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madchemist89 said:
I have tried boswellia a few times, and it has never seemed to work. I question the quality of any data backing it.
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A colleague told me the same, but she had been using lower doses (1200 mg/d). Maybe it's a dose issue?
 
madchemist89 said:
I have tried boswellia a few times, and it has never seemed to work. I question the quality of any data backing it.
Click to expand...

I have been using it in combo with steroids. I have had good patient tolerance of it. Some patients that have imaging edema and are minimally or asymptomatic I've used it as solo therapy and some have improved, but whether that's just a test-of-time effect or the boswellia I don't know.

I would not at this point use it as monotherapy for a truly symptomatic patient.

Make no mistake though, it's not rapid success like bev.
 
Anybody else just google what the hell boswellia is? People are really substituting this for steroids?

What's next, Reiki energy rings?

Even ivermectin has legitimate mechanisms and data in vitro. I have a patient on active surveillance taking it whose PSA is now 7 after originally presenting with a PSA of 15. I don't have another explanation for why. But it's fashionable to hate on the horse drug while simultaneously extoling the benefits of marijuana and adderall as the pinnacle of real medicine (the fact they make you high definitely has nothing to do with it). People are dumb, especially people who use reddit.
 
alwaysbeIMRTing said:
Anybody else just google what the hell boswellia is? People are really substituting this for steroids?

What's next, Reiki energy rings?

Even ivermectin has legitimate mechanisms and data in vitro. I have a patient on active surveillance taking it whose PSA is now 7 after originally presenting with a PSA of 15. I don't have another explanation for why. But it's fashionable to hate on the horse drug while simultaneously extoling the benefits of marijuana and adderall as the pinnacle of real medicine (the fact they make you high definitely has nothing to do with it). People are dumb, especially people who use reddit.
Click to expand...

I use Reddit 😞
 
There are some studies on this (not large by any measure, or cooperative group, or multi-institutional) ...

pubmed.ncbi.nlm.nih.gov

Boswellia serrata acts on cerebral edema in patients irradiated for brain tumors: a prospective, randomized, placebo-controlled, double-blind pilot trial - PubMed

BS significantly reduced cerebral edema measured by MRI in the study population. BS could potentially be steroid-sparing for patients receiving brain irradiation. Our findings will need to be further validated in larger studies.
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov

may reduce inflammation after stroke ... Functional improvement and immune-inflammatory cytokines profile of ischaemic stroke patients after treatment with boswellic acids: a randomized, double-blind, placebo-controlled, pilot trial - PubMed

may help after TBI (not total body irradiation) ... Boswellia serrata extract shows cognitive benefits in a double-blind, randomized, placebo-controlled pilot clinical trial in individuals who suffered traumatic brain injury - PubMed ... Effect of a Boswellia and Ginger Mixture on the Memory Dysfunction of the Mild Traumatic Brain Injury Patients: A Randomized, Double-Blind Controlled Trial - PubMed
 
pubmed.ncbi.nlm.nih.gov

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 pubmed.ncbi.nlm.nih.gov
Chartreuse Wombat said:
It's all a simulation...
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While we are ruminating on quality of data, unsubstantiated interventions, etc...

What are we referencing above? I am unwilling to spend $60+ to evaluate the full article from this particular publication, but the abstract could be AI generated....no reference to sample size, every desirable endpoint validated with an exceptionally good p value? This is the wake of a single blind trial comparing 3Gy to 0.3 Gy and showing no differences.

Regardless...the potential harm done has to always be considered. Data is often weak. I'll never diss Reiki (unless it's used as a substitute for a proven effective intervention) as I can't imaging anyone doing harm with it. Low dose XRT isn't quite harmless, but in an elderly person it's close.

Boswellia in lieu of steroids? I think sourcing probably important. Probably not very toxic (and yes, long term steroids are substantially dangerous, I have witnessed both psychosis and terrible gastritis with relatively short durations) but hard to know exactly what you are giving.
 
communitydoc13 said:
I'll never diss Reiki (unless it's used as a substitute for a proven effective intervention) as I can't imaging anyone doing harm with it.
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The problem I have with physically harmless "woo" quackery is that it scams the intellectually vulnerable and gullible out of their financial resources and more importantly wastes time and guides them away from treatments that actually work. I have had multiple patients with curative cancers go to Mexico for high dose vitamin C then re-present a year later for palliative radiation to their widespread mets.

Reiki and energy healing is 100% bs. I have known MDs that do it and it is 100% done to generate cash on the side to fund their lifestyle of Bentley, Prada, etc. Ms Cleo call-me-now from 1990s late night tv ads is more legitimate.
 
Palex80 said:
So, which formulation of Boswellia is good, based on your experience?
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Target is 4000-4200 mg per day in divided doses. The key point is that supplements are not regulated like pharmaceuticals, quality control is "voluntary". Your patient can order Bos capsules off Amazon and they may be 0% boswellia and all of that is totally legal. There is also a counterfeit market that follows trends, so if this supplement "seems" popular in the mainstream world, the quality issue will get a lot worse.

Josh Palmer has two really nice patient hand outs with a pill option and a powder option. If you reach out, he will send them to you. I was using the NOW brand 500 mg capsules, but its just a lot of pills for most patients. Evan didn't seem to understand my point there I guess, but I struggle to get people to take 8-9 pills a day on top of their other medications.

I will switch to the Palmer recommendation that is 1200 mg per capsule, from TNVitamins, looks like a high quality formulation on my review.

I dont really understand why he attacked me. I would not use this in an acute setting where a patient has life threatening or significant symptoms from RN. The way I use this most is to get people off chronic steroids. It is beyond absurd for our open access ASTRO journal to ponder if Bos should be "first line" when they are tweeting about a frickin case report. That was the point of my original tweet.

I prescribed it the other day for someone who has mild RN symptoms with some edema on MRI. Tried steroids, symptoms improved, but didnt like them, so now just living a less quality life. Great use of Boswellia there in my opinion.
 
I have also had patients use the NOW brand. It is a lot of pills. At one point, I was also recommending oral probiotic for head and neck patients based on a phase 3 trial from JCO, but no luck in my clinic there either.
 
NotMattSpraker said:
Target is 4000-4200 mg per day in divided doses. The key point is that supplements are not regulated like pharmaceuticals, quality control is "voluntary". Your patient can order Bos capsules off Amazon and they may be 0% boswellia and all of that is totally legal. There is also a counterfeit market that follows trends, so if this supplement "seems" popular in the mainstream world, the quality issue will get a lot worse.

Josh Palmer has two really nice patient hand outs with a pill option and a powder option. If you reach out, he will send them to you. I was using the NOW brand 500 mg capsules, but its just a lot of pills for most patients. Evan didn't seem to understand my point there I guess, but I struggle to get people to take 8-9 pills a day on top of their other medications.

I will switch to the Palmer recommendation that is 1200 mg per capsule, from TNVitamins, looks like a high quality formulation on my review.

I dont really understand why he attacked me. I would not use this in an acute setting where a patient has life threatening or significant symptoms from RN. The way I use this most is to get people off chronic steroids. It is beyond absurd for our open access ASTRO journal to ponder if Bos should be "first line" when they are tweeting about a frickin case report. That was the point of my original tweet.

I prescribed it the other day for someone who has mild RN symptoms with some edema on MRI. Tried steroids, symptoms improved, but didnt like them, so now just living a less quality life. Great use of Boswellia there in my opinion.
Click to expand...

This has been my exact strategy/experience.

That TN Vitamins brand is also available on Amazon and I literally just help patients order it on the app. Sometimes patients grand kids order it instead if not smart phone savvy and in those cases I just print out a screen shot on amazon.
 
communitydoc13 said:
long term steroids are substantially dangerous, I have witnessed both psychosis
Click to expand...
IMG_3107.jpeg
 
madchemist89 said:
I have also had patients use the NOW brand. It is a lot of pills. At one point, I was also recommending oral probiotic for head and neck patients based on a phase 3 trial from JCO, but no luck in my clinic there either.
Click to expand...

NOW is a really good brand overall.

BobbyHeenan said:
That TN Vitamins brand is also available on Amazon and I literally just help patients order it on the app. Sometimes patients grand kids order it instead if not smart phone savvy and in those cases I just print out a screen shot on amazon.
Click to expand...

I think amazon is okay if it is the company's amazon store and you know for sure its coming from them. I like iherb.com as well, they often have good prices.
 
NotMattSpraker said:
NOW is a really good brand overall.



I think amazon is okay if it is the company's amazon store and you know for sure its coming from them. I like iherb.com as well, they often have good prices.
Click to expand...

Oh wow, I'm naive. I will have to pay closer attention that the TN Vitamins amazon link is from their amazon store. Good tip!
 
pikachu said:
Can someone pls explain to me what the heck they are talking about here? How can treating a phantom be urgent? deeply confused

View attachment 406928
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What is the point they are trying to make? Is it that untrained people can deliver radiation through a big bucket of water? If so, big whoop. There has already been evidence of people irradiating their actual spines (no phantoms) without any technical support at all. The future of Rad Onc?
 
OTN said:
Got spicy on The Bird tonight

Click to expand...

Are we in Bizzaro world?

Coke Zero doesn't give you psychosis or DKA either - but I don't tell my patient with symptomatic radiaiton necrosis take it.

Herbs are not regulated by the FDA - you don't know the quality, the dose, or anything else about it. That's what they nutritional industrial complex gets to put whatever they want in a bottle and charge you $50. It is for recreational and pretend purposes anyway.
 
If you follow the body building supplement world, there is a pretty big recent scandal with creatine gummies in that most of them have zero creatine in them. Which makes sense because if you have ever taken 5g of creatine, you understand that there is basically no way that could be put into anything that remotely resembles a gummy candy. The supplement space is rife with scams, especially stuff sold on Amazon. There are so many counterfeit products on Amazon and sellers will counterfeit anything - things you would never even think about being counterfeited or faked. Be careful.
 
Gfunk6 said:
Are we in Bizzaro world?

Coke Zero doesn't give you psychosis or DKA either - but I don't tell my patient with symptomatic radiaiton necrosis take it.

Herbs are not regulated by the FDA - you don't know the quality, the dose, or anything else about it. That's what they nutritional industrial complex gets to put whatever they want in a bottle and charge you $50. It is for recreational and pretend purposes anyway.
Click to expand...

There are more positive RCTs of Boswellia for (radiographic) RN/edema than there are supporting protons for treatment of prostate cancer. Just sayin.

(I still use Dex tho)
 
NotMattSpraker said:
There are more positive RCTs of Boswellia for (radiographic) RN/edema than there are supporting protons for treatment of prostate cancer. Just sayin.

(I still use Dex tho)
Click to expand...
From Open Evidence:

"The evidence for Boswellia in the treatment of symptomatic radiation necrosis is limited and primarily extrapolated from studies of its effect on cerebral edema in patients undergoing brain irradiation. The most relevant clinical data come from a prospective, randomized, placebo-controlled, double-blind pilot trial in which Boswellia serrata (4,200 mg/day) was administered to patients with primary or secondary malignant brain tumors during radiotherapy. In this study, Boswellia was associated with a significantly greater reduction in cerebral edema volume on MRI compared to placebo (reduction >75% in 60% of Boswellia-treated patients vs. 26% in placebo; P=0.023P=0.023). However, the study did not specifically enroll patients with established symptomatic radiation necrosis, and the reduction in dexamethasone requirement was not statistically significant. Adverse effects were mild, mainly gastrointestinal discomfort.[1]
Mechanistically, Boswellia and its boswellic acids have demonstrated anti-inflammatory and anti-edematous properties in preclinical models, including inhibition of leukotriene synthesis and modulation of cytokine production, which may be relevant to the pathophysiology of radiation necrosis.[2-5] However, pharmacokinetic limitations and questions about bioavailability remain unresolved.[2]
There are no major society guidelines (e.g., ASTRO, EANO) endorsing Boswellia for the treatment of symptomatic radiation necrosis, and its use should be considered investigational. Standard management remains corticosteroids, with consideration of bevacizumab or surgical intervention in refractory cases.
In summary, Boswellia has shown some efficacy in reducing cerebral edema in irradiated brain tumor patients, but direct evidence for its use in symptomatic radiation necrosis is lacking, and it is not recommended as standard therapy.[1-3]"

Also, in the Cancer (2011) clinical trial cited above, here is what the authors had to say about their Boswellia sourcing:

"BS product H15 (350 mg; Hecht Pharma, Stinstedt, Germany) was selected for use in the study. H15 does not contain any other ingredients apart from BS. The capsules were bought by the pharmacy of the University Hospital Freiburg. Lot numbers of the product were exactly listed."

This is NOT the same as picking it up in your local GNC.
 
we all have cases in which patients can't tolerate steroids for too long or we dont want them to be on steroids forever. this seems like a gap to try to fill, with an intervention that is low risk. reminds me of OA for RT.

props to the OSU group for raising awareness and sharing their experience, IMO.

I havent tried but will soon.
 
Gfunk6 said:
From Open Evidence:

"The evidence for Boswellia in the treatment of symptomatic radiation necrosis is limited and primarily extrapolated from studies of its effect on cerebral edema in patients undergoing brain irradiation. The most relevant clinical data come from a prospective, randomized, placebo-controlled, double-blind pilot trial in which Boswellia serrata (4,200 mg/day) was administered to patients with primary or secondary malignant brain tumors during radiotherapy. In this study, Boswellia was associated with a significantly greater reduction in cerebral edema volume on MRI compared to placebo (reduction >75% in 60% of Boswellia-treated patients vs. 26% in placebo; P=0.023P=0.023). However, the study did not specifically enroll patients with established symptomatic radiation necrosis, and the reduction in dexamethasone requirement was not statistically significant. Adverse effects were mild, mainly gastrointestinal discomfort.[1]
Mechanistically, Boswellia and its boswellic acids have demonstrated anti-inflammatory and anti-edematous properties in preclinical models, including inhibition of leukotriene synthesis and modulation of cytokine production, which may be relevant to the pathophysiology of radiation necrosis.[2-5] However, pharmacokinetic limitations and questions about bioavailability remain unresolved.[2]
There are no major society guidelines (e.g., ASTRO, EANO) endorsing Boswellia for the treatment of symptomatic radiation necrosis, and its use should be considered investigational. Standard management remains corticosteroids, with consideration of bevacizumab or surgical intervention in refractory cases.
In summary, Boswellia has shown some efficacy in reducing cerebral edema in irradiated brain tumor patients, but direct evidence for its use in symptomatic radiation necrosis is lacking, and it is not recommended as standard therapy.[1-3]"

Also, in the Cancer (2011) clinical trial cited above, here is what the authors had to say about their Boswellia sourcing:

"BS product H15 (350 mg; Hecht Pharma, Stinstedt, Germany) was selected for use in the study. H15 does not contain any other ingredients apart from BS. The capsules were bought by the pharmacy of the University Hospital Freiburg. Lot numbers of the product were exactly listed."

This is NOT the same as picking it up in your local GNC.
Click to expand...

Yes, we agree, except that you can get quality Boswellia in the US and there are other options than the H15 product. GNC sells high and low quality supplements.

H15 is still Boswellia, but this is one of the challenges with studying supplements. It's hard to compare across formulations but you want one that at least has a listed percentage of AKBA or boswellic acids. There are other acids that may have some effects and those can be mixed in.

The randomized trial is interesting, but people extrapolate it like crazy. Theres also a small randomized placebo study for breast dermatitis.
 
Last edited:
1753870424259.png


Now take a closer look at that image.

1753870515668.png


Patient 098, randomized to "W(hole) Pelvis"



At what point during the trial conduct did the randomization arm play a role? At contouring.
One arm was prostate-only, the other prostate + lymphatics.
All other trial procedures, assessments were identical in both arms.

Question:
Does disclosing the randomization arm on the patient file produce a (subconcious) bias, for example when scoring (&reporting) toxicities?
 
I mean you dont need it on the patient file to potentially introduce a potential bias lol. you treated the patient, you know the plan. but I wouldnt put a ton of stock into the bias here. but its always an issue. see proton vs photon trials.
 
grenz said:
Can someone paste the content from the tweet for those of us not in X?
Click to expand...
First They Cut
(The CMS Comedy of Errors Edition)

First they slashed the urologists’ RVUs,
 and I did not speak out—
  because I was still billing 44 fractions.

Then they gutted the medical oncologists’ reimbursement,
 and I did not speak out—
  because at least my weekly OTVs still counted.

Then they chopped the diagnostic radiologists’ pay,
 and I did not speak out—
  because they never even came to tumor board.

Then they “modernized” physics and dosimetry rates,
 and I did not speak out—
  because the beam still turned on when the RTTs pushed the button.

Then they “revalued” radiation oncology—
 which is CMS-speak for your wRVUs just went on hospice—
 and there was no one left to sign my MIPS attestation
  when the linac went dark.

And finally, they whispered sweet nothings about
 “value-based care” and “patient convenience,”
  which turned out to mean
 5 fractions for everyone, forever,
 because hypofractionation is CMS’s love language.
 
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