What Does It Mean When Breast Cancer Metastasizes To Bones
As mentioned earlier, metastatic breast cancer is when cancer has spread beyond the breast and the surrounding lymph nodes to other parts of the body. This can happen either because a cancer has come back after treatment or because a cancer did not respond to treatment or wasn’t treated in time, allowing it to spread. In the case of metastatic breast cancer in the bones, cancer cells take up residence in parts of a person’s bone, causing lesions that replace healthy tissue with cancer cells.
Modern science still doesn’t quite understand exactly how cancers metastasize, Nancy Lin, MD, a medical oncologist who specializes in breast cancer treatment at Dana-Farber Cancer Institute in Boston, Massachusetts, tells Health. “We know that at some point the cancer manages to find its way into the bloodstream and then through that is able to get to other parts of the body,” she says. Beyond that, it’s unclear why certain cancers tend to spread to specific spots in the body like the bones, but there are some theories.
Any part of your skeletal system can be impacted by metastatic cancer, but per the American Cancer Society , the spine is the most common site of bone metastasis. Other areas include the hip, femur, upper arm, ribs, and skull.
What Is Secondary Breast Cancer In The Bone
When cancer that started in the breast has spread to the bones, its called secondary or metastatic breast cancer in the bone.
Some people also refer to it as bone metastases or bone mets.
The bones most commonly affected are the:
- Upper bones of the arms and legs
The cells that have spread to the bone are breast cancer cells. Its not the same as having cancer that starts in the bone.
Breast cancer cells can spread to the bone through the lymphatic system or the blood.
Origin And Characterization Of Cafs In The Tumor Microenvironment
The origin of CAFs in the tumor microenvironment remains to be elucidated, but they might be derived from resident fibroblasts , actively recruited bone marrow-derived cells or cells that undergo epithelial-mesenchymal transition .
Due to the phenotypical and functional heterogeneity of CAFs there are no unique markers to identify them but commonly used ones include SMA, fibroblast-specific protein1 , fibroblast activation protein , platelet derived growth factor receptors , vimentin, and tenascin C . Several in vitro studies demonstrate that MSCs can differentiate into SMA -expressing myofibroblasts upon cancer cell stimulation . For instance, studies by Mishra and colleagues show that human bone marrow-derived MSCs can acquire a CAF-like, myofibroblastic phenotype upon prolonged stimulation with conditioned medium from MDA-MB-231 breast cancer cells. Importantly, these cells expressed CAF markers including SMA, SDF-1, vimentin, and FSP as determined by immunofluorescence staining. Gene expression analysis revealed that cancer-conditioned medium upregulated the expression of CAF-associated genes including SDF-1, platelet derived growth factor and MMP9, suggesting that exposure to cancer cells induces hMSC differentiation into a CAF-resembling state .
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Bone Weakening And Fracture
Secondary breast cancer in the bone may mean the affected bones are weakened, which can increase the risk of a fracture.
If a bone has fractured you may need surgery to try to repair the fracture. You may also be given drug treatment to stop this happening in the future. You may have radiotherapy after the surgery.
What Is Metastatic Breast Cancer In Bones
Metastasis describes the spread of cancer from where it started to another part of the body. This happens when cancer cells break from the primary tumor and enter the lymph system or bloodstream. From there, they can travel throughout the body and form new tumors.
Metastatic breast cancer in bones is not the same as bone cancer. Its made up of breast cells, not bone cells. Its also called stage 4 or advanced breast cancer.
A 2019 research review showed that bone is the most common site of breast cancer metastasis. Breastcancer.org says that for more than half of women with metastatic breast cancer, bones are the first site of metastasis. The bones most likely to be affected are:
- long bones in your arms and legs
Other common sites of breast cancer metastasis include your liver and lungs.
Signs and symptoms vary depending on where the cancer has spread and how big the tumors are.
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A New Treatment Meets Achieves Both Purposes
There is a revolutionary new noninvasive treatment to ease pain and put the brakes on local bone mets by ablating the bone tumor . It is called MR-guided Focused Ultrasound .
MRgFUS begins with identification and planning. Magnetic resonance imaging reveals the location, size and extent of the lesion. This same imaging allows the physician to plan strategically targeted delivery of ultrasound to the lesion. The ultrasound beams are aimed from numerous different directions, and each one passes harmlessly through skin and other tissues. Then, when the beams converge, they generate a short blast of lethal heat at the point where they meet. This heat destroys the bone mets at that site, and deadens the nerves that send pain messages to the brain.
Within 3-7 days, most patients have significant pain reduction in many cases, almost none.
Symptoms If Cancer Has Spread To The Bones
You may have any of these symptoms if your cancer has spread to the bones:
- an ache or pain in the affected bone
- breaks in the bones because they are weaker
- breathlessness, looking pale, bruising and bleeding due to low levels of blood cells blood cells are made in the bone marrow and can be crowded out by the cancer cells
Sometimes when bones are damaged by advanced cancer, the bones release calcium into the blood. This is called hypercalcaemia and can cause various symptoms such as:
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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.
Metastatic Breast Cancer Treatment
Metastatic breast cancer can have different presentations for each patient, and can behave differently from one person to the next. But for most, individualized treatment can slow the spread of cancer, lessen the impact of symptoms or both.
We see patients with a whole host of presentations and degrees of aggressiveness. Were not looking at all metastatic diagnoses with the same lens. When planning treatment and supportive care, we look at each individual patient and consider all aspects of their health and well-being.
The mainstay of therapy in the setting of metastatic disease is systemic therapy, Habibi explains.
Systemic therapies use medicines, and may include:
Local therapy: Examples of this approach include surgery and radiation directed at one or more specific spots where breast cancer has spread. Local therapy can be used to address oligometastatic breast cancer, which is breast cancer that has spread to just one spot or to a limited number of areas.
If a metastatic area remains stable with treatment, it can be treated as a chronic disease, Habibi says, noting that in these situations, the strategy is preventing the cancer from advancing. For oligometastatic breast cancer, he says that a combination of chemotherapy, radiation treatments or surgery to remove cancerous areas can address symptoms and extend life.
Regional therapy includes surgery or radiation to treat metastatic cancer in nearby affected lymph nodes.
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Talking To Family And Friends About Metastatic Breast Cancer
Telling your loved ones about a recurrence of breast cancer may be more difficult than it was telling them about the original diagnosis. If this is a first diagnosis and its metastatic, telling friends and family can also be extremely challenging. You may be concerned about upsetting your family and friends or worried about how they will react. Even after youve shared the news, you may find it difficult to communicate openly at times. Sometimes its uncomfortable to ask for help, answer questions about how youre doing, or tell well-meaning relatives and friends that you need some time and space for yourself.
The most important thing to keep in mind is that youre always in control of the conversation. Its entirely up to you how much information you want to share.
Surgery Of The Bone/radiotherapy
If a fracture of the bone has occurred or is likely to occur, then an orthopedic assessment is necessary to determine if a surgical intervention is needed before RT or RT alone is adequate. In emergent cases where a spinal compression has occurred, surgical decompression is the optimal treatment of choice. If surgery is not feasible, then an emergent RT is also an option .
Osteoclasts And The Vicious Cycle Model Of Bone Loss
The entry of breast cancer cells into the bone micro-environment synergistically increases the complexity of cell-cell interactions. A working model to describe the bone remodeling compartment in the presence of metastatic cancer cells has been referred to as the ‘vicious cycle of bone metastasis’ . There are many excellent reviews describing this paradigm from its inception in the 1990 s. The minimal essential components are osteoblasts, osteoclasts, tumor cells and the mineralized bone matrix. According to this paradigm, the tumor cells produce a variety of growth factors, most notably parathyroid hormone-related protein . The role of PTHrP in bone metabolism is not fully understood, but it is known to cause upregulation of RANKL and downregulation of OPG , thus enhancing osteoclast function leading to bone degradation. In the process, growth factors stored in the matrix, such as transforming growth factor -, vascular endothelial growth factor , insulin-like growth factors , bone morphogenic proteins and fibroblast-derived factors, as well as calcium, are released into the bone microenvironment. These factors can stimulate the tumor cells to proliferate and produce more growth factors and more PTHrP, further perpetuating the vicious cycle of bone metastasis.
The Role Of The Microenvironment In Bone Metastasis
The striking contrast between the abundance of circulating tumor cells and the relative rarity of metastatic events strongly suggests that the metastatic process is very inefficient and takes much more than simply the presence of cancer cells in the circulation . Once a cell has overcome the intrinsic barriers to carcinogenesis, it will need to overcome additional environmental barriers that have been evolutionarily perfected to protect multicellular organisms and maintain their homeostasis . Typical environmental barriers include physical , chemical , hypoxia, and low PH), and biological peptides) components .
Once distant from the primary tumor site and resident in the bone narrow, breast cancer cells establish a tight interaction with the marrow microenvironment . Resident metastatic breast cancer cells secrete a plethora of osteolytic factors , capable of both receptor activator of NF-ÎºB ligand -dependent and -independent activation of osteoclast formation and bone resorption . Tumor activation of bone resorption occurs via direct activation of osteoclasts, and their precursors derived from the monocyte/macrophage lineage cells resident in the bone marrow, and are independent of RANKL . Monocytes are also activated to form osteoclasts via indirect effects on osteoblasts, leading to osteoclastogenesis mediated by RANKL. In the presence of colony-stimulating factor 1 , RANK-L promotes the entire process of osteoclastogenesis and the activation of bone resorption .
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Managing Your Feelings About Metastatic Breast Cancer
Regardless of whether metastatic breast cancer is a first diagnosis or a recurrence, its normal for people to feel angry, scared, stressed, outraged, depressed, or calm. You may question the treatments youve had, feel mad at your doctors, or be prepared to deal with the diagnosis in a matter-of-fact way. There is no right or wrong way to come to terms with a metastatic breast cancer diagnosis.
Many people find it helps to concentrate on understanding the diagnosis, learning all they can about different treatment options, and taking the time to get second opinions. Information can give people a feeling of control, which can help them manage any fears they may have.
Loss of control is a huge issue for women diagnosed with metastatic breast cancer, said Musa Mayer, author of Advanced Breast Cancer: A Guide to Living with Metastatic Disease and patient advocate. The process of gathering information and learning about the disease and treatment can be very stabilizing and help women feel more in control.
Some people with metastatic breast cancer may feel the urge to withdraw from social connection. But in interviews and publications, many people who are living with metastatic breast cancer have said that distancing themselves from loved ones wasnt very helpful in dealing with their diagnosis.
Still, its important to remember that everyone deals with fear and stress differently. Coming to terms with the diagnosis takes time and is different for everyone.
Soil And Seed Hypothesis
Langenbeck once said that Every cancer cell must be viewed as a living organism capable of development. When plants seed, the seeds are carried in all directions, but they only can survive and grow if they land in the right soil. In 1882, Fuchs argued that certain organs might be susceptible to secondary cancer. In 1889, Stephen Paget proposed the seed and soil hypothesis, which held that tumor cells could only grow in fertile soil . He argued that in BC, bones suffer in a way that no embolic theory alone could explain . Therefore, bone tissue must have a specific microenvironment that supports BC cell growth and development. BC bone metastasis is a complex process involving many kinds of cells and cell growth factors . However, it is unclear which cells and cytokines are involved. Therefore, the first thing we need to do is to understand the soil and the seed.
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Getting Emotional Support After A Metastatic Breast Cancer Diagnosis
Most people find it helpful to talk openly about any fears, worries, or frustrations they may have while living with breast cancer. While some people choose to confide in friends and family members, others may prefer to talk in a cancer support group setting either in person or online. In either setting, you can talk with other women facing similar challenges and get firsthand advice about managing side effects, fear, and stress.
If support groups dont appeal to you, you may want to talk to an expert in cancer care such as an oncology social worker, a psychiatrist, a psychologist, or a counselor. Your medical team can probably recommend someone or help point you in the right direction.
Many people get emotional support and strength from their faith. You may find comfort in praying and talking to members or leaders of your spiritual community. If you need help finding faith-based support, many hospitals have a chaplain who helps guide people of all faiths to nearby organizations.
You also might need some support at home and at work. Some treatments can make you feel tired and unable to do some of your usual activities. Let people who care about you help out with daily chores or tasks:
Read more about getting emotional support after a metastatic breast cancer diagnosis:
Will I Need More Than One Treatment For Metastatic Breast Cancer
Medications are important for metastatic breast cancer to help control its spread. Resistance to therapies may develop, which can lead your care team to recommend a change in treatment.
When you start a treatment regimen, you and your care team will see how:
- The cancer responds to the therapy.
- The side effects impact you.
If the treatment isnt working or the side effects are unbearable, your care team can discuss switching the treatment method. They may recommend a different drug, dosage or schedule.
There are many treatments available. If one therapy isnt working for you for whatever reason, there is usually another one you can try.
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High Blood Calcium Levels
When cancer spreads to the bones, too much calcium from the bones can be released into the bloodstream. This is called hypercalcemia.
High blood calcium levels can cause problems such as
- Feeling thirsty all the time and drinking lots of liquids
- Muscle weakness
- Kidney failure.
Treatment includes giving large amounts of intravenous fluids to protect the affected kidneys and medicines such as bisphosphonate drugs to bring blood calcium levels down quickly. Once the calcium level is back to normal, treating the cancer can help keep the calcium level from getting too high again.
How Effective Are Treatments For Bone Metastases
Although current treatments for bone metastases are unable to completely remove all cancer cells, many women with bone metastases can live for many years with extremely good quality of life.
The effect of bone metastasis on your prognosis is individual and depends on what type of cancer you have, where it has spread to and how you respond to various treatments. The main aim of any treatment is to control pain and other symptoms so you can enjoy your day-to- day activities as much as possible.
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Survival Rates Of Bone Metastases
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