Tuesday, 3 July 2012

Interview with Richard Shaffer, radiotherapy specialist for Ledderhose and Dupuytren's

Today I have an interview with Dr Richard Shaffer, a specialist that uses Radiotherapy to treat both Dupuytren’s and  Ledderhose.

Dr Shaffer initially became interested in treating Dupuytren's disease as a result of his experience treating skin cancers with radiotherapy, and an ongoing interest in radiotherapy for benign disease. Following the publication of the NICE guidance which approved the use of radiotherapy for Dupuytren's disease in November 2010, he set up a service treating patients in Guildford (Surrey) and is now offering this service to patients in North London (Elstree), Southampton, Portsmouth and Birmingham in partnership with Cancer Partners UK.

I have actually had my Ledderhose treated with radiotherapy with Dr Shaffer and can say that I found him very easy to talk to and he was very knowledgeable about these diseases and it was a no-brainer to ask him to take part in my blog by doing one of these interviews.

1) How long have you been treating Dupuytren's and Ledderhose disease? 

I started treating patients with radiotherapy for these conditions in April 2011 after it was approved by NICE (National Institute for Clinical Excellence). I was originally asked to consider radiotherapy treatment for a patient with Dupuytren's disease by a local hand surgeon, and I started getting more and more interested in the conditions from there.

2) Roughly how many Dupuytren's patients have you treated and how many Ledderhose patients have you treated? 

I've treated at least 100 patients in the last year - mostly with Dupuytren's disease. Perhaps 10-20% of the total have Ledderhose disease, and I've treated some patients for both conditions.

3) How common do you think Dupuytren's and Ledderhose are in the UK? They are supposedly more common in males then females and have been linked to smoking, alcohol consumption and diabetes are these risk factors you see in your patients?

This is clearly a very common disease - I've heard figures of 1 million patients with Dupuytren's disease in the UK.

The risk factors that you mention are often present, but I have treated some patients without any of those risk factors.

4) Roughly what percentage of the patients you have treated have had a family history of these diseases? 

Around half of my patients have a family history of these conditions.

5) You treat with radiotherapy, what is the success rate on these diseases with radiotherapy? My understanding is that in total there are 10 doses of 3Gy of radiation, how does this compare to something like cancer? 

The dose of radiation used to treat Dupuytren's disease is much lower than that used to treat cancer, and therefore generally has only very mild side-effects.

In early Dupuytren's disease (i.e. where there is minimal contracture of the fingers), radiotherapy results in stopping the disease from getting worse in approximately 80% of people treated. Also, it reduces the need for surgery from 30% to 7%. So, while there are no absolute assurances, it seems to be an effective treatment. Although the treatment is primarily aimed at preventing the disease getting worse, I have noticed that many patients get an improvement in the consistency or size of the nodules (lumps), the pain associated with the nodules, or sometimes an improvement in the ability to straighten the fingers.

In Ledderhose disease, radiotherapy has approximately an 80% success rate in reducing the size of the lumps and/or the symptoms of the disease.

6) To the best of my knowledge it is not known exactly how RT helps DD/LD? Do you have any theories/ knowledge on this? 

Radiotherapy is effective in the early stage of the disease where there is inflammation, and acts by affecting the cells that produce the scarring associated with the disease.

7) Why is radiotherapy a better course of action than surgery? (Mainly thinking of Ledderhose here but also Dupuytren's)

Ledderhose - Simple surgery to remove the lumps is associated with a high chance of the disease coming back, sometimes worse than before the surgery. More radical (extensive) surgery is associated with many side-effects and in my opinion should be considered only as a last resort. Radiotherapy has few side-effects, although it is important to discuss the small theoretical risk of causing cancer (as you mention below). Radiotherapy can be very effective for many people in reducing symptoms (i.e. reducing pain and reducing the size of the lumps) and increasing function (i.e. improving walking).

Dupuytren's - Radiotherapy and surgery have different roles. The role of surgery is to correct contracture and increase function once there is already contracture (fixed bending) of the finger(s). In contrast, radiotherapy is used only in the early stages in order to prevent the contracture forming in the first place.

8) Clearly with radiotherapy there is an increased risk of cancer, realistically want do you think the increased risk is to say a 25, 50 and 75 year old patients? I have previously seen this calculation - http://www.dupuytren-online.de/downloads/Risk%20of%20cancer%20with%20radiation%20therapy%20of%20Morbus%20Dupuytren.htm - what are your thoughts on it?

I think that that is a reasonable calculation, although it does rely on many underlying assumptions.

I normally quote a "theoretical but small" risk of cancer, and pay particular attention to underlining this with younger patients. I would suggest that overall, a 1 in 1000 risk of developing a skin cancer over your lifetime due to the radiation would be a reasonable estimate.

9) What are your thoughts on other treatments that are becoming available such as Xiapex? 

Xiapex is certainly an interesting development, and is hopefully only the first of other new "biological" treatments for these diseases.

There is also recent data for the use of Xiapex in Peyronie's disease. However, I am not aware of any proven role for Xiapex in the management of Ledderhose disease.

10) Finally do you have any advice or other information that you would like to share with Dupuytren's / Ledderhose patients and what's your website address? 

At present, I am concentrating on trying to give information to patients and to GPs about the role that radiotherapy has in the early treatment of these disease. Many of my patients have been told that there is no treatment until their fingers are contracted, which would be too late for radiotherapy. I'm hoping that we can change that culture so that more patients get referred for early treatment of the disease before the complications arise.

For Dupuytren's disease, I generally treat patients who have both:
1. Nodules on the palm (with or without cords) + who have no finger contracture, or contracture of less than 10 degrees.
2. Progressive disease i.e. getting worse in the last 6-12 months

I have also treated a number of patients soon after needle aponeurotomy in order to stop the contracture recurring.

For Ledderhose disease, there is a balance between treating too early and too late.
There are no hard and fast rules as to the right time to treat, but the principles for making a decision are:

a. In general, treating early is probably more effective than treating later
b. Many patients are never be bothered by the lumps in their feet, so many choose not to have treatment if the lumps do not cause symptoms.

I'd be very happy to answer any further queries. My website is:  http://www.thedupuytrenspractice.com/

Thank you for asking me to take part in this survey.

Richard Shaffer.

Below is some updated information I have been provided with: 

Dr Shaffer is an oncologist who specialises in the use of radiotherapy in treating benign conditions. He operates a private practice (www.thedupuytrenspractice.com) in Guildford where he treats early stage Dupuytren’s disease, all stages of Ledderhose disease and those suffering from plantar fasciitis. Although the initial consultation will be held in Guildford you can receive treatment in any of the following locations;

·         Birmingham
·         Elstree
·         Guildford
·         Milton Keynes
·         Nottingham
·         Oxford
·         Portsmouth
·         Southampton

You can book an appointment with Dr Shaffer by contacting his secretary using any of the details below.

Sue Verschoyle
01483 442598