News | August 26, 2009

ACR Calls NEJM Article on Radiation Concerns "Misinformed"

August 27, 2009 - In a public statement issued yesterday, the American College of Radiology (ACR) said, "Patients are urged not to delay or avoid seeking needed imaging care because of radiation concerns raised in a study and an ill-advised and misinformed perspective published in the August 27 New England Journal of Medicine (NEJM)."

The ACR points out that in conjunction with other imaging stakeholders, it has long been effectively addressing issues regarding radiation dose from medical imaging exams and inappropriate utilization of these scans. The College points out "Medical imaging exams and image-guided procedures are increasingly replacing more invasive and often more costly techniques, while saving and extending lives everyday."

In “Exposure to Low-Dose Ionizing Radiation from Medical Imaging Procedures,” Reza Fazel, M.D., M.Sc., and colleagues reported that imaging procedures are a key source of ionizing radiation exposure in the U.S. and that repeat exams can result in high cumulative doses of radiation. They also recognize that: “An important reason for the growing use of such procedures stems from their ability to radically improve patient care.” The ACR thanks the study authors for addressing these issues.

However, it should be made clear that the patients who experienced the higher doses of radiation (and repeated exams) outlined in the study were almost certainly cancer patients and others with chronic illnesses whose conditions necessitated repeat exams to gauge effectiveness of their treatment and/or help ensure their short term survival. For these patients, who would otherwise be forced to undergo invasive surgeries, and who without the information gleaned from these scans, may have suffered serious health setbacks, or even death, the benefits of these exams clearly outweigh the risk of long-term adverse health effects from radiation. For most other patients, repeated exams and the high levels of radiation discussed in the study are not reality. It is important to understand this to provide context and avoid unnecessary hysteria that may lead to patients foregoing necessary imaging care and placing their health in jeopardy.

The Fazel study also points out that nearly 82 percent of the total administered dose occurred outside of the hospital setting. Radiologists perform less than a third of nonhospital imaging.1 Most of the scans explored in the study were performed by nonradiologist providers that self-referred patients to their own imaging equipment. Studies have shown that when providers can refer patients to their own scanners or those in which they have a financial interest, imaging is greatly increased.2,3,4 Many of these providers have little to no imaging or radiation safety training. Knowledge of the correct use of these technologies is not universal.


More serious and ill-advised claims are made in “Elements of Danger – The Case of Medical Imaging,” an accompanying “perspective” which states, among other things, that “with few exceptions - such as mammography - most radiologic imaging tests offer net negative results. There is no evidence to support this claim which is refuted by a recent paper from the National Bureau of Economic Research which directly attributes advanced medical imaging with increased life expectancy.5

In regard to utilization patterns, the perspective states "Physicians can easily defend their practices because their specialty societies argue that the procedures are 'appropriate' The issue of radiation exposure is unlikely to come up." This is patently false. ACR Appropriateness Criteria® ( ), created more than a decade ago and available to all providers, help physicians prescribe the most appropriate imaging exam for more than 210 clinical conditions and do factor radiation dose into the decision making process. ACR Appropriateness Criteria are used by many private insurers in their coverage process as well as point of entry decision making software in use at Massachusetts General Hospital and elsewhere to help determine the most appropriate exams for patients.

The perspective also negatively categorizes scans by stating that patients "incurred costs for procedures of uncertain value," noted the College, because Negative exams are of value. They preclude further costly and invasive exploratory techniques, rule out disease, provide a baseline to monitor patient health, and provide the patient with peace of mind.

Efforts to Reduce Radiation Dose:

The radiology community has embraced the ‘ALARA’ or ‘as low as reasonably achievable’ concept espousing that providers use only the amount of radiation necessary to obtain optimal images. Radiologists are working to lower dose and to educate elected officials, government agency staff, and referring physicians of the need for further steps toward this goal. The ACR, in an effort to stem the unnecessary growth in radiation dose that Americans receive from imaging, has worked with other radiology organizations to educate all stakeholders in the principles of radiation safety and appropriate utilization of imaging.

For years, the ACR has promoted radiation safety among radiologist, nonradiologists, and the public through the ACR Practice Guidelines and Technical Standards, facility accreditation programs, government relations efforts, ACR Appropriateness Criteria to educate referring physicians on the most appropriate imaging exams for given indications, continuing medical education offerings, and the ACR patient education Web site,, a cooperative effort with the Radiological Society of North America, RSNA.

ACR accreditation mandates that the providers reading scans meet basic education and training standards, that the imaging equipment is surveyed regularly by a medical physicist to ensure that it is functioning properly and radiation dose is not excessive, and that the technologists administering the test are appropriately certified.

The College also published the ACR White Paper on Radiation Dose in Medicine : a far-reaching and extensive set of 33 recommendations designed to counteract medical and societal trends which have contributed to any increased radiation dose that Americans may experience as this beneficial technology advances. To date, 27 of the 33 recommendations have been completed or are in progress.

In 2007, the Society for Pediatric Imaging (SPR) initiated the Alliance for Radiation Safety in Pediatric Imaging, which the ACR joined as a founding member. The Alliance is conducting the Image Gently campaign ( to make providers aware of opportunities to lower the radiation dose used in the imaging of children and now encompasses 44 medical organizations from the United States and around the world. The Alliance, among other things, is collaborating with imaging manufacturers to standardize dose assessment and display for children and to improve technologist education, ensuring that CT scanning radiation levels are appropriate for children

Produced “My Child’s Medical Imaging Record” card, which can be downloaded from the Image Gently site and allows parents to record where and when a study was performed as well as the type of radiologic exam. According to ACR, this can help their future medical providers make more informed decisions regarding optimal timing of additional radiologic examinations.

- Sunshine JH, Bansal S, Evans RG. Radiology performed by non-radiologists in the United States: Who does what? AJR .1993;61:419-429.

- Aronovitz LG. Referrals to physician-owned imaging facilities warrant HCFA’s scrutiny: General Accounting Office report to the U.S. House of Representatives. Washington, DC: GAO, 1994:5 Publication GAO/HEHS-95-2.

- Hillman BJ, Olson GT, Griffith PE, et al. Physicians’ utilization and charges for outpatient diagnostic imaging in a Medicare population. JAMA. 1992;268:2050-4.

- Gazelle, Scott. “Utilization of Diagnostic Medical Imaging: Comparison of Radiologist Referral versus Same-Specialty Referral1.” Radiology: Volume 245: Number 2—November 2007.

- Lichtenberg, Frank. The Quality of Medical Care, Behavioral Risk Factors, and Longevity. National Bureau of Economic Research (June 2009).

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