Building a Low-Dose Radiation Therapy Program for Benign Disease

The University of Pittsburgh Medical Center (UPMC) faculty have organized the 2026 Radiation Oncology Conference to evoke discussion amongst experts in radiation oncology on topics ranging from low-dose radiation for benign diseases to staff considerations when building out new service lines.

Tyler Wilhite, MD, the regional vice chair of radiation oncology at UPMC Hillman Cancer Center, who oversaw the network’s implementation of low-dose radiation therapy (LDRT) for benign disease, is one of those faculty who will be speaking at the conference. As a result of his work in establishing the LDRT service line, his presentation will be: “Low-Dose RT for Benign Disease.”

In an interview with CancerNetwork® ahead of the conference, Wilhite discussed the growth of the LDRT program since he treated the first patient in December 2023, the operational and staff education considerations that came with standing up the service line across a regional network, and how reimbursement works for a noncancerous indication. He also detailed the current evidence base for LDRT in arthritis, how it compares with the level 1 evidence that guides oncology care, and the structural reasons the modality remains less commonly used in the United States than in German-speaking countries.

Wilhite closed by discussing which referral partners proved crucial to the program’s growth and why site-to-site variability has been minimal.

CancerNetwork: What are you hoping to share with attendees of the Radiation Oncology Conference about the process of standing up a service line across a regional network?

Wilhite: I’ll be talking about low-dose radiation for benign disease, and that’s a topic that’s grown increasingly in popularity nationwide over the past 3 years. I’ll tell the story of the evolution of that program, which started in December of 2023 when I treated the first patient. At this point, every day in our network, we’re treating numerous patients with arthritis. I think we’re actually close to treating about 1000 patients at this point overall, and it’s a service that we offer broadly. [In the presentation], I’ll talk through the nuts and bolts of how other institutions could develop and sustain their own programs.

During the process of rolling the program out, what unexpected operational or regulatory considerations did you encounter?

Fortunately, there’s a lot of parallel between this and things we were already doing. A lot of these cases, in many ways, are more straightforward than many of the cancer cases that we manage. There are some differences from a patient-experience perspective. There are some differences in how we triage things and navigate our schedules. There are some differences in terms of educating our staff and how we navigate certain things like prior authorization. For example, with many of these cases, because they’re less urgent than cancer cases, we will get the prior authorization up front, and that’s based on some of the different challenges that we’ve observed over the years. Over the years, there have been some different ways insurance companies have reacted to this, and although it is a medically necessary, standard, accepted procedure, it’s one that was less commonly utilized in the US. Although now it’s far more common—there’s much more data even within the US, and there are ongoing clinical trials—part of it was just a lack of familiarity beforehand, and that goes across the board. Many of our staff had worked in radiation oncology and radiation therapy for many years and had never seen radiation used in this way. They appreciated the opportunities to become more knowledgeable about it. As a patient goes through treatment, it’s really a team sport in terms of all the different individuals who they interact with. Our staff really appreciates being able to answer questions and speak intelligently about this treatment, how it works, and what the expectations are.

Altogether, it’s been very rewarding. The patient outcomes are generally good. Patients are very appreciative. It’s a good option for them. Many of the people we treat are elderly, and there might be reasons why they can no longer take nonsteroidal anti-inflammatory drugs. For example, I saw a patient yesterday who had recurrent GI bleeds, and he was no longer able to take those medications. He also wouldn’t be a very good candidate for surgery based on his age and other comorbidities. The low-dose radiation fits nicely for a lot of these patients as something that is very safe and easy to do.

What does the current evidence base look like for low-dose radiation therapy in benign disease like arthritis, and how does it compare with the evidence base in the more established oncology indications?

In oncology care, the data are typically extremely strong. We’re privileged in that many of the clinical decisions we make are guided by level 1 evidence with phase 3 randomized controlled trials. Not in all cases, but in many cases, we have very good data to lean into. But in the arthritis domain, that is not true. It is not the same. I don’t think it’s fair to hold the arthritis treatments to the same standard, because the data just doesn’t exist.

What are people typically getting that would be in the category for radiation? When you get to the point of a joint replacement, that, in my opinion, is a much more severe circumstance—there are some scenarios where joint replacement can be helpful, but it’s not really a surgery vs radiation question here for arthritis. The joint replacement is really a much more severe option in terms of the severity of disease and what’s expected there, and also there are many people who are 80 to 90 years old who are not medically good candidates for surgical intervention. Many of these patients end up getting injections indefinitely. They’ll get cortisone injections every 3 months, almost like a bridge to nowhere. When those don’t work, people will pay cash for platelet-rich plasma injections into their joints. To my knowledge, there’s never been a randomized controlled trial showing benefit to either of those injection interventions. There have been meta-analyses published comparing cortisone and platelet-rich plasma with things like saline—placebo, basically—that have not shown a benefit yet. Those remain reimbursed. Those remain very broadly prescribed, really without question.

Low-dose radiation has been done for over 100 years. These same doses were actually used even within the US to treat infections back in the 1930s and 1940s. A lot of the excitement for that disappeared with the improvements in things like antibiotics, and a lot of the enthusiasm for using low-dose radiation for arthritis dissipated in the US with the advent of better anti-inflammatory drugs. In both of those situations, it’s not so much that the radiation wasn’t helpful; it’s just that it was more practical and made more sense to lean into the pharmacologic solutions for those problems. But within the German-speaking countries—Austria, Germany, and those places—they’ve always done [low-dose radiation]. They’ve always continued to deliver low-dose radiation for arthritis. With that said, the last couple years is when US radiation oncologists have discovered this. Once you start doing it, it’s pretty clear that it’s helpful to people, and patients are very appreciative.

In terms of the data, there’s a tremendous amount of retrospective data—the majority of it comes from Germany. With the advent of [artificial intelligence], all these papers are now easily available in the English language. Up until a couple years ago, it was a little difficult to find English translations of all these papers because they have been doing studies, but we’ll just say the majority of the data is retrospective. There basically are papers on every single site that could develop arthritis—foot, ankle, hand, shoulders, elbows, knees, hips—and if you summarize across the board, about 8 out of 10 patients have a positive result. That’s with an extremely low risk of adverse effects [AEs]. In fact, in my personal practice, I’ve yet to see a single AE from this. It’s such a low dose that it’s just extremely well tolerated.

We think that it reduces inflammation—maybe that’s the way that it’s helpful. But the truth is that there could be more than just that going on. I believe there are many different cellular and intracellular interactions that we don’t fully understand from the way that radiation interacts with a living cellular environment. There are some laboratory studies showing that radiation at these low doses can reduce inflammation of cells in a petri dish. But in truth, with a living person, the environment is much more complex. We have a strong suspicion based on publications, including thousands and thousands of patients, that at least retrospectively it seems to work about 80% of the time.

But there are starting to be some randomized trials, which are of interest as well. One thing I’ll touch on in my talk: last year, the randomized controlled [LoRD-KNeA trial (NCT05562271)] for knee osteoarthritis was done in South Korea, and they showed a statistically significant benefit at 4 months.¹ That was about a 30% improvement. About 70% vs 40% of patients had reduced pain, having received the low-dose radiation to the standard dose that we do vs a fake or sham treatment. That’s basically a placebo-controlled trial showing you an absolute difference of 30% benefit in people who receive the low-dose radiation. In my view, that’s much better evidence than any of the injections have.

In truth, the question might be why isn’t low-dose radiation more commonly utilized? I think the answer is structural, political, and historical. The fact is that in the US, we train as radiation oncologists, and have 4 years of residency. It’s almost entirely solid tumor focused, just by virtue of what we use radiation for most commonly in the US, so we don’t have any focused training on orthopedic indications or things like this. In Germany, it’s part of the gig. It’s a normal, routine part of the job.

What you’ll find is—even this year at the [American Society of Radiation Oncology Annual Meeting], there was some interest in a trial done in Russia, where they treated several hundred patients with knee osteoarthritis.² They followed them with MRI, and showed that the disease was actually less severe over time in the people who got the radiation. There was a lower risk of needing a surgery on the knee. The MRIs looked better over time, so there was a reanalysis of that in collaboration with an American and British physician. I wouldn’t be surprised if you see more clinical trials in the US undertaken to answer these questions. There are 2 randomized trials at Mayo Clinic in Minnesota right now that are being conducted, and they will both enroll several hundred patients. They are testing one on knees and one on hands. That’ll be really good data for us.

[Low-dose radiation therapy for benign disease] is a new thing in the US. It’s growing. There are some reasons why it was out of favor, but it’s a safe, effective option for patients, and it really doesn’t interfere with anything. If a patient still wants to have injections or wants to have a surgery, there’s no reason why they can’t. There’s no detriment from the radiation itself. It’s such a low dose; it doesn’t really interfere with anything.

One of the big themes of this conference is professional collaboration. What specialties or referral partners were most important for getting this program off the ground?

To summarize, it’s more than just orthopedic surgery. We’ve probably had more synergy with rheumatology and primary care physicians because primary care physicians manage the majority of arthritis cases. They’re often very appreciative if there’s something that could be potentially helpful for these patients. As people are living longer and medical care in general is getting better, you have a lot of these patients who are in their 80s or 90s who are in pain and really could use some relief. This is just a very safe, easy thing to do. The medical specialties are where I found more traction because a lot of the people that we’re treating wouldn’t be favorable surgical candidates either way. I have had some referrals from orthopedic surgeons, but I’d say the majority have come from [primary care physicians].

While you were rolling this out? What differences did you encounter on a site-to-site basis, such as local resources or patient populations?

The really fortunate thing about this is that it’s low tech. It utilizes our most simple planning techniques, which are available at any of our radiation oncology facilities. I would argue that any radiation oncology facility in the US that offers radiation for cancer should, in theory, have the capability to do this for arthritis. There’s a bit of a learning curve for the physician and the staff, but as long as some straightforward principles are followed, it can be done quite easily.

That’s one thing that makes it very appealing from a network standpoint: the fact that there should be no difference in quality between any of our sites. We’re able to meet people where they are. This isn’t necessarily something where someone needs to travel a long distance, as long as the local team is comfortable with [the procedure]. A lot of times, we’ve had some situations where a patient wants to receive a treatment closer to home, and maybe the physician hasn’t done it before, so there could be a little bit of reluctance just based on lack of experience.

But altogether, it’s simple enough that if the physician’s willing to be open-minded to it, it’s usually pretty easy to help them understand how to do this—once they do it a couple times, they realize it’s actually quite easy. More importantly, they realize it works. The patients are appreciative, and that is a good feeling. Usually, even if there’s a bit of friction for the first patient or so, once physicians start doing it, they realize that it’s a good thing. Then, usually it kind of flows downhill from there. That explains the growth of our program over time.

References

1. Clinical trial of low-dose radiation therapy in patients with knee osteoarthritis (LoRD-KNeA Trial) (LoRD-KNeA). ClinicalTrials.gov. Updated April 27, 2026. Accessed October 8, 2026. https://tinyurl.com/4puj82mn
2. Makarova M, Shaffer RE, Koneru B, et al. Randomized trial of low-dose radiotherapy for knee osteoarthritis: patient-reported, structural, and long-term clinical endpoints. Presented at the 2026 American Society for Radiation Oncology (ASTRO) Annual Meeting; September 26-30, 2026; Boston, MA.