Communicating Radiation Risk Presentation title Presenter name

Lifestyle Choices Modify Risk Communicating Radiation Risk V1 Created 18/3/2008

Radiation Phobia Our clients by and large perceive radiation as sinister. Chernobyl Overall 56 people died as a consequence of the 1986 Chernobyl reactor accident. There have been 4000+ cases of childhood thyroid cancer. 15 Million people in Belarus, Ukraine and Russia developed psychosomatic disorders post the Chernobyl accident10. Communicating Radiation Risk V1 Created 18/3/2008

Risk Perception Underestimate large risks and over estimate small risks2 Most people regard activities in involving a risk of 1 in a 1,000,000 or below as exceedingly safe2 People find it less easy to ignore a risk of death of 1 in a 1,0002 Communicating Radiation Risk V1 Created 18/3/2008

Risk Perception Perceive as less risky Voluntary Personal control Fair Credible source Perceive as greater risk Man made Delivery in an environment or by a person we don’t trust1 Communicating Radiation Risk V1 Created 18/3/2008

Balancing Radiation Risk Justification - restrict use of diagnostic imaging to only those who will benefit. Informed of risk Patients should not refuse diagnostic tests based on exaggerated estimations of the risk. Communicating Radiation Risk V1 Created 18/3/2008

Radiation Effects Evidence Hiroshima and Nagasaki Chernobyl and other radiation incidents Occupationally exposed groups Populations in high background radiation areas Medical radiation groups Communicating Radiation Risk V1 Created 18/3/2008

Available http://www.fda.gov/cdrh/rsnaii.html, 5/6/07 Radiation Bioeffects Immediate Effects Skin necrosis / erythema Alopecia Cataracts Available http://www.fda.gov/cdrh/rsnaii.html, 5/6/07 Thorat J & Hwang P. Journal of Stroke and Cebrovascular Diseases Vol 16 (1) 2007 Communicating Radiation Risk V1 Created 18/3/2008

Follow-up All patients with estimated skin doses of 3 Gy should be followed up 10-14 days after exposure. Radiation skin injury may present late and the association not considered if no documentation A system to identify repeat procedures should be set up9 Communicating Radiation Risk V1 Created 18/3/2008

Radiation Bioeffects Long Term Effects Cancer (primary risk) Genetic defects in the children of exposed parents Mental retardation in the children of mothers exposed during pregnancy Image available http://be.img.v4.skyrock.com/be0/farfadetino/pics/447586895_small on 15/4/2008 Communicating Radiation Risk V1 Created 18/3/2008

Source: http://www.bmj.com/cgi/content/full/328/7439/578 Leukaemia and Cancer Attributable lifetime risk for a single small dose of radiation according to age at time of exposure. Radiation has been shown to increase the risk for leukaemia and many types of cancer in adults and children The radiation risk is higher in younger age groups Source: http://www.bmj.com/cgi/content/full/328/7439/578 Communicating Radiation Risk V1 Created 18/3/2008

Cancer Risk 64 Slice CT Coronary Angiography Source Einstein A. Cardiosource 2007 Available http://www.medscape.com/viewarticle/567538 on 18/03/2007 Communicating Radiation Risk V1 Created 18/3/2008

Radiation Fact or Fallacy? About 413 cancers per (1.3% of all cancers) in Australia could be attributable to diagnostic x-rays6 There is a 1:1000 chance of developing cancer from a single CT Chest (10 mSv)8 The risk of cancer from a single CT Chest are < 1:10,000 if the patient is older than 50 years and 1:550 for a 1 year old patient 8. Communicating Radiation Risk V1 Created 18/3/2008

Scientific Conjecture New research indicates that low doses of radiation are actually beneficial and reduce these natural risks. (Available http://www.magma.ca/~mitchel/ 13/03/2007). This is controversial LNT Model Radiation Hormesis Model Communicating Radiation Risk V1 Created 18/3/2008

Prenatal Exposure Childhood Cancer Risk Radiation Dose Radiology Procedure X-ray Dose to Conceptus4,5 Estimated Childhood Cancer Incidence Estimated Lifetime Cancer Incidence (after exposure at age 10) No Radiation Exposure above background MR & US 0 mGy 0.30% 38% < 50 mGy Chest 0.04 mGy Bone Scan 5 mGy Ba Enema 10 mGy W/Body PET 15 mGy CT Pelvis 25 mGy 0.3% - 1% 38% - 40% 50 – 500 mGy 1% - 6% 40% - 55% Potential Childhood Cancer health Effects From Acute Prenatal Radiation Exposure Source adapted from: Centers for Disease Control Fact Sheet Radiation Emergencies Available http://www.bt.cdc.gov/radiation/prenatalphysician.asp on 18/03/2008 Communicating Radiation Risk V1 Created 18/3/2008

Prenatal Exposure Non Cancer Risk Acute Radiation Dose to the Embryo / Foetus Radiology Procedure X-ray Dose to Conceptus4,5 Time Post Conception Blastogenesis Organogenesis Foetogenesis (Up to 2 wks) (2 - 7 wks) (8 - 15 wks) (16 - 25 wks) (26 - 38 wks) < 50 mGy MR & US 0 mGy Chest 0.04 mGy Bone Scan 5 mGy Ba Enema 10 mGy W/ Body PET 15 mGy CT Pelvis 25 mGy Non - cancer health effects not detectable 50 – 500 mGy Failure to implant Malformations. Growth Retardation Growth Retardation Reduction in IQ Mental retardation Non - cancer health effects unlikely Potential Non Cancer health Effects From Acute Prenatal Radiation Exposure Source adapted from: Centers for Disease Control Fact Sheet Radiation Emergencies Fact Sheet Radiation Emergencies Available http://www.bt.cdc.gov/radiation/prenatalphysician.asp on 18/03/2008 Communicating Radiation Risk V1 Created 18/3/2008

Informed Consent The modern maxim is to allow patients to make informed decisions on their own health care The current lack of consistency in obtaining informed consent for radiation risk clashes with the accepted legal and ethical standards for giving patients information2. There is suboptimal awareness of radiation risks by both health care providers and clients. We declare the risk for anaphylactoid reactions for I.V. contrast (1:250,000) in a CT Abdomen but do not stress the radiation risk (1:1000) Communicating Radiation Risk V1 Created 18/3/2008

Radiation Risk Disclosure Approaches No mention of the risk2 Such practices disregard patients rights and violate basic principles of informed consent Understate the risk2 “A nuclear medicine scan is safe with an exposure almost always less than a common x-ray” Specific detailing of the risks2 “Your Nuclear Medicine scan involves exposure to radiation. Although it can vary from person to person your whole body exposure will be about 15 millisieverts. This is about 6 times the average annual background radiation exposure in South East Queensland. Although no harmful effects are expected , your long term risks from this exposure may be 1 in 1000. Harmful effects could include the development of cancer and genetic changes.” Communicating Radiation Risk V1 Created 18/3/2008

How to Explain Radiation Risk Be honest, clear and compassionate Be clear about what you do know and open about what you don’t know. To the extent possible tell people they are safe and why this is true Listen and deal with specific concerns1 Communicating Radiation Risk V1 Created 18/3/2008

Communication Approaches All education strategies on radiation exposure risk have limitations Use a variety of media Dose Quantification Risk Comparisons Avoid conflicting messages Communicating Radiation Risk V1 Created 18/3/2008

Relative Radiation Risk Adapted from American College of Radiology Relative Radiation Level Information available at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/RRLInformation.aspx on 18/03/2008 Communicating Radiation Risk V1 Created 18/3/2008

Relative Radiation Risk Picano E., B.M.J 2004 available http://bmj.com/cgi/content/full/329/7470/949#BIBL on 3/3/2008 Communicating Radiation Risk V1 Created 18/3/2008

Relative Radiation Risk Adapted from RadiologyInfo available http://www.radiologyinfo.org on 13/3/2007 Communicating Radiation Risk V1 Created 18/3/2008

Ordinary Life Equivalent Risk An Abdominal CT Scan (10 mSv) has the following equivalent risks: Smoking 140 cigarettes Driving 6,000 Km in a car Flying 40,000 Km in a jet Canoeing for 5 hours Adapted from information by H.S. Low Sir Charles Gairdner Hospital available http://www.scgh.health.wa.gov.au/departments/medical_research/ppt/Radiation_in_Diagnostic_Radiology_(for_Research)_Dr_Vincent_H_S_Low.ppt on 11/3/2008 Communicating Radiation Risk V1 Created 18/3/2008

Consent Language Generator Chest. This research study involves exposure to radiation from a Chest (PA), ... The total amount of radiation that you will receive in this study is about 0.02 mSv, and is approximately equivalent to a uniform whole body exposure of 2 days of exposure to natural background radiation. This use involves minimal risk …. CT Chest This research study involves exposure to radiation from a CT chest - helical, ... The total amount of radiation that you will receive in this study is about 13 mSv, and is approximately equivalent to a whole body exposure of 1582 days (4.333 years) of exposure to natural background radiation. This use involves minimal risk ... RADAR Medical Procedures Dose Calculator and Consent Language Generator Available http://www.doseinfo-radar.com/RADARDoseRiskClac.html on 03/03/2008 Communicating Radiation Risk V1 Created 18/3/2008

Radiation Exposure Radiation is an inevitable component in our society and is capable of both good and harm. Careful decision making is necessary if we are to reap its benefits and avoid unnecessary risks. Communicating Radiation Risk V1 Created 18/3/2008

Conclusions The principal of patient autonomy in radiology procedure participation might be reinforced by making it mandatory to obtain informed consent for all examinations with an associated radiation risk of 1 in 10,000 or worse22. Better knowledge of radiation risks will help us avoid perpetuating small individual risks into substantial population risks22 Communicating Radiation Risk V1 Created 18/3/2008

References Washington State Department of Health – Office of Radiation Protection Fact Sheet 17, How to explain radiation risk. Available http://www.doh.wa.gov/ehp/rp/factsheets/factsheets-htm/fs17explradrisk.htm on 18/03/2008 Picano E., Informed consent and communication of risk from radiological and nuclear medicine examinations: how to escape from a communication inferno, BMJ 329 2004. Stewart et al., Computed radiography data mining and surveillance as an ongoing quality assurance improvement process., American Journal of Roentgenology, Vol 189, 2007. McCollough C.H., Radiation exposure and pregnancy: When should we be concerned, Radiographics, 27(4) 2007. Kettunen A., Radiation dose and radiation risk to foetuses and newborns during x-ray examinations, STUK-A204, May 2004. Dickie G.J. & Fitchew R. S., Medical radiation and the risk of cancer, MJA 180 (11) 2004. Martin D.R. & Semelka R.C., Health effects of ionising radiation from diagnostic CT imaging: Consideration of alternative imaging strategies, Applied Radiology 36 (6) 2007. ICRP Report 85, International Commission on Radiological Protection: www.icrp.org Jaworowski Z., Radiation risk and ethics, Phsysics Today 52 (9) 1999 Communicating Radiation Risk V1 Created 18/3/2008

Gold Coast Health Service District Presentation title Thank You Presenter name