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Radiation Exposure and Imaging Utilization
EDITORIAL
BRUCE J. HILLMAN, MD
Radiation Exposure and Imaging Utilization Less is more. —Mies van der Rohe
There’s a definite theme to this issue that has more to do with timing than anything preplanned. Late last year, Brenner and Hall [1] published a much ballyhooed article purporting that in the not so distant future, roughly 2% of all cancer will be the result of carcinogenesis induced by diagnostic radiation. The article was based on the assumption that the damage from even low-level radiation is cumulative, and that the risk for carcinogenesis increases linearly with accrued dose without any initial threshold. No fewer than 5 articles in this issue of JACR are related in one way or another to risks associated with diagnostic radiation. Two of the 3 “Opinion” columns take their cue from the assumption that diagnostic levels of radiation may indeed be harmful and address radiologists’ role in reducing unnecessary exposure. Emmanouil Karatzis, MD, and Peter Danias, MD, address a specific application, drawing readers’ attention to the risks associated with cardiac imaging. The piece by Giles Boland, MD, indicates that information technology could play an important role in advising referring physicians on the most appropriate imaging and thereby reducing unnecessary utilization. In distinction, the column by Reuben Mezrich, MD, questions the assumptions from which Brenner and Hall drew their conclusions. In this article, the author raises reasonable doubt as to the validity of the no-threshold, linear-risk hypothesis, citing key data that draw these assumptions into question. He calls on the ACR to conduct research that will directly measure the effect of
low-level diagnostic exposure on the risk for carcinogenesis. Regardless of the debate over how much risk for cancer development is really imparted by diagnostic levels of radiation, it is reasonable now for radiologists to act conservatively. The ACR has been preparing radiologists to be more cautious about radiation exposure for some time, the efforts culminating in the ACR white paper on radiation exposure published in 2007 [2]. Two articles in this month’s JACR address how to operationalize some of the recommendations of the Blue Ribbon Panel on Radiation Dose in Medicine. This month’s “Technology Talk,” column by Beth Schueler, PhD, addresses the need to instill estimates of radiation dose into ACR Appropriateness Criteria® as a means of educating (or, in most cases, reeducating) ourselves to what risk may exist. The article by Steven Birnbaum, MD, details an enviably comprehensive community-based program he has worked with in New Hampshire for which there already is ample experience. The upshot of all of these articles is a multifaceted look at a complex set of issues. As can be derived from reading them, the concerns over radiation, regardless of how grounded they may be, derive from the convergence of a number of current trends: ●
●
© 2008 American College of Radiology 0091-2182/08/$34.00 ● DOI 10.1016/j.jacr.2008.03.006
Our literature is constantly disseminating information about new applications of ionizing radiation-based techniques, which are adopted by radiologists. The population is aging and incurring a greater burden of chronic disease. Imaging is increasingly used to screen for, diagnose, stage, and monitor treatment for conditions such as nephrolithiasis, ar-
●
●
●
●
thritis, and inflammatory bowel disease. There are increasing demands placed on the time of referring physicians. Imaging is now commonly used as a triaging technology, especially in emergency rooms, but also by office-based physicians. Patients who in the past might have received no imaging at all are increasingly receiving high-technology examinations. The capacity of all imaging, but especially computed tomography, has greatly expanded. There are many more machines, and they are capable of generating more examinations per day than before. The growing adoption of office-based imaging by nonradiologists is contributory. Inevitably, greater capacity means more examinations, regardless of whether all of that utilization is truly indicated. Imaging examinations are becoming more complex. This is driven by an often inappropriate desire to reduce uncertainty, even in situations in which there is low a priori probability of disease. Incentives are aligned to increase the amount of imaging. Patients want imaging to be sure that “nothing is missed.” Referring physicians see imaging as a way of making their activities more efficient and absolving themselves of legal exposure. Radiologists earn more the more they do and fear alienating their referring physicians.
There is no getting past the current controversy. Boland is correct that enhanced public awareness of diagnostic radiation exposure exacerbates the already extant financial concerns among payers about increasing imaging utilization. Radiologists need to educate themselves 689
690 Editorial
about the dosages of radiation they are conferring on patients and deal with the broader issue of the inappropriate use of imaging.
REFERENCES 1. Brenner DJ, Hall EJ. Computed tomography—an increasing source of radiation exposure. N Engl J Med 2007;357:2277-84.
2. Amis ES KE, et al. logy white medicine. J 84.
Jr, Butler PF, Applegate American College of Radiopaper on radiation dose in Am Coll Radiol 2007;4:272-
Bruce J. Hillman, MD, Department of Radiology, University of Virginia Health System, PO Box 800170, Charlottesville, VA 22908; email: [email protected].
BRUCE J. HILLMAN, MD
Radiation Exposure and Imaging Utilization Less is more. —Mies van der Rohe
There’s a definite theme to this issue that has more to do with timing than anything preplanned. Late last year, Brenner and Hall [1] published a much ballyhooed article purporting that in the not so distant future, roughly 2% of all cancer will be the result of carcinogenesis induced by diagnostic radiation. The article was based on the assumption that the damage from even low-level radiation is cumulative, and that the risk for carcinogenesis increases linearly with accrued dose without any initial threshold. No fewer than 5 articles in this issue of JACR are related in one way or another to risks associated with diagnostic radiation. Two of the 3 “Opinion” columns take their cue from the assumption that diagnostic levels of radiation may indeed be harmful and address radiologists’ role in reducing unnecessary exposure. Emmanouil Karatzis, MD, and Peter Danias, MD, address a specific application, drawing readers’ attention to the risks associated with cardiac imaging. The piece by Giles Boland, MD, indicates that information technology could play an important role in advising referring physicians on the most appropriate imaging and thereby reducing unnecessary utilization. In distinction, the column by Reuben Mezrich, MD, questions the assumptions from which Brenner and Hall drew their conclusions. In this article, the author raises reasonable doubt as to the validity of the no-threshold, linear-risk hypothesis, citing key data that draw these assumptions into question. He calls on the ACR to conduct research that will directly measure the effect of
low-level diagnostic exposure on the risk for carcinogenesis. Regardless of the debate over how much risk for cancer development is really imparted by diagnostic levels of radiation, it is reasonable now for radiologists to act conservatively. The ACR has been preparing radiologists to be more cautious about radiation exposure for some time, the efforts culminating in the ACR white paper on radiation exposure published in 2007 [2]. Two articles in this month’s JACR address how to operationalize some of the recommendations of the Blue Ribbon Panel on Radiation Dose in Medicine. This month’s “Technology Talk,” column by Beth Schueler, PhD, addresses the need to instill estimates of radiation dose into ACR Appropriateness Criteria® as a means of educating (or, in most cases, reeducating) ourselves to what risk may exist. The article by Steven Birnbaum, MD, details an enviably comprehensive community-based program he has worked with in New Hampshire for which there already is ample experience. The upshot of all of these articles is a multifaceted look at a complex set of issues. As can be derived from reading them, the concerns over radiation, regardless of how grounded they may be, derive from the convergence of a number of current trends: ●
●
© 2008 American College of Radiology 0091-2182/08/$34.00 ● DOI 10.1016/j.jacr.2008.03.006
Our literature is constantly disseminating information about new applications of ionizing radiation-based techniques, which are adopted by radiologists. The population is aging and incurring a greater burden of chronic disease. Imaging is increasingly used to screen for, diagnose, stage, and monitor treatment for conditions such as nephrolithiasis, ar-
●
●
●
●
thritis, and inflammatory bowel disease. There are increasing demands placed on the time of referring physicians. Imaging is now commonly used as a triaging technology, especially in emergency rooms, but also by office-based physicians. Patients who in the past might have received no imaging at all are increasingly receiving high-technology examinations. The capacity of all imaging, but especially computed tomography, has greatly expanded. There are many more machines, and they are capable of generating more examinations per day than before. The growing adoption of office-based imaging by nonradiologists is contributory. Inevitably, greater capacity means more examinations, regardless of whether all of that utilization is truly indicated. Imaging examinations are becoming more complex. This is driven by an often inappropriate desire to reduce uncertainty, even in situations in which there is low a priori probability of disease. Incentives are aligned to increase the amount of imaging. Patients want imaging to be sure that “nothing is missed.” Referring physicians see imaging as a way of making their activities more efficient and absolving themselves of legal exposure. Radiologists earn more the more they do and fear alienating their referring physicians.
There is no getting past the current controversy. Boland is correct that enhanced public awareness of diagnostic radiation exposure exacerbates the already extant financial concerns among payers about increasing imaging utilization. Radiologists need to educate themselves 689
690 Editorial
about the dosages of radiation they are conferring on patients and deal with the broader issue of the inappropriate use of imaging.
REFERENCES 1. Brenner DJ, Hall EJ. Computed tomography—an increasing source of radiation exposure. N Engl J Med 2007;357:2277-84.
2. Amis ES KE, et al. logy white medicine. J 84.
Jr, Butler PF, Applegate American College of Radiopaper on radiation dose in Am Coll Radiol 2007;4:272-
Bruce J. Hillman, MD, Department of Radiology, University of Virginia Health System, PO Box 800170, Charlottesville, VA 22908; email: [email protected].