Benign Disease

[Fpg1245]

Inflammation:

Low Dose Radiation Therapy Induces Long-Lasting Reduction of Pain and Immune Modulations in the Peripheral Blood – Interim Analysis of the IMMO-LDRT01 Trial​

Frontiers | Low Dose Radiation Therapy Induces Long-Lasting Reduction of Pain and Immune Modulations in the Peripheral Blood – Interim Analysis of the IMMO-LDRT01 Trial

The treatment of chronic inflammatory and degenerative diseases by low dose radiation therapy (LDRT) is promising especially for patients who were refractory...

doi.org

Low-Dose Radiotherapy Leads to a Systemic Anti-Inflammatory Shift in the Pre-Clinical K/BxN Serum Transfer Model and Reduces Osteoarthritic Pain in Patients​

Frontiers | Low-Dose Radiotherapy Leads to a Systemic Anti-Inflammatory Shift in the Pre-Clinical K/BxN Serum Transfer Model and Reduces Osteoarthritic Pain in Patients

Osteoarthritis (OA) is the leading degenerative joint disease in the western world and leads, if left untreated, to a progressive deterioration of joint func...

doi.org

I already tried pulling these out when trying to expand our foot print in this area. Nobody really was all that enthusiastic or impressed. Had 2 that came through treatment. You’d think with all the OA and RA out there even a small sliver would make it’s way here

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[SneakyBooger]

I already tried pulling these out when trying to expand our foot print in this area. Nobody really was all that enthusiastic or impressed. Had 2 that came through treatment. You’d think with all the OA and RA out there even a small sliver would make it’s way here

Bummer.

I had a PCP call me last week and say, "What did you do to Mr. SoAndSo?" I was thinking "uh oh".

Then he said "His knees are WONDERFUL!"

He asked me to explain LDRT for arthritis to him and his med student and when we were getting off the phone he said "I am going to send you many many patients". The next day he sent 4 consult requests and hasn't stopped since.

I had another discussion with a different PCP several months ago and it ended in a similar manner.

I am seriously considering an arthritis only practice. We'll see how it goes. No prior auth's either.

 

[Fpg1245]

Bummer.

I had a PCP call me last week and say, "What did you do to Mr. SoAndSo?" I was thinking "uh oh".

Then he said "His knees are WONDERFUL!"

He asked me to explain LDRT for arthritis to him and his med student and when we were getting off the phone he said "I am going to send you many many patients". The next day he sent 4 consult requests and hasn't stopped since.

I had another discussion with a different PCP several months ago and it ended in a similar manner.

I am seriously considering an arthritis only practice. We'll see how it goes. No prior auth's either.

I wish there was a better way. Really

 

[SneakyBooger]

I wish there was a better way. Really

Just gotta give it time. It will come.

 

[SneakyBooger]

I just had a patient drive 3 hours across state lines and passing 6 other cancer centers to come for an arthritis consult...

 

[deleted1111261]

I just had a patient drive 3 hours across state lines and passing 6 other cancer centers to come for an arthritis consult...

That is awesome

 

[metallica81788]

Starting buying some billboard space

I'm talking Bucee's and Ron Jon level advertisements

 

[grenz]

Could a few of you guys band together and start collecting the same QoL data (like Simul’s), then publish in PRO or something? I’d feel a lot more comfortable with this if I started seeing American data

 

[elementaryschooleconomics]

Could a few of you guys band together and start collecting the same QoL data (like Simul’s), then publish in PRO or something? I’d feel a lot more comfortable with this if I started seeing American data

Yes.

I would normally say expect more data in 2023, but that might be overly optimistic. Everyone quitting healthcare hasn't exactly sped up the IRB process...

But there are a couple of groups with red-blooded Americans involved.

 

[fiji128]

Could a few of you guys band together and start collecting the same QoL data (like Simul’s), then publish in PRO or something? I’d feel a lot more comfortable with this if I started seeing American data

This is a nice recent review article in the red journal. Hopefully it was published as a prelude to establishing future prospective trails. Have to say that overall I'm also skeptical of all the claims being made in this space but am willing to follow the data.

The Use of Low-Dose Radiation Therapy in Osteoarthritis: A Review​

DEFINE_ME

 

[deleted1111261]

This is a nice recent review article in the red journal. Hopefully it was published as a prelude to establishing future prospective trails. Have to say that overall I'm also skeptical of all the claims being made in this space but am willing to follow the data.

The Use of Low-Dose Radiation Therapy in Osteoarthritis: A Review​

DEFINE_ME

30-40k German patients are treated annually.

The outcomes data is better than much of what we use to actually treat patients. The data is stronger for this than for example PORT for N2 lung cancer.

It is literally atoxic.

It is very inexpensive.

I know the folks moving forward with studies and am somewhat involved, but there will be issues. The one negative RCT basically did everything wrong. All the Dutch had to do was ask the Germans what the intervention arm would be. Instead, they made up their own way to do it.

If you truly have interest, here is how to do it for “free”. Ask an on treatment patient if they want to try it. See if it works.

 

[deleted1111261]

Could a few of you guys band together and start collecting the same QoL data (like Simul’s), then publish in PRO or something? I’d feel a lot more comfortable with this if I started seeing American data

We are collecting data for all the patients

I’ll open source it.

Not giving Elsevier or PRO a penny

 

[fiji128]

This is different then cancer data. I agree that the treatment is atoxic so very little to no clinical downside to treatment.

But... for example it is claimed that "there are strong data to suggest a benefit of LDRT in plantar fasciitis, with about 80% efficacy in pain reduction." Ok plantar fasciitis is caused by micro tears in the plantar aponeurosis due to mechanical stress. Not sure it even has anything to do with inflammation from what I've read. Almost all cases will resolve over 6 to 12 months. So is any of this due to RT effect or just time.

 

[deleted1111261]

This is different then cancer data. I agree that the treatment is atoxic so very little to no clinical downside to treatment.

But... for example it is claimed that "there are strong data to suggest a benefit of LDRT in plantar fasciitis, with about 80% efficacy in pain reduction." Ok plantar fasciitis is caused by micro tears in the plantar aponeurosis due to mechanical stress. Not sure it even has anything to do with inflammation from what I've read. Almost all cases will resolve over 6 to 12 months. So is any of this due to RT effect or just time.

It’s the bone spurs and fibromas I’m treating, not the whole sole of the foot. Cannot fix PF. Can treat the inflamed areas.

Again, there is more to this - I’m not minimizing your concerns - I have been thinking about this for 5 years @OTN is probably the grandfather of this treatment in the States. If you read his posts, he never calls it a panacea or a cure-all. It is in adjunct that may help some patients.

 

[fiji128]

I am by no means writing it off. Would be great if this became a standard of care in PCP and ortho clinics like nsaids, injections, surgery and physical therapy but I think we need a lot more data before these referring docs will embrace it.

 

[TheWallnerus]

This is different then cancer data. I agree that the treatment is atoxic so very little to no clinical downside to treatment.

But... for example it is claimed that "there are strong data to suggest a benefit of LDRT in plantar fasciitis, with about 80% efficacy in pain reduction." Ok plantar fasciitis is caused by micro tears in the plantar aponeurosis due to mechanical stress. Not sure it even has anything to do with inflammation from what I've read. Almost all cases will resolve over 6 to 12 months. So is any of this due to RT effect or just time.

The same could be said for cortisone injections (drug effect vs tincture of time) in the plantar fascia, which the podiatrists do all the time

However as we know there is randomized data that RT is superior to cortisone injections for PF

I also am not sure plantar fasciitis is “caused” by micro-tears at least not in all cases

 

[Sheldor]

Just to throw in another anecdote, my LD-RT arthritis patients have had borderline miraculous responses. Like wheelchair bound to walking around with 0 pain and back to their normal life, pretty incredible.

 

[TheWallnerus]

Just to throw in another anecdote, my LD-RT arthritis patients have had borderline miraculous responses. Like wheelchair bound to walking around with 0 pain and back to their normal life, pretty incredible.

These responses are under-reported to zero-reported in the trials

They’re like “Flowers for Algernon” responses

If I gave an IQ improving serum in a 1000 patient trial and the avg IQ post treatment was 100 in Arm A and 100.5 in Arm B, every rad onc would say “see it clearly does not work”

But if 1 out of 50 patients got an IQ improvement of 50 points, the serum is actually miraculously working… but the people reporting its results are unimaginative dolts

 

[dogjam]

Thanks so much to everyone here for all the great information and guidance. I am planning to start an "arthritis program" here at our center. Seems like a good way to get it going would be with a registry trial. Has anyone done or considered this? Any protocol templates out there that you'd be willing to share? Any thoughts/suggestions as we start this up? Once the registry trial is set up, we would then market to/inform the PCPs in our system.

 

[Sheldor]

These responses are under-reported to zero-reported in the trials

They’re like “Flowers for Algernon” responses

If I gave an IQ improving serum in a 1000 patient trial and the avg IQ post treatment was 100 in Arm A and 100.5 in Arm B, every rad onc would say “see it clearly does not work”

But if 1 out of 50 patients got an IQ improvement of 50 points, the serum is actually miraculously working… but the people reporting its results are unimaginative dolts

It's true, treating arthritis is such a mind set shift from our usual oncologic care that it is actually difficult mentally to adjust to. And sometimes, you'll do it and they wont' get better, and you know what, that's okay! Do you think ortho/pain folks lose sleep when the steroid shot doesn't work for someone? Sometimes its worth trying because 80% effectiveness means 20% won't get better, but 80% will!! Anyway, I actually have multiple "miracles" where they go so much better that it blew my mind. Response tends be somewhat durable too, with significant improvement for 12+ months.

 

[Sheldor]

Thanks so much to everyone here for all the great information and guidance. I am planning to start an "arthritis program" here at our center. Seems like a good way to get it going would be with a registry trial. Has anyone done or considered this? Any protocol templates out there that you'd be willing to share? Any thoughts/suggestions as we start this up? Once the registry trial is set up, we would then market to/inform the PCPs in our system.

I'm curious why you feel the need to do a registry trial? It is approved by insurance as a standard of care treatment (Including evilcare!!) It is a standard of care around the world, notably in Europe another large 1st world nation. Not that I fault you, but isn't this sort of whats wrong with our field? Its 3 Gy over 3 weeks. Standard of care for all insurances. Its like we can't take a good thing when it comes, haha

You think that when they have some new insurance approved steroid shot they do a registry trial down at the pain clinic?

Not to specifically attack your idea Dogjam, I get it, I have the same indoctrination in our field and when I first read your post thought, "oh ya, thats a good idea", but sometimes, isn't okay to just treat the patient with a well established treatment with decades of evidence from around the world?

 

[dogjam]

I hear you and agree re: registry trial being unnecessary, but I'm hospital-employed and think that having patients treated on registry will lend a bit more legitimacy to this endeavor. Plus it's easy to do and will facilitate the "marketing." But I do agree re: broader problems in our field.

 

[xrt123]

Registry trial would be great to go to ortho/PCP and say "Hey look at this. Try sending a patient."

 

[Sheldor]

Registry trial would be great to go to ortho/PCP and say "Hey look at this. Try sending a patient."

I agree, but again, when the pain docs come and speak to us and give talks about some new cool nerve ablation thingy ma bopper that helps with pain, they don't say we are starting a registry trial please send us patients! They say, this is the best thing since sliced bread, send us patients and we will help them because have this crazy cool success rate!! Ortho/PCP are NOT oncolgists, they really don't care about a "registry trial." They just want their patients to feel better.

Remember, this isn't oncology, its arthritis. Maybe some academic PCPs wouldn't send their 85 year old refractory arthritis patients without a trial, but again, seems unnecessary.

We as a field are our own worst enemy sometimes. We have a proven treatment, that works well, with zero side effects, and we still feel the need to prove ourselves, haha

(Again, not attacking, I feel the same urge you do, but just playing devil's advocate)

 

[deleted1111261]

100%

Agree with the statements above. There are some bold people on this forum and nationally trying to help people and having results. “We need more data” as a rallying cry is just not inspiring.

Let’s go out and actually help people.

 

[deleted1111261]

I am by no means writing it off. Would be great if this became a standard of care in PCP and ortho clinics like nsaids, injections, surgery and physical therapy but I think we need a lot more data before these referring docs will embrace it.

What is the evidence for injections ? I have not found much against placebo/no intervention that is randomized. Surgery outcomes for plantar fasciitis are dismal. PT is decent, but the adherence rate to several months of treatment remains low.

 

[metallica81788]

100%

Agree with the statements above. There are some bold people on this forum and nationally trying to help people and having results. “We need more data” as a rallying cry is just not inspiring.

Let’s go out and actually help people.

I've said it before - shooters shoot, surgeons cut

Radoncs... pontificate and self shame? Look for randomized phase 3 data?

 

[TheWallnerus]

I agree, but again, when the pain docs come and speak to us and give talks about some new cool nerve ablation thingy ma bopper that helps with pain, they don't say we are starting a registry trial please send us patients! They say, this is the best thing since sliced bread, send us patients and we will help them because have this crazy cool success rate!! Ortho/PCP are NOT oncolgists, they really don't care about a "registry trial." They just want their patients to feel better.

Remember, this isn't oncology, its arthritis. Maybe some academic PCPs wouldn't send their 85 year old refractory arthritis patients without a trial, but again, seems unnecessary.

We as a field are our own worst enemy sometimes. We have a proven treatment, that works well, with zero side effects, and we still feel the need to prove ourselves, haha

(Again, not attacking, I feel the same urge you do, but just playing devil's advocate)

May I retweet this

In Times Square

 

[Sheldor]

Couple other thoughts since I got all worked up about needing a trial to do a standard of care treatment:

1. Don't rush to go get patients from Ortho/Fam med. You should have a roster of hundreds/thousands of patients that you're seeing in your follow up clinic!! These patients are perfect for you to help: they already know you, aren't scared of radiation, and tend to be in the age group where you wouldn't need to think twice about LD-RT for arthritis. You could probably fill up a lin ac just with patients you already know who have arthritis and metastatic cancer. (Side note, these patients also generally aren't candidates for aggressive interventions like hip replacements since they have metastatic cancer, so they desperately need relief anyway.)
2. If someone has metastatic cancer, we don't think twice about 300 cGy x 10 to their proximal femur, but we need a study to deliver 50 cGy x 6?

Listen to your patients, they will almost always mention their joint pain and/or arthritis and we blow right past. Mention to them that you can help, and then after all their cancer care is complete and things are stable, bring it back up. If they just got 1200 x 5, and you explain exactly how low dose this RT treatment is (Take 25% of just one of your treatments, then divide that by 6!). They'll ask where to sign for their treatment.

Last point, medicare, united, blue cross, evicore all have this as a standard of care for arthritis, when in the past have they rushed to help us out by approving a cutting edge/unproven treatment? Why is evicore easier to convince than radiation oncologists who literally do the treatment? Just some random thoughts.

 

[deleted1111261]

Sticky!!

 

[Ray D. Ayshun]

 

[Fpg1245]

I've said it before - shooters shoot, surgeons cut

Radoncs... pontificate and self shame? Look for randomized phase 3 data?

You have to admit. It’s a pretty pervasive attitude. We learn data at the expense of well everything else. See a modern rad onc residency.

May I retweet this

In Times Square

Yeah I wouldn’t be upset if we started adopting the pain physician mentality. Not in the least.

 

[SneakyBooger]

My goal is to build a strong arthritis program and eventually leave the oncologic care to the next generation. Eventually...

 

[NotMattSpraker]

I'm curious why you feel the need to do a registry trial? It is approved by insurance as a standard of care treatment (Including evilcare!!) It is a standard of care around the world, notably in Europe another large 1st world nation. Not that I fault you, but isn't this sort of whats wrong with our field? Its 3 Gy over 3 weeks. Standard of care for all insurances. Its like we can't take a good thing when it comes, haha

You think that when they have some new insurance approved steroid shot they do a registry trial down at the pain clinic?

Not to specifically attack your idea Dogjam, I get it, I have the same indoctrination in our field and when I first read your post thought, "oh ya, thats a good idea", but sometimes, isn't okay to just treat the patient with a well established treatment with decades of evidence from around the world?

My group decided to start a registry. The motivation was that it's unusual (for the US) and we were interested in tracking outcomes. I'm especially interested because PROs and pain are challenging outcomes to study prospectively, so it's fun to do more of that.

There are other upsides. It formalizes RT as treatment in the "system OA pathway" (employed here, with strong PCP and busy ortho) and we discussed using the project to motivate the system's foundation fundraising. We're also planning some QI studies.

I would have no reservations doing it without a registry though, there is randomized data. This is a standard treatment.

 

[deleted1111261]

Case:

40 yo woman with receptor positive early stage breast cancer s/p appropriate treatment who is now on endocrine therapy.

Her hands hurt terribly. ROM decreased. Hard time opening jars. Suffering.

Any one ever treat this type of joint pain / arthropathy with LD RT? Would you consider it?

 

[radoncftw]

Case:

40 yo woman with receptor positive early stage breast cancer s/p appropriate treatment who is now on endocrine therapy.

Her hands hurt terribly. ROM decreased. Hard time opening jars. Suffering.

Any one ever treat this type of joint pain / arthropathy with LD RT? Would you consider it?

go for it. let us know how it turns out.
would honestly be a win win. you help the patient symptoms and they stay on ET for their cancer.

 

[Palex80]

My colleague treated the painful knees of a glioblastoma patient last year, parallel to the s.o.c. postoperative GBM RT course.
Guess which intervention benefitted the patient most.

 

[Sheldor]

Case:

40 yo woman with receptor positive early stage breast cancer s/p appropriate treatment who is now on endocrine therapy.

Her hands hurt terribly. ROM decreased. Hard time opening jars. Suffering.

Any one ever treat this type of joint pain / arthropathy with LD RT? Would you consider it?

I'll be honest, hands have been one of the hardest things for me to get a response with. I have found that it is extremely important to not try to be too precise with hands because I think the pain can often be related some of the tendon/musculature insertions that are pretty convoluted, so if you do it, I'd go big.

40 years old is tough, in genera this is my thought process:

60+ = No second thought, I'd treat
Metastatic cancer, or Stage III lung/GBM, etc = Treat without a second thought
50+ = Likely treat, would take the whole clinical scenario into account
40+ = I've only treated a couple people this young, tends to be severe scenario where it drastically effects their quality of life, to the point where they can't do the things they enjoy.

If clinically it makes sense but you're worried about her age, could try one hand first, just to see if you get a response, that way if it doesn't help she's had half the radiation exposure.

 

[deleted1111261]

Thanks.

Interesting. Hands is where I’ve had the most success.

Re: field size with hands - I have been treating the whole hand no matter where they point at being the pain spot.

I’m going to reach out to some Germans, too

 

[Palex80]

I’m going to reach out to some Germans, too

You should go visit some!

 

[grenz]

100%

Agree with the statements above. There are some bold people on this forum and nationally trying to help people and having results. “We need more data” as a rallying cry is just not inspiring.

Let’s go out and actually help people.

I hear the urgency, but how long will it be before Evicore starts saying need more randomized data and denies routinely. They track the claims and will notice an uptick. Should start doing RCTs now if you want to still be doing this in 5 years

 

[medgator]

I hear the urgency, but how long will it be before Evicore starts saying need more randomized data and denies routinely. They track the claims and will notice an uptick. Should start doing RCTs now if you want to still be doing this in 5 years

Evilcore doesn't care about data... They have the most capricious guidelines on the planet and will sometimes not even follow NCCN. The focus is on trying to curtail anything expensive as much as possible (igrt, imrt, sbrt in oligomets etc).

Through 2020 many of us routinely had to submit 3D vs IMRT plans on stage 3 lung pts despite the clear IMRT data from rtog 0617. Many people also had prostate SBRT denied during the pandemic in certain high risk pts etc who needed to finish quickly

 

[deleted1111261]

I hear the urgency, but how long will it be before Evicore starts saying need more randomized data and denies routinely. They track the claims and will notice an uptick. Should start doing RCTs now if you want to still be doing this in 5 years

Maybe

But I’d literally have to treat 30-50 to equal cost of 1 prostate sbrt at a hospital based center

 

[medgator]

Maybe

But I’d literally have to treat 30-50 to equal cost of 1 prostate sbrt at a hospital based center

Bingo... Evilcore doesn't generally go after low cost stuff. This is below their radar imo. Like electrons for skin cancer

 

[taserlaser]

Bingo... Evilcore doesn't generally go after low cost stuff. This is below their radar imo. Like electrons for skin cancer

Reimbursement for you US folk is definitely strange. I’m working on a complex 3-site electron plan with custom cutouts right now for a benign skin condition which has sucked a fair amount of therapist resources. I WISH it was better suited for ortho, would have saved so much time…

 

[Palex80]

Reimbursement for you US folk is definitely strange. I’m working on a complex 3-site electron plan with custom cutouts right now for a benign skin condition which has sucked a fair amount of therapist resources. I WISH it was better suited for ortho, would have saved so much time…

What are electrons?

 

[TheWallnerus]

What are electrons?

1/2000th the mass, and 1/2000th the reimbursement, of protons

 

[deleted1111261]

Reimbursement for you US folk is definitely strange. I’m working on a complex 3-site electron plan with custom cutouts right now for a benign skin condition which has sucked a fair amount of therapist resources. I WISH it was better suited for ortho, would have saved so much time…

We have bizarre discussions about IMRT because of reimbursement. I’m friends with Canadian dosi and it’s insane not to consider vmat for bone Mets. Here, you’re a dirtbag

 

[TheWallnerus]

We have bizarre discussions about IMRT because of reimbursement. I’m friends with Canadian dosi and it’s insane not to consider vmat for bone Mets. Here, you’re a dirtbag

Thats Mr. Dirtbag to you, buddy

 

[Sheldor]

Thanks.

Interesting. Hands is where I’ve had the most success.

Re: field size with hands - I have been treating the whole hand no matter where they point at being the pain spot.

I’m going to reach out to some Germans, too

I love that, I actually did my most recent hand patient whole hand and had much better success, may have been thinking too oncologically in my initial patients a while back.

Please report back what you hear from our German colleagues! I'd love to know how routinely they treat people in their 40's, if you have the chance to ask