Multinational data on cumulative radiation exposure of patients from recurrent radiological procedures: call for action

Abstract

Objectives

To have a global picture of the recurrent use of CT imaging to a level where cumulative effective dose (CED) to individual patients may be exceeding 100 mSv at which organ doses typically are in a range at which radiation effects are of concern

Methods

The IAEA convened a meeting in 2019 with participants from 26 countries, representatives of various organizations, and experts in radiology, medical physics, radiation biology, and epidemiology. Participants were asked to collect data prior to the meeting on cumulative radiation doses to assess the magnitude of patients above a defined level of CED.

Results

It was observed that the number of patients with CED ≥ 100 mSv is much larger than previously known or anticipated. Studies were presented in the meeting with data from about 3.2 million patients who underwent imaging procedures over periods of between 1 and 5 years in different hospitals. It is probable that an additional 0.9 million patients reach the CED ≥ 100 mSv every year globally.

Conclusions

There is a need for urgent actions by all stakeholders to address the issue of high cumulative radiation doses to patients. The actions include development of appropriateness criteria/referral guidelines by professional societies for patients who require recurrent imaging studies, development of CT machines with lower radiation dose than today by manufacturers, and development of policies by risk management organizations to enhance patient radiation safety. Alert values for cumulative radiation exposures of patients should be set up and introduced in dose monitoring systems.

Key Points

• Recurrent radiological imaging procedures leading to high radiation dose to patients are more common than ever before.

• Tracking of radiation exposure of individual patients provides useful information on cumulative radiation dose.

• There is a need for urgent actions by all stakeholders to address the issue of high cumulative radiation doses to patients.

This is a preview of subscription content, log in to check access.

Abbreviations

CED:

Cumulative effective dose

References

  1. 1.

    European Commission (2014) Radiation Protection No. 180: Medical Radiation exposure of the European Population. Available via https://ec.europa.eu/energy/sites/ener/files/documents/RP180.pdf

  2. 2.

    Howard SA, Rosenthal MH, Qin L et al (2018) Quantifying decreased radiation exposure from modern CT scan technology and surveillance programs of germ cell tumors. Am J Clin Oncol 41:949–952

  3. 3.

    Rehani MM, Frush DP (2011) Patient exposure tracking: the IAEA smart card project. Radiat Prot Dosimetry 147:314–316

    Article  Google Scholar 

  4. 4.

    Rehani MM, Kushi JF (2013) A study of smart card for radiation exposure history of patient. AJR Am J Roentgenol 200:780–782

    Article  Google Scholar 

  5. 5.

    Harrison JD, Balonov M, Martin CJ et al (2016) Use of effective dose. Ann ICRP 45:215–224

    CAS  Article  Google Scholar 

  6. 6.

    Brambilla M, De Mauri A, Leva L, Carriero A, Picano E (2013) Cumulative radiation dose from medical imaging in chronic adult patients. Am J Med 126:480–486

    Article  Google Scholar 

  7. 7.

    Brambilla M, De Mauri A, Lizio D et al (2014) Cumulative radiation dose estimates from medical imaging in paediatric patients with non-oncologic chronic illnesses. A systematic review. Phys Med 30:403–412

    Article  Google Scholar 

  8. 8.

    Triantopoulou S, Tsapaki V (2017) Does clinical indication play a role in CT radiation dose in pediatric patients? Phys Med 41:53–57

    Article  Google Scholar 

  9. 9.

    Rehani MM (2019) Looking for solutions: vision and a call-for-attention for radiation research scientists. Int J Radiat Biol 95:793–796

    CAS  Article  Google Scholar 

  10. 10.

    Rehani MM, Yang K, Melick ER, et al (2019) Patients undergoing recurrent CT scans: assessing the magnitude. Eur Radiol https://doi.org/10.1007/s00330-019-06523-y

  11. 11.

    Rehani MM, Melick ER, Alvi RM et al (2019) Patients undergoing recurrent CT exams: Assessment of patients with non-malignant diseases, reasons for imaging and imaging appropriateness. Eur Radiol https://doi.org/10.1007/s00330-019-06551-8

  12. 12.

    United Nations Scientific Committee on the Effects of Atomic Radiation (2017) Sources, effects and risks of ionizing radiation. Available via https://www.unscear.org/docs/publications/2017/UNSCEAR_2017_Annex-B.pdf. Last accessed on 08/07/2019

  13. 13.

    National Council of Radiation Protection and Measurements (2018) Implications of recent epidemiologic studies for the linear-non-threshold model and radiation protection. NCRP Commentary No. 27. Bethesda, Maryland: NCRP

  14. 14.

    Holmberg O, Malone J, Rehani M, McLean D, Czarwinski R (2010) Current issues and actions in radiation protection of patients. Eur J Radiol 76:15–19

    Article  Google Scholar 

  15. 15.

    Seuri R, Rehani MM, Kortesniemi M (2013) How tracking radiologic procedures and dose helps: experience from Finland. AJR Am J Roentgenol 200:771–775

    Article  Google Scholar 

  16. 16.

    Rehani MM (2017) Patient radiation exposure and dose tracking: a perspective. J Med Imaging (Bellingham) 4:031206

    Article  Google Scholar 

  17. 17.

    Sodickson A, Baeyens PF, Andriole KP et al (2009) Recurrent CT, cumulative radiation exposure, and associated radiation-induced cancer risks from CT of adults. Radiology 251:175–184

    Article  Google Scholar 

  18. 18.

    Fazel R, Krumholtz HM, Wang Y et al (2009) Exposure to low-dose ionizing radiation from medical imaging procedures. N Engl J Med 361:849–857

    CAS  Article  Google Scholar 

  19. 19.

    Chen J, Einstein AJ, Fazel R et al (2010) Cumulative exposure to ionizing radiation from diagnostic and therapeutic cardiac imaging procedures. A population-based analysis. J Am Coll Cardiol 56:702–711

    Article  Google Scholar 

  20. 20.

    Einstein AJ, Weiner SD, Berheim A et al (2010) Multiple testing, cumulative radiation dose, and clinical indications in patients undergoing myocardial perfusion imaging. JAMA 304:2137–2144

    CAS  Article  Google Scholar 

  21. 21.

    Stein EG, Haramati LB, Bellin E et al (2010) Radiation exposure form medical imaging in patients with chronic and recurrent conditions. J Am Coll Radiol 7:351–359

    Article  Google Scholar 

  22. 22.

    Kaul P, Medvedev S, Hohmann SF, Douglas PS, Peterson ED, Patel MR (2010) Ionizing radiation exposure to patients admitted with acute myocardial infarction in the United States. Circulation 122:2160–2169

    Article  Google Scholar 

  23. 23.

    Eisenberg MJ, Afilalo J, Lawler PR, Abrahamowicz M, Richard H, Pilote L (2011) Cancer risk related to low-dose ionizing radiation from cardiac imaging in patients after acute myocardial infarction. CMAJ 183:430–436

    Article  Google Scholar 

  24. 24.

    Lawler PR, Afilalo J, Eisenberg MJ, Pilote L (2011) Exposure to low-dose ionizing radiation from cardiac imaging among patients with myocardial infarction. Am J Cardiol 109:31–35

    Article  Google Scholar 

  25. 25.

    Kinsella SM, Coyle JP, Long EB et al (2010) Maintenance hemodialysis patients have high cumulative radiation exposure. Kidney Int 78:789–793

    Article  Google Scholar 

  26. 26.

    De Mauri A, Brambilla M, Chiarinotti D, Matheoud R, Carriero A, De Leo M (2011) Estimated radiation exposure from medical imaging in hemodialysis patients. J Am Soc Nephrol 22:571–578

    Article  Google Scholar 

  27. 27.

    Coyle J, Kinsella S, McCarthy S et al (2011) Cumulative ionizing radiation exposure in patients with end stage kidney disease: a 6-year retrospective analysis. Abdom Imaging 37:632–638

    Article  Google Scholar 

  28. 28.

    De Mauri A, Brambilla M, Izzo C et al (2012) Cumulative radiation dose from medical imaging in kidney transplant patients. Nephrol Dial Transplant 27:3645–3651

    Article  Google Scholar 

  29. 29.

    Desmond AN, McWilliams S, Maher MM, Shanahan F, Quigley EM (2012) Radiation exposure from diagnostic imaging among patients with gastrointestinal disorders. Clin Gastroenterol Hepatol 10:259–265

    Article  Google Scholar 

  30. 30.

    Levi Z, Fraser E, Krongrad R et al (2009) Factors associated with radiation exposure in patients with inflammatory bowel disease. Aliment Pharmacol Ther 30:1128–1136

    CAS  Article  Google Scholar 

  31. 31.

    Kroeker KI, Lam S, Birchall I, Fedorak RN (2011) Patients with IBD are exposed to high levels of ionizing radiation through CT scan diagnostic imaging. A five-year study. J Clin Gastroenterol 45:34–39

    Article  Google Scholar 

  32. 32.

    Butcher RO, Nixon E, Sapundzieski M, Filobbos R, Limdi JK (2012) Radiation exposure in patients with inflammatory bowel disease-primum non nocere? Scand J Gastroenterol 47:1192–1199

    Article  Google Scholar 

  33. 33.

    Estay C, Simian D, Lubascher J, Figueroa C, O’Brien A, Quera R (2015) Ionizing radiation exposure in patients with inflammatory bowel disease: are we overexposing our patients? J Dig Dis 16:83–89

    Article  Google Scholar 

  34. 34.

    Chatu S, Poullis A, Holmes R, Greenhalgh R, Pollok RC (2013) Temporal trends in imaging and associated radiation exposure in inflammatory bowel disease. Int J Clin Pract 67:1057–1065

    CAS  Article  Google Scholar 

  35. 35.

    Jung YS, Park DI, Kim ER et al (2013) Quantifying exposure to diagnostic radiation and factors associated with exposure to high levels of radiation in Korean patients with inflammatory bowel disease. Inflamm Bowel Dis 19:1852–1857

  36. 36.

    Fuchs Y, Markowitz J, Weinstein T, Kohn N, Choi-Rosen J, Levine J (2011) Pediatric inflammatory bowel disease and imaging-related radiation: are we increasing the likelihood of malignancy? J Pediatr Gastroenterol Nutr 52:80–285

    Article  Google Scholar 

  37. 37.

    Sauer CG, Kugathasan S, Martin DR, Applegate KE (2011) Medical radiation exposure in children with inflammatory bowel disease estimates high cumulative doses. Inflamm Bowel Dis 17:2326–2232

    Article  Google Scholar 

  38. 38.

    Huang JS, Tobin A, Harvey L, Nelson TR (2011) Diagnostic medical radiation in pediatric patients with inflammatory bowel disease. J Pediatr Gastroenterol Nutr 53:502–506

    Article  Google Scholar 

  39. 39.

    Brambilla M, Cerini P, Lizio D, Vigna L, Carriero A, Fossaceca R (2015) Cumulative radiation dose and radiation risk from medical imaging in patients subjected to endovascular aortic aneurysm repair. Radiol Med 120:563–570

    Article  Google Scholar 

  40. 40.

    Noor M, Shekhdar J, Banner NR (2011) Radiation exposure after heart transplantation: trends and significance. J Heart Lung Transplant 30:309–314

    Article  Google Scholar 

  41. 41.

    Johnson JN, Hornik CP, Li JS et al (2014) Cumulative radiation exposure and cancer risk estimation in children with heart disease. Circulation. 130:161–167

  42. 42.

    Seal A, Hawkes M, Bhargava R et al (2017) Radiation exposure from diagnostic imaging in a cohort of pediatric transplant recipients. PLoS One 12:e0167922

  43. 43.

    De Mauri A, Matheoud R, Carriero A, Lizio D, Chiarinotti D, Brambilla M (2017) Radiation exposure from medical imaging in dialyzed patients undergoing renal pre-transplant evaluation. J Nephrol 30:141–146

    Article  Google Scholar 

  44. 44.

    Naidu J, Wong Z, Palaniappan S et al (2017) Radiation exposure in patients with inflammatory bowel disease: a fourteen-year review at a tertiary care centre in Malaysia. Asian Pac J Cancer Prev 18:933–939

    PubMed  PubMed Central  Google Scholar 

  45. 45.

    Englund H, Lidén KK, Lind T, Sundström T, Karling P (2017) Radiation exposure in patients with inflammatory bowel disease and irritable bowel syndrome in the years 2001-2011. Scand J Gastroenterol 52:300–305

  46. 46.

    Hou JK, Malaty HM, Thirumurthi S (2014) Radiation exposure from diagnostic imaging studies among patients with inflammatory bowel disease in a safety-net health-care system. Dig Dis Sci 59:546–553

    Article  Google Scholar 

  47. 47.

    Kalender G, Milan L, Stock UA, Endisch A, Kornberger A (2018) Long-term radiation exposure in patients undergoing EVAR: reflecting clinical day-to-day practice to assess realistic radiation burden. Clin Hemorheol Microcirc. https://doi.org/10.3233/CH-170344

  48. 48.

    Markar SR, Vidal-Diez A, Sounderajah V et al (2018) A population-based cohort study examining the risk of abdominal cancer after endovascular abdominal aortic aneurysm repair. J Vasc Surg. https://doi.org/10.1016/j.jvs.2018.09.058

  49. 49.

    Manning BJ, O’Neill SM, Haider SN, Colgan MP, Madhavan P, Moore DJ (2009) Duplex ultrasound in aneurysm surveillance following endovascular aneurysm repair: a comparison with computed tomography aortography. J Vasc Surg 49:60–65

    Article  Google Scholar 

  50. 50.

    Ding A, Gao Y, Liu H et al (2015) VirtualDose: a software for reporting organ doses from CT for adult and pediatric patients. Phys Med Biol 60:5601–5625

  51. 51.

    Council Directive 2013/59/EURATOM of 5 December 2013 laying down basic safety standards for protection against the dangers arising from exposure to ionising radiation, and repealing Directives 89/618/Euratom, 90/641/Euratom, 96/29/Euratom, 97/43/Euratom and 2003/122/Euratom, Official Journal L 13, 17/01/2014

  52. 52.

    Remedios D, Hierath M, Ashford N et al (2014) European survey on imaging referral guidelines. Insights Imaging 5:15–23

  53. 53.

    Remedios D, France B, Alexander M (2017) Making the best value of clinical radiology: iRefer Guidelines, 8th edition. Clin Radiol 72:705–707

    CAS  Article  Google Scholar 

Download references

Acknowledgments

The authors wish to acknowledge the contribution of the following colleagues for responding to the survey and for providing data: Avramova-Cholakova Simona, Bigand Emeline, Bosmans Hilde, Faj Dario, Fitton Isabelle, Georgiev Emil, Griciene Birute, Habib Geryes Bouchra, Kotiaho Antti, Kulich Miloslav, Krynke Leonid, La Grange Cindy, Le Roy Julien, Melchor Joyce, Milyan Yuriy, Plagnol Vincent, Rampado Osvaldo, Rosales Espizua Francisco Javier, Sana Paolo, Sanchez Roberto, Salat Dusan, and Tölli Jukka.

Funding

Participation in the IAEA meeting was funded by the IAEA, the Governments of the participating Member States, or by the represented international organization. No funding support was provided by the IAEA or other agencies for conducting the survey and this work.

Author information

Affiliations

Authors

Corresponding author

Correspondence to Marco Brambilla.

Ethics declarations

Guarantor

The scientific guarantor of this publication is Madan M Rehani.

Conflict of interest

The authors declare that they have no conflict of interest.

Statistics and biometry

No complex statistical methods were necessary for this paper.

Informed consent

Written informed consent was not required for this study because no change of intervention in patient management was part of the work that involved data analysis retrospectively.

Ethical approval

Institutional Review Board approval was not required because only summary data (total numbers) were needed for the analysis. The centers providing data were responsible to follow their local rules.

Methodology

• retrospective

• observational

• multicenter study

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Brambilla, M., Vassileva, J., Kuchcinska, A. et al. Multinational data on cumulative radiation exposure of patients from recurrent radiological procedures: call for action. Eur Radiol 30, 2493–2501 (2020). https://doi.org/10.1007/s00330-019-06528-7

Download citation

Keywords

  • Radiation protection
  • Patient safety
  • Radiologic Technology
  • Risk
  • Radiation dosage