Benign Disease
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Although arguably greater cachet when it was ACR Appropriate Use Criteria
I liked this document overall. However, the cancer risk discussion is over the top in my opinion. It would be strengthened with discussion and education of BEIR and ICRP risk modeling and guidance. Specifically, that you cannot really model an individual's cancer risk at all, and you should not even try for exposures less than 25 mSv (their hand example was 13 mSv).
Physicists have done a lot of work on this over decades and it feels a bit like fear mongering when this work is not discussed.
The comment about shielding the testicles in a hip case makes little sense for patients >50 when juxtaposed with the rest of our practices in oncology.
I understand the idea that some may ignore ALARA or the principles of quality radiation planning and delivery because its "only 3 Gy".
But I think some of these folks are missing the "reasonably" part of ALARA.
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Exclusive: She Couldn’t Lift an iPhone, Now She Deadlifts 180 Pounds With Surprise Treatment
There’s a resurgence of interest in the use of a “forgotten” non-invasive treatment for pain due to osteoarthritis, tennis elbow and plantar fasciitis. “I have my life back,” patient says.
www.today.com
I am not convinced of the "risk" of treating the spine unless "someone" knows something they are not telling the rest of us...
Exclusive: She Couldn’t Lift an iPhone, Now She Deadlifts 180 Pounds With Surprise Treatment
There’s a resurgence of interest in the use of a “forgotten” non-invasive treatment for pain due to osteoarthritis, tennis elbow and plantar fasciitis. “I have my life back,” patient says.
I am not convinced of the "risk" of treating the spine unless "someone" knows something they are not telling the rest of us...
I am very skeptical. Every document/white paper that mentions this refers to a paper about treating ankylosing spondylitis with an open field - AP - PA to a dose of 20 Gy in 5 fx, just blasting away probably with cobalt in the 1960s.
We are talking about 3 Gy in 6 Fx with a linear accelerator given qOD to limited fields.
Even though there is no documented 2ndary malignancy in the literature of patients treated with LDRT, for some reason the cabal of "experts" has made spine treatment an unforgiveable sin.
I was definitely treating in the past, but I'm now going to hold off, even though it appears to have same efficacy as other sites.
This plus the 3D volumes .. I don't know. This whole thing is turning so "rad onc". I think I liked it when it was me and Beckta and Mudit and others doing this because it was a cool new treatment to offer. Rather than turn it into whatever it has become with paid training, webinars, lectures, consultancies and guidelines. It's all just made up. The Germans were treating to a point before. I have no idea why we are going nuts trying to "spare medial compartment" blah blah blah. It's 3 Gy in 6 Fx. Don't be cute. Treat the joint and surrounding tissues. Use the old plain film diagrams.
People are doing FLAME boost and ablative pancreas SBRT / hypofrac without paying someone money to learn how to do it. One of the best things about this field is I could read about a technique, email Chris Crane or the Dutch guys who did the microboost study and learn how to do it. No accreditation for this, but now there are people going around accrediting giving a joint 3 Gy? What a world!
Happy Father's Day
Exclusive: She Couldn’t Lift an iPhone, Now She Deadlifts 180 Pounds With Surprise Treatment
There’s a resurgence of interest in the use of a “forgotten” non-invasive treatment for pain due to osteoarthritis, tennis elbow and plantar fasciitis. “I have my life back,” patient says.
I am not convinced of the "risk" of treating the spine unless "someone" knows something they are not telling the rest of us...
Spot on lol.
I would guess if you treated all comers with a prior diagnosis of OA and complaint of pain, hands and knees would have a better efficacy rate than spine. In my experience, spine pain is just a lot more often multifactorial with "non-inflammatory contributions" to the pain. I do offer it, but less often, and sometimes as a last resort with lower expectations of success.
Spine is "numerically riskier" than hands and knees with all the caveats of secondary malignancy modeling, but all of the risk is very low. Its still a reasonable treatment to offer the right patient.
OA researchers are starting to characterize OA phenotypes that may have differential response to treatments. Its an interesting literature, not ready for clinic prime time.
Seems like a better way to personalize treatment than treating isolated joint compartments.
I offer LDRT to all comers in all joints. Spine/shoulders/knees/hands/ankles/hips you name it. Complete nonsense to try and say the spine shouldn't be treated. Is there a lower chance it will work? Seems that way from the data. Is the chance zero? No. However, the chance of side effects or 2nd malignancy is super close to zero, so the therapeutic ratio is significantly in the favor of RT.
I'm not surprised at all that the radonc powers that be overcomplicated this by an order of magnitude. Academic radonc has a massive "forest for the trees" problem and always has.
I'm not surprised at all that the radonc powers that be overcomplicated this by an order of magnitude. Academic radonc has a massive "forest for the trees" problem and always has.
Wasn’t there an academic rad onc that used to tell you RT for OA was “scammy”
I agree with you. What is different in the spine, IMHO, is:
- the range of possible diagnoses is greater than in joints. Osteochondrosis intervertebralis, Disc Protrusion/Herniation, Facet Joint Syndrome, Spondylosis, Spinal Stenosis due to thickened ligaments, ... With many patients having a combination of these pathologies, so that even LDRT may work for one, it won't relieve symptoms caused by others.
- how symptoms may be projected. A pathology at one level can cause symptoms on another level.
But we try stuff empirically or minimal benefit all the time in medicine and even in RadOnc
We give 50-60/5 to unbiopsied lung tumors. We radiate 75% of older women with breast cancer to marginally decrease recurrence. We treat bone mets with RT with zero RCTs against placebo or sham RT.
This is a weird restriction
We give 50-60/5 to unbiopsied lung tumors. We radiate 75% of older women with breast cancer to marginally decrease recurrence. We treat bone mets with RT with zero RCTs against placebo or sham RT.
This is a weird restriction
*We irradiate 😉
The number needed to treat for any benefit for old women with favorable risk breast cancer is in the neighborhood of ten.
The NNT for “spine OA” in my experience is about two.
Also I can’t practically tangibly tell who I help or not with the breast RT, but often I can tell with the spine RT. “Job satisfaction” and all that.
not good examples as a counter argument IMO.
all of these have a benefit, even if marginal in the case of elderly women with breast cancer.
example Palex is talking about is a situation in which there is a question about the nature of the problem, only one of which responds to RT.
Adjuvant RT has no benefit in 8-9 out of the 10 women who get it. I don't know as much about the odds of a response if we indiscriminately irradiated the spines of patients with pain, but I wouldn't be surprised if higher. I'm sure the durability is higher with breast RT, but as Wallnerus said, it's a decently high NNT.
yeah true
but I guess at least I know they have cancer.
idk I dont have a strong opinion on it and I dont see it as a contraindication at all. I have not seen or read directly what was said, but if someone is saying 'have caution in spine' I think it's fine? it's not a rule. its not bad IMO to have some rigor around reporting and guidelines for this. some people wont treat without guidelines or some sort of support from some sort of authority whether it be society support or similar.
all of that coming over the past few years is why so many more people are treating. thats net benefit for patients and for the field. So I dont see it as a bad thing that it's no longer 'rogue' to offer IMO.
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That's the thing, though. Most of them don't (all the **** the wallnerus will post about positive bone marrow biopsies notwithstanding). I say this as i sit here contouring a left breast in a 70 yo who at least had the decency to have triple negative disease (doing 5 fx sib btw.)
Here is their case discussion in the AUC.
I think payors will jump on the exceptional circumstances language and use it to deny approval. I think this table is overly conservative and not in line with the risk modeling principles they use for other anatomic sites.
This is totally the latest example of "rad onc being weird". Not surprising, especially given some of these folks COI, but I do think the frustration with the opining on this specific type of case is valid.
got it thanks.
I get it. but also - I feel like this is focusing one one small part of it when to me the bigger point and victory is that this even exists, when this would have been totally out of the realm of possibilities just a few years ago!
I have looked through the ARS AUC guidelines before. often they will include cases of 'NO' so I am sure they specifically designed this question for a no. I think the no makes all the other 'yeses' stronger.
again I think the net benefit of this document FAR outweighs this one nitpick.
just my opinion.
Also I think some people worry too much. Please come post here if a payer cites th as guidelines to refuse your planned lumbar spine RT
I get it. but also - I feel like this is focusing one one small part of it when to me the bigger point and victory is that this even exists, when this would have been totally out of the realm of possibilities just a few years ago!
I have looked through the ARS AUC guidelines before. often they will include cases of 'NO' so I am sure they specifically designed this question for a no. I think the no makes all the other 'yeses' stronger.
again I think the net benefit of this document FAR outweighs this one nitpick.
just my opinion.
Also I think some people worry too much. Please come post here if a payer cites th as guidelines to refuse your planned lumbar spine RT
It’s less to me issue of getting reimbursed.
If the only national guide line says hell no, I don’t think I’m going to do it.
They just aren’t making an evidence based decision, IMO
I see your point
What radiation guideline writers never seem to realize is that it is very hard to unf*ck a pig. Bringing ankylosing spondylitis into the argument was very porcine.
A patient may very well accept the risk of secondary malignancy, which is probably much lower than the risk of death from NSAIDS.
This part is 100% right. It overall helps us a lot. Lower back was maybe 10% of patients, but there is no shortage of DJD to make up for it. It’s just how hard you want to go. I’m at times overwhelmed by it. I’d way rather see cancer patients.
How about an obese 35 year old who responds a little to corticosteroid and would be eligible for replacement with some weight loss.
Not an uncommon case. I've been sent this patient a few times. Even better for teaching, someone that hasn't tried physical therapy.
I think the AUC is fine and Im not worried about anything. My only real gripe is just like why does rad onc gotta be so weird. Just please stop being weird.
I dont think you need a "no" case. That seems like a weird rad onc thing.
There are other guidelines you can look at to compare to see my opinion of not weird, pain society for steroid injections or rheum for OA.
Wonder if possible to discuss the toxicity of a $100K spine surgery (and recovery time, risks, etc) vs the toxicity of second malignancy risk and hematopoietic risk of $3K spine LDRT. I wonder.
I tell my DCIS patients that the flu is more dangerous than their condition.
Same for most Prostate and favorable breast ca over 70.
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One thing I will put out here is my #1 referring ortho doc says that his best responders are those who had a knee replacement in the past and still have pain. He absolutely loves LDRT.
Interesting. Any case reports/inclusion of patients in trials to support this? This is good to know
Saw her in f/u again recently. Now almost 7 years out and still no pain in the knees.
I don't see an ASTRO thread yet. This is great to see - the reduction in TKA is big.
So is orthovoltage the new SOC?I don't see an ASTRO thread yet. This is great to see - the reduction in TKA is big.
"orthovoltage LDRT (4.5 Gy in 10 fractions)"
I don't see an ASTRO thread yet. This is great to see - the reduction in TKA is big.
Interesting Rx
Have people on here been treating with higher doses than 0.5 Gy x6 or altering the Rx for different clinical considerations?
I sometimes use 6 x 1 Gy for small joints.
Had dinner with the vet rad onc in town and her and her colleagues would either do two fractions of three gray or four of 1.5 gray for dog elbows. Apparently it works well
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Conveniently, using orthovoltage allows non-rad oncs to deliver this treatment right?
Exactly.
And give 10 fx 🙂
And 77280x10
Perhaps ultrasound daily ?
And 77280x10
Perhaps ultrasound daily ?
I wish we could just have some godamn stability in LDRT for OA dosing, especially when data suggesting 1Gy x 6 may not show signal, but 0.05Gy x 6 and 0.5Gy x 6 both seem efficacious.
It’s the whole is this effect real and not placebo thing. Long term followup from another RCT helps with this but is not the most common/standard dosing! Clarifying the biological effect range would be nice. But also if it works it works… 🤷♂️
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Tip: do not look at any reports from, oh, say, the 2010s and earlier, from anywhere on the planet.
