Culture Imposed by Image Gently Carries Substantial Medical Risks
I’ve been engaged with the struggle to counter excessive fear of radiation for many years. Since I come at the battle from a perspective of the avoided benefits of nuclear energy production resulting from the imposed fear, I have been focused on that aspect of countering radiation misinformation.
My associates and I have often assumed that the practitioners of nuclear medicine were not as affected by the long-running anti-radiation efforts. It seemed from the outside that most people clearly recognized the tremendous benefits given to millions of individual humans by the use of radiation. We have often discussed how illogical it seemed to us that people readily accepted radiation doses that were hundreds to thousands of times higher for medical uses and would recoil in fear from the same doses if they happened to originate from accidental exposures because of an event at a nuclear power plant.
In the relatively recent past, I’ve learned that I was wrong assume that the nuclear medicine had escaped being affected by the increasingly negative effects of the fear campaign. Organizations are working hard to encourage an approach to the use of radiation that has limited effective medical treatment and diagnosis. There is a crying need for efforts to expose the incorrect messages focused on medical practitioners asking them to avoid using well-proven treatments and effective tools in order to limit radiation doses to essentially the equivalent of ALARA (As Low As Reasonably Achievable). As is the case in the power business, there is no established definition of the word “reasonable.”
The logical result is that some people who are naturally driven to provide the best possible service feel like they must strive to achieve a radiation dose of zero if possible. The effort to achieve a zero dose requires the imposition of other risks that are often greater than the ones that arise from using a moderate doses of radiation to achieve superior outcomes.
As part of the SARI discussion regarding Brant Ulsh’s story of how radiophobia hit home in his family, Dr. Mervyn Cohen provided a poignant response that deserves wider exposure. He has agreed to allow me to publish that response to make it more accessible for public discussion.
Dear SARI concerned friends,
I am a pediatric radiologist with great concern about what is happening. Society is frightening patients and their physicians with “CT is dangerous” rather than extolling the virtues of CT and the explaining the great risks of a missed diagnosis by not performing a needed CT scan.
I so sorry that Brant and his family had to counter a misinformed Pediatrician, in addition to all the trauma and worry of having an ill child. Thank you all so much for your e mail comments, in response to Brant’s story.
We are in a most unfortunate situation. Although most radiologists will accept that any cancer risk from CT is tiny, the Image Gently and other campaigns over the last ten years have created a new unfavorable culture.
Despite the knowledge that any CT risk is tiny in relation to normal everyday risks of living our radiology journals persist in spreading the message that CT use must be decreased. This is not rational, but it is understandable. This culture manifests in many ways in our radiology journals and is the repeated in the public media.
We’ve seen endless articles using experimental models simulating disease showing that readers can achieve an unchanged accuracy as dose is decreased; the articles fail to point out that eventually dose will be so low that disease will be missed.
We’ve seen many similar publications of CT of pathology in humans, when dose reduction is simulated by adding noise to images. Almost every article that compares modalities includes as a stated disadvantage of any imaging use x-rays “but…CT, chest x-ray, etc uses radiation”., as if this is something terrible. We seldom see statements that the best modality should be chosen to achieve an accurate diagnosis, and that this decision must be made irrespective of the use of radiation.
The American College of Radiology publishes many “Appropriateness Criteria®” with recommendations for which imaging modality to use for any specific clinical indication. Every one of the tables in these publication has a 0-4 star rating for the amount of radiation given to a patient by each imaging study. I have argued that this creates a perception that the radiation is dangerous and should strongly influence the choice of imaging modality; I am but a small voice.
I do have some comments on the appendicitis diagnosis. The choice of ultrasound as the initial imaging, rather than CT is not wrong. What is horrific and very wrong are the Pediatricians reasons for this choice i.e. not wanting to do a CT because of radiation. This resonates loudly with me. It is the prevailing culture that I describe above. At most large children’s hospitals in the USA in 2014, the management of suspected appendicitis goes like this.
- Very certain that the child has appendicitis – go straight to surgery
- Suspect appendicitis – do ultrasound . It is cheaper and quicker than CT. (it is not definitely wrong to do CT but consensus favors ultrasound first)
This has three outcomes:
- Appendix is well seen and looks normal – no appendicitis
- Appendix is well seen and abnormal – surgery for appendicitis
- Appendix cannot be seen (this happens for a variety of reasons such as the appendix is hidden behind something, abnormal appendix position, inexperienced technologist etc ) – perform CT scan for further evaluation.
Thus CT is used, but in a relatively small number of children with appendicitis.
Our challenge is to change the culture. At my own children’s hospital I frequently ask my Pediatrician and Pediatric Surgeons what message they are getting at their national meetings and from their journals regarding CT and radiation. The response from intelligent, wonderful people is scary. The culture I described above is dominant. Our challenge is to mount a large education campaign to change the culture – never easy.
Best wishes to all.
Mervyn
Mervyn Cohen
Pediatric Radiologist
I thank Dr. Cohen for giving permission to reprint his heartfelt, knowledge-based message. Information like the above can help people understand the widespread nature of radiophobia and the importance of spreading accurate information about radiation health effects. People, especially including medical professionals, need good information so they can make appropriate, well-reasoned decisions in what are often life-versus-death situations.
The situation has obviously gotten out of hand when busy practitioners have been inundated with incorrect information leading them to slow or stop the use of some of their most effective technology tools to find and cure disease.
Rod,
I am thankful for this comment. It is amazing to me that in the context of medicine – where a clear diagnosis is most important that we would be finding ways to reduce the clarity of the images out of an assumed fear.
Over and over I see these types of campaigns that assume a problem without every actually stating the dangers – especially comparative dangers. Just speak the name “Fukushima” and people assume that a horrible terrible disaster is being mentioned. The word Radiation has come to mean the most dangerous type of hazard. How sad, and in the case of Physicians how concerning!
We are ALL going to die! The risk of death is 100% The only questions are how long until it happens and what the cause will be. But on the way there, a doctor can be of immense help in keeping us a healthy as possible. Diagnostic tools are most valuable in this effort. The constant sale of fear about using those tools is frustrating and angering.
What a change in attitude for the medical profession from the time when Radium was first discovered and became so incredibly valuable because of it’s positive health effects.
But we are being deniers for not agreeing with the consensus…
Recently a friend was treated for cancer, not sure if it was glandular, but it mostly affected his tongue. As a result of the radiation treatments, he beat the cancer. However, his hearing seems to be badly damaged, according to his doctors, due to the radiation treatments. Assuming his doctors are correct……if he was not battling cancer, and was subjected to the same dosages, (say due to an event at a nuclear power plant), is it unreasonable to assume that such “side effects” might result from the exposure?
Here’s an article about negligible Cancer risk if you live next to one.(nuke plant)
http://www.cancer.gov/cancertopics/factsheet/Risk/nuclear-facilities
Here’s a kind of article on relative risks:
http://www.phyast.pitt.edu/~blc/book/chapter8.html
Dose received at nuke plants is very well controlled. Those places are under the public eye.
You know if they are destroying cells, the ears, sinuses, tongue are all in that general area. It seems conceivable that they could have taken out some good cells with the bad. If the doctors say it was due to the treatments, they are in the best position to know.
Yea, look at the doses and exposures. ( 50-70 Gy region dose(?) I believe – med to high risk for hearing loss) Its doing what its supposed to do (directly kill susceptible tissues) albeit a bit too well. Certain chemotherapies are a more associated with hearing loss. The hearing loss is also frequently treatable, may improve over time and as the treatments get more precise the chance hearing loss is diminished.
Incidentally, Ive even seen antinukes on their blogs advising people not to ever get radiation treatment for serious disease. Head and neck cancer is serious but frequently successfully treated. Even at the ridiculously high doses some of these lifesaving treatments require, cancer occurring as a result is what I would consider very rare (chances falling roughly in the ones in a thousand range – frequently treatable as well), and of course, with respect to far lower and different kinds of doses, like those used in some imaging, the dose response does not seem to even follow a linear pattern.
Yes it is “unreasonable”. There is a huge difference between *isolated*, mega doses of radiation that are used during cancer treatments and whole body exposure encountered during a Nuclear Power Plant accident.
800 REM exposure to a cancer tumor (isolated) kills the cancer cells and the side effects are very limited to the area being treated.
800 REM exposure (acute) to the whole body…….death. Of course, the highest doses seen at Fukushima so far are 50 REM (Operators who chose to see rather than wear their respirators)…..at most. This amount will have zero permanent effects.
So, it would be impossible to encounter collimated, mega levels of radiation during an accident at a Nuke Plant that would only affect a very specific location of the body. There are reasons nobody has been over exposed at Fukushima…….it takes A LOT of acute radiation exposure……and Japan is not the Soviet Union.
In any kind of radiotherapy regimen you are treating the affected area to the tolerance of the normal tissue. You’d generally like to give the tumor more, but at some point you have to stop to spare the normal areas too much damage. In the hospital I use they have a gamma knife which uses a stereotactic approach to delivering higher doses to targeted volumes and lowering exposure to intervening areas. Likewise, in certain types of non-implantation brachytherapy, choice of source can make a significant difference. I was involved in a research program to develop an alternative to the use of iridium 192 in treatment of post-angioplasty restenosis. It used a short-lived beta source mounted on the same catheter as the iridium source, but spared the surrounding tissue from gamma exposure. That development effort was spurred in part by concern of exposure to the 192Ir.
Bonds, you are not taking into account what truly makes the biggest difference between the two. Notice also that treatment for tumors frequently goes well beyond 8 Sievert (800 rem), many protocols go up to 40 and some even 60 Sievert.
The biggest difference is that the dose is delivered by increments of around 2 Sv at a time, leaving enough time to the sane tissues to recover between two session. 2 Sv is the maximum where the deterministic effects are visible, but manageable. However for the tumors tissues it’s much more difficult to recover from those 2 Sv, it’s frequently said that’s because they more replicate more frequently, but that’s ignoring another important factor which is that what allows them to evolve faster is that almost always many of their normal ADN repair mechanism, like the p53 gene that initiates apoptosis (defective cell death), are defectives.
800 REM was just a random number I threw out there as an example. The little reading Ive done about cancer treatments and the amount of exposure they require was truly mind blowing I must say…….especially for somebody who has had “every mrem counts” tattooed into their subconscious via the ALARA principles at work. Of course, even I, sitting here as a Health Physics Tech who is employed at the Northwest’s only Nuclear Power Plant will tell you this is very far from truth……..unless you are talking only about a number and not actual risks to the average Joe Radworker.
“We lived in Lincolnshire from 1956 to 1959, with a huge garden where we grew all our own vegetables and fruit, and kept chickens (breakfast always included at least one boiled egg). One summer the entire family was ill. Measles, mumps, chickenpox, rubella, one after the other, all three children. My mother caught mumps, my father caught chickenpox. It was as though we had suddenly been cursed – we had always been remarkably healthy until then.
After that summer we returned to our usual robust healthiness; though both my parents died somewhat early. Cancer is not a disease that appears often in the family tree and never, as far as I can see, in the direct line; we’re prone to strokes and heart attacks, but usually at a ripe-ish old age, not at 53 and 61 which was the age that my mother and father, respectively, died. Their parents lived into their 80s and 90s, as their parents and grandparents had done – we’re a long-lived family (one gt gt grandmother died in 1925 aged 104).
It wasn’t until decades later that I was watching a programme about the Windscale fire with a map of the fallout and realised we had been in the centre of that path and that the summer of illness had been the summer that followed that fire.
Was that bout of illness connected to our radiation exposure?” I saw this statement and question posted on a comment section of an article but the no name was given. Would the Windscale fire fallout have provided enough of a dose to provoke lowered immunity for them and earlier death later on?
No lowered immunity was seen in Japan bomb survivors nor around Fukushima. Windscale released about 0.5% the radioiodine of Fukushima-Daiichi so these effects are not expected.
http://en.wikipedia.org/wiki/Windscale_fire
Dear Jamie,
Please see the most recent discussion in the scientific literature on sex ratio changes after Windscale:
http://www.ncbi.nlm.nih.gov/pubmed/24796350 (original article by Victor Grech)
http://iospress.metapress.com/content/w7p16x52540m2644/fulltext.pdf (letter by Koerblein)
http://iospress.metapress.com/content/e51kh1363381601g/fulltext.pdf (letter by Scherb/Kusmierz/Voigt)
http://iospress.metapress.com/content/vn32874706683735/fulltext.pdf (response letter by Grech/author)
Sex ratio changes indicate lethal mutations on the X chromosome. Sex ratio changes and cancer belong to the so called “radiation induced genetic effects”. However, radiation that may destroy DNA can also lead to other disturbances in normal cell functionality.
The sex ratio changes after Windscale are very similar to the ones observed after Chernobyl; see e.g. ourcorresponding articles listed in PubMed.
Kind regards,
Hagen Scherb
I apologize, I realize the last comment was not in the context of medical doses and side effects, but reading the question about poa’s friend, I figured my question was fairly similar, but still sorry If my question was too outside of the realm of what’s being discussed here.
He doesn’t seem to care as long as its broadly related to the topic and doesn’t fray out too far and indeed the A listers here seem to not be having any important conversations at the time.
I hadn’t read much on the Windscale fire ( http://en.wikipedia.org/wiki/Windscale_fire )( 10 October 1957). It was a graphite research reactor. Some of the guys here may know more about that one.
I no medical “expert” but I checked and there was a huge measles outbreak in Ireland in the late 50’s. Mumps was going strong then too. German measles was really pronounced then as well. Widespread vaccinations were for some of these things was just coming into play in the late 50s. So as kids bring this kind of thing home not to mention more people traveling and meeting in post war Europe and of course once you get it you are usually immune, So I think its not really that unusual although Im sure it seemed so at the time.
I also noticed a wet and disastrous (storm related ) summer in 56 in the UK and that kind of thing both keeps people indoors and stirs them up over a geographic scale and can have repercussions for years.
As for cancer becoming more common – Ive been doing some reading and I cant see any real trends that is true despite how it seems . Indeed the opposite seems to be generally true as a strong trend, and survivability has vastly improved. People are living far longer and the strongest risk factor for cancer is of course, age. In past accounts of cancer I have noticed it seemed to take people very quickly and in reading they didn’t seem to think or dwell on accidental or disease death like we do. Im not saying we are any better but I think things were rather harsh for people in previous times, so much so that if you paid attention to it, the bad would be completely overwhelming. Blocking it would be more than nostalgia, part of basic survival, even probably more so than now.
Jamie, did your parents smoke ?
No they did not…
@Jamie
As I understand your initial comment, you were quoting someone else’s story about living near Windscale. Do you know if that person’s parents — the ones who died young — smoked?
No, I don’t know if they smoked. I don’t know anything other than that they lived downwind of the accident. So if there were other factors in place I wouldn’t know and they dident say. It was an older comment,and would have asked if I had been part of that discussion several months ago.but I was mostly wondering if the radiation dose that they received was enough to cause any issue. There doesent seem to be any information out there on approx dose downwinders of that accident would have received.
@Jamie
There is no possibility that the radiation doses received as a result of the Windscale fire of October 11-12 1957 were the causes of the rash of illnesses in the summer of 1958. The principal isotope of concern released was I-131, which has an 8 day half life. That means it would have completely disappeared by mid January.
All other isotopes resulted in a minor portion of the total exposure, which was already quite low on a per person basis.
http://www.ncbi.nlm.nih.gov/pubmed/6335136
Got it(:
oh that’s smart, even if it was close to the release and if at a dose that could somehow possibly interfere/suppress immunity.
Don Cox, the statement and question I put down regarding the family affected by all the illness, wasn’t my family. I just happened to see that question anonymously posted on a forum and was curious and brought it here(: I don’t know that person and there very well could have been other factors playing into their illness and earlier death. But I found the correlation interesting.
Hmmm, I thought I had replied to you Rod, but it’s not showing. So just in case: No I don’t know if they smoked,the comment I posted was several months old on the forum I found it on so I never had a chance to ask the person and comments were closed on that discussion. Interesting though the person never mentioned their personal health or that of his/ her siblings, and they were children at the time so if little ones are supposedly more susceptible I would think they would also have had issues…
You’re looking in the wrong place. You properly threaded your reply to Rod, but you’re probably looking at the bottom of thepage.
There’s a long history of over-exposure & adverse health effects in medical radiation imaging — among practitioners.
It leads me to wonder whether, after decades of halfway-effective safety campaigns trying to convince radiologists & technicians to protect themselves properly, someone didn’t just come to the conclusion that it would be easier to convince them to take the issue seriously if it were couched in terms of risk to the patient.