Benign Disease

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How are you all setting up plantar fasciitis and what sorts of field arrangements?
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I just had a breast follow-up pin me down and promise to try RT for her knee OA. Apparently, I’ve chatter with her about it a couple times in past 2 years after reading this thread but I haven’t had the guts to try this yet. She’s gonna be my first. Are y’all doing 50 cGy x 6 fractions QOD? Do you plan retreat in 12 weeks? I’m seeing different things when reviewing all these threads. Thanks!
 
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Yes

Mention the re - tx up front, that it’s a two stage treatment, but some patients do not require the second stage

Bill lightly, no IGRT please, don’t want them to take this away. It’s been a godsend
 
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Bequerel said:
I just had a breast follow-up pin me down and promise to try RT for her knee OA. Apparently, I’ve chatter with her about it a couple times in past 2 years after reading this thread but I haven’t had the guts to try this yet. She’s gonna be my first. Are y’all doing 50 cGy x 6 fractions QOD? Do you plan retreat in 12 weeks? I’m seeing different things when reviewing all these threads. Thanks!
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“Haven’t had the guts”

This always mystifies me what a weird affect we have sometimes in rad onc. You don’t need permission from your former PD to give 3 Gy to an arthritic knee. You don’t need to worry about what some rad onc across town is going to think. The radiation police won’t come drag you out of bed. Merrick Garland isn’t going to perp walk you. No one besides rad oncs care what other rad oncs think. You don’t need guts to give a worldwide standard of care medical treatment, just a cerebral cortex.
 
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RealSimulD said:
Yes

Mention the re - tx up front, that it’s a two stage treatment, but some patients do not require the second stage

Bill lightly, no IGRT please, don’t want them to take this away. It’s been a godsend
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Do you give second stage to anyone who doesn’t have complete pain relief?
 
Bequerel said:
Do you give second stage to anyone who doesn’t have complete pain relief?
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No.

Some people want all 12 from start. Most want to see how the 6 go. If they have relief, usually wait til it wears off before offering. If they have no relief, then 12 weeks they can restart, but many choose not to. I remain as nonchalant about it - this is purely elective and I never want to feel like a salesman (although there is that aspect of it that exists)
 
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TheWallnerus said:
“Haven’t had the guts”

This always mystifies me what a weird affect we have sometimes in rad onc. You don’t need permission from your former PD to give 3 Gy to an arthritic knee. You don’t need to worry about what some rad onc across town is going to think. The radiation police won’t come drag you out of bed. Merrick Garland isn’t going to perp walk you. No one besides rad oncs care what other rad oncs think. You don’t need guts to give a worldwide standard of care medical treatment, just a cerebral cortex.
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We are our own worst critics
 
RealSimulD said:
No.

Some people want all 12 from start. Most want to see how the 6 go. If they have relief, usually wait til it wears off before offering. If they have no relief, then 12 weeks they can restart, but many choose not to. I remain as nonchalant about it - this is purely elective and I never want to feel like a salesman (although there is that aspect of it that exists)
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How does the approval process go for round 2? Do you ask for 12 up front or resim them after 6 for a second course?
 
Ray D. Ayshun said:
How does the approval process go for round 2? Do you ask for 12 up front or resim them after 6 for a second course?
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This is what I would like to know. I've done a couple medicare without an issue, but I just had to go to evicore P2P to get an ankle course approved. I am dreading the process for a second course if needed
 
Scrybe9 said:
This is what I would like to know. I've done a couple medicare without an issue, but I just had to go to evicore P2P to get an ankle course approved. I am dreading the process for a second course if needed
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We’ve started to ask for 12 up front

I’ve only had one P2P. She wondered why not 5 fx - she was assuming it was treated like a met
 
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RealSimulD said:
We’ve started to ask for 12 up front

I’ve only had one P2P. She wondered why not 5 fx - she was assuming it was treated like a met
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I explained that the patient met the evicore criteria under benign diesease, using CPT M19.071 (OA of ankle), and wanted to know why the P2P was needed. The response was, "well we can't just let everyone have radiation." I honestly didn't know what to say.

The patient clearly had failed all available treatment options, so there was no ground for denial. But that didn't stop them from trying.
 
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Haha
Scrybe9 said:
I explained that the patient met the evicore criteria under benign diesease, using CPT M19.071 (OA of ankle), and wanted to know why the P2P was needed. The response was, "well we can't just let everyone have radiation." I honestly didn't know what to say.

The patient clearly had failed all available treatment options, so there was no ground for denial. But that didn't stop them from trying.
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Sad. I write notes now with "evicore criteria" in them to prevent p2ps. So far so good.
 
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Scrybe9 said:
"Well we can't just let everyone have radiation." I honestly didn't know what to say.
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"Don't worry. I will make sure you won't get any radiation, when you are in pain."
 
Scrybe9 said:
The response was, "well we can't just let everyone have radiation." I honestly didn't know what to say.
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Can't we?
The use of radiation for arthritis in this country would save billions of dollars a year.
 
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Didnt the Dutch do a study in this years ago and show its BS?
 
OTN said:
Can't we?
The use of radiation for arthritis in this country would save billions of dollars a year.
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What's a joint replacement go for all-in at this point? 100k?

EDIT:
Appliance itself
OR fee
Post op stay
Surgeon and Anesthesia reimbursement
Pain control/blood thinners post op
PT/OT for months with associated facility fees
Any needed durable medical equipment
Occasional Complication management/Reoperation

Not sure how much of this gets bundled in those sites that do bundled reimbursement for replacements. My guess is only the top line items.
 
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Fpg1245 said:
Didnt the Dutch do a study in this years ago and show its BS?
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The Swiss, but they used different dosing and fractionation than the Germans. In my experience, which mirrors the german one, going from qd to qod improved outcomes. I use 3 gy qod. Swiss study used 6 gy qd.
 
RealSimulD said:
Where did that come from?
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The German POC study from 2018 states single fraction doses are 0.5 - 1.0 Gy to total doses of 2-8 Gy are being used.

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The European (mostly Germany) literature in which the prescription practices are described is relatively few. Many used kV therapies. Those that described their MV prescription practices almost entirely prescribe to isocenter. I have only found 1 publication prescribing to a 3D volume.

60 cgy is one of the more common single fraction doses evaluated. I don't know what developments led to the choice of 60 cgy -- maybe it was an "educated guess". If dose is prescribed to the isocenter, that correlates with a lower dose covering the entirety of the joint. If I prescribe 50 cgy to a volume (the joint) the isocenter dose is between 60 to 100 cgy.

My insurers will only pay for 5 fractions. Therefore, I have limited my prescription to 5 fractions which delivers a total dose to the isocenter meeting or exceeding 300 cgy as described by DEGRO.

Regarding dose/fraction, several in vitro studies have shown more beneficial effects on immunomodulators with doses between 30 - 70 cgy compared with higher doses. The most effective dose/fraction (and total dose) are unknown, as far as I can tell. But, it appears to me that the lower the dose/fraction the greater the anti-inflammatory effect. What should the total dose be? I don't know, but suspect the lower the better there also. There are many patients who report significant pain relief within 1 or 2 fractions. Makes me wonder if those patients really need to complete the remainder of their treatments.

I started out treating 5 x 60 cgy. For the past couple years I have been treating with 5 x 50 cgy to a volume (i.e., the joint). I have treated hundreds of joints with this regimen since and haven't noticed a detriment to response rate.

Fortunately, or unfortunately depending on how you look at it, my arthritis practice has taken off as patients return to their PCP's/Ortho's and they see the results. I had to limit the number of arthritis patients I see in a week as it was crowding out my ability to take care of oncology patients. I have arthritis consults commonly booked out 3+ months now. But, it doesn't seem to bother them as they have already been told by their orthopod that it will be 5-6 mos before they can have surgery for their joint anyway. I am currently treating the spouse of one of my top referrers.

When I started this years ago I did not believe it would work. I thought the Europeans were quacks! I am amazed by what I have seen and wish I had started doing this sooner as it can have a tremendous positive impact on a patient's life.
 
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Amazing. Thanks for sharing SB. I'll forgive you for changing up the fractionation scheme and making prospective evaluation of this regimen in the US more difficult (again)!
 
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3 follow ups today
All with relief , 2 with pain scores from 7 down to 1
It’s such an interesting treatment
 
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sirspamalot said:
Do we have a huge study showing this is not sorcery? I mean, I know there are smaller +/- studies..
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No, but neither do any other arthritis treatments
 
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Asked this in the business section, so will ask here as well for general input. Any particular insurances problematic/impossible to get rt approved for osteoarthritis?
 
Ray D. Ayshun said:
I'm being reasonable. Otoh, healthhelp and AIM make no mention of this, or really any benign disease in their manual
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Any carrier with half a brain can do the math and should be drooling over this vs paying out for a joint replacement!
 
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evilbooyaa said:
Can't get approved or rejected until you ask...

Have you tried asking for approval yet?
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Yeah. In process. Just curious what people have said to healthelp for prior auth should it be rejeacted/require P2P. This could be much ado about nothing. Particularly as AIM and Healthhelp say nothing about treating keloid, plantar/palmar fibromatosis, HO, or other benign diseases in their guidelines.
 
Ray D. Ayshun said:
Yeah. In process. Just curious what people have said to healthelp for prior auth should it be rejeacted/require P2P. This could be much ado about nothing. Particularly as AIM and Healthhelp say nothing about treating keloid, plantar/palmar fibromatosis, HO, or other benign diseases in their guidelines.
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Oh, well if that's the case then you should be fine. If they deny just use the lines from EviCore's medical justification bit. Pit one against the other.
 
Ray D. Ayshun said:
Asked this in the business section, so will ask here as well for general input. Any particular insurances problematic/impossible to get rt approved for osteoarthritis?
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I have treated hundreds, maybe a thousand joints by now. Never been denied.
 
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Just called up a patient I treated for Hailey-Hailey last year, 9 months out. Since the treatment, they can’t believe how good their quality of life has been. Have another referral soon. Not a lot of patients, but seems there’s a pocket of them, and they seem to all know each other. I gave 16 Gy / 8 fr EOD.
 
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