Management issues in bone pain

Abstract

Bone is a common site of metastatic disease with common tumours, in particular, lung, breast, and prostate, frequently spreading to the skeleton. Particular problems may arise from skeletal metastases; pain is a common problem in over 75% of patients and pathological fracture can be catastrophic in terms of mobility and integrity of the spinal canal. The function of the skeleton results in specific challenges when dealing with bone pain, with most patients having multiple sites of metastases, many having variable pain intensity in relation to movement and weight bearing, and more difficult cases progressing to develop neurological complications. Prevention of bone metastases and skeletal damage is an important approach and pain management requires optimization of medication and radiotherapy. Pathological fractures present a specific challenge, best treated surgically and with the role of radiotherapy still poorly defined. A new paradigm has emerged with the recognition that, in some patients, bone metastases may represent an oligometastatic state in which ablative treatment such as stereotactic radiotherapy can result in a prolonged disease-free interval and deferred toxic systemic treatment interventions.