Managing Cancer That Has Spread To The Bone In Prostate Cancer Patients

“For men that have bone metastases, we have several therapeutic options available,” Dr. Jeffrey Jones, chair of urology research at Baylor College of Medicine in Houston, tells SurvivorNet. “We don’t have any that are completely curative … right now, the main issue is to control pain that occurs in the bone when you have metastasis there. The other thing we concern ourselves with is the potential for metastasis to weaken the bone and cause fractures. So, there are several things we do for the fracture risk.”

How Prostate Cancer Spreads To The Bone

Prostate cancer spreads when cells from the original tumor break away and travel through the bloodstream or lymphatic system to distant parts of the body. Once lodged in the bone, prostate cancer cells often trigger the creation of abnormal, dense bone tissue — known as osteoblastic lesions. While this sounds like extra bone growth, it actually makes bones weaker and more prone to fractures.

Certain areas of the skeleton are especially at risk. The spine, particularly the lumbar vertebrae, is a common site. The pelvis, ribs, hips, and the long bones of the legs and arms are also frequent targets.

Symptoms Of Bone Metastases

Bone metastases can be silent in the early stages, but as they progress, they often cause noticeable symptoms. Pain is the most common and can range from a dull, persistent ache to sharper, more debilitating discomfort that worsens with movement or at night. Pain in the lower back, hips, or ribs is especially common. Weakened bone structure increases the risk of fractures, even from minor injuries or normal activities.

If metastases occur in the spine, they can compress the spinal cord, leading to numbness, tingling, weakness, or loss of bladder and bowel control — symptoms that require immediate medical attention.

Bone metastases can also reduce mobility, either from pain, fractures, or stiffness. Fatigue is common and may result from the cancer itself, the chronic pain it causes, or anemia if the bone marrow is affected.

How Doctors Diagnose Bone Metastases

If bone metastases are suspected, your healthcare team will use a combination of imaging and blood tests to confirm and assess the extent of the disease. A bone scan (scintigraphy) is a common first step; it uses a small amount of radioactive tracer to highlight areas of abnormal bone activity. Magnetic resonance imaging (MRI) provides detailed pictures of bones and surrounding tissues, including the spinal cord, while computed tomography (CT) scans show structural changes and can detect fractures or lesions.

Positron emission tomography (PET) scans, particularly those using prostate-specific membrane antigen (PSMA) tracers, are increasingly being used for their high sensitivity in detecting prostate cancer spread. In some cases, standard X-rays are still helpful for visualizing fractures or severe bone damage. Blood tests are also part of the workup. Prostate-specific antigen (PSA) levels can indicate cancer activity, alkaline phosphatase may be elevated when bone turnover is increased, and complete blood counts (CBC) help assess for anemia caused by bone marrow involvement.

Treatment Options

Treating bone metastases usually involves a combination of therapies designed to control the cancer, protect the bones, and reduce symptoms.

Systemic treatments that affect the whole body form the cornerstone of care. Androgen deprivation therapy (ADT) lowers testosterone levels, slowing the growth of prostate cancer cells. Many patients also receive newer hormone therapies, such as abiraterone, enzalutamide, apalutamide, or darolutamide, which work even when the cancer becomes resistant to traditional ADT. Chemotherapy with drugs like docetaxel can be used when hormone therapy is no longer effective, and some patients may benefit from immunotherapy, such as sipuleucel-T.

Bone-strengthening medications are important in reducing the risk of fractures and other skeletal problems.

These might include:

• Bisphosphonates like zoledronic acid
• The monoclonal antibody denosumab

Both can help slow bone breakdown and maintain strength. These can be combined with other approaches, Dr. Jones says.

“We’ll often put the patient on a combination of vitamin D supplementation, calcium supplementation, and a bisphosphonate or a RANKL inhibitor,” he explains.

Radiation therapy is also a key part of treatment. External beam radiation therapy (EBRT) can target painful bone lesions, while stereotactic body radiation therapy (SBRT) delivers high doses of radiation precisely to small metastatic sites.

Radiation therapy can provide rapid relief and prevent skeletal fractures.

Pain management is crucial and can include anti-inflammatory medications, opioids, corticosteroids, or nerve blocks, depending on the severity. In cases where bones are at high risk for fracture or have already broken, orthopedic surgery may be needed to stabilize the area using rods, plates, or bone cement.

Radioligand Therapy

Radioligand therapy (RLT) is an exciting newer approach for metastatic prostate cancer.

This treatment uses a molecule designed to attach specifically to PSMA, a protein found on most prostate cancer cells.

“Radioactive isotopes which will hone to the bone and deliver radiation energy to where the bone is active, in this case, where the prostate cancer is eroding the bone,” Dr. Jones explains.

One example is lutetium-177–PSMA-617 (marketed as Pluvicto), which is FDA-approved for certain men with advanced disease who have already tried other treatments. Clinical studies have shown that RLT can shrink tumors, lower PSA levels, and improve symptoms, particularly in patients with bone metastases. Side effects are usually mild and may include fatigue, nausea, dry mouth, or temporary bone marrow suppression. Because it is targeted, RLT is generally better tolerated than many traditional cancer therapies.

Living With Bone Metastases

A diagnosis of bone metastases can feel overwhelming, but many men live for years with effective treatment and symptom control. Staying physically active, within safe limits advised by your doctor, can help maintain bone and muscle strength. Promptly reporting any new symptoms — especially worsening pain or neurological changes — allows for early intervention before complications become severe.

Regular follow-up visits, including imaging and blood tests, are essential to monitor disease activity and adjust treatment as needed.

While bone metastases remain a serious complication of prostate cancer, advances in detection and treatment have greatly improved outcomes. With the right combination of therapies and support, it is possible to manage symptoms, maintain independence, and continue living a fulfilling life.

Questions To Ask Your Doctor

• How will I be monitored while being treated for bone metastasis?
• Are there any supplements I should take alongside treatment?
• What can I do at home to care for my bones?
• What symptoms should I be aware of and report right away?

Content independently created by SurvivorNet with support from Novartis Pharmaceuticals Corp.

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