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Cooperative Medicine Chest NHS Article

Bone cancer (sarcoma)

Click here to go to the NHS Choices website

Introduction


Primary bone cancer is cancer that starts in the bone, rather than starting in another part of the body and then spreading to the bone. The latter is known as secondary bone cancer. Unlike primary bone cancer, secondary bone cancer is common in cases of advanced cancer.

A painful feeling in your bone is the most common symptom of primary bone cancer.

How common is bone cancer?

Primary bone cancer is a rare type of cancer that accounts for just one in every 500 cases of cancer in the UK each year. There are an estimated 500 cases every year. The cause of most cases of bone cancer is unknown.

Types of primary bone cancer

The four most common types of primary bone cancer are:

  • osteosarcoma
  • Ewing's sarcoma
  • chondrosarcoma
  • spindle cell sarcoma

The different types are described below.

Osteosarcoma

Osteosarcoma is the most common type of bone cancer, with an estimated 150 cases a year in the UK. Most cases of osteosarcoma develop in children and young people who are between the ages of five and 20, making it the third most common cancer in young people (after leukaemia and brain tumours).

Osteosarcoma usually develops in the larger bones, such as the thigh bone (femur) or the shin bone (tibia).

Ewing's sarcoma

Each year, in the UK, there are an estimated 100 cases of Ewing's sarcoma. As with osteosarcoma, Ewing's sarcoma usually develops in children and young people aged 10-20, although 10% of cases develop in people who are over 20.

Ewing's sarcoma usually develops in the pelvis, thigh bone or shin bone.

Chondrosarcoma

In the UK, there are an estimated 80 cases of chondrosarcoma each year. This type of bone cancer usually develops in adults who are between the ages of 40 and 50.

Chondrosarcoma begins in the cartilage cells before spreading to the bone. Cartilage is a tough, flexible tissue that lines the surface of many bones and joints.

The most common sites for chondrosarcoma to develop are:

  • pelvis
  • thigh bone
  • upper arm bone (humerus)
  • shoulder blade (scapula)
  • ribs

Spindle cell sarcoma

There are an estimated 80 cases of spindle cell sarcoma every year. Spindle cell sarcoma is very similar to osterosarcoma in terms of its symptoms and treatment, but it affects older adults (who are 40 or over).

Rarer types of bone cancer

Rarer types of bone cancer include:

  • chordoma, a type of cancer that starts in the base of the spine and usually affects men between the ages of 40 and 50
  • angiosarcomas, a type of cancer than can start anywhere in the skeleton (sometimes in multiple sites at once) and usually affects adults who are aged 20 or over

Outlook

The most important factor in determining the likely outlook for cases of bone cancer is whether the cancer has spread from the bone to other parts of the body (metastasis).

The most common places in the body for the cancer to spread to are the lungs, and secondary lung cancer can be challenging to treat.

If bone cancer is diagnosed before it spreads out of the bone(s), the outlook is moderate to good because a cure is often achievable. This type of cancer is known as localised bone cancer.

Health professionals use a general measurement of a "five-year survival rate" when describing cancer statistics. However, it's important to make clear that the five-year measurement is not an absolute measurement and it does not mean that people with bone cancer only have a five-year life expectancy.

For cases of localised bone cancer:

  • Between 55%-70% of people with osteosarcoma will live for at least five years after receiving the diagnosis.
  • About 70% of people with Ewing's sarcoma will live for at least five years after receiving the diagnosis.
  • About 80% of people with chondrosarcoma will live for at least five years after receiving the diagnosis.
  • About 60% of people with spindle cell sarcoma will live for at least five years after receiving the diagnosis.

If the bone cancer has spread to other parts of the body, the outlook is not as favourable because a cure is often not possible. This type of bone cancer is known as metastatic bone cancer.

For cases of metastatic bone cancer:

  • About 30% of people with osteosarcoma will live for at least five years after receiving a diagnosis.
  • About 30% of people with Ewing's sarcoma will live for at least five years after receiving a diagnosis.
  • Between 10%-30% of people with chondrosarcoma will live for at least five years after receiving a diagnosis.
  • About 25% of people with spindle cell sarcoma will live for at least five years after receiving a diagnosis.

Bone cancer is usually treated with a combination of chemotherapy, radiotherapy, and surgery.

Blood
Blood supplies oxygen to the body and removes carbon dioxide. It is pumped around the body by the heart.
Bone marrow
Bone marrow is the soft, spongy tissue in the centre of bones that produces blood cells.
Joint
Joints are the connection point between two bones that allow movement.
Malignant
Malignant is a term used to describe a life-threatening or worsening condition. In the case of tumours, malignant means cancerous.
Prognosis
A prognosis is a prediction of the possible outcome of a disease or condition.
Spine
The spine supports the skeleton, and surrounds and protects the delicate spinal cord and nerves. It is made up of 33 bones called the vertebrae.
Tissues
Body tissue is made up of groups of cells that perform a specific job, such as protecting the body against infection, producing movement or storing fat.

Symptoms of bone cancer


Bone pain is the most common symptom of bone cancer. It usually begins with a feeling of tenderness in the affected bone, and then gradually progresses to a persistent ache that often feels worse during the night and when using the affected bone.

In cases of Ewing sarcoma, bone pain is a symptom that usually gets stronger quite quickly.

Bone pain that is caused by bone cancer is sometimes wrongly mistaken for arthritis in adults and "growing pains" in children and teenagers.

If you have bone cancer, you may also experience inflammation (swelling) or detect a noticeable lump on or around the affected bone. If the bone is near a joint, the swelling may make using the joint difficult.

Less common symptoms of bone cancer include:

  • a high temperature (fever) of 38C (100.4F) or above
  • unexplained weight loss
  • sweating

When to seek medical advice

If your child is experiencing persistent bone pain that lasts for more than three days, take them to visit your GP. Bone pain is unlikely to be the result of growing pains if it lasts longer than three days.

You should also visit your GP if you are an adult and you experience persistent bone pain. While the majority of cases of bone pain are caused by arthritis, the symptom requires a medical diagnosis. If you have arthritis, you will also benefit from having an early diagnosis.

Joint
Joints are the connection point between two bones that allow movement.
Lungs
Lungs are a pair of organs in the chest that control breathing. They remove carbon dioxide from the blood and replace it with oxygen.
Numbness
Numbness refers to a lack of sensation in a part of the body.
Pain
Pain is an unpleasant physical or emotional feeling that your body produces as a warning sign that it has been damaged.

Causes of bone cancer


How does cancer begin?

Cancer begins with an alteration to the structure of the deoxyribonucleic acid (DNA) that is found in all human cells. This is known as a genetic mutation. The DNA provides the cells with a basic set of instructions, such as when to grow and reproduce.

The mutation changes these instructions so that the cells carry on growing. This causes them to reproduce uncontrollably, producing a lump of tissue known as a tumour.

How does cancer spread?

Most cancers grow and spread to other parts of the body via the lymphatic system.

The lymphatic system is a series of glands (or nodes) that are spread throughout your body, much like your blood circulation system. The lymph glands produce many of the specialised cells that are needed by your immune system.

Bone cancer is unusual in that as well as spreading via the lymphatic system it can also spread via the blood. This is why it often spreads to the lungs as cancerous cells can "leak" out of the bone into the blood and then travel into the lungs.

Known risk factors

Bone cancer is a poorly understood condition and, as a result, only a small number of risk factors for the condition have been identified. These are outlined below.

  • Previous exposure to high doses of radiation, such as undergoing radiotherapy; however, the increased risk that is associated with radiotherapy is small.
  • Having Paget's disease, which is an uncommon bone condition that causes weakening of the bones. Around one in 100 people with the condition will develop bone cancer in later life.
  • Having a rare genetic condition known as Li-Fraumeni syndrome.
  • Having a previous history of retinoblastoma, which is a rare type of childhood cancer that develops in the eye.

Research has also found that babies who are born with an umbilical hernia are three times more likely to develop Ewing sarcoma than the population at large.

An umbilical hernia occurs in 1%-2% of all births and is where tissue pokes through the part of the abdomen near to the navel (belly button). It is thought that as an unborn baby develops, the unknown factors that cause the hernia to develop may also contribute to an increased risk of Ewing sarcoma.

However, the increased risk is still very small in relative terms, as only one in 110,000 children with an umbilical hernia will go on to develop Ewing sarcoma.

Possible risk factors

A possible risk factor for osterosarcoma is experiencing rapid bone growth during puberty (a growth spurt). Most teenagers who develop osterosarcoma are taller than average.

The possible link between growth spurts and osterosarcoma may also explain why most cases develop in teenagers.

One study found a possible increased risk of osterosarcoma in people whose parents worked in farming around the time they were conceived. This may be due to exposure to pesticides.

However, the researchers who carried out the study emphasised that it was a small study and research involving a larger number of people is needed to confirm or deny this suggested risk factor.

Benign
Benign refers to a condition that should not become life-threatening. In relation to tumours, benign means not cancerous.
Doses
Dose is a measured quantity of a medicine to be taken at any one time, such as a specified amount of medication.
Gene
Genes contain information that you inherit from your parents, such as eye or hair colour. They are carried by chromosomes.
Genetic
Genetic is a term that refers to genes (the characteristics inherited from a family member).

Diagnosing bone cancer


If you visit your GP with symptoms of bone pain, they will probably carry out a physical examination of the affected bone. They may also refer you for blood tests, which can sometimes be useful in confirming or ruling out other conditions such as an infection or some types of arthritis.

If no obvious cause can be found, it is likely that you will be referred to an orthopaedic surgeon (a specialist in bone conditions) at your local hospital for further testing.

X-rays

The surgeon may arrange a series of X-rays of your affected bone to be taken.

X-rays can often detect damage to the bones that is caused by cancer, or new bone cells that have started to grow around the cancer. They are also often useful in determining whether you have primary or secondary bone cancer.

X-rays cannot provide a definitive diagnosis of bone cancer, but they can indicate whether further investigation is needed.

If your X-rays suggest that you may have bone cancer, it is likely that you will be referred to a specialist centre with expertise in diagnosing and treating the condition.

As bone cancer is very rare, it makes sense to have a small number of specialist centres, rather than spreading resources and trained staff across the whole of the health service.

MRI scan

A magnetic resonance imaging (MRI) scan uses a strong magnetic field and radio waves to produce detailed pictures of the inside of the affected bone.

A MRI scan is an effective way of assessing the size and spread of any cancerous tumour inside the bones.

If you need to have a MRI scan, you will lie on your back and a small "receiving device" will be placed behind, or around, the part of your body being scanned. You will then be moved into a large tube where the scan will take place. The procedure usually lasts about 30 minutes.

A MRI scan is not painful, but some people may find it a little claustrophobic. If you sometimes get claustrophobia, tell the radiographer (who operates the MRI scanner) because they may be able to give you a sedative to help you relax.

CT scan

A computerised tomography (CT) scan involves taking a series of X-rays and using a computer to reassemble them into a detailed three-dimensional (3-D) image of your body.

CT scans are often used to check if the cancer has spread to your lungs. Chest X-rays may also be taken for this purpose.

Bone scans

A bone scan can provide more detailed information about the inside of your bones than an X-ray. A bone scan involves a small amount of radioactive material being injected into your veins. Abnormal areas of bone will absorb the material at a faster rate than normal bone. Therefore, any abnormal areas of bone that are affected by cancer will show up as "hot-spots" on the scan.

Biopsy

The most definitive way of confirming a diagnosis of bone cancer is to take a sample of affected bone and send it to a laboratory for testing. This is known as a biopsy.

A biopsy can also determine exactly what type of bone cancer you have, and what grade your cancer is. A grading system is used to describe how aggressive the cancer is, and how likely it is that it will spread, with high grade cancers being the most aggressive. This information is important for planning treatment.

The two ways that a biopsy can be performed are:

  • A core needle biopsy, performed under a local anesthetic, and is where a long, thin needle is inserted into the bone and used to remove a sample of tissue.
  • An open biopsy, performed under a general anesthetic, and is where the surgeon makes an incision in the affected bone in order to remove a sample of tissue.

You may need to have an open biopsy if the results of a core needle biopsy are inconclusive.

Biopsy
A biopsy is a test that involves taking a small sample of tissue from the body so it can be examined.
MRI
MRI stands for magnetic resonance imaging. It is the use of magnets and radio waves to take detailed pictures of inside the body.
Prognosis
A prognosis is a prediction of the possible outcome of a disease or condition.
Swelling
Inflammation is the body's response to infection, irritation or injury, which causes redness, swelling, pain and sometimes a feeling of heat in the affected area.
Tissue
Body tissue is made up of groups of cells that perform a specific job, such as protecting the body against infection, producing movement or storing fat.
Veins
Veins are blood vessels that carry blood from the rest of the body back to the heart.
X-ray
An X-ray is a painless way of producing pictures of inside the body using radiation.

Treatment for bone cancer


Your care team

If you are diagnosed with bone cancer, it is likely that you will be referred to a specialist centre with experience in treating bone cancer. At specialist bone cancer centres there are teams of specialist health professionals who work together to treat bone cancer. These types of teams are known as multi-disciplinary teams (MDTs). See the box to the left.

If you have bone cancer, you may see several, or all, of these healthcare professionals as part of your treatment.

Deciding what treatment is best for you can be difficult. Your cancer team will make recommendations, but the final decision will be yours.

Before going to hospital to discuss your treatment options, you may find it useful to write a list of questions to ask the specialist. For example, you may want to find out what the advantages and disadvantages of particular treatments are.

Your treatment plan

The different types of bone cancer are usually treated in a similar way. Firstly, chemotherapy is given in order to try to shrink the tumour(s). This may then be followed by a course of radiotherapy to shrink the tumour(s) further.

However, in cases of osterosarcoma, radiotherapy is rarely used because it has limited effectiveness in treating this type of bone cancer.

Following chemotherapy and/or radiotherapy, surgery may be carried out to remove the section of cancerous bone. In many cases, it is possible to maintain the function of the body part from where the section of the bone was taken from. This is known as limb-sparing surgery (see below).

In some cases - for example, if the cancer has spread beyond the bone into the surrounding blood vessels - it will be necessary to amputate some, or all, of the limb. However, due to advances in diagnosis and treatment, only a minority of cases (about 15%) require amputation.

If cancer has spread to the lungs, surgery can also be used to remove the affected portion of the lungs. The Health A-Z article about lung cancer provides more information about surgery for lung cancer.

Following surgery, further sessions of radiotherapy and/or chemotherapy may be given in order to destroy any remaining cancerous cells.

Limb-sparing surgery

Limb-sparing surgery is usually possible when the cancer has not spread beyond the bone, and the affected bone itself is in an easily accessible position such as:

  • the arm
  • the leg
  • the shoulder
  • the pelvis
  • the hip

The most common type of limb-sparing surgery involves removing the section of affected bone as well as some of the surrounding tissue (in case any cancerous cells have spread into the tissue). The removed section of bone is then replaced with a metal implant called a prosthesis.

In some cases, it may be possible to take a sample of bone from another part of the body and use it as an alternative to prosthesis. This type of operation is known as a bone graft.

If the cancer is near a joint, such as the knee joint, it may be necessary to remove the joint and replace it with an artificial one, which is made from a combination of plastic, metal, and ceramics.

Artificial joints can be used to replace:

  • a knee joint
  • a hip joint
  • a shoulder joint

The most common complication of limb-sparing surgery is a post-operative infection, which occurs in one out of every 10 cases. Any infection can make the prosthesis or artificial joint unstable. If this occurs, further surgery may be required to repair it.

In the most serious cases of infection, repairing the prosthesis or joint may not be possible and amputation will be required.

Amputation

Amputation is usually required:

  • if the cancer has spread beyond the bone into major blood vessels and/or nerves
  • if the cancer has spread beyond the bone into your skin
  • if you develop a serious infection after limb-sparing surgery
  • if the cancer has developed in a part of the body where limb sparing surgery is not technically possible, such as in the ankle

Being told that you need to have an amputation can be devastating, particularly for children. Your care team will understand the shock and fear that you, or your child, may be feeling and will be able to provide counselling and other support as required.

In some cases, your care team may be able to introduce you or your child to someone who has had an amputation, and they will be able to give you advice and support about living with an amputation.

Artificial limbs are now very advanced and convenient to use. For example, people with an artificial leg are able to walk, run and play sport. In many cases, an artificial limb allows a wider range of movement than a limb that is repaired with limb-sparing surgery.

Research has also found that most people who have an amputation are able to enjoy the same quality of life as people who have limb-sparing surgery.

After having surgery, it is likely that you will be in some pain, particularly around your stump (the point at which your limb was removed) so you will be given painkillers.

Once your stump has healed, you will be fitted with an artificial limb. These are usually custom-made in order to make wearing it and using it as comfortable as possible.

When you are able to leave hospital, you will be referred to a local limb centre. Limb centres provide advice, support and treatment for people with artificial limbs.

At the limb centre, you will be given physiotherapy and occupational therapy (therapy that is designed to improve the skills that you need for day-to-day living) so that you can make the best use of your artificial limb.

Any adjustments to your limb that may be required as you grow older can also be carried out at the limb centre.

Chemotherapy

Chemotherapy uses powerful cancer-killing medication to treat cancer.

There are four ways that chemotherapy can be used to treat bone cancer. It can be used:

  • before surgery to shrink the tumour, making it more likely that you will only require limb-sparing surgery
  • in combination with radiotherapy before surgery (chemoradiation); this approach works particularly well in the treatment of Ewing sarcoma
  • after surgery in order to prevent the cancer returning
  • to control symptoms in cases where a cure is not possible (this is known as palliative chemotherapy)

Chemotherapy treatments are usually given in cycles. A cycle involves taking the chemotherapy medication for several days, and then having a break for a few weeks to allow your body to recover from the effects of the treatment.

The number of cycles that you require will depend on the type and the grade of your bone cancer. For example, some people may only require six cycles of treatment while others may need up to 14 cycles.

Chemotherapy for bone cancer involves taking a combination of different medications. The medications are usually delivered via a drip into your vein, or into a tube that is connected to one of the blood vessels in your chest.

Side effects of chemotherapy include:

  • nausea
  • vomiting
  • diarrhoea
  • loss of appetite
  • mouth ulcers
  • tiredness
  • skin rashes
  • infertility
  • hair loss (following treatment, your hair should take between three to six months to grow back)

Most of the side effects associated with chemotherapy should resolve once your treatment has finished.

However, there is a risk that you will be permanently infertile. Depending on the type of chemotherapy medication that is used, this risk can range from between 13%-80%. Your care team will be able to provide more detailed information about the specific risk to your fertility.

If you wish to have children, it may be possible to take samples of your sperm (men) or eggs (women) so that they can be used later in fertility treatments, such as IVF.

Chemotherapy can also weaken your immune system, making you more vulnerable to infection. Inform your care team and/or your GP as soon as possible if you experience the possible signs of an infection, such as:

  • a high temperature (fever) of 38C (100.4F) or above
  • coughs
  • sore throat
  • a feeling of being generally unwell

Radiotherapy

Radiotherapy is a type of treatment that uses pulses of radiation to destroy cancerous cells.

As with chemotherapy, radiotherapy can be used before and after surgery to treat bone cancer, or it can be used to control the symptoms and slow the spread of cancer when a cure is not possible.

Radiotherapy is usually given five days a week with a break from treatment over the weekend. Each session of radiotherapy usually lasts around 10-15 minutes. Most people require between two and five weeks of treatment.

Common side effects of radiotherapy include:

  • reddening and irritation of the skin of the body part being treated (this can feel much like sunburn)
  • joint pain in the part of the body that is being treated
  • nausea
  • hair loss in the body part being treated
  • tiredness

These side effects will pass once the radiotherapy has been completed, although feelings of tiredness may persist for several weeks.

Chemotherapy
Chemotherapy is a treatment of an illness or disease with a chemical substance, e.g. in the treatment of cancer.
Joint
Joints are the connection point between two bones that allow movement.
Radiotherapy
Radiation therapy uses x-rays to treat disease, especially cancer.
Spine
The spine supports the skeleton, and surrounds and protects the delicate spinal cord and nerves. It is made up of 33 bones called the vertebrae.
Veins
Veins are blood vessels that carry blood from the rest of the body back to the heart.

Complications of bone cancer


Phantom limb pain

Many people who have an amputation find that they experience a sensation that their limb is still attached to their body and is causing them pain. This is known as phantom limb pain.

The causes of phantom limb pain are unknown, but it is thought that the pain may be the result of nerve endings in the stump sending abnormal nerve impulses that your brain interprets as pain.

If, after having a limb amputated, you experience phantom limb pain, let the staff at your limb centre know because there are a number of treatments available, such as:

  • painkillers
  • hypnosis
  • anti-epileptic medications
  • antidepressant medications

Anti-epileptic and antidepressant medications were originally designed to treat epilepsy and depression, but they have since proved to be effective in treating certain types of nerve pain.


NICE guidelines for treatment of sarcoma


According to Dr Rob Grimer, consultant orthopaedic oncologist at the Royal Orthopaedic Hospital and lead clinician on the Guideline Development Group, one of the biggest problems in the care and treatment of people with sarcoma is the delay in diagnosis.

"People are not diagnosed until their tumour is quite big, 10 centimetres on average," he says.

"Even when GPs suspect a sarcoma, they don't always know where to refer the patient. We envisaged, and it is actually happening, that a network of sarcoma centres would be set up across the country where anyone with a suspected sarcoma could be referred for diagnosis and then treatment. Patients will be seen by experts as opposed to what has been happening, where they were seen by people who were neither experienced nor interested in the problem," he says.

NICE believes that the key to improving outcomes for people with sarcoma is the rapid referral of patients to a specialist sarcoma treatment centre for diagnosis after having an X-ray.

NICE recommends that everyone with a confirmed diagnosis should have their care supervised by a multidisciplinary team, made up of healthcare professionals who work together to provide specialist care for bone cancer patients.

The guidelines cover all sarcomas, which means they cover tumours of the body's connective tissues: cartilage, fat, blood vessels, nerves and muscles as well as bones.

For more information, download the NICE guidance.


'It never crossed my mind that I might not survive'


Carol Starkey, 20, from Bromsgrove, Worcs, was diagnosed with bone cancer in her shoulder only three weeks after she started university.

"It was February 2006 when I first noticed the aches in my right shoulder. I thought it was a pulled muscle and I expected it to sort itself out, but it didn't. The ache would wake me up at night and I could feel it when I was driving.

"I went to my GP who thought I was studying too hard and that it might be Repetitive Strain Injury from using my computer. He told me to take painkillers. The pain didn't stop and, after a holiday to Sicily, I went back to see him. He sent me for physio, thinking it might be tendonitis. I also had ultrasound and acupuncture but the pain still didn't go away.

"Then one day, when I was getting out of a swimming pool, my right arm completely gave way. It was really painful and I lost all power in it for about a half an hour.

"My GP gave me a cortisone injection, which he said would keep me pain-free for two weeks which was exactly what I wanted. I was off to Honduras for an expedition that involved walking, backpacking and scuba diving. I coped, but I couldn't sleep as I was in constant pain and I didn't have the strength in my arm to lift anything.

"The GP then referred me to a specialist who said I should have a further course of cortisone. A few weeks later I felt my shoulder pop which was followed by the most excruciating pain. For the first time, I saw a big bulge on the front of my shoulder, which I thought meant it was dislocated. I went straight to A&E.

"I had an X-ray which showed two fractures of the humerus, the bone in the upper arm. The doctor told me it needed further investigation and referred me to the Royal Orthopaedic Hospital in Birmingham.

"After several scans, X-rays and a biopsy, the doctor showed me the X-ray of the lump on my shoulder. When he mentioned the word cancer, it came as a complete bombshell. I'd had no inkling as I'd never even heard of bone cancer.

"I wasn't upset by the thought of treatment. Nor was I bothered about losing my hair. I was upset by the fact that I wouldn't be able to do water sports in the future. It never crossed my mind that I might not survive.

"Although it had taken eight months to get a diagnosis, the treatment began just over a week later. I went to the Young Person's Unit at the Queen Elizabeth Hospital, Birmingham. It was brilliant and it made so much difference to be with people of my own age. I was very grateful for that.

"I had six cycles of chemotherapy which meant three weeks in hospital followed by two weeks at home for each cycle. I was very sick at first and spent a lot of time in hospital. It took over my whole life.

"The tumour did shrink, but not by as much as the doctors would have liked so I had to have radiotherapy. After the second cycle of chemotherapy, in January 2007, I had surgery. In a three-hour operation, they removed 20 centimetres of my humerus and replaced it with a metal artificial bone.

"It was difficult at first - I needed a sling for six weeks and my arm was quite weak. It was hard to chop food and to write, but the physio and practising has helped a lot. Now I can cook most of the things I used to be able to.

"I have got back into some sports too. I can swim breastroke, I have begun driving powerboats and begun canoeing again. We do a lot of walking as a family and I've been able to do that again. My fitness came back quite quickly. Sadly, I will never be able to do contact sport because there's too much danger of the prosthesis getting dislodged.

"My advice to a young person who suspects they might have bone cancer is to think of seeking a second opinion if your pain is not being taken seriously. Also, don't get discouraged by the treatment. The first few weeks of chemotherapy are the worst. After that it gets better."


See what the doctor sees with Map of Medicine


The Map of Medicine is used by doctors throughout the NHS to determine the best treatment options for their patients. NHS Choices offers everyone in England exclusive and free access to this cutting-edge internet resource, which lets you see exactly what your doctor sees.

The information in the Map has been approved by the UK's leading clinical experts, is based on the best available clinical evidence, and is continually updated. To take advantage of this unique resource go to:

Map of Medicine: bone sarcoma


Bonecancer(sarcoma)



Access to new treatment


How does a drug receive a licence that allows it to be marketed?

A pharmaceutical company will make an application to one of two drug regulatory bodies: either the European Agency for the Evaluation of Medicinal Products (EMEA) or the UK's Medicines and Healthcare Products Regulatory Agency (MHRA). The application and all the research evidence is then examined by experts, who judge the drug's safety, quality and effectiveness.

Neither the Department of Health nor the National Institute for Health and Clinical Excellence (NICE) play any part in this process. The application is a confidential matter between the drug company and the regulatory body

Will the NHS fund an unlicensed drug if my doctor wants to prescribe it for me?

It is possible for your doctor to prescribe a drug outside the indications (uses) it is licensed for, if they are willing to take personal responsibility for this 'off-licence' use of a treatment. He or she would make this decision after discussing with you the potential risks and taking into account your medical history.

Your local primary care trust (PCT) may also need to be involved, as it would have to decide whether to support your doctor's decision and pay for the drug from NHS budgets.
The licensing process is designed to ensure that a drug is both safe and effective. It's important to balance the possibility of introducing the benefits that new drugs may bring with the need to ensure that they are safe. For example, it is important to ensure that potential side effects from a drug do not outweigh the benefits for which the drug is prescribed.

What is NICE's role?

Sometimes when a drug is licensed it is important to give the NHS advice about whether or not it is clinically and cost effective for use in the NHS. This is to ensure that the NHS spends its money on the most efficient treatments.

The National Institute for Health and Clinical Excellence (NICE), an independent body, provides this advice to the NHS in England and Wales. NICE focuses its work on treatments that are of particular significance and where its advice will be of most benefit.

If NICE recommends that a treatment should be used in the NHS, a PCT must fund its use for eligible patients (i.e. those who meet the criteria specified in the NICE guidance). This ensures that there is national consistency in how the NHS uses these treatments.

Can I have a drug that is licensed but has not been appraised by NICE?

NICE does not issue guidance until a drug is licensed. The way in which a drug will be used is not always clear until the licensing process is completed. Between a drug being licensed and final NICE guidance being available, primary care trusts (PCTs) will decide whether to fund new treatments if and when they receive a request from a local patient or doctor.

A PCT should not refuse to fund a licensed treatment just because guidance is not available from NICE. They have to base their decision on an assessment of the evidence and the health needs of their local population.

These types of decisions are not new. NICE does not issue guidance on every licensed drug and PCTs already make many decisions locally about the use of their funds for different treatments. PCTs are best placed to make these decisions either until NICE guidance is available or where NICE guidance will not be produced.

Why aren't I entitled to any treatment I want under patient choice?

The NHS does not have a limitless pot of money. Funding a particular drug/treatment means that these funds cannot then be used to pay for other sorts of healthcare. It is important that the health service uses treatments that are effective enough to justify their cost.

If you have any concerns about the treatment you have been offered, you can discuss this with your doctor or the Patient Advice and Liaison Service (PALS) at your local hospital.

European Agency for the Evaluation of Medicinal Products (EMEA), Medicines and Healthcare Products Regulatory Agency (MHRA), new medicines, new treatments, medicine, treatment


Medicine-guides


The list below is a combination of the and brand names of medicines available in the UK. Each name provides a link to a separate website (Medicine Guides) where you can find detailed information about the medicine. The information is provided as part of an on-going medicine information project between NHS Direct, Datapharm Communications Ltd and other organisations.

The medicines listed below hold a UK licence to allow their use in the treatment of this condition. medicines are not included.

The list is continually reviewed and updated but it may not be complete as the project is still in progress and guides for new medicines may still be in development.

If you are taking one of these medicines for a different condition, or your medicine for this condition is not mentioned here at all, speak to your prescriber, GP or pharmacist, or contact NHS Direct on 0845 46 47.


The materials in this website are provided by Medicine Chest and NHS Choices.  Neither Co-operative Group Limited or Co-operative Healthcare Limited (trading as The Co-operative Pharmacy or otherwise) shall be in any way responsible or liable for its content.

The materials in this website are in no way intended to replace the professional medical care, advice, diagnosis or treatment of a doctor.  The website does not have answers to all problems and answers to specific problems may not apply to everyone.  If you notice medical symptoms or feel unwell, you should consult your doctor.  For further information, consult the terms and conditions.