The American College of Radiology (ACR) urges that results of a study (Pearce et al) to be published in the Lancet regarding radiation risk from pediatric computed tomography (CT) scans should not keep parents from getting needed medical imaging care for their children, but should be discussed with their physician and factored into their shared decision making before an imaging scan is performed.

Medical imaging exams are directly linked to greater life expectancy, declines in cancer mortality rates, and are generally safer and less expensive than the invasive procedures that they replace. Scans also reduce the number of invasive surgeries, unnecessary hospital admissions, and length of hospital stays. However, widespread use has resulted in increased radiation exposure for Americans — including children.

“CT scans are most often performed on children who have experienced trauma to the head, neck or spine, or may suffer from neurological disorders or injury, or may need fast and accurate evaluation for complex and life threatening clinical issues such as pneumonia complications or chest infections. If an imaging scan is warranted, the immediate benefits outweigh what is still a very small long-term risk. Parents should certainly discuss risk with their provider, but not refuse care that may save and extend their child’s life,” said Marta Schulman, MD, FACR, FAAP, chair of the American College of Radiology Pediatric Imaging Commission.

Parents should keep a record of their child’s X-ray history and before their child receives any scan ask their physician:

• How will having this exam improve my child’s health care?
• Are there alternatives that do not use radiation which are equally as good?
• Will my child receive a “kid-size” radiation dose?
• Is this facility ACR-accredited?

ACR accreditation ensures that:

1. The physician interpreting scans has met stringent education and training standards
2. The technologists operating the equipment are certified by the appropriate body
3. The imaging equipment is surveyed regularly by a medical physicist to make sure that is functioning properly and is taking optimal images without excess radiation.

The ACR advises that no imaging exam should be performed unless there
is a clear medical benefit. The ACR supports the use of the optimal level of radiation needed in imaging
exams to achieve necessary results.

The government can help ensure appropriate imaging and lower the radiation dose that Americans receive from scans each year by:

1. Requiring Accreditation of all imaging facilities (including hospitals) — ACR accreditation signifies that the equipment is surveyed regularly by a medical physicist, the technologists appropriately certified and the interpreting physicians have met stringent education and training standards. This avoids repeat imaging due to poor quality scans and the associated radiation exposure. Patients can find accredited facilities at ACR.org

2. Encouraging/Incentivizing use of ACR Appropriateness Criteria® based decision support/exam order entry systems — These systems educate providers on which exam is best for a patient’s condition (or when no scan is warranted). This process ensures that patients get the right scan for the right reason at the right time, reduces inappropriate imaging, helps avoid unnecessary exposure to radiation, and is proven to improve quality and lower cost by ensuring appropriate imaging and that providers obtain needed information from the correct scan.

3. Encouraging/Incentivizing participation in the ACR Dose Index Registry® — Facilities contribute anonymized, HIPPA compliant dose information on every scan and periodically compare their dose indices to national benchmarks. This ongoing and regular feedback allows facilities opportunities to adjust dose accordingly and gauge how their radiation reduction efforts are working over-time.

Regarding the specifics of the Lancet Study

Children who get CT scans are doing so because of an immediate and significant health condition. These are not screening exams given to the general population of children. The authors stressed that the absolute lifetime cancer risks found in the study are very small compared with the lifetime risk of developing cancer in the general population, and are likely small compared with the benefits of a clinically justified scan. The authors correctly point out that the “immediate benefits of CT outweigh the long-term risks in many settings and because of CT’s diagnostic accuracy and speed of scanning, notably removing the need for anaesthesia and sedation in young patients.” This implies that many more lives may have been saved and improved by the information obtained from these scans. The use of appropriateness criteria to maximize the benefit relative to risk has been a major emphasis of the ACR. The authors correctly note that CT scanners from the period studied (1989-2003) used radiation doses much higher than those of today. Current protocols also allow for use of much lower dose than the study period. As the authors highlight, providers are far more aware of the potential risks involved than in years past and largely are proceeding as if low doses of radiation cause harm. This approach has governed the ACR’s long history of efforts to reduce dose and ensure appropriate imaging including:

1. Image Gently® — ACR is a founding member of the Alliance for Radiation Safety in Pediatric Imaging along with the American Association of Physicists in Medicine (AAPM), the American Society of Radiologic Technologists (ASRT) and the Society for Pediatric Radiology (SPR). Image Gently educates providers on opportunities to lower radiation dose used in the imaging of children. The campaign, started in Jan. 2008, now includes 70 Medical Organizations Worldwide.

2. Image Wisely® — ACR, Along with the Radiological Society of North America (RSNA), AAPM and ASRT co-founded the initiative to educate physicians on opportunities to lower dose and ensure appropriate imaging. The initiative also provides patient education materials, including a patient medical imaging record card developed with the FDA.

3. Choosing Wisely® — ACR identified a list of imaging exams whose necessity (and alternatives) should be discussed before ordering. The ACR partnered with Consumer Reports to distribute patient-friendly resources for consumers and physicians to engage in important conversations regarding these medical imaging exams. The ACR worked with the American Board of Internal Medicine Foundation and 8 other organizations on the Choosing Wisely campaign.

While opportunities remain to ensure appropriate ordering of scans, it should also be noted that imaging use is down since 2008. Imaging is also the slowest growing of all physician services among privately insured according to the Health Care Cost Institute. We urge providers and patients to take advantage of the Image Gently and Image Wisely materials as well as the Choosing Wisely list and other ACR quality and safety programs to help ensure the best imaging care possible, make efficient use of health care resources, and keep medical imaging safe, effective and accessible.

For more information regarding radiation exposure from medical imaging exams, the ACR urges patients and providers to visit the radiology safety section of the ACR website and the radiation safety section of RadiologyInfo.org, the patient information site co-managed by the ACR and the RSNA.