Bone Cancer: Types of Treatment

Approved by the Cancer.Net Editorial Board, 11/2018

ON THIS PAGE: You will learn about the different types of treatments doctors use for people with this bone cancer. Use the menu to see other pages.

This section explains the types of treatments that are the standard of care for bone cancer. “Standard of care” means the best treatments known. When making treatment plan decisions, you are encouraged to consider clinical trials as an option. A clinical trial is a research study that tests a new approach to treatment. Doctors want to learn whether the new treatment is safe, effective, and possibly better than the standard treatment. Clinical trials can test a new drug, a new combination of standard treatments, or new doses of standard drugs or other treatments. Clinical trials are an option to consider for treatment and care for all stages of cancer. Your doctor can help you consider all your treatment options. Learn more about clinical trials in the About Clinical Trials and Latest Research sections of this guide.

Treatment overview

In cancer care, different types of doctors often work together to create a patient’s overall treatment plan that combines different types of treatments. This is called a multidisciplinary team. Cancer care teams include a variety of other health care professionals, such as physician assistants, nurse practitioners, oncology nurses, physical therapists, occupational therapists, social workers, pharmacists, counselors, dietitians, and others.

Descriptions of the common types of treatments used for bone cancer are listed below. Your care plan also includes treatments for symptoms and side effects, an important part of cancer care.

Treatment options and recommendations depend on several factors, including the type, stage, and grade of cancer; possible side effects; and the patient’s preferences and overall health. Take time to learn about all of your treatment options and be sure to ask questions about things that are unclear. Talk with your doctor about the goals of each treatment and what you can expect while receiving the treatment. These types of talks are called “shared decision making.” Shared decision making is when you and your doctors work together to choose treatments that fit the goals of your care. Shared decision making is particularly important for bone cancer because there are different treatment options. Learn more about making treatment decisions.

For a low-grade primary bone tumor, the main treatment is surgery. The goal of surgery is to remove the tumor and a margin of healthy bone or tissue around the tumor to make sure all of the cancer cells are gone.

For a high-grade primary bone tumor, doctors often use a combination of treatments. These include surgery, systemic therapy using medication, and radiation therapy.

Surgery

Surgery is the removal of the tumor and some surrounding healthy tissue during an operation. Surgical oncologists and orthopedic oncologists are doctors who specialize in treating bone cancer using surgery. Surgery for bone cancer often involves a wide excision of the tumor. A wide excision means that the tumor is removed, along with a margin of healthy tissue around it in all directions. Before surgery, talk with your health care team about the possible side effects from the specific surgery you will have. Learn more about the basics of cancer surgery.

If the tumor is in an arm or leg, techniques to keep the arm or leg intact are used whenever possible. This is sometimes called "limb salvage." However, amputation, which is the removal of the arm or leg with the tumor, is sometimes necessary, depending on the tumor’s size and/or location. 

Wide excision surgical techniques have reduced the number of amputations performed for people with bone cancer. More than 90% of patients can be treated with limb-sparing surgery rather than amputation. These conservative surgeries often require prostheses, such as metal plates or bone from other parts of the body, to replace the missing bone and provide strength to the leftover bone. This is called reconstructive surgery. Surgeons use soft tissue, such as muscle, to cover the reconstruction area. The tissue helps with healing and reduces the risk of infection.

For some patients, amputation may offer the best option for treating the cancer. These include people whose cancer is located where it cannot be completely removed by surgery, patients who cannot undergo reconstruction, and patients in whom the surgical area cannot be fully covered with soft tissue.

Children with bone cancer may require amputation more often than adults because their bones grow more. To avoid amputation, some children can be fitted for expandable joint prostheses that adjust as the skeleton grows. These prostheses require several procedures to adjust bone length as the child grows.

It is important to remember that the operation that results in the most useful and strongest limb may be different from the one that gives the most normal appearance. Rehabilitation can be very helpful after bone cancer surgery. This includes physical therapy, which can help maximize the patient’s physical abilities. Rehabilitation can also help a person cope with the social and emotional effects of bone cancer surgery, including the challenges of losing a limb if amputation was necessary. Talk with your health care team about support options.

Therapies using medication

Systemic therapy is the use of medication to destroy cancer cells. This type of medication is given through the bloodstream to reach cancer cells throughout the body. Systemic therapies are generally prescribed by a medical oncologist, a doctor who specializes in treating cancer with medication.

Common ways to give systemic therapies include an intravenous (IV) tube placed into a vein using a needle or in a pill or capsule that is swallowed (orally).

The types of systemic therapies used for bone cancer may include:

  • Chemotherapy

  • Targeted therapy

  • Immunotherapy

Each of these types of therapies is discussed below in more detail. A person may receive 1 type of systemic therapy at a time or a combination of systemic therapies given at the same time. They can also be given as part of a treatment plan that includes surgery and/or radiation therapy.

The medications used to treat cancer are continually being evaluated. Talking with your doctor is often the best way to learn about the medications prescribed for you, their purpose, and their potential side effects or interactions with other medications. It is also important to let your doctor know if you are taking any other prescription or over-the-counter medications or supplements. Herbs, supplements, and other drugs can interact with cancer medications. Learn more about your prescriptions by using searchable drug databases.

Chemotherapy

Chemotherapy is the use of drugs to destroy cancer cells, usually by keeping the cancer cells from growing, dividing, and making more cells.

A chemotherapy regimen, or schedule, usually consists of a specific number of cycles given over a set period of time. A patient may receive 1 drug at a time or a combination of different drugs given at the same time. Chemotherapy for bone cancer can usually be an outpatient treatment, which is treatment given at a clinic or doctor’s office instead of requiring the patient to be admitted to a hospital.

Surgery alone is not usually enough treatment for people with some types of bone cancers, particularly osteosarcoma. These cancers sometimes recur as distant metastases, most often in the lungs, from cancer cells that escaped from the original tumor. Chemotherapy has helped people with some types of bone cancer live longer. In addition, chemotherapy is often useful for treating cancer that has visibly spread at the time of diagnosis.

Fast-growing types of bone cancer are often treated with chemotherapy before surgery. Chemotherapy that is given before surgery is called preoperative chemotherapy, neoadjuvant chemotherapy, or induction chemotherapy. For most high-grade tumors, the oncologist may give chemotherapy for 3 to 4 cycles before surgery to shrink the primary tumor and make it easier to remove. Chemotherapy before surgery may also help patients live longer because it destroys cancer cells that have spread from the original tumor. The tumor’s response to chemotherapy, which is evaluated using a microscope after the primary tumor has been removed, can be used to better determine the prognosis.

After the patient has recovered from surgery, he or she may receive more chemotherapy to destroy any remaining tumor cells. This is called postoperative or adjuvant chemotherapy. The use of chemotherapy to shrink the tumor before surgery combined with chemotherapy after surgery has saved many lives and many patients’ limbs.

The specific chemotherapy drugs used depend on the type of bone cancer. Each type of bone cancer is different, in much the same way as breast cancer is different from lung cancer. Here is a list of drugs often used for 2 of the most common types of bone cancer.

Common drugs for osteosarcoma include:

  • Cisplatin (available as a generic drug)

  • Doxorubicin (available as a generic drug)

  • Ifosfamide (Ifex)

  • Methotrexate (Rheumatrex, Trexall)

Common drugs for Ewing sarcoma include:

  • Vincristine (Vincasar)

  • Doxorubicin

  • Cyclophosphamide (Neosar)

  • Ifosfamide (Ifex)

  • Etoposide (Etopophos)

  • Dactinomycin (Cosmegen)

The side effects of chemotherapy depend on the individual and the dose used, but they can include fatigue, risk of infection, nausea and vomiting, hair loss, loss of appetite, and diarrhea. These side effects usually go away after treatment is finished. However, your doctor will monitor you for potential long-term side effects (see Follow-up Care).

Learn more about the basics of chemotherapy.

Targeted therapy

Targeted therapy is a treatment that targets the cancer’s specific genes, proteins, or the tissue environment that contributes to cancer growth and survival. This type of treatment blocks the growth and spread of cancer cells while limiting damage to healthy cells.

Not all tumors have the same targets. To find the most effective treatment, your doctor may run tests to identify the genes, proteins, and other factors in your tumor. This helps doctors better match each patient with the most effective treatment whenever possible. In addition, research studies continue to find out more about specific molecular targets and new treatments directed at them. Learn more about the basics of targeted treatments.

A small percentage of sarcomas, less than 1%, have a mutation in the neurotrophic receptor tyrosine kinase (NTRK) gene. Larotrectinib (Vitrakvi) is an NTRK inhibitor that is now approved for any cancer that has a specific mutation in the NTRK gene. The most common side effects include fatigue, nausea, dizziness, vomiting, increased liver enzymes, cough, constipation, and diarrhea.

Talk with your doctor about possible side effects for a specific medication and how they can be managed.

Immunotherapy

Immunotherapy, also called biologic therapy, is designed to boost the body's natural defenses to fight the cancer. It uses materials made either by the body or in a laboratory to improve, target, or restore immune system function.

Immunotherapy is generally not approved for the treatment of sarcomas, including bone cancer, because they have not been tested well enough. Many recent approved immunotherapy treatments for other types of cancer involve “immune checkpoint inhibitors.” These drugs are given to take the brakes off the body’s natural immune response against the cancer in the body. The current methods of immunotherapy do have problems because these drugs also activate immune responses against normal body parts, a process called autoimmunity. Some of these drugs are approved to treat other cancers. However, if testing on your bone tumor shows that it has specific problems with repairing DNA damage, called microsatellite instability-high (MSI-H) or mismatch repair deficiency (dMMR; this occurs in less than 1% of sarcomas), then a checkpoint inhibitor called pembrolizumab (Keytruda) may be used.

Different types of immunotherapy can cause different side effects. Common side effects include skin reactions, flu-like symptoms, diarrhea, and weight changes. Talk with your doctor about possible side effects for the immunotherapy recommended for you. Learn more about the basics of immunotherapy.

Radiation therapy

Radiation therapy is the use of high-energy x-rays or other particles to destroy cancer cells. A doctor who specializes in giving radiation therapy to treat cancer is a radiation oncologist. The most common type of radiation treatment is called external-beam radiation therapy, which is radiation given from a machine outside the body. When radiation treatment is given using implants, it is called internal radiation therapy or brachytherapy. A radiation therapy regimen, or schedule, usually consists of a specific number of treatments given over a set period of time.

For bone cancer, radiation therapy is most often used for a tumor that cannot be removed with surgery. Radiation therapy may also be done before surgery to shrink the tumor, or it may be done after surgery to destroy any remaining cancer cells. Radiation therapy makes it possible to do less extensive surgery, often preserving the arm or leg. Radiation therapy may also be used to relieve pain for people as part of supportive or palliative care (see below).

Side effects from radiation therapy may include fatigue, mild skin reactions, upset stomach, and loose bowel movements. Most side effects go away soon after treatment is finished. Learn more about the basics of radiation therapy.

Physical, emotional, and social effects of cancer

Cancer and its treatment cause physical symptoms and side effects, as well as emotional, social, and financial effects. Managing all of these effects is called palliative care or supportive care. It is an important part of your care that is included along with treatments intended to slow, stop, or eliminate the cancer.

Palliative care focuses on improving how you feel during treatment by managing symptoms and supporting patients and their families with other, non-medical needs. Any person, regardless of age or type and stage of cancer, may receive this type of care. And it often works best when it is started right after a cancer diagnosis. People who receive palliative care along with treatment for the cancer often have less severe symptoms, better quality of life, and report they are more satisfied with treatment.

Palliative treatments vary widely and often include medication, nutritional changes, relaxation techniques, emotional and spiritual support, and other therapies. You may also receive palliative treatments similar to those meant to get rid of the cancer, such as chemotherapy, surgery, or radiation therapy.

Before treatment begins, talk with your doctor about the goals of each treatment in the treatment plan. You should also talk about the possible side effects of the specific treatment plan and palliative care options.

During treatment, your health care team may ask you to answer questions about your symptoms and side effects and to describe each problem. Be sure to tell the health care team if you are experiencing a problem. This helps the health care team treat any symptoms and side effects as quickly as possible. It can also help prevent more serious problems in the future.

Learn more about the importance of tracking side effects in another part of this guide. Learn more about palliative care in a separate section of this website.

Metastatic bone cancer

If cancer spreads to another part in the body from where it started, doctors call it metastatic cancer. If this happens, it is a good idea to talk with doctors who have experience in treating it. Doctors can have different opinions about the best standard treatment plan. Clinical trials might also be an option. Learn more about getting a second opinion before starting treatment, so you are comfortable with your chosen treatment plan.

Your treatment plan may include a combination of surgery, chemotherapy, and radiation therapy. Palliative care will also be important to help relieve symptoms and side effects.

For most people, a diagnosis of metastatic cancer is very stressful and, at times, difficult to bear. You and your family are encouraged to talk about how you feel with doctors, nurses, social workers, or other members of the health care team. It may also be helpful to talk with other patients, including through a support group.

Remission and the chance of recurrence

A remission is when cancer cannot be detected in the body and there are no symptoms. This may also be called having “no evidence of disease” or “NED.”

A remission may be temporary or permanent. This uncertainty causes many people to worry that the cancer will come back. While many remissions are permanent, it is important to talk with your doctor about the possibility of the cancer returning. Understanding your risk of recurrence and the treatment options may help you feel more prepared if the cancer does return. Learn more about coping with the fear of recurrence.

If the cancer returns after the original treatment, it is called recurrent cancer. It may come back in the same place (called a local recurrence), nearby (regional recurrence), or in another place (distant recurrence).

When this occurs, a new cycle of testing will begin again to learn as much as possible about the recurrence. After this testing is done, you and your doctor will talk about the treatment options. Often the treatment plan will include the treatments described above, such as surgery, chemotherapy, and radiation therapy, but they may be used in a different combination or given at a different pace. Your doctor may suggest clinical trials that are studying new ways to treat this type of recurrent cancer. Whichever treatment plan you choose, palliative care will be important for relieving symptoms and side effects.

People with recurrent cancer often experience emotions such as disbelief or fear. You are encouraged to talk with the health care team about these feelings and ask about support services to help you cope. Learn more about dealing with cancer recurrence.

If treatment does not work

Recovery from bone cancer is not always possible. If the cancer cannot be cured or controlled, the disease may be called advanced or terminal.

This diagnosis is stressful, and for many people, advanced cancer is difficult to discuss. However, it is important to have open and honest conversations with your health care team to express your feelings, preferences, and concerns. The health care team has special skills, experience, and knowledge to support patients and their families and is there to help. Making sure a person is physically comfortable, free from pain, and emotionally supported is extremely important.

People who have advanced cancer and who are expected to live less than 6 months may want to consider hospice care. Hospice care is designed to provide the best possible quality of life for people who are near the end of life. You and your family are encouraged to talk with the health care team about hospice care options, which include hospice care at home, a special hospice center, or other health care locations. Nursing care and special equipment can make staying at home a workable option for many families. Learn more about advanced cancer care planning.

After the death of a loved one, many people need support to help them cope with the loss. Learn more about grief and loss.

The next section in this guide is About Clinical Trials. It offers more information about research studies that are focused on finding better ways to care for people with cancer. Use the menu to choose a different section to read in this guide.