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Health condition · Clinically reviewed

Bone metastasis, imaging, bone-directed therapy and when to escalate.

Cancer that has spread to bone is common, treatable and best managed by a multidisciplinary team. Fast recognition of spinal cord compression, hypercalcaemia and fracture risk changes outcomes.

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A radiographer guides a patient onto the bed of an advanced 3 Tesla MRI scanner in a London imaging suite

Why trust this guide

  • 01

    Clinically reviewed

    Written by our editorial team and reviewed by a registered UK clinician before publication.

  • 02

    Sourced from guidance

    Checked against NICE, ESMO, BOA and peer-reviewed sources you can see at the end.

  • 03

    Current for 2026

    Reflects modern UK practice including PSMA-lutetium-177, denosumab, SBRT and metastatic spinal cord compression pathways.

Key facts

Bone metastasis at a glance.

The essentials in plain English. What it is, where it goes, and how UK teams look after it today.

  • What it is

    Spread of cancer to bone. Far more common than primary bone cancer and one of the leading causes of cancer-related pain.

  • Primary sources

    Breast (50 to 70 percent), prostate (65 to 75 percent), lung, kidney, thyroid, multiple myeloma and melanoma.

  • Where it goes

    Vertebrae (thoracic more than lumbar or cervical), pelvis, ribs, skull and the proximal femur and humerus.

  • Types

    Osteolytic (breast, lung, kidney, thyroid, myeloma), osteoblastic (prostate, carcinoid) and mixed (breast).

  • Emergencies

    Spinal cord compression, pathological fracture and hypercalcaemia of malignancy all need urgent action.

  • Bone-directed care

    Zoledronic acid and denosumab reduce skeletal-related events. Radiotherapy, radioisotopes and surgery all play a role.

Why this guide matters

A team plan, not a single scan.

Bone metastasis is common, treatable and best managed by an MDT. The three points below shape everything else on this page.

  • Recognise the emergencies

    Spinal cord compression, hypercalcaemia and impending fracture all need same-day action. Delay changes outcomes.

  • Bone-directed therapy adds years of comfort

    Zoledronic acid or denosumab cut fracture and cord-compression risk. Dental review comes first.

  • Radiotherapy relieves pain fast

    A single 8 Gy fraction often takes the worst edge off within days. Radioisotopes and PSMA-lutetium widen the toolkit.

How the diagnosis is made

From first symptoms to a clear plan.

The steps a UK oncology or orthopaedic team will normally follow, in order, so you know what to expect and why.

  1. 01

    Assessing

    History and examination

    Persistent, progressive pain that is worse at night and not activity-related is the classic story. Ask about the primary cancer, weight loss and neurology.

  2. 02

    Assessing

    Bloods and markers

    FBC, calcium, PTH, LDH, alkaline phosphatase, PSA in men and disease-appropriate tumour markers help stage the picture.

  3. 03

    Assessing

    Whole-body bone scan

    A radionuclide bone scan (with SPECT for detail) picks up lytic and blastic deposits across the skeleton in one sitting.

  4. 04

    Confirming

    CT for architecture

    CT shows cortical destruction, fracture risk and gives a road map for biopsy or fixation.

  5. 05

    Confirming

    Urgent MRI whole spine

    The best test for vertebral marrow, soft-tissue extension and suspected metastatic spinal cord compression. Do it within 24 hours if MSCC is possible.

  6. 06

    Confirming

    PET-CT tailored to primary

    FDG for most lytic disease, PSMA for prostate, FAPI in selected cases and DOTATATE for neuroendocrine tumours.

  7. 07

    Planning

    Biopsy and Mirels score

    Biopsy for isolated or unknown-primary disease and for molecular profiling. Mirels score sizes up fracture risk and the case for prophylactic fixation.

Typical timeline: urgent imaging within 24 hours when MSCC is suspected, MDT plan in days.

Symptoms

What bone metastasis actually feels like.

Night-worse bone pain, fracture, hypercalcaemia and cord compression are the patterns to know. The features on the right mean it is time to escalate.

  • Persistent bone pain

    Deep, progressive pain that is worse at night and not eased by rest is the most common presenting symptom.

  • Pathological fracture

    A break after minor trauma, or with no trauma at all. Femur, humerus and vertebrae are the classic sites.

  • Hypercalcaemia of malignancy

    Polyuria, polydipsia, confusion, arrhythmia and acute kidney injury. Needs urgent IV fluids and bone-directed therapy.

  • Spinal cord compression

    Back pain with radicular features, weakness, sensory change or bladder and bowel disturbance. A medical emergency.

  • Marrow infiltration

    Anaemia, thrombocytopenia and leucopenia when marrow is heavily replaced by tumour.

  • Neurological features

    Nerve-root pain, cranial neuropathies or focal weakness from mass effect at the skull base or spine.

  • Immobility and falls

    Pain and fracture risk drive deconditioning and falls, which then feed back into more fractures.

  • Red flag - suspected MSCC

    New back pain with weakness, numbness or bladder or bowel change in anyone with cancer needs urgent MRI within 24 hours.

Treatment

How bone metastasis is treated in the UK.

Systemic therapy treats the underlying cancer. Bone-directed drugs, radiotherapy, radioisotopes and orthopaedic surgery protect the skeleton and control pain.

  • Systemic anti-cancer therapy

    Treat the underlying cancer. Hormonal therapy for breast and prostate, targeted agents, chemotherapy and immunotherapy all reduce bone-disease progression.

  • Bisphosphonates

    Zoledronic acid 4 mg IV every 3 to 4 weeks cuts skeletal-related events and treats hypercalcaemia. Dental review first.

  • Denosumab

    Xgeva 120 mg subcutaneously every four weeks is an alternative to zoledronic acid. Watch for hypocalcaemia and osteonecrosis of the jaw.

  • External beam radiotherapy

    Single 8 Gy or fractionated 20 to 30 Gy for painful bone metastases and palliation. Fast, effective pain relief in most patients.

  • Stereotactic body radiotherapy

    SBRT delivers precise, ablative doses to oligometastatic deposits and to spine lesions where cord tolerance matters.

  • Radioisotopes

    Radium-223 for symptomatic bone-only metastatic castration-resistant prostate cancer. Strontium-89 and samarium-153 in selected cases.

  • PSMA-lutetium-177 (Pluvicto)

    Targeted radioligand therapy for PSMA-positive metastatic castration-resistant prostate cancer, licensed in the UK from 2022.

  • Orthopaedic surgery

    Prophylactic fixation (Mirels score above 8), fracture fixation, arthroplasty near joints and vertebroplasty or kyphoplasty for painful vertebral disease.

What this guide is based on

The sources behind every claim on this page.

UK national guidance and specialist society standards, current at the time of last review.

Key references

Guidelines and standards we relied on.

A quiet reminder

This guide is for information, not medical advice.

Your oncology, orthopaedic and palliative-care teams know your history and can tell you which parts apply to you. If in doubt, get seen.

  • NICE. Metastatic spinal cord compression in adults (CG75).

  • NICE. Prostate cancer: diagnosis and management (NG131).

  • ESMO Clinical Practice Guidelines. Bone health in cancer patients.

  • British Orthopaedic Association (BOOS) and BASO. Metastatic bone disease standards of care.

  • MHRA. Denosumab and bisphosphonates - osteonecrosis of the jaw safety information.

Red flags

When bone metastasis needs urgent attention.

These are the situations that change the plan, the pathway and often the outcome. If in doubt, contact the acute oncology service or A&E.

  • Suspected spinal cord compression

    New back pain with weakness, sensory change or bladder or bowel disturbance in anyone with cancer. Urgent MRI whole spine within 24 hours, dexamethasone and MSCC coordinator referral.

  • Impending pathological fracture

    A lytic lesion in a weight-bearing long bone with a Mirels score above 8. Refer for prophylactic fixation before it breaks.

  • Hypercalcaemia of malignancy

    Confusion, polyuria, arrhythmia or AKI with a raised corrected calcium. Admit for IV fluids and bone-directed therapy.

  • Cauda equina features

    Saddle anaesthesia, urinary retention or bilateral leg weakness needs same-day imaging and surgical review.

  • Osteonecrosis of the jaw

    Exposed bone, pain or non-healing sockets on bisphosphonates or denosumab. Stop dental extractions and refer to oral surgery.

  • Unexplained bone pain in known cancer

    New, persistent, night-worse pain in a previously well site deserves imaging, not just analgesia.

  • Rapidly worsening anaemia or cytopenias

    Bone marrow infiltration or myeloma progression. Repeat FBC, film and haematology referral.

  • Skull base symptoms

    New cranial nerve palsies, facial numbness or diplopia can flag skull-base metastasis needing MRI and prompt oncology review.

  • Pain uncontrolled on step-3 opioids

    Escalate to specialist palliative care, interventional pain and radiotherapy review rather than titrating opioids alone.

Living with it

A treatable condition, with a clear team around you.

Four things that make the biggest difference day to day. An MDT you know, steady bone-directed therapy, a layered pain plan and the right support behind you.

A quiet reminder

Ask about red flags early, not late.

New back pain, a change in continence or a sudden thirst is worth a same-day call. Early action saves function and time.

  1. 01 Team

    Metastatic bone MDT

    Oncology, orthopaedics, spinal surgery, radiology, palliative care and a specialist nurse should all be involved from the start.

  2. 02 Bone

    Stay on bone-directed therapy

    Regular zoledronic acid or denosumab reduces fractures and cord compression. Keep dental reviews and calcium and vitamin D on board.

  3. 03 Pain

    A layered pain plan

    WHO ladder analgesia, adjuvants like gabapentin or duloxetine, targeted radiotherapy and interventional options when needed.

  4. 04 Support

    Charities and community

    Macmillan, Marie Curie, Prostate Cancer UK and Breast Cancer Now offer nurse helplines, benefits advice and peer support.

Frequently asked

Everything we get asked about bone metastasis.

Quick answers on imaging, bone-directed therapy, radiotherapy and surgery.

  • What is bone metastasis?

    Bone metastasis is the spread of a cancer that started elsewhere in the body to the skeleton. It is much more common than primary bone cancer. Breast, prostate, lung, kidney, thyroid, multiple myeloma and melanoma are the tumours that most often involve bone.

  • How is bone metastasis diagnosed?

    A whole-body bone scan picks up most lytic and blastic deposits. CT shows the bony architecture and helps plan biopsy or fixation. MRI of the whole spine is the best test when spinal cord compression is suspected and should be done within 24 hours. PET-CT (FDG, PSMA, FAPI or DOTATATE depending on the primary) adds detail. A biopsy is used for isolated or unknown-primary disease and for molecular profiling.

  • What is metastatic spinal cord compression and why is it an emergency?

    MSCC happens when a bony or soft-tissue deposit presses on the spinal cord or cauda equina. Untreated it causes permanent paralysis, sensory loss and loss of bladder and bowel function. Any new back pain with weakness, numbness or bladder or bowel change in someone with cancer needs urgent MRI whole spine within 24 hours, high-dose dexamethasone and referral to the MSCC coordinator for radiotherapy or surgery.

  • What are bisphosphonates and denosumab used for?

    Both drugs strengthen bone and reduce skeletal-related events like fractures, cord compression and the need for radiotherapy or surgery. Zoledronic acid is given as a 4 mg intravenous infusion every three to four weeks. Denosumab (Xgeva) is a 120 mg subcutaneous injection every four weeks. Both need a dental check before starting because of the risk of osteonecrosis of the jaw, and denosumab needs calcium and vitamin D to prevent hypocalcaemia.

  • How is bone pain from metastases treated?

    Systemic anti-cancer therapy treats the underlying disease. External beam radiotherapy (often a single 8 Gy fraction) relieves localised bone pain quickly. Stereotactic body radiotherapy is used for spine and oligometastatic deposits. Radioisotopes like radium-223 (for prostate cancer) or PSMA-lutetium-177 target multiple bone sites at once. The WHO analgesic ladder, adjuvants like gabapentin and interventional pain techniques fill in the gaps.

  • When is surgery needed for bone metastases?

    Surgery is used for prophylactic fixation of long-bone lesions with a Mirels score above 8, for fixation of pathological fractures, for arthroplasty near joints, for vertebroplasty or kyphoplasty in painful vertebral disease and occasionally for tumour resection in solitary metastases. Spinal cord compression may need urgent decompression and stabilisation before radiotherapy.

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