Joy Yvette Payne, PhD Student

1
Be Your Own AdvocateUnderstanding Ionizing
Radiation and Exposure from Medical Imaging

• Joy Yvette Payne, PhD Student
• Walden UniversityPUBH 8165-1
• Dr. Robert Marino
• Fall, 2011

2
Objectives
At the end of this presentation you will be able
to
3
Introduction
Natural News. (2010). Use of high-radiation CT
scans in emergency rooms triples over nine years.
Retrieved October 20, 2011 from
http//www.naturalnews.com/030776_CT_scans_radiat
ion.html New York Timers. (2010). Radiation,
Risks Are Focus of Breast Screening Study.
Retrieved October 21, 2011 from
http//www.nytimes.com/2010/08/24/science/24breast
.html USA Today. (2010). Cancer risks prompt
doctors to try to lower imaging scan radiation.
Retrieved October 21, 2011 from
http//www.usatoday.com/news/health/2010-05-05-rad
iation05_st_N.htm
4
Radiation Waves Penetration Power
U.S. Environmental Protection Agency (EPA).
(2011e) . Why are some atoms Radioactive.
Retrieved October 13, 2011 from
http//www.epa.gov/rpdweb00/understand/radiation.h
tml
5
Common Radiation Units and Symbol

• Sievert (Sv)1 unit of equivalent dose
  (international)
• 1 Sv 100 rem (0.001 Sv 1mSv)
• Rem1 - US unit of measurement
• Millirem (mrem) 1/1000 of a rem
• Gray (Gy) 1 unit of absorbed dose
  (international)
• Used to describe radiation treatment dose
• Rad1 US unit of absorbed dose
• 1 Gy 100 rad

1. U.S. Environmental Protection Agency (EPA).
(2011a). Radiation Protection Basics. Retrieved
October 7, 2011 from http//www.epa.gov/radiation
/understand/protection_basics.html 2..U. S.
Environmental Protection Agency (EPA). (2011d).
Radiation Protection. Radiation Symbols.
Retrieved October 7, 2011 from http//www.epa.gov/
rpdweb00/understand/symbols.html
6
Exposure Limits and Averages
Annual Radiation Dose Limits Agency
Radiation Worker - 5,000 mrem NRC, "occupationally" exposed
General Public - 100 mrem NRC, member of the public
General Public - 10 mrem EPA, air pathway
General Public - 4 mrem EPA, drinking water pathway
U.S. Environmental Protection Agency (EPA) U.S.
Nuclear Regulatory Commission (NRC)
Average Annual Dose Natural Sources 310 mrem
Average Annual Dose All Sources 620 mrem
U.S. Environmental Protection Agency (EPA).
(2007). Radiation Risks and Realities. Retrieved
October 7, 2011 from http//epa.gov/radiation/docs
/402-k-07-006.pdf U. S. Nuclear Regulatory
Commission. (2011a). Fact Sheet on Biological
Effects of Radiation. Retrieved October 14, 2011
from http//www.nrc.gov/reading-rm/doc-collections
/fact-sheets/bio-effects-radiation.html
7
Biological Effects of Radiation

• Outcomes of living cells
• Cells die and replace themselves (normal process)
• Cells repair themselves - no left-over damage
• Cells incorrectly repair themselves biophysical
  changes

• Doses around 1 Sievert (Sv) may lead to heart
  disease, stroke, digestive disorders and
  respiratory disease.
• The exact effects of the cumulative health
  effects of exposure to ionizing radiation are
  difficult to determine.

U. S. Nuclear Regulatory Commission. (2011a).
Fact Sheet on Biological Effects of Radiation.
Retrieved October 10, 2011 from
http//www.nrc.gov/reading-rm/doc-collections/fact
-sheets/bio-effects-radiation.html
8
Health Effects Based on Acute Exposure
Exposure (rem) Health Effect Time to Onset(without treatment)
5-10 changes in blood chemistry  
50   nausea  hours
55   fatigue  
70 vomiting  
75 hair loss 2-3 weeks
90 diarrhea  
100 hemorrhage  
400 possible death within 2 months
1,000 destruction of intestinal lining  
  internal bleeding and death  1-2 weeks
2,000 damage to central nervous system  
  loss of consciousness death Minutes/hours to days
U.S. Environmental Protection Agency (EPA).
(2011c). Radiation Protection. Health Effects.
Retrieved October 1, 2011 from http//epa.gov/radi
ation/understand/health_effects.html
9
Estimated Health Effects of Radiationin Pregnancy

• Increased Cancer Risk
• Depends on amount of radiation and amount of time
  exposed
• If acute exposure to 500 Chest X rays,
  increased risk about 2
• Other health effects are unlikely when the dose
  to the fetus is very low
• During 1st two weeks of pregnancy greatest
  concern is death
• Weeks 2-18 birth defects, especially mental
  retardation
• If 1000 fetuses exposed to 1 rem radiation 1 to
  4 would be born with mental retardation
• Week 18 to birth unlikely effects, unless dose
  is very high
• Genetic mutations both parents exposed to 1 rem
  of radiation
• In 1 million births, 50 severe hereditary effects
  expected
• Compared to 100,000 other cases of genetic
  defects

Centers for Disease Control and Protection (CDC).
(2011). Emergency Preparedness and Response.
Radiation and Pregnancy A Fact Sheet. Retrieved
October 3, 2011 from http//www.bt.cdc.gov/radiati
on/prenatal.asp U. S. Nuclear Regulatory
Commission. (2011a). Fact Sheet on Biological
Effects of Radiation. Retrieved October 10, 2011
from http//www.nrc.gov/reading-rm/doc-collections
/fact-sheets/bio-effects-radiation.html
10
Estimated Health Effects of Exposure toIonizing
Radiation Lifetime Exposure

• Cancer increased risk of developing cancer with
  increasing doses of radiation
• 10,000 people exposed to 1 rem in small doses
  over their lifetime
• 2000 non-radiation deaths expected (baseline)
• 5 or 6 radiation deaths would occur
• Indistinguishable from cancer from other causes
• Normal exposure to background radiation per year
  is 3/10 of a rem (300mrem)
• Cancers do not appear until many years after the
  radiation has been received

U. S. Environmental Protection Agency (EPA).
(2007). Radiation Risks and Realities. Retrieved
October 7, 2011 from http//epa.gov/radiation/docs
/402-k-07-006.pdf U.S. Nuclear
Regulatory Commission. (2011b). Radiation
Exposure and Cancer. Retrieved October 3, 2011
from http//www.nrc.gov/about-nrc/radiation/health
-effects/rad-exposure-cancer.html
11
Benefits / Uses of Radiation

• Some televisions and computers
• Smoke detectors
• Power (illumination)
• Steel and paper factories
• Inspection
• Security - Airport
• Welds airplanes/boats

• Sterilization of hospital supplies
• Diagnostic imaging
• Therapeutic
• Medicine
• Treatment (XRT)

American Nuclear Association. (2008). Societal
Benefits of Radiation Position Statement.
Retrieved Oct 7, 2011 from http//www.ans.org/pi/p
s/docs/ps73.pdf
12
U.S. Population Exposed to Increased Radiation

• In March, 2009, the National Council on Radiation
  Protection and Measurement released a critical
  report that indicated that radiation dose to the
  United States population had risen dramatically
  since the early 1980s.

Schauer, D. A. Linton, O. W. (2009). National
Council on Radiation Protection and Measurements
Report shows substantial medical exposure
increase. Radiology, 253 (2), 293-296.
13
Sources of U.S. Radiation Exposure
U. S. Nuclear Regulatory Commission. (2011a).
Fact Sheet on Biological Effects of Radiation.
Retrieved October 10, 2011 from
http//www.nrc.gov/reading-rm/doc-collections/fact
-sheets/bio-effects-radiation.html
14
Medical Imaging Procedures / Examples

• Standard projection x-rays
• Chest, hip, dental x-rays,
• Mammogram
• CT scan (CAT Scan)
• Head, chest, abdomen
• Nuclear medicine procedures
• Angiogram
• Fluoroscopy
• Used in cardiac catherazation

U. S. Food and Drug Administration. (2010b).
White Paper Initiative to Reduce Unnecessary
Radiation Exposure from Medical Imaging Retrieved
October 1, 2011 from http//www.fda.gov/downloads/
Radiation-EmittingProducts/RadiationSafety/Radiati
onDoseReduction/UCM235128.pdf
15
Radiation Doses of Medical Imaging Procedures
Procedure Dose Range, mSv Average Dose, mSv Chest X-ray Equivalent Dose
X-rays
Chest 0.02-0.67 0.34 1
L-spine 0.8-2.4 1.6 4.7
Hip 0.3-0.6 0.4 1.1
Barium enema 7-9 8 23.5
Mammography 0.07-0.89 0.48 1.4
Upper GI tract 3.6 3.6 10.6
Dental 0.02-0.334 0.18 0.53
CT scans
Thoracic 8.3-11.7 10 29.4
Abdomen 7.6-16 11.8 35
Pelvis 10-13 11.5 33.8
Angiographs
Cardiac 71.9 71.9 211.5
Medscape Reference. (2011). Ionizing Radiation
Exposure with Medical Imaging . Abbreviated from
Table 4. Retrieved October 12, 2011 from
http//emedicine.medscape.com/article/1464228-over
view
16
Public Health Concern
Millions of exams performed each year Estimates
that 1 in 270 Women 1 in 600 Men who undergo CT
coronary angiography at age 40 will develop
cancer from that CT scan1
1. Smith-Bindman, R., Lipson, J., Marcus, R.,
Kim, K. P., Mahesh, M., Gould, R. (2009).
Radiation dose associated with common computed
tomography examinations and the associated
lifetime attributable risk of cancer. Archives of
Internal Medicine, 169(22), 2078-2086. 2. U.
S. Food and Drug Administration. (2010b). White
Paper Initiative to Reduce Unnecessary Radiation
Exposure from Medical Imaging Retrieved October
1, 2011 from http//www.fda.gov/downloads/Radiatio
n-EmittingProducts/RadiationSafety/RadiationDoseRe
duction/UCM235128.pdf
17
Balance Risk and Benefits

• Some level of exposure is necessary
• Determine extent of injury
• Determine extent of disease
• Support diagnosis or treatment
• Exposure from medical procedures should not be
  feared but must be respected
• ALARA Principle as low as reasonably
  achievable
• Risks reduction by decreasing unnecessary
  exposure

Medscape Reference. (2011). Ionizing Radiation
Exposure with Medical Imaging . Retrieved October
12, 2011 from http//emedicine.medscape.com/artic
le/1464228-overview
18
Radiation Protection Principle
SHIELDING
TIME
DISTANCE
U.S. Environmental Protection Agency (EPA).
(2011a). Radiation Protection Basics. Retrieved
October 7, 2011 from http//www.epa.gov/radiation
/understand/protection_basics.html
19
Safe Use of Medical Imaging Devices
U. S. Food and Drug Administration. (2010)b.
White Paper Initiative to Reduce Unnecessary
Radiation Exposure from Medical Imaging Retrieved
October 1, 2011 from http//www.fda.gov/downloads/
Radiation-EmittingProducts/RadiationSafety/Radiati
onDoseReduction/UCM235128.pdf
20
FDA and Partners Initiative

• Reduce Unnecessary Radiation Exposure from
  Medical Imaging
• Promote safe use of medical imaging devices
• Support informed clinical decision making
• Increase patient awareness

U. S. Food and Drug Administration. (2010b).
White Paper Initiative to Reduce Unnecessary
Radiation Exposure from Medical Imaging Retrieved
October 1, 2011 from http//www.fda.gov/downloads/
Radiation-EmittingProducts/RadiationSafety/Radiati
onDoseReduction/UCM235128.pdf
21
Image Gently Campaign

• Primary Objective raise awareness of the
  opportunities to lower radiation dose in the
  imaging of children
• Ultimate Goal change practice
• Strategy straightforward information provided to
  every member of the care team
•  

www.imagegently.org
http//www.imagewisely.org/
The Alliance for Radiation Safety in Pediatric
Imaging. (2011). Image Gently. Retrieved October
12, 2011 from http//www.pedrad.org/associations/5
364/ig/ Image Wisely. (2010b). Radiation
Safety in Adult Medical Imaging. Retrieved
October 15, 2011 from http//www.imagewisely.org/2
.
22
Informed Clinical Decision Making

• FDA Actions / Recommendations
• Establish requirements for manufacturers of
  imaging equipment to record radiation dose
  information for use in patient charts or in a
  dose registry
• Recommend continued development of criteria for
  appropriate medical imaging use

U. S. Food and Drug Administration. (2010b).
White Paper Initiative to Reduce Unnecessary
Radiation Exposure from Medical Imaging Retrieved
October 1, 2011 from http//www.fda.gov/downloads/
Radiation-EmittingProducts/RadiationSafety/Radiati
onDoseReduction/UCM235128.pdf
23
American College of Radiology Appropriateness
Criteria
http//www.acr.org/SecondaryMainMenuCategories/qua
lity_safety/app_criteria.aspx

• Interventional Radiology Topics
• Radiation Oncology Topics
• Bone Metastases
• Brain Metastases
• Breast
• Gynecology
• Head Neck
• Hodgkins Lymphoma
• Lung
• Prostate
• Rectal/Anal

• Diagnostic Imaging Topics
• Breast
• Cardiac
• Gastrointestinal
• Musculoskeletal
• Neurologic
• Pediatric
• Thoracic
• Vascular
• Womens

American College of Radiology. (2011). ACR
Appropriateness Criteria. Retrieved October 7,
2011 from http//www.acr.org/ac.
24
Ask your doctor

• Why do I need this exam?
• How will information from this exam improve my
  health?
• Are there others tests , as good, that do not use
  radiation?

Image Wisely. (2010a). Patients. Retrieved
October 15, 2011 from http//www.imagewisely.org/P
atients.aspx?CSRT11519610464130392779
25
Increase Patient Awareness

• FDA collaboration with American College of
  Radiology and Radiological Society of North
  America to develop medical imaging card tool for
  tracking medical procedures
• Paper tracking
• Electronic tracking
• Radiation dose calculators

U. S. Food and Drug Administration. (2010b).
White Paper Initiative to Reduce Unnecessary
Radiation Exposure from Medical Imaging Retrieved
October 1, 2011 from http//www.fda.gov/downloads/
Radiation-EmittingProducts/RadiationSafety/Radiati
onDoseReduction/UCM235128.pdf
26
My Medical Imaging History
U.S. Food and Drug Administration. (2010a). My
Medical Imaging History. Retrieved October 11,
2011 from http//www.fda.gov/downloads/Radiation-E
mittingProducts/RadiationSafety/RadiationDoseReduc
tion/UCM235128.pdf
27
Calculate Your Radiation Dose

• Open this hyperlink to the EPA website
• http//epa.gov/radiation/understand/calculate.html
  

Source Your Average Annual Dose (mrem)
Cosmic radiation at sea level (from outer space) 26
What is the elevation (in feet) of your town?  Choose from dropdown
Terrestrial (from the ground)
Terrestrial (from the ground)
What region of the US do you live in?  Choose from dropdown EX Gulf Coast Region
Internal radiation (in your body)
Internal radiation (in your body)
From food and water, (e.g., potassium) 40
From air, (radon) 200
Do you wear a plutonium powered pacemaker?  Choose from dropdown (Y/N)
Do you have porcelain crowns or false teeth?   Choose from dropdown (Y/N)
U.S. Environmental Protection Agency. (2011b).
Radiation Protection. Calculate Your Radiation
Dose. Retrieved Oct 1, 2011 from
http//epa.gov/radiation/understand/calculate.html
28
Know Your Risks and Advocate!

• 48 of radiation exposure in the U.S. is from
  medical procedures
• Cumulative exposure may lead to long term health
  problems, especially cancer
• Document and share your medical imaging history
  with your doctor
• Calculate and know your estimated annual
  radiation exposure
• Discuss, with your doctor, the need for imaging
  or alternatives that may be available
• Have a healthy respect for radiation it provides
  great benefit to our society

29
References

• American College of Radiology. (2011). ACR
  Appropriateness Criteria. Retrieved October 7,
  2011 from http//www.acr.org/ac.
• American Nuclear Association. (2008). Societal
  Benefits of Radiation Position Statement.
  Retrieved October 7, 2011 from http//www.ans.org/
  pi/ps/docs/ps73.pdf
• Berrington de González, A. Darby, S. (2004).
  Risk of cancer from diagnostic X-rays Estimates
  for the UK and 14 other countries. Lancet, 363,
  345-51.
• Centers for Disease Control and Protection (CDC).
  (2011). Emergency Preparedness and Response.
  Radiation and Pregnancy A Fact Sheet. Retrieved
  October 3, 2011 from http//www.bt.cdc.gov/radiati
  on/prenatal.asp
• Health Physics Society. (2011). Radiation Basics.
  Retrieved October 9, 2011 from
  http//www.hps.org/publicinformation/ate/faqs/radi
  ation.htmlI
• Image Wisely. (2010a). Patients. Retrieved
  October 15, 2011 from http//www.imagewisely.org/P
  atients.aspx?CSRT11519610464130392779

30
References

• Image Wisely. (2010b). Radiation Safety in Adult
  Medical Imaging. Retrieved October 15, 2011 from
  http//www.imagewisely.org/
• McCollough, C. H., Schuler, B. A., Atwell, T. D.,
  Braun, N. N., Regner, D. M., Brown, D. L.,
  LeRoy, A. J. (2007). Radiation Exposure and
  Pregnancy When Should We Be Concerned?
  Radiographics, 27, 909-917. doi
  10.1148/rg.274065149
• Medscape Reference. (2011). Ionizing Radiation
  Exposure with Medical Imaging. Retrieved October
  12, 2011 from http//emedicine.medscape.com/artic
  le/1464228-overview
• Natural News. (2010). Use of high-radiation CT
  scans in emergency rooms triples over nine years.
  Retrieved October 20, 2011 from
  http//www.naturalnews.com/030776_CT_scans_radiat
  ion.html
• New York Timers. (2010). Radiation, Risks Are
  Focus of Breast Screening Study. Retrieved
  October 21, 2011 from http//www.nytimes.com/2010/
  08/24/science/24breast.html
• Schauer, D. A. Linton, O. W. (2009). National
  Council on Radiation Protection and Measurements
  Report shows substantial medical exposure
  increase. Radiology, 253 (2), 293-296.

31
References

• Smith-Bindman, R., Lipson, J., Marcus, R., Kim,
  K. P., Mahesh, M., Gould, R. (2009). Radiation
  dose associated with common computed tomography
  examinations and the associated lifetime
  attributable risk of cancer. Archives of Internal
  Medicine, 169(22), 2078-2086.
• The Alliance for Radiation Safety in Pediatric
  Imaging. (2011). Image Gently. Retrieved October
  12, 2011 from http//www.pedrad.org/associations/5
  364/ig/
• USA Today. (2010). Cancer risks prompt doctors to
  try to lower imaging scan radiation. Retrieved
  October 21, 2011 from http//www.usatoday.com/news
  /health/2010-05-05-radiation05_st_N.htm
• U. S. Environmental Protection Agency (EPA).
  (2007). Radiation Risks and Realities. Retrieved
  October 7, 2011 from http//epa.gov/radiation/docs
  /402-k-07-006.pdf
• U. S. Environmental Protection Agency (EPA).
  (2011a). Radiation Protection Basics. Retrieved
  October 7, 2011 from http//www.epa.gov/radiatio
  n/understand/protection_basics.html
• U.S. Environmental Protection Agency (EPA).
  (2011b). Radiation Protection. Calculate Your
  Radiation Dose. Retrieved Oct 1, 2011 from
  http//epa.gov/radiation/understand/calculate.html
  

32
References

• U.S. Environmental Protection Agency (EPA).
  (2011c). Radiation Protection. Health Effects.
  Retrieved October 1, 2011 from http//epa.gov/radi
  ation/understand/health_effects.html
• U. S. Environmental Protection Agency (EPA).
  (2011d). Radiation Protection. Radiation Symbols.
  Retrieved October 7, 2011 from http//www.epa.gov/
  rpdweb00/understand/symbols.html
• U. S. Environmental Protection Agency (EPA).
  (2011e) Why are some atoms Radioactive. Retrieved
  October 13, 2011 from http//www.epa.gov/rpdweb00/
  understand/radiation.html
• U.S. Food and Drug Administration. (2010a). My
  Medical Imaging History. Retrieved October 11,
  2011 from http//www.fda.gov/downloads/Radiation-E
  mittingProducts/RadiationSafety/RadiationDoseReduc
  tion/UCM235128.pdf
• U. S. Food and Drug Administration. (2010b).
  White Paper Initiative to Reduce Unnecessary
  Radiation Exposure from Medical Imaging Retrieved
  October 1, 2011 from http//www.fda.gov/downloads/
  Radiation-EmittingProducts/RadiationSafety/Radiati
  onDoseReduction/UCM235128.pdf
• U. S. Nuclear Regulatory Commission. (2011a).
  Fact Sheet on Biological Effects of Radiation.
  Retrieved October 10, 2011 from
  http//www.nrc.gov/reading-rm/doc-collections/fact
  -sheets/bio-effects-radiation.htmlh
• U.S. Nuclear Regulatory Commission. (2011b).
  Radiation Exposure and Cancer. Retrieved October
  3, 2011 from http//www.nrc.gov/about-nrc/radiatio
  n/health-effects/rad-exposure-cancer.html

33
Additional Resources

• American Academy of Pediatrics. (2009). Imaging
  and Medical Radiation Safety Important
  Information for Parents. Retrieved October 21,
  2011 from http//www.aap.org/sections/radiology/Ra
  diologyParentPage.pdf
• Furry Elephant. (n.d.). Lesson 5 How radiation
  harms. Retrieved October 21, 2011 from
  http//www.furryelephant.com/content/radioactivity
  /nuclear-radiation-health-effects/
• RadiologInfo.org. (2011). Patient Safety
  Radiation Exposure in X-ray and CT Examinations.
  Retrieved October 21, 2011 from
  http//www.radiologyinfo.org/en/safety/index.cfm?p
  gsfty_xray
• U.S. Food and Drug Administration. (2009). FDA
  Makes Interim Recommendations to Address Concern
  of Excess Radiation Exposure during CT Perfusion
  Imaging. Retrieved October 21, 2011 from
  http//www.fda.gov/NewsEvents/Newsroom/PressAnnoun
  cements/2009/ucm193190.htm
• U.S. Food and Drug Administration. (2010). Safety
  Investigation of CT Brain Perfusion Scans Update
  11/9/2010. Retrieved October 21, 2010 from
  http//www.fda.gov/MedicalDevices/Safety/Alertsand
  Notices/ucm185898.htm
• World Health Organization. (2011). Ionizing
  Radiation. Retrieved October 21, 2011 from
  http//www.who.int/ionizing_radiation/about/what_i
  s_ir/en/index.html