It's Your Health Radio, a special podcast series presented by Henry Mayo Newhall Hospital. Here's Melanie Cole.

Melanie Cole, MS (Host): Welcome to It's Your Health Radio with Henry Mayo Newhall Hospital. I'm Melanie Cole. And today, we're talking about low-dose radiation therapy, or LDRT, and who it's for and really what it is.

Joining me, we have a panel for you today with Dr. May Lin Tao. You all remember her. She's been on with us many times. She's a Clinical Professor of Radiation Oncology at the Keck School of Medicine and the Medical Director of the Keck Medicine of USC Henry Mayo Newhall Hospital Cancer Program. And joining Dr. Tao today is Julie Burns. She's a radiation oncology nurse for Keck Medicine of USC. She has also been a low-dose radiation therapy patient.

So, this is going to be a really interesting show. Thank you both for joining us today. So Dr. Tao, I'd like to start with you. First, give us a little background on how you two know each other and give us some context to work with here.

Dr. May Lin Tao: So, good morning, Melanie. I've been a radiation oncologist now for going on over 25 years. And Julie and I have been working as a pair doctor-nurse for probably over 15 years, maybe more than that. Julie, you might remember.

Julie Burns: Yeah.

Dr. May Lin Tao: I think it's been more. And many, many, many, many of our patients have been cancer patients. But most recently, there's been a surge because of increasing clinical evidence and adoption of some practices that have been more done in Europe than they've been done in the United States of applying radiation at very, very low doses. So, completely different mechanism of treatment for benign entities.

In particular, when we talk about low-dose radiation for chronic inflammatory diseases. And it's a pretty common affliction. Many, many of us have had arthritis or some kind of bursitis, fasciitis, tendonitis, those kinds of things. And so, Julie, of course, had that as a issue as a patient. And so, she was one of our relatively recent patients that we treated. So, I can tell you a little bit more about low dose. I don't know if Julie wants to introduce herself.

Julie Burns: Yes. Hi, I'm Julie, and I've worked with Dr. Tao, she mentioned, for many, many years. And yes, we've had treated quite a number of patients for benign conditions using the low-dose radiation. And I actually started to see the benefits that many patients received after getting their treatments. And I've suffered from the plantar fasciitis, also some hand and knee joint pain. So, that's why I decided to go ahead and try it for myself.

Melanie Cole, MS: Well, thank you both for explaining a little bit about that. So, Dr. Tao, what is low-dose radiation therapy? You mentioned a few things that it could be used for and that we've always thought of radiation therapy as being simply a one of the modalities in adjuvant therapies for cancer. But now, you're using it for so many other things. Tell us a little bit about it.

Dr. May Lin Tao: So, low-dose radiation is really kind of a whole separate ball of wax than the radiation therapy that we use for cancer treatments. So, the first distinction is the dose and the mechanism for how it works. So, I often like to say really the dose we're using for this application is probably 1% or even less of that than a dose we typically give for cancer treatment.

So, hence, it makes sense that the mechanism for how it works is really quite different. So, there is not what we call a tumorcidal effect because there's no tumor there and really not trying to kill cells. But what we're trying to do is really kind of affect the immune trafficking, is the term I like to use in situations where there's a chronic inflammatory cycle being set up. So arthritis, fasciitis, any of these itises, which is just code word of saying inflammation. There's a whole immune cascade that your body does to respond to these areas where there might be some trauma or just degenerative changes over time, or sometimes it happens spontaneously where you get a lot of inflammation in an area.

And so, the low-dose radiation actually cuts that inflammatory cycle along multiple points along that cycle and quiets down that inflammation and hence, typically what we'll see in those who are responders is a decrease in the pain and more functionality and just an improved quality of life. It's not everybody who has that level of response. Probably the richest information we have is in the setting of osteoarthritis, where it seems to have the biggest application, certainly in Europe and the United States. And that's probably just because it's the most common entity that we deal with in this category.

I'd say about two-thirds to 75% of patients will say they have a significant response. And in patients who only have a partial response, we'll sometimes even give a second course of radiation, typically two or three months later, and those patients can enjoy even an additional response. So, it's not everybody. But for those who do have a response, it can be a real game-changer in terms of their quality of life and their functionality.

Julie Burns: Yes, I agree with Dr. Tao. Seeing the patients that we have treated, we do have about two-thirds of all of our patients have had response and have had either complete response or has had a reduction in pain and increased function and mobility.

Melanie Cole, MS: Well, thank you for telling us about that, both of you. It's really fascinating how these kinds of things ebb and flow into different categories, and then they work for different conditions. That's so interesting to me. So Julie, speak about patient selection, because as Dr. Tao was speaking about the itises and some of the things that it might be used for, how do we know if somebody is a candidate for this type of treatment?

Julie Burns: So, we bring them in and Dr. Tao will do a consultation evaluation. It's typically for patients that are over 50 years of age, and we usually like to get an X-ray to see any the indication for osteoarthritis. There is a scale that's used when X-rays are obtained. It's the Kellgren-Lawrence scale, and that is used to determine the level of osteoarthritis that the patient may have.

Some of the other inflammatory conditions, such as plantar fasciitis or bursitis, that's done by clinical assessments. And patients, they would be coming in to get their treatments over six courses, over a two-week period.

Melanie Cole, MS: So Julie, expand then a little bit on, what that typical treatment regimen consists of over a two-week period, six courses. Tell us how long it takes. Is it like an MRI? Tell us what it's like.

Julie Burns: Yes. So for our machine, before we start any type of radiation treatment, we do have to have a planning session. And in that planning session, you're brought in. You will be placed on a CAT scan table in the position that you'll be in for your radiation treatments. They sometimes will make a little mold for your hands to lay on or for your knees or feet to lay in. And that way, they can replicate that same position each time that you come in for your treatments. So, that initial planning session is separate from the six sessions that are given for treatment, and that typically takes about 30 to 40 minutes in time.

And then, about a week later, you'll start your radiation treatments, and it's usually every other day. The treatments take about 15 minutes each session. You come in, you get your treatment, and then you leave. You'll meet with the doctor and myself at least once during those sessions just to check in to see how everything is doing. But the treatments are relatively quick, painless, you're laying on a table. Our machine looks very similar to a CAT scan, which is a donut-shaped machine. And so, it is open on both ends. And the treatments, again, are very quick, about 10 to 15 minutes each session.

Melanie Cole, MS: So Julie, tell us a little bit about your story. You've received LDRT, and tell us about your experience. What was it for and how did it work for you?

Julie Burns: Yes. So I first received this for my plantar fasciitis in my feet. Recently, my feet were becoming very sore, particularly every morning. It was very difficult to get up and walk. I would have to take ibuprofen, and it took me a while before, you know, I was able to walk. I would even come into work limping because the pain was so bad. So, that's when I decided to get the treatment for the plantar fasciitis. And I would say after the second session, I noticed an improvement where I did not have to take any medications for the pain. And then, in fact, I was able to get up out of bed most mornings with very limited pain and very limited stiffness. And now, here we are six, months later, I am able to get up. I don't have to take any medications. I do dancing as a hobby, and I can really do all of my dance steps without suffering after or during. So, that's really been a plus for me and helped me during my quality of life.

Secondly, I did it for my hands and my knees together for my osteoarthritis. My knees when walking, you know, they would get a little painful. And then, my hands, particularly when I was driving, I noticed holding onto the steering wheel, they would get quite stiff and achy. So. I've had really great results with my hands. I no longer get the achiness or the stiffness that I had once before, and that continues to this day. My knees, they did improve. Overall, there was improvement. It wasn't as dramatic as the other two sites, but I'm still very pleased because I don't have to take pain medications and I can still get up and about. I do have better range of motion overall.

Melanie Cole, MS: That's so cool. I was just telling you off the air that I started suffering from some ankle pain and upper arch and foot pain, and I've tried all the orthotics, and I wear all the great shoes. So, this is really cool for all of us to hear that this is sort of a new type of therapy. Dr. Tao, where do you see LDRT fitting in for these kinds of arthritic conditions versus something like pain management, cortisone shots, you know, systemic therapies, topical therapies? Where do you see this in that continuum of care? Because we always like to say, you know, conservative measures first, and these kinds of conditions can really be, as Julie said, life-limiting. So, tell us where this fits in.

Dr. May Lin Tao: Yeah. I also just want to first mention that, although we think of it as "new" in the United States, it actually has been around for many, many decades. In fact, the first described case of using low-dose radiation for the arthritis was at the turn of the century, and that, in fact, was in the United States.

And then, around the 50s or so and the 60s, as we started to develop better things in orthopedic medicine and physical therapy became more sophisticated and we had better anti-inflammatories which were readily accessible, it sort of fell out of favor in the States, although it continued to really be in pretty active use in Europe and particularly in Germany. So, if you consider the worldwide experience, that's where they're using it a lot. So, it tends to be used a little bit earlier, I suspect in Europe than it tends to be used in the United States. Our routine still in the United States when someone has these kinds of conditions is usually first starting off with conservative measures about just like footwear or weight loss, things you can do to relieve the pressure. And then, usually, ibuprofen or some kind of other inflammatory agent. It could be even topical. And then, patients for the large joints will often see orthopedic medicine because that's kind of the usual referral when we have joint issues and they may get a cortisone injection.

Now, they're using hyaluronic gel injections, although the evidence behind that is a little bit more limited. So, that's often not paid for by insurance. And I think there was just a recognition that patients were still suffering from these entities and there was a need for more therapy short of getting a joint replacement, which is ultimately the way to fix osteoarthritis in the permanent long run, if you really want to definitively address it.

But it's a pretty large jump for folks. So, it's kind of in that setting, that low-dose radiation sort of regrew in the United States in how we're seeing it applied today. But oftentimes, I would say most commonly, we'll have seen patients that have come through that have already at least tried oral anti-inflammatories, physical therapy, and/or injections.

Melanie Cole, MS: Cool. So, what about insurance, Dr. Tao? Is this something that is typically covered? Because as we hear more about things like PRP and, you know, these various modalities, insurance doesn't necessarily cover those. What about this?

Dr. May Lin Tao: Yeah. So for Medicare patients, it's never an issue. So, our good old government insurance covers it without any problem. Many of the PPOs do too, and the HMOs, but not all. So, any facility in which you go to get this kind of treatment, meaning any radiation facility, we certainly always do pre-authorization checks and make sure that it's covered under your benefits. And we have a whole process of leading patients through potentially financial assistance or what, you know, the estimate may be if there was out-of-pocket payment. So, I would say most insurance is covered, but not all the commercial ones.

Melanie Cole, MS: Yeah, that's good to know. So Julie, as we get ready to wrap up here, and I want to give you each a chance for a final thought. As a radiation oncology nurse, and you've seen the use of radiation therapy for so many different conditions, what do you want people to know about not only your expertise in using low-dose radiation therapy now, but also your experience using it?

And for people that might be a little weary and say, "Oh, radiation," or, "Oh, this" you know, all the different things that might be myths that you can bust up here, what do you want them to know about the ease of using this kind of therapy and the outcomes you experienced?

Julie Burns: Yes. I'd say that this is a really great option, and I feel that for patients that do have any underlying inflammatory conditions such as osteoarthritis, this can be a very good option, particularly for those patients in the older population where maybe they're on certain medications such as blood thinners and they're not able to take any of the NSAIDs or, you know, nonsteroidal anti-inflammatory medications that would really help for their pain.

Also, if surgery may not be an option for them, I think that this is a really good way for them to try it out and to see if it would help reduce their pain and increase their quality of life by increasing their functionality, decreasing their stiffness and overall mobility. The side effect profile is very minimal. There are little to no side effects. Occasionally, patients may have some skin redness to the area of treatment. And there's only been, like, one in 1,000 patients that have had any type of skin reaction. There hasn't been any recorded secondary malignancies associated with receiving low-dose radiation. And it's very easy to do. When you're getting the radiation, you don't feel anything. It's not painful, and it's very quick. And I've seen a lot of patients that have had great results with their improved mobility, decreased stiffness and decreased pain.

Melanie Cole, MS: That's such great information and I'm glad it worked for you. Thank you for sharing your experience and your story. And Dr. Tao, last word to you. What do you want people to know about this option, this modality for treatment of the various body conditions that can affect our quality of life?

Dr. May Lin Tao: Part of it is like when we do anything in medicine, we look at the risk-benefit ratio. So, we admitted that it's not 100%, but the truth is there's rarely anything in medicine that's 100%. But for those for which it makes a difference, the difference as Julie used for her own self, can be quite dramatic. It can really be a game-changer when other avenues haven't worked.

The other thing is the bar in terms of like what you need to go through to actually get the low-dose radiation is pretty low. The treatment sessions, there's only six of them. They're given typically a couple of times a week. You're only in the department maybe or a clinic for about 15 minutes, 20 minutes, in and out. You don't feel any acute toxicity. I would say, truthfully, it's rare that anybody experiences anything. We haven't seen any real skin reaction. We've had one or two out of now probably close to 200 sites that we've treated where a patient says they get short-lived fatigue.

There's a theoretical risk, as Julie mentioned, of secondary malignancies, which is always something we think about when we consider radiation, but there's never been any reported cases of that for the application in osteoarthritis. And that includes the European or German experience.

So, the risks, shall we say, associated with it are really pretty minimal. And it doesn't obviate you getting anything else. So, one, if they were to go on to get, for example, even a knee replacement, this does not prevent, or increase the risk for complications that we know of. People can go on to get injections. So, it doesn't hold you back from trying other things should that be the case.

The durability, meaning how long it lasts, I think we're still learning about. The literature would suggest up to two years or so. Julie, she's been several months now out from treatment, and I would say we have a number of patients several months later, because we like to continue to follow our patients that tell us there's still a benefit.

Melanie Cole, MS: Wow, that is great. You know, the more tools in the armamentarium of pain management and arthritic conditions, the better. So, this is just one more, and it sounds like it's getting great results. So, thank you both for sharing your expertise and your experiences and telling us about LDRT and the results that it can possibly have for patients that are experiencing pain.

So, thank you again. And to learn more about LDRT or to schedule a consultation, you can call 661-839-1810. You can also visit our website at henrymayo.com for more information. You know, you can always visit the free Henry Mayo Newhall Hospital online health information library at library.henrymayo.com because we have so much great information there, and you can find information on all kinds of topics, including LDRT.

Thank you so much for listening to this episode of It's Your Health Radio with Henry Mayo Newhall Hospital. I'm Melanie Cole. Until next time.