Bone Scans and Advanced Prostate Cancer (2025 Guide)

Advanced prostate cancer often spreads to the bones. Doctors use bone scans to find these bone metastases early. This guide explains the different bone scan technologies and treatments for prostate cancer that has spread to bone, in clear terms. We also include a comparison table of scan types, a breakdown of treatments (including new therapies), and key questions to ask your doctor.

Bone Scans in Advanced Prostate Cancer

Bone scans are imaging tests that show if prostate cancer has spread to your bones. They work by using tiny amounts of radioactive tracers that highlight areas of bone change. Prostate cancer in the bone causes bone cells to react, and scans can detect this activity as “hot spots.” Below are the main bone scan technologies used in 2025, explained in plain language.

Technetium-99m Bone Scintigraphy (Standard Bone Scan)

Technetium-99m bone scintigraphy is the classic bone scan. It involves an injection of a small amount of a radioactive tracer (technetium-99m labeled compound) that travels through the bloodstream and gets absorbed by bones. Areas where cancer is growing in bone will absorb more tracer and light up as dark spots on the scan image​ pmc.ncbi.nlm.nih.gov. This scan can image the entire skeleton at once and is widely available in most hospitals​.

 

Benefits: Technetium bone scans are commonly used because they are relatively inexpensive and available almost everywhere​. They can survey all the bones in the body in one session. Doctors have decades of experience with this scan.

 

Limitations: The standard bone scan has moderate sensitivity and can miss very small or early bone metastases​. It also has moderate to low specificity, meaning not everything that lights up is cancer​. Other conditions—like arthritis, old fractures, or infections—can also cause “hot spots” on the scan​. In other words, a bone scan might show an abnormal area that isn’t actually cancer. If the scan is unclear, doctors may need additional imaging. Overall, this scan is good at finding obvious bone metastases, but it may not detect very tiny lesions and can sometimes give false alarms.

 

Sodium Fluoride PET (NaF PET) Scan

Sodium fluoride PET is an advanced bone scan using a PET scanner with a tracer called fluorine-18 sodium fluoride (NaF). Like the standard bone scan, this tracer goes to areas of bone turnover (where bone is breaking down or building up). Cancer in the bone causes rapid bone turnover, so NaF PET highlights those spots with high detail. A PET scan then detects the tracer, and a CT is often combined to show the anatomy.

Benefits: NaF PET scans are very sensitive and provide high-resolution images of the bones​. They can detect smaller bone metastases than a standard bone scan in many cases​. One analysis showed that NaF PET correctly finds about 97–98% of bone metastases (high sensitivity)​. The images are clearer because fluoride is taken up strongly by bone and clears quickly from the blood, giving a good contrast​. This means NaF PET can reveal bone tumors that might be missed on a regular bone scan. It is a powerful tool for confirming bone metastases.

Limitations: Sodium fluoride PET is not specific to cancer outside the bones. It will show bone metastases, but it does not provide information about cancer in lymph nodes or other organs​. Because of this, it’s usually not used alone for full cancer staging—other scans would be needed to see soft tissues​. NaF PET is also more expensive and not as widely available as technetium bone scans​. In many regions, it is used in research or special cases rather than as a routine test. Additionally, some benign bone conditions can still cause uptake on NaF PET, so while it’s very sensitive, there can still be false positives (though its specificity is higher than standard bone scans)​. In summary, NaF PET is an excellent bone-specific scan with superior image quality, but limited availability and focus (bones only).

PSMA PET-CT Scan

PSMA PET-CT is a newer, highly advanced scan that has changed how doctors find prostate cancer spread. PSMA stands for prostate-specific membrane antigen, a protein found in high amounts on prostate cancer cells. In a PSMA PET scan, a radioactive tracer is attached to a molecule that seeks out PSMA. After injection, this tracer binds to prostate cancer cells wherever they are (bone or other organs). The PET scan then shows bright spots wherever the cancer cells are, and a combined CT scan gives detailed location information.

Benefits: PSMA PET-CT is extremely sensitive and can detect very small metastases. Studies show it can find more metastatic tumors than conventional bone scans and CT scans​. For example, one meta-analysis found that PSMA PET had a sensitivity of about 97% for bone metastases, compared to about 86% for the standard bone scan​. It is also very specific – in the same analysis PSMA PET had about 100% specificity for bone metastases, versus 95% for the bone scan​. This means PSMA PET is less likely to give false positives. The major advantage is that PSMA PET-CT scans the whole body for cancer, not just the bones. It can detect cancer in lymph nodes, liver, lung, or any other site during the same scan, as long as those cancer cells express PSMA. This comprehensive view often leads to changes in treatment plans; doctors can tailor therapy better when they know exactly where the cancer is​. PSMA PET-CT has been rapidly adopted into practice for staging and restaging prostate cancer because of its superior accuracy​. Even at low PSA levels or early recurrence, PSMA PET can sometimes find metastases that old scans would miss.

Limitations: The main limitation of PSMA PET-CT in 2025 is availability and cost. Not all hospitals have access to PSMA PET tracers or the specialized PET scanners needed, though availability is improving each year. It can be expensive, and insurance coverage may vary by region. Additionally, PSMA PET works best when prostate cancer cells produce the PSMA protein; in rare cases where tumors are PSMA-negative or have transformed into a different type, the scan might not show those lesions. There can also be uptake of the tracer in some normal organs (like salivary glands) or benign conditions, but doctors are trained to distinguish these from true metastases. Overall, however, PSMA PET-CT is considered a game-changer for detecting prostate cancer spread with high accuracy​.

Comparison of Bone Scan Technologies

The table below compares the three bone imaging technologies, summarizing how they work, along with their benefits and limitations:

Scan Type How It Works (Layman’s Terms) Benefits Limitations
Technetium-99m Bone Scan Injection of technetium-99m tracer that highlights areas of new bone growth. Cancer in bone appears as dark “hot spots” on a camera scan. Widely available; relatively low cost​. Scans the whole skeleton in one test. Decades of usage and well-understood results. Moderate sensitivity – can miss very small lesions​. Not very specific – other bone conditions (arthritis, fractures) can also light up​. Does not show cancer outside the bones.
NaF PET Scan(Sodium Fluoride PET) Injection of radioactive fluoride (^18F) that sticks to bones where there is rapid turnover. A PET scanner creates a detailed 3D image of the skeleton. Very high sensitivity – detects small bone metastases that might be missed by standard bone scans​. Clear, high-resolution images​. Good at confirming if an abnormal bone spot is cancer. Limited availability and higher cost​. Focuses only on bones (won’t show soft-tissue tumors)​.  Still can’t always distinguish cancer from non-cancer bone changes (some false positives remain).
PSMA PET-CT Injection of a tracer that targets PSMA on prostate cancer cells. PET-CT scanner then highlights cancer anywhere in the body (bone or other organs) that has PSMA. Extremely sensitive and specific for prostate cancer metastases​. Can find very small tumors. One scan covers the whole body (bones, lymph nodes, organs)​. Often detects spread more accurately than standard scans, improving treatment decisions​. Expensive and not yet available in all centers. Requires cancer cells to have PSMA; rare variants might not show up. Some uptake in benign areas can occur, but much less than with older scans.

Key: PET = Positron Emission Tomography; CT = Computed Tomography; PSMA = Prostate-Specific Membrane Antigen.

Treatments for Advanced Prostate Cancer with Bone Metastases

When prostate cancer has spread to the bones, treatment usually involves a combination of therapies. The goals are to control the cancer throughout the body, prolong life, relieve symptoms, and protect the bones from fractures or pain. Below is a breakdown of current approved treatments and emerging therapies for advanced prostate cancer with bone metastases.

Systemic Cancer Therapies (Hormone Therapy and Chemotherapy)

Androgen Deprivation Therapy (ADT) is the cornerstone of treatment for advanced prostate cancer. ADT (through injections or surgery to lower testosterone) slows cancer growth in both the prostate and any metastases. Most patients with bone metastases will be on ADT if not already, because prostate cancer typically needs testosterone to grow. In addition, newer hormonal medications (such as abiraterone and enzalutamide) are often used in metastatic cases. These drugs further block the cancer’s ability to use hormones and have been shown to improve survival in advanced prostate cancer. Chemotherapy (like docetaxel or cabazitaxel) is another systemic treatment that can kill prostate cancer cells, including those in the bones, and is commonly used when the disease progresses despite hormone therapy. Multiple treatments have been shown to help men with metastatic prostate cancer live longer. In fact, there are at least six approved therapies for metastatic castration-resistant prostate cancer that improve survival; these include hormone-based pills, chemotherapy, immunotherapy (sipuleucel-T vaccine), and a radiopharmaceutical (radium-223)​ pmc.ncbi.nlm.nih.gov. Your oncology team will tailor a combination of these systemic treatments based on your specific situation. While hormone therapies and chemotherapy treat cancer throughout the body, the following therapies specifically address bone metastases or bone health:

Radionuclide Therapy (Radioisotope Treatments for Bone Metastases)

Radionuclide therapy involves using radioactive substances that seek out bone metastases and deliver radiation directly to those cancer spots. These therapies are given by injection into the bloodstream. The radiation they emit is targeted mostly to bones where cancer is present, causing DNA damage to tumor cells.

  • Radium-223 (Xofigo): Radium-223 is an FDA-approved radionuclide therapy specifically for prostate cancer that has spread to bones. Radium-223 is sometimes described as a “liquid radiation” – it behaves similarly to calcium, so it homes in on bones, especially areas with active metastases, and gives off alpha radiation to kill cancer cells in the bone. Treatment is usually an injection once a month for six months. Radium-223 is unique because it’s the only therapy among the life-prolonging treatments that specifically targets bone metastases​ pmc.ncbi.nlm.nih.gov. It has been shown to improve survival in men with metastatic castration-resistant prostate cancer (mCRPC) with bone metastases​. In the pivotal ALSYMPCA study, men who received radium-223 lived longer on average than those who did not. Radium-223 also delays skeletal-related events (like fractures or spinal cord compression) and can reduce bone pain​. Importantly, radium-223’s alpha particles travel only a very short distance in tissue, so the radiation mainly affects the tumor in bone and spares surrounding healthy tissues like bone marrow to a greater extent than some other radiation types. Patients often experience pain relief in bone lesions after radium-223 therapy, and it’s generally well tolerated; the most common side effects include mild anemia or temporary lowering of blood cell counts. This treatment is usually offered to patients whose cancer is resistant to hormone therapy and who have multiple bone metastases (and no significant spread to organs like liver or lung, since radium targets bone).

     

  • Beta-emitting radiopharmaceuticals (older treatments): Before radium-223, other radioactive drugs like strontium-89 and samarium-153 were used to treat bone metastases. These agents also travel to bones and give off beta radiation. They were effective at reducing bone pain in many patients​. However, these older therapies did not show an improvement in survival​. They were mainly used for pain palliation when other options were limited. Today, radium-223 has largely replaced them due to its survival benefit, but they are noted historically as proof that bone-targeted radiation can help manage symptoms.

     

  • PSMA-targeted Radioligand Therapy (Lutetium-177 PSMA): An emerging form of radionuclide therapy uses the same PSMA targeting principle as the PSMA PET scan, but attached to a therapeutic radioactive particle. The most notable is Lutetium-177 PSMA-617 (sold under brand name Pluvicto®, approved in 2022). In this therapy, a molecule seeks out PSMA on prostate cancer cells (anywhere in the body, including bone) and delivers Lutetium-177, which emits beta radiation to kill the cancer cell. It is a systemic treatment like chemotherapy, given by IV infusion, typically every 6 weeks for several cycles. Lutetium-177 PSMA is an important new option for men with advanced prostate cancer that has spread to bones and other organs after other treatments. A recent clinical study showed that adding Lu-177 PSMA therapy improved overall survival. Men who received this therapy lived a median of 15.3 months versus 11.3 months for those who received standard care alone​ pubmed.ncbi.nlm.nih.gov. This radioligand therapy can shrink tumors and reduce PSA levels in many patients. Common side effects include dry mouth (from salivary gland uptake), nausea, fatigue, and lowered blood counts, but it is generally manageable. As of 2025, Lutetium-177 PSMA is becoming part of standard care in advanced cases (particularly after other treatments like chemo and novel hormones have been tried). It represents a bridge between diagnostics and therapy – sometimes called “theranostics” – using the same target (PSMA) for both imaging and treatment. Researchers continue to develop similar therapies, including those with different radioactive particles (like Actinium-225), but those are experimental at this time.

     

Overall, radionuclide therapies offer a way to attack cancer in the bones directly with radiation from within. Radium-223 is used when disease is mostly in bones, and PSMA radioligand therapy can be used even when cancer is in bones and other places, as long as the cancer cells have PSMA. These treatments can be used alongside or after other systemic therapies, based on a doctor’s recommendation.

Bisphosphonates and Other Bone-Strengthening Agents

Cancer in the bones can weaken them, leading to pain, high risk of fractures, and other complications (often called skeletal-related events). Bisphosphonates are drugs that help strengthen bones and reduce the damage caused by cancer’s spread to bone. The most commonly used bisphosphonate in advanced prostate cancer is zoledronic acid (Zometa). Zoledronic acid is given as an intravenous infusion, usually once every 4 weeks (though studies have shown it can be given every 12 weeks with similar effectiveness in some cases). It works by inhibiting osteoclasts, the cells that break down bone, thereby slowing bone destruction.

Benefits: Bisphosphonates have been shown to reduce bone complications in men with prostate cancer that has spread to bone pmc.ncbi.nlm.nih.gov. For instance, zoledronic acid can decrease the rate of fractures, spinal cord compressions, or the need for radiation or surgery on bones. In one of the key studies, men taking zoledronic acid had fewer skeletal-related events than those on placebo​. These drugs can also help with bone pain to some extent and improve quality of life by strengthening the bone structure.

 

Denosumab (Xgeva): Denosumab is another bone-targeted therapy, though it is not a bisphosphonate. It is a monoclonal antibody that blocks RANKL, a protein involved in bone breakdown. Denosumab is given as a subcutaneous injection (under the skin) every 4 weeks. It has been shown to be at least as effective as zoledronic acid – in fact, a clinical trial found denosumab was slightly more effective in delaying the first bone complication compared to zoledronic acid​. In that study, about 30% of patients on zoledronic acid had a bone complication within the time frame versus about 25% of those on denosumab​. Because it is not cleared through the kidneys, denosumab can be used in patients with poorer kidney function (where zoledronic might be risky).

Using either a bisphosphonate or denosumab is now standard for men with metastatic prostate cancer to the bone, in addition to treatments that target the cancer itself​. These drugs do not directly kill cancer cells, but they make the bone environment less conducive to cancer growth and help prevent fractures and other issues. Doctors typically start bone-strengthening therapy when metastatic bone disease is confirmed, unless there are contraindications.

 

Limitations and Side Effects: Both zoledronic acid and denosumab can have side effects. A rare but serious side effect is osteonecrosis of the jaw (ONJ) – an area of the jawbone that does not heal properly after an injury, which can happen in a small percentage of patients​. Good dental hygiene and regular dental check-ups before and during treatment are important to minimize this risk​. Calcium and vitamin D supplements are recommended with these treatments to prevent low calcium levels in the blood​. Zoledronic acid can sometimes cause flu-like symptoms after the infusion (fever, aches) for a day or two. Denosumab can cause low calcium levels, so monitoring is required. Both treatments, despite these risks, have an established role in preventing bone fractures and other bone problems in metastatic prostate cancer​. They do not, however, improve survival on their own; their benefit is in reducing complications and improving comfort.

 

Other Supportive Treatments for Bone Metastases

In addition to the above, doctors use other treatments to manage symptoms and prevent problems from bone metastases:

  • External Beam Radiation Therapy (EBRT): This is localized radiation directed at a particular bone lesion. It is very effective for relieving pain in a specific area (for example, a painful spine or hip metastasis). EBRT does not treat the whole body, but it can greatly improve quality of life by easing bone pain or preventing a tumor from compressing nerves or the spinal cord.

  • Pain Medications: Pain from bone metastases can be significant. Oncologists will often prescribe analgesics ranging from anti-inflammatory drugs to opioids, depending on severity. The goal is to keep the patient comfortable and able to function.

  • Orthopedic Interventions: In cases where a bone is at high risk of fracture (such as a weight-bearing bone with a large metastasis), orthopedic procedures may be considered. This can include surgery to stabilize a bone (using rods, screws, or cement) or procedures like kyphoplasty for spinal bone issues. These interventions are on a case-by-case basis to maintain mobility and prevent breaks.

  • Calcium and Vitamin D: Patients with bone metastases, especially those on ADT or bone-strengthening agents, should maintain good bone health with calcium and vitamin D supplements (unless contraindicated)​ pmc.ncbi.nlm.nih.gov. ADT can cause bone thinning (osteoporosis), so these supplements, along with weight-bearing exercise as tolerated, can help keep the bones as strong as possible.

     

In summary, treating advanced prostate cancer with bone metastases requires a multi-pronged approach. Therapies like hormone treatments and chemotherapy attack the cancer broadly, while radionuclide therapies deliver radiation to cancer in the bones, and bone-modifying agents like bisphosphonates/denosumab fortify the skeleton. Newer options like PSMA PET-guided radioligand therapy are expanding the toolkit for oncologists in 2025, offering hope for improved outcomes. Your oncology team will personalize your treatment plan based on factors like how widespread the cancer is, your overall health, prior treatments, and your preferences.

Questions to Ask Your Doctor

Dealing with advanced prostate cancer and bone metastases can be overwhelming. It’s important to have open conversations with your healthcare providers. Here is a list of questions you might consider asking your doctor about bone scans and treatment options:

  • “What type of bone scan are we using, and why is it the best choice for me?” – Understand whether you will have a standard technetium bone scan, a PSMA PET-CT, or another scan, and what the scan will show.

  • “What do the results of my bone scan mean for my treatment plan?” – Have the doctor explain how extensive the bone metastases are and how that influences therapy (e.g. more aggressive treatment if many spots are found).

  • “How often will I need repeat bone scans or other imaging?” – Learn the schedule for monitoring. Some patients get scans every few months or as needed to track the disease.

  • “Are more advanced scans like PSMA PET-CT available to me?” – If you have only had a standard bone scan, ask if a PSMA PET could provide additional information in your case, especially if the bone scan is negative but suspicion remains high (or vice versa).

  • “What treatments do you recommend for my bone metastases?” – This open-ended question lets the doctor outline the plan, including hormone therapy, chemotherapy, radium-223, etc.

  • “How will these treatments help me, and what are their side effects?” – Make sure you understand the goal of each therapy (for example, prolonging life, reducing pain, preventing fractures) and the potential risks or side effects (like fatigue, risk of infections, bone marrow suppression, etc.).

  • “Should I be taking a bisphosphonate or denosumab to protect my bones?” – If not already addressed, ask if you need a bone-strengthening agent and discuss the pros and cons of zoledronic acid vs. denosumab in your situation.

  • “Is radionuclide therapy such as radium-223 or Lutetium-177 PSMA an option for me now or in the future?”– Depending on your disease status, these might be options. Ask if you are a candidate and at what point in therapy they would be considered.

  • “What can be done to manage bone pain or other symptoms I have?” – Discuss pain medications, localized radiation, or other interventions to keep symptoms under control.

  • “How can I maintain my bone health during treatment?” – This can include questions about diet, supplements (calcium/vitamin D), exercise, or referrals to specialists (like an endocrinologist or orthopedic doctor) if needed.

  • “What signs of complications should I watch out for?” – For example, new severe pain could indicate a fracture or spinal cord compression. Know what symptoms are red flags that need immediate attention.

Remember, it’s your right to understand your care. Don’t hesitate to ask for clarification or further information about anything you find confusing. Keeping a written list of questions and even taking notes during appointments can help ensure your concerns are addressed. The landscape of advanced prostate cancer treatment is evolving, and as of 2025 there are more options than ever. Working closely with your doctors, you can make informed decisions that align with your health goals and improve your quality of life.

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