What you should tell your patients about radiation
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What you should tell your What you should tell your patients about radiation patients about radiation
Lisa Lowe MD, FAAPLisa Lowe MD, FAAPProfessor, Univ of MO-Kansas CityProfessor, Univ of MO-Kansas City
Pediatric Radiologist, Children’s Mercy Pediatric Radiologist, Children’s Mercy Hospitals & ClinicsHospitals & Clinics
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Learning Objectives
After this talk, learner should be able to:• Explain general radiation risk to
patients and parents• State ways to lower radiation exposure
in children• Be able to list helpful resources to
determine the best radiology test
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Outline
• History and Background
• Radiation Risk• Increased use of CT• Image Gently• Helpful resources • What can you say?• What can we do?
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History: Roentgen discovers the X-ray!
• Dec 1895 – Publication• 1 week later -
radiograph of wife’s hand
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History: Radiology - fastest translational research
• Mid 1896, in practice, including fluoroscopy
• < 9 months from publication
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History: X rays became a public spectacle
• Patented shoe fitting fluoroscope– Bloomingdales
• FASCINATION!
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History: Side effects appeared later
• Vision impaired• Skin injury• Hair loss
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History: Risk of radiation “exposed”
• 1956 Alice Stewart, MD, reports X-Ray risks to fetuses– Argued no radiation was safe– Radiation effects grossly underestimated
• 1945 US drops atomic bomb– Life Span Study cohort of atomic bomb survivors– > 50 years– Hiroshima Nagasaki– Increased risk of
solid cancers– Children highest
cancer mortality rates
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Radiation risk: Biological effects of radiation
Damage to DNA• Damage to DNA is rapid • Damage to DNA may lead to genomic instability• Induction of cancer takes many years
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• Children are more radiosensitive• Longer lifetime to manifest
radiation-induced injury (cancer, cataracts)
• Children 2-10x more sensitive than adults
Radiation Risks in Children:No Debate
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Increased use X-rays: Invention of CT
• 1979 Nobel Prize in Physics
Allan Cormack Godfrey Hounsfield
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Increased use: Helical CT
• Significant increase in the use of CT from 2001 to 2006– Increase of 10% per year
• 62 million CTs done per year– 6-11% of all CT’s done in children
• Initially multidetector and 3D CT increased radiation doses by 3 to 10X
• 50% of all medical radiation• ?? Dose quantification
Arch, Michael and Donald P. Frush. “Pediatric Body MDCT: A 5-year follow up survey of scanning parameters used by Pediatric Radiologists.” AJR 2008; 191: 611-617.
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Increased use of CT:AJR Feb 2001
< 20% cases
1 in 500 - 1,000
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Brenner et al: AJR 2001
Increased use & radiation risk
• Each exam (therefore dose) is cumulative
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Hall. Pediatric Radiology. Apr 2002
Increased use & radiation risk
• AGE at exposure is most important risk factor• Females 2X males
– Breast– Thyroid
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Image Gently Campaign
• Society for Pediatrics Radiology (SPR) & American Academy of Pediatrics (AAP) plus 33 other medical organizations formed the Alliance for Radiation Safety in Pediatric Imaging - 2008
• Represents over 400,000 healthcare professionals promoting appropriate and high quality CT for children
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Image Gently Campaign
• ALARA principle– As Low As Reasonably
Achievable• 4 Image Gently guidelines:
– Scan only when necessary– Scan only indicated region– Reduce or “child-size” the
radiation dose– Scan once– www.imagegently.com
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Helpful resources: ACR website
• Imaging guidelines and appropriateness criteria on the Amer College of Radiology (ACR) website:– http://www.acr.org/s_acr/bin.asp?TrackID=&S
ID=1&DID=14800&CID=1848&VID=2&DOC=File.PDF
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Helpful resources: AAP website
• Radiology section of the AAP
• Imaging guidelines: http://www.aap.org/sections/radiology/default.cfmRadiation safety information for parents & pediatricians
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Radiation report card
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Helpful resources: CMH Radiology website
• Children’s Mercy Hospital Radiology website
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Sample newsletters:
• Image gently campaign
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How do we respond?
One size does NOT fit all We all must ask?• Appropriate to do
exam?• Appropriate timing of
exam?• Appropriate modality?
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• Radiologists’ responsibility Understand radiation doses Review requests for higher dose
studies Discuss with clinicians and
parents/patients PRN Child size technical factors
How Do We Respond?
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Examples
• Sinus CT– Old: 150 mAs– New: 30 mAs
• Scoliosis CT• Craniosynostosis CT
5x lower dose!}
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• Pediatricians’ responsibility:Understand radiation doses of modalities
Know which facilities are “kid friendly!Don’t ass-u-me?ASK, even demand!
Order on medical indications not parental/legal pressure
Discuss options with radiologist PRN Consider information for parents PRN
How Do We Respond?
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Talking to parents
1. Discuss risk vs. benefit2. Use websites for more detailed
explanations3. Compare to other every day risks
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Typical radiation doses compared compared to background (3.5 mSv/yr)to background (3.5 mSv/yr)
Procedure Effective dose Comparable background dose*
Chest x-ray 0.02mSv 1 monthVCUG 0.3mSv 3 monthsDental X-rays 0.9 mSv 6 monthsLumbar spine 1.3 mSv 7 monthsCT head 2mSv 8 monthsUpper GI 3mSv 1 yearBarium enema 7mSv 2.3 yearsCT abdomen 10mSv 3 years1 Airline flight 0.3mSv 2-3 months
*Average background dose is 3.5 mSv/year
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Risk of death from various activities
Activity Risk of death per million/year
Having a chest X-ray 1Visiting Denver for 2 months 1Traveling 5,000 by air 5Fishing (drowning) 10Traveling 1,500 miles by car 40Motorcycling for 1,000 200Smoking 1 pack/day 3,500Being > 55 years age 10,000
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What is CMH doing to lower doses?
Pediatric radiologist is actively involved
• Using US and MRI when possible– Appendicitis and screening
• Pulsed fluoroscopy– UGI/VCUG – Up to 10X less dose
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What is CMH doing to lower doses?
Pediatric radiologist is actively involved• Child size all CT doses
– New protocols: 5x less dose
• Av CT dose: 2009– CMH: 1025 mSv – Other providers: 1818 mSv
44% less 44% less radiation!!radiation!!
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What is CMH doing to lower doses?
We make sure your patient gets the:• Right test (best test with least radiation)
– ? US or MRI• Right time
– ? Does something else need to be done first?• Right way (individualize protocols)
– ? Contrast or not– Lowest radiation dose possible
• 44% less for CT on average
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Thanks for your attention
Questions?