Exploring Radiation Therapy for Osteoarthritis

Podcast Transcript

Dale Shepard, MD, PhD: Cancer Advances, a Cleveland Clinic podcast for medical professionals exploring the latest innovative research and clinical advances in the field of oncology. Thank you for joining us for another episode of Cancer Advances. I'm your host, Dr. Dale Shepherd, a Medical Oncologist and Co-Director of the Sarcoma Program at Cleveland Clinic. Today I'm happy to be joined by Dr. Shauna Campbell, a Radiation Oncologist and Co-Director of the sarcoma program here at Cleveland Clinic. She was previously a guest on this podcast to discuss ultra-hypofractionated radiotherapy for soft tissue sarcoma, and that episode is still available for you to listen to. She's here today to discuss radiation therapy for osteoarthritis. So welcome.

Shauna Campbell, DO: Thank you, Dr. Shepherd. I'm happy to be here. And a little change of pace from what we talked about last time.

Dale Shepard, MD, PhD: It is a change of pace. In fact, just point out a couple of minutes ago, this is the first Cancer Advances podcast where we're not going to talk about cancer, but we're going to talk about therapies oftentimes used for cancer for something being osteoarthritis.

Shauna Campbell, DO: Absolutely. Yeah. Typically radiation therapy is used in the treatment of just about every type of cancer, but what a lot of people don't know is there are a handful of benign or non-malignant causes that can actually be really effectively treated with radiation and often very low dose radiation. So that's what I look forward to talking about today.

Dale Shepard, MD, PhD: Excellent. Before we start, remind us a little bit about what you do here at Cleveland Clinic.

Shauna Campbell, DO: Yep. So I am a radiation oncologist here at Cleveland Clinic and I am fortunate enough to work side by side with you as co-director of the sarcoma program. So one of the things I specialize in is the treatment of bone and soft tissue cancers. Talking about arthritis, there's a little bit of a relation there as far as talking about joints and bones, that sort of thing.

Dale Shepard, MD, PhD: Excellent. So going to talk about osteoarthritis. A lot of people that might be listening in different backgrounds, of course everyone has a basic understanding of osteoarthritis, but maybe give us a little bit of a backdrop about how we normally think about treatment.

Shauna Campbell, DO: Yeah. So osteoarthritis is something that's very, very common, far more common even than cancer. It's about the seventh leading cause of disability worldwide. It can affect people of all ages, but tends to be more common in our more senior older population. It's especially common once people are over the age of 60 or 70 years old. Often we think about chronic long-term joint stiffness, pain, loss of mobility as far as the impact of osteoarthritis. And historically it's a degenerative process of the joints. But we also have learned that there's a significant complex like inflammatory aspect when it comes to osteoarthritis, and that's really how radiation therapy comes into play for that. But before we talk about radiation therapy for osteoarthritis, we can review of the more common treatment options that we're all probably very familiar with. First going to start off with treatment in the sense of just lifestyle modifications. Those are the easiest thing. Looking at changes in diet, changes in weight. If we're overweight, we have a lot of impact on those joints. So weight loss is one of the things we talk about. Lifestyle modifications. If wearing something as simple as a knee brace can help relieve the pressure, that's excellent.

And then from lifestyle modifications, if somebody still has significant pain or discomfort related to their arthritis, then we start looking at things like more simple pharmacologic management. So over-the-counter, for example, NSAIDs is probably one of the most common treatment options for people with osteoarthritis and we can all take those occasionally. But when you have somebody that has persistent pain, taking NSAIDs every day can come with some other effects such as bleeding within the gastrointestinal system, some cardiovascular effects so they can come with their own set of risks as well.

And then when we look along the spectrum for people who tend to have more debility related to osteoarthritis, then we start talking about joint injections like steroids. And eventually at the farthest end of the spectrum is where we have joint replacements. So a knee replacement, that sort of thing, which can be the most effective means of treating the pain of somebody with osteoarthritis, but it can be a little bit more complicated for some people that they may not be a candidate for it or may not have impairment enough to justify going through a joint replacement.

Dale Shepard, MD, PhD: So, radiation is not something that most people have probably thought about or known anyone who's really had treatment with radiation for their arthritis, but this is not something new. And so gives us a little bit of an idea of the history of use of radiation.

Shauna Campbell, DO: First, why do we think radiation works for this? And I mentioned the inflammatory aspect of osteoarthritis is one of the driving mechanisms of the disease and the pain associated with that disease. And radiation, when we use low dose radiation, we're actually trying to take advantage of the anti-inflammatory effect of radiation, which we actually don't see at our typical doses that we use in the cancer world. So this is low dose radiation. So overall quite different. Now you ask when was this first started? The earliest series we can find is the early 1900s or so where it was noted that low dose radiation resulted in improvement in arthritis pain in a select group of patients. Now that was obviously a really, really long time ago, and since then we've had studies that have been performed, a lot of which have been done in Europe. Europe has actually adopted radiation therapy for benign conditions at a lot faster of a rate than we have in the United States. So while we're talking about this as a new treatment in the US, they've been doing it in Europe for a much, much longer period of time and have a lot of experience.

And osteoarthritis, for example in Germany, radiation therapy is an established and recommended treatment option for those patients. It's especially useful in areas that have perhaps more limited access to surgeries such as joint replacements, which is not really a problem we have here in the United States, but has increased the earlier adoption of it in Europe.

Dale Shepard, MD, PhD: We’re talking about arthritis, we're specifically talking about osteoarthritis. Do we think it works for things like rheumatoid arthritis or is it more limited to osteoarthritis?

Shauna Campbell, DO: We limit it to osteoarthritis. The mechanism of the disease is going to be different. Although they both share the name arthritis, those others are quite different. So we do reserve this for osteoarthritis patients.

Dale Shepard, MD, PhD: That’s why I thought early on we're probably going to start just saying arthritis, but we set the stage that we're talking osteoarthritis.

Shauna Campbell, DO: Absolutely. It's a mouthful.

Dale Shepard, MD, PhD: So, there you go. So how have we gone about resurrecting use of that here at the clinic? How are we incorporating this? What kind of patients have we chosen to start treating? Who would be a candidate?

Shauna Campbell, DO: So, what we look to is the studies that have been done so far. Studying any treatment within osteoarthritis can get a little bit complicated because there's a lot of studies that have shown even when you compare a treatment with a placebo that even some patients who get the placebo will note an improvement in their pain. So the study of this is overall very complex, but what we've seen is that the best literature is for the treatment of arthritis in the knee joint as well as in the hands of people. And so that is where most of the literature comes from. Now you could say, "Well, what about a shoulder? What about an ankle?" There are some smaller studies that have been published in those disease sites here at Cleveland Clinic and around the country we look at the evidence available. And for example, you think of the knee, that's a large joint that is a weight-bearing joint compared with the hand, which is a smaller joint and not weight-bearing. So then you would say, "Okay. Now look at the shoulder." I might not have a huge clinical trial of a thousand patients with arthritis of the shoulder, but I can say if it's a large joint like the knee and it's more of a weight-bearing type of joint, a load-bearing joint that I can extrapolate from the data from knees and hands to most of the other joints.

So we are open to considering radiation therapy for joints beyond the knee and hand, and it's just a discussion in understanding more so what the degree of arthritis is that people have by looking at their x-rays. That's something that's important when we see people for a consultation is looking at is this the most advanced stage of arthritis where you've got complete lack of the joint space, you've got bone-on-bone sort of thing. When you've got that kind of mechanical pain, you have to think radiation isn't going to rebuild that. You could expect somebody with severe, severe pain on the far end of the spectrum, they're probably going to be better suited with a joint replacement where you're just addressing that entire problem. But for people that have what I would describe as more middle-of-the-road or moderate arthritis is where we can see preserving that existing joint that's there and reducing the inflammation can have the biggest impact on their pain control and long-term function.

Dale Shepard, MD, PhD: It sounds like there's a sweet spot. You have to be symptomatic enough, you can't be too advanced of joint destruction. If the disease is too advanced, you might not get benefit, but if we have these patients who just medically can't get joint replacements, is there still an advantage even short-term for those patients?

Shauna Campbell, DO: Right. Absolutely. It does. It just comes down to a discussion and what the expectations are of treatment. The really great thing about considering radiation for this is, although it might sound a little bit scary to folks who aren't used to radiation therapy, this is a very low dose of radiation and in all the studies that have been done, there's really no acute side effects that have been reported in very large groups of patients. So that's the first thing I always take into consideration is, is the treatment I'm offering, does it have significant side effects that's associated with it? And overall this is a very safe option that's available with very low if dare I say, no side effects associated with it. And so moving forward with that, we get this where I'll have a 90-year-old woman that comes in with severe hip or knee pain, is not a candidate for a joint replacement due to age and other factors. And even though the evidence might not be as high level for delivering radiation to her as far as the improvement in pain, I do think it's worth trying for even people at that far end of the spectrum that just don't have other options and are suffering.

Whereas when you deal with more the moderate mid-range type of arthritis, that's where we're willing to consider it in a larger group of patients as well. Typically the patients we consider here at Cleveland Clinic tend to be over the age of 60, and then we look at the grade of their arthritis. Again looking for somebody with symptomatic more moderate changes on their x-rays. Those are the patients that we tend to see the highest potential for clinical improvement. And in the studies that we've looked at of this, you're going to see what we do is we start with a single course of radiation and about half to two thirds of patients can see a considerable improvement even after just that first course of radiation.

Dale Shepard, MD, PhD: You mentioned before about side effects, but I can imagine that this is a stumbling block for some patients. I can have patients who don't want to get a CT scan every three or four times a year. And so then when you start talking about radiating for a benign condition, our patients pretty accepting ultimately?

Shauna Campbell, DO: As physicians, the one thing we have to always consider when using radiation therapy as any treatment option is we always have to acknowledge the scariest thing about radiation is the risk of a secondary malignancy or the risk of causing a cancer. That is the thing we have to be most judicious about our use in is being very careful about that. Now what we tend to see is in the arthritis population, we're talking about treating people who are 60 plus years old and the dose of radiation that we're using is exquisitely low. So there have been no cases that have been published demonstrating a cause of cancer developing in a patient who received radiation for arthritis. There hasn't been anything published like that. And the doses that we use are so, so, so low that we feel very confident that the risk is extremely low. We all have a risk of developing a cancer. One in eight women can develop a breast cancer. That baseline risk. Inherently we all have a risk of developing a breast cancer or lung cancer or prostate cancer is probably much higher than even the possible increased risk we introduce with using radiation for arthritis.

Dale Shepard, MD, PhD: You mentioned joints that we have more data for. You talked about hands, you talked about knees. Are there particular joints that you try to avoid?

Shauna Campbell, DO: There's not really, we try to avoid other than the spine is probably the one area where the data is most limited. You're treating a slightly larger area. When we have arthritis within the spine, it's usually a bigger region. It's harder to pinpoint than just one individual joint. The spine does have the least amount of evidence for that. And what we tend to avoid with the spine just because there's so much mechanical components, the nerve compression, the disc disease, that sort of thing, it's a very multifactorial within the spine. But otherwise looking at hands, wrists, elbows, shoulders, hips, knees, ankles, those are the main joints and cover really most of our bases for patients with symptomatic arthritis.

Dale Shepard, MD, PhD:  Do we have real world information from Germany and European countries about these other joints as well?

Shauna Campbell, DO: We do. It's a little bit more limited outside of the knee and the hand, but there are a series that demonstrate the effectiveness of radiation within those. So I do think it is safe within those, it's just a conversation between the physician and the patient and understanding that.

Dale Shepard, MD, PhD: From a logistics standpoint, we're not talking about SBRT trying to avoid an aorta low dose. This is pretty widely available in most centers.

Shauna Campbell, DO: It is. Within Cleveland Clinic all of our radiation oncologists are fully capable of doing this. We have very clear guidelines we've created for the treatment of patients with arthritis. What is usually involved is you come in, you sit down with one of the radiation oncologists for a consultation to talk about the radiation, the possible risk benefits, radiation oncologists will review your x-rays, review prior treatments that you've had and what the overall clinical picture looks like for you. And then from there, once it's decided if radiation therapy is the right treatment for your arthritis, then there's a planning day, which is just a basic CT scan of the area where we outline what the radiation treatment field is going to look like. And we've been able to really standardize that based on are we treating the knee, the hand, the wrist, and what that radiation field is supposed to look like. So that's the treatment planning day.

And then the actual treatment consists of six radiation treatments. That's usually given twice per week. So patients will come to the radiation oncology department for two treatments a week for a total of three weeks, and it only takes about 10 or 15 minutes per treatment. Patients can receive this at any of our Cleveland Clinic sites within Ohio, Florida. It's available everywhere.

Dale Shepard, MD, PhD: Who would usually make that referral? How does that happen? So one might imagine primary care might be trying to manage the arthritis, one might imagine maybe an orthopedic surgeon goes, well, I could do a joint, but maybe try this first. What's the usual path to consult?

Shauna Campbell, DO: So, you're right. So it can be primary care physicians can make a lot of referrals. Rheumatology manages a lot of patients with arthritis as well. Orthopedic surgeons. And then we get a lot of patients that call on their own that say, "Hey, I heard about this from some article or podcast," or that kind of thing. And we even get patients that just call on their own. A lot of patients that we actually treat to be our own existing patients as well. So folks that we have treated for other cancers over the years, and then when they come to see me for follow-up, they talk about, oh, my shoulder arthritis is really bad and I find we're no longer talking about their cancer that I previously treated, but their driving complaint is actually their arthritis in their shoulder. So that's also a significant number of people that we treat for arthritis that are already familiar with radiation therapy and there already are patients.

Dale Shepard, MD, PhD: You talked about that's sweet spot, not controlled with things like nonsteroidal anti-inflammatories. Maybe you don't quite need a joint replacement. How does this compare to patients that might benefit from a joint injections, steroid injections, those sorts of things?

Shauna Campbell, DO: These are all options for a similar group of patients. I would say that joint injections, steroid injections are more common. For example, from orthopedic surgeons, from rheumatologists, this is their go-to. They've been doing this for a very, very long time. So I would say there's a lot of patients end up doing some kind of joint injections. But the challenge with those joint injections is they're often not long-term sustained effect. They may temporarily work, but are we talking about somebody that requires a joint injection every three to four months? Are they eventually getting tired of that? Can the steroid joint injection actually eventually lead to some decline in the cartilage itself? So it gets to be a little bit more common. So I'd say a lot of patients end up with some kind of joint injection just because that's been around longer. The physicians who tend to manage these patients, that is within their scope of practice. So it's really easy. Somebody comes into your office for an arthritis consult and they say, "Well, I could give you a joint injection right now." And so they go forward with that.

But when we consider radiation therapy, if you've had a joint injection before, that's no problem. Radiation therapy does not prevent you from getting joint injections in the future. It does not prevent you from getting a joint replacement in the future. We have not seen increased complications in somebody that subsequently decides to go on for a knee replacement in the future if the radiation therapy did not provide adequate relief for them.

Dale Shepard, MD, PhD: When we think about lots of people are going to listen to the podcast, lots of people are going to get interested in radiation. How do we consider capacity? Millions of people have arthritis.

Shauna Campbell, DO: It's true. It's true.

Dale Shepard, MD, PhD: What if this picks up in popularity again and how do we manage that? Do we have the ability to treat lots of people?

Shauna Campbell, DO: We do have the ability to treat lots of people. The thing that works in our favor is this is overall very simple. From a radiation therapy side of it, we are able to streamline the process. For example, when I see somebody with a cancer diagnosis, I need 60 minutes to sit down and talk with them, go through the whole diagnosis, all the details. When it comes to an arthritis patient, I don't need that full 60 minutes. So from the physician, there's a little less as far as direct need. Our advanced practice providers are also a really important part of our practice in helping us fill in any gaps that we have as far as availability. And like I mentioned, we really streamlined the treatment planning process. And then with respect to time on the machines, we do have to acknowledge that everyone takes up an appointment slot on the machine.

But we're fortunate right now that we're able to account for that. And what may happen is it's important ... We try and avoid any wait times for all of our patients. Of course, our cancer patients, our priority is getting them in right away. Arthritis patients, it is possible that if we were to have an increased demand, there might need to be a little bit more of a waiting time. So by setting that prioritization in the different streams that you put patients through. Is this a cancer patient that's calling and needs a consultation or is this somebody with a benign condition like arthritis that could potentially wait a little bit longer in order to preserve our access and ensure that all of our patients are being appropriately taken care of?

Dale Shepard, MD, PhD: Well, there's certainly a lot of arthritis. It certainly causes tremendous morbidity, lots of disability, tremendous human suffering standpoint and cost. And so it's an interesting topic. Appreciate you being here for the first non-cancer talk.

Shauna Campbell, DO: Absolutely.

Dale Shepard, MD, PhD: No. Great insights. Thank you.

Shauna Campbell, DO: Absolutely. Thank you for having me.

Dale Shepard, MD, PhD:  To make a direct online referral to our Cancer Institute, complete our online cancer patient referral form by visiting clevelandclinic.org/cancerpatientreferrals. You will receive confirmation once the appointment is scheduled.

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