Benign Disease

[SneakyBooger]

I do dictate in my note that there have been no reports of RT having a detrimental effect on surgical outcomes should the pt ever undergo surgery.

Again, FWIW.

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[Palex80]

I do dictate in my note that there have been no reports of RT having a detrimental effect on surgical outcomes should the pt ever undergo surgery.

Again, FWIW.

As long as you work with low dose RT, it should be no issue.

Occasionaly we do treat Morbus Lederrhose, Dupuytren or even Peyronie. Doses there are higher: 10 x 3 Gy in two series or 7 x 3 Gy in one series. These can doses can potentially affect subsequent surgery.

The same goes for preoperative or postoperative RT for heterotopic ossification prophylaxis. You generally either give preop 1 x 7 Gy or post-op 5 x 3.5 Gy (for instance). Both of these schedules can affect wound healing.

 

[SneakyBooger]

76YO, severe arthritic shoulder pain, 10/10, throbbing, awakens him every night.

Completed RT today. States after 2nd treatment pain was 2/10 and was able to sleep throughout the night without awakening in pain - said this was the first time he has been able to sleep through the night without pain in years. The throbbing is gone.

 

[taserlaser]

Treated a young lady with bad rheumatoid and chronic synovitis of the knee who had failed many biologics. Ortho would have did a total synovectomy and thought her risk of recurrence was very high, and radiation synovectomy wasn’t on the table so trialed 20Gy of external beam. In the end, just caused a flare 2 weeks out, but still early, and will have to wait and see.

 

[theradiator]

76YO, severe arthritic shoulder pain, 10/10, throbbing, awakens him every night.

Completed RT today. States after 2nd treatment pain was 2/10 and was able to sleep throughout the night without awakening in pain - said this was the first time he has been able to sleep through the night without pain in years. The throbbing is gone.

DEFINE_ME

 

[Palex80]

Treated a young lady with bad rheumatoid and chronic synovitis of the knee who had failed many biologics. Ortho would have did a total synovectomy and thought her risk of recurrence was very high, and radiation synovectomy wasn’t on the table so trialed 20Gy of external beam. In the end, just caused a flare 2 weeks out, but still early, and will have to wait and see.

For PVNS we generally give 35/2.5, however there is some literature pointing out that 20 Gy is fine too.

Low-dose external beam radiotherapy as a postoperative treatment for patients with diffuse pigmented villonodular synovitis of the knee: 4 recurrences in 23 patients followed for mean 9 years - PubMed

Postoperative external beam radiotherapy is an effective and acceptable modality to prevent local recurrence and preserve joint function in patients with diffuse PVNS of the knee. Low-dose (20 Gy) radiotherapy appears to be as effective as moderate-dose treatment (around 35 Gy).

www.ncbi.nlm.nih.gov

 

[taserlaser]

For PVNS we generally give 35/2.5, however there is some literature pointing out that 20 Gy is fine too.

Low-dose external beam radiotherapy as a postoperative treatment for patients with diffuse pigmented villonodular synovitis of the knee: 4 recurrences in 23 patients followed for mean 9 years - PubMed

Postoperative external beam radiotherapy is an effective and acceptable modality to prevent local recurrence and preserve joint function in patients with diffuse PVNS of the knee. Low-dose (20 Gy) radiotherapy appears to be as effective as moderate-dose treatment (around 35 Gy).

www.ncbi.nlm.nih.gov

Yeah, I was doing a small lit search when we were deciding a dose. Have tended to do a lot more 40Gy/20 for PVNS. Iirc I found some dosimetry papers showing radiation synovectomy gives a dose to the synovium of about 25 Gy, with responses also showing at about half the dose, so ended up with 20 Gy in context of the PVNS data.

 

[OTN]

DEFINE_ME

According to the Germans, the doses used in this trial (1 Gy per tx) were too high, and their follow-up was too short. German data shows a substantially higher rate of pain control than was identified in this study. Germans have initiated their own clinical trial, so stay tuned.

I've seen 13 patients back so far 1 month after completion of low-dose XRT (3 Gy in 5 fx). and 10 have experienced either partial or complete pain relief. Will continue to report back.

 

[scarbrtj]

If there were a 200 patient trial showing no difference in LC with or without XRT post lumpectomy, wouldn’t mean time to abandon XRT. Translation: a smallish negative trial does little to nothing in changing a standard of care.

 

[Sheldor]

How do you guys bill for this? What ICD 10 are you using? Apparently medicare doesn't cover M codes? Seems like a cool thing to be able to offer.

 

[evilbooyaa]

@SneakyBooger and @OTN can you folks provide some updates on the OA practice?

 

[scarbrtj]

How do you guys bill for this? What ICD 10 are you using? Apparently medicare doesn't cover M codes? Seems like a cool thing to be able to offer.

Are you saying that an ICD-10 dx M code precludes Medicare paying for RT. E.g., plantar fasciitis is an ICD-10 M code for which RT is universally well established, historically paid for... as is Dupuytren's too I believe... is the alternative just use equivalent ICD-9 codes. MOD: perhaps this is better for the "other" forum.

 

[OTN]

@SneakyBooger and @OTN can you folks provide some updates on the OA practice? As a new attending trying to drum up business at my sleepy location I would be interested in hearing an update on this.

I've been offering to my follow-up patients, and I've treated 25+ over the last year. ~80% chance of significant pain improvement and/or decrease in opioid use. No acute or chronic side effects.

I've treated one patient who was referred by one of my follow-ups, but otherwise I haven't been advertising outside of the clinic.

I haven't had a single payer denial.

 

[Ray D. Ayshun]

I've been offering to my follow-up patients, and I've treated 25+ over the last year. ~80% chance of significant pain improvement and/or decrease in opioid use. No acute or chronic side effects.

I've treated one patient who was referred by one of my follow-ups, but otherwise I haven't been advertising outside of the clinic.

I haven't had a single payer denial.

What's the trigger to treat? As in, what do they have to fail before you'd treat, etc?

 

[Krukenberg]

I've been offering to my follow-up patients, and I've treated 25+ over the last year. ~80% chance of significant pain improvement and/or decrease in opioid use. No acute or chronic side effects.

I've treated one patient who was referred by one of my follow-ups, but otherwise I haven't been advertising outside of the clinic.

I haven't had a single payer denial.

Are these patients who aren’t eligible for joint replacements? I’d be worried that you could screw up their chances of getting a replacement if the orthopod balks at replacing an irradiated joint. Their outcomes get tracked and, since it’s elective, they are free to say no to any patient.

 

[evilbooyaa]

Are these patients who aren’t eligible for joint replacements? I’d be worried that you could screw up their chances of getting a replacement if the orthopod balks at replacing an irradiated joint. Their outcomes get tracked and, since it’s elective, they are free to say no to any patient.

Hopefully ortho can understand that a total of ~3Gy is not going to negatively affect their surgery....

Thx for sharing, OTN.

 

[scarbrtj]

Hopefully ortho can understand that a total of ~3Gy is not going to negatively affect their surgery....

Thx for sharing, OTN.

It's almost reasonable to think about counseling such patients to keep that part of their history silent in talking to other non-radiation medicine physicians so they don't get medically inappropriately "radiodiscriminated" against.

 

[Mandelin Rain]

“Now, this will be just our little secret, right?”

 

[Ray D. Ayshun]

Have you had previous radiation therapy?

I had my knee treated one time. I got 6 treatments. I thought they said I got 3 Grays or whatever that is.

I asked if you had previous radiation therapy, not if you've been to a tanning bed.

 

[Krukenberg]

Hopefully ortho can understand that a total of ~3Gy is not going to negatively affect their surgery....

Thx for sharing, OTN.

Is there data for that statement? Hardware failure is a really challenging problem and if I were an orthopedic surgery with a busy OR schedule I would think twice about anyone treated with radiation to the joint

 

[scarbrtj]

I do dictate in my note that there have been no reports of RT having a detrimental effect on surgical outcomes should the pt ever undergo surgery.

Again, FWIW.

Hopefully ortho can understand that a total of ~3Gy is not going to negatively affect their surgery....

Thx for sharing, OTN.

Is there data for that statement? Hardware failure is a really challenging problem and if I were an orthopedic surgery with a busy OR schedule I would think twice about anyone treated with radiation to the joint

If you look at all the German literature, some patients do go on to get their hips/knees done after RT and there's never been a single negative report. However if there were a hardware failure and the patient had received ~3 Gy to the joint, that failure would be wholly ascribed to the RT versus any of the other usual and/or random reasons joints fail. IMHO that'd be predictable, and wrong. In oncological situations where we give ~45-50Gy to a site preop, I'm not sure there's convincing data that such intentional, high dose preop RT leads to worse surgical outcomes than patients who get same-operated on sans RT (but postop RT shows a worser* trend). There's actually good data that doses in the ~3Gy range to the whole body or large parts of the body get completely forgiven... straight from Hall: "Heavily irradiated survivors of accidents in the nuclear industry have been followed for many years; their medical history mirrors that of any aging population. A high incidence of shortened lifespan, early malignancies after a short latency, and rapidly progressing cataracts have not been observed." Finally NASA studies human radiation exposure a lot, and their "musculoskeletal" published guidance on doses in the 1-5 Gy range essentially says there's no data (one way or the other) to show any bad long term effects.

*it's a word

 

[thecarbonionangle]

What diagnosis are people using for arthritis?

on another note, is anybody venturing into cardiac sbrt? Approached your EP guy? Is this being paid for?

 

[OTN]

What diagnosis are people using for arthritis?

on another note, is anybody venturing into cardiac sbrt? Approached your EP guy? Is this being paid for?

I use the standard ICD10 arthritis codes- insurance has never denied. I've treated 30+ patients now in more than a year. 85% rate of improvement, with some incredible success stories. I'm absolutely a believer, and if they keep cutting oncology reimbursement, I know exactly what I'm going to do in the future to stay away from breadlines. I haven't advertised to a single referring physician.

I've done 2 cases of cardiac SBRT. Both were inpatients with very severe refractory VTach, and SBRT worked for them. Highly satisfying, but not reimbursed, as expected. I approached EP in town and asked if they wanted to collaborate, and they said they did. IMO worth establishing referral patterns if (when?) it does get covered down the line.

 

[Ray D. Ayshun]

I use the standard ICD10 arthritis codes- insurance has never denied. I've treated 30+ patients now in more than a year. 85% rate of improvement, with some incredible success stories. I'm absolutely a believer, and if they keep cutting oncology reimbursement, I know exactly what I'm going to do in the future to stay away from breadlines. I haven't advertised to a single referring physician.

I've done 2 cases of cardiac SBRT. Both were inpatients with very severe refractory VTach, and SBRT worked for them. Highly satisfying, but not reimbursed, as expected. I approached EP in town and asked if they wanted to collaborate, and they said they did. IMO worth establishing referral patterns if (when?) it does get covered down the line.

What's the scheme you use again, 0.5 x 6 fx?

 

[Tigerstang]

I use the standard ICD10 arthritis codes- insurance has never denied. I've treated 30+ patients now in more than a year. 85% rate of improvement, with some incredible success stories. I'm absolutely a believer, and if they keep cutting oncology reimbursement, I know exactly what I'm going to do in the future to stay away from breadlines. I haven't advertised to a single referring physician.

I've done 2 cases of cardiac SBRT. Both were inpatients with very severe refractory VTach, and SBRT worked for them. Highly satisfying, but not reimbursed, as expected. I approached EP in town and asked if they wanted to collaborate, and they said they did. IMO worth establishing referral patterns if (when?) it does get covered down the line.

What payers for cardiac? Medicare or private?

 

[OTN]

What's the scheme you use again, 0.5 x 6 fx?

Yep. I've been doing qday, but may switch to QOD as per the Germans.

VTach patients were both older, so Medicare.

 

[thecarbonionangle]

I use the standard ICD10 arthritis codes- insurance has never denied. I've treated 30+ patients now in more than a year. 85% rate of improvement, with some incredible success stories. I'm absolutely a believer, and if they keep cutting oncology reimbursement, I know exactly what I'm going to do in the future to stay away from breadlines. I haven't advertised to a single referring physician.

I've done 2 cases of cardiac SBRT. Both were inpatients with very severe refractory VTach, and SBRT worked for them. Highly satisfying, but not reimbursed, as expected. I approached EP in town and asked if they wanted to collaborate, and they said they did. IMO worth establishing referral patterns if (when?) it does get covered down the line.

So you basically treated the heart for free to already have it established anticipating a code in future? Is there one in works anybody know?

 

[OTN]

So you basically treated the heart for free to already have it established anticipating a code in future? Is there one in works anybody know?

I'm treating now so if the code gets created the referral patterns from EP are already established.

Cliff Robinson is working with the FDA and government to get things moving forward when it comes to the code, from what I've heard.

 

[scarbrtj]

I'm treating now so if the code gets created the referral patterns from EP are already established.

Cliff Robinson is working with the FDA and government to get things moving forward when it comes to the code, from what I've heard.

that Cliff's a real mensch

 

[BobbyHeenan]

Had a self referral today for Dupuytren's after her hand surgeon said don't get radiation., if you need surgery down the road it'll make it harder.

She has early disease, no limited ROM (Tubiana stage N - just a small minor itchy/bothersome palm nodule). There is data to treat I think. Her father apparently had debilitating Dupuytren's in the past requiring surgery (steroid injection refractory).

I'm getting her to see a second hand surgeon, but I actually think reasonable to treat here.

 

[Krukenberg]

Had a self referral today for Dupuytren's after her hand surgeon said don't get radiation., if you need surgery down the road it'll make it harder.

She has early disease, no limited ROM (Tubiana stage N - just a small minor itchy/bothersome palm nodule). There is data to treat I think. Her father apparently had debilitating Dupuytren's in the past requiring surgery (steroid injection refractory).

I'm getting her to see a second hand surgeon, but I actually think reasonable to treat here.

the best data for Dupuytrrns RT is when it’s early stage. Unfortunately the referrals I’ve seen are beyond advanced

 

[scarbrtj]

Had a self referral today for Dupuytren's after her hand surgeon said don't get radiation., if you need surgery down the road it'll make it harder.

She has early disease, no limited ROM (Tubiana stage N - just a small minor itchy/bothersome palm nodule). There is data to treat I think. Her father apparently had debilitating Dupuytren's in the past requiring surgery (steroid injection refractory).

I'm getting her to see a second hand surgeon, but I actually think reasonable to treat here.

John won't mention this

 

[Palex80]

How do you guys bill for this? What ICD 10 are you using? Apparently medicare doesn't cover M codes? Seems like a cool thing to be able to offer.

Use C49.9. Argue that you are inducing a sarcoma anyway, so it's fine to bill for that beforehand.

 

[elementaryschooleconomics]

Use C49.9. Argue that you are inducing a sarcoma anyway, so it's fine to bill for that beforehand.

[Ralph Weichselbaum has entered the chat]

 

[SneakyBooger]

Anybody else doing arthritis yet?

I have seen some amazing responses (and some total lack of responses). Med Onc's, family physicians, internists, orthopods, coworkers are sending me referrals.

Wish I had offered this to patients years ago.

When radiation "oncology" goes bust you will find me in a double wide trailer with an orthovoltage machine on the side of the highway at the entrance to The Villages fixing all kinds of arthritis.

There is no ACO for arthritis and I have seen no rad induced sarcomas over the past couple years or so since I started it.

 

[OTN]

Anybody else doing arthritis yet?

I have seen some amazing responses (and some total lack of responses). Med Onc's, family physicians, internists, orthopods, coworkers are sending me referrals.

Wish I had offered this to patients years ago.

When radiation "oncology" goes bust you will find me in a double wide trailer with an orthovoltage machine on the side of the highway at the entrance to The Villages fixing all kinds of arthritis.

There is no ACO for arthritis and I have seen no rad induced sarcomas over the past couple years or so since I started it.

Yep! I've treated about 30 patients over the last 2 years. 80% response rate. Some complete, most partial response. Zero side effects from treatment. Some patients had tremendous, life-changing relief.

 

[SneakyBooger]

Some patients had tremendous, life-changing relief.

Absolutely! I had 2 of those this week.

 

[elementaryschooleconomics]

Everyone still sticking with 0.5Gy x6? QD or QOD or something else?

 

[OTN]

Everyone still sticking with 0.5Gy x6? QD or QOD or something else?

I'm doing 5 x 60 cGy. I've been doing QD and was going to change if my results weren't as good as the Germans' QOD dosing, but it appears they're pretty similar. Easier for patients and staff to schedule QD.

 

[SneakyBooger]

I am doing 60cGy x 5 QOD

 

[thecarbonionangle]

I am doing 60cGy x 5 QOD

What diagnosis are you using and is this reimbursed same as number of fx?

 

[evilbooyaa]

Anybody else doing arthritis yet?

I have seen some amazing responses (and some total lack of responses). Med Onc's, family physicians, internists, orthopods, coworkers are sending me referrals.

Wish I had offered this to patients years ago.

When radiation "oncology" goes bust you will find me in a double wide trailer with an orthovoltage machine on the side of the highway at the entrance to The Villages fixing all kinds of arthritis.

There is no ACO for arthritis and I have seen no rad induced sarcomas over the past couple years or so since I started it.

I have discussed it with a few local Orthos on patients that have arthritis. I've been met with an amount of 'Oh really?' followed by 'Well I don't know if she's ready for it yet, she's still a candidate for a xxx replacement'. The two patients I can think of where I offered it (but said that I would discuss with their Ortho before I did anything) ended up seeing Ortho for consideration of TKR and a steroid injection, respectively, so not entirely sure what to make of that.

So.... not taking off for sure, and I think I may have to be more established in my practice before I have enough of a follow-up panel to get the first one. I imagine the first one is the hardest (assuming 1st treatment goes well and patient goes back to Ortho with their improvements).

@SneakyBooger and @OTN how long into practice were you guys before you did your first arthritis case?

 

[dieABRdie]

Anybody else doing arthritis yet?

I have seen some amazing responses (and some total lack of responses). Med Onc's, family physicians, internists, orthopods, coworkers are sending me referrals.

Wish I had offered this to patients years ago.

When radiation "oncology" goes bust you will find me in a double wide trailer with an orthovoltage machine on the side of the highway at the entrance to The Villages fixing all kinds of arthritis.

There is no ACO for arthritis and I have seen no rad induced sarcomas over the past couple years or so since I started it.

I almost treated my first patient for this... but it was Rheumatoid rather than Osteo arthritis. Her Rheumatologist scoffed at the idea so I didn't push it. He said "this is not an FDA approved indication."

Anyone know if there's a source I could point to for RT as an "approved" indication for arthritis?

 

[Neuronix]

Anyone know if there's a source I could point to for RT as an "approved" indication for arthritis?

That's not how radiation devices are regulated.

There is an intended use statement for each radiation device. Varian keeps it nice and broad.

https://www.accessdata.fda.gov/cdrh_docs/pdf11/K111106.pdf

"The TrueBeam™ system is intended to provide stereotactic radiosurgery and precision radiotherapy for lesions, tumors, and conditions anywhere in the body where radiation treatment is indicated."

If you want to be more specific detail on how the devices should be utilized, you have to look to all the usual sources (books, journal articles, guidelines, etc). As far as the FDA is concerned, you can use a linac for anything you (a qualified physician) think it's indicated for.

 

[Chartreuse Wombat]

That's not how radiation devices are regulated.

There is an intended use statement for each radiation device. Varian keeps it nice and broad.

https://www.accessdata.fda.gov/cdrh_docs/pdf11/K111106.pdf

"The TrueBeam™ system is intended to provide stereotactic radiosurgery and precision radiotherapy for lesions, tumors, and conditions anywhere in the body where radiation treatment is indicated."

If you want to be more specific detail on how the devices should be utilized, you have to look to all the usual sources (books, journal articles, guidelines, etc). As far as the FDA is concerned, you can use a linac for anything you (a qualified physician) think it's indicated for.

Analogous to "ablation" technologies (HIFU is approved for ablation of prostate tissue-no mention of cancer)

 

[OTN]

I have discussed it with a few local Orthos on patients that have arthritis. I've been met with an amount of 'Oh really?' followed by 'Well I don't know if she's ready for it yet, she's still a candidate for a xxx replacement'. The two patients I can think of where I offered it (but said that I would discuss with their Ortho before I did anything) ended up seeing Ortho for consideration of TKR and a steroid injection, respectively, so not entirely sure what to make of that.

So.... not taking off for sure, and I think I may have to be more established in my practice before I have enough of a follow-up panel to get the first one. I imagine the first one is the hardest (assuming 1st treatment goes well and patient goes back to Ortho with their improvements).

@SneakyBooger and @OTN how long into practice were you guys before you did your first arthritis case?

I was about 7 years in, but would have offered it earlier, had I seen the data.

I've treated about 30 patients now. 85% with pain relief after treatment. Some complete/life changing, most not complete but patients happy with the relief they were able to get.

I've use it to help bridge patients to knee replacement, and that's worked well. I have yet to market to orthopods or rheumatologists and just mentioning it to my follow up patients.

 

[dieABRdie]

I was about 7 years in, but would have offered it earlier, had I seen the data.

I've treated about 30 patients now. 85% with pain relief after treatment. Some complete/life changing, most not complete but patients happy with the relief they were able to get.

I've use it to help bridge patients to knee replacement, and that's worked well. I have yet to market to orthopods or rheumatologists and just mentioning it to my follow up patients.

Thanks!

What diagnosis code do you use?

Any issues with reimbursement?

And any idea how long you are seeing responses for in the patients that do respond?

 

[OTN]

Thanks!

What diagnosis code do you use?

Any issues with reimbursement?

And any idea how long you are seeing responses for in the patients that do respond?

I use whichever arthritis code is appropriate and haven’t had problems with that approach.

No reimbursement issues at all, but conventional RT is cheap.

It usually takes a few weeks for pts to see relief.

 

[elementaryschooleconomics]

No reimbursement issues at all, but conventional RT is cheap.

Cost to society is small, but individual RadOncs can make a decent amount of money?

LET'S REGULATE THEM INTO THE GROUND.

Sincerely,
CMS

 

[OTN]

Cost to society is small, but individual RadOncs can make a decent amount of money?

LET'S REGULATE THEM INTO THE GROUND.

Sincerely,
CMS

The effect seems real enough to me that I think there's a good business model to be made by not taking insurance and just taking direct payments. Joint pain is a huge industry in this overweight country. As long as your marketing budget is many multiples of your machine budget I think you would do very well. Private equity groups: feel free to PM me .