343–The evolving role of radiation: cancer treatment, low-dose treatments for arthritis, & much more

Sanjay has now treated about 70 cases, adopting a protocol derived from extensive German observational studies and two (albeit underpowered) randomised trials. He emphasises that the total dose (3 Gy) is the equivalent of a single typical cancer therapy fraction and that the total-body dose is negligible, comparable to a CT scan. The treatment is painless, requires only a few minutes on the table, and patients can immediately resume activity. He addresses the turf-war issue directly: some orthopaedic surgeons and podiatrists resist, but Medicare and most private insurers cover the treatment, and patient testimonials are building. He has seen dramatic results—surgeons with plantar fasciitis returning to the OR, piano players with de Quervain’s tenosynovitis regaining pain-free range of motion. The fields are intentionally large to cover the entire symptomatic area, a concept opposite to that of cancer excision, because the goal is to quench inflammation, not to ablate a discrete target. He is also piloting the combination of radiation with orthobiologics (PRP, stem cells) as a synergistic approach.

Sanjay walks through the entire treatment pathway, from the initial consultation through CT simulation and treatment delivery. The CT simulation is done with the patient in a reproducible, custom-moulded position (arm abducted, torso slightly elevated on a wing board, using a vacuum-lock immobilisation bag). The radiation team—dosimetrist, physicist, and physician—spends about a week developing a 3D plan that shows dose-volume histograms for the target and every adjacent organ. Historically, women were treated with Cobalt-60 machines that caused severe confluent skin breakdown; with modern linear accelerators, the photon energy is higher and skin dose is dramatically lower, so most patients experience at most a mild sunburn. He explains the concept of “tangential beams” that graze the chest wall, and the ability to add an extra 10–16 Gy boost directly over the resection cavity if margins are close or positive. The entire course, once feared as disfiguring, now allows most women to continue working and exercising throughout.

Sanjay describes how, in the pre-radiation era, keloids would almost invariably recur after simple excision, often larger than before. The radiation is delivered while the fibroblasts are still activated but before they form the dense collagen mass. He works with dermatologists to have patients come directly from the procedure suite to his linear accelerator, delivering the first fraction the same day. The cosmetic results are typically flat, soft scars indistinguishable from normal surgical scars, with no radiation dermatitis. This is one of the few benign indications that is relatively well-accepted in the U.S., and patients can find lists of treating physicians through Facebook support groups.

Sanjay points out that this indication is better established in Europe, where it has been used for decades. In the U.S., awareness is growing through online patient communities and forward-thinking hand surgeons. The dose of 15 Gy is five times that of the arthritis protocol but remains orders of magnitude lower than a typical tumor dose, and the hand is a highly favourable site because vital organs are far removed. He has treated only a handful of cases but has seen encouraging results.

Sanjay describes that the dose to the prostate now reaches 70-80 Gy while the penile bulb, rectum, and bladder receive near-zero dose because of daily cone-beam CT verification, careful management of bladder and rectal filling, and the use of modern accelerators that shape the beam to sub-millimetre accuracy. In his personal series of about 7,000 modern prostate cases, he cannot recall a single patient who was continent before treatment and became incontinent afterward. Impotence rates are dramatically lower than surgical series, though they are confounded by the concurrent use of ADT in intermediate- and high-risk patients. The recent availability of the Decipher genomic classifier and the AI-based Artera test—now in NCCN guidelines—allows him to identify favourable intermediate-risk patients who can skip ADT altogether, which he first did for his own father. This stratification is transforming practice: about a quarter of Gleason 3+4 patients no longer need androgen deprivation. He also notes that oligometastatic disease can be controlled with stereotactic body radiation, and PSMA PET enables focal treatment of recurrences, further narrowing the gap with surgery plus salvage radiation.

Sanjay notes that the volume of whole brain radiation has plummeted to perhaps 10% of what it was 20-30 years ago. When whole brain is still indicated—for instance, in small-cell lung cancer where prophylactic cranial irradiation (PCI) uses a milder 20 Gy/5-fx—modern IMRT allows the radiation oncologist to carve out the hippocampi, preserving memory while treating the remainder of the brain. For limited numbers of metastases, stereotactic radiosurgery (single or few fractions) to the individual lesions is preferred. He acknowledges that glioblastoma remains a devastating exception, but even there, advances like proton therapy are being explored to reduce integral brain dose. The overall theme is one of smaller volumes, lower normal-tissue doses, and a recognition that the brain’s cognitive reserve must be protected.