternum , femur , rib , humerus , skull , mandible , clavicle , and scapula .

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Triple Negative Breast Cancer

With this type of breast cancer, the breast cancer cells dont have ER+ or PR+ receptors. They dont overproduce the HER2 protein, so hormone therapy isnt very effective.

Instead, triple negative stage 4 breast cancer is usually treated with chemotherapy. Radiation therapy may also be an option, depending on the site of metastasis.

Why Does Metastatic Breast Cancer Happen

Most often, metastatic cancer occurs because treatment didnt destroy all the cancer cells. Sometimes, a few cells remain dormant, or are hidden and undetectable. Then, for reasons providers dont fully understand, the cells begin to grow and spread again.

De novo metastatic breast cancer means that at the time of initial diagnosis, the breast cancer has already spread to other parts of the body. In the absence of treatment, the cancer spreads.

There is nothing you can do to keep breast cancer from metastasizing. And metastatic breast cancer doesnt happen because of something you did.

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Can Metastatic Breast Cancer Go Into Remission

Metastatic breast cancer may never go away completely. But treatment can control its spread. Cancer may even go into remission at some points. This means you have fewer signs and symptoms of cancer.

A treatment break may be considered in certain situations, including if remission occurs or if someone is experiencing intolerable side effects. A pause in treatment can help you feel your best and improve your quality of life.

Advances In Treatment Of Metastatic Breast Cancer With Bone Metastasis

Dr. David Schuster on Detecting Bone Metastases in Breast Cancer

Ziping Wu, Jinsong Lu

Department of Breast Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University , China

Contributions: Conception and design: All authors Administrative support: None Provision of study materials or patients: All authors Collection and assembly of data: All authors Data analysis and interpretation: All authors Manuscript writing: All authors Final approval of manuscript: All authors.

Correspondence to:

Abstract: Bone is the most commonly seen metastatic site in all the metastatic breast cancer . Treatment includes systemic treatment according to different molecular subtypes and specified treatment of the bone. Bisphosphonate and denosumab are the only two drugs approved to use in bone metastatic site. The optimal dosing schedule and duration of the drugs are still under research. New drugs and therapies including curcuminoids, sunitinib and nano particles are potentially available in the near future.

Keywords: Metastatic breast cancer bone metastasis bisphosphonate denosumab

Submitted Jun 01, 2018. Accepted for publication Jun 07, 2018.

doi: 10.21037/cco.2018.06.05

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How Is Metastatic Breast Cancer Treated

The main treatment for metastatic breast cancer is systemic therapy. These therapies treat the entire body. Systemic treatments may include a combination of:

Your care team will plan your treatment based on:

  • Body parts cancer has reached.
  • Past breast cancer treatments.
  • Tumor biology, or how the cancer cells look and behave.

Overall Survival From Distant Disease Diagnosis By Bone Metastasis Characteristics Adjusting For Age Race/ethnicity Smoking Status And Bmi

Number of metastases remained a statistically significant predictor of OS after adjusting for age, race, BMI, and smoking status. In a univariable analysis, patients with multiple metastases had an 82% increased hazard of death , and after adjusting for age at breast cancer diagnosis, race/ethnicity, BMI, and smoking status, patients with multiple versus single bone metastases had a 78% increased hazard of death .

Similarly, location of metastases remained a statistically significant predictor of OS after adjusting for age, race, BMI, and smoking status. In a univariable analysis, metastasis location was significantly associated with OS = 31.22 p< .0001), and patients with both axial and appendicular metastasis at time of BOM diagnosis had a 69% increased hazard of death relative to patients with metastases confined to the appendicular skeleton . There was no significant difference in OS among patients who had axialonly versus appendicularonly metastases . After adjusting for age at breast cancer diagnosis, race/ethnicity, BMI, and smoking status, patients with both axial and appendicular metastases had a 65% increased hazard of death relative to patients with metastases confined to the axial skeleton.

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Whats The Life Expectancy With Metastatic Breast Cancer In Bones

Metastatic breast cancer in the bones is not curable, and the prognosis typically isn’t as positive as earlier-stage cancers. Per the ACS, the five-year relative survival rate of a personal with distant breast cancer is 28%. That means that people with metastatic breast cancer are about 28% as likely to be alive five years after diagnosis as people who don’t have that cancer.

However, data shows that metastatic breast cancer in the bones seems to have the best survival rate compared to other types of metastatic breast cancer. A 2019 study published in the journal BMC Cancer looked at five years of data to track the survival rates of stage four breast cancer patients and calculated specific rates based on the site of metastasis. The researchers found that patients with bone metastasis had the best overall survival rate of 50.5% after three years. This means that 50.5% of patients were still alive three years after diagnosis.

Other research has estimated that the one-year survival rate of metastatic breast cancer in the bones is 51% and the five-year survival rate is 13%.

But these numbers are estimates, not foregone conclusions. A lot of factors can impact a person’s prognosis, says Dr. Lin, including the type of cancer they have, where it spread, how old they are, and any other pre-existing conditions or health problems they have. And some cancers respond better to treatment than others, which absolutely affects a person’s survival.

The Importance Of Osteoblasts In Osteolytic Breast Cancer Metastasis

Bone metastasis

Just as osteoblasts are a critical partner in normal bone remodeling, they are vital to the metastatic osteolytic process. Because osteoblasts secrete both RANKL and OPG, they are major mediators of osteoclastogenesis . Current therapies consist of blocking osteoclast activity as a means of disrupting the vicious cycle. Bisphosphonates such as zoledronic acid bind to hydroxyapatite of the bone matrix and are ingested by osteoclasts, which then undergo apoptosis. However, this approach has not entirely solved the problem. Administration of bisphosphonates may slow osteolytic lesion progression and stabilize or increase overall bone density, but does not bring about healing . There is evidence in both humans and animals that bone loss in osteolytic metastasis is partly due to the failure of the osteoblasts to produce new osteoid for the bone matrix.

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