Hey OTN - any luck on your quest for expansion?

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SneakyBooger

SneakyBooger

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OTN said:
Hey all,

I've been placed on a task force in our large private practice, the goal of which is to look at ways to expand the role of us radoncs. Facing reimbursement pressures, hypofractionation, etc, we want to try to find new ways we can treat cancer patients or look to expand treatments or techniques we're not utilizing to their full potential.

There have been some good preliminary discussions on this board before regarding this very issue, so I thought I would pick everyone's brain to see what people think. Nothing at this point is off the table, so go nuts.

I'll start: We do dose to volume, so why not cryoablation for prostate ca failure after definitive XRT?
Click to expand...

Hey OTN, did you ever complete your search?

If so, anything good to share?

Thx - SB
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Nothing really Earth-shattering. I've treated one patient successfully for refractory psoriasis of the soles of the feet (6 Gy in 1 Gy fractions) and another for the worst case of hidradenitis suppurativa that anyone's ever seen (successfully! Patient and derm are very happy), but not much else to note right now.
 
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I guess I should also say that the SBRT for VTach process continues successfully under Cliff Robinson at WashU, and I expect our practice to (hopefully) join the collaborative group for treatment once it's open.
 
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xrthopeful said:
RT for arthritis
Click to expand...
SneakyBooger said:
Hopeful, I actually did giggle when I read this, but then I realized that I might very well be heading that way. Any suggestions for dose? LOL
Click to expand...
medgator said:
Funny how things come full circle.... Wasn't that done before? Around the same time they used to treat acne...
Click to expand...

Not wrong...

r6BaoGx.png
 
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Use of radiation for osteoarthritis:
Incidence of about 10% above age 60; US population above age 60, about 75 million;
So about ~7.5 million cases a year
Average XRT fractions per patient, about 7 (retreats factored in)
Thus about ~50 million XRT fractions per year in theory possible for osteoarthritis

Use of radiation for cancer:
Incidence of about 1 million "XRT-able" cases per year
Average XRT fractions per patient, about 25
Thus about ~25 million XRT fractions per year in theory possible for cancer

Therefore... the potential market for radiotherapy is twice as big for arthritis than it is for cancer.

(Could also show that the XRT market for Peyronie's is about as big* as it is for cancer; another calc for another day.)

*that's what she said
 
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From the German Cooperative Group on Benign Diseases, RedJ, 2018:

"In total, of the 53,932 patients receiving RT in 2014, 36,830 (68%) had benign diseases. Of those, 16,989 patients (46%) were treated for degenerative diseases, another 14,936 (40%) for osteoarthritis, 1563 (4%) for hyperproliferative diseases, and 2440 (7%) for functional disorders"
 
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I sent the article to some ortho friends in my hunt camp and they replied immediately saying they would absolutely be interested.

The wait from time that hip replacement surgery is recommended until the surgery date is 6 months right now.

Their clinic overflows with arthritic hips and knees.
 
The German practice guidelines on RT for benign disease are actually a really interesting read...

www.ncbi.nlm.nih.gov

Radiotherapy for non-malignant disorders: state of the art and update of the evidence-based practice guidelines - PubMed

Every year in Germany about 50,000 patients are referred and treated by radiotherapy (RT) for "non-malignant disorders". This highly successful treatment is applied only for specific indications such as preservation or recovery of the quality of life by means of pain reduction or resolution...
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov
 
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Imagine all the rad oncs that would fart in another rad onc’s general direction if, and it’s theoretically possible, a rad onc confined his practice to painful joints giving a few gray a pop. On the plus side, a residency to learn how to do this could be just a few hours in duration.
 
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I've attended the SABR symposium, and we may be treating our first patient soon. However, until big changes happen in EP and big data moves SBRT out of the "for refractory VTach" realm and into first-line treatment for either VT or AFib, it's not really going to move the needle in terms of clinic volume. Data DOES exist for AFib, but I'm not holding my breath for the EP docs to research themselves out of a job.

I have one hidradenitis suppurativa patient that I've had to treat 6 times now. Her dermatologist says her dz is the worst she's ever seen, and she is very happy with how well she has responded to our tx. Not a huge pt population here, but the pt has been very happy as well with the outcome.

Arthritis, however, is a different story. I've simulated 14 patients in the last two months and have seen 6 in follow-up. 5 of the 6 reported significant pain improvement. No SEs, of course. I've only been offering to my follow-ups thus far, as I haven't yet wanted to fully establish a program, mostly because I don't want to overwhelm the clinic with non-oncologic patients, as I still have a very busy radiation oncology practice that needs to take priority. Patients are happier to have an option to possibly help with their arthritic pain than they were when I told them radiation could cure their cancer, so it is fulfilling, that I can attest to. 3 Gy in 5 fx.

I wish we had better data for RT for shingles pain, as there is a LOT out there. However, I couldn't really find much outside of that single ASTRO abstract from 2005, so it's not something I've yet started to offer. The data is compelling, though. I'm disappointed we haven't seen any research about this topic, as shingles is so very prevalent. Varian, are you reading this? Want to sponsor a trial?

All in all, it's clear "radiation medicine" for inflammatory conditions (a hand surgeon friend of mine from a different state claims the amount of epicondylitis out there is massive, for example) is understudied and underutilized, especially when you consider both the low cost and low SE profile of conventional XRT to 3 Gy. The German randomized ARTHRORAD trial (0.5 Gy x 6) should give us better data, but I haven't heard anything about the timing of its release.
 
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Interesting that many decades ago they treated tons of benign conditions with radiation, then the pendulum swung away when we learned of its toxicities, and now the pendulum is swinging back again
 
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Trying to think about how I would incorporate this into my practice. I like the idea of starting with follow-ups. I envision my nurse or ma having all my patients fill out a quick arthritis screening tool that would be in addition to the countless other row and other paperwork that they have to complete. Something like the aua form that I give to all Prostate patients. This could easily trigger a possible discussion about rt treatment. Does such an objective screening tool exist?
 
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OTN said:
I've attended the SABR symposium, and we may be treating our first patient soon. However, until big changes happen in EP and big data moves SBRT out of the "for refractory VTach" realm and into first-line treatment for either VT or AFib, it's not really going to move the needle in terms of clinic volume. Data DOES exist for AFib, but I'm not holding my breath for the EP docs to research themselves out of a job.

I have one hidradenitis suppurativa patient that I've had to treat 6 times now. Her dermatologist says her dz is the worst she's ever seen, and she is very happy with how well she has responded to our tx. Not a huge pt population here, but the pt has been very happy as well with the outcome.

Arthritis, however, is a different story. I've simulated 14 patients in the last two months and have seen 6 in follow-up. 5 of the 6 reported significant pain improvement. No SEs, of course. I've only been offering to my follow-ups thus far, as I haven't yet wanted to fully establish a program, mostly because I don't want to overwhelm the clinic with non-oncologic patients, as I still have a very busy radiation oncology practice that needs to take priority. Patients are happier to have an option to possibly help with their arthritic pain than they were when I told them radiation could cure their cancer, so it is fulfilling, that I can attest to. 3 Gy in 5 fx.

I wish we had better data for RT for shingles pain, as there is a LOT out there. However, I couldn't really find much outside of that single ASTRO abstract from 2005, so it's not something I've yet started to offer. The data is compelling, though. I'm disappointed we haven't seen any research about this topic, as shingles is so very prevalent. Varian, are you reading this? Want to sponsor a trial?

All in all, it's clear "radiation medicine" for inflammatory conditions (a hand surgeon friend of mine from a different state claims the amount of epicondylitis out there is massive, for example) is understudied and underutilized, especially when you consider both the low cost and low SE profile of conventional XRT to 3 Gy. The German randomized ARTHRORAD trial (0.5 Gy x 6) should give us better data, but I haven't heard anything about the timing of its release.
Click to expand...

This is interesting.... Today I was actually declining to treat a myeloma patient's hips because its almost certainly from osteoarthritis rather than myeloma. Should I change my mind? This patient is debilitated with pain (needs a walker) and if 3Gy in 5 fx would help him it seems like it would be worth it. How durable is the effect?

EDIT: Just saw the "Benign Disease" thread....
 
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