Diagnosis and referral of adults with suspected bony metastases

### What you need to know Of the 44 million people worldwide who are living with treated cancer, 30-80% will experience bone metastases.12345 Metastatic bone disease (MBD) can lead to pain, loss of function, and pathological (low energy) fractures.67 Patients can present to any specialty, and half of those with a first recurrence present to primary care.8 Initial diagnosis can be difficult as lesions may not be visible on radiographs until 50-70% of bone has been destroyed.9 Early treatment can reduce the need for surgery and improve outcomes101112; therefore, a high degree of suspicion is essential when assessing cancer patients with new bone pain. Despite evidence that outcomes are better when we operate to stabilise bony lesions before they break, more than half of patients are not referred for surgery until they have sustained a pathological fracture.41314 Guidelines from the British Orthopaedic Oncology Society for good practice in metastatic bone disease were published in 201512 and called for targeted guidance for oncology and primary care to ensure that patients who could benefit from surgery were referred to their …