Types of Treatment for Bone cancer

Executive Summary

The different types of standard treatments for bone cancer are explained in detail. Standard treatments are used along with the integration of effective treatment planning. Clinical trials are used as an innovative treatment approach that combines different therapies and drugs for treating bone sarcoma. Surgery is recommended for low-grade primary bone tumor. A high-grade primary bone tumour is treated using a different combination of treatments. Surgery involving reconstructive surgery is the most common treatment for bone sarcoma. Chemotherapy is used with various other drugs for different types of tumors. Radiation therapy and immunotherapy are also the common treatment approach for bone sarcoma. Palliative care is provided to the patients to cope with mental, physical or financial issues while involving medication, nutritional changes, emotional and spiritual support and other relaxation therapies.

Treatment of Bone Cancer

“Standard to care” refers to the best-known Treatment for Bone cancer. In cancer care, different doctors work together to bring out an overall treatment plan for the patient. This is called a multidisciplinary team. 

Treatment options and recommendations usually depend on several factors, including the type, stage and grade of cancer, possible side effects, and patient preferences and overall health ^​1​.

• For a low-grade primary bone tumor, the main treatment option is surgery. The target of the surgery is to remove the tumor and a margin of healthy tissue surrounding it to make sure that all cancer cells are gone.
• For a high-grade primary bone tumor, combinations of treatments are often used. 

Surgery

Surgery is the removal of a tumor and its surrounding healthy tissue during an operation. Surgical oncologists and orthopaedic oncologists are doctors who specialize in treating bone sarcoma using surgery ^​2​. 

Bone sarcoma surgery often involves a wide excision of the tumor. A wide excision means removing the tumor and a margin of healthy tissue surrounding it to ensure that all cancer cells are gone. 

If the tumor is present in the leg or arm, techniques to keep the arm or leg intact are used, sometimes called limb-sparing or limb salvage. However, depending upon the size of the tumor, occasionally amputation, that is, removal of arm or leg, becomes necessary.

Wide excision surgical techniques have lessened the number of amputations carried out for people with bone sarcoma. Around 90% of patients can be treated with limb-sparing surgery rather than amputation. Limb sparing techniques, also called reconstructive surgery, can require prostheses such as metal plates or bones from other parts to provide strength ^​3​. Surgeons use soft tissue, like a muscle, to cover the reconstruction area. The tissue assists with healing and reduces the risk of infection.

While for some patients whose sarcoma is located at a position where it cannot be eradicated, or the soft tissue cannot fully cover the surgical area, and patients who cannot undergo reconstruction surgery, the best-offered treatment is amputation. 

After an amputation, prostheses are needed. Since children’s bones are often still growing, some can be fitted for expandable joint prostheses that adjust as the skeleton grows. These prostheses require several procedures to accommodate the bone length as the child grows.

Surgery can also be used to treat sarcoma that has spread or metastasized to other parts of the body, like lung metastases. If there are few tumors in the lung and they have appeared a long time after the primary bone tumor was removed, surgery offers a high chance of curing the disease.

Rehabilitation after bone sarcoma surgery can be essential, which includes physical therapy. Physical therapy helps maximize the patient’s physical ability. Rehabilitation can help a person manage surgery’s social and emotional effects, including the challenges of losing a limb if amputation is necessary.  

Also Read: Dietary Approaches for Cancer.

Chemotherapy

Some patients may receive chemotherapy post-surgery from killing left out cancerous cells, called adjuvant chemotherapy, while some may receive chemotherapy first called neoadjuvant therapy. 

Chemotherapy is a Treatment for Bone cancer which uses medicine to kill or stop the growth of cancerous cells. Depending upon the stage, different chemotherapy is given. The point that makes a difference is how the chemotherapy enters the body and which cells it affects.

Chemotherapy for bone sarcoma is usually outpatient; hence, treatment can be given at a clinic or doctor’s office instead of staying in a hospital.

For people with Ewing sarcoma or osteosarcoma, surgery alone is usually not enough. These cancers can recur as distant metastases, mainly in the lungs. 

Fast-growing sarcomas are often treated with chemotherapy before surgery. For high-grade cancers, the oncologist may give 3 or 4 cycles before surgery to reduce the size of the tumour. Chemotherapy before surgery may help patients live longer because it destroys cancer cells that have spread from the original tumour. The tumour’s response to chemotherapy can be used to determine the prognosis better. To evaluate the effectiveness of the chemotherapy, tumour cells are looked at under a microscope after the primary tumour has been removed to see what percentage of cells were killed. This is called the necrosis factor.

After recovering from the surgery, patients may go through more chemotherapies to kill the remaining tumour cells. 

The drugs used in chemotherapy are different for different types of bone sarcoma ^​4​.

A list of drugs used for 2 of the most common types of bone sarcoma is given below:

Common drugs for osteosarcoma

1. Doxorubicin
2. Cisplatin
3. Methotrexate
4. ifosfamide

Common drugs for Ewing sarcoma

1. Doxorubicin
2. Vincristine
3. Cyclophosphamide
4. Ifosfamide
5. Dactinomycin
6. Etoposide

The side effects of chemotherapy depend upon the individual and the dose used. Still, they can include fatigue, risk of infection, nausea and vomiting, hair loss, loss of appetite, and diarrhoea. These side effects typically go away after treatment is finished.

Radiation Therapy

Radiation therapy uses high-energy X-rays or particles to kill cancer cells ^​5​.

Radiation therapy is Treatment for Bone cancer which is commonly used for a tumour that cannot be removed with surgery for bone sarcoma. Radiation therapy can be done before surgery to shrink the tumour, or it may be done after surgery to knock down remaining cancer cells. Radiation therapy makes it feasible to do less extensive surgery, often protecting the arm or leg. 

Radiation therapy can be used in people with bone cancer that can’t be eliminated with surgery. After surgery, radiation therapy is used to destroy any cancer cells that may be left behind. Radiation therapy may help control signs and symptoms for people with advanced bone cancer, such as pain.

Radiation therapy is also used to relieve pain for people as part of supportive or palliative care.

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

Targeted therapy

Targeted therapy is a Treatment for Bone cancer which aims at any factor that contributes to the growth and development of cancer cells. It can be a specific protein, gene or tissue environment. These treatments are typical and do not harm surrounding cells like those in chemotherapy or Radiotherapy.

All tumors do not have the same target; doctors may recommend testing to understand better changes in the individual tumor’s genes and proteins ^​6​. 

A small proportion of sarcomas, less than 1%, have a mutation in the neurotrophic receptor tyrosine kinase (NTRK) gene. Larotrectinib (Vitrakvi) is an NTRK inhibitor now approved for any cancer with specific mutations in the NTRK gene.

The most common side effects include nausea, fatigue, vomiting, dizziness, increased liver enzymes, cough, constipation, and diarrhoea.

Immunotherapy

Immunotherapy, a type of biological therapy, uses artificial or natural substances to harness our immune system to fight. 

Immunotherapy is not approved for treating sarcomas, including bone sarcomas, because they have not been tested well enough. 

Suppose testing on your bone tumour shows that it has specific problems with repairing DNA damage, called microsatellite instability-high (MSI-H) or mismatch repair deficiency. In that case, a checkpoint inhibitor called pembrolizumab (Keytruda) or dostarlimab (Jemperli) may be used.

Different types of immunotherapy can cause other side effects. Common side effects include flu-like symptoms, skin reactions, diarrhoea, and weight changes.

Palliative Care

Cancer and its treatment have side effects that can be mental, physical or financial and managing the effects are palliative or supportive care.

Palliative care includes medication, nutritional changes, emotional and spiritual support and other relaxation therapies. 

Palliative care focuses on alleviating how you feel during treatment by managing symptoms and supporting patients and their families with other non-medical needs. Regardless of type and stage of Cancer age, any person may receive this type of care.

Remission and the chance of recurrence

When cancer can’t be detected in the body, and there are no symptoms, this is known as remission. This may also be called having ‘no evidence of disease’ or ‘NED.’

A remission can be temporary or permanent. Many people worry about the recurrence of cancer.

If Treatment Doesn’t Work

Recovery from bone sarcoma is not always possible. If cancer can’t be treated or controlled, it leads to advanced or terminal cancer. It is vital to have straightforward conversations with your health care team to express your feelings, preferences, and concerns. The health care team has unique skills, knowledge, and experience to assist patients and their families. Ensuring that a person is physically comfortable, free from pain, and emotionally supported is extremely important. 

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