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[CurbYourExpectations]

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We have 72 months of followup on pf with durable pain relief. Have you really even tried to look through the literature?

Yeah, sorry to offend. Have read through some literature, seems like many negative randomized trials, but good results on retrospective studies. Didn't see the russian trial in full yet, can't seem to find it anywhere online. But glad to see people on here excited about it. I do hope it works out, hopefully the Mayo trial is positive.

 

[TheWallnerus]

Didn't see the russian trial in full yet, can't seem to find it anywhere online

Posted here 😉

 

[NotMattSpraker]

Yeah, sorry to offend. Have read through some literature, seems like many negative randomized trials, but good results on retrospective studies. Didn't see the russian trial in full yet, can't seem to find it anywhere online. But glad to see people on here excited about it. I do hope it works out, hopefully the Mayo trial is positive.

This is just not an accurate way to describe the literature. There are multiple prospective single arm studies that show good effect. There are two negative randomized trials, I wouldn't call that many. There are also evidence based critiques of those trials that make it reasonable to question their validity. Are you aware of "many" more? Maybe I dont know them.

Theres also a whole literature about the biological effects of low dose radiotherapy out of Europe, including LDRT for arthritis, other conditions, and whole body LDRT in radon spas.

There is a lot to learn about LDRT, but I dont see the point of throwing out the entire concept because there is no sham trial.

Id actually argue a sham trial would be a waste of resources given that the risks are so low and the alternative interventions aren't held to the same standard. The excitement around LDRT in my system is that its a new option for patients that need more options.

If you don't believe it, don't offer it.

It just a lot easier to do that on SDN than sitting in front of an 85 year old who is miserable, shots dont work, they aren't eligible for surgery, and their PCP has nothing else to offer them.

 

[CurbYourExpectations]

This is just not an accurate way to describe the literature. There are multiple prospective single arm studies that show good effect. There are two negative randomized trials, I wouldn't call that many. There are also evidence based critiques of those trials that make it reasonable to question their validity. Are you aware of "many" more? Maybe I dont know them.

Theres also a whole literature about the biological effects of low dose radiotherapy out of Europe, including LDRT for arthritis, other conditions, and whole body LDRT in radon spas.

There is a lot to learn about LDRT, but I dont see the point of throwing out the entire concept because there is no sham trial.

Id actually argue a sham trial would be a waste of resources given that the risks are so low and the alternative interventions aren't held to the same standard. The excitement around LDRT in my system is that its a new option for patients that need more options.

If you don't believe it, don't offer it.

It just a lot easier to do that on SDN than sitting in front of an 85 year old who is miserable, shots dont work, they aren't eligible for surgery, and their PCP has nothing else to offer them.

Sorry fair points. The other RCTs showed no difference compared to 0.3gy in 0.05gy fx, but not necessarily not real that's true. I agree if you believe in it then offer it. I am happy that there was a randomized trial that shows benefit, this hasn't been mentioned in any of the reviews I've read so far.

IDK if I agree with there shouldn't be a well done sham trial, even the Russian trial that people are quoting says there needs to be more data. "Although our results provided sufficient evidence in favor of experimental treatment, it is necessary to replicate these findings in other clinical settings. In addition, longer follow-up is required." I am excited to see what the Mayo trial shows.

And I hope you are right and that it is beneficial.

 

[NotMattSpraker]

Sorry to offend.

Fair points. The other RCTs showed no difference compared to 0.3gy in 0.05gy fx, but not necessarily not real that's true. I agree if you believe in it then offer it. I am happy that there was a randomized trial that shows benefit, this hasn't been mentioned in any of the reviews I've read so far.

IDK if I agree with there shouldn't be a well done sham trial, even the Russian trial that people are quoting says there needs to be more data. "Although our results provided sufficient evidence in favor of experimental treatment, it is necessary to replicate these findings in other clinical settings. In addition, longer follow-up is required." I am excited to see what the Mayo trial shows.

Not offended, and reasonable people can disagree on the sham trial question.

I just tend to be pragmatic with my practice. There are negative sham trials of corticosteroid injections but dozens of them are given every day in my system. Id rather offer my patients this treatment than withhold it and feel self-satisfied about like... "evidence based medicine" or something.

 

[TheWallnerus]

Sorry fair points. The other RCTs showed no difference compared to 0.3gy in 0.05gy fx, but not necessarily not real that's true. I agree if you believe in it then offer it. I am happy that there was a randomized trial that shows benefit, this hasn't been mentioned in any of the reviews I've read so far.

IDK if I agree with there shouldn't be a well done sham trial, even the Russian trial that people are quoting says there needs to be more data. "Although our results provided sufficient evidence in favor of experimental treatment, it is necessary to replicate these findings in other clinical settings. In addition, longer follow-up is required." I am excited to see what the Mayo trial shows.

And I hope you are right and that it is beneficial.

There’s gonna have to be an America sham trial for stable reimbursement. BCBS California has policy to not cover LDRT for OA eg.

 

[BobbyHeenan]

There’s gonna have to be an America sham trial for stable reimbursement. BCBS California has policy to not cover LDRT for OA eg.

Pipe dream, but wouldn't CMS and/or linac manufacturers LOVE to fund this study, because surely a course of LDRT is less than a surgery or a lifetime of injections?

Imagine a world where they won't auth a hip or knee replacement until the patient tried a course of LDRT (the way they do for PT).

 

[communitydoc13]

Id actually argue a sham trial would be a waste of resources given that the risks are so low and the alternative interventions aren't held to the same standard.

I'm actually fine participating in healing by placebo. Placebo undoubtedly impacts our effectiveness regarding palliation and may positively impact outcomes like survival.

I agree with @CurbYourExpectations that the data is not strong. There is also the risk of aggressive commoditization of interventions that are pretty much placebo...lots (as in lots) of these...kinda what most people do in the world of wellness.

But for refractory pain in older patients...passes my reasonableness test. Just make the experience damn good for the patient.

 

[NotMattSpraker]

...kinda what most people do in the world of wellness.

True. Or orthopedic surgery.

 

[emt409]

OTOH, as Herman Suit used to say, “There is no clinical indication for even one picogray outside the target volume.” And if one followed the logic that the dose spill outside the joint capsule contributes zero clinical efficacy, protons (which is the most precise radiation currently available, or photon stereotactic precision and accuracy) would actually make imminently more clinical sense than the wide field (aka imprecise) approaches everyone currently uses.

True. Protons make more clinical sense for most situations if we ignore their cost. Better yet, we can send to Mayo Jax for carbon.

 

[communitydoc13]

True. Protons make more clinical sense for most situations if we ignore their cost. Better yet, we can send to Mayo Jax for carbon.

Meh...the body is a highly variable dosimeter when it comes to particles (excluding photons). That intrinsic dosimetric uncertainty may well shrink or destroy our "therapeutic window" right within the target volume while sparing us dose outside of the target.

I think there is more data indicating this phenomenon than the converse (clinically significant reductions in low dose bath) in actual clinical practice.

 

[evilbooyaa]

Actually yes, I have some one THR on beam now.

Why are ppl pretending the MOA is some magical mystery?

It’s just an anti-inflammatory bath.

The more severe the OA, the quicker pain recurs.

Gr 2’s may not ever need a retreatment. Gr 4’s recur in a month or 2.

Maybe weekly or biweekly maintenance is the answer.

I don’t know the optimal regimen yet, but the rad bio is certainly not complicated.

To say that this is the sole and only potential MOA when the people who have done this longer than you and I have been alive don't have the same level of confidence in the MOA at the molecular level, is ignorant hubris.

Why would anti-inflammatory in the joint capsule matter in someone who is s/p THR? They don't even have a joint capsule anymore to warrant the anti-inflammatory response.

I'm a 'believer' in that I offer it, but to have supreme confidence in the MOA as to how it may be helping the patient, is just not backed by our current evidence base. There is a reason the recommended fields for joint OA are broad... even if it's dogma, you'd have to essentially prove that treating smaller focused fields still benefits patients, which no one is actively doing.

 

[evilbooyaa]

Sorry fair points. The other RCTs showed no difference compared to 0.3gy in 0.05gy fx, but not necessarily not real that's true. I agree if you believe in it then offer it. I am happy that there was a randomized trial that shows benefit, this hasn't been mentioned in any of the reviews I've read so far.

IDK if I agree with there shouldn't be a well done sham trial, even the Russian trial that people are quoting says there needs to be more data. "Although our results provided sufficient evidence in favor of experimental treatment, it is necessary to replicate these findings in other clinical settings. In addition, longer follow-up is required." I am excited to see what the Mayo trial shows.

And I hope you are right and that it is beneficial.

Effects of low dose rate radiotherapy on pain relief, performance score, and quality of life in patients with knee osteoarthritis; a double-blind sham-controlled randomized clinical trial - PubMed

Results showed significant pain score improvements and enhanced joint function with no adverse effects. Findings were compared with previous studies, revealing mixed conclusions on low dose radiation therapy (LDRT) efficacy. Mechanistic hypotheses suggest LDRT may modulate inflammatory pathways...

pubmed.ncbi.nlm.nih.gov

Sham-controlled, benefit of 0.5Gy x 6 compared to sham placebo.

Sufficient?

That being said, I do support a Sham-controlled placebo trial in a US population. Of course those who are not in academics are not curious about this, will continue to treat. And that's fine, while we ask the question as to whether this works or not.

Requiring OA patients to undergo LDRT prior to considering joint replacement would be such a dramatic change in paradigm that departments wouldn't know how to treat the patients they were sent.

 

[alwaysbeIMRTing]

True. Protons make more clinical sense for most situations if we ignore their cost.

You misspelled IMRT.
Always be IMRTing.
Almost never be hydrogenioning.

Also good news in terms of IMRT cost! Medicare says they cost the same as a taco bell value menu now.

 

[NotMattSpraker]

Effects of low dose rate radiotherapy on pain relief, performance score, and quality of life in patients with knee osteoarthritis; a double-blind sham-controlled randomized clinical trial - PubMed

Results showed significant pain score improvements and enhanced joint function with no adverse effects. Findings were compared with previous studies, revealing mixed conclusions on low dose radiation therapy (LDRT) efficacy. Mechanistic hypotheses suggest LDRT may modulate inflammatory pathways...

pubmed.ncbi.nlm.nih.gov

Sham-controlled, benefit of 0.5Gy x 6 compared to sham placebo.

Sufficient?

That being said, I do support a Sham-controlled placebo trial in a US population. Of course those who are not in academics are not curious about this, will continue to treat. And that's fine, while we ask the question as to whether this works or not.

Requiring OA patients to undergo LDRT prior to considering joint replacement would be such a dramatic change in paradigm that departments wouldn't know how to treat the patients they were sent.

I am curious.

 

[CurbYourExpectations]

We would need to hire tons of APRTs

 

[radiaterMike]

Also good news in terms of IMRT cost! Medicare says they cost the same as a taco bell value menu now.

IMRT (for many indications) reduces risk of GI toxicity. One can validly argue that the taco bell value menu does the opposite, supporting a higher level of value added care with IMRT.

 

[alwaysbeIMRTing]

Medicare already covers chiropractic in many cases, which is complete quackery.
And now there is this b.s. to expand it even further: https://www.congress.gov/bill/119th-congress/house-bill/539
While payments for legitimate evidence based medicine like radiation for cancer are cut and LDRT for OA is ridiculed as a scam.

Go after the real quackery and harmful products from pharma that basically fund CNN and Fox News at this point. There is lots of it out there. LDRT is anti-inflammatory and works. Leave LDRT alone!

 

[maxxor]

Sometimes I have these quack dreams where I get an old CT scanner and then hire a physicist to design a protocol that does the same dose as an LDRT fraction and then I charge patients cash per “session”.

Is this a dumb idea? Who wants to partner? (In my state, I can buy a CT scanner. No CON problem, as long as it’s owned by a physician. Can’t buy any therapeutic radiation equipment with a multi year CON process).

 

[TheWallnerus]

Sometimes I have these quack dreams where I get an old CT scanner and then hire a physicist to design a protocol that does the same dose as an LDRT fraction and then I charge patients cash per “session”.

Is this a dumb idea? Who wants to partner? (In my state, I can buy a CT scanner. No CON problem, as long as it’s owned by a physician. Can’t buy any therapeutic radiation equipment with a multi year CON process).

State?

 

[alwaysbeIMRTing]

It would probably take over an hour to practically deliver 50 cGy to a knee with a CT scanner and you would probably melt the thing down and get your pants sued off when something goes wrong. Also you definitely aren't targeting only the joint capsule with your dirty, toxic dose bath.

So... yes try this. I would recommend in Mexico.

 

[Palex80]

It would probably take over an hour to practically deliver 50 cGy to a knee with a CT scanner and you would probably melt the thing down and get your pants sued off when something goes wrong. Also you definitely aren't targeting only the joint capsule with your dirty, toxic dose bath.

So... yes try this. I would recommend in Mexico.

There are people out there who know how to perform this

California hospital fined $25,000 for pediatric CT radiation overdose

A California hospital where a 2-year-old child received a massive overdose of radiation during a series of CT scans has been hit with a $25,000 fine by state regulatory authorities, who found that the facility did not follow its own written policies and procedures regarding radiation safety.

www.auntminnie.com

 

[CurbYourExpectations]

Uh yikes

 

[emt409]

Sometimes I have these quack dreams where I get an old CT scanner and then hire a physicist to design a protocol that does the same dose as an LDRT fraction and then I charge patients cash per “session”.

Is this a dumb idea? Who wants to partner? (In my state, I can buy a CT scanner. No CON problem, as long as it’s owned by a physician. Can’t buy any therapeutic radiation equipment with a multi year CON process).

Buy tomo and just say you’re always doing a high dose MVCT?

 

[emt409]

To say that this is the sole and only potential MOA when the people who have done this longer than you and I have been alive don't have the same level of confidence in the MOA at the molecular level, is ignorant hubris.

Why would anti-inflammatory in the joint capsule matter in someone who is s/p THR? They don't even have a joint capsule anymore to warrant the anti-inflammatory response.

I'm a 'believer' in that I offer it, but to have supreme confidence in the MOA as to how it may be helping the patient, is just not backed by our current evidence base. There is a reason the recommended fields for joint OA are broad... even if it's dogma, you'd have to essentially prove that treating smaller focused fields still benefits patients, which no one is actively doing.

I didn’t say it was the only mechanism. This argument is like criticizing someone for saying DNA damage inducing mitotic catastrophe is main MOA RT for cancer. Sure there are other mechanisms, but there is a main one.

Also, unless the capsule is badly diseased, it’s typically repaired and/or heals after an arthroplasty.

And yes, in a post-op setting where that’s not the case, shocking- your CTV could change.

 

[CaesarRO]

And those that have ran a randomized trial on it.

I just want to see one randomized trial show benefit if tens of thousands are going to start getting irradiated in the US. We are never this blind to data in this field, other than this.

Just to pile on a little late in the conversation, but if you look at the evidence for other interventions for arthritis there is precious little RCT data showing a benefit. This includes things like cortisone injections and joint replacements

 

[drowsy12]

 

[Music Man Stan]

Would any of the moderators be willing to move all the talk about Low-Dose XRT for osteoarthritis into the Business of Radiation Oncology private forum? Any outsider who's reading this is really going to either question the integrity of the people in our specialty OR question our ability to understand trial data especially when it relates to pain. Remember fellow oncologists - the placebo effect is incredibly strong in pain trials. We're sounding a lot like chiropractors now...