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American College of Radiology White Paper on Radiation Dose in Medicine

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The benefits of diagnostic imaging are immense and have revolutionized the practice of medicine. The increased sophistication and clinical efficacy of imaging have resulted in its dramatic growth over the past quarter century. Although data derived from the atomic bomb survivors in Japan and other events suggest that the expanding use of imaging modalities using ionizing radiation may eventually result in an increased incidence of cancer in the exposed population, this problem can likely be minimized by preventing the inappropriate use of such imaging and by optimizing studies that are performed to obtain the best image quality with the lowest radiation dose. The ACR, which has been an advocate for radiation safety since its inception in 1924, convened the ACR Blue Ribbon Panel on Radiation Dose in Medicine to address these issues. This white paper details a proposed action plan for the college derived from the deliberations of that panel.

Introduction

Ionizing radiation has been used for diagnostic purposes in medicine for more than a century. The benefits are immense and certainly exceed the risks. The more recent development of remarkable equipment such as multidetector row computed tomography and the increased utilization of x-ray and nuclear medicine imaging studies have improved the lives of our patients and, along with other new modalities, revolutionized the practice of medicine. However, this dramatic evolution of imaging has also resulted in a significant increase in the population’s cumulative exposure to ionizing radiation. Will this cause an increased incidence of cancer years down the line? Although the answer to that question is currently under debate, the presumption is that it will.

Consequently, there is increasing international and federal interest in, and scrutiny of, radiation dose from imaging procedures. Although there has been recent widespread interest in patient safety issues [1], the possible hazards associated with radiation exposure generally have not been brought into clear focus by the public or members of the medical community other than radiologists. The ACR, pursuing its commitment to radiation safety, currently supports the following activities: accreditation programs, practice guidelines and technical standards [2], Appropriateness Criteria® [3], a dose index registry (in progress), educational programs, the RadiologyInfo public information Web site (jointly developed with the Radiological Society of North America [RSNA]) [4], collaborations with government and legislators on safety issues, and research activities such as the ACR Imaging Network (ACRIN)®. To further enhance radiology’s leadership role in the arena of patient safety, the chairman of the ACR Board of Chancellors convened the ACR Blue Ribbon Panel on Radiation Dose in Medicine to assess the current situation and to develop an action plan for the ACR that would further protect patients and inform the public. Panel members included private practice and academic diagnostic radiologists, medical physicists, representatives of industry and regulatory groups, and a patient advocate. This white paper is the result of the panel’s deliberations.

Section snippets

Scope of the Problem

Over the past quarter century, there has been a rapid growth in both the number of diagnostic x-ray examinations and the introduction of newer, very valuable, but also relatively high-dose technologies (see Table 1 [5, 6, 7, 8]). In 1987, medical x-rays and nuclear medicine studies contributed less than 15% of the average yearly radiation exposure received by the US population; the large majority was attributable to radon and other natural sources [9]. Two decades later, because of the dramatic

Measurements

Recommendations

  • The ACR should adopt the policy of expressing quantitative radiation dose values as dose estimates and replace the term dose with dose estimate as ACR publications are revised.

  • The ACR should support the development of a national database for radiation dose indices to address the actual range of exposures for x-ray examinations.

There are references to radiation dose and radiation exposure throughout this paper. It is critical for the reader to understand the terminology,

Referring Physicians

Recommendations

  • The ACR should work to convince the Liaison Committee on Medical Education and the Association of American Medical Colleges of the need for a standard methodology of introducing medical students to radiation exposure in medical imaging and offer to prepare learning materials in support of this initiative.

  • The ACR should work with the American Medical Association to ensure the wide dissemination and enactment of its Council Report on Diagnostic Radiation Exposure.

  • The ACR should

Radiologists

Recommendations

  • The ACR should support the current multiorganizational effort to improve radiology resident training in medical physics.

  • The ACR should include additional questions on radiation safety and patient dose in its Annual In-Training Examination.

  • The ACR should request that the American Board of Radiology consider requiring at least 1 self-assessment module on patient safety, to include radiation dose, every 10 years as an integral part of the maintenance of certification.

  • The ACR should

Technologists

Recommendations

  • The ACR should encourage radiology practices to provide in-service training on radiation safety issues for their technologists on a regular basis.

  • The ACR should phase in the requirement that at least 1 technologist per accredited CT site hold the American Registry of Radiologic Technologists advanced registry in computed tomography and that at least 1 technologist per accredited nuclear medicine site hold the advanced registry in nuclear medicine or certification by the Nuclear

Patients

Recommendations

  • The ACR should, in collaboration with the RSNA, install a prominent patient safety link on the RadiologyInfo home page and regularly review and update information on the Web site regarding the risks and benefits of imaging procedures.

  • The ACR should install a prominent patient safety link on the ACRIN® home page that will lead patients to information on risks and benefits associated with participation in current ACRIN research protocols.

  • The ACR should work with patient advocacy

Medical Physicists

Recommendations

  • The ACR should work with the AAPM to develop a credentialing program for nonradiologist physicians who use fluoroscopy.

  • The ACR should task its Commission on Education and Commission on Medical Physics to develop more effective teaching methodologies for medical physics in support of the AAPM-RSNA initiative on physics education for radiology residents.

  • The ACR should implement a periodic review and update of its primer on radiation risk [54].

Although much of the ACR’s effort

Vendors

Recommendations

  • The ACR should work with the National Electrical Manufacturers Association (NEMA) to encourage vendors to ensure that their application specialists are familiar with imaging protocols that emphasize the standard of as low as reasonably achievable for their new equipment.

  • The ACR should work with NEMA to encourage vendors to adopt a standardized approach describing exposure indices for computed radiography and digital radiography.

  • The ACR should continue working with NEMA to

Regulatory Agencies, Accrediting Bodies, and Third-party Payers

Recommendations

  • The ACR should approach the FDA and the US Nuclear Regulatory Commission (NRC) and seek input on how it can better support their efforts to minimize unnecessary radiation exposure.

  • The ACR should continue working with the Conference of Radiation Control Program Directors (CRCPD) task force developing the document “Suggested State Regulations for Control of Radiation” and encourage its member states to uniformly adopt appropriate regulations.

  • The ACR should encourage the Joint

Conclusions

Many questions remain unanswered regarding the fundamental mechanisms of radiation injury. Deoxyribonucleic acid breakage, chromosomal aberrations, and gene mutations caused by radiation exposure, as well as the potential for deoxyribonucleic acid to repair itself between radiation exposures, are important avenues for further investigation. The intensive study of actual occurrences, such as workplace exposure of radiologists, the long-term fate of patients treated with radiation therapy, and

ACR Blue Ribbon Panel on Radiation Dose in Medicine

The members of the ACR Blue Ribbon Panel on Radiation Dose in Medicine are E. Stephen Amis, Jr, MD, chair (radiologist); Kimberly E. Applegate, MD, (radiologist); Steven B. Birnbaum, MD (radiologist); Libby F. Brateman, PhD (medical physicist); Priscilla F. Butler, MS (medical physicist, ACR staff member); James M. Hevezi, PhD (medical physicist); Kalpana M. Kanal, PhD (medical physicist); Paul A. Larson, MD (radiologist); Barbara LeStage (patient advocate); Richard T. Mather, PhD (NEMA

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