Study Design And Setting
This nationwide historical cohort study was conducted in Denmark , whose entire population receives tax-supported healthcare from the Danish National Health Service. Since 1968, the Civil Registration System has assigned to every Danish citizen a unique 10-digit civil registration number encoded for date of birth and gender. The CRS also tracks address changes, dates of emigration and changes in vital status, and allows for unambiguous linkage among all Danish population-based administrative and health registries.
The nationwide Danish Cancer Registry has recorded all incident cases of cancer in Denmark since 1943. The DCR collects data on patient demographics, tumour site, tumour morphology and tumour stage at diagnosis. The Danish National Registry of Patients has collected electronic data on hospitalisations since 1977 and on outpatient and emergency room visits since 1995. For each hospital contact, the DNRP records dates of admission and discharge, surgical procedures, and up to 20 diagnoses coded by physicians at discharge as per the Danish version of the International Classification of Diseases, 10th revision .
What Can I Expect While Living With Metastatic Breast Cancer
Your care team will monitor you every few months to check if the cancer is responding to treatment, and also to see if you are having any side effects. The process of restaging the cancer includes:
- History/physical exam.
- Imaging tests, including CTs and bone scan or PET scan.
Before your scans or tests, its normal to feel anxiety. It may help to bring a friend or family member to the appointment with you.
Mechanisms Of Breast Cancer Metastasis
No one really knows what factors will make a certain patient more or less susceptible to breast cancer metastasis.
There is growing awareness that part of that susceptibility is due to host factors. The host factors are the characteristics of the non-malignant cells and the general biological environment surrounding the malignant breast tumor.
Sometimes the host factors are referred to as the pre-metastatic niche and it is thought that bone-marrow-derived progenitor cells may directly influence the dissemination of malignant cells to distant areas.
Non-neoplastichost cells within the tumor may also play a key role in the regulation of breast cancer metastasis.
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Too Much Calcium In The Blood
Too much calcium in the blood can cause symptoms such as:
- Passing large amounts of urine
Hypercalcaemia is a medical emergency and can be serious if not diagnosed quickly. Its important to know who to report these symptoms to if they occur, so check this with your treatment team.
To relieve symptoms you might be told to drink plenty of water. However, many people will need to be given fluids into a vein to help flush the calcium out of the body.
If youre not already having bone-strengthening drugs, your treatment team will prescribe these.
Eating foods that contain calcium or taking prescribed calcium supplements does not cause hypercalcaemia.
Breast Cancer Subtypes Hormonal And Her2 Status And Survival Rates
Many research studies over the years have shown that Estrogen-positive breast cancers have better survival rates than all of the Estrogen-negative subtypes.
Progesterone-positive breast cancer also appears to have improved survival rates in comparison to progesterone-negative cases.
A recent research study combines hormone receptivity, HER2 status and stage and found some interesting results:-
For ER+ sub-types survival rates were significantly better than all other subtypes. For example, at stage 1b,
ER+ PR+ HER2- 5-year survival rates were 98.6%ER+ PR- HER2+ 5-year survival rates were 97.3%
The subtype triple negative breast cancer had the worst survival rates over all three stages. At stage I the 5-year survival rate was 92.9% and at stage III 48.9%.
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What Bones Do Breast Cancer Affect
Although metastatic breast cancer can potentially occur in any bone in the body, it most often affects the ribs, spine, pelvis and long bones in the arms and legs. Breast cancer that has spread to the bones may cause: Sudden bone pain, such as hip or back pain, which may feel similar to the discomfort associated with arthritis or exercise strain
Aggressive And Advanced Metastatic Breast Cancer
Habibi says the most extreme situations involve patients who are diagnosed with a very fast, aggressive breast cancer that has already spread to multiple organs and begins to overwhelm the body. For those patients, palliative care is important, concentrating on local control, pain management and avoiding bleeding and infection.
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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.
What Is The Best Treatment For Bone Metastases
Bone-modifying medications are a newer treatment for bone metastases and can be very effective. Bisphosphonates such as Zometa are not only effective in reducing pain from metastases but appear to have anti-cancer effects as well. These medications may also reduce the chance of further bone metastases and improve survival. Xgeva may also be effective in treating bone metastases while improving survival.
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Cancer Patients With Bone Metastasis
We included all adult residents of Denmark diagnosed with cancer in the Danish Cancer Registry from 1 January 1994 to 31 December 2010, and with a diagnosis of bone metastasis registered in the Danish National Patient Registry on or after the date of primary cancer diagnosis until 31 December 2012. DNRP holds discharge diagnoses from all inpatient admissions to Danish hospitals since 1977 and hospital outpatient clinic diagnoses since 1995. For each visit, the DNPR includes information on admission and discharge, procedures and up to 20 diagnoses. Since 1994, the diagnostic information has been coded according to the International Classification of Diseases, 10th Revision. All diagnostic codes are given in the online .
What Are The Symptoms Of Bone Metastases
If your breast cancer spreads to the bones, you may experience some of the symptoms described below. Symptoms may vary depending on the location and size of the cancerous deposit. Sometimes bone metastases dont cause any symptoms at all and they are picked up on a routine scan. It is also possible for some metastases and not others to be bothersome. Symptoms may develop over weeks or months. Its very important for you to tell your doctors and nurses about any new symptoms or any change in symptoms.
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Univariable And Multivariable Analysis
In univariate analysis, we found that patients of older age, black race, higher grade tumors, HR/HER2 subtype, high T stage , unmarried status, uninsured status, visceral involvement , no primary tumor surgery displayed worse OS .
Table 2 Univariate and multivariate cox progression of OS and BCSS of breast cancer patients with initial bone metastasis.
These statistically significant factors were included in the multivariate analysis. Patients older than 60 years old , black race , T3 stage were significantly related to worse OS. Compared with HR+/HER2 patients, HR+/HER2+ and HR/HER2+ subtype showed improved OS , while HR/HER2 subtype demonstrated the worst outcome . Social factors like marital status and insurance status were also associated with OS.
Among the 6,860 patients with bone metastatic lesions, 4096 cases demonstrated bone-only metastasis and 2,764 cases displayed concurrent visceral metastases. The outcome was much worse when combining visceral metastases . In terms of BCSS, univariate and multivariate results identified the same prognostic factors as OS .
Advances In Treatment Of Metastatic Breast Cancer With Bone Metastasis
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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Characteristics And Survival In Bone Metastatic Breast Cancer Patients With Different Hormone Receptor Status: A Population
- 1Department of Oncology, Shengjing Hospital of China Medical University, Shenyang, China
- 2Innovative Cancer Drug Research and Development Engineering Center of Liaoning Province, Shengjing Hospital of China Medical University, Shenyang, China
- 3Department of Gastrointestinal Surgery, Yantai Affiliated Hospital of Binzhou Medical University, Yantai, China
Background: Accumulating preclinical evidence has uncovered the indispensable role of steroid hormone and their receptors, namely, estrogen receptor and progesterone receptor , in the development of bone metastases in breast cancer. Limited data are available regarding the survival difference between different hormone receptor subgroups, and its prognostic significance is uncertain now. Such data are important for risk stratification and needed to formulate specialized regimen for bone metastatic breast cancer.
Methods: From the year of diagnosis 2010 to 2018, 554,585 breast cancer patients, among which are 19,439 with bone metastasis and 10,447 with bone-only metastasis, were extracted from the Surveillance, Epidemiology, and End Results database. KaplanMeier survival analysis was performed to compare the survival difference between the different HR status subgroups. Univariate and multivariate Cox proportional hazard regression was used to validate the prognostic role of HR status and identify other prognostic factors in bone metastatic breast cancer.
Can Cancer Metastasis To The Knee
When malignancy is the etiology of the pain, it is usually due to a primary tumor of the osseous structures or soft tissues of the knee joint. Metastatic disease involving the knee joint is uncommon, with few cases reported in the literature. Of these reported cases, metastatic colon cancer is exceedingly rare.
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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.
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.
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How Do Doctors Know If Breast Cancer Has Spread
One of the most important tests when someone is diagnosed with metastatic breast cancer is a tumor biopsy. A biopsy is the removal of a small amount of tissue for examination under a microscope. A biopsy can be done from many parts of the body, including lymph nodes, lungs, liver, bone, skin, or body fluids.
Medications For Mild Bone Pain
Bone pain often responds to heat, or to mild pain relievers such as ibuprofen , naproxen or acetaminophen .
Although you can get these medications without a prescription, check with your health care provider before taking them. For example, if you have a low platelet count, or your kidneys are not functioning normally, or you have heart failure, your health care provider may advise you not to take ibuprofen or naproxen.
Learn more about these medications in metastatic breast cancer care.
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Metastatic Breast Cancer In Bones Treatments
Metastatic breast cancer in the bones is typically not curable. Dr. Taiwo said that healthcare providers instead focus on slowing cancer growth and managing symptoms.
“The focus really is trying to extend life and maintain quality of life,” explained Dr. Taiwo.
Healthcare professionals usually prescribe traditional medications like chemotherapy and immunotherapy. They’ll also try targeted treatments for specific cancer types. For example, they may use hormone treatments for estrogen receptor-positive breast cancer, added Dr. Tsarwhas.
But many bone-strengthening medications help people, like Prolia . Those medications help slow bone degradation and reduce the risk of fractures, Dr. Tsarwhas said.
Dr. Lin added that many of the treatments are similar to what people with osteoporosis take.
Localized radiation treatment can also help shrink bone cancer cells and reduce pain. Dr. Taiwo said that treatment could improve a patient’s quality of life since bone lesions can be painful.
“We also look for any bones that might have the potential to cause a problem in terms of a fracture,” Dr. Lin added. In those cases, Dr. Lin said healthcare providers often send people to orthopedic surgeons for preventative surgeries to help stabilize bones.
For example, surgeons can use medical-grade bone cement to seal and support existing fractures. Or they may recommend joint-replacement surgery to ensure a person has pain-free mobility.
Risk Stratification And Survival
According to prognostic scores derived from regression coefficients, patients were stratified into three risk groups . X-tile software was adopted to determine the optimal cutoff value of risk stratification, including low- , intermediate- , and high-risk groups . Intermediate- and high-risk groups had significantly worse prognosis in comparison with the low-risk group . In the validation set of 307 patients, intermediate- and high-risk groups were also related with significantly increased death risk compared with the low-risk group, showing the strong ability for discrimination in our prognostic model . The median OS of three groups were 39.97, 21.03, and 8.80 months with the 3 year OS rates of 54, 25, and 1%, respectively.
Table 3. Calculation of the score and cutoff points of the prognostic groups.
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When Can Bone Metastases Occur
Bone metastases may be present when metastatic breast cancer is first diagnosed, or the cancer may spread to the bones later.
The bones are the first site of metastases for almost half of women diagnosed with metastatic breast cancer . For many of these women, the bones will be the only site of metastases .
Forms Of Prognostic Scoring
Another way to predict overall outcomes for cancers is through prognostic Scoring. The prognosis for small-cell lung cancer can be done through Manchester score.
International Prognostic Index is used for prognosis of a condition like Non-Hodgkin lymphoma. There are also certain other conditions where prognostic indicators are used like Drug mediated Liver Dysfunctions and exercise stress test after myocardial infarction. Prognostic indicators are also used to predict the overall outcome of patients with multiple myeloma.
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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.
What Are The Most Common Areas Of Breast Cancer
The most common areas of breast cancer metastasis are the bones, lungs and liver. Following an initial breast cancer diagnosis, a patient will receive a personalized monitoring plan for metastatic reoccurrence from their care team. Depending on the specific parts of the body affected, the symptoms of metastatic breast cancer can vary.
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What Is Metastatic Breast Cancer
Metastasis is the process by which cancer cells spread. In the case of metastatic breast cancer, the cancer originated in breast tissue, then spread to other parts of the body.
Metastatic cancer is further described as local, regional or distant, depending on the location of the cancer cells in relation to the original tumor.
- Localized metastatic breast cancer often means the breast cancer has spread to nearby lymph nodes.
- The more distant locations include the bones, lungs, skin, liver and brain, although its possible for other parts of the body to be affected.
Its important to remember that every cancer is unique and that your experience may not necessarily be the same as that of another breast cancer patient. With a personalized treatment plan, metastatic breast cancer is typically treatable. A recent National Cancer Institute study found that the number of U.S. women living longer with distant metastatic breast cancer is growing, thanks to advances in treatments.
Its also important to prepare yourself with information about the disease, its symptoms and how its detected and treated.
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