Who treats bone cancer?
Bone cancer is usually treated by a team of health care providers. The team includes:
- an orthopaedic surgeon who specializes in conditions of the bones and joints
- a clinical oncologist or cancer specialist
- a pathologist
- a radiologist
- pain relief specialist or palliative care specialist
- a psychologist
- a cancer nurse
- a social worker
These are termed multi-disciplinary teams that assist people with bone cancer. 1-6
Types of treatment of bone cancer
Bone cancers are usually treated with three modalities of treatment:
- Chemotherapy – with the use of anticancer drugs that are used to shrink the tumors
- Surgical therapy
- Radiation therapy
Most patients need a combination of these therapeutic approaches for management of bone cancer. Different types of bone cancer are usually treated in a similar way.
The treatment usually begins with chemotherapy to prevent spread and shrink the tumor and thereafter surgery may be carried out to remove the section of cancerous bone.
Earlier surgery meant removal of the affected limb altogether – or limb amputation. These days it is possible to reconstruct the part of the bone that is removed using metallic implants. This is called limb sparing surgery.
Radiotherapy is used after surgery to kill any residual cancer cells. It is helpful in some types of cancer (such as Ewing’s sarcoma, for example).
Chemotherapy for bone cancer
Cancer killing medications are used to kill the tumor cells and shrink the tumor. This may be given before surgery, in combination with radiotherapy before surgery (chemoradiation) as is preferred in Ewing sarcoma, after surgery to prevent the cancer from returning and to control the symptoms in very advanced and non-curable bone cancers.
Chemotherapy may be given in cycles. Patient may or may not be admitted to the hospital but may have to visit the day care centers where the drug may be injected into their veins using infusions.
A cycle involves taking the chemotherapy medication for several days followed by a gap of a few weeks to allow the body to recover from the effects of the treatment.
A low grade cancer requires less number of chemotherapy cycles than a high grade tumor.
Medications that are used in bone cancer chemotherapy include:
- Methotrexate with Leucovorin
Common side effects include:
- loss of appetite
- loss of hair
- mouth ulcers
- risk of infections
- infertility etc.
Since bone cancers affect children and young people the risk of infertility after chemotherapy should be considered and patients or their guardians should be counselled regarding choice of sperm or egg storage for future fertility choices.
Radiation therapy for bone cancer
Radiation therapy uses high energy X-ray or gamma ray beams to kill the cancer cells. This may be used before and after surgery to treat bone cancer.
Radiotherapy sessions may also be administered in cycles five days a week with a break from treatment over the weekends. Side effects of radiation therapy include skin burns, rashes, weakness, nausea, loss of hair etc.
Limb-sparing surgery is preferred if the cancer has not spread beyond the bone, and the affected bone itself is in an easily accessible position like in one of the arms, legs, shoulder, hip etc.
The surgery involves removing the section of affected bone and a bit of the surrounding healthy bone (just in case the cancer has spread to the tissues) and replacement of the part of the bone with a metal implant called prosthesis.
As an alternative bone grafts from another part of the body may also be used as a replacement.
If the cancer has affected a joint like the knee, elbow or shoulder joint, an artificial joint may have to be placed. The artificial joint is usually a combination of plastic, metal, and ceramics.
Amputation is needed if the cancer has spread beyond the bone and affected blood vessels and nerves, skin or if the limb sparing surgery has failed. Amputation is also opted if the bone that is affected is not easily accessible like the ankle joint.
Patients who require an amputation need counselling and may need help of an occupational therapist and counselling for opting an artificial limb.
Some agents have been developed for use against bone cancers. These originate from the cells of the body and are thus termed biological therapy. These target the cancer cells selectively and thus cause less side effects than chemotherapeutic agents.
A new medication called mifamurtide has recently been approved for the treatment of high-grade osteosarcoma. This agent is an immune macrophage stimulant. It acts by stimulating the immune system to produce specialised cells that can kill the cancer cells selectively. This means less side effects than seen with conventional chemotherapy agents.
Mifamurtide is given after surgery and also in combination with chemotherapy. It serves to kill any remaining cancerous cells and to help prevent the cancer from returning.
Common side effects include nausea, vomiting, headache, constipation, allergies, muscle and joint pain, hearing loss, blurring of vision etc.
Outcome of bone cancer
The outcome of bone cancer is determined by survival for at least five years after diagnosis. For localised osteosarcoma and Ewing’s sarcoma five year survival is seen in around 60% and 70% people respectively.
Those in whom the osteosarcoma or Ewing’s sarcoma has spread the chances of five year survival is only 10% and 30% respectively.
For those with low-grade chondrosarcoma 8 out of 10 people may survive five years after diagnosis and for high-grade chondrosarcoma only 3 out of 10 people may survive five years after treatment.