Latest / Rad Chat / E217: Dr. Richard Shaffer - Radiotherapy for Benign Conditions

Transcript

E217: Dr. Richard Shaffer - Radiotherapy for Benign Conditions · Rad Chat

• Naman Julka-Anderson (00:00) Hello everyone and welcome to Rad Chat, founded by me, Naman Julka- Anderson. Jo McNamara Rad Chat Host (00:04) and me, Jo McNamara. So Rad Chat is a forward thinking global knowledge hub where healthcare professionals can advance their expertise in radiotherapy and oncology. Unlike traditional academic resources, we blend real world experience, expert insights, best practice, and of course, most importantly, patient perspectives. Naman Julka-Anderson (00:23) We make advanced knowledge engaging and accessible, supporting continuous learning and professional development without compromising patient care or personal time. By providing insights into both technical skills and career development, helping you progress confidently in your field and shape your professional future. Jo McNamara Rad Chat Host (00:39) Just to let you know, our episodes may contain sensitive and difficult topics that you may find distressing or triggering. Naman (00:46) So this episode is part of the Education Workforce Development series, where we will be hearing from our guest Dr. Richard Shaffer talking about the role of radiotherapy in treating benign c conditions. Hi Richard, how are you? Richard (00:57) Yeah, good, good. Thanks for having me on. Naman (01:00) Thanks for being on, so could you just start and tell us and our listeners just a bit about your background, what you do now. Richard (01:06) Sure, well I'm a clinical oncologist and I guess I had pretty standard training but I went to Vancouver and did a fellowship for about 18 months. It was all about technical ready therapy so at the time it was all about IMRT versus VMAT and SRS stuff and that was really actually my passion and then I came back, finished my training, did a consultant job in Guildford doing brain neurology and skin. And I think it's fair to say that by the time I came to nine or 10 years into that, I sort of, that time came to an end, let's just put it that way. And so that's when I actually left the NHS. But sort of taking it back to the beginning of my consultant job, on probably about six months in, a local hand surgeon said, look, I've got this patient with Dupuytren's disease. You know, I've heard about radiotherapy. Do you know anything about it? And I said, no, but it sounds interesting. And that was my first patient. And so basically I treated one patient. I paid someone to make a website, 250 quid. It was called something like dupatransradiotherapy.co.uk. And I basically started my benign radiotherapy practice pretty well within six months of starting my consultant job. So obviously 99 % of my time was taken up by treating the brain and the prostate but there was already that sort of seed in me. And during my training also I was treating heterotopic ossification and keloids. The normal bits of gynaecomastia, things you don't even think about that are benign, but we all get trained to do and we don't really think of as benign. And then I had this sort of new thing and I was sort of wondering whether it was okay. I'd never been taught how to do it. I didn't know anyone else who was doing it. And I asked, actually a colleague who was a much sort of more senior oncologist, know, does this seem okay to you? And he said, look, you know, when I was doing it in the eighties, we used to this all the time. It's like not a big deal. So it sort of made me feel okay. And then fast forward to 2019 when I left, I'd probably treated, I don't know, one and a half thousand patients with Dupuytren's disease. And I left to develop, you know, a practice, but also just to sort of see if I can make that my thing. And I didn't really think that I was going to stop treating cancer, but when you're not in the MDT and stuff, that just sort of fades away. And so that sort of gradually, I still see a few prostate patients, but basically it faded away. And that really became the focus of what I did. So I thought, what are the angles that I can use to sort of get involved in this? So. I started working with xstrahl who made the KV machine, know, the auto voltage machines, became the medical director. I started international organisation looking at this subject. What else did I do? I'll think of it, but you know, various bits and pieces. And then I guess the really transformative time for me was I went to Germany, sat in their clinics and really looked at what they're doing because, you know, this is a massive part of their practice, which I'll talk about. I'm sure as we have our conversation and really learn from the masters, know, the sort of seat of where this is. And that's sort of how it, how it sort of came, you know, to where I am now. I'll stop talking at that point, but that's a brief phrase here anyway. Jo (04:32) No one... I love it, I love it. I also love the fact that, you know... a normal person would be like yeah I'm moving away from this area I think I'll dabble in something else you're like right no I'm going headfirst into this and I'm going to change my whole career and change practice worldwide I think that's incredible that that's kind of what you've led and for any listeners what's the difference between benign and malignant Richard (05:00) Well, I mean, it's quite interesting. I've been thinking about words a lot recently. And by the way, I actually call myself an ex-oncologist now, because obviously I trained as an oncologist, but I just don't treat cancer anymore. So I actually call myself a radiotherapy specialist, which is a little bit of a new or radiation medicine specialist. I think words are really important. If we call ourselves oncologists, it implies we're cancer doctors and then it becomes a little bit more difficult than to move into non-cancer conditions. So addressing your question, what does benign mean? Well, I mean, it means not cancer. And that's a slightly odd way of putting it, because if someone, a normal person, has osteoarthritis, let's say, they don't think, that's amazing, I don't have cancer. They just think, I've got osteoarthritis. So it's a little bit weird that we talk about things in terms of the not being malignant. And that's a very sort of specific way. So in the States, they're calling it functional medicine now. I just call it radiation medicine or radiotherapy really. But benign, yeah, non-counter conditions. Naman (06:07) Do you miss the oncology aspect? Richard (06:11) No, I don't actually. I don't. I mean, it was funny. I left about a year before Covid. There was no plan, obviously, to do that. And, you know, at the time I started to feel slightly guilty and I thought, you know, I'm going to go back and do something. And I thought, you know, what am I going to do? You know, I could go to a vaccination clinic but I'm not like a super vaccinator, so let's go and do some oncology clinics. So I went back and I did some prostate cancer clinics and I thought this is fine and it's the same as it was and I don't really miss it, that's honest truth. And I think part of it is the real joy for me of benign radiotherapy. There are quite a number of things, but one of the things is that I am a... I guess, an expert in something quite niche. Whereas I always felt when I was working in prostate and brain that I was just someone, just another guy doing it. And anything I'm going to add is adding another 0.01 % into the knowledge base or, know, obviously you help your patients, that's important. But in terms of really making a difference past the one-on-one, I really felt that I wasn't really offering very much. Whereas now, rather than a 0.1 % change, I can make a 50 % change or a 200 % change. And it really feels like you can make massive difference in this new subject. Jo (07:56) So you mentioned a little bit about Germany. Why are they the leaders in treating benign conditions with radiotherapy? How's that kind of evolved? Richard (08:05) So, well, if we just go back, x-rays invented in, 1895. First patient treated with x-rays in 1896, which is actually a benign patient. It was a five-year-old girl with a hairy nevus on her back. And she was way over-treated, terrible side effects. But after that, you until sort of 1960, they worked out doses, they worked out indications, and then they standardized the treatments. So until 1960 was really a very large part of the practice. From 1960 onwards there were some changes. One change, there were new treatments. So non-steroidals, they didn't really exist before then, and also steroids as well. So those were obviously things that you could use for these benign conditions. The other thing that happened is particularly the Court Brown Dole paper, which was the secondary leukaemia, secondary to radiotherapy for ankylosing spondylitis. Now that paper is, there's a lot of issues with that paper. First of all, these are very high dose, average dose of 40 gray, they treat a large part of the spine. But the real issue is that actually both leukaemia and enclosing spondylitis are HLA-B27 associated. So actually it may well be that those patients were more likely to get leukaemia in the first place. So all of those things mean actually maybe the whole thing was overstated, but things... like that and other sort of radiation-induced cancer scares basically and you know rationing and you know other treatments as I said sort of put people off treating it. But what happened is you know in the parts of the world particularly behind the Iron curtain they didn't have enough money to buy these new treatments and so they just carried on with these old cheap treatments basically they just literally carried on and then fast forward to 1989 when the Berlin Wall comes down and then East Germany and West Germany start talking to each other and the East Germans and the West German doctors start talking and then the West Germans start learning from the East Germans about this sort of whole tradition that was lost to the Western world. And then my colleague Heinrich Siegenschmidt, who really is the one that I've learned a lot of this from, he started the DEGRO, the German Benign Radiotherapy Group, he led for about 25 years, and they really started to do lots of trials, guidelines, educational courses and really brought it to a massive thing in Germany. mean, they now treat 150,000 patients a year roughly in a population of 87 million. I mean, for our population, that would be more than 100,000 patients a year if we did the same as then. And so that's really how it came about. But then, of course, the Germans did it in Germany and Austria and Switzerland and also another couple of European countries. But it just didn't really come to the Anglo-American countries. It just, I don't know, it just didn't really cut through. I think lots of reasons for that, partly because a lot of the stuff was in German, and also because the evidence they produced wasn't perhaps at the sort of standard that we would hope and expect. A lot of what they did was lots and lots of case, like massive case series, but not randomised controlled trials. And so, you know, if people were looking at these treatments, they were like, well, you know, historical evidence, but you know, not really mainstream. Naman (11:29) So I suppose for anyone listening, is it safe, and how many conditions can you treat? Richard (11:35) Okay, so just to take the history a little bit further forward. So, you know, over the last sort of 10, 20 years, it has now started to become more mainstream. I mean, it was really pretty well the major theme last year in Astro, for instance, and this year actually, you know, it's another very large theme again. And so this is becoming much more acceptable. In 2022, there's a paper, a review paper in the Red Journal about radiotherapy for osteoarthritis. So the Germans, sorry, the Americans have taken osteoarthritis as, in inverted commas, as an easy thing they can treat. I think it's because you can just encompass it in one word, even though it's lots of different things. So osteoarthritis is a really big thing. Tendonopathy or tendonitis, bursitis, plantar fasciitis, those sort of things. So in Germany, about 45 % of what they treat is osteoarthritis. Another 45 % of what they treat is tendinopathy bursitis. And then bits and pieces are other things like dupuytren's, which no doubt we'll talk about. And then you've got the sort of intracranial sort of benign tumors, trigeminal neuralgia, acoustics, that sort of thing. So most of what we treat is musculoskeletal conditions. Osteoarthritis and tendinopathy are the main things. And I, in my mind, call that low dose radiotherapy. Why do I call it low dose? Well, obviously It is a low dose, but really it's a very low dose. And it's a completely different concept from what we use for cancer, let's just say, I know we're talking to a very educated audience, but let's just say for cancer using, you know, roughly 60 to 80 Gray total dose as an anti-proliferative treatment for cancer that really wants to grow a lot. So that's why you have to use such a high dose. For benign hyperproliferative conditions, you'll be using an intermediate dose of let's say 20, 30 gray. So that would be a keloid or dupuytren's or plantified bromatosis. And essentially that again is stopping your benign overgrowth conditions growing. You don't need as high a dose as you do for cancer. But when you come onto low dose radiotherapy, it's just a completely different concept. There's no anti-proliferative side. It's just used as an anti-inflammatory treatment. And so basically, we use three gray and six fractions as our standard dose. 0.5 gray per fraction. Why do we do that? They found experimentally in radiobiological experiments that between 0.3 and 0.7 gray is the sweet spot for the anti-inflammatory action. Now, if you go below that, there is some debate you still might get some anti-inflammatory effect. But if you go too much above that, you actually lose your anti-inflammatory effect. So it's not like more dose, more effect. It's actually there's a window of opportunity dose-wise. And so this is the low dose radiotherapy sort of realm. So low dose, low toxicity. Basically, with 3 Gray, there isn't really any toxicity. That's the honest truth. I always tell my patients they might get a little bit of red skin, they might get a bit of hair loss in that area. Also, actually, if you're treating someone with, let's just say, I don't know, plantar fasciitis, know, so heel pain. I always say, well, there's a 20 % chance your pain might get worse before it gets better. That's another side effect I tell them about. If you're using the intermediate doses, then you might get some skin redness, and it's a little bit like you get, obviously, let's say in a breast treatment, but much less because of lower dose. So, you know, long-term, I normally say there's a 20 % chance of grade two dryness that they just need to put a bit of moisturiser on. But the really important part is does radiotherapy when you give it for benign disease cause cancer? And that is the real sort of golden question. And the answer is yes, but it's much more complex than that. And so if you think about it in two separate extremes, let's go back to the ankylosing spondylitis example. So let's just say I'm treating someone's spine, but I'm only using three gray. But the problem with treating someone's spine is you've got red bone marrow there. And therefore, you've got a risk of haematological malignancy. Think about haematological malignancy, one, not a good thing to get, but two, has a low latency periods. In other words, the time between giving radiation and actually getting that leukaemia is, let's say, five to 10 years. So if I'm treating someone in their 70s for spinal osteoarthritis, I would be worried about treating a 70-year-old because they're likely to live for long enough to even have a very small chance of getting something quite serious. So we tend not to treat the spine. You never say never, but we tend not to treat the spine for that reason. Now, if I'm treating someone's hand, let's say, base of thumb osteoarthritis or even the whole hand, then basically what's there? It's essentially skin and a bit of muscle and bone. The skin really is the main organ at risk in terms of radiation-induced cancer. And the risk of a basal cell carcinoma, which is the risk, with a 20 to 30 year latency, so in other words, 20 to 30 years on average between irradiating and getting that increased risk of a BCC, is 0.1 % in a 50-year-old. Now, it's less for someone older, about double for someone who's in their 20s. And so, 0.1%, if you relate that to your risk of skin cancer in your lifetime, maybe it's... 10%, maybe a little bit more, depending on your sun exposure. And so I always try and put it in context of what's your baseline risk, about 10%, what's your added risk, by the way, completely unproven, never been the case, about 0.1%. And so when you put it in that context, actually this is a very, very low risk treatment in terms of radiation induced cancer. Now there is an intermediate stage. So if you were to treat the shoulder or the hip, then there is about 1 to 2 % of the bone marrow of the body bone marrow there. So you do get a slightly increased risk of haematological malignancy, again, very, very low risk. And for most people that is worthwhile to get rid of their pain, get them back to what they need to do and so on and so on. But it's just worth bearing in mind that that is a sort of intermediate thing. And then the last thing I'll say is obviously dose matters, volume matters, age of patient matters, you know, all of these things are important. The main thing to think about is where you're treating and therefore what are your sort of organs where you might cause a cancer. Jo (18:12) And I suppose for some of these benign conditions, it's also thinking about how are they impacting quality of life for patients and what treatments have they had previously? Because I certainly have colleagues who have been in pain for much of their life, especially when we talk about kind of arthritis and things like that, that, you know, it really can be debilitating. At what point would you choose radiotherapy over maybe some of the more traditional treatments? Richard (18:38) So I mean, well, I'll answer a different question first, if that's okay. So the first thing is, if you don't treat, what's going to happen to them? Because even having osteoarthritis, people think of it as a painful condition, but what happens if you're in pain, you stop exercising, and that obviously can impact your health to a major extent. The second thing you need to think about is if you don't give radiotherapy and have a different condition, what's the risk of those conditions? So patients with osteoarthritis, they're going to be taking non-steroidals. We all know about the side effects of non-steroidals, gastric, nephrotoxic, et cetera. Or of course, surgery, which is incredibly common, has risks of GA. Actually, 20 % of people who have a knee replacement still have pain and stiffness despite the surgery. So it's not like the golden bullet. So anyway, so you need to think about what either what happens if you don't treat or what happens if they have alternative treatments. But coming on to your question, if you think about osteoarthritis, or at least I think about it in a very simplistic way, so basically you think, okay, you start to get osteoarthritis, what are the things you need to think about in terms of self-management? So you'd be thinking about exercises, you'd be thinking of, and you know, keeping fit, you'd be thinking about weight management, because we know obviously, for weight-bearing joints, that puts less load, but also actually there's some inflammatory issues that you get from having more adipose tissue. You'll be thinking about braces, you'll be thinking about education, know, all these sort of conservative treatments. On the other end, there's surgery, and that's really for end-stage disease. Now, after conservative treatment, you can think of having medication. I've already sort of talked about why medication isn't necessarily a wonderful thing to have regularly and in the long term. And there are injections as well, although I have to say most injections don't have very good evidence behind them, despite what people say. Steroid injections actually make things worse. They give you temporary benefit, but actually they reduce the cartilage in a joint. And things like PRP, hyaluronic acid, all that sort of thing. Honestly, the evidence isn't that great. They can definitely be helpful for some people, but you have to be a little bit aware of that and they're also not necessarily available on the NHS either. So basically where does radiotherapy fit in? I would say everything after conservative treatment and before surgery. So if someone basically has tried conservative treatment for at least three to six months let's say and they say look I've tried all of that, I've lost weight, I'm exercising, you know I'm doing all these things, I'm eating healthily, you know whatever it might be but I'm still in pain and you know their x-ray tells you they absolutely don't need to have surgery and they don't want surgery anyway because that's a massive undertaking, then we have the opportunity to help someone who's in pain to get out of pain. And that really, so that middle ground I would say is a very, very wide spectrum right from three months of conservative treatment up to maybe knee surgery but perhaps can delay surgery. Funnily enough, actually, there is evidence coming out in this year's ASTRO, which basically shows that we may well be able to stop people needing joint replacements as a result of radiotherapy. There's actual sort of objective data and also looking at delaying change on MRIs as well by giving low dose radiotherapy as well. we think there are now starting to look like some structural benefits as well. But the main reason really why we give it is to get people out of pain. And because it's a tiny dose you can actually repeat it quite a number of times as well. So if you treat someone, they get two years of out of pain, means of being able to exercise, all that sort of thing, they come back and say, you know, my pain's come back, just treat them again. It's pretty straightforward. Naman (22:38) That's interesting because obviously with bigger doses we wouldn't normally go down the re radiation route. How does it work as well for I guess capacity? And are the orthopeadic surgeons going to come after you after saying radiotherapy is is the way forward and not some yeah, chunky surgery? Richard (22:57) Well, let's deal with the surgical side of things. When I started doing Dupuytren's disease, I remember going to see my first few surgeons. Let's just say they were cold calls. And I didn't get a very good response. In fact, I would say that it was a little bit hostile. And I think that, you know, looking back, maybe I didn't say it in the right way, you know, because I was just starting out doing it and just, you know, just... trying to sort of talk to people, find out stuff from them, but also trying to get patients, obviously. And I think that whenever I talk to people about these treatments, you always need to think, well, where's the conflict here? So if I go to hip surgeons and I say, don't worry, you don't need to do any hip replacements anymore, I'm going to sort it all out with ready therapy, they're not going to be delighted. Whereas if I go to a hip surgeon and I say, look, I'm not going to touch your osteoarthritis. But I know you don't really like doing gluteal tendinopathy, know, GTPS, Greater Trochanteric Pain Syndrome or Trochanteric Rositis. So this is where people get pain on the outside of their hip. And this is actually, you know, something that is quite, you know, you can have physio, you know, people do injections, you shouldn't really. People do take out the bursa, that doesn't work very well, you know, it's not an easy treatment. It's not an easy condition to treat if it doesn't go away with conservative treatments. And so, you know, if I go to someone who treats hip patients and say, look, I don't want your osteoarthritis, but I'll take your GTPS and help you with those. That's a good way in. And similarly, with the Dupuytrens, the great thing is, surgeons, basically, they treat it when your finger's contracted. basically, surgery is a mechanical treatment for a mechanical problem. We treat in the early stage where you've got a biological issue, i.e. you've got nodules, cords, and basically as a preventative treatment to stop it becoming contracture. So essentially, As long as you've got your surgeons on board, everyone understands this is my territory and this is your territory. I mean, don't get me wrong, as a radiation oncologist, I'm very used to being in the same territory. mean, I was a prostate oncologist. So, know, there's prostatectomy, there's radiotherapy, there's, you know, there's high food, there's all these things that everyone's sort of competing. But, you know, I'm very, very conflict avoidant. So I always try and go in there, you know not trying to say, well, you don't have to do that anymore, I'll do it. Really trying to look at what's the issues you don't like dealing with. So for instance, tennis elbow is a really good one. Surgeons don't like doing that. It's not really a surgical thing. And again, if it doesn't work with physio, actually steroid injections have been shown to be worse than placebo. again, people are trying to PRP all these things. They just don't really work. So radiotherapy comes in with an 85 % chance of getting rid of these people's pain. You know, similarly with shoulder issues, you 88 % chance of getting rid of people's pain. You see, these are very effective treatments, very, very safe, very, very low dose. But of course, we do need to make these connections and we need to form these relationships. So I guess what I would say is, you know, I've been doing benign radiotherapy for at least 16 years, and it's a very slow process, you know, and what I find is, every year I gain sort of two or three friendly collaborators, you know, with whom, you know, it does go both ways actually. You know, let's say we do have trans disease, you know, I'll get people who are just too late for radiotherapy, I'll send them to a surgeon to get surgery. Or actually, you know, a new concept is you can do surgery and then do radiotherapy afterwards, like an adjuvant sort of treatment. So, you know, there are more and more ways that you can work together. And then a little bit like your question, is it safe? There's always going to be some basic questions they ask. Does it work? Is it safe? Is it going to interfere in my surgery? So, you know, as long as you can answer those questions, you're sort of in there. Jo (26:55) Why aren't we seeing benign conditions being treated in the NHS? You know, I used to treat a lot of keloid scars actually. I used to work at Leicester Royal Infirmary and used to treat a lot of keloids but never saw any other benign conditions and I certainly know now lots of our therapeutic radiographer colleagues don't see a lot of benign conditions being treated. Why is that? Richard (27:21) I think that is something to do with NHS, well now that I'm out of the NHS I'll call it rationing, but you you could more nicely call it capacity let's say. So I think there are a number of issues actually and there is a capacity issue and that's very real, it's more real in some places than others and I think that there definitely have been places that have sort of popped up, particularly with Dupuytrens, that want to treat some patients. And then what they find after they've treated some and their heads gone above the parapet, that the funders basically say, we don't want you to do this anymore. So I think that has something that in the Dupuytron's world has become quite familiar. People have had a local push to do it, and then they've done it, and then they've been asked to stop doing it. So I think that has certainly been one thing. I think, you know, what I would say is, I was talking a little bit about the history, and I think because there was so long, let's say 20, 30 years where people in the NHS were not doing most of these things, that you sort of lose this, obviously you lose knowledge, you lose awareness that it even exists, but to some extent you also lose, I think there's something that I would term medical culture, or even radiotherapy culture, let's say, whereas, we call ourselves radiation oncologists. mean, that never used to be the case, but one, it's a naming thing. Two, it's this sort of assumption aspect. So we assume that radiotherapy is a cancer treatment, full stop. And we assume that if you're treating non-cancer conditions, then there's a risk of cancer, and therefore it's dangerous, and therefore shouldn't be done. Or we assume that if it's not done in the NHS, it can't be effective. Or if we assume that there's all these assumptions I think that people make. I think that, know, so there is part of, I say it's exactly our fault, but I think some of it lies with people are just so busy that they just don't look at these things again. I think, you know, the awareness, a slight fear aspect. But what I found when I went to Germany is the reason why I went there actually is because I knew that I wanted to treat these big conditions, osteoarthritis tendinopathy. And I looked in the literature quite hard and there was plenty telling me that there was enough sort of signal saying that it works. There was absolutely nothing telling me how to do it. And so basically what I went to do was to sit in clinics, I speak no German, but then ask like 10,000 questions. And basically I wrote everything down, it was just for myself. when I, you know, I realised at the end of that sort of two or three years, that for someone who has a massive interest in this, if it's taken me that time, it would take someone else that time. So there is this quite big barrier to starting actually. And I don't actually think the barrier is about doses or even fields. It's more about MSK culture. So what I mean by that is like, I have not looked at an X-ray of the shoulder and definitely not an MRI for 25 years. That sort of dates me slightly. But also I'd not examined a shoulder for 25 years either. And so when you get a patient coming into your clinic and they say, I've got shoulder pain, like I just sort of break down slightly or would before anyway. I'm just like, my God, know, am I treating the right thing? I don't know how to look at an MRI. I don't even know what the bones are called anymore. Like what, you know, what the surgery, you know, how do I communicate this? So basically this is why I started an educational program in this area because I just felt if it's taking me that long, then I need to sort of help other people to sort of start this process. And so I really went back to the beginning. It literally goes back to what are the bones, what are the muscles, know, anatomy, physiology, what are the conditions? So for instance, going back to dupuytren's, what is it? How does it progress? What are the other treatments? And then onto radiotherapy. So getting the sort of the other culture. I mean, again, couldn't remember the bones of the wrist. Couldn't remember, didn't even really appreciate that you don't just have your fingers, you also have a ray. So that's your little finger in your fifth ray. This might seem completely obvious to you, but for me, was just I had to relearn all this stuff. So what I've done is create this program, and I've been going around and delivering this program with my colleague, Professor Seegenschmiedt and we've done it in various places around the world. And we've now probably taught six or 70 people and maybe the same again, just an online course and sort of formed a network of people who are interested enough to have done this program. I mean, coming back to the question, I guess what I'm trying to say is, you know, this program, I literally stand there for 18 hours teaching, which is why I have so many words coming out of my mouth while I'm talking to you. I've got a lot to say, but there's a lot to know. You know, I think a lot of people look at the Red Journal paper about radiotherapy for osteoarthritis and they're like, I know the dose, I know the fields, I'm just going to do it. And I just feel there's so much that people really do not know. And not only do they not know it, they don't even know they don't know it. That's the thing. Jo (32:53) It's so funny you say that because even in radiotherapy education, even when we're teaching anatomy, now that you've said it, I don't think we necessarily go through the hand or the feet or areas that we don't commonly see that develop cancer. We typically just avoid or say, yeah, just make sure you know that. But nobody ever really retains it because Richard (33:17) Yeah, Jo (33:17) you don't see it in clinic. Richard (33:19) that's right. That's right. Unless I guess you're like, unless you're a sarcoma doctor or you you treat loss of camera or I guess, but no, I mean, look, you know, so these are really new things. It's not just the bits of the body. It's the whole culture and the jargon, you know, so understand, you know, what is a fasciatomy and a fasciotomy and arthroplasty and a partial knee, you know, all of this stuff. And all of these things have implications. And, you know, when you're talking to your referrers, and you don't know what a partial neopropasty is or you don't know what the the retropatellar space, you start to look like you might have a tool but you don't really know what the nail is. So I think all of those things are obviously important to treat these patients properly, they really are, but also important so that you're sort of part of that group. And I have to say, you know, I do feel strongly. I mean, we now have a sort of pseudo MDT. I mean, as part of the course, I've been mentoring a lot of other radiation oncologists. And that is an MDT in terms of, you know, there's a bunch of people there. But, you know, I think if this were to become widespread, you know, let's just go back to the NHS question. Let's just say it were to happen in the NHS. Believe me, it needs an MDT no less than any cancer needs an MDT. Because you need to appreciate the anatomy, need to appreciate the pathological changes. You think about the differential diagnosis, you need to think about the alternative treatments. You need to have other people advocating for their own treatment, all of that. So I think that you wouldn't call it a tumor board, but certainly there are a lot of... similar things between treating cancer and treating non-cancer conditions, albeit your referrers different, your doses are different, and really, as I say, it's not part of our culture. That's probably the main thing. Naman (35:17) Is it mainly private you can get this? and how does it work, I guess, with costings? So comparing Richard (35:22) Yeah. Naman (35:23) to, yeah, what the NHS might spend on a person compared to someone spending in private? Richard (35:28) So yeah, mean, most of these things are now really just private. I mean, coming back to keloids actually. So was interesting you said about keloids because when I was in the NHS, that was one thing that I was treating a few of. But honestly, I probably saw one every six months. And the issue actually, funny enough, it's very easy to treat lots of things on the NHS and they go under the radar as long as there aren't too many of them, find, or I found. But you know, the issue was that elective surgery became so much more difficult to get funding for. So my plastic surgeon, he could never get funding to do keloids. So I hardly got any of them through. That was the bar there. There are still things, as I say, that you can do. mean, Hestropic ossification, that was always a great one. But what's happened again, like with some of these other conditions, is now people use non-steroidals. It's like gynaecomastia. Again, people use Tamoxifen. There are alternative treatments. And I think that the issue is there that if you're, let's say, the urologist using Tamoxifen for gynaecomastia, you can just do it. You don't need to give the patient elsewhere. And so I think that's another thing. Sorry, I'm getting off the subject. So you want us to talk about private medicine. So, I mean, just to be aware, I am now just, I only work privately. and so in terms of the radiotherapy side of things, roughly these treatments cost about three or 4,000 pounds for a patient. So if you were to put that in the context of needing, let's say, a knee replacement, that might be 15,000 20,000 pounds. I'm not trying to say it's cheap, but I'm just trying to say that when you think about the other things that people do pay for in private medicine, it's a relatively modest fees for that. And I think part of the reason why it's much cheaper I mean, just to be aware that, you know, a private prostate cancer might cost 20, 25,000 pounds. I mean, maybe even more if you're having it on a big fancy machine like an MR. Like I would imagine, you know, but basically the reason is because this is very, very simple treatment. So essentially this is going to be a single electron field for a hand. It's going to be a parallel pair for a shoulder. About as complex as I ever get is putting some bolus on. So this is not difficult radiotherapy at all. And so technically it's not terribly challenging. I think the most challenging things are knowing, as I said before, about the sort of landscape of treatments and really deciding whether this treatment is the right treatment for your patient and how to live with that. And so those for me are the challenges. Naman (38:23) So Richard, we're coming to the end of the episode. We do have probably more things we'd like to ask you, but we always like to end with top tips for our listeners. What can you give them, please? Richard (38:32) think there's probably a few different groups of people that I like to give tips to. So one group obviously is the patients. So I think this is a massively underused modality of treatment. And I think for people who are in pain, who are either not yet ready for surgery or are too frail for surgery or who don't want to have injections, then radiotherapy can really be a massive change in how you lead your life. I mean, I've had people just tell you about one patient. She was actually a relative of someone I used to work with and she's had plantar fasciitis for 12 years on and off. And she said that it just took over her life. She couldn't do anything. And basically she came to me. was one of my first plantar fasciitis patients. So I scanned her, found out that she did actually have plantar fasciitis. It all fitted together. I treated it with three grain six fractions. She has 80 to 90 reduction in pain and a much reduced area of where her pain was. And she just said it was completely transformative. And the interesting thing that I find is I get more thanks from patients doing non-cancer conditions, honestly, than I did from people whose lives I saved, actually. And so I find it very gratifying, but that truly is because it's a very effective treatment. And there's something also particularly good about someone who's in pain, they come in, they're limping, they're telling you what they can't do, I'll always score their pain, do a functional score, whatever it is. And then basically you review them three months after the treatment, they're like, actually I'm now able to play tennis again. Or actually I'm, you know, whatever the thing is. So something very gratifying. So that's the patients. So just have the treatment. I guess simply. For referrers. I mean, I've talked a little bit about how, you know, it's always a little bit problematic, particularly in private medicine, to be honest, you know, trying to get referers to refer your patients. And I think there are definitely some referers, a lot of referers, who just want the best for their patients. And I think that this is just another really good option. I mean, one of, for instance, I work with lots of sports and exercise doctors, and one of them says what he now does is he does conservative treatments and then one injection, shockwave, and then one injection and then the patients come to me. And so, you know, there may well be others who do more injections. There may be others who, you know, won't send the patients a bit earlier or whatever. You know, but this has at some point to find its place in the pathway. The problem is, you know, because I'm basically the only person who's terribly interested in this, there's not really enough of a voice in the UK for me to change pathways. But certainly when I talk to potential referers, I actually find now it's started to become more more seen in the world. For instance, if you look on the Facebook groups, patients are saying, I've heard about low dose radiotherapy. Anyone had it here? they're like, yeah, I've had it. It really helped. So there is definitely some rising awareness. So that's referers. So radiation oncologists, I would say, you know, it is a little bit of a tricky one because as I say, there's a little bit of hill to climb. And I also think if you're in the NHS, that's going to be pretty tricky actually to get it. You know, I don't want to put anything in anyone's way. But what I would say is it's been, I would say the best time of my career ever actually you know, and in so many ways. You know, I feel that I probably, just for me, have done more good in the world than I've done as an actual oncologist. And I think for me that's because obviously I see patients, but also I've taught a lot of other people. And I've just seen something that's been my passion for 16 years become, you know, the new thing in the world. And that's been immensely gratifying. So... You know, it might be a little bit niche, it might feel a little bit obscure, might feel something like is really outside of people's lanes, but all the same, you know, I really do think that it's a great thing that you can do for patients and ultimately that's what we're here for. Naman (43:01) Amazing. Thank you so much. It's been very insightful. I feel like I've learned loads. Richard (43:05) Pleasure. Thanks so much, been pleasure. Naman (43:07) So thank you all listening to Rad Chat with me, Naman Julka-Anderson and Jo McNamara. Thanks for listening and take care. Naman Julka-Anderson (43:13) You can use this episode as part of our free, continual professional development, accredited content, which offers flexible learning that fits your busy schedule. Just check out the show notes for the reflective questions, links to literature and resources, and a link to complete the form to receive your accredited certificate. Jo McNamara Rad Chat Host (43:29) Stay up to date with the latest radiotherapy and oncology advancements by liking and following us on social media channels and hitting subscribe wherever you get your podcasts. Naman Julka-Anderson (43:39) Join a supportive community designed by professionals who understand the unique challenges of radiotherapy and oncology. Check out our website www.radchat.co.uk. Together we're actively working to improve our profession and make a lasting positive impact on cancer care. Jo McNamara Rad Chat Host (43:55) It goes without saying that we can't achieve this alone. It takes all of us working together to create real change. That's why we value every voice and every contribution. We ask that you listen and learn, spread the word, share your story and if you need to, contact us. Naman Julka-Anderson (44:11) If you like what we're doing, buy us a coffee, keep us caffeinated, go to our website to find out more. Thank you all for listening and take care.