Greg Freiherr has reported on developments in radiology since 1983. He runs the consulting service, The Freiherr Group.
The New Merchants of Death
In 1934, a Senate committee opened hearings its chairman said would show that America’s involvement in WWI was “not a matter of national honor and national defense, but a matter of profit for the few.” Ninety-three hearings and 200 witnesses, however, did little to support that claim. Rather the hearings drew increased attention to arms manufacturers as “merchants of death” and inspired Congress to pass three neutrality acts that signaled “profound American opposition to overseas involvement” in the years preceding America’s entry into WWII.1
Recently, Consumer Reports portrayed radiology as a new kind of death merchant. In an “investigative report” published online January 27, 2015, and slated for its March 2015 issue, Consumer Reports heralded “The surprising dangers of computed tomography (CT) scans and X-rays,” stating in the article that “one-third of CT scans in the U.S. (about 24 million by current estimates) serve little if any medical purpose.”
The article presented radiologists as callously exposing unwitting patients to deadly radiation, stating that the overuse of CT is caused at least partly “by greed and money,” and advising readers to get a second opinion “if your doctor owns a CT scanner or has a financial interest in an imaging center.”
The medical community agrees that minimizing radiation dose is important. National and international efforts to raise awareness about the need to reduce dosage are underway. These include Image Gently, developed by the Alliance for Radiation Safety in Pediatric Imaging; Image Wisely, run jointly by the American College of Radiology (ACR), the Radiological Society of North America (RSNA) and American Society of Radiologic Technologists (ASRT); and EuroSafe Imaging, organized by the European Society of Radiology.
More remains to be done. Every trade meeting where CT is discussed features a speaker or paper addressing ways to cut dose through image-enhancing software or techniques that cut the voltage applied to X-ray generators.
Low-dose scanners have proliferated in vendor portfolios since the late-2000s. That these scanners, or low-dose upgrades, have not been more widely adopted is a withering indictment of the medical community, one curiously absent from the Consumer Reports article.
Going directly to consumers with concerns about dose has merit. But sowing fear, as Consumer Reports has done, with assertions that 15,000 Americans will “die this year because of cancers caused by the radiation in CT scans alone” has a better chance of producing medical luddites than an informed populace.
In reality, estimates of cancers caused by imaging procedures are highly speculative “because of various random and systematic uncertainties embedded in them,” wrote William R. Hendee, Ph.D., emeritus professor of radiology, radiation oncology at the Medical College of Wisconsin, in “Risk of medical imaging,” published in 2013 in the Biomedical Imaging and Intervention Journal.
In his paper, Hendee wrote that “over the past few years papers have appeared in the scientific literature that predict thousands of cancers and cancer deaths each year in populations of patients receiving medical imaging procedures (primarily computed tomography) employing ionizing radiation. The predictions in these papers are computed by estimating very small and hypothetical risks at low radiation doses and multiplying these speculative estimates by large numbers of patients experiencing medical imaging. The public media use these papers to develop print and electronic news releases that raise anxiety in parents, families and patients, at times causing them to delay or defer needed imaging procedures. Decisions to delay or defer examinations constitute real risks to patients, as contrasted with the hypothetical risks presented in the papers.”
Consumer Reports drew blindly from these assertions, citing researchers who estimate that “at least 2 percent of all future cancers in the U.S. — approximately 29,000 cases and 15,000 deaths per year — will stem from CT scans alone.”
Some scientifically gathered data do indicate that CT radiation presents a significant, albeit small, risk to patient welfare. To its credit, Consumer Reports found and responsibly presented such data, specifically a 2013 Australian study that linked CT to the development of six more cancers per 10,000 pediatric patients than would naturally occur.
What’s aggravating is the magazine’s use of half-truths and innuendo to create unwarranted fear. Consumer Reports stated that there are no federal radiation limits for any kind of CT imaging. It did not, however, say 43 states license facilities that expose patients to ionizing radiation, and more have laws pending to do the same.
The states did so in response to the Consumer-Patient Radiation Health and Safety Act, adopted in 1981 by the U.S. Congress, which directs states to voluntarily develop minimum standards for state certification and licensure of personnel who perform medical and dental radiologic procedures.
Similarly, the feds have enacted guidelines for the exposure of patients to ionizing radiation, updating them as recently as January, when the EPA revised radiation protection guidelines for federal facilities that image patients with X-rays. The voluntary guidelines outline recommendations “to keep patient dose as low as reasonably achievable without compromising the quality of patient care.”
And, if Consumer Reports is to be taken literally, the word “any” is contradicted by its own website, which last fall recommended limitations on lung CT screening — limitations that have since been adopted by Medicare. And, in its most recent article about the dangers of CT and X-ray, Consumer Reports states that, “starting in 2016, the Centers for Medicare and Medicaid Services plans to cut reimbursement rates if CT machines don’t have the most recent safety features.”
Nowhere is contradiction more obvious than in the headline that states “The Surprising Dangers of CT Scans and X-rays”, which is followed by text that reads: “It’s not surprising, then, that many patients have mistaken assumptions about the dangers of medical radiation.” So … which is it? Surprising or not?
Consumer Reports’ shortcomings do not diminish the increasing need for action. While the annual number of CT procedures in the U.S. dropped about 5 percent in 2012 and again by that amount in 2013, according to IMV Medical information Division, volume appears to be on the rise, jumping from 76 million in 2013 to 81.2 million in 2014.
Patients who, in conversations with their primary physicians, cite legitimate and documented concerns about radiation have a better chance of effecting change than those who come armed with exaggerated fears about cancer and death.
· Does the institution to which a patient is being referred apply a low-dose regimen?
· How much radiation will be exposed to the patient in the specific exam being ordered?
· If a child is being scanned, will the tech apply a pediatric protocol?
Referring physicians who must answer such questions might ask the same of the radiologists to whom they refer patients. And that can only lead to safer practices.
Radiology is moving in the right direction. Questions from patients, based on fact, will help radiology get to where it is going. Articles based on innuendo and half-truths will not. Instead, just as Senate hearings 80 years ago enabled warmongers to overwhelm Europe at the start of World War II, such attacks on radiology will stir fear that may prevent patients from obtaining needed medical imaging.
1. https://www.senate.gov/artandhistory/history/minute/merchants_of_death.htm, accessed Feb. 3, 2015.