ASTRO President Sameer Keole, MD, FASTRO, introduced this year’s symposium topic, centered around the 2025 Annual Meeting’s theme, “Rediscovering Radiation Medicine and Exploring New Indications.” Themes that consistently emerged included normalizing the term “nonmalignant” over “benign” to acknowledge the debilitating daily impacts of the diseases, the importance of staying curious and collaborating with other fields in order to devise the most comprehensive treatments, and defining value of newer treatments in a way that speaks to all parties ranging from patients to payers.
Session I, “Potential, Pitfalls and a Path Forward for Radiotherapy beyond Cancer,” began with Jarad Martin, MD, MBChB, PhD, BSc, GAustMS, hailing “a new dawn for our specialty.” He presented the example of Usain Bolt receiving LDRT for plantar fasciitis, and after which, he quipped, Bolt went on to do “fairly well” at the Olympics. Radiotherapy acts as a local anti-inflammatory. Dupuytren’s disease is another condition where the potential to help patients is tremendous, as treatment is scalable. Dr. Martin advised: “There are a bunch of levers that we must pull to take the most advantage of this, including medical technology companies and societies. There’s a whole universe of possible applications, life changing for patients. Clinical trials are critical as is engaging with the right gatekeepers.”
Paul Werker, MD, PhD, a Dutch plastic surgeon, offered a measured perspective, drawing on expertise with Dupuytren’s disease. He underscored the need for rigorous, prospective research to meet the hesitancy of hand surgeons due to the numerous side effects radiation therapy might incur, including higher rates of wound complications. He succinctly advised, “Surgeons fear complications so evidence is needed. Build relationships with hand surgeons – work together to get the best results for patients!”
Heidi Prather, DO, explored osteoarthritis as a chronic condition. She delved into the emerging role of LDRT in symptom management, emphasizing metabolic contributions to disease and co-treatment strategies that may enhance outcomes. She described her current work climate: “I am drinking from a fire hydrant and I need help with providing care, and I think you may have part of that solution.” Dr. Prather sees an opportunity to pair with radiation oncologists, applying reduced inflammation potentials for symptom reduction.
Gopal Bajaj, MD, MBA, FASTRO, challenged us to start calling what we’re doing “functional radiotherapy.” He observed that the number of clinical verticals is vast, yet there are real barriers to scale in the U.S., both actual and existential. He observed the current landscape: “We have a safe, precise and effective intervention, and a thoughtful and motivated foundation, with decades of foundational experience, with a desire to alleviate suffering and help more patients. However, there is a fair amount of regulatory ambiguity, and we are not entrenched into the normal treatment pathways and guidelines for a lot of these conditions we are looking to enter into. When things get big, we’re going to have a lot to answer to, and this is an opportunity for both international and inter-society collaboration.” He noted the need for more clarity on conditions with better patient selection, yet this isn’t an unfamiliar challenge. The field has done this before, with each wave of innovation in radiation oncology from IMRT to IGRT and SBRT, fueled by rigorous aggregation of data. “We must show value. We have to show gain of function, avoidance of invasive interventions. We need to avoid pitfalls such as over-generalization, demonstrate equipoise in discussing both the risk and benefits.” We learn more from them than ourselves, this is not our wheelhouse. We need to reallocate resources to prospective randomized data, engage our multidisciplinary stakeholders, partner with them to breach silos of referral and integrate into pathways.
Jan Kriz, MD, PhD, moderated the over-arching discussion afterward. Dr. Keole described a future that includes functional RT programs both inside and outside cancer centers, embedded cross-collaborative radiation therapy pathways in multiple specialties, cooperative group trials for nonmalignant disease, and multidisciplinary guidelines that legitimize our role and expand our reach. Our field has been steadfast gatekeepers of a very powerful technology. We must engage in a balancing act of optimism and scientific rigor. Germany has shown some ways to do this, as a survey indicated that annually irradiated patients have been treated for nonmalignant conditions, many for osteoarthritis. There is an acceptance among patients, trusting results of low dose radiotherapy, along with wide acceptance among physicians to apply these measures. Annual society meetings have offered educational sessions for residents and interested colleagues, and a guideline that was first published in 2012 provides structure and comprehensiveness.
Dr. Keole posited that ASTRO’s role could be to create a lasting framework, including functional task groups looking at a wide number of indications. More international collaboration has to be the hallmark of what we do, we can’t just reinvent the wheel for all these different conditions. ASTRO’s foundation, the Radiation Oncology Institute (ROI), has a role to play here, as the nonmalignant space is one where it can fund the research.
Session II, “Coding Relief — Billing RT for Nonmalignant Diseases,” reminded us that while we are health care practitioners, infrastructure matters. Amar Rewari, MD, MBA, FASTRO, said it best: Coding is the language that turns treatment into value, and he provided examples on how to bill compliantly in this evolving space, while also noting resources that will continue to be offered such as the Virtual Coding and Coverage Seminar this December.
Led by Markus Bredel, MD, PhD, and Evan Thomas, MD, PhD, Session III, “Precision Without Incision — The New Era of Functional Radiosurgery,” walked attendees through imaging pathways and technological tools. Dr. Bredel offered tangible examples of how radiosurgery has helped with tremors, of which the most dominant form is Parkinson’s disease. The older the patient, the higher the incidence, with approximately 5% of the adult population over 60 dealing with some form. While not malignant, tremors can be disabling for patients, including tremendous stigma and isolation. Radiation therapy is far less invasive than deep brain stimulation for this condition. The visual examples he showed were powerful testimonials at the possible quality of life improvement.
Dr. Thomas discussed even less traveled routes in functional brain radiosurgery, such as central pain and behavioral disorders for which SRS remains a keystone. We’re moving toward a future of sophisticated circuit-based modulation, driven by major advances in connectomics and functional neuroimaging. He presented possible treatments for psychiatric disorders, noting that the goal is to intelligently and precisely modulate specific, dysfunctional networks. He shared notable examples for psychiatric conditions including OCD and major depressive disorder. There is both “peril and reward” in doing these procedures, and the field is rapidly evolving from targeting anatomical points to modulating personalized connectomic guided modulation. “As we continue to merge the power of this minimally invasive approach with revolutionary insights from modern neuroscience, we’re on the cusp of designing many entirely new therapies for conditions once considered untreatable.”
Dr. Keole asked practically, how can we raise up the next generation of trainees to begin exploring these possibilities? Dr. Bredel noted the importance of developing a pipeline, where we go from advanced imaging studies, to integrating them into treatment planning systems, for which industry partnerships will help tremendously. He encouraged the idea that every radiosurgical program identify one member of their group to focus on this and also mentioned two available courses for advanced functional radiosurgery training, one in Marseille, France, and the other El Salvador.
Clifford Robinson, MD, FASTRO, and Phillip Cuculich, MD, presented Session IV, “Cardiac Radioablation — Past, Present and Future,” showing how stereotactic arrhythmia radiotherapy (STAR) is transforming the treatment landscape for patients with life-threatening ventricular tachycardia. Lessons learned from low dose scatter to the non-targeted heart have provided an exciting new avenue to consider low dose radiotherapy for heart failure. Dr. Cuculich described these building efforts as a story of curiosity, courage, change and collaboration, a safer way to treat the heart, applying energy to make the scar electrically inert, but structurally intact. “Let’s reimagine the entire ablation procedure. If we can figure out where arrhythmias are coming from, from cardiac imaging and then marry that with the ability to noninvasively treat, you’re talking about a brand new approach to treating people.”
They presented the challenges of speaking the same language when practitioners are fixated on their perspective. They advised working through disconnects early on, and to recalibrate thinking. They posed that cardiology and radiation therapy might be the perfect multidisciplinary match. After all, they use precisely focused treatments to destroy diseased tissue and think in terms of energy deposition to a target – what remarkable commonalities!
