Transcript cogitation about agitation from lac+usc

V
O
M
I
T
VICTIMS
OF
MEDICAL
IMAGING
TECHNOLOGY
IMAGING RISK ANALYSIS
WK Mallon MD DTMH,
FAAEM, FACEP
Associate Professor of Emergency Medicine
Keck School of Medicine at USC
Los Angeles County + USC Medical Center
CONFLICTS OF INTEREST
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I work at a Level 1 trauma center that panscans trauma patients regularly
Made a movie “CODE BLACK” and
Sonosite supported that venture (no salary),
and obviously UTZ has no ionizing radiation
EMA faculty (a source of EBM for this)
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No HIPAA sensitive material here-in.
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AGE AND GENDER
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Age: more TIME for malignant
transformation to occur
Age: greater vulnerability of tissues ?
Age: intellectual development in process
Gender: different tissues for cancer
Gender: breast exposures important
FIRST
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CT is the major exposure to diagnostic
radiation accounting for 75-85% of the total
THEREFORE, I will focus there
NO DOUBT, CT is a fabulous diagnostic
tool, that has saved many lives, & advanced
diagnosis specific treatments for many….
I DO NOT recommend abandoning this
powerful tool in any way
THE QUESTION IS HARM
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Can a powerful diagnostic tool cause harm?
Radiation risks: NO DOUBT they are real
Financial risks: NO DOUBT CT imaging is
very expensive and a COST contributor
Contrast risks: allergy & renal issues
Chasing the array of INCIDENTALOMAS
is another big problem often ignored in the
discussion……
So, HARM is a real problem
LOTS OF HARD DATA
REGARDING RADIATION
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Hiroshima Excess Death Data
BEIR VII data
Phantom tissue block measurements
Clinical measurements of exposures
Calculations of Excess Cancers
Actual Cancers measurements
CT usage data and diagnostic yield estimates
ATOM BOMB SURVIVORS
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550,000 patient years of F/U for 10,500 survivors
over the years 1986-1990
They are still dying: 420 excess deaths here
This data is excellent population whole body dose
exposure and resulting cancers which take decades
to emerge
“WE DON’T KNOW”…. “military radiation differs”
“Speculation and estimates”…..
Pierce DA et al, Radiation Res 1996 July; 146(1): 1-7
RISK / BENEFIT
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This is THE question, both R & B must be
assessed and quantitated in EVERY imaging
scenario before you order
I offer data suggesting RISK is being
ignored, and as a result the use of CT has
expanded way beyond medical reason and is
being employed way too often with very
little patient benefit
IONIZING RADIATION
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CT → 6000 cancers per year: 50% fatal
Under-recognized
Clinicians “lack understanding”
Risk benefit assessments lacking
Cumulative dose concerns missing
Unnecessary CT is a problem…..
Health Devices. 2007 Feb;36(2):41-2, 44-63
PLUS THE RADIATION
RISK IS CUMMULATIVE !
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It all adds up:
“The cumulative effect of imaging procedures is
what’s so troubling, but no one — neither
doctors nor patients — seems to be tracking
that danger.” (from Scientific American expose)
Biological effects of ionizing radiation (BEIR)
are unforgiving, the insults keep adding on
Thus, total exposure is being ignored.
HAS BENEFIT GONE UP
TOO? NO.
UMMM, NO
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Washington State database of 85,790 pts!
Compared prior to CT/UTZ/lap outcomes
to cases after these modalities were widely
employed for appy diagnosis….
No change in neg lap rate 1987 – 1998
No change in women, children, elderly
Perforation rates did not decrease either….
Flum DR et al, JAMA 2002 Jan 2; 287(1):43-4
INJURY RELATED CT
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Panscan strategy is a disaster being employed
on low risk patients without benefit
From 1998-2007 trauma CT imaging tripled,
WITHOUT increased dx, hospitalization, or
interventions, or mortality Korley et al JAMA 2010
Ahmadina et al, JoT 2012
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Harm ignored in peds trauma Brunetti et al JoT 2011
4.4 xs thyroid Ca deaths, 41.4 xs breast Ca deaths,
13.3 xs leukemia deaths/100,000 pts based on
measured (not estimated) exposures Tien et al JoT 2007
PANSCAN BEFORE & AFTER
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Set 20 mSv as a threshold number: risk for
CANCER is greater than 1/1000 at this #.
655 patients before, 624 after panscan intro
12% exceeded threshold before AND 20%
exceeded after, without a CHANGE in the
missed injury rate
Increased exposure WITHOUT benefit! Asha
et al, Emerg Med Australasia Feb 2012
TRAUMA TRANSFERS
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Higher level of care requests, many
transferred because a CT at the first hospital
made a diagnosis…. (tech issues noted)
Then what? REPEAT CT??!
A perfect demonstration of medically cavalier
approach to radiation risk. 78% of 207 got
repeat scans! Liepert et al, J Surg Res 2011
Other studies echo the findings….
NO CT OR OBSERVATION
NEPHROLITHIASIS
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Marked increase use of CT, but alas, no
concommitant increase in stone diagnosis
Hyams et al, J Urol 2011
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Recurrent condition, some are scanned over
and over again ignoring cummulative dose.
19/4000 had 6 or more CTs, and 1 patient
had 18 scans! Katz et al, Am J Roent 2006
And there are GOOD alternatives here…..
CARDIAC IMAGING
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One common statement is why fear
“theoretical” future cancer “estimates”?
We can’t know, it has never been measured
FALSE: McGill U. actually followed cardiac
patients with known ionizing medical
radiation exposures & measured the resulting
non-theoretical cancers
Cancer increased 3% for every 10mSv in the
as predicted manner Eisenberg et al CMAJ 2011
CT CORONARY ANGIOGRAPHY:
LIFETIME ATTRIBUTABLE RISK
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Age
Age
Age
Age
MALES
20: 1 in 686
40: 1 in 1007
60: 1 in 1241
80: 1 in 3261
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Age
Age
Age
Age
FEMALES
20: 1 in 143
40: 1 in 284
60: 1 in 466
80: 1 in 1338
Eistein AJ et al, JAMA 298(3):317, July 18, 2007
AGE ISSUES: THE YOUNG
HAVE GREATER RISK
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Looked at 200 CTs age < 35
Many deemed unnecessary (or easily replaced
by MRI which is superior for the clinical
query made by the clinician).
In total, 30% of CTs were “unjustified”
Oikarinen et al, Eur Radiol 2009
THE COSTS & CHARGES
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For patients it is the charges….
A CT will add $2000 to an ED visit (easy)
Patients are harmed by the collections when
un or under-insured, or large deductibles
In 2007, of 5000 debtors filing for
bankruptcy 62% had a medical component!
Most had insurance and were employed!
Himmelstein et al, Am J Med 2009
LAST, BUT NOT LEAST:
INCIDENTALOMAS
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Commonly found in trauma patients
43% had something, 60% of those
warranted further eval, 15% were possible
cancers. Munk et al, J Emerg Med 2010
Peds Trauma Head CTs: 4% had non-trauma
findings = incidentalomas
F/U critical additional element of trauma
imaging Rogers et al, Pediatrics 2013
V O M I T IS REALITY
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V = Victims
O = Of
M = Medical
I = Imaging
T = Technology
SO IS RISK BEING
EXAGGERATED ?
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Quite the contrary.
Risk is largely being ignored !
We have more and more scans with less
and less benefit…..the data is irrefutable and
from multiple sources
HEME ONC is a growth industry!