Benign Disease

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Ray D. Ayshun said:
Anybody reatreating arthritis a year later? 2 years later? Yearly?
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Of course! This is considered standard of care, if clinical benefit was achieved with the prior course of radiotherapy.

I am not aware of an upper limit. I have treated some with 3-4 courses over years.
 
RickyScott said:
If 5gy is not very harmful for the heart, would be a real problem for protons
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“The Mevion S100GRAND is the newest technology that finally, FINALLY allows for the personalized cancer care Americans deserve. I can treat your breast cancer with high dose and heal your cardiomyopathy with low dose while sparing toxic, unnecessary dose to nearby esophagus that would otherwise occur with x-rays”

Haha I get it now, this is so much easier than running a clinical trial. Took me like 5 minutes on my handheld device!
 
Anyone do the German OA regimen while a patient is getting chemo? He’s getting q2 week 5FU, leucovorin, and antibody
 
grenz said:
Anyone do the German OA regimen while a patient is getting chemo? He’s getting q2 week 5FU, leucovorin, and antibody
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If you would do a chest CT on someone like this

LDRT to the hands eg will be just as safe… or dangerous
 
RealSimulD said:
Haha! I have a few percent getting pain flares and such. Something weird happens and then all around town “that quack Parikh is doing weird ****”
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Pain flare through LDRT is actually a good sign!

You can tell your patients about that. Anecdotally, those with pain flare are the ones that benefit the most, long term.
It‘s a bit like the skin rash from cetuximab for H&N cancer.
 
Palex80 said:
Pain flare through LDRT is actually a good sign!

You can tell your patients about that. Anecdotally, those with pain flare are the ones that benefit the most, long term.
It‘s a bit like the skin rash from cetuximab for H&N cancer.
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I absolutely agree. I tell my patients this as well.

Obviously the plural of "anecdote" is not "data", but at this point, the volume of this observation in my practice is such that I'm trying to figure out a timeline/plan to do some sort of prospective observation trial on it.

I would also expand this to seeing any change at all is a "good" sign. Meaning it doesn't just have to be a pain flare, it could be transient improvement, or alteration in the perception of pain (sharp vs dull etc) - all of that increases my optimism for a particular case.
 
elementaryschooleconomics said:
I absolutely agree. I tell my patients this as well.

Obviously the plural of "anecdote" is not "data", but at this point, the volume of this observation in my practice is such that I'm trying to figure out a timeline/plan to do some sort of prospective observation trial on it.

I would also expand this to seeing any change at all is a "good" sign. Meaning it doesn't just have to be a pain flare, it could be transient improvement, or alteration in the perception of pain (sharp vs dull etc) - all of that increases my optimism for a particular case.
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Is this during the treatment course or after?

Anybody done it for AI-induced joint pain and notice a difference vs standard OA?
 
CaesarRO said:
Is this during the treatment course or after?

Anybody done it for AI-induced joint pain and notice a difference vs standard OA?
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Im really hoping to get a trial off the ground for this, or if there is one in planning somewhere maybe join.

Seems like a no brainer, but I do think a phase II trial would be the way to go given that it is a new indication in theory.
 
CaesarRO said:
Is this during the treatment course or after?

Anybody done it for AI-induced joint pain and notice a difference vs standard OA?
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I've done it for AI-induced joint pain.

The tough part about a trial for AI-induced vs OA would be time. The earlier we get to OA to treat it the better, but we can almost never get to it as early as we can AI-induced joint pain. Hard to control for that variable.
 
OTN said:
I've done it for AI-induced joint pain.

The tough part about a trial for AI-induced vs OA would be time. The earlier we get to OA to treat it the better, but we can almost never get to it as early as we can AI-induced joint pain. Hard to control for that variable.
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I think would be worthwhile evaluating essentially independently of OA. Treat LDRT for AI joint pains like we used to prophylactically radiate mens breast tissue who were going on Bicalutamide.
 
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OTN said:
I've done it for AI-induced joint pain.

The tough part about a trial for AI-induced vs OA would be time. The earlier we get to OA to treat it the better, but we can almost never get to it as early as we can AI-induced joint pain. Hard to control for that variable.
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Yea RT versus sham for AI induced only, separate from OA. The literature I’ve read argues its similar mechanism but it’s a different indication/population for sure.

It would be cool to look at hormone therapy adherence as one of the end points.

Anecdotally I’ve seen a lot of people stop it due to joint pain.
 
Had a Medicare advantage payer ask me for "Medicare guidelines" showing radiation is approved for OA/plantar fasciitis before they would approve it. Anyone run into this and use anything from Medicare to get these treatments approved?
 
WanderingRad3 said:
Had a Medicare advantage payer ask me for "Medicare guidelines" showing radiation is approved for OA/plantar fasciitis before they would approve it. Anyone run into this and use anything from Medicare to get these treatments approved?
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There are no NCDs for any treatment any radiation oncologist in America does for any condition. So they have come up with the stupidest, or smartest, reason ever to deny.
 
WanderingRad3 said:
Had a Medicare advantage payer ask me for "Medicare guidelines" showing radiation is approved for OA/plantar fasciitis before they would approve it. Anyone run into this and use anything from Medicare to get these treatments approved?
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WOW.

That's quite the tactic they're trying out.

Was it the MA payer who asked you, or the benefits manager contracted by the payer?

Regardless, per the Medicare guidelines:

1701957936120.png


Part B covers medically necessary radiation treatments in an outpatient clinic.

At this point in time, I don't believe there is an NCD that specifically says "LDRT for OA is covered". Which would be insane...because Medicare guidelines are not like NCCN guidelines. There are many treatments we give daily that aren't explicitly defined in the guidelines.

Of course, outpatient radiation therapy is obviously covered. So if we (the physicians) think a service is "medically necessary", Medicare should cover it.

Let's look at what they definitely WON'T cover:

1701960997594.png


Here is what I stick to for "medically necessary" arguments:

1) I don't diagnose them with OA/PF myself, they come with an existing diagnosis.
2) This basically always means they've tried and failed at least one, usually multiple other types of treatments.
3) Symptomatic OA/PF that has failed prior lines of therapy = LDRT is medically necessary
4) For things like OA, it's significantly cheaper to do LDRT than a joint replacement (couple thousand dollars with no inpatient stay vs $100,000 and inpatient time, etc)
5) There is a mountain of evidence in the literature to cite

To ask you for proof of Medicare coverage is insane. I would "reverse Uno" them and explain your medical necessity argument...and demand they show you where it's NOT covered in Medicare guidelines.
 
elementaryschooleconomics said:
WOW.

That's quite the tactic they're trying out.

Was it the MA payer who asked you, or the benefits manager contracted by the payer?

Regardless, per the Medicare guidelines:

View attachment 379552

Part B covers medically necessary radiation treatments in an outpatient clinic.

At this point in time, I don't believe there is an NCD that specifically says "LDRT for OA is covered". Which would be insane...because Medicare guidelines are not like NCCN guidelines. There are many treatments we give daily that aren't explicitly defined in the guidelines.

Of course, outpatient radiation therapy is obviously covered. So if we (the physicians) think a service is "medically necessary", Medicare should cover it.

Let's look at what they definitely WON'T cover:

View attachment 379555

Here is what I stick to for "medically necessary" arguments:

1) I don't diagnose them with OA/PF myself, they come with an existing diagnosis.
2) This basically always means they've tried and failed at least one, usually multiple other types of treatments.
3) Symptomatic OA/PF that has failed prior lines of therapy = LDRT is medically necessary
4) For things like OA, it's significantly cheaper to do LDRT than a joint replacement (couple thousand dollars with no inpatient stay vs $100,000 and inpatient time, etc)
5) There is a mountain of evidence in the literature to cite

To ask you for proof of Medicare coverage is insane. I would "reverse Uno" them and explain your medical necessity argument...and demand they show you where it's NOT covered in Medicare guidelines.
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And I forgot to add:

No one should stop at the first appeal, if they deny you. Appeal again. There are 5 levels of Medicare (and MA) appeals - use them.

This is an active "battleground", so to speak. This isn't some treatment some rando sketchy RadOnc cooked up in a run-down shack near Orlando.

In other parts of the world, this has been continuously done for a century. Literally, a century. Tens of thousands of people get LDRT for OA/PF per year. We actually don't know, and I don't want to be hyperbolic, but if we're talking global, it's probably over a hundred thousand people per year now.

Preserving the "linac babysitting laws" won't help the specialty endure. Strongly establishing a method and indication that significantly expands our scope, however, will.

And oh yeah. It gives patients in pain another option, and significantly reduces the economic burden on society (comparing LDRT to joint replacement, long term medications, repeat steroid injections, etc).

But: they're going to fight it. "They" would be, of course, the payers. They're not in the business of medicine, they're in the business of making money. And paying for services means they can't make $50 billion dollars per quarter so...you know, they don't like it.
 
OTN said:
To whom did you market?
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I did no marketing. Started using it with my cancer patients. Those patients spread the word to their other docs, family members, friends.

Now I have consults from PCP's, Orthopods, Pain clinics, self referrals. I had one patient come from over 4 hrs away.
 
SneakyBooger said:
I did no marketing. Started using it with my cancer patients. Those patients spread the word to their other docs, family members, friends.

Now I have consults from PCP's, Orthopods, Pain clinics, self referrals. I had one patient come from over 4 hrs away.
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How late is your center running/how far out are new starts? I gotta say, if OA pushed me into extended hours I’d regret opening the spigot
 
grenz said:
How late is your center running/how far out are new starts? I gotta say, if OA pushed me into extended hours I’d regret opening the spigot
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No late hours. Starts within 5-10 days unless there are insurance approval delays.
 
grenz said:
How late is your center running/how far out are new starts? I gotta say, if OA pushed me into extended hours I’d regret opening the spigot
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whoa your practice must be booming if you are worried about extended hours with OA!
 
They discontinued the main collegenase formulation in Canada a few years ago. Our Dupuytrens numbers are up quite a bit. My colleague sees maybe 2 weekly
 
Palex80 said:
Would that be ethical? I'm not sure. Maybe with a crossover after an early assessment?
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Haha no, I was kidding. This is what people say sometimes about LDRT. I don't think it would be unethical though for a lot of patients as conservative therapy is first line treatment for many of these conditions.

I think that trial is pretty reasonable and a good use of non-inferiority, comparing a less invasive procedure to a more invasive one. Im not sure why they would compare against radiation or why people think this makes radiation less attractive for DC.

I treat patients that prefer LDRT over an injection for arthritis; I've never argued it is better to any referring. It is an alternative.

It would be cool to show superiority of radiotherapy over other procedures, but it seems like our efforts are better spent on awareness right now. It is still true that virtually every referring physician/APP I talk to has never heard of this treatment.
 
thesauce said:
RT is done at an earlier stage in the disease process. Corrective procedures such as collagenase are only used once contracture has set in.
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You are absolutely right.
 
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