Benign Disease

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OTN said:
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 😉.
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So I have a few patients I treated for other cancers who have been begging me to treat their arthritis. I don’t even know how they heard of this but I guess now I might just start sliding them into the back door.
 
dieABRdie said:
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?
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Medicare has determined low dose radiotherapy is medically necessary. I have the reference around here somewhere - I got it from @scarbrtj some time ago.
 
SneakyBooger said:
Medicare has determined low dose radiotherapy is medically necessary. I have the reference around here somewhere - I got it from @scarbrtj some time ago.
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If you could post I would appreciate it. I'm getting a lot of weird looks.
 
dieABRdie said:
If you could post I would appreciate it. I'm getting a lot of weird looks.
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I don't have the CMS one, but on what I think is the latest update to the Evicore guidelines (September 2020), it starts on page 144 of the PDF:

1619556542296.png


Prior versions had "osteoarthritis" as its own category, but in September 2020 it got lumped into "degenerative skeletal and joint disorders", which is arguably better because it's more broad.

Here's the subsection:

1619556702176.png
 
SneakyBooger said:
Still going strong. Just completed bilateral hands and patient stated the pain response was "amazing" and he is now able to get back to putting up cow fencing.
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How durable are the responses? Anyone try this for DDD
 
Lamount said:
How durable are the responses? Anyone try this for DDD
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Not sure as I release them after the 1st f/u. However, I routinely have patients send their family members and friends for treatment.

(EDIT) I should probably add - there are many patients whom I had seen longer term up until CoVid hit. Most responders reported continued pain response on followup. I have had many patients who did not respond initially undergo a 2nd course and the majority of those did respond thereafter.
 
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Lamount said:
Degenerative disk disease.
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Gotcha.

I haven't used XRT on the spine as I haven't seen any literature on spinal low dose RT.

One of my partners treated a patient to the spine and it was not effective.
 
SneakyBooger said:
Gotcha.

I haven't used XRT on the spine as I haven't seen any literature on spinal low dose RT.

One of my partners treated a patient to the spine and it was not effective.
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My mother-in-law (about age 74) had severe low back pain for many years. Was highly encouraged to proceed forward with surgery for about 2 years by her orthopedic surgeon. Her X-rays and CT scan looked a little gnarly with poor alignment, etc. My read of the literature is that much of this low back pain can be termed "osteoarthritis." As a lark, I told her: why not try 5 fractions of 0.7 Gy to the L-spine and if it doesn't work then go get the surgery. She was pretty skeptical, as was I, but we went for it. Insurance paid btw.

Fast forward 1.5 years. She never got the surgery. Back felt much better within weeks of tx. Has since taken care of one grandbaby, lifting in and out of crib multiple times daily etc etc. Some low back pain returning over last couple months. Surgeon again recommending surgery. She wants to come back to me for RT. I will probably be re-treating her next month. Only back I have ever treated.

euQ5pOi.jpg
 
TheWallnerus said:
My mother-in-law (about age 74) had severe low back pain for many years. Was highly encouraged to proceed forward with surgery for about 2 years by her orthopedic surgeon. Her X-rays and CT scan looked a little gnarly with poor alignment, etc. My read of the literature is that much of this low back pain can be termed "osteoarthritis." As a lark, I told her: why not try 5 fractions of 0.7 Gy to the L-spine and if it doesn't work then go get the surgery. She was pretty skeptical, as was I, but we went for it. Insurance paid btw.

Fast forward 1.5 years. She never got the surgery. Back felt much better within weeks of tx. Has since taken care of one grandbaby, lifting in and out of crib multiple times daily etc etc. Some low back pain returning over last couple months. Surgeon again recommending surgery. She wants to come back to me for RT. I will probably be re-treating her next month. Only back I have ever treated.

euQ5pOi.jpg
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Hmmm this is fascinating. I've tried to dig into the (German) literature about osteoarthritis but also haven't seen much/anything about DDD or things in the spine in general, guess I need to read more.
 
TheWallnerus said:
My mother-in-law (about age 74) had severe low back pain for many years. Was highly encouraged to proceed forward with surgery for about 2 years by her orthopedic surgeon. Her X-rays and CT scan looked a little gnarly with poor alignment, etc. My read of the literature is that much of this low back pain can be termed "osteoarthritis." As a lark, I told her: why not try 5 fractions of 0.7 Gy to the L-spine and if it doesn't work then go get the surgery. She was pretty skeptical, as was I, but we went for it. Insurance paid btw.

Fast forward 1.5 years. She never got the surgery. Back felt much better within weeks of tx. Has since taken care of one grandbaby, lifting in and out of crib multiple times daily etc etc. Some low back pain returning over last couple months. Surgeon again recommending surgery. She wants to come back to me for RT. I will probably be re-treating her next month. Only back I have ever treated.

euQ5pOi.jpg
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Great to know! Thank you my friend.
 
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Today 3 patients stated they wanted to have LDRT for arthritis.

One breast cancer patient approached me as I ended our routine breast f/u and asked if I was still doing LDRT for arthritis. I was almost out the door when she did so. She said one of her friends, also a patient of mine, had described her favorable response. So I went back in to discuss it and she starts next week.

The word is getting out.
 
Yesterday one of the busiest family practitioners in town called. Said a patient recently underwent LDRT for arthritis of the hands and had an excellent response. They wanted to know more about LDRT for arthritis. They ended by saying, "I have a lot of patients to send you".

The word is getting out more and more...
 
SneakyBooger said:
Yesterday one of the busiest family practitioners in town called. Said a patient recently underwent LDRT for arthritis of the hands and had an excellent response. They wanted to know more about LDRT for arthritis. They ended by saying, "I have a lot of patients to send you".

The word is getting out more and more...
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That’s really cool. What sort of data/protocols do they use for this. I currently have zero such patients. Just got done talking to cards about refractory Vfib vtach. They like it but haven’t treated one.
 
SneakyBooger said:
Yesterday one of the busiest family practitioners in town called. Said a patient recently underwent LDRT for arthritis of the hands and had an excellent response. They wanted to know more about LDRT for arthritis. They ended by saying, "I have a lot of patients to send you".

The word is getting out more and more...
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Keep this to yourself. Now 5 new programs are gonna open.
 
getting the ball rolling on my first arthritis patient. A shoulder and hip. Was hoping to just do a bunch of knees but gotta start somewhere. Sre those of you treating this doing 2D plans and prescribing to midline, making a volume, 3D plans?

Reposting this in business thread...
 
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Ray D. Ayshun said:
getting the ball rolling on my first arthritis patient. A shoulder and hip. Was hoping to just do a bunch of knees but gotta start somewhere. Sre those of you treating this doing 2D plans and prescribing to midline, making a volume, 3D plans?

Reposting this in business thread...
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You might also want to consider the evidence behind these treatments is thin and unfavorable when done as an RCT. How are you convincing referring’s this is legit therapy?

reader.elsevier.com

Lack of beneficial effects of low-dose radiation therapy on hand osteoarthritis symptoms and inflammation: a randomised, blinded, sham-controlled trial

Low-dose radiation therapy (LDRT) is widely used as treatment for osteoarthritis (OA) in some countries, while relatively unknown in others. Systemati…
reader.elsevier.com reader.elsevier.com

 
Fpg1245 said:
You might also want to consider the evidence behind these treatments is thin and unfavorable when done as an RCT. How are you convincing referring’s this is legit therapy?

reader.elsevier.com

Lack of beneficial effects of low-dose radiation therapy on hand osteoarthritis symptoms and inflammation: a randomised, blinded, sham-controlled trial

Low-dose radiation therapy (LDRT) is widely used as treatment for osteoarthritis (OA) in some countries, while relatively unknown in others. Systemati…
reader.elsevier.com reader.elsevier.com

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That RCT used doses which were 2x higher than those used in Germany, so it's unfortunately not applicable to the German arthritis regimen. One can SAY that 6 Gy in 6 fractions QOD should work as well as 3 Gy in 5 fx QOD, but we don't really know. So, the Swiss data was an RCT of the Swiss regimen, not the preferred German one.
 
Fpg1245 said:
You might also want to consider the evidence behind these treatments is thin and unfavorable when done as an RCT. How are you convincing referring’s this is legit therapy?

reader.elsevier.com

Lack of beneficial effects of low-dose radiation therapy on hand osteoarthritis symptoms and inflammation: a randomised, blinded, sham-controlled trial

Low-dose radiation therapy (LDRT) is widely used as treatment for osteoarthritis (OA) in some countries, while relatively unknown in others. Systemati…
reader.elsevier.com reader.elsevier.com

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I have considered it. Even in that trial, 30% of the participants saw an improvement. Also, there's this:
I'm honest with my patients about the prospects. They're at their wits end. If 60-90% of Europeans are subjectively feeling less pain I'm not gonna argue that objectively they aren't. That's absurd. Might want to consider what pain actually is...
 
Ray D. Ayshun said:
I have considered it. Even in that trial, 30% of the participants saw an improvement. Also, there's this:
I'm honest with my patients about the prospects. They're at their wits end. If 60-90% of Europeans are subjectively feeling less pain I'm not gonna argue that objectively they aren't. That's absurd. Might want to consider what pain actually is...
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Additionally, data shows the placebo effect for pain can be as high as 60%. German arthritis data, and my own internal data, shows a pain improvement rate of 85%.

I've had some very skeptical patients who ended up with a lot of relief, which is always a good sign. I'm a believer.
 
OTN said:
Additionally, data shows the placebo effect for pain can be as high as 60%. German arthritis data, and my own internal data, shows a pain improvement rate of 85%.

I've had some very skeptical patients who ended up with a lot of relief, which is always a good sign. I'm a believer.
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Alright it’s mostly internal data collected, opinions on the nature of pain, and anecdote. I really really don’t want to be a skeptic but I need to go to my referring with something stronger than this.
 
Fpg1245 said:
Alright it’s mostly internal data collected, opinions on the nature of pain, and anecdote. I really really don’t want to be a skeptic but I need to go to my referring with something stronger than this.
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I hear you. It's all we have right now, unfortunately. If you go to them with the red journal article and German data, that might be enough. The nice thing about this low-dose RT is that the chance of harm to the patient is as close to zero as we can get in medicine, and the treatment is cheap compared with other forms of joint pain treatment.

RCTs are being performed in Germany, as they have an actual functioning group of academic radiation oncologists who are asking good clinical questions. Stay tuned.
 
Fpg1245 said:
You made my day with functional academic radiation oncologists.
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I'm not sure how others started, but I had no luck with discussing this with referring docs. I did that partly to see if they'd send me anyone, and partly to let them know I'm gonna do it in the long run regardless. I didn't tell Ortho the trial evidence isn't great in supporting joint injections, though rt is perhaps mechanistically similar, which I did tell them. In any case, I'm now mentioning this to my patients, and honest about the controversies. My patients have said essentially, "well I have nothing to lose and lots to gain." After I do 10 patients (preferably shoulders, hips and knees, and not hands like the trial you posted), I'll reassess, and go no further if I'm not helping, placebo or not. I am quantifying things with a vas score, and more simply, an, are you happy you did it? If anything, the way I'm explaining this to them up front, gives them permission to say it did nothing. If the first ten look good, that's the data I'll take back to primary care.
 
Ray D. Ayshun said:
I'm not sure how others started, but I had no luck with discussing this with referring docs. I did that partly to see if they'd send me anyone, and partly to let them know I'm gonna do it in the long run regardless. I didn't tell Ortho the trial evidence isn't great in supporting joint injections, though rt is perhaps mechanistically similar, which I did tell them. In any case, I'm now mentioning this to my patients, and honest about the controversies. My patients have said essentially, "well I have nothing to lose and lots to gain." After I do 10 patients (preferably shoulders, hips and knees, and not hands like the trial you posted), I'll reassess, and go no further if I'm not helping, placebo or not. I am quantifying things with a vas score, and more simply, an, are you happy you did it? If anything, the way I'm explaining this to them up front, gives them permission to say it did nothing. If the first ten look good, that's the data I'll take back to primary care.
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I mean that’s an honest approach and really when you step back and compare to other treatments utilized by orthos and other specialties and what not…We definitely hold ourselves to a higher evidence bar
 
Ray D. Ayshun said:
I'm not sure how others started, but I had no luck with discussing this with referring docs. I did that partly to see if they'd send me anyone, and partly to let them know I'm gonna do it in the long run regardless. I didn't tell Ortho the trial evidence isn't great in supporting joint injections, though rt is perhaps mechanistically similar, which I did tell them. In any case, I'm now mentioning this to my patients, and honest about the controversies. My patients have said essentially, "well I have nothing to lose and lots to gain." After I do 10 patients (preferably shoulders, hips and knees, and not hands like the trial you posted), I'll reassess, and go no further if I'm not helping, placebo or not. I am quantifying things with a vas score, and more simply, an, are you happy you did it? If anything, the way I'm explaining this to them up front, gives them permission to say it did nothing. If the first ten look good, that's the data I'll take back to primary care.
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I also haven't had much luck with referring docs, but I think that's because I was going to ortho/rheum/pain management. They're not interested in other treatments as much, naturally. I've only been talking with my follow-ups, but I've been able to treat about 50 of them and a handful of their family and friends who wanted the treatment after seeing the benefit.

I'm going to try primary care next. I think there will be some low-hanging fruit there.

I also agree about the strength of the data here being at least as strong as data for other treatments. This isn't oncology. Big difference.
 
How long until a proton paper on this shows up? Many are saying it! “Low dose bath”? They got something for that!
 
OTN said:
I also haven't had much luck with referring docs, but I think that's because I was going to ortho/rheum/pain management.
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Rheums (for the most part) performed the randomized knee OA trial … which was negative 🙂
 
pubmed.ncbi.nlm.nih.gov

Low-dose radiation therapy for hand osteoarthritis: shaking hands again? - PubMed

LDRT appears to be safe and useful for HOA and is associated with good rates of pain relief and functionality improvements. However, further studies are necessary to confirm these promising results.
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov

Prospective Spanish study showing 100 patients with hand OA with 94% reporting pain improvement… hard to think this is placebo
 
I just casually ask my follow-up patients (and their family members). I haven't been aggressively pursuing this at the moment because I'm pretty busy with our "regular" patients, but even just half-hearted "hey you wanna try this" captures patients easily.

What I've discovered: there's a tremendous number of older folks out there who aren't getting much relief from medications and/or injections, and have been told their "only" option is joint replacement. Giving them a third option, without 18 Phase III RCTs and 30 years of data but also without really any risk/side effects, is an option many are eager to try.
 
I haven't really started yet but I'm pitching the idea to some of my older follow ups.

Not putting up a billboard or even talking with orthos yet, I'd rather try on a cohort of my own patients and see how it goes. I'm not trying to have massive amounts of new patients beating down the doors.
 
hookem19 said:
pubmed.ncbi.nlm.nih.gov

Low-dose radiation therapy for hand osteoarthritis: shaking hands again? - PubMed

LDRT appears to be safe and useful for HOA and is associated with good rates of pain relief and functionality improvements. However, further studies are necessary to confirm these promising results.
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov

Prospective Spanish study showing 100 patients with hand OA with 94% reporting pain improvement… hard to think this is placebo
Click to expand...
Promising but hypothesis forming. Procedures are a powerful placebo. In the Urolift trial vast majority had a response to sham (though less then active arm)

Should be an easy trial to accrue for though. Everyone has osteo. Meds suck/don’t work.
 
OTN said:
Additionally, data shows the placebo effect for pain can be as high as 60%. German arthritis data, and my own internal data, shows a pain improvement rate of 85%.

I've had some very skeptical patients who ended up with a lot of relief, which is always a good sign. I'm a believer.
Click to expand...

I agree. I was the most skeptical of its benefits but truly see some great improvement. The downside is minimal and it is life-changing some of the time.
 
Hand osteoarthritis is the lowest hanging fruit, in my humble opinion.
These patients generally suffer for years and treating hands is easier to sell to anyone (patients and other physicians) than a major joint.

You can use photons, one beam 6-MV with a bolus.
If you have an orthovoltage machine, treating from each side with 0.5 Gy works well too, you get about 0.5 Gy in the middle of the joint too (depending on how thick the fingers are and how much kV your machine can deliver, you may need to add/substract a bit of dose).
 
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