Should the ALARA concept and the Image Gently campaign be terminated?

May 18, 2016

About 15 years ago, an article in American Journal of Roentgenology raised concerns about the radiation dose from pediatric CT scans based on the linear no-threshold (LNT) model and based on the claim that children are more radiosensitive, i.e. they have a higher risk of radiation-induced cancer. This article received a lot of publicity with coverage by USA Today and other popular media. In response to the public concerns, the pediatric radiology community adopted the ALARA concept, that CT scans should be performed with radiation doses as low as reasonably achievable (ALARA). The radiological community also launched the Image Gently campaign whose mission is to improve safe and effective imaging care of children worldwide through advocacy. Though not stated explicitly in the mission statement, the LNT model is implied in their campaign to perform pediatric imaging with very low radiation doses, i.e. image gently. 

 

What are the consequences of the ALARA concept and Image Gently campaign? One consequence is that there has been a reduction of radiation dose pediatric patients receive from CT scans.  If the LNT model were valid, and children are more radiosensitive, then the dose reduction would reduce the risk of cancer in the children that were imaged. However, the LNT model is not valid and children are not more radiosensitive. Another consequence of reducing radiation dose from CT scans is that the CT scan image quality goes down. If the image quality went down too much, it would be difficult to make accurate diagnosis from the CT scan images. According to one estimate, about one in 20 pediatric abdomen CT scans performed are of nondiagnostic quality, i.e. the image quality is so bad that it would be difficult to make a proper diagnosis. Since the LNT model is not valid, reducing CT radiation dose would not reduce cancers, but the misdiagnosis because of reduced image quality would cause immediate harm to pediatric patients. Thus, the ALARA concept and Image Gently campaigns are causing real harm to pediatric patients while claiming to protect them from radiation-induced cancers. The Image Gently campaign should be discontinued in order to protect the health of pediatric patients.

 

I made the above arguments in my presentation at the International Pediatric Radiology 2016 conference on May 17, 2016 in a session entitled "Should the ALARA concept and the Image Gently campaign be terminated?".  Whereas no one in the audience or other speakers in the session defended the LNT model, the support for ALARA concept and Image Gently campaign continues to be strong. In the absence of the LNT model, ALARA and Image Gently have no justification. 

 

If you have children or grandchildren, and are concerned that they may receive nondiagnostic CT scans if they happen to need CT scans, you need to raise your voice and state that such scans are not acceptable, and that you want the radiological community to pay attention to image quality and not radiation dose, since the radiation doses from CT scans are quite low, and would not increase cancer risk. Without active action by parents and grandparents, the current Image Gently campaign would continue, harming pediatric patients. Here is an example of avoided pediatric CT scan due to radiation dose concerns and the disastrous result: Child dies from bowel necrosis after failure to diagnose volvulus.  If you wish to avoid epitaphs such as shown below, you need to take action.

 

 

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Should the ALARA concept and the Image Gently campaign be terminated?

May 18, 2016

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