Melanie Cole, MS (Host): Welcome to AHN Med Talks, an informative resource for physicians across various specialties as we delve into the latest medical insights and best practices, ensuring you stay at the forefront of your field.

I'm Melanie Cole. And today, we're highlighting osteoarthritis treatments in radiation-oncology. Joining me is Dr. Chirag Shah. He's a radiation-oncologist and the Division chair of Radiation-Oncology at AHN Cancer Institute at Allegheny General Hospital.

Dr. Shah, thank you so much for joining us today. Before we get into this, tell us a little bit about the burden of osteoarthritis and what has been the historical treatment. So, why are we doing this exciting new modality?

Dr. Chirag Shah: Yeah. Thank you for having me, Melanie. Osteoarthritis is one of the most common health afflictions facing Americans, particularly as our population ages. It's a disease that can not only cause discomfort, it can impact quality of life.

Traditionally, treatments have ranged from the very basic treatments that we think about, things like physical therapy, anti-inflammatories to more invasive procedures like injections of steroids and synthetic joint fluids, and then to the most invasive, which have been typically things like joint replacements. And all of these treatments can be effective at different stages of osteoarthritis. But there's been a need and a want for another non-invasive treatment for osteoarthritis, and that's where low-dose radiation offers an opportunity.

Melanie Cole, MS: That's really cool. So, why are we seeing a resurgence in the use of radiation for benign disease? When did this start? Give us a little evolution of this.

Dr. Chirag Shah: I think it's interesting when people ask me about this exciting new technique. And I have to laugh a little bit and tell them that this is a technique that dates back to the 1900s. So shortly after the discovery of radiation and the beginning of using it for medical treatments, it was studied for the use of benign diseases. And one of those benign diseases was osteoarthritis. So, some of the first reports come out in the 1930s and 1940s showing the benefits of low-dose radiation for arthritis. It fell away as a treatment in the 1970s and 1980s in the United States, but remained a common treatment choice in Europe. One-third of all radiation treatments in Germany, for example, are for benign disease.

I think what we've seen over the past five years or so is a resurgence in the United States as people have become interested and programs and guidelines have been developed, such that it was even an article in the Washington Post recently discussing the use of low-dose radiation for osteoarthritis.

Melanie Cole, MS: Wow, that's pretty cool. And it has been around quite a long time. So, tell us a little bit about the process itself and the data that surrounds this low-dose RT for arthritis. What are we seeing as far as outcomes, patient satisfaction, ease of application, all of that?

Dr. Chirag Shah: Yeah. So, I think it's important to talk through kind of the data and then kind of what it means for patients. So, we have robust data on the use of low-dose radiation therapy for arthritis. And I think the first thing that patients ask me is what does low-dose radiation mean? And I'm primarily a breast cancer oncologist, and so I use that as a good comparison. The total dose we use for low-dose radiation is about 10% of the dose we use for breast cancer treatment, so at a much lower dose per treatment. And studies have consistently shown anywhere from a 50% up to a 70% or 80% benefit with the use of low-dose radiation for osteoarthritis. And that can include things like pain, functional outcomes, and quality of life. There was even a recent randomized trial looking at low-dose radiation therapy for arthritis of the knees that showed a positive benefit with the use of low-dose radiation for osteoarthritis.

In terms of what this means for patients, we typically see patients for consultation first, making sure that they're good candidates for radiation. We don't treat patients who had previously had knee replacements or joint replacements of the affected area. We make sure that they don't have a history of conditions that would exacerbate side effects of radiation. And we make sure that their pain and discomfort isn't caused by an alternative etiology. For example, I saw a patient who had a tear in their meniscus and it was unlikely low-dose radiation was going to impact that. And so, we talk about discriminating what we can help with and what we can't. If they decide to proceed with treatment, we do a CAT scan to plan the radiation to create a three-dimensional model of the joint. And then, they subsequently undergo treatment two to three times a week for just six total treatments. Each treatment takes about 10 to 15 minutes. They lay on the table, the affected joint is treated, and they're on their way.

In terms of side effects, in a series of about a thousand patients, one patient had mild redness of the skin. Long-term, these doses are very low. So, we don't expect any issues with long-term healing. We don't expect any issues if the patient needs a joint replacement down the road, as the doses are very low. And they're able to do all their normal activities during the course of low-dose radiation as well.

Melanie Cole, MS: Well, my next question was going to be about counseling patients on the benefits versus the risks, and you just basically said the risks-- that's great for patients. What are they saying about this?

Dr. Chirag Shah: Yeah, you know, we've had really great outcomes. So, we started the program at AHN in early 2025. We've treated several hundred patients so far, and we've heard really great stories. We've heard from patients who were previously really struggling to use their joint who come in telling us that they feel so much better and are doing great. And we have patients telling us that this is going to allow them to avoid having a surgery or needing continued injections. So, that's been great.

I do always counsel patients that some patients unfortunately don't get that benefit. And that while many do, some don't. I always also, in terms of long-term risk, counsel patients that any x-ray, whether that be a chest x-ray, a CT scan or low-dose radiation for arthritis can in theory cause a cancer. But we feel that risk to be very, very low given the dosages of radiation we're using.

Melanie Cole, MS: Yeah. Low-dose radiation really has so many benefits and we're learning so much more. What other diseases or conditions do you see emerging or growing areas for low-dose radiation therapy? It's a pretty exciting time in your field.

Dr. Chirag Shah: Yeah. I think it's one of those Back to the Future times in the specialty of radiation oncology. And that we had kind of abandoned some of these ideas of benign disease. Actually, my group recently just published a paper in the Lancet Medical Journal using low-dose radiation for hydradenitis, which is a chronic skin condition that's very hard to treat. We also have considered using radiation for things like plantar fasciitis, another inflammatory condition, as well as things like keloids and other benign conditions. So we continue to see growth of the use of benign indications for radiation, and I expect that to continue in the years to come.

Melanie Cole, MS: Dr. Shah, tell us a little bit about the AHN Department of Radiation-Oncology, the approach to radiation for benign disease. Tell us about your team and the multidisciplinary approach to all of these conditions.

Dr. Chirag Shah: The radiation-oncology department in the Allegheny Health Network Cancer Institute is actually 12 separate centers in our network currently. And we have 22 radiation oncologists as well as many radiation physicists, therapists, nurses, dosimetrist. So, we're a big group. And really as part of benign disease, I joined the Cancer Institute a year ago as the chairman. And my approach to benign disease is to be consistent. So regardless of what center your patients are seen at in the Allegheny Health Network, they're going to get consistent treatment.

And what that means for benign disease, for example, is we have a department-wide guideline. So, that helps with things like the age that we treat patients at, the indications, the workup, all of that, but also how we treat the patients in terms of the radiation. So, making sure the fields are standardized, the doses we're using are standardized. The regimens are standardized. That way, my biggest goal has been it shouldn't matter what center in the enterprise you're treated at, you'll be treated the same. And that's really been effective.

Also, every one of these cases is peer-reviewed, meaning another physician or another group of physician reviews the case on top of the primary doctor to make sure we're following that ethos of high quality, high consistency, radiation care. We're similarly using those approaches when we expand into other benign indications, making sure that we're doing it in a thoughtful evidence-based way that allows consistent high-quality care to be delivered.

Melanie Cole, MS: That's so important. And, Dr. Shah, finally tell us a little bit about life after radiation therapy for osteoarthritis, as we know that it is degenerative and chronic and age-related as we get on in years, where do you see this going? What do you see happening for these patients? Do they come back in a few years later? Do they still continue? There are NSAIDs or there are other medications for that joint. What happens after?

Dr. Chirag Shah: You know, in terms of what happens after the radiation, it really depends on how the patients respond. Patients who have a complete response after that first course of radiation, I typically tell them to stay in touch. And if they need anything, to call me anytime. I often will hear-- and I remember a very interesting story. I had a patient who had knee osteoarthritis and I treated them. And they told me they got so excited about playing pickleball, they overdid it. And so, about six months to a year later, we had some pain come back and I retreated them, and that made them feel better.

And if they do get symptoms, we can retreat them in that situation. Also if it eventually progresses, they may end up needing to see orthopedic surgery for a replacement. For the patients I see in followup who have had a partial response will often offer them a second course of radiation therapy even three months after their first course to see if we can get them to a complete response. And the goal is if they're feeling better to get off their NSAIDs if they don't need them to be increasingly active and being functional. So, that's how we approach it. We do have the opportunity to retreat, and we are a part of their multidisciplinary team throughout their care journey.

Melanie Cole, MS: This is great information. Dr. Shah, do you have any final thoughts for other providers that are counseling their patients about possible radiation therapy for osteoarthritis? And what you'd like them to know about what you're doing there at the AHN Cancer Institute?

Dr. Chirag Shah: I think just like most diseases in healthcare, osteoarthritis is a multidisciplinary team. And so, I spent a large part of my initial journey in this program meeting with primary care physicians, orthopedic surgeons, sports medicine physicians. And if you ever have a patient that has a question, never hesitate to reach out to me or my team. We're happy to look at x-rays, discuss through the treatments, discuss alternatives, and to see patients whenever needed. So really, it is a team sport and we're always here to engage with our colleagues on this topic or any other.

Melanie Cole, MS: Great information, Dr. Shah. So well put. Thank you so much for sharing your expertise with us today. And to learn more or to refer your patient to Dr. Shah, please call 844-MD-REFER, or you can visit findcare.ahn.org. Thank you so much for listening to this edition of AHN Med Talks with the Allegheny Health Network. I'm Melanie Cole.