Radiotherapy for Bone Cancer: Types, Success Rate, Side Effects And More

Bone sarcomas are rare cancers, representing about 0.2% of all malignancies. Osteosarcoma and Ewing sarcoma mainly affect children and young adults, while chondrosarcoma and chordoma are more often diagnosed after the age of 40. Their management is complex and relies on a multidisciplinary approach, with surgery as the central treatment whenever possible. Radiotherapy has an important role in situations where surgery is not feasible, margins are positive, or for tumors close to critical structures. Advances such as IMRT, proton therapy, carbon ion therapy, and stereotactic techniques have expanded its use by allowing higher doses with less damage to surrounding tissues.

In addition to primary bone sarcomas, secondary bone metastases are common in advanced cancers such as breast, prostate, and lung. These lesions can cause severe pain, fractures, and reduced quality of life. Radiotherapy is widely used for palliation in this setting, helping to relieve pain, prevent fractures, and improve mobility, often with short treatment courses that are well tolerated.

What is Radiotherapy for Bone Cancer?

Radiotherapy for bone cancer uses high-energy rays or particles to damage the DNA of cancer cells, making them unable to grow and divide. Its role depends on whether the disease is a primary bone sarcoma or secondary bone metastasis.

• In primary bone sarcomas (such as osteosarcoma, Ewing sarcoma, chondrosarcoma, or chordoma), surgery is the main treatment. Radiotherapy is added when tumors cannot be completely removed, are in difficult locations, or when margins are close or positive. In Ewing sarcoma, radiotherapy can even serve as a primary local control option when surgery is not feasible.
• In secondary bone cancer (metastases from cancers like breast, prostate, or lung), radiotherapy is mainly palliative. It helps control pain, reduces the risk of fractures, and improves mobility and quality of life.

Modern techniques such as IMRT, proton therapy, stereotactic radiosurgery, and carbon ion therapy allow higher doses to be delivered more precisely to tumors, while sparing nearby healthy tissues and reducing side effects.

How is Radiotherapy for Bone Cancer Administered/ Delivered?

Radiotherapy for bone cancer is usually delivered as external beam radiation therapy, in which high-energy beams are directed from a machine outside the body toward the tumor. Before treatment begins, imaging such as CT or MRI is used to map the tumor and surrounding structures with precision, and in some cases a custom mould or mask is made to keep the patient in the same position during each session.

During treatment, the patient lies on a couch while a linear accelerator delivers radiation from several angles. The treatment itself is painless and lasts only a few minutes, although the setup and positioning may take longer. Depending on the clinical situation, radiotherapy can be given as a single session or as a course of daily treatments over one to two weeks.

Advances in technology have made radiotherapy more accurate and effective. Intensity-modulated radiation therapy uses computer programs to shape and vary the strength of the beams, allowing a higher dose to reach the tumor while protecting nearby tissue. Proton and carbon ion therapy take advantage of the physical properties of particles that release most of their energy directly in the tumor, minimizing exposure to critical organs. Stereotactic techniques deliver very high doses with extreme precision, often in one or a few sessions, which is particularly useful for small or difficult-to-reach tumors. In some cases, brachytherapy is used, in which radioactive material is placed directly inside or near the tumor, sometimes even during surgery.

For secondary bone metastases, radiotherapy can also be given to larger areas of the body through hemibody irradiation, used when multiple sites are affected, or through injections of radioactive substances such as strontium-89 or radium-223. These radioisotopes travel through the bloodstream and collect in the bones, where they release radiation that helps to reduce pain and control symptoms.

Side Effects of Radiotherapy for Pancreatic Cancer

Radiotherapy is an important treatment option in pancreatic cancer, either alone or combined with chemotherapy and surgery. While it can help control tumor growth and relieve symptoms, radiation also affects nearby healthy tissues, leading to side effects. These can be divided into short-term, which appear during or shortly after treatment, and long-term, which may develop months or years later.

Short-term side effects

Common short-term effects include fatigue, nausea, vomiting, loss of appetite, and diarrhea. Some patients may also experience abdominal discomfort or skin irritation in the treated area. These side effects usually improve within a few weeks after treatment ends and can often be managed with supportive care.

Long-term side effects

Over time, radiotherapy may cause more lasting problems. These include chronic changes in bowel habits, persistent abdominal pain, or scarring of nearby tissues such as the stomach or intestines. In rare cases, long-term effects can involve liver or kidney function, or narrowing of the bile ducts or intestines due to radiation-induced fibrosis. Although less common, these late effects can significantly affect quality of life, making careful planning and modern techniques essential to limit radiation exposure to healthy organs.

How is Radiotherapy for Bone Cancer Administered/ Delivered?

Radiotherapy for bone cancer is usually delivered as external beam radiation therapy, in which high-energy beams are directed from a machine outside the body toward the tumor. Before treatment begins, imaging such as CT or MRI is used to map the tumor and surrounding structures with precision, and in some cases a custom mould or mask is made to keep the patient in the same position during each session.

During treatment, the patient lies on a couch while a linear accelerator delivers radiation from several angles. The treatment itself is painless and lasts only a few minutes, although the setup and positioning may take longer. Depending on the clinical situation, radiotherapy can be given as a single session or as a course of daily treatments over one to two weeks.

Advances in technology have made radiotherapy more accurate and effective. Intensity-modulated radiation therapy uses computer programs to shape and vary the strength of the beams, allowing a higher dose to reach the tumor while protecting nearby tissue. Proton and carbon ion therapy take advantage of the physical properties of particles that release most of their energy directly in the tumor, minimizing exposure to critical organs. Stereotactic techniques deliver very high doses with extreme precision, often in one or a few sessions, which is particularly useful for small or difficult-to-reach tumors. In some cases, brachytherapy is used, in which radioactive material is placed directly inside or near the tumor, sometimes even during surgery.

For secondary bone metastases, radiotherapy can also be given to larger areas of the body through hemibody irradiation, used when multiple sites are affected, or through injections of radioactive substances such as strontium-89 or radium-223. These radioisotopes travel through the bloodstream and collect in the bones, where they release radiation that helps to reduce pain and control symptoms.

Read OncoDaily’s Special Article About Radiotherapy For Soft Tissue Sarcomas

Side Effects of Radiotherapy For Bone Cancer

Radiotherapy is often part of the treatment plan for bone cancer, whether given after surgery, as a primary approach for unresectable tumors, or to ease symptoms caused by secondary bone metastases. While modern techniques allow radiation to be delivered more precisely, healthy tissues close to the tumor can still be affected, leading to side effects that vary depending on the treatment site, the dose, and the type of radiotherapy used.

Short-term Effects

Short-term effects are generally mild and may include fatigue, redness or irritation of the skin in the treated area, temporary hair loss, and a brief flare in bone pain that settles after a few days. When the abdomen or pelvis is treated, nausea, diarrhea, or urinary discomfort may occur, while radiation to the chest may affect breathing or cause irritation of the lungs.

Long-term side effects

Long-term side effects are less common but more serious. Radiation near the jaw can damage salivary glands and teeth, while treatment to the spine or skull may affect nerves, leading to headaches, weakness, or cognitive problems that appear months or years later. Pelvic irradiation can affect the bladder, bowel, or reproductive organs, sometimes causing lasting changes in function. Radiation involving joints may reduce mobility and cause stiffness or pain. A rare but important risk is the development of a second cancer in the irradiated area, particularly in younger patients and after high cumulative doses, although the overall likelihood is small compared with the benefits of treatment.

In the palliative setting for secondary bone metastases, side effects are usually limited, since the doses are lower and the focus is on comfort. Patients may still feel tired, develop mild skin reactions, or experience short-term digestive upset, but these effects often improve quickly once treatment ends.]

How Long Does It Take to See Results?

The time it takes to notice results after radiotherapy for bone cancer depends on whether the treatment is given with curative or palliative intent.

When radiotherapy is used to control pain from secondary bone metastases, many patients begin to feel relief within one to two weeks after treatment. In some cases, improvement is noticed in just a few days, while for others it may take several weeks. The pain relief can last for months, and in some people, the benefit is long-lasting.

For primary bone sarcomas, where radiotherapy is aimed at controlling or shrinking the tumor, the response is usually assessed over a longer period. Imaging studies such as MRI or CT are done weeks to months after treatment to evaluate changes in the tumor and to determine if the cancer has been controlled. Because these tumors are relatively resistant to radiation, the effects are more gradual and often become clear only after a follow-up period.

In both settings, the main goal is not just immediate relief but sustained control of symptoms or local disease.

How Many Radiotherapy Sessions for Bone Cancer?

The number of radiotherapy sessions for bone cancer varies depending on the type of disease and the treatment goal.

For secondary bone metastases, radiotherapy is often given in short courses. Some patients receive a single session that can provide pain relief lasting weeks or months, while others may have daily treatments over one to two weeks (typically five sessions per week). The choice depends on the number of bone lesions, the severity of symptoms, and the patient’s overall condition.

For primary bone sarcomas, treatment usually requires higher doses, which are divided into many small fractions to protect surrounding healthy tissue. In this setting, radiotherapy is delivered once a day, five days a week, over several weeks. The total number of sessions may range from 20 to more than 30, especially if the goal is to achieve long-term local control of the tumor.

Advanced approaches like stereotactic body radiotherapy may use fewer, very focused sessions, while radioisotope therapy for bone metastases is given as one or several injections rather than multiple external sessions.

What Are The Recent Advances in Radiotherapy for Bone Cancer?

Wong et al., in a 2024 publication in Radiation Oncology, reported two cases exploring pulsed low-dose rate radiotherapy (PLDR) as a re-irradiation strategy for bulky recurrent bone sarcoma. The first patient, a 76-year-old man with recurrent pelvic chondrosarcoma, received PLDR with a total of 70 Gy and has remained disease-free with no significant toxicity for 60 months.

The second patient, an 82-year-old woman with recurrent shoulder chondrosarcoma, was treated palliatively with 50 Gy using PLDR, which led to resolution of brachial plexopathy, though local progression occurred 8 months later. These cases suggest that PLDR may offer a promising and tolerable approach for re-irradiation in selected patients with unresectable recurrent sarcomas.

Daugherty et al. reported in Radiation Oncology (2024) on a prospective single-arm clinical trial investigating proton FLASH radiotherapy for painful thoracic bone metastases. Under an FDA investigational device exemption, 10 patients with 1–3 lesions (excluding spine) receive 8 Gy in a single fraction at ultra-high dose rates (≥40 Gy/s). The trial assesses safety, pain relief, and workflow feasibility, with follow-up at multiple intervals up to 12 months. This study builds on the earlier FAST-01 trial and aims to generate the first clinical data on proton FLASH for thoracic bone metastases, potentially paving the way for its use in broader patient populations, including curative settings.

How Can Patients Support Their Health During Radiotherapy For Bone Cancer?

During radiotherapy for bone cancer, patients can take steps to protect their overall well-being and manage side effects more effectively. Supportive care measures play an important role in helping the body tolerate treatment, maintain strength, and improve quality of life.

Nutrition and Hydration

Maintaining a balanced diet helps the body cope with treatment and recover more effectively. Patients are encouraged to eat small, frequent meals rich in protein and calories, and to stay well hydrated, especially if radiotherapy affects the abdomen or pelvis.

Managing Side Effects

Simple measures can ease short-term discomforts. Using gentle skin care products on treated areas, resting when feeling fatigued, and taking prescribed medicines for nausea, diarrhea, or pain can make treatment more tolerable. Patients should inform their care team promptly if side effects worsen, as adjustments and supportive treatments are available.

Physical Activity and Mobility

Light activity, such as short walks or stretching, can improve energy levels and reduce stiffness, especially if radiotherapy involves the spine, pelvis, or joints. At the same time, patients should avoid overexertion and take precautions to prevent falls or fractures in weakened bones.

Emotional and Social Support

The stress of living with bone cancer and undergoing radiotherapy can be significant. Support from family, friends, patient groups, or mental health professionals can help patients manage anxiety, depression, or isolation during treatment.

Follow-Up and Communication

Regular check-ins with the oncology team are important to monitor side effects, adjust treatment plans, and evaluate response. Open communication ensures that new symptoms are addressed quickly and that patients receive the full benefit of radiotherapy while protecting overall health.

Written By Aren Karapetyan, MD