Bone Metastasis in Prostate Cancer: Standards, Multidisciplinary Care and Surgical Innovation

Bone is one of the most common sites to which prostate cancer spreads, and bone metastases together with their complications continue to shape a patient's functional status, quality of life and the treatment options that remain open later on. Recognising the risk of bone involvement earlier, treating it according to established standards, and using multidisciplinary collaboration within an overall treatment framework are questions that clinical practice has to keep returning to. At the same time, precision medicine and minimally invasive techniques are widening the ways in which surgery can be applied, which places new demands on clinical judgement and on the breadth of a physician's skills.

These were the questions put to Prof. Lin Guowen, chief physician and MD in the Department of Urology at Fudan University Shanghai Cancer Center and an invited expert in urologic oncology surgery at Shanghai GOBROAD Cancer Hospital, affiliated with China Pharmaceutical University. In the interview he set out where the diagnosis and treatment of bone metastasis in prostate cancer currently stand, how a multidisciplinary team should be organised around it, and where surgical treatment is heading.

Why Bone Metastasis Dominates the Prostate Cancer Picture

Bone is the most frequent distant site of prostate cancer spread: bone accounts for 88.7% of all metastatic sites in the disease, and around 81.2% of patients will develop bone metastases at some point in the course of their illness. Because prostate cancer screening is not yet widespread in China, the position at diagnosis is considerably worse than in countries that screen: 54% of newly diagnosed patients in China already have bone metastases at the moment their cancer is found.

Bone metastases bring skeletal-related events with them, among them pathological fracture, spinal cord compression, radiotherapy to bone and bone surgery. Each of these affects quality of life and long-term prognosis, and each adds to the burden that a patient carries. Once bone involvement is present, tumour burden is high and the disease burden heavier, survival shortens and the risk of death rises. In published data the five-year survival rate is 56.0% for patients without bone metastases, and below 3.0% for those with them.

Three Gaps in Diagnosis

The first gap is in surveillance. During follow-up, clinicians pay markedly less attention to screening for bone metastases than they do at the initial consultation, and there are cases in which a bone metastasis is only confirmed after the patient has already sustained a fracture.

The second gap is in identifying who is at high risk. More than half of clinicians do not have a complete command of the criteria that define a high-risk patient. Bone pain remains the main trigger for investigation, while asymptomatic high-risk patients are less often screened proactively.

The third gap is in the use of assessment tools. Bone scans and bone turnover markers are underused, and the standardised application of multimodal imaging still has considerable room to improve.

Three Gaps in Treatment, and Three Shifts That Would Close Them

On the treatment side, the most conspicuous problem is that bone-targeted drugs are not used according to standard. A national survey of current practice identified three specific failings. First, bone-targeted therapy is started far too late: 95.0% of clinicians had not begun a bone-targeted drug within three months of a confirmed diagnosis of bone metastasis. Second, dosing intervals are not respected: 59.4% of clinicians reported extending the injection interval. Third, treatment duration is too short: 88.4% of clinicians stopped the bone-targeted drug early once the disease was stable or symptoms had eased.

Three shifts follow from these findings, and Prof. Lin argued that all three are needed together. Screening should move from being triggered by bone pain to proactive monitoring of high-risk patients. Bone-targeted therapy should move from being started after pain appears to being started at the moment of diagnosis. And drug management should move from arbitrary discontinuation to standardised management across the whole course of the disease. Only then does the incidence of skeletal-related events fall, and only then does the prognosis of patients with bone metastatic prostate cancer improve.

What Surgery Contributes Inside a Multidisciplinary Team

Within a multidisciplinary team, the role of surgery is shifting from working alone to working in concert with others. Treating a patient with bone metastases requires urology, medical oncology, radiation oncology, orthopaedics, nuclear medicine and dentistry to work together, because any single specialty sees only part of the problem. Practice in China still falls short of that ideal. In tier three and tier four cities only 21.7% of hospitals run a prostate cancer multidisciplinary team at all; in tier one and tier two cities such teams are common, at 88.3%, but orthopaedic surgeons take part in only 40.2% of them and dental participation is lower still.

Where a team does function, surgery adds value at three levels. The first is preventive. For a weight-bearing bone metastasis that is about to fracture, or has already begun to, prophylactic internal fixation can avert the fracture and the loss of function that comes with it; for spinal metastases with a risk of cord compression, timely decompression and spinal stabilisation are the key means of protecting neurological function.

The second is diagnostic. For an isolated, suspicious bone lesion on imaging, a CT-guided bone biopsy can provide the pathological confirmation on which treatment decisions rest. This matters most in metastatic castration-resistant prostate cancer, where there may be no soft-tissue lesion to sample and where chemotherapy or radiotherapy cannot properly begin until histology has been established.

The third is therapeutic, and it is where the innovation is happening. In oligometastatic prostate cancer, cytoreductive radical prostatectomy of the primary tumour can improve local control and long-term survival on top of systemic therapy. In highly selected patients with a small number of bone metastases, directed surgical resection of the metastatic deposit is being explored in research settings.

Bone-Targeted Therapy as the Systemic Backbone

Inside a multidisciplinary plan, bone-targeted drugs are not an optional addition but the foundation. Surgery can deal with a local structural complication, but it cannot suppress the systemic process of bone destruction at its source. Denosumab, a fully human monoclonal antibody against RANKL, blocks osteoclast activation at the level of the signalling pathway itself and achieves potent bone protection.

The 2026 CSCO guidelines for the diagnosis and treatment of prostate cancer list denosumab as a class I recommendation for the management of bone metastases in metastatic castration-resistant disease across the whole course of treatment. The guidelines also emphasise that it should be started as soon as bone metastasis is confirmed, at 120 mg subcutaneously every four weeks.

The reason for that emphasis is that bone-targeted agents do more than prevent and delay skeletal-related events; they also extend survival. The PEACE-3 study, which combined systemic therapy with a bone-targeted agent and a radiopharmaceutical, reported a median overall survival of 71.59 months in metastatic castration-resistant prostate cancer, more than double the 30.69 months seen in the group that did not receive the bone-targeted agent.

The conclusion Prof. Lin drew is that surgery, bone-targeted drugs, systemic therapy and radiotherapy are not alternatives to one another. Surgery provides local structural stability, the bone-targeted agent provides systemic bone protection, systemic therapy controls the progress of the tumour and radiotherapy controls individual lesions. All four are needed, and it is their combination that produces durable benefit.

Robotics, Artificial Intelligence and Individualised Surgery

Surgical treatment of bone metastatic prostate cancer is moving away from coarse resection towards precise preservation of function, and away from decisions taken on experience towards decisions taken on data. In robotic surgery, new platforms that combine force feedback, fluorescence imaging and augmented reality navigation have made bone-related procedures considerably more precise. In resection of spinal metastases, robotic assistance supports high-accuracy screw placement and lowers the risk of neurovascular injury; in resection of pelvic metastases, intraoperative navigation can display the boundary of the lesion and its relationship to adjacent structures in three dimensions in real time, so that a safe margin is achieved while as much function as possible is preserved.

Artificial intelligence is beginning to reshape how multidisciplinary teams operate. It can assist with image interpretation, matching a patient's case against treatment guidelines, screening for clinical trials and predicting prognosis. In standardised clinical settings, published work reports concordance of around 70% between AI assessment and the judgement of multidisciplinary experts, with particular strengths in automatically quantifying bone metastatic burden and in identifying oligometastatic disease precisely. The intent is for AI to serve as an assistant to the team rather than a replacement for expert judgement, helping it integrate multimodal information more efficiently and reach more precisely individualised decisions.

Alongside these, digital preoperative planning, 3D-printed patient-specific implants and real-time intraoperative fluorescence navigation have made genuinely tailored surgery possible in bone metastases. Custom prostheses for large pelvic defects and minimally invasive percutaneous fixation systems for spinal metastases both improve safety during the operation and shorten recovery afterwards.

Advice for Younger Surgeons

Prof. Lin offered three directions for young doctors entering this field. The first is to build systematic thinking: bone metastasis in prostate cancer is not an isolated orthopaedic problem, and surgical technique has to be considered within the management of the disease as a whole, including how it interacts with systemic therapy and bone-targeted drugs. The second is to embrace technological convergence, learning robotic surgery, AI-assisted decision-making and image navigation actively and turning technical capability into clinical benefit. The third is to hold to evidence-based practice, using innovation as a means rather than an end and making responsible decisions within a multidisciplinary framework. Depth of surgical craft, breadth of multidisciplinary perspective and rigour of evidence, he said, are what allow a clinician to keep improving in a field as complex as this one.

About the Expert and the Hospital

Prof. Lin Guowen is a chief physician, MD and master's supervisor. He is a chief physician in the Department of Urology at Fudan University Shanghai Cancer Center and an invited expert in urologic oncology surgery at Shanghai GOBROAD Cancer Hospital, affiliated with China Pharmaceutical University. His clinical work centres on urologic tumours, with a particular focus on the diagnosis and treatment of prostate cancer and on the surgical management of advanced and metastatic disease.

Shanghai GOBROAD Cancer Hospital is located at 170 Taibei East Road in the Pudong New Area of Shanghai. It is a tertiary medical insurance designated institution with a total floor area of around 70,000 square metres, 400 beds open in the first phase, and a second phase under construction that is expected to come into use in 2027, bringing the combined total to around 700 beds. The hospital concentrates on solid tumours, brings in established expert teams from China and abroad, and is built around clinical research and public-benefit services.

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