Patient Radiation Dose and Risk - The RT's Role

Continue Continue Continue Continue Continue Continue Continue Continue Continue Continue Continue Continue Continue Continue Continue Continue Continue Patient Radiation Dose and Risk Replace with another key visual or illustration. Patient Radiation Dose & Risk The RT’s Role in the Ongoing Debate This online training will review many of the most recent, empirically supported theories and concepts of medical radiation dose and risk. Also discussed, will be the role of CT technologists in this debate and outline specific approaches to effectively communicate with patients and healthcare peers on this issue. Daniel DeMaio, M.Ed., RT(R)(CT) Associate Professor and Director Radiologic Technology Program University of Hartford Introduction Welcome to the online training, Patient Radiation Dose and Risk, The RT's role in the ongoing debate. This content was prepared by Daniel DeMaio. Dan has been an educator in medical imaging for more than 30 years, and is currently an associate professor and director of the radiologic Technology program at the University of Hartford in Connecticut. Dan is an author of Mosleys Exam Review for computed Tomography, a leading resource for technologists preparing for the ARRT exam in CT, now in its third edition. He is active in the radiology profession, at both the state and national level. He served two terms as president of the Connecticut Society for Radiologic Technologists. He's also served the ASRT in multiple roles, including chair of the Practice Standards Council, the Bylaws Committee, and the Commission. He is currently a member of the ASRT Board of Directors, serving as speaker of the House of Delegates. intro.mp3 Table with 2 columns and 4 rows Not all pages contain audio. Some pages invite you to read for yourself or watch a video. All pages show a ? button in the lower-right corner. Select the ? button to get a quick guide through the navigation elements. Select the button on the left upper corner to display or hide the menu. ? Navigation Hints Before you start, we would like to give you a few tips on how to navigate: Enjoy the course! Select the X to close the pop-up. Click Next to continue. ? Navigation Hints Replace with another key visual or illustration. Objectives Describe current issues regarding medical radiation dose and risk Describe current issues regarding medical radiation dose and risk Describe current issues regarding medical radiation dose and risk Describe current issues regarding medical radiation dose and risk Outline some essential dose-risk concepts and factors Outline some essential dose-risk concepts and factors Outline some essential dose-risk concepts and factors Describe the role of the medical imaging professional as a radiation health expert Describe the role of the medical imaging professional as a radiation health expert Describe the role of the medical imaging professional as a radiation health expert Identify the literature supported best practices for discussing dose and risk with patients Radiation Dose Risk Technologists Objectives The objectives of this course are as follows: Describe the current landscape of the radiographic utilization. Recognize the patient perspective of the potential danger of radiation exposure, Interpret various dose metrics,Assess the estimated risk of patient exposure,and lastly, Define and compare a procedure’s effective dose to average background radiation dose. objectives.mp3 ? Our Profession – the current view.. Radiologic Sciences The patient’s! Click to view the Source info Source info Illustration from the International Atomic Energy Agency Current view the focus of this online training is to brush up on a little bit of science, to make sure that we can have informed, appropriate conversations with patients, and why this is so important. This is a different sign and symbol that you'll see sometimes posted. This is from the International Atomic Energy agency, and it encapsulates what has and is going on. If you take a look at this diagram, you know who we are, what we do as far as radiation. Here is the image that's given to our patients and the direction for what they should do, which is to get as far away from radiology staff and the facility as humanly possible. this is the message that a lot of patients have, not only from symbols like this, but think about how often your patients are going on the Internet the night before a procedure to find out what the risks are, seeing the dangers of medical radiation exposure. It is scary, and that is what patients are doing before going in for a procedure. ? The Dose/Risk Conversation When a patient asks about DOSE….. RISK is what they really want to know about. Dose and risk So when a patient asks you questions about dose. What they are really asking, is what the risk is for a particular procedure. Am I going to get cancer from this test? Is it safe? ? Some History Reports a dramatic increase in the amount of radiation from medical imaging procedures: Computed tomography (CT) Cardiac nuclear medicine AAPM quickly responds: NCRP report does not quantify risk for individuals Should not deter patients from getting medically-appropriate imaging exams CT scans help save thousands of lives every day Per-capita analyses exaggerate dose For an appropriately ordered exam, the benefit greatly outweighs the risk Click to view the Source info Source info Thurston, Jim. "NCRP Report No. 160: ionizing radiation exposure of the population of the United States." (2010): 6327. NCRP If you think about what's happened, since about 2009, this is a copy of front cover of NCRP report, and it really started a landslide of conversation and attention to radiation dose appropriately. If you think about CT alone, what has happened since the late 80's, early 90's. think about how the technology has changed over the last 15 to 20 years, it has been a slice number war. It became more and more slices, just 30 seconds for a chest, abdomen, and pelvis. That is not nearly fast enough. Let's get down to 20 seconds, 15 seconds, basically a dose war, and not just in CT, but in X-ray as well. Now, it's all about performing exams fast, but also making sure that they are being done at the lowest dose. That was not the case before 2009. in 2009, the NCRP told us a really important thing, that there was a dramatic increase in radiation exposure, medical radiation exposure, from our imaging procedures, primarily CT and nuclear medicine, mostly because of the cardiac exams in Nuc Med.. many organizations defended this claim and responded very quickly, but it kind of fell on deaf ears. The defense was essentially saying hey, the work that we do is really, really important. Think about exploratory surgery and how often that was performed so many years ago. The field of Radiology is now, exploratory surgery. think about all the things that have happened in healthcare because of the work that is done in Radiology. Is radiation exposure increasing? Yes. But, the outcomes are so incredible that it's worth it, especially CT's, it saves lives, thousands of lives, every single year, just in this country alone. ? Radiation From CT Scans Linked to Cancer Deaths "CT scans deliver far more radiation than has been believed and may contribute to 29,000 new cancers each year, along with 14,500 deaths..." December 2009 Click to view the Source info Source info de González, Amy Berrington, et al. "Projected cancer risks from computed tomographic scans performed in the United States in 2007." Archives of internal medicine 169.22 (2009): 2071-2077. USA Today this made headlines everywhere. CT Scans contribute to 29,000 new cancers every year, killing nearly 15,000 people annually. Pretty dramatic stuff. And that was a published paper, a very reputable journal, using data extrapolated from prior sources, that will be discussed in more detail in upcoming slides. ? Fast-forward: 2014 NY Times This is from the New York Times. Look at the language. Neither doctors, nor patients want to return to the days before CT scans. but we need to find ways to use them without killing people in the process. That was the opinion section of the New York Times in January of 2014. ? Our Profession Responds Justification Optimization Technology Regulation Profession responds over the last 14 or 15 years, think of the amazing ways our profession has responded to these important points. Justification, optimization, technologyand, regulation. ? Justification Adult Criteria Adult Criteria Adult Criteria Pediatric Criteria Pediatric Criteria Pediatric Criteria Choosing Wisely Choosing Wisely Choosing Wisely Select each button for more information about ACR Appropriateness Criteria Click to view the Source info Source info http://www.acr.org/Quality-Safety/Appropriateness-Criteria Options layer 1 First and foremost, justification. An older screenshot, but this is the ACR appropriateness criteria that the referring practitioners are using to decide which type of procedure to offer, based on different clinical indications. Here, the radiation dose associated with the CT scan of the abdomen and pelvis with contrast, is seen. layer 2 Here is a look at a pediatric patient. Certainly, an ultrasound of the abdomen appears to be the most appropriate test. Ultrasound is a great tool that the referring physicians and ordering practitioners have at their disposal. Layer 3 Choosing wisely. The different rules that the american board of internal medicine put forth on recommendations about the different tests. Justification (ABIM) Recommends against: CT to r/o appendicitis in children; ultrasound first! CT for pulmonary embolism (PE) when there is low pre-test probability CT of the brain for uncomplicated headache Source info The product names and/or brands referred to are the property of their respective trademark holders. http://www.abimfoundation.org/Initiatives/Choosing-Wisely.aspx Click to view the Source info Justification - Appendicitis - Pediatric Justification ? Optimization Select the tab arrows to learn more. image gently IMAGE WISELYTM Click to view the Source info Source info The product names and/or brands referred to are the property of their respective trademark holders. Optimization layer 1 Thinking about all that's happened in our profession, for instance image gently, taking a pledge every year. There are a lot of great resources on image gently that are updated constantly. Layer 2 Thinking about all that's happened in our profession, for instance image gently, taking a pledge every year. There are a lot of great resources on image gently that are updated constantly. Layer 3 Image wisely for Radiographers. Similar to image gently, great resources, and again this website is constantly updated. IMAGE WISELY Radiation Safety in Adult Medical Imaging The “Pledge” Vendor-specific dose reduction information Patient Medical Imaging Record RAD, CT, NM, Fluoroscopy Diagnostic Reference Levels http://www.imagewisely.org Select the X in the upper right corner to continue. The Alliance for Radiation in Pediatric Imaging The “Pledge” CT “Child-size” Protocols Patient & Physician Information Select the X in the upper right corner to continue. http://www.imagegently.org image gently ? Technology Technology - CT Photon Counting Detector CT Technology - Radiography Utilization Select the tab arrows to learn more. Technology tech – ct If you have been doing CT for a couple of decades or more, just think about how much has changed, All surrounding dose, this is incredible technology. Automatic tube current modulation seems like old news now, but AEC for CT was life changing for CT technology, When used properly. There are still technologists out there who, unfortunately, do not really know for sure how the tube current modulation systems work. Some of this technology is very, very advanced and very complicated, and when implemented and used properly, can significantly decrease dose. Photon counting Just when we thought it couldn't get any better, Photon counting CT was introduced. I thought that once the leap was made to spiral, and then multi slice CT, we were done. Photon counting CT is going to again, Revolutionize the CT imaging modality. It has such huge potential. While it is in the early stages, the technology is going to do great things. It produces images with incredibly high resolution, that offer the opportunity to again, dramatically decrease dose. How low can it go? CT scanning is commonly below 1 millisievert effective dose. We get to the point where the X-ray dose for a CT scan is going to be near, or perhaps, lower than some Radiographic procedures. Photon counting detector CT is amazing technology. Radiography Think about how much standard Radiography has changed. It's not electron CR and DR, But again, if you started off in film, Think about how drastically radiography has changed. The vendors in our field have responded really magnificently with the need to decrease dose on the systems, and at the same time, examinations have become much safer. just a couple of things as far as what is being done in radiography. From 1959 to 2012, for an AP pelvis, there has been a 95% reduction in gonadal dose. That is an important statistic because it is one that is used quite often, to inform why it is not necessary to shield anymore. At the same time dose is coming down, utilization is going up. We did have a dip in CT utilization for a while, right after all those headlines came out, that were discussed in previous slides. Utilization There was a period of time, 2013, 14,15, where CT utilization across the country dipped a little bit. I’d be curious to know how that affected patient outcome. But people aren't having CT studies because they're bored on a Saturday night. They are having them because we're helping to save their lives and to improve outcomes. Increased Utilization Select the X in the upper right corner to continue. Click to view the Source info Source info Source: Trends in Use of Medical Imaging in U.S. Health Care Systems and in Ontario, Canada, 2000-2016 JAMA Growth in utilization has slowed, but continues to rise. Only pediatric CT has decreased slightly. Overall, CT utilization has continued to increase after a brief period (2009-2011) of stagnation. Technology - Radiography Significant Advances in Digital Radiographic Technology Select the X in the upper right corner to continue. Click to view the Source info Source info * Frantzen, Marij J., et al. "Gonad shielding in paediatric pelvic radiography: disadvantages prevail over benefit." Insights into imaging 3.1 (2012): 23-32. Advanced Digital Detectors (MAX) High kVp/Low mAs Techniques Exposure/Deviation Indices (EI) Improved Filtration/Tube Design 1959 2012: >95% reduction in gonadal dose for an AP pelvis radiograph* Siemens Ysio Max Technology - Photon Counting Select the X in the upper right corner to continue. Quantum Max detector: direct signal conversion High resolution at low dose Improved contrast-to-noise ratio Comprehensive spectral imaging – material discrimination “…PCD-CT opens up a range of new opportunities that may inspire a new momentum for clinical CT imaging.” (Sartoretti, et.al., 2023). Click to view the Source info Source info Sartoretti, T., Wildberger, J. E., Flohr, T., & Alkadhi, H. (2023). Photon-Counting detector CT: Early clinical experience review. The British Journal of Radiology, 20220544. Technology - CT Automatic Tube Current Modulation (ATCM) - AEC for CT (Siemens CARE Dose4D) Automated Tube Potential Selection (Siemens CARE kV) Improved detector efficiency (Siemens Stellar) Iterative reconstruction (Siemens ADMIRE®*) Dual-energy CT (Siemens Dual Source - DSCT) Select the X in the upper right corner to continue. Significant Advances in CT Dose Reduction Technology Click to view the disclaimer Source info *In clinical practice, the use of ADMIRE may reduce CT patient dose depending on the clinical task, patient size, anatomical location, and clinical practice. A consultation with a radiologist and a physicist should be made to determine the appropriate dose to obtain diagnostic image quality for the particular clinical task. ? Where are we today? Utilization continues to increase, but patient exposure & dose has significantly decreased… But, what about… Where are we today? So where are we today? Utilization continues to increase, but patient exposure and dose significantly decreased. But what about risk? Again, that is the focus of this training, and that is what the patients are most interested in. ? So is there risk, or isnt there? “…extensive epidemiological and biological evidence suggest that exposure to radiation in the same range as that routinely delivered by CT increases a person's risk of developing cancer.” “What is needed is a systemic and seismic shift in educating physicians and patients, in having candid conversations with patients around imaging that acknowledge the tradeoffs, and in justifying the use of all medical radiation exposure.” Click to view the Source info Source info JAMA Netw Open. 2021;4(10):e2129681. doi:10.1001/jamanetworkopen.2021.29681 Is there risk or isnt there? this is interesting. There is a 50 50 divide, currently in the literature. We have 1/2 of one team coming in as the procedures are incredibly safe, and there's almost no risk. Then, there is a whole other group of scientists that are saying, well, hold on, not so fast. But this group here - this statement. Extensive epidemiological and biological evidence suggest that exposure to radiation in the same range as that routinely delivered by CT increases the person's risk of developing cancer. ? For dose in excess of 100 mSv, …the science is clear: Ionizing radiation exposure can have serious adverse effects. Dose in excess of 100mSv this is interesting. There is a 50 50 divide, currently in the literature. We have 1/2 of one team coming in as the procedures are incredibly safe, and there's almost no risk. Then, there is a whole other group of scientists that are saying, well, hold on, not so fast. But this group here - this statement. Extensive epidemiological and biological evidence suggest that exposure to radiation in the same range as that routinely delivered by CT increases the person's risk of developing cancer. Empirical Support for Significant Risk? ? But what about risk to radiation in the low-dose range? Diagnostic Radiography Computed Tomography Nuclear Medicine What does the literature report tell us? Low dose range but it's on the low dose side where there is still a lot of confusion. Was their empirical support for significant risk for low dose? Lets take a look at What the literature tells us. What is this? What does it mean? ? July 2020 – Journal of the National Cancer Institute Study Design: Meta-analysis of 26 studies assessing the link between exposure to environmental, medical and occupational radiation and excess relative risk (ERR) for the development of a malignancy. Conclusions: “new epidemiological studies directly support excess cancer risks from low-dose ionizing radiation. Furthermore, the magnitude of the cancer risks from these low-dose radiation exposures was statistically compatible with the radiation dose-related cancer risks of the atomic bomb survivors.” ERR This is another article, and this is not old stuff, July of 2020. The meta analysis of 26 different studies, epidemiologic studies linking radiation exposure, and risk. And definitely conclusions of these authors were that these studies support excess cancer risks from low dose ionizing radiation. And what is this telling us? There is most certainly, still a risk. And the term being used, Excess relative risk. What is that? What does that mean? Excess relative risk? E-R-R. But cancer, right? Is exposure to ionizing radiation our only risk factor, When cancer is concerned? Of course not, but there's already a baseline inherent risk for anyone to develop a malignancy. It is really important to stay up to date and continue to look at this type of data. It's important to understand that we really need to focus on excess relative risk. The work that you do is not the only source of risk for developing cancer. Quite the opposite. You're looking to diagnose those cancers early to help save lives. So excess relative risk is a very important term that will be discussed a bit more in upcoming slides. ? Medical Radiation & Cancer What’s the risk? Absolute Risk - the probability that a person who is disease free at a specific age will develop cancer following radiation exposure. Relative Risk - the risk of developing cancer from radiation exposure, above and beyond the natural incidence of the disease. Medical Radiation and Cancer here are some definitions. There's an absolute risk of developing a cancer from medical radiation exposure, and the definition for relative risk. Its important to understand these terms so that when reading literature, you're able to engage and have informed conversations with patients. ? Cancer: An all-too-common outcome Between 2013-2017, the naturally occurring cancer rate was approximately 442 per 100,000 individuals per year. Resulting in: 158/100,000 deaths per year These rates continue to decline. Click to view the Source info Source info National Cancer Institute. https://www.cancer.gov/about-cancer/understanding/statistics All too common - Cancer cancer, there is an all too common occurrence. These numbers are pretty startling. 158 deaths per 100,000 individuals per year. Thankfully, that number continues to decline. Cancer incidence continues to increase, but that is not necessarily a bad thing, more incidence means with todays technology, it is being detected earlier and more frequently. It is sometimes stated as such in literature , But that's based on the work that is being done in the field of Radiology today. What's really important is that mortality is falling. But still, these numbers are pretty sharp, and still pretty spot on. ? How does exposure to medical radiation increase risk? Excess Relative Risk (ERR) - increased risk due to medical radiation exposure: Children – 10-15% lifetime risk* Adults – 4.1-4.8%* Over 60 – minimal/no risk* Entire population – 5.5-6.0%* *per Sv of effective dose. Click to view the Source info Source info Peck, D. J., & Samei, E. (2017). How to understand and communicate radiation risk. Image Wisely. ERR_perSv Some important facts about excess relative risk or ERR as discussed in previous slides. So these are not small numbers necessarily when you first look at them. But here's the thing about reading the literature, Why understanding radiation units, that we're going to do a brief review on here, are so important. If a lay person red these numbers, a Possible 10 to 15% increase in risk for pediatric patients developing cancer, that is a big number. Importantly, understanding that, that is Per sievert of effective dose. And that is only important, if you understand what that means. But there's a gap sometimes. Graduating from radiology school, most probably have no idea what these units really mean. It is important to understand what these units mean. So again, good, informed conversations with patients can really help them understand data like this. So yes, if you were exposed to one seivert effective dose of radiation, you have pretty significant increase in cancer. But we're not gonna be anywhere near that amount of effective dose. Less than, or at milisievert, a thousandth of this number, and therefore the percentage of incidents, is a thousand of these percentage points, that's a huge difference. Again, important to understand these facts and the science behind it all. ? Meta-analysis - studies Pediatric Radiology Lancet Oncology Radiology Select the tab arrows to learn more. Dose articles layer1 peds This meta analysis is from the Pediatric Radiology journal, published in September of 2020. It states that there is no additional risk for prenatal exposure. The data suggests that there are no epidemiologic studies that demonstrate significant risks when Performing CTA's to rule out pulmonary emboli on pregnant patients. It is always important to remember though, that not having evidence Of risk, Is not the same thing as having evidence of no risk. Just because we don't have evidence, Doesn't mean it doesn't exist. That's always important to keep in the back of your mind as well. But the rest of the statement says CT exposure in childhood appears to be associated with increased risk of cancer. No significant risk with the diagnostic radiographs. The work that is being done as a radiographer, seems to not be demonstrating any significant risks. layer 2 lancette Fast forward, not too long ago, late 2022, And the lancette, this is not a small publication, this is pretty important stuff. CT imaging increases brain cancer risk in children by up to five fold. Of course, it finds its way onto many websites. That's a pretty startling statistic, and some of the data here, As far as these numbers, one must take them all with a grain of salt. By the time this was written, And went through peer review, and then was published, The numbers have plummeted since then, so the dose that is associated with CT of The brain still continue to decrease every year, but nevertheless, it is a startling statistic. The Counter Argument Click to view the Source info Source info Hricak, H., Brenner, D. J., Adelstein, S. J., Frush, D. P., Hall, E. J., Howell, R. W., ... & Wagner, L. K. (2011). Managing radiation use in medical imaging: a multifaceted challenge. Radiology, 258(3), 889-905. “….there is reasonable, though not definitive, epidemiological evidence that organ doses in the range from 5 to 125 mSv result in a very small but statistically significant increase in cancer risk.” However, “… the radiogenic excess cancer risk associated with diagnostic radiation levels…is orders of magnitude smaller than the spontaneous cancer risk.” (Hricak, et.al. Radiology 2010) Lancet Oncology - December 2022 Summary: 658,752 CT patients under the age of 22 165 brain cancers occurred Mean cumulative brain dose: 47.4 mGy for all individuals 76.0 mGy for those diagnosed with cancer Significant linear dose-response relationship observed Click to view the Source info Source info Hauptmann, M., Byrnes, G., Cardis, E., Bernier, M. O., Blettner, M., Dabin, J., ... & Kesminiene, A. (2022). Brain cancer after radiation exposure from CT examinations of children and young adults: results from the EPI-CT cohort study. The Lancet Oncology. Pediatric Radiology - 2020 Study Design: Meta-analysis of 24 epidemiological studies between 2000 – 2019 for patients undergoing ionizing radiation-based medical imaging below 22 years of age. Conclusions: No additional risk from pre-natal exposure. CT exposure in childhood appears to be associated with increased risk of cancer while no significant association was observed with diagnostic radiographs. Select the X in the upper right corner to continue. ? How do we make sense out of all of this? Here’s how: Brush-up on your understanding of radiation science. Become an expert in radiation dose & risk! Become an expert ? Dose Metrics: Exposure - Roentgen (R, mR) Absorbed dose - Gray (Gy) Effective Dose - Sievert (Sv) 1 1 1 1 2 2 2 2 3 3 3 3 4 4 4 4 Select each numbered button to learn more. The Science of Medical Radiation & Risk A Review A review base Here is a good place to start. These dose metrics are important to brush up on. these are still the most commonly used. The typical physicist report about tube output, or exposure, uses Roentgen or the Milli Roetgen. Absorb dose is the grey and effective dose is Sievert. what do these terms really mean? L1 As discussed in previous slides, the studies showed effective dose, because that is the unit that is most commonly used. Effective dose is Measured in sieverts, usually millisieverts, And it accounts for tissue radiosensitivity. The definition, a dose of radiation to a particular organ can be equated to a comparable whole body dose, based on the radio sensitivity of the tissue exposed. Effective dose is a whole body dose. But, What does that mean? L2 Calculating effective dose: There are given tissue weighting factors of various radio sensitivities of different tissues, and here, all of these values add up to one. What does that mean? An estimation of effective dose first and foremost, and that's what's most important. L3 Here is a sample estimation. These numbers are not accurate and are easy random numbers for this calculation example. Lets say for arguments sake, the average glandular dose for a mammo is 3 mGy. That is the absorbed dose of breast tissue during a mammo. The breast tissue weighting factor is 0.12, pretty high radiosensitivity of breast tissue. That makes sense, right? We can calculate effective dose by multiplying the absorbed dose by the tissue weighting factor. Again, What does this mean? Why did the number gets smaller? Why the .36 millisievert? Whole body dose. We need to be able to connect the dots. Why did the number get smaller? L4 When 3 milligrays of glandular breast dose is the same as if the individual had received 0.36 millisieverts, For the whole body. Its equating two very different things. It's taking a partial body exposure, And equating that dose to the whole body. Why? We arent exposing the patients full body during a mamogram? Why do this conversion? Why do we need the Sievert to give us whole body dose? Because We need to make a comparison. everything that is known about radiation dose and risk comes to us from post World War Two Japan. It is a true statement, to a certain extent, that most of what we know about the risk of medical radiation exposure comes to us From nuclear events, which is obviously a very different type of radiation exposure than the patients are receiving. 3 mGy of glandular breast dose is the same as receiving 0.36 mSv to the whole body! Effective dose for a mammo = 0.36 mSv Partial body exposure Whole body dose equivalent For a given mammogram: Average glandular dose ~ 3 mGy Breast tissue weighting factor = 0.12 Effective dose = 3 x 0.12 = 0.36 mSv Exposure - Roentgen (R, mR) Absorbed dose - Gray (Gy) Effective Dose - Sievert (Sv) Sample Estimation *Other tissues combined: adrenal glands, extrathoracic region, gall bladder, hear, kidneys, lymphatic nodes, muscle, oral mucosa, pancreas, prostate gland, small intestine, spleen, thymus, uterus/cervix. Click to view the Source info Source info Adapted from: Wrixon AD, New ICRP recommendations, J. Radiol. Prot. 2008: 28: 161-168 ? Effective dose may be determined by multiplying the dose to each organ/tissue by their individual weighting factors and then summing all. Calculation of effective dose Table with 2 columns and 6 rows Tissue Tissue Weighing Factor, WT Bone-marrow, colon, lung, stomach, breast (14 others combined*) 0.12 (6) Gonads 0.08 (1) Bladder, esophagus, liver, thyroid 0.04 (4) Bone surface, brain, salivary glands, skin 0.01 (4) Total 0.01 x 4 = .04 1.00 0.04 x 4 = .16 0.08 x 1 = .08 0.12 x 6 = .72 Estimation Select the X in the upper right corner to continue. Effective Dose (E, EfD, ED) Measured in Sieverts (usually mSv) Accounts for tissue radiosensitivity A dose of radiation to a particular organ/tissue can be equated to a comparable whole-body dose based upon the radiosensitivity of the tissue exposed. ? Why consider whole body dose when we image body parts? Hiroshima 1945 Chernobyl 1986 Fukushima 2011 Hiroshima As we think about August in 1945, the two cities of Hiroshima and Nagasaki in Japan, two atomic weapons were detonated so close to the surface of those two cities. Scientists from all over the world, especially the United States, rushed to Japan to study the effects of radiation exposure of those cities. it has become really one of the most powerful epidemiologic studies in scientific history, that is still ongoing today. scientists on an annual basis, track cancer incidence of the citizen, and the offspring of the citizen, from World War Two, Japan, And get great data linking radiation exposure for the incidence of disease. there's some really significant differences here for the work that we do. ? Longitudinal Epidemiological Studies Single dose Particulate radiation No fractionation Single dose The single dose incident for the most part, Wasn't even X-ray, a lot of the most dangerous energy, was particulate radiation, fast neutrons, Beta and Alpha Particles. It got into the water and into the food supply, that were ingested, and breathed in by citizens. very different from the work that we do. There was also no fractionation relative to dose. ? From Hiroshima to Empirical Literature… Estimated absorbed partial body dose (mGy) Risk Estimation Effective whole-body dose (mSv) Tissue Sensitivity Data Comparison Empirical literature What did that data do? Scientists were able to estimate, and then based on the distance the individual was from Ground Zero, then be able to estimate partial body doses, Using tissue sensitivity figure, then calculate effective whole body dose, and then do a data comparison. ? Apples-to-Oranges? Do these comparisons accurately estimate risk from medical radiation exposure? Empirical literature And if this seems like an apples to oranges comparison, it's certainly is. In that group of scientists that are out there saying that there's no risk, This is pretty much what they’re basing it on. But that data set, as good as it might be, should not be used to generate risk values for the radiology profession. right or wrong, its not for us to say, But again, radiology is stuck in the middle of all of it. ? Some Definitively Say – NO! According to Tubiana, Feinendegen, et.al: "...there is no evidence of carcinogenic effects for acute radiation doses less than 100 mSv and for chronic irradiation doses at less than 500 Sv." Click to view the Source info Source info Tubiana M, Feinendegen LE, et.al. The linear no-threshold relationship is inconsistent with radiation biologic and experimental data. Radiology 2009; 251 (1): 13-22. Some say no! Now, some folks out there say definitely no, you can't use that data. This is a very widely cited study that says that there is no evidence of carcinogenic effects for acute radiation doses less than 100 millisieverts. And if you start to read the literature, especially the data coming from the physicist, again, related to the shielding conversation, that 100 millisieverts seems to be the line in the sand. There is no risk below 100 millisieverts, and again, the work that radiology professionals are doing, is far below it. That has become a very, very important number. ? But what about this study…? (2012) Some say no! here's another study. if you are performing a pediatric CT, the cumulative dose is about 50 milligray. Now that's still pretty high, but we're getting close to what you might see for some extensive CT studies. this is published again, in The Lancet, but a dose of 50 milligray might almost triple the risk of leukemia, and it might triple the risk of brain cancer. might almost, is not really science, . Again, startling stats that made their way to many publications. ? …..and this one? Click to view the Source info Source info Mathews, J. D., Forsythe, A. V., Brady, Z., Butler, M. W., Goergen, S. K., Byrnes, G. B., ... & Darby, S. C. (2013). Cancer risk in 680 000 people exposed to computed tomography scans in childhood or adolescence: data linkage study of 11 million Australians. Bmj, 346. BMJ_24% greater Here is one more. Cancer risk of 680,000 pediatric patients in Australia. All types of cancer incidence was 24% greater in Individuals that have had CT studies. These are not small numbers. Here is the issue though. Many radiology professionals have started to push back, and say, well, hold on a second. These are restrospective studies. We pulled data On children who are having CT studies Of the head. They weren't there for the fun of it. They were symptomatic. And those symptoms were not controlled for these studies. So of course there was a higher incidence of leukemia or brain cancer because they had symptoms that brought them to the facility in the first place. ? Here is what the patients read: June 07, 2012 Headline coverage appeared in numerous new headlines: Reuters Fox News NY Times UK Telegraph Childhood CT_brain cancer Again, this is what winds up happening. From those same studies, headline News. Reuters, Fox News, New York Times, and UK Telegraph. This is what the patients are seeing. According to the scientists, who are reporting that exposure to low doses of ionizing radiation, Not only are they not harmful, but actually good for us. That they initiate the body's immune response and improve our ability to ward off future exposure to radiation. Radiology professionals get stuck in the middle of all this contraversy because RT’s are the ones on the frontline with the patients having to answer to all of their questions about dose and risk. ? Communication How do we communicate all of this to the patients? Communication is key! How to communicate to the patients How do we communicate all of this to the patients? it all comes back to the risk versus benefit continuum. So we start from the beginning, when a patient asks. ? Risk vs. Benefit Continuum Dose or risk Dose or risk Relative Risk Level Relative Risk Level Relative Risk Level BERT BERT Patient Perception Patient Perception Select each button for more information. Developers: for additional options for buttons and states visit https://ux.siemens-healthineers.com/ui-marcom/components/button/usage/index.html card options in buttons Risk vs. Benefit Continuum l1 Dose or risk When a patient asks How much dose am I receiving from this procedure? What They really want to know, is, what the risk is. if you're telling them somewhere between .2 and 1.2 millisieverts, That is not answering the question that they want. What's the risk of the procedure? Two methods are going to be discussed. The first one is known as relative risk level and the second one is background equivalent radiation time or BERT. There is a way for everyone to all be saying the same thing, conveying the same message to the patients. when the patients ask, Am I going to glow in the dark from this? Is this test safe? Is this going to give me cancer? If all radiology professionals can start to get on the same page, it would be a great positive step forward. L2 Relative risk level So relative risk level? It's pretty straightforward. A method of describing the excessive risk of developing a fatal cancer from radiation exposure – above and beyond the natural risk. it takes into account that idea of excess relative risk. It's important for radiology professionals to be the largest and most vocal positive proponents of the profession because if we wait for somebody else to do that, It is not gonna happen. in the conversations with patients, we need to make sure that we are not their primary source of radiation exposure. These two methods, when combined, can do that.. What is the risk of this procedure above and beyond the naturally occurring risks? That is what needs to be focused on. L2_2 RRL The the ACR provides a nice table. This has been in a few publications , and It is these words here in the middle that are really important. What is the risk of this procedure? Well, Mrs. Jones, the risk is negligible. That's a tough word. And my goodness, all of the patients not going to understand what negligible means. Is there risk? Incredibly small? Is there no risk? There is Never no risk with anything. But the risk is so small they can effectively be ignored. That's how small it is. It's not dismissing their question. It's not saying it was more dangerous to drive here or more dangerous to get on a plane. They know that. And you are the expert in radiation health. And the patients are expecting a valid answer, not some risk comparison or something else that's not related. Is there risk of this procedure? These words get a little bit more problematic as You go down the chart. For interventional or multiphase CT perhaps the risk is moderate. That is not a very comfortable word, but again, that patient is there for very valid reasons and odds are, they have greater concerns than what their radiation exposure going to be. That's a conversation in most instances, that gets a little bit easier. L3BERT The second method Is background equivalent radiation time or commonly known as BERT. again, this is very similar to the idea of Flying Cross country. The Dose that they receive from the test is the same as flying from New York to London. Well, then we're gonna need to talk about a couple of things. We need to know Altitude, air speed, prevalence of sunspots? do You have all that data? But giving a response that really doesn't have any scientific basis doesnt do the patient any good. there's a way to do that a little more intelligently, more sensitively and more accurately, And that's using BERT. BERT2 these numbers are not hard and fast. They are once again from the ACR, Who gives us really good data. A CT of the abdomen and pelvis Pre and post contrast. if That's still even being done. Let's say the effective dose is 20 millisieverts. That still is on the high side, based on what's happening out there today, but it's about the amount of exposure you get just from living on Earth for seven years. That's not a small amount of time. But if you go up the chart. Chest Xray, about the exposure we get in about 10 days now. Why is it so important? Again, it points out for the patient that we are not the only source of their radiation exposure. Right. Think back to being in school, and instructors first tell you about the natural sources of ionizing radiation. like right now? the class is being exposed to radiation. Yes. Right now, everyone is. On the ground, in the air, from each other, it's the truth. And it's a good reminder for the patients, again, that they receive or they get dose and exposure from all different types sources. Radiology procedures are not the only source of radiation exposure. If these two approaches are used, together, radiology professionals are actively answering the question, and we're all saying the same thing, with the same messaging. BERT 3 Here is an excerpt from radiologyinfo.org, which is a combined resource from the ACR from RSNA. It lists out all the doses for the common radiology procedures, and their comparable background amount, or BERT. In the upper top right corner, click the resources tab, select and save the BERT pdf from this online training, and have it as a handy resource for your facility. Misperceptions "CT scans are the biggest culprits, delivering as much as 500 times the radiation of a standard X-ray, and potentially causing an estimated 1.5 to 2 percent of all cancers in the United States." Click to view the Source info Source info Radiation Fallout: Which Screenings Are Safe?, Dr. Oz http://www.oprah.com/health/Are-X-Rays-and-CT-Scans-Safe-Radiation-Risks-Dr-Oz Select the X in the upper right corner to continue. 2. Background Equivalent Radiation Time (BERT) A method of expressing the dose received from a given procedure in terms of the normal background radiation we are exposed to naturally. Select the X in the upper right corner to continue. 1. Relative Risk Level A method of describing the excessive risk of developing a fatal cancer from radiation exposure - above and beyond the natural risk. Select the X in the upper right corner to continue. Select the X in the upper right corner to continue. Dose or Risk? Methods to discuss risk with patients When a patient asks the question, "How much dose am I receiving from this procedure?" What they really mean is, "What is the risk of this procedure?" Relative Risk Level Background Equivalent Radiation Time (BERT) ? Communicating Risk to Patients DO: Tell the truth Avoid absolutes Stay calm/positive Clarify - make sure you're understood Cite trustworthy data DONT: Use complicated jargon Talk theory without clear non-technical explanation Discuss worst-case scenarios Directly link risk & benefit Compare unrelated risks Do's and Dont's a couple of Do’s and don’ts. Patient asks what the risk is, or is it dangerous? Being truthful is always best. Avoid absolutes and stay calm. Be sure to clarify and ensure you are being understood, and if you are going to cite, make sure it it is trustworthy data. Don’t, use complicated jargon or discuss theory without a clear non technical explanation. Do not discuss worst-case scenarios or directly link risk and benefit, and do not, compare unrelated risks such as flying in a plane or going to the dentist. ? Communicating Risk to Patients Banana Equivalent Dose 1,000 bananas = 1 chest x-ray One cross-country flight = 1 chest x-ray Dont compare unrelated risks Here is the banana equivalent dose. Yes, this is a real thing. Many patients are going to see this. There are charts and tables online that relate a total number of ingested bananas to a chest xray. 1,000 bananas, You would have to ingest that. Is it the same radiation exposure as the one Chest Xray? no. Same thing with the cross country flight. Driving home again, The point that all radiology professionals need to be on the same page about the responses used when patients ask these risk-related questions. 1 1 2 3 4 The Role of the Medical Imaging Professional Move the dial to each number to learn more. The R.T base layer 1 rts matter The safety of radiographic procedures is predicated on the fact that an R.T. is performing them. L2 everything matters . High-quality and safe radiographic imaging is not a given. It depends on knowledge and skill – and the consistent implementation of best practices. The knowledge and skills of an R.T is paramount. Systems are all automated now, does contrast matter? collimation? shielding? mAs and kVp? It ALL matters! Impact on practice L3 If the procedures doses are so safe, and if Automation guarantees image quality all the time, couldn’t anyone perform these radiographic procedures? why is an RT needed? L4 become and expert with some of the advocacy efforts that are going on across the country related to licensure, you know this is no joke. And let's not help it along. such as Failing to remember and put into practice all the little things that do matter, that are so important. Being an expert is important. No one can do this job better than a licensed RT. If you're familiar with some of the advocacy efforts that are going on across the country related to licensure, you know this is no joke. And let's not help it along, such as failing to remember, and put into practice all the little things that DO matter, and that are so important. Being an expert is important. No one can do this job better than a licensed RT. Become an expert Select the X in the upper right corner to continue. Impact Doses are so low and the procedures are so safe, and if automation guarantees image quality all the time………. Couldn’t anyone perform these radiographic procedures? Why is an RT needed? High-quality and safe radiographic imaging is not a given. It depends on R.T’s – knowledge and skills – and the consistent implementation of best practices and messaging to the patients. It all matters – R.T’s matter – and it’s important to let others know it. Everything Matters Select the X in the upper right corner to continue. Shielding Collimation mAs and kVp Contrast It ALL matters! The safety of radiographic procedures is predicated on the fact that an R.T. is performing them… The Role of the Medical Imaging Professional Select the X in the upper right corner to continue. ? Conclusions The work that is done in the Radiology profession saves lives and significantly improves patient outcomes. Conclusion The work that is done in the Radiology profession saves lives, and significantly improves patient outcomes. Never underestimate the importance of being an RT. ? Reduce patient exposure, but don't go too far… "Less dose...is not always better: Reducing dose to the point at which image quality is clinically degraded may obscure the diagnostic information being sought." "There is no radiogenic risk if the patient does not survive long enough to manifest cancer." Conclusion Reducing dose to the point at which image quality is clinically degraded, may obscure the diagnostic information being sought. And this quote couldn't be more true: there is no radiogenic risk if the patient does not survive long enough to manifest cancer. Assessment Welcome to the assessment. For each question, select the button to the left of your answer, and then select Submit. You will have 3 attempts to take this assessment and to successfully pass this course, you must receive a score of 80% or higher. You will receive your score when you have completed the assessment. Note: If you close the learning activity at any time before you have finished the quiz, your answers will not be saved. Select Start to begin. Start Assessment Select the best answer. ? 50% 95% Question 1 of 8 From 1995 - 2012, the gonadal dose for an AP pelvis radiograph decreased by _____. 75% 85% Multiple Choice Select the best answer. ? 10 mSv 100 mSv 85 mSv Question 2 of 8 The science is clear, in that, for doses in excess of _____, ionizing radiation exposure can have serious adverse effects. 95 mSv Multiple Choice Select the best answer. ? excess relative risk excess relative radiation Question 3 of 8 ERR stands for: extra radiation risk excess radiation risk Multiple Choice Select the best answer. ? True Question 4 of 8 The probability that a person who is disease free at a specific age will develop cancer following radiation exposure is known as absolute risk. False Multiple Choice Exposure Roentgen (R, mR) Absorbed dose Gray (Gy) Effective Dose Sievert (Sv) Drag each response from the right column to its corresponding item in the left column. Match the correct dose metrics. ? Question 5 of 8 Matching Select the best answer. ? Background Equivalent Radiation Time Background Equivalent Relative Time Question 6 of 8 What does the acronym BERT stand for? Background Equal Radiation Time Background Equivalent Radiation Tracking Multiple Choice ? Select all that apply. Question 7 of 8 tell the truth directly link risk with benefit stay calm and positive cite trustworthy data avoid absolutes All of the following are acceptable actions to take when discussing dose and risk with a patient EXCEPT: Multiple Answer Select the best answer. ? the tissue weighting factor none of the above Question 8 of 8 Effective dose can be calculated by multiplying the absorbed dose by _____. BERT ERR Multiple Choice Retry Assessment Results %Quiz1.ScorePercent%% %Quiz1.PassPercent%% Continue YOUR SCORE: PASSING SCORE: Results Slide You have exceeded your number of assessment attempts. Exit You did not pass the course. Select Retry to continue. Congratulations. You passed the course. Exit To access your Certificate of Completion, select the Certificates tab from the learning activity overview page. You can also access the certificate from your PEPconnect transcript. You have completed the Patient Radiation Dose and Risk assessment. Completion Question Bank 1 Patient Radiation Dose and Risk BERT_Radiation Doses from common examinations 1 Patient Radiation Dose and Risk 1.1 Introduction 1.2 Navigation Hints 1.3 Objectives 1.4 Current view 1.5 Dose and risk 1.6 NCRP 1.7 USA Today 1.8 NY Times 1.9 Profession responds 1.10 Options 1.11 Optimization 1.12 Technology 1.13 Where are we today? 1.14 Is there risk or isnt there? 1.15 Dose in excess of 100mSv 1.16 Low dose range 1.17 ERR 1.18 Medical Radiation and Cancer 1.19 All too common - Cancer 1.20 ERR_perSv 1.21 Dose articles 1.22 Become an expert 1.23 A review 1.24 Hiroshima 1.25 Single dose 1.27 Empirical literature 1.29 Some say no! 1.30 BMJ_24% greater 1.31 Childhood CT_brain cancer 1.32 How to communicate to the patients 1.33 Risk vs. Benefit Continuum 1.34 Do's and Dont's 1.35 Dont compare unrelated risks 1.36 The R.T 1.38 Conclusion 1.39 Assessment 1.49 Completion