Royal College of Radiologists document on Radiotherapy for benign conditions

Royal College of Radiologists

A new document covering the radiotherapy treatment of benign conditions has been published by the Royal College of Radiologists. A link to the document can be found here.

It was written by five of us, all clinical oncologists, and it includes chapters on normal tissue responses to radiation, the risk of radiation-induced carcinoma, and chapters on the treatment of many specific conditions, including Dupuytren’s disease, Ledderhose disease and Plantar Fasciitis.

Using radiotherapy to treat benign conditions

Radiotherapy is used most commonly for the treatment of cancer, but is also used to varying degrees for the treatment of non-cancer (benign) conditions and benign tumours. It works in two ways – via an anti-proliferative effect (i.e. stopping things growing) and an anti-inflammatory effect.

These mechanisms come into play to different degrees in different conditions. The doses used are generally lower than those used for the treatment of cancer, although they vary very widely.

The evidence for many of the conditions is based on case studies or series. However, for some conditions, for instance plantar fasciitis, there is evidence from randomised controlled trials.

Radiotherapy is already used for some of these conditions in the UK, although its use is variable and generally in small numbers compared with its use in Germany for example. There are several possible reasons for this:

With a limited amount of equipment, staffing, and money, there is a limit to the amount of radiotherapy that can be delivered, and treating cancer is generally very much the priority.

Many UK oncologists have little experience of treating many of the benign conditions listed, although treatment of e.g. keloids, heterotopic ossification and gynaecomastia is very standard practise.

There is a fear of inducing radiation-induced carcinoma (RIC) in these patients. The chapter in the document deals with this in great detail, and there is also a summary of the risk of this at the end of the summary of evidence for each condition. Clearly, its use in young people is to be avoided and the use over areas where malignancy is more likely (for instance, bone marrow and breast) is also to be avoided if there are other effective treatments that do not have this risk attached.

However, the risk of side-effects from alternative treatments also needs to be taken into account. Clearly, this is a complex discussion that needs to be had between the patient and the oncologist, and will take into account the disease pathology, disease site, dose of radiation, various risks (including RIC), and the availability and risks of alternative treatments.

Increasing awareness

Many oncologists have had little, if any, training in the use of radiotherapy for the treatment of many of these conditions. I hope that this document will lead to discussions with other medical specialties that normally treat these conditions (e.g. hand and foot surgeons for Dupuytren’s and Ledderhose diseases and plantar fasciitis), and also lead to a greater awareness amongst oncologists of the role of radiotherapy in these conditions.