Benign Disease

[scarbrtj]

Well here in the US, the neurosurgeons need rad oncs to use the GK.....

I can not give you any web citations; too old. But there was a time that the entire field of neurosurgery was lobbying the govt so strenuously they came in a hair's breadth of not needing radiation oncologists.

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[xrthopeful]

I can not give you any web citations; too old. But there was a time that the entire field of neurosurgery was lobbying the govt so strenuously they came in a hair's breadth of not needing radiation oncologists.

Right and that’s what we need to hope never happens. That’s why I actually see the one silver lining in requiring us to take boards in physics and rad bio. It helps keeps us unique and valuable.

Otherwise one could imagine a future where neurosurgeons planned brain cases and urologists did prostate cases and ENTs did head and neck cases etc. it’s not really that useful at all in day to day practice but ‘understanding radiation’ and proving it in a board exam setting is what keeps us in the game.

Never forget that

 

[SneakyBooger]

aRThritis, vitamin R

"can't say aRThritis without RT"

 

[SneakyBooger]

Can do orthovoltage (for arthritis) without board certification, so for those unfortunate individuals who didn't/don't pass the boards, there might a niche here for you.

Our local derm does more XRT than most departments - they even have a tech come in on weekends and give treatments - no doc on site.

Lets see, what are the downsides: No hospital privileges, treat Medicare only, no follow ups, no call, no prior auth, no MOC, no toxicity, no supervision requirements.

Sounds better than derm.

Somebody tell those residents in Australia!

Hmmmmmm...

 

[scarbrtj]

Can do orthovoltage (for arthritis) without board certification, so for those unfortunate individuals who didn't/don't pass the boards, there might a niche here for you.

Our local derm does more XRT than most departments - they even have a tech come in on weekends and give treatments - no doc on site.

Lets see, what are the downsides: No hospital privileges, treat Medicare only, no follow ups, no call, no prior auth, no MOC, no toxicity, no supervision requirements.

Sounds better than derm.

Somebody tell those residents in Australia!

Hmmmmmm...

When I was last in Australia and browsing through their RANZCR journal, I saw a job advertised for a radiologist in Darwin for $1 million a year. I think the Australians might be doing OK. Don't know about rad onc salaries but did see a lot of jobs advertised for rad onc too.

"Our local derm does more XRT than most departments." This would be my point. I think there is a growing world of "radiation therapy" that's going on out there, completely separate from and under the radar from the radiation oncologists and their sphere of influence. But, you know, radiation oncologists' spheres are great. We have the best spheres. Our spheres are top-notch.

 

[SneakyBooger]

Another (not so) benign disease we might be able to help:

 

[xrthopeful]

I got a murine model only practice


You wouldn’t believe the straight cash I’ve been generating

The wRVUs are so insane they would make a grown man cry

 

[deleted941485]

When I was last in Australia and browsing through their RANZCR journal, I saw a job advertised for a radiologist in Darwin for $1 million a year. I think the Australians might be doing OK. Don't know about rad onc salaries but did see a lot of jobs advertised for rad onc too.

"Our local derm does more XRT than most departments." This would be my point. I think there is a growing world of "radiation therapy" that's going on out there, completely separate from and under the radar from the radiation oncologists and their sphere of influence. But, you know, radiation oncologists' spheres are great. We have the best spheres. Our spheres are top-notch.

Canada radiologists has a similar boom few years back 700K starting salaries in the Alberta metro area. But again the positions fill quite quickly as you’d expect and the boom quickly busted.

 

[SneakyBooger]

I got a murine model only practice

I bet you have some highly cognitive elderly rats!

 

[Palex80]

Well here in the US, the neurosurgeons need rad oncs to use the GK.....

This is the same here too. But people can be "bought" and asked to simply sign stuff, while others do all the work.

 

[Palex80]

Right and that’s what we need to hope never happens. That’s why I actually see the one silver lining in requiring us to take boards in physics and rad bio. It helps keeps us unique and valuable.

Otherwise one could imagine a future where neurosurgeons planned brain cases and urologists did prostate cases and ENTs did head and neck cases etc. it’s not really that useful at all in day to day practice but ‘understanding radiation’ and proving it in a board exam setting is what keeps us in the game.

Never forget that

It has happened in the past. Gynecologists used to do all the RT for gynecologic cancer themselves.

Another example where we may be left out of the loop and ophthalmologists may do all the treatments on their own: wet AMD

StereoTactic radiotherapy for wet Age-Related macular degeneration (STAR): study protocol for a randomised controlled clinical trial - PubMed

International Standard Randomised Controlled Trial Number: ISRCTN12884465. Registered on 28 November 2014. ClinicalTrials.gov: NCT02243878 . Registered on 17 September 2014.

www.ncbi.nlm.nih.gov

And as far as neurosurgery is concerned: There are new machines that make cranial radiotherapy easier and the treatment facility can be a normal office:

https://zapsurgical.com/

(Looks cute, doesn't it?)

 

[xrthopeful]

Well at least the rad oncs have to be ‘bought’ so they still can be kept in loop financially

 

[medgator]

Well at least the rad oncs have to be ‘bought’ so they still can be kept in loop financially

Price based on supply and demand

 

[SneakyBooger]

Price based on supply and demand

Unfortunately, that is a separate and major issue that is outside of the scope of this thread, but point well taken...

 

[SneakyBooger]

Saw my first osteoarthritis consult this week (previously Tx'd for prostate cancer years ago). Insurance approved the request for 5 fractions. Will update you with the results.

 

[scarbrtj]

Saw my first osteoarthritis consult this week (previously Tx'd for prostate cancer years ago). Insurance approved the request for 5 fractions. Will update you with the results.

Good work
@xrthopeful is gonna be rich
But please don't bankrupt the system

 

[Palex80]

Saw my first osteoarthritis consult this week (previously Tx'd for prostate cancer years ago). Insurance approved the request for 5 fractions. Will update you with the results.

One a side note: I've seen a couple of prostate cancer patient claiming their hip arthritis got better when they received RT for their prostate cancer.
It seems that inciddental dose to the hips delivered during prostate RT has an effect...

 

[xrt123]

What insurance? DId it go to peer to peer? To me this is a real potential benefit for some people and would be nice to have some information about how this got approved. Thanks

 

[SneakyBooger]

No peer to peer. Immediately approved for 5 fractions - insurance co. uses Evicore. Our billing dept has identified approximately 30 insurance products that use Evicore.

Not sure what will happen with AIM - need to look into that. @scarbrtj, you are the local expert for insurance coverage, you know if AIM has same criteria?

 

[scarbrtj]

No peer to peer. Immediately approved for 5 fractions - insurance co. uses Evicore. Our billing dept has identified approximately 30 insurance products that use Evicore.

Not sure what will happen with AIM - need to look into that. @scarbrtj, you are the local expert for insurance coverage, you know if AIM has same criteria?

No guarantees but I have never seen them disagree. Evicore is a bit of outlier because they are so exhaustive/comprehensive in their written guidelines. Other companies have radiation guidelines of course but Evicore goes into detail about benign indications.

 

[SneakyBooger]

Arthritis pt #1 has undergone 2 fractions thus far.

Pt wobbled into clinic for 1st fraction with significant knee pain. Could barely walk unassisted.

Yesterday came walking into the clinic for fraction #2 and looked (almost) pain free. I will meet with this pt after final treatment and get more info.

The Northern Europeans might be right.

Saw my 3rd arthritis consult yesterday - this pt was sent by orthopod.

Will keep updated.

 

[taserlaser]

Saw a 80ish patient in follow up. Treated 8Gy/1 several months ago for recurrent spontaneous hemarthrosis of knee, previous TKA. Best 2 months of her life - pain free for first time in 50 years. Back got better too as wasn’t compensating on gait. Had small rebleed after. Asked us to retreat, will see how it goes with another 8.

 

[scarbrtj]

Saw a 80ish patient in follow up. Treated 8Gy/1 several months ago for recurrent spontaneous hemarthrosis of knee, previous TKA. Best 2 months of her life - pain free for first time in 50 years. Back got better too as wasn’t compensating on gait. Had small rebleed after. Asked us to retreat, will see how it goes with another 8.

Amazing how many bad backs are actually not bad backs but bad knees

 

[SneakyBooger]

Seeing a shoulder consult today. Another pt sent by orthopod.

A prostate patient sent his wife for consult and will begin treating her hand next week.

My 1st arthritis pt will be completing treatment to knee today and I will see him after.

 

[OTN]

Seeing a shoulder consult today. Another pt sent by orthopod.

A prostate patient sent his wife for consult and will begin treating her hand next week.

My 1st arthritis pt will be completing treatment to knee today and I will see him after.

What dose/fractionation have you settled on? Targeting/volumes?

 

[taserlaser]

Someone else at my practice was planning a plantar fasciitis as well. But that referral it seems was more patient driven than referring physician as I understand.

 

[SneakyBooger]

What dose/fractionation have you settled on? Targeting/volumes?

60 cGy x 5

 

[SneakyBooger]

My 1st arthritis pt will be completing treatment to knee today and I will see him after.

Pt states his pain was 6/10 prior to RT and 2/10 after. So, he is a happy camper.

He said after his first treatment he was already feeling better and went online looking for used surfboards - he then laughed but stated he was serious.

 

[Krukenberg]

Pt states his pain was 6/10 prior to RT and 2/10 after. So, he is a happy camper.

He said after his first treatment he was already feeling better and went online looking for used surfboards - he then laughed but stated he was serious.

Would be awesome if you could follow up these patients up to a year and report back what kind of durability of pain relief you’re seeing.

With such a fast relief of pain it makes me wonder whether that was the placebo effect at work for that guy.

 

[firewicket]

What do you all think about treating conglomerate lesion in Coal Workers Lung (pneumoconiosis) that are causing near obstruction.
They are PET avid meaning there is an inflammatory component.
I can't find any data on it though, but it seems like it should work as an anti-inflammatory.
Any on have experience?

 

[SneakyBooger]

Update:

All 8 pts that have completed RT for arthritis (thus far) have had relief in pain. One went from 10/10 to 0/10 - however she stated her pain was a 10/10 while pleasantly conversing with me so I take that response with a grain of salt. Most have gone from a 6-7 to 2-3.

I currently have an additional 6 pts undergoing treatment now.

3 pts have requested additional treatment to other painful sites at completion of their current RT.

When I mention the potential benefit of RT for arthritis to pts 80% immediately and without hesitation state they want to proceed.

Treatment sites have included: shoulders, hands, hips, knees, ankles.

I just completed treatment of a lawyer for severe daily arthralgias in 2 joints due to endocrine therapy. Stated pain was having a significant impact on their QOL and ADL. Pt was miserable prior to beginning RT and had minor depression due to pain. At completion of treatment pt informed me they were very skeptical anything would have helped them. Pt was giddy with how much pain had improved with RT. I'm not kidding - giddy. Pt was extremely thankful stating this was the best they had felt since the arthralgias began.

Unlike with cancer treatment, some insurances charge a copay for each treatment. No pt has complained about having to pay a copay.

Placebo? Maybe? But sure seems promising so far.

 

[thecarbonionangle]

Update:

All 8 pts that have completed RT for arthritis (thus far) have had relief in pain. One went from 10/10 to 0/10 - however she stated her pain was a 10/10 while pleasantly conversing with me so I take that response with a grain of salt. Most have gone from a 6-7 to 2-3.

I currently have an additional 6 pts undergoing treatment now.

3 pts have requested additional treatment to other painful sites at completion of their current RT.

When I mention the potential benefit of RT for arthritis to pts 80% immediately and without hesitation state they want to proceed.

Treatment sites have included: shoulders, hands, hips, knees, ankles.

I just completed treatment of a lawyer for severe daily arthralgias in 2 joints due to endocrine therapy. Stated pain was having a significant impact on their QOL and ADL. Pt was miserable prior to beginning RT and had minor depression due to pain. At completion of treatment pt informed me they were very skeptical anything would have helped them. Pt was giddy with how much pain had improved with RT. I'm not kidding - giddy. Pt was extremely thankful stating this was the best they had felt since the arthralgias began.

Unlike with cancer treatment, some insurances charge a copay for each treatment. No pt has complained about having to pay a copay.

Placebo? Maybe? But sure seems promising so far.

What dose/fractionation?

 

[SneakyBooger]

60 x 5 = 300 cGy

 

[Krukenberg]

Have you been getting feedback from referring orthopods?

 

[hockyfan]

60 x 5 = 300 cGy

Seems like most of the data supports 0.5 Gy / fx (although German guidelines allow up to 1 Gy), just curious how you decided on 0.6 Gy?

 

[SneakyBooger]

Have you been getting feedback from referring orthopods?

Not yet but pts haven't seen orthopods in f/u yet.

 

[SneakyBooger]

Seems like most of the data supports 0.5 Gy / fx (although German guidelines allow up to 1 Gy), just curious how you decided on 0.6 Gy?

Compromise between 0.5 - 1.0.

From German POC study:

 

[Krukenberg]

You could write up a nice little series already

 

[evilbooyaa]

Agree with above. Not sure how much non-German data there is. Would be useful to some to show it works in the American population too.

 

[xrt123]

Thanks for updating us on this. It sounds like you have created your own referral base because I am sure if the patient's walk away happy word will spread.

 

[RadOncDoc21]

Awesome stuff SB! You’re our new hope!

 

[SneakyBooger]

This is THE worst case scenario.
Hypofrac
APM
Loss of direct supervision requirement
Residency expansion

Get ready for actual breadlines.

Well, arthritis is a very rewarding area to expand into. The vast majority of patients are begging for something that works and looks like RT is effective for the majority based on my small sample. My partners were skeptical at first (as was I) but are now starting to offer it to their patients after seeing responses in mine. Have had no denials from insurance companies.

A pt with Achilles tendonitis completed this past week. She was as happy as could be. Pain went from 8/10 to 2-3/10 and she no longer had to wear an ankle boot. Said she had already been singing the praises of RT to 30 or so of her friends about how wonderful RT was for her ankle.

 

[radoncgrad2019]

awesome to hear.

remind me of the dose/frac you use?

have you repeated any courses?

 

[SneakyBooger]

60 cGy X 5

No repeats as of yet but expect them to come later as the program matures.

I have had several patients state that it worked so well that they want other joints treated.

 

[radoncgrad2019]

wait so it's only 3 Gy in 5 fractions. whoa.

 

[SneakyBooger]

When my first few patients were seeing me at the end of treatment telling me their pain had improved, some significantly, I would say "Really? Are you sure?" They were certain.

 

[taserlaser]

awesome to hear.

remind me of the dose/frac you use?

have you repeated any courses?

I had a repeat course in a more complicated patient. She really had to beg me for it... she had a TKA and spontaneous hemarthrosis from ages ago and nothing was helping her. The treatment for was for the hémarthrose. She responded excellently for several months, but then relapsed. She got 8 and then 8 Gy though due to the indication not truly being arthritis, though.

 

[mheat3]

When my first few patients were seeing me at the end of treatment telling me their pain had improved, some significantly, I would say "Really? Are you sure?" They were certain.

What insurance mix have you seen for the treated patients? Also any further insight into which ICD to use for billing?

Awesome job doing this!

 

[SneakyBooger]

What insurance mix have you seen for the treated patients? Also any further insight into which ICD to use for billing?

Awesome job doing this!

Medicare and private insurers.

Don't know what ICD is used. We have a small army of "Insurance Specialists" that do all the preauth for us.

 

[Palex80]

When my first few patients were seeing me at the end of treatment telling me their pain had improved, some significantly, I would say "Really? Are you sure?" They were certain.

A "good sign" to predict response to treatment is an increase in pain immediately after the first fraction. This is something many you have seen when treating bone mets too, patients describe more pain after the first fraction which then fades off (some use steroids, there was even a randomized trial a while ago looking into that flare phenomenon).

"More pain" after the first fraction for arthritis treatment can be predictive for a durable response. However it's mostly seen in patients with an inflammatory component.


On a side note:

6 x 0.5 Gy has worked in a patient with atypical pain syndrome of the infraorbital nerve. Patient responded and remained pain-free for 2 years.