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Perspective | Less Is More

Questioning Protocol

Randi Redmond Oster, MBA1
[+] Author Affiliations
1Well Path Press, Fairfield, Connecticut
JAMA Intern Med. 2014;174(5):667. doi:10.1001/jamainternmed.2014.107.
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My 15-year-old son Gary is saying there are spasms in his intestines that won’t stop. He’s in so much pain that he’s beyond crying. He sits in the car silently, as if he’s entered a soundproof room from which I am banished, as I drive him to the emergency department (ED). This makes the sixth trip to the ED in a year. Less than a month ago, he had surgery to remove sections of his small and large intestine because of Crohn disease. But he’s never been in this much pain. I am terrified.

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Carcinogenic Concerns Regarding CT Scans are Unwarranted
Posted on April 19, 2014
Mohan Doss
Diagnostic Imaging, Fox Chase Cancer Center, Philadelphia, PA
Conflict of Interest: None Declared
This comment is regarding the Less is More Perspective [1] by Ms. Oster entitled “Questioning Protocol”. In the article, the author expressed carcinogenic concerns about the radiation dose from CT scans, and referred to the 2009 study from National Cancer Institute (NCI) which concluded that the CT scans in the USA in 2007 are likely to result in 29,000 future cancers [2]. This study utilized the cancer risk model from BEIR VII report [3], which used atomic bomb survivor data to justify the linear no-threshold (LNT) model for radiation-induced cancers. Analysis of the recent update to the atomic bomb survivor data has shown that the data no longer support the LNT model [4]. In fact, the data are consistent with a radiation hormesis model, implying a reduction of cancers for low doses of radiation [5]. Also, considerable amount of evidence has been published since the time of the BEIR VII report showing reduction of cancers from radiation doses corresponding to multiple CT scans, including (i) reduction of second cancers per kg of tissue in radiation therapy patients in parts of body subjected to radiation dose of ~20 cGy, (ii) reduction of cancers in residents of apartments in Taiwan who were exposed to ~5 cGy because of Co-60 contamination in building materials, and (iii) reduction of cancers in non-Hodgkin’s lymphoma patients who had been given radiation dose of 10 or 20 cGy between standard radiation treatments [5]. In view of such evidences for the reduction of cancers following low dose radiation, the LNT model based cancer risk model of the BEIR VII report and the resulting conclusion of the NCI study [2] can no longer be considered to be valid. In the absence of any cancer risk from low dose radiation, it is indeed appropriate to use the better imaging modality of CT for diagnosing emergency patients, as the standard x-rays are a poor substitute for the diagnostic excellence of the CT scans, especially in identifying unsuspected reasons for the emergency. The LNT model based radiation safety paradigm that is currently in use is a major hindrance to providing the best care to patients since it raises these unjustified carcinogenic concerns regarding CT scans among the physicians and the public. A change in the radiation safety paradigm is warranted away from the no-threshold model to one that recognizes a threshold dose, in order to bring the paradigm in compliance with present knowledge, and to enable better patient care.References 1. Redmond Oster R. Questioning protocol. JAMA Internal Medicine. 2014.2. Berrington de Gonzalez A, Mahesh M, Kim KP, et al. Projected cancer risks from computed tomographic scans performed in the United States in 2007. Arch Intern Med. Dec 14 2009;169(22):2071-2077.3. NRC. Health risks from exposure to low levels of ionizing radiation : BEIR VII Phase 2, National Research Council (U.S.). Committee to Assess Health Risks from Exposure to Low Level of Ionizing Radiation. Washington, D.C.: National Academies Press; 2006.4. Doss M. Radiation doses from radiological imaging do not increase the risk of cancer. British Journal of Radiology. 2014;87:20140085.5. Doss M. Linear No-Threshold Model vs. Radiation Hormesis. Dose Response. 2013;11(4):480-497.
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