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Bone metastases — pain, fractures and bone-modifying drugs
Bone metastases are treated with three tools: radiation for pain (a single 8 Gy fraction works as well as a long course), stabilising surgery for a fracture or impending fracture, and bone-modifying drugs — zoledronic acid or denosumab — that reduce skeletal events.
Why it matters in the exam
The topic is asked in every exam, mainly in the radiation part: the difference between a single 8 Gy fraction and a multi-fraction course, what to do with a femoral neck metastasis at risk of fracture, and what to explain before denosumab. Scenarios include prostate, breast and lung cancer with bone pain.
An important point is selecting patients for bone-modifying drugs: in hormone-sensitive prostate cancer they were not shown to prevent skeletal events, so they are given in the castration-resistant phase. Side effects — hypocalcaemia and jaw osteonecrosis — and pre-treatment preparation are also asked, as is the distinction between lytic and blastic metastases and its implications for imaging.
Key points
- A single 8 Gy fraction relieves bone metastasis pain as well as a long course, but with more retreatments.
- A long-bone metastasis at high fracture risk is treated with stabilising surgery followed by radiation.
- Zoledronic acid and denosumab reduce skeletal events, and before treatment a dental check, calcium and vitamin D are needed.
- In prostate cancer bone-modifying drugs are given for metastases only in the castration-resistant phase.
- In lytic metastases and myeloma a bone scan may be normal, so CT or PET is preferred.
Summary table
| Issue | Recommendation | Exam detail |
|---|---|---|
| Types of metastases | Lytic — lung, kidney, thyroid, myeloma; blastic — prostate; mixed — breast | In myeloma and purely lytic metastases a bone scan may be normal — CT or PET is preferred |
| Radiation for pain | A single 8 Gy fraction equals 20 Gy in 5 fractions or 30 Gy in 10 fractions for pain relief | After a single fraction there are more retreatments; pain flare after radiation — dexamethasone prevents it |
| Impending fracture in a long bone | Stabilising surgery followed by radiation | Destruction of more than half of the cortex, a large lytic lesion or pain on weight bearing — high fracture risk |
| Bone-modifying drugs | Zoledronic acid or denosumab | Reduce fractures, cord compression and the need for radiation or surgery |
| Before bone-modifying drugs | Dental check, calcium and vitamin D | Zoledronic acid — adjust to kidney function; denosumab — hypocalcaemia, and rapid bone loss after stopping |
| Prostate cancer | Bone-modifying drugs only in the castration-resistant phase with metastases | Radium-223 for symptomatic bone metastases without visceral metastases |
| Few metastases | SBRT can achieve better local control than conventional radiation | For a single metastasis or a radioresistant tumour |
A free exam question
בת 66, הסובלת מסרטן שד גרורתי לעצמות מטופלת ב- capcitabine ו zolanderic acid . פנתה למיון בשל שלשולים מרובים, הקאות, טטניות בגפיים ובלבול. איזו מתופעות הלוואי קשורה לזומרה? (the question as examined, in Hebrew)
- א. הקאות
- ב. שלשולים
- ג. טטניות
- ד. בלבול
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Sources
- ESMO Clinical Practice Guideline: Bone health in cancer, 2020 — Bone metastases and bone-modifying agents
- ASTRO Guideline: Palliative radiation therapy for symptomatic bone metastases, 2024 — Dose and fractionation
- Gunderson and Tepper's Clinical Radiation Oncology, 5th ed. (2021) — Palliation of bone metastases
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.