Introduction

Arthritis is an ailment that affects inflammation of the joints. It happens when the smooth cushions that basically are in between our bones, the cartilage, starts to wear down. When that cushion thins, the bones rub together, it causes pain, it causes inflammation, stiffness and swelling. If left untreated or left unmanaged, it can really affect someone’s daily life activities. Something as simple as holding a toothbrush, right? Or going up and down stairs. It can really inhibit independence. Low dose rate radiation is one option that can either be the primary treatment for osteoarthritis because nothing else worked or as an adjunct and a complement.

Hello, and welcome to Aging Matters, a program featuring aging-related topics of interest to older adults and their families. I’m Cheryl Beversdorf, your host. While there are estimated to be more than 100 types of arthritis, osteoarthritis is the most common form of arthritis affecting 32.5 million US adults. This condition may be treated with different options, including surgery, in addition to a non-invasive treatment called Low Dose Radiation Therapy, or LDRT. Today, my guest is Dr. Robert Hong, Radiation Oncologist at Virginia Hospital Center in Arlington, Virginia. He will talk about risk factors, symptoms and diagnosis of osteoarthritis among older adults and available treatment options. He’ll also discuss Low Dose Radiation Therapy, again, LDRT, and when it’s the treatment of choice for management of osteoarthritis. So welcome, Dr. Hong, and thanks for joining me today.

Cheryl, thank you very much for having me this morning. I’m very happy that we’re speaking about this. It’s an important topic that affects many people. And so hopefully, with the information that we present, it will benefit some of you out there suffering from this condition.

Osteoarthritis Risk Factors

Tell us a little bit more about osteoarthritis. We all say we have it, but give us a few more details. Is it most common among older people? And what are the risk factors that usually cause arthritis?

Sure. Arthritis generally is an element that affects inflammation of the joints. Now, osteoarthritis specifically is the most common form of arthritis generally. It happens when the smooth cushions that basically are in between our bones, the cartilage, starts to wear down. When that cushion thins, the bones rub together, it causes pain, it causes inflammation, stiffness, and swelling. And it really is the most common form of arthritis. And as we get older, it can get worse with wear and tear. And it also can get worse as injuries occur, or after heavy usage. So I call it the wear and tear arthritis, and indeed, it’s the most common form.

So let’s talk about the risk factors. Are there more likely to be men who have it, rather than women? Could it be obesity that causes it? You mentioned about injuries. Are there other factors?

So osteoarthritis, again, I call it the type of arthritis that is most described as wear and tear. Age is the biggest factor. My nephew told me a riddle the other day. He said, what goes up and never comes down? Well, the answer is age. And so the risk of developing osteoarthritis really only increases as we live our lives, participate in our daily activities. But age isn’t the only risk factor. Genetics, prior injuries, obesity, extra body weight. If you’re very active and have any repetitive stress injury from either work, sports, and you don’t have to be a professional athlete, you could be a weekend warrior and develop worsening osteoarthritis and it’s mediated mostly by inflammation. Some people are born with slightly misaligned joints. We know people, you may have heard of scoliosis, right? And so if you even have a minor alignment in the way you were born, the way God made you, that may put you at additional risk of wear and tear osteoarthritis. Anything that stresses a joint over time increases the risk. And so osteoarthritis is a common ailment that afflicts just about all of us in some way or another.

And is it women more than men, or are there certain races that might be more likely to have osteoarthritis or is it pretty across the board?

It’s across the board. I will say again, age is the biggest factor. I don’t think that there’s any predominance related to gender, men equally to women. It’s not something that necessarily is different across racial and ethnic groups. I would say that again, anything that stresses a joint over time increases risk. Imagine we’re sitting here today and as we’re typing, if we don’t have pads under our wrists or some sort of brace, just even typing over a long period of time, when you’re 70, 75, 80, just by playing the piano once or twice a week. Stress over a joint over time increases risk. It can cause inflammation and pain.

Does osteoarthritis affect all the joints over time? Are your elbows more likely to get it than your knees or your hips? The symptoms, when do those start?

Symptoms & Diagnosis

It really flicks patients of older age. Again, age is the biggest risk factor. When we think about the root cause, the origin source of osteoarthritis, it really involves the cartilage between our bones wearing down. When these wear down, there’s friction, it causes inflammation, and usually it’s pain. Sometimes it’s morning stiffness. People may develop swelling in the shoulder, the elbow, the knee, the joint that’s afflicted. Oftentimes, there’s a clicking or a grinding feeling. It’s harder to move. Based on the patients that we’ve treated and based on the joints that are most afflicted, I would say the knees are a very common place. The hips, I’ve treated patients with spine osteoarthritis, very commonly involving the hands, the big toes, the ankles are also affected. Any joint that feels that wear and tear stress, that pounding on the pavement, even if you’re just taking a long walk, those repetitive, stressful movements to the bones and joints are what causes worsening of osteoarthritis.

But are there long-term effects and outcomes of osteoarthritis so that if we don’t get some treatment, there may be some additional symptoms that might occur?

Yes, absolutely. So osteoarthritis doesn’t just show up all of a sudden one day after waking up. It’s something that progresses very slowly over time. And if left untreated or left unmanaged, it can really affect someone’s daily life activities. Something as simple as holding a toothbrush, right? Or going up and down stairs. It can really inhibit independence. But the good news is that with the right combination of lifestyle changes, exercise, diet, modifications, medical management, and in severe cases, invasive interventions like steroid injections or surgeries. Ideally, we can use this right combination of non-invasive lifestyle changes to slow down the progression of osteoarthritis. And so that’s what we encourage. But sometimes it progresses rapidly, and it causes a lot of dysfunction and pain, and we need to intervene.

And if our listeners are beginning to think, well, maybe I have it, might they also look at their family history? Might there be mom or dad or grandpa and grandma who had osteoarthritis? If there is a history of osteoarthritis in the family, would one be more likely to also eventually have it? Is it more environmental or is it more genetic or a little of both? I’m just wondering whether those folks who, you know, there isn’t any family history, might be less likely to get a diagnosis of osteoarthritis.

Right, right. If osteoarthritis is prevalent in your family, your odds of developing osteoarthritis are higher. Now, there are some congenital inherited forms of osteoarthritis, like juvenile arthritis that’s immune mediated, right? So that’s not the type of arthritis that we’re talking about here. We’re talking about wear and tear arthritis. But if you have misaligned joints, if you have scoliosis, if you have diabetes and weight issues, these are all really lifestyle factors and environmental issues that matter a great deal in whether or not you develop osteoarthritis and whether or not it progresses onto more severe forms. And the good news is that you can offset a lot of the risk factors for osteoarthritis with exercise, diet, medical management. The problem really though is if you’re at a point where the arthritis is causing significant impairment in your independence and your ability to do daily normal life activities, exercise will inevitably be prescribed by your doctor, right? Well, how do you exercise if you can’t even walk up the stairs because of pain in your knees? So there is a bit of a catch-22 here. And so it’s very important to recognize that sometimes you have osteoarthritis to a point where the typical lifestyle modifications may be impaired because of the pain.

And thank you for mentioning that, Dr. Hong, because I just wanted to touch on a little bit the mental, the emotional, and even the social issues associated with living with osteoarthritis. It’s not just those physical symptoms that you’ve already described for us, but I suspect that this disease can really impact folks in so many different ways.

I 100% agree, it really can. Chronic pain wears people down, both physically, emotionally. There’s a sense of anxiety, frustration. When you’re not able to do little things, you have to ask people to help with simple things, like buttoning your shirt, right? You can become very isolated. That’s why addressing the emotional well-being, the social emotional health is a key part of arthritis care.

You are a radiation oncologist, and we’re going to be talking about LDRT in a moment. But give us a scenario now of what happens next. People are beginning to experience these particular symptoms. So how is osteoarthritis diagnosed? Was it usually a primary care physician? What types of tests confirm that someone has a diagnosis of osteoarthritis? What do we need to know about next steps?

Well, by the time someone comes to me, they know they’ve had it, and most likely have had it for many years. But in general, we always start with a good history and physical exam. We ask what the triggers are. If there was a inciting traumatic event, if there was a fall or a tear, if there was prior surgery. And then we bring them in, and we do a comprehensive history and physical exam. We feel the joint, we do range of motion analysis, we look and feel for swelling and tenderness. And then you have diagnostic exams and studies, x-rays, MRIs of the joint or the anatomic space. But really, most of the diagnosis comes from the patient describing symptoms and how they feel day to day.

So, given that information and those diagnostic tests, then there are an array of treatments available, medications, physical therapy, steroid injections. Would those be the considered early treatments of choice? What determines what is going to be the right treatment for the patient, the symptoms, the diagnosis with respect to these first three? The medications, the physical therapy, steroid, and eventually joint surgery. So.

Initial Treatment Options

Sure. I think this is kind of beginning to take us to the heart of the matter here. We have pain, we’re suffering, and it’s impairing our daily life. What can we do about it? I believe that the interventions and the things that we prescribe and advise for patients suffering from osteoarthritis are layered. They’re multi-factorial. It involves lifestyle modification advice, dietary advice, but I also think it starts with physical therapy, losing weight, treating kind of root causes. And then obviously once we establish those things and maybe even in parallel, we’ll start medications. We have anti-inflammatory medications. And then if we need to intervene even further, that’s when we talk about invasive procedures like steroid injections or even total joint replacement.

Are there considerations then with each of these possible treatments, like medications, if somebody has got four or five or six medications, is there a concern about side effects or getting to physical therapy or steroids? There might be some side effects there. Are you already a part of the team to help determine what’s the best treatment of choice for somebody with osteoarthritis? What’s the process?

The process generally involves communication with even the primary care provider, the interventional radiologist, the orthopedist, referring patients to me. Now, you can come directly to me, and I will confirm and make sure that if there are other interventions, like anti-inflammatories, medications, potential need for X-rays and MRIs, I can help facilitate that. But most of my patients are referred to me by the subspecialists who have been trying to help and remedy the problems, and then asking for help at that point, because either the medications stopped working, or they’re causing side effects like affecting kidney function or gastrointestinal problems. Steroid injections can decrease inflammation with direct insertion and shots into the joint, but they only offer short-term relief when the pain flares up. And if you do injections on a chronic basis, it can actually make the problem worse by making the tissues weaker. And then, if you’re at a point where you have a joint where the cushion is completely gone, or if you’re bone on bone, then surgery may be necessary at that point. But we’re dealing with people who may be in their 80s, who may have additional risks that prevent a surgery from being safe. And so, when the pain severely limits your quality of life and nothing else help, and hip or knee replacement is not something that you’re interested in, because it’s reserved maybe for the most advanced cases, or you’re at risk of developing complications from the surgery itself. That’s when the patients come to me or are referred to me. And that’s when we start speaking about low-dose radiotherapy to treat their problems.

When LDRT Becomes Option

Okay. So, as I understand it then, a physician has prescribed medications or physical therapy and steroid injections and they’re not working, but they still would then be good candidates for low-dose radiation therapy. Is that what I’m hearing you saying?

Yeah. That is absolutely correct. And in fact, if you have, let’s say, a medical regimen that works, but you’re hesitant to take additional pills or increase the dose for fear of how it may affect your kidneys or your heart, that’s when low-dose radiation can be an adjunct or a complement to the existing medication. So just because we’re treating with a different modality doesn’t mean that you abandon the treatments that work, right? So it’s a wonderful way to complement what works. The ultimate goal is to somehow decrease the inflammation, decrease the pain, improve your quality of life. And really the ultimate goal is to get you, no pun intended, get you back on your feet so that you can become a productive member of society and participate with your family, your loved ones, your community. And so low-dose rate radiation is one option that I think is available now here in our community and other communities nationwide that can either be the primary treatment for osteoarthritis because nothing else worked or as an adjunct and a complement.

And so anybody could be a good candidate for low-dose radiation therapy. Is that true?

Yes, it is. I think where low-dose rate radiation therapy really helps a lot of people are the situations when patients have severe pain that limits quality of life and nothing else helps. They’ve done physical therapy. They’ve tried prescription anti-inflammatories. They have had limited injections into the joints. And oftentimes, these are patients who have been recommended for a total knee replacement or a hip replacement. But they fear that undergoing surgery at 75 years old or 80 years old, or you could even be younger and just want to avoid an invasive procedure and the risks associated with it, low-dose rate radiation therapy is a potential treatment that could push the surgery down the road or it may solve the issue with the pain that allows you to exercise again and lose weight and lessen the stress on the joints because of opportunities to make lifestyle changes. So, I think low-dose rate radiation therapy is an important topic to have people understand that it may not fix everything, but it may get you to a point where you can start making changes that can address the root cause, whatever that may be.

Understanding LDRT

Okay, well, that’s a good segue into talking about low-dose radiation therapy. And I’m sure that our listeners are going, whoa, radiation therapy, that perhaps may cause people to want to take a step backwards and wonder, what are we talking about in terms of the dosage? Because usually we hear about radiation therapy in connection with treatment of cancer. And so give us a basic definition of low-dose radiation therapy. Is it considered safe? What do we need to know just to get started here?

Sure. So I would say the difference between the radiation we use to treat cancer versus radiation we use to mitigate pain from osteoarthritis is dose. And let me clarify this a little bit, and then I’ll go into the weeds a bit. In cancer, the goal is to try to kill the cancer cells with high doses of radiation, but at the same time have the normal tissues that are inevitably surrounding the tumor or the space where the tumor was receive less radiation. But we end up using much higher doses of radiation to treat cancer. In low-dose rate radiation, the dose is about one-tenth of that. It’s very low, it’s gentle, it’s designed to calm inflammation, not damage tissue. And so, the focus of the radiation when we use low-dose rate radiation is to provide treatment to the joint, not to treat the joint to regrow the cushion or to do any sort of damage to the joint at all. In fact, it’s such a low dose, the goal is to help mitigate the inflammatory cells that cause the inflammation and the pain and the swelling. So we’ve studied it now for almost a half century. It’s very safe, especially for older adults.

Can LDRT be used for some other joint issues or conditions that relate to the joint? And if so, which ones?

Yes, absolutely. Low-dose rate radiation can be used for chronic tendon and ligament inflammation, things like plantar fasciitis, tennis elbow, bursitis. We’ve treated many patients with the pution’s contracture of the hands. Anywhere where there’s inflammation causing ongoing pain is something that could be treated and could benefit from low-dose rate radiation therapy.

And I would assume that again, the decision to use LDRT for those other conditions would follow the same process that we talked about in terms of osteoarthritis, that if some of these other treatments don’t work, like physical therapy or medications, then LDRT would also be chosen. Is that correct?

Oh, absolutely. Whenever I give these seminars, talks, webinars, now a podcast, I like to describe an example where Usain Bolt, who was a multiple gold medal winner in Tractum Field in 2008 in the spring, he traveled to Germany and received low-dose rate radiotherapy for a nagging injury of his Achilles tendonitis. Here we’re talking about a chronic tendon inflammation from a patient who obviously is a world-renowned athlete. And later in the summer in Beijing, he went on to win multiple gold medals and broke world records. Now, I give this example to demonstrate that even people like Usain Bolt, trust this modality to help their ailments, but I can’t promise patients that they’re going to go on to win gold medals.

Well, that’s okay. We just want to be treated here. And I just wanted to make sure that the rest of us who have these various conditions go through the process as well, and maybe eventually get a chance to see you if that’s appropriate. I would imagine also that perhaps if you’re over 65 and you’re considering this, folks would want to know, is it covered by Medicare? But if you’re not 65, how are insurance companies dealing with this? Is this something that they’re ready to pay for? What can you tell us about insurance?

LDRT Process & History

It’s most major insurers and certainly Medicare plans cover low-dose radiation. But generally, the requirement is that other interventions, more conservative managements have been tried. And as long as someone like me, a radiation specialist who’s certified, prescribes and plans the treatment, most Medicare and most major insurance plans cover it without problems.

Okay. That’s a good thing. Before we get into more some of the details that people would want to know, give us a little bit of history. I was intrigued. This treatment used to be used more, and then it seemed to kind of disappear for a while. So it sounds like it’s not a new idea. Tell us kind of what the evolution was, and now is this also being used in other countries? What should we know about how it got started and why it became a possible treatment?

Sure. This type of treatment has been used now for almost half a century. In America, it was prevalent and we used it often in the 80s. I started practicing in the early 2000s, so it wasn’t something that I was specifically trained in. I trained in more sophisticated manner of using radiation to treat cancer. But treating low dose rate radiotherapy for indications of osteoarthritis is quite old. It’s been used predominantly in Europe and specifically in Germany. In fact, Germany has official guidelines and recommendations. While in America, the majority of the patients that I treat in the department are cancer indications, oncology indications. In Germany, almost a third to a quarter of the indications that undergo treatment in their linear accelerators are actually osteoarthritis patients. In the UK, currently, they have national guidelines that have been written and published. So in the US, it’s been here, but we have focused, at least in the 90s and 2000s, on using various medical interventions, COX-2 inhibitors and other pills. Now that has evolved into a resurgence and renewal of using low-dose rate radiation. The population in America is aging, and so there are more people who are suffering from this ailment, and many don’t want to have surgery. And so I think while it may not be something that’s familiar to patients and to doctors even in the current day and age, it’s a treatment modality that’s well vetted and has been used for many decades. So I would say it’s newer to the US, but it’s gaining popularity because it’s safe, effective, and medication-free.

And are you seeing also that more and more physicians that actually ordinarily treat arthritis are collaborating with you to include this as a possible treatment of choice? Is that also increasing?

Yeah, absolutely. I think platforms like yours doing this podcast, I for the first time did a webinar. I’ve given a talk over Zoom to over 150 primary care providers locally. I’ve spoken with orthopedic surgeons. It’s a wonderful opportunity to get the word out. And I’ll give you an anecdote. I recently had a conversation with my own primary care provider who sees many other patients. And he saw my webinar. We were discussing this modality. And as we were speaking, he mentioned this one patient that he’s been managing for over five years who had terrible knee arthritis, but also had a blood condition that prohibited surgery. And really, he did not have a good medical intervention and solution. And after our conversation, literally 24 hours later, he sends a referral. I get him in. We have a conversation. And he’s one of our success stories. And so I think this outreach is important because when you have this chronic pain that’s developed over many years and you’ve tried physical therapy, you’ve tried medications, you’ve tried injections, and you may or may not need surgery, but don’t want to undergo the surgery, now there’s an intervention in this low dose rate therapy that hopefully can help.

If I or one of the patients that you just described was ready to do that, what happens next? They come to see you. What do you say to them? What is that process going to look like? How long is it going to take? How is it going to relieve the joint pain? Are there any side effects that people need to know? What should they look forward to happening next?

Well, let’s start from what are we trying to do here? What is the goal? And the goal is to relieve pain. How does it relieve pain? Well, the mechanism works at the cellular level by calming inflammatory cells and mediators of inflammation and reducing the pain signals in the joint space, whether it’s your thumb, your hand, your elbow, your knee. So rather than masking the symptoms, it actually helps restore balance inside the tissue by calming these inflammatory pathways. And when we do this, the benefits that we see after the treatment, and we’ll get into the specifics of the treatment in a second, but what I’m seeing and what we’ve seen across the board is pain relief, there’s better range of motion, there’s less need for medications or injections, and the treatments are very quick. They’re painless, they last only a few minutes each, and many patients feel improvement within weeks of the treatment.

Okay, so give us some scenarios of what would be the approach for a patient.

Number one, if you as a patient feel like this is something that is an intervention you’d like to consider, that this resonates with you, that this is giving you an aha moment, oh my gosh, why haven’t I heard of this? You can schedule an initial consultation, and with that initial consultation, we’ll sit down, I’ll review all of your medical history relevant to the problem at hand. We’ll go over your medications, we’ll go over alternatives and possible options for you. Oftentimes, they’ve already done that on their own. And so during that consultation, we’ll really then start talking about what the goals are for the treatment, what the risks and benefits are. And at that point, I’ll describe either specifically or generally studies that are showing 70 to 80% of patients who undergo this treatment experience meaningful pain relief, often lasting months or even years. The side effects are minimal because the radiation dose is extremely low. Once we decide that it’s the right intervention for that particular patient, the next step will be getting insurance authorization. And sometimes I will in advance, depending on their insurance, have insurance authorization so we can save a step. But the next in-person appointment after determining that it’s a good option for that individual, that patient, and the next appointment is a scan of that joint called a CT simulation. So that CT simulation doesn’t require any injections. You just wear comfortable clothes and we show up. And then we immobilize, let’s say the knee, if it’s the knee or the elbow, in a reproducible position and we take a very quick CT simulation of that space. And I like to describe this process as the road mapping or the blueprint. So the CT simulation provides the imaging by which then I will help identify the joint space, draw out targets in the computer. And before the patient even leaves that appointment, we will schedule six 10-minute appointments, generally scheduled every other day over the course of two to three weeks. So it starts with the conversation with either your primary care, with your orthopedist, with the doctor that you’ve been speaking with, but you don’t even need a direct referral from them. If you have exhausted those options, you can call my office directly for a primary consultation. So once you come in for consult, then we discuss the pros and cons. I examine you, review all the diagnostic studies, and then once we determine that’s the route we want to go, we schedule a CT simulation. That CT simulation serves as the most important step for me to plan your treatment. It generally takes me three or four days to plan a treatment. We’ll have you come back for your first treatment. We’ll take x-rays verifying that we’re hitting the right target, that everything lines up. And then after six 15-minute treatments, again, delivered every other day over the course of two or three weeks, I’ll see you back in three months for a post-treatment evaluation.

And if I have arthritis both in my shoulder and in my hip, then when I come in for my treatment, will I have received that treatment at the same time?

That’s a very good question. There are some joint spaces that can be treated simultaneously. For example, we have a patient where both knees are equally painful, and they’re both wear and tear arthritis, osteoarthritis. So in that patient, we’re treating both knees simultaneously. But then I have a patient who has plantar fasciitis, and then thumb arthritis. So that patient will either opt to treat one joint first, and then go on to the neck sequentially, or we can treat both on different days. So instead of coming in every other day for treatment of one joint, we have them coming every day with alternating joints on each day. So it depends on the proximity of the sites, but generally, we treat each joint separately.

Okay. And the approach that you just described, Dr. Hong, given the fact that Aging Matters is a podcast that’s broadcast all over the country, is your approach pretty much what patients in other parts of the country could expect to if they were going to choose to have this option for treatment?

I believe so. I think we’re starting to standardize the protocols. In fact, this year at our International Congress hosted in San Francisco, we call it ASTRO, the American Society of Radiation Oncology, which I’m a member. For the first time, and as far as I can remember, the focus wasn’t just on cancer. It was almost equally focused on what we’re now calling functional disorders, which osteoarthritis was the prominent topic of conversation. And so I think with our international organization, starting to focus on functional disorders and helping people with osteoarthritis, increasing public awareness. Articles were published in the Washington Post and New York Post recently within the past few months. I do think local community facilities will provide this type of treatment, at least I hope so, to their communities, delivered in a very similar way that I described.

And I was just wondering if, given that it’s kind of become rejuvenated, are there still research studies going on, or is it pretty much of an accepted procedure now that is okay and is safe? Or is research still being done to improve it?

I would say absolutely. We’re constantly researching everything. Even if it works, then we’re going to research how to make it better. It’s a well-established, well-vetted standard of care to treat osteoarthritis using low-dose rate radiation. But we are studying it, like we’re studying treatments for breast cancer, lung cancer, head and neck cancer, prostate cancer. So we’re always striving to get better in terms of understanding and improving our treatments. But absolutely, it’s considered a standard of care, it’s covered by insurance, it’s routinely used, widespread, often in other parts of the world. My hope is that we’re going to help people in America, and specifically in the metro DC area in Arlington County, in the DMV, empowering patients with this modality as an option for them.

And as you are assessing a patient, tell us again who is a good candidate for LDRT, and might there be some contraindications that you say, even though it might work and it might be the best treatment of choice, given the circumstances, that there are certain patients with certain conditions that perhaps you would say, no, I don’t think this is the right choice for you.

LDRT Effectiveness & Risks

Sure. So in general, I will say any person with a chronic joint pain or inflammation who haven’t had enough relief from other treatments, whether it’s medical, steroid injections, or surgery, are eligible candidates. We generally avoid LDRT for younger patients during pregnancy, or if there’s active infection or cancer in the same area. So I would say that anyone with chronic joint pain or inflammation who isn’t pregnant or under the age of 50 is an ideal candidate.

Would you also say that there are certain risks that people need to be aware of? Might side effects also occur with some patients? Again, depending on, maybe they’re on other medications or they have other conditions. Just want to make sure our listeners understand all of the possibilities.

Sure. I’ll address the big pink elephant in the room. The biggest fear among patients regarding radiation generally is the idea that radiation causes cancer itself. And that’s not untrue. However, low dose rate radiation delivers a very low dose of radiation. It is 70 to 80 percent effective once the prescription of radiation is delivered to that joint in reducing inflammation and decreasing pain. The risks are very low. Some of the risks that are more tangible and potentially affecting patients who are undergoing treatments, and some may feel a little fatigue. They may see some mild skin redness, but serious effects are rare. The long-term cancer risk, this big pink elephant in the room, is considered negligible, especially in older adults. And when you look at the thousands of patients enrolled on studies that have been published worldwide, there has not been a single cancer caused as a result of low dose rate radiation for osteoarthritis. So, I will say that it’s an intervention that’s a lot of potential benefit with very little risk involved.

And once someone has completed the treatment, then you’ve talked about less pain. How long is that going to last? Is somebody going to have to come back in six months, or is it going to be the rest of their life, depending on how old they are?

It really depends, yeah, it really depends. So I will say that the majority of the people get relief within three months of treatment, and it can last six months, a year. I’ve had patients that have come back two years later requiring a second course. If the pain returns, the treatment can be repeated. The follow up is very simple, and it’s really based on how you’re feeling. But again, in a third of the patients, it may not work. I’ll give you an example. I had a very sweet woman that came into my clinic, and she was elderly and had bone-on-bone knee arthritis. And she was so excited and optimistic. And immediately, I examined her. I saw her orthopedic consultation. I saw her MRIs. And I told her directly, I said, listen, you have very severe arthritis in this knee. I think that it may help, but because of the advanced nature of her arthritis, I kind of set the stage for her to understand that bone-on-bone with constant pain may not be ideal. But we tried the treatment. She got some mild relief, but within three months, it came back. And so for her, I didn’t recommend that we repeat the treatment because I don’t think it was a matter of the dose or the technique or the timing. I just think that her arthritis was very severe and advanced. Now, if you do have severe arthritis or mild to moderate arthritis, again, it works in about 70% of the time. And if it does work, it may be durable for six months, for years. I have patients who have never come back and the pain never came back. The good news is that if it works and the pain returns, the dose is so low that the treatment can be repeated.

You mentioned a little earlier about after someone has the treatment, that they come back to see you. Is that usually for the purpose of just checking in to make sure that it’s been effective and next steps? Or is there some other follow-up care that’s required?

You know, it’s funny you mentioned research earlier. I’m not in a big academic facility. We’re in a very advanced community hospital, so my day-to-day is to help people. I’m boots on the ground helping people in the clinic. And so for my patients, I am following them up in three months and then in six months. And every follow-up, we have a qualified questionnaire that we’re asking them. So I’m in the process of building a book of information to see if I can find any trends or any outcomes that may help me individualize and personalize the treatment further. Again, it helps more often than not, but it may not always show improvement. And so even if it does not show improvement, we will help look and facilitate for other causes or other interventions like biologic injections, nerve blocks, or surgery. The key is that we will help personalize the treatment for each patient. So, I think that it’s a great intervention to try, acknowledging that it may not work, but in the majority of patients it does. And if it does work, more often than not, the effect is very durable, lasting many months and even years.

Future & Access to LDRT

In addition to being used for osteoarthritis, this can be something that’s used maybe for other types of arthritis or other health conditions. I mean, your point is well taken about the fact that adults are living longer. My goodness, they’re living in their 90s. If this has been found to be so effective with a very common chronic condition for older adults, what else can we see?

Well, I mean, I think I have to be very clear here. So, low dose rate radiation calms the inflammatory mediators in these inflamed joints. It works at the cellular level, affecting white blood cells, macrophages, reducing the signals that recruit the cells to the joint that cause pain. And so with that said, any inflammatory mediated aching pain related to osteoarthritis or wear and tear, low dose rate radiation is an option for those patients. If you have an autoimmune mediated arthritis that causes pain, low dose rate radiation is not going to be effective. In that case, biologic therapies, immunotherapy, and the specialist that would need to manage you would be a rheumatologist.

The reason I was asking, I believe it was an article in the Washington Post this morning about inflammation, and that it relates to other types of maladies and conditions in older adults. In fact, it referred to cognitive issues like Alzheimer’s disease. And that was why I was wondering if, again, because we’ve got a population that’s continuing to get older, if new studies are being explored or possible procedures to use something like this since the focus is on reducing inflammation, that it might be eventually applied to other conditions.

I think that these are areas of investigation, and it’s something that I look forward to learning more about and reading about. I’ll give you an example. There are some suggestions in some corners of the world in research labs, far away or maybe even close by, where very low doses of radiation targeting the brain can help mediate some of these unknown, very hard to treat forms of dementia. There are places in Seoul, South Korea, for example, where psychiatrists are using focused radiation, in this case, not low dose rate, but more a functional intervention to apply radiation to help with certain psychiatric disorders that are rooted in certain eloquent areas of the brain that are disrupted. So I do agree that there are many use case scenarios that are being looked at, not only for low dose rate radiation, but for functional disorders that are non-oncologic. And so it’s a very exciting time. I think that there are hundreds, if not thousands, of people suffering in our communities with osteoarthritis that have tried everything under the sun. Well, now we have an intervention that may help. And so that’s exciting to me in terms of bringing a modality that we have in our community, that we have long established a center of excellence for treating things like hard to reach cancers, breast cancers, brain tumors, prostate cancer. And now we’re able to bring our facility and our resources to help people relieve their functional disorders and specifically osteoarthritis.

You are located at Virginia Hospital Center in Arlington, Virginia. Is the treatment that you were talking about, LDRT, always offered, I should say, in a hospital setting or could it be in a clinic? I’m thinking, again, there might be listeners who are located in rural areas and quite a ways from, say, the nearest hospital. And I was wondering if as this treatment becomes more popular, that there might be other settings that patients or people who are interested in getting the procedure might want to have. And where they could look. What should they know?

The treatment is delivered using a machine called a linear accelerator. A linear accelerator produces the radiation and the radiation can be modulated, whether it’s low dose, high dose, it can be shaped. And again, the majority of our volume involves helping patients with cancer using the same machine. So to answer your question directly, patients who live in other states or don’t have access to Virginia Hospital Center, I would say the number one, see your primary care provider or the physician specialist that’s managing your particular element at the time, ask for a referral for a radiation department. For example, I’m affiliated with Georgetown here. Their department is not actually called the radiation oncology department, it’s called the Department of Radiation Medicine. And so, if you’re interested in pursuing this type of treatment, reach out to your local radiation oncologist, whether it’s the hospital or a freestanding center, but if they have a linear accelerator, which is the machine that delivers the treatment, then at that point, it really depends on the physician at that center and whether or not he or she knows how to do this or is aware or willing to do this type of treatment for you.

Based on what you just said, would they need a referral or could they actually get in touch directly with the individual that provides the treatment, the radiation?

It’s a good point. It depends on the network. But for us here at Virginia Hospital Center, you can call us directly. You don’t need a referral. But I think it really depends on the mechanism that your insurer and maybe your health system that you’re a part of requires. For example, if you’re part of Kaiser Permanente, you’re going to need a referral through their organization. And so you couldn’t just call and be independently treated without a referral per se. Or if you’re part of an organization that’s integrated. So integrated meaning the primary care only refers to a specialist within the system. You would have to find out whether or not a radiation oncologist is directly available to you based on that system or your insurer. So it can get a little bit complicated. But for us here at Virginia Hospital Center, because we’re independent, we’re a not-for-profit, we’re a community hospital, any patient who listens to this and thinks they’re eligible can just call the office and make a self-referred direct appointment.

Well, we’re getting close to the end, but I had one more question that also occurred to me as far as permission to do this procedure. And again, the concerns may be when you use the word radiation. Oftentimes, older adults have family members that join them when they come to see you or when they’re getting the recommendation from the physician, the primary care physician, as well as you. Is there ever a situation where the patient might be ready and the family member not so much, or vice versa? The family member thinks that this is something that the mom or dad should have, and the mom and dad is not quite interested. Is there some type of resolution that comes about as a result of making the decision here?

You know, it’s funny you mentioned that. I’m seeing more and more children bringing their parents in to have a consultation and treatment because their parents have been complaining about osteoarthritic pain that have progressively impacted their daily life activities over many months and years without improvement, without any meaningful improvement from injections or medications, and they don’t want surgery. So oftentimes, it’s the children recruiting their parents to me. More often than not, it’s the patient themselves coming directly. I would say we aim to personalize treatment for each patient. I think that it’s one of those things where if you’re in chronic pain and you’re functionally unable to do little things, again, it can be very socially isolating. And when you get into that emotional space where nothing’s working, sometimes you kind of shut off. You’re not listening to podcasts. You’re not seeking advice. You’re not actively pursuing any remedy because you’ve almost kind of given up. Right? And so I’m hopeful that whether it’s a direct referral from the patient, him or herself, or it’s a caregiver who listens to this and recognizes, and it kind of sparks an idea for somebody they care about, or if it’s a kid or a spouse of a parent who may benefit, I think that you shouldn’t be afraid of low dose radiation. Okay? It’s a proven method to help decrease the inflammation, to get people, again, no pun intended, to get people back on their feet again. The risks are minimal, maybe some skin irritation, maybe a little bit of swelling, but not even that has been seen routinely in the hundreds of patients we’ve treated here. The biggest fear of the radiation causing cancer itself, I think, has been sufficiently debunked by demonstrating that not a single second cancer has been reported in the thousands and many decades of patients who have been studied worldwide. So, really, I think it’s really about finding something that may help your quality of life and get you back as an engaged member of society. And really, I think that older people, people who, again, may not have very many options available to them, are ideal candidates for this procedure.

If folks want to learn a little bit more, as we always laugh now about Dr. Google, has all kinds of advice there, but are there certain resources on the Internet that perhaps people could read more about, in addition to, of course, talking with their physician and the radiation oncologist such as yourself. But just in case that folks are interested in some resources online, can you share some with us?

Sure. So I’m obviously a physician at Virginia Hospital Center. So VHC Health provides consultations, educational materials for anyone interested in learning more about LDR and the American Society of Radiation Oncology, believe it or not, is based right here in Arlington, Virginia. It’s our international organization. We refer to it as ASTRO. They have great patient resources online. So I think if you just type in low dose rate or LDR radiation for osteoarthritis into Google or ChachiPT or Gemini, you’re going to get a plethora of information supporting and educating you about LDRT for osteoarthritis. So plenty of avenues online. But again, I think the key is to personalize treatment for each patient. And so once you read about it and you get sufficiently educated to the point where you want to actually learn more about it with the intent of potentially getting treated, I would say call and schedule an appointment for consultation. But there’s plenty of information out there. Again, it’s kind of a hot topic right now, published in the Washington Post, in the New York Post. There’s a lot of kind of awareness about it right now. So the best thing to do is do your research as you normally would online. Like I said, Astro, VHC Health, Google. But then ultimately, give me a call, schedule an appointment. We can do a consultation and very quickly and easily determine whether or not this is a treatment for you.

Okay. Any other final comments that you want to make? Or have you said it all today?

Cheryl, I just want to say thank you so much. This is my first podcast I’ve ever done, but you’ve made it easy. It’s been a pleasure to help raise awareness about new ways to manage joint pain safely and effectively. It’s something that I hope can benefit a lot of people out there that are suffering in silence that feel like they have no other choice. I’d love to come back on and talk to you about cancer treatments. It’s October, it’s Breast Cancer Awareness Month. So there’s lots out there that we need to educate our community. But thank you so much, it’s really been a pleasure.

Well, and thank you, and you’re absolutely right. Having done this program now for nine years, almost ten years soon, I never run out of aging matters. So it’s been a pleasure, and I want to thank Dr. Robert Hong, Radiation Oncologist at Virginia Hospital Center in Arlington, Virginia, for joining me today. Thank you so much, Dr. Hong. You’ve given us so much information.

Thank you, Cheryl.

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