2009 Villforth Lecture, CRCPD Annual Meeting, Columbus Ohio
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  • From the National Cancer Institute’s booklet titled “Radiation Therapy and You: Support for People With Cancer” These booklets are available from NCI (the National Cancer Institute). NCI is a federal agency that is part of the National Institutes of Health. Call 1-800-422-6237 (1-800-4-CANCER) or visit www.cancer.gov. (See page 59 for more information.)

2009 Villforth Lecture, CRCPD Annual Meeting, Columbus Ohio 2009 Villforth Lecture, CRCPD Annual Meeting, Columbus Ohio Presentation Transcript

  • Communicating Risk with the Patient Richard J. Vetter, PhD CHP John Villforth Lecture 41 st Annual CRCPD Meeting
  • Disclaimers
    • The opinions expressed in this presentation are my own and do not necessarily reflect those of other members of the health physics, medical physics, or physician community nor those of my employer or any advisory committee on which I sit.
  • Outline
    • What risk?
    • Communicating risk
    • Systems communication
    • Role of professional organizations
    • Role of medical RSO
  • Perceptions of Risk
    • Lawyers, Read Carefully:
    New members and chairs to AAHP standing Committees in 2009, as described in Attachment 1, are submitted to the President for his nomination. I contacted candidate appointees by either phone or e-mail, and they have agreed to serve if approved by the Executive Committee. I tried to achieve gender and geographical balance in these appointments, with preference given to individuals with a solid track record of performance. For two committees (Appeals and Title Protection & Professional Recognition) I was able to recruit CHPs who also have law degrees, which may benefit committee deliberations. Each nominee had expressed interest in serving on the committee(s) for which recommended, as determined by their dues envelope or from direct expressions of interest and subsequently confirmed by telephone or e-mail interview. The initial candidate pool was based largely on expressions of interest on the dues envelopes. In addition, two candidates were solicited who had not expressed interest on their dues envelopes but had expressed interest to me or the chair of a committee. A third candidate had been recommended by a previous committee chair.
  • Perceptions of Risk
    • Lawyers, Read Carefully:
    New members and chairs to AAHP standing Committees in 2009, as described in Attachment 1, are submitted to the President for his nomination. I contacted candidate appointees by either phone or e-mail, and they have agreed to serve if approved by the Executive Committee. I tried to achieve gender and geographical balance in these appointments, with preference given to individuals with a solid track record of performance. For two committees (Appeals and Title Protection & Professional Recognition) I was able to recruit CHPs who also have law degrees, which may benefit committee deliberations. Each nominee had expressed interest in serving on the committee(s) for which recommended, as determined by their dues envelope or from direct expressions of interest and subsequently confirmed by telephone or e-mail interview. The initial candidate pool was based largely on expressions of interest on the dues envelopes. In addition, two candidates were solicited who had not expressed interest on their dues envelopes but had expressed interest to me or the chair of a committee. A third candidate had been recommended by a previous committee chair. Never Mind
  • Communicating Risk with the Patient
  • What Risk?
    • Case: 60-yo male with chest pain
    • Patient: “My chest hurts, Doctor.”
    • Doctor: “I think you have a blocked artery; we need to conduct a nuclear scan of your heart.”
    • Patient: “Am I going to die?”
    • What should the doctor say?
    What Risk?
    • Doctor:
    • (a) “I don’t know yet, but the nuclear scan could increase your risk of cancer by about a tenth of a percent.”
    What Risk?
    • Doctor:
    • (b) “I don’t know yet, but the nuclear scan will tell us whether blood flow to part of your heart is blocked and will help us determine treatment options.”
    What Risk?
  • Conversation
    • Test options:
      • Sestamibi
      • Thallium
      • Echocardiography
    • Factors: age, sex (higher radiation risk in females), other medical problems
    • Treatment options; possibly.
    • Radiation risk; possibly, not likely.
  • Communicating Risk to Patients
    • Patients are focused on their condition
    • Patients aware of radiation risk?
    • Physicians in position to discuss risk
    • Pamphlets & Handouts
    • Patient Education departments
  • What Do Doctors Know About Radiation?
    • Physicians (Southern Med J 89: 1067; 1996)
    • Physicians (BMJ 327: 371; 2003)
    • Pediatric surgeons (J Pediatr Surg 42: 1157; 2007)
    • Non Radiologists (BJR 70: 102; 1997, Rofo 179: 261; 2007)
  • Radiation After Mastectomy
    • Approximately 1/5 th of patients with strong indication received no RT
    • Most common reason: lack of physician recommendation
    • Cancer 115: 1185; 2009
  • Systems Communications
  • Systems Communication Chest CT scans may be obtained using either a low-dose technique or a standard technique. The low-dose technique provides radiation exposure equal to 10 two-view chest x rays of the lungs, plus one mammogram of each breast. A CT scan of the chest performed using a standard-dose technique provides radiation exposure that is 10 times higher than the low-dose technique but shows many tissues and organs more clearly. The risk of cancer from the radiation exposure of a CT scan is estimated to be extremely low. However, a very small risk does exist that the radiation exposure associated with a CT scan may cause some cancers to develop.
  • Pamphlets
    • What are x rays and what do they do?
    • Are x rays safe?
    • How is exposure to radiation measured?
    • What are the sources of radiation exposure?
  • Pamphlets
    • How much radiation do I receive in an x-ray exam?
    • Should I have x-ray examinations if I am pregnant?
    • Do MRI and ultrasound use x rays?
  • Pamphlets
    • Examination Dose (mSv)
    • Chest radiograph 0.1-0.2
    • Dental bitewing <0.1
    • Mammogram 0.3-0.6
    • Head CT 1-2
    • Chest CT 5-7
    • Coronary angiogram 5-10
    • Nuclear Medicine
    • heart scan 13-16
  • Appointment Guide
    • List of appointments
    • Instructions
    • Information about exams
  • Role of ICRP & NCRP
    • Highly technical reports
    • Focused reports aimed at professional community
    • Direct impact on practicing physician unlikely
    • Indirect impact on patient/physician relationship unknown
  • Health Protection Agency (NRPB) http://www.hpa.org.uk/
  • Alliance for Radiation Safety in Pediatric Imaging
    • Founders:
    • Society of Pediatric Radiology
    • American Association of Physicists in Medicine
    • American College of Radiology
    • American Society of Radiologic Technologists
    http://www.pedrad.org/associations/5364/ig/
  • Alliance for Radiation Safety in Pediatric Imaging
    • 17 Affiliate Organizations including:
    • Conference of Radiation Control Program Directors
    • National Council on Radiation Protection and Measurements
    • Radiological Society of North America
    http://www.pedrad.org/associations/5364/ig/
  • Alliance for Radiation Safety in Pediatric Imaging http://www.pedrad.org/associations/5364/ig/
  • Alliance for Radiation Safety in Pediatric Imaging
    • Image Gently campaign
    • When CT is the right thing to do:
      • Child size the kVp and mA
      • One scan is often enough
      • Scan only the indicated area
    http://www.pedrad.org/associations/5364/ig/
  • Role of Professional Associations
    • Inform members (e.g. physicians)
    • Inform other professionals
    • Inform the public
  • Role of Professional Associations
    • Radiological Society of North America
    • American College of Radiology
    • American Board of Radiology
    • American Roentgen Ray Society
    • American Association of Physicists in Medicine
    • Health Physics Society
  • Health Physics Society (www.hps.org)
    • Physician documents ( http://hps.org/physicians/documents/index.html )
      • Doses, Risk Benefit, Radiation and Pregnancy
    • Fact sheets (http://hps.org/hpspublications/radiationfactsheets.html)
    • Ask the Experts (http://hps.org/publicinformation/asktheexperts.cfm)
      • >7000 questions (Health Phys 90 (suppl): S53; 2006)
    • Primer (http://www.radiationanswers.org)
  • IAEA
    • Be Informed About the Safe Use of Ionizing Radiation in Medicine
    • Information to help health professionals achieve safer use of radiation in medicine for the benefit of patients
    http://rpop.iaea.org/RPOP/RPoP/Content/index.htm
  • IAEA
    • Actions to Protect Patients In:
    • Radiology
    • Radiotherapy
    • Nuclear Medicine
    • Interventional Radiology
    • Interventional Cardiology
    • Other Specialties & Imaging Modalities
    http://rpop.iaea.org/RPOP/RPoP/Content/index.htm
  • IAEA
    • Is there a risk of cancer being caused by a CT angiographic procedure?
    • Excess cancer risk at doses below 100 mSv is a debatable issue… Since doses from cardiac CT scans are lower than this, the potential risk can only be estimated…, but multiple CT scans performed on the same patient may result in 100 mSv or more. The ICRP has estimated that the radiogenic fatal cancer risk for an adult population is about 5%/Sv
    http://rpop.iaea.org/RPOP/RPoP/Content/index.htm
  • IAEA 20% 0. 125% 25 mSv 20% 0.05% 10 mSv 20% 0.015-0.025 3-5 mSv 20% 0.01 2 mSv 20% 0.005% 1 mSv Approximate spontaneous risk of fatal cancers Approximate risk per scan of fatal radiogenic cancer a Approximate effective dose(mSv)
  • AHRQ
    • Radiation exposure resulting from CT colonography is reported to be 10 mSv per examination. The harms of radiation at this dose are not certain, but the linear no-threshold model predicts that 1 additional individual per 1000 would develop cancer in his or her lifetime at this level of exposure.
    http://www.ahrq.gov/clinic/uspstf08/colocancer/colors.htm
  • HHS
    • Agency for Healthcare Research and Quality:
    • to improve the quality, safety, efficiency, and effectiveness of health care for all Americans.
    • http://www.ahrq.gov/
  • What is radiation Radiation therapy (also called radiotherapy) is a cancer therapy? treatment that uses high doses of radiation to kill cancer cells and stop them from spreading. At low doses, radiation is used as an x-ray to see inside your body and take pictures, such as x-rays of your teeth or broken bones. Radiation used in cancer treatment works in much the same way, except that it is given at higher doses. Questions and Answers About Radiation Therapy How is radiation Radiation therapy can be external beam (when a machine therapy given? outside your body aims radiation at cancer cells) or internal (when radiation is put inside your body, in or near the cancer cells). Sometimes people get both forms of radiation therapy. To learn more about external beam radiation therapy, see page 9. To learn more about internal radiation therapy, see page 15. http://www.ahrq.gov/about/annualmtg08/090908slides/Hahn.ppt#290,12,Slide 12
  • What the Medical RSO Can Do
    • Encourage Radiology, Nuclear Medicine, Nuclear Cardiology to present appropriateness and radiation dose to Medicine
    • Encourage hospital to provide printed information to patients
    • Encourage ALARA
  • Mayo Cardiac Imaging Appropriateness Project
    • Apply appropriateness criteria
    • Reduce inappropriate studies (14%)
      • Asymptomatic
      • Pre op, low risk surgery
      • Symptomatic low probability CAD
      • Interpretable ECG
    • Educate physicians (to educate their patients)
  • Mayo Cardiac Imaging Appropriateness Project
    • Nuclear Cardiology Chair provided seminar to medical departments and grand rounds
    • Phone calls to physicians when appropriateness of order is questioned
  • Mayo Cardiac Imaging Appropriateness Project
    • Stress Test E (mSv)
    • Tc-99m SPECT 15
    • Th-201 Chloride 35
    • Stress Echo 0
  • Newsletters
  • Survey of Patient Release Information on Radiation and Security Checkpoints
  • 65 yo male: “Doctor, I’m worried about the radiation from that nuclear cardiology scan you ordered for me. Will it give me cancer?” So, is medical radiation bad for you?
  • A Conversation with the Doctor
    • Discuss appropriateness of tests:
    • Sestamibi
    • Discuss cancer risk:
      • Low risk of cancer, maybe 0.1%
      • (BEIR VII incidence: 0.06% 65 yo male;
      • 0.25% 20 yo female)
      • Risk of cardiac death is ~ 33%, likely higher in this patient
  • Red meat is not bad for you. Fuzzy green meat is bad for you. So, is medical radiation bad for you?
  • THE END