2009 Villforth Lecture, CRCPD Annual Meeting, Columbus Ohio

RJVetter 5/18/200RJVetter 5/18/20099

Communicating Risk with the Communicating Risk with the PatientPatient

Richard J. Vetter, PhD CHPRichard J. Vetter, PhD CHP

John Villforth LectureJohn Villforth Lecture

4141stst Annual CRCPD Meeting Annual CRCPD Meeting


DisclaimersDisclaimers

The opinions expressed in this presentation The opinions expressed in this presentation are my own and do not necessarily reflect are my own and do not necessarily reflect those of other members of the health those of other members of the health physics, medical physics, or physician physics, medical physics, or physician community nor those of my employer or community nor those of my employer or any advisory committee on which I sit.any advisory committee on which I sit.


OutlineOutline

• What risk?What risk?• Communicating riskCommunicating risk• Systems communicationSystems communication• Role of professional organizationsRole of professional organizations• Role of medical RSORole of medical RSO


Perceptions of RiskPerceptions of Risk

Lawyers, Read Carefully:Lawyers, Read Carefully:

New members and chairs to AAHP standing Committees in 2009, New members and chairs to AAHP standing Committees in 2009, as described in Attachment 1, are submitted to the President for as described in Attachment 1, are submitted to the President for his nomination. I contacted candidate appointees by either his nomination. I contacted candidate appointees by either phone or e-mail, and they have agreed to serve if approved by phone or e-mail, and they have agreed to serve if approved by the Executive Committee. I tried to achieve gender and the Executive Committee. I tried to achieve gender and geographical balance in these appointments, with preference geographical balance in these appointments, with preference given to individuals with a solid track record of performance. For given to individuals with a solid track record of performance. For two committees (Appeals and Title Protection & Professional two committees (Appeals and Title Protection & Professional Recognition) I was able to recruit CHPs who also have law Recognition) I was able to recruit CHPs who also have law degrees, which may benefit committee deliberations. Each degrees, which may benefit committee deliberations. Each nominee had expressed interest in serving on the committee(s) nominee had expressed interest in serving on the committee(s) for which recommended, as determined by their dues envelope for which recommended, as determined by their dues envelope or from direct expressions of interest and subsequently or from direct expressions of interest and subsequently confirmed by telephone or e-mail interview. The initial candidate confirmed by telephone or e-mail interview. The initial candidate pool was based largely on expressions of interest on the dues pool was based largely on expressions of interest on the dues envelopes. In addition, two candidates were solicited who had envelopes. In addition, two candidates were solicited who had not expressed interest on their dues envelopes but had not expressed interest on their dues envelopes but had expressed interest to me or the chair of a committee. A third expressed interest to me or the chair of a committee. A third candidate had been recommended by a previous committee candidate had been recommended by a previous committee chair.chair.


Perceptions of RiskPerceptions of Risk

Lawyers, Read Carefully:Lawyers, Read Carefully:

New members and chairs to AAHP standing Committees in 2009, New members and chairs to AAHP standing Committees in 2009, as described in Attachment 1, are submitted to the President for as described in Attachment 1, are submitted to the President for his nomination. I contacted candidate appointees by either his nomination. I contacted candidate appointees by either phone or e-mail, and they have agreed to serve if approved by phone or e-mail, and they have agreed to serve if approved by the Executive Committee. I tried to achieve gender and the Executive Committee. I tried to achieve gender and geographical balance in these appointments, with preference geographical balance in these appointments, with preference given to individuals with a solid track record of performance. For given to individuals with a solid track record of performance. For two committees (Appeals and Title Protection & Professional two committees (Appeals and Title Protection & Professional Recognition) I was able to recruit CHPs who also have law Recognition) I was able to recruit CHPs who also have law degrees, which may benefit committee deliberations. Each degrees, which may benefit committee deliberations. Each nominee had expressed interest in serving on the committee(s) nominee had expressed interest in serving on the committee(s) for which recommended, as determined by their dues envelope for which recommended, as determined by their dues envelope or from direct expressions of interest and subsequently or from direct expressions of interest and subsequently confirmed by telephone or e-mail interview. The initial candidate confirmed by telephone or e-mail interview. The initial candidate pool was based largely on expressions of interest on the dues pool was based largely on expressions of interest on the dues envelopes. In addition, two candidates were solicited who had envelopes. In addition, two candidates were solicited who had not expressed interest on their dues envelopes but had not expressed interest on their dues envelopes but had expressed interest to me or the chair of a committee. A third expressed interest to me or the chair of a committee. A third candidate had been recommended by a previous committee candidate had been recommended by a previous committee chair.chair.

Never Mind


Communicating Risk with the Communicating Risk with the PatientPatient


What Risk?What Risk?

Case: 60-yo male with chest painCase: 60-yo male with chest pain

Patient: “My chest hurts, Doctor.”Patient: “My chest hurts, Doctor.”

Doctor: “I think you have a blocked artery; Doctor: “I think you have a blocked artery; we need to conduct a nuclear scan of we need to conduct a nuclear scan of your heart.”your heart.”


Patient: “Am I going to die?”Patient: “Am I going to die?”

What should the doctor say?What should the doctor say?



Doctor: Doctor:

(a)(a) “I don’t know yet, but the nuclear “I don’t know yet, but the nuclear scan could increase your risk of scan could increase your risk of cancer by about a tenth of a cancer by about a tenth of a

percent.”percent.”



Doctor: Doctor:

(b)(b) “I don’t know yet, but the nuclear “I don’t know yet, but the nuclear scan will tell us whether blood flow scan will tell us whether blood flow to part of your heart is blocked to part of your heart is blocked

and and will help us determine treatment will help us determine treatment options.”options.”



ConversationConversation

• Test options:Test options:• SestamibiSestamibi• ThalliumThallium• EchocardiographyEchocardiography

• Factors: age, sex (higher radiation risk in Factors: age, sex (higher radiation risk in females), other medical problems females), other medical problems

• Treatment options; possibly.Treatment options; possibly.• Radiation risk; possibly, not likely.Radiation risk; possibly, not likely.


Communicating Risk to Communicating Risk to PatientsPatients

• Patients are focused on their conditionPatients are focused on their condition• Patients aware of radiation risk?Patients aware of radiation risk?• Physicians in position to discuss riskPhysicians in position to discuss risk• Pamphlets & HandoutsPamphlets & Handouts• Patient Education departmentsPatient Education departments


What Do Doctors Know About What Do Doctors Know About Radiation?Radiation?

• Physicians Physicians (Southern Med J 89: 1067; 1996)(Southern Med J 89: 1067; 1996)

• Physicians Physicians (BMJ 327: 371; 2003)(BMJ 327: 371; 2003)

• Pediatric surgeons Pediatric surgeons (J Pediatr Surg 42: 1157; 2007)(J Pediatr Surg 42: 1157; 2007)

• Non Radiologists Non Radiologists (BJR 70: 102; 1997, Rofo 179: (BJR 70: 102; 1997, Rofo 179: 261; 2007)261; 2007)


Radiation After MastectomyRadiation After Mastectomy

• Approximately 1/5Approximately 1/5thth of patients with of patients with strong indication received no RTstrong indication received no RT

• Most common reason: lack of physician Most common reason: lack of physician recommendationrecommendation

Cancer 115: 1185; 2009Cancer 115: 1185; 2009


Systems CommunicationsSystems Communications


Systems CommunicationSystems CommunicationChest 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.


PamphletsPamphlets

• What are x rays and what What are x rays and what do they do?do they do?

• Are x rays safe?Are x rays safe?• How is exposure to How is exposure to

radiation measured?radiation measured?• What are the sources of What are the sources of

radiation exposure?radiation exposure?


PamphletsPamphlets

• How much radiation do I How much radiation do I receive in an x-ray exam?receive in an x-ray exam?

• Should I have x-ray Should I have x-ray examinations if I am examinations if I am pregnant?pregnant?

• Do MRI and ultrasound use Do MRI and ultrasound use x rays?x rays?


PamphletsPamphlets

ExaminationExamination Dose (mSv)Dose (mSv)

Chest radiographChest radiograph 0.1-0.20.1-0.2

Dental bitewingDental bitewing <0.1<0.1

MammogramMammogram 0.3-0.60.3-0.6

Head CTHead CT 1-21-2

Chest CTChest CT 5-75-7

Coronary angiogramCoronary angiogram 5-105-10

Nuclear MedicineNuclear Medicine

heart scanheart scan 13-1613-16


Appointment GuideAppointment Guide

• List of appointmentsList of appointments• InstructionsInstructions• Information about examsInformation about exams


Role of ICRP & NCRPRole of ICRP & NCRP

• Highly technical reportsHighly technical reports• Focused reports aimed at professional Focused reports aimed at professional

communitycommunity• Direct impact on practicing physician Direct impact on practicing physician

unlikelyunlikely• Indirect impact on patient/physician Indirect impact on patient/physician

relationship unknownrelationship unknown


Health Protection AgencyHealth Protection Agency(NRPB)(NRPB)

http://www.hpa.org.uk/


Alliance for Radiation Safety in Alliance for Radiation Safety in Pediatric ImagingPediatric Imaging

http://www.pedrad.org/associations/5364/ig/

Founders: Founders: • Society of Pediatric RadiologySociety of Pediatric Radiology• American Association of Physicists in American Association of Physicists in

MedicineMedicine• American College of RadiologyAmerican College of Radiology• American Society of Radiologic American Society of Radiologic

TechnologistsTechnologists




17 Affiliate Organizations including:17 Affiliate Organizations including:• Conference of Radiation Control Conference of Radiation Control

Program DirectorsProgram Directors• National Council on Radiation Protection National Council on Radiation Protection

and Measurementsand Measurements• Radiological Society of North AmericaRadiological Society of North America






• Image Gently campaignImage Gently campaign• When CT is the right thing to do:When CT is the right thing to do:

• Child size the kVp and mAChild size the kVp and mA• One scan is often enoughOne scan is often enough• Scan only the indicated areaScan only the indicated area



Role of Professional Role of Professional AssociationsAssociations

• Inform members (e.g. physicians)Inform members (e.g. physicians)• Inform other professionalsInform other professionals• Inform the publicInform the public


Role of Professional Role of Professional AssociationsAssociations

• Radiological Society of North AmericaRadiological Society of North America• American College of RadiologyAmerican College of Radiology• American Board of RadiologyAmerican Board of Radiology• American Roentgen Ray SocietyAmerican Roentgen Ray Society• American Association of Physicists in American Association of Physicists in

MedicineMedicine• Health Physics SocietyHealth Physics Society


Health Physics Society Health Physics Society (www.hps.org)(www.hps.org)

• Physician documents Physician documents ((http://hps.org/physicians/documents/index.htmlhttp://hps.org/physicians/documents/index.html))

• Doses, Risk Benefit, Radiation and PregnancyDoses, Risk Benefit, Radiation and Pregnancy• Fact sheets Fact sheets

(http://hps.org/hpspublications/radiationfactsheets.html)(http://hps.org/hpspublications/radiationfactsheets.html)

• Ask the Experts Ask the Experts (http://hps.org/publicinformation/asktheexperts.cfm)(http://hps.org/publicinformation/asktheexperts.cfm)

• >7000 questions >7000 questions (Health Phys 90 (suppl): S53; 2006)(Health Phys 90 (suppl): S53; 2006)

• Primer Primer (http://www.radiationanswers.org)(http://www.radiationanswers.org)


IAEAIAEA

• Be Informed About the Be Informed About the Safe UseSafe Use of of Ionizing Radiation in MedicineIonizing Radiation in Medicine

• Information to help health professionals Information to help health professionals achieve safer use of radiation in achieve safer use of radiation in medicine for the benefit of patients medicine for the benefit of patients

http://rpop.iaea.org/RPOP/RPoP/Content/index.htm


IAEAIAEA

• Actions to Protect Patients In:Actions to Protect Patients In:• RadiologyRadiology • RadiotherapyRadiotherapy • Nuclear MedicineNuclear Medicine • Interventional RadiologyInterventional Radiology • Interventional CardiologyInterventional Cardiology • Other Specialties & Imaging ModalitiesOther Specialties & Imaging Modalities



IAEAIAEA

• Is there a risk of cancer being caused by a Is there a risk of cancer being caused by a CT angiographic procedure?CT angiographic procedure?

• Excess cancer risk at doses below 100 mSv is a Excess cancer risk at doses below 100 mSv is a debatable issue… Since doses from cardiac CT debatable issue… Since doses from cardiac CT scans are lower than this, the potential risk can only scans are lower than this, the potential risk can only be estimated…, but multiple CT scans performed on be estimated…, but multiple CT scans performed on the same patient may result in 100 mSv or more. The the same patient may result in 100 mSv or more. The ICRPICRP has estimated that the radiogenic fatal cancer has estimated that the radiogenic fatal cancer risk for an adult population is about 5%/Svrisk for an adult population is about 5%/Sv



IAEAIAEA

Approximate effective

dose(mSv)

Approximate risk per scan of fatal

radiogenic cancera

Approximate spontaneous risk of fatal cancers

1 mSv 0.005% 20%

2 mSv 0.01 20%

3-5 mSv 0.015-0.025 20%

10 mSv 0.05% 20%

25 mSv 0. 125% 20%


AHRQAHRQ

Radiation exposure resulting from CT Radiation exposure resulting from CT colonography is reported to be 10 mSv colonography is reported to be 10 mSv per examination. The harms of radiation per examination. The harms of radiation at this dose are not certain, but the at this dose are not certain, but the linear no-threshold model predicts that 1 linear no-threshold model predicts that 1 additional individual per 1000 would additional individual per 1000 would develop cancer in his or her lifetime at develop cancer in his or her lifetime at this level of exposure.this level of exposure.

http://www.ahrq.gov/clinic/uspstf08/colocancer/colors.htm


HHSHHS

Agency for Healthcare Research and Quality:Agency for Healthcare Research and Quality:to improve the quality, safety, efficiency, and effectiveness of to improve the quality, safety, efficiency, and effectiveness of

health care for all Americans. health care for all Americans.

http://www.ahrq.gov/http://www.ahrq.gov/


What is radiation Radiation therapy (also called radiotherapy) is a cancertherapy? treatment that uses high doses of radiation to kill cancer cells

and stop them from spreading. At low doses, radiation is usedas an x-ray to see inside your body and take pictures, such asx-rays of your teeth or broken bones. Radiation used incancer treatment works in much the same way, except that it isgiven at higher doses.

Questions and Answers About Radiation Therapy

How is radiation Radiation therapy can be external beam (when a machinetherapy given? outside your body aims radiation at cancer cells) or internal

(when radiation is put inside your body, in or near the cancercells). Sometimes people get both forms of radiation therapy.To learn more about external beam radiation therapy, see page9. 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 DoWhat the Medical RSO Can Do

• Encourage Radiology, Nuclear Encourage Radiology, Nuclear Medicine, Nuclear Cardiology to present Medicine, Nuclear Cardiology to present appropriateness and radiation dose to appropriateness and radiation dose to MedicineMedicine

• Encourage hospital to provide printed Encourage hospital to provide printed information to patientsinformation to patients

• Encourage ALARAEncourage ALARA


Mayo Cardiac Imaging Mayo Cardiac Imaging Appropriateness ProjectAppropriateness Project

• Apply appropriateness criteriaApply appropriateness criteria• Reduce inappropriate studies (14%)Reduce inappropriate studies (14%)

• AsymptomaticAsymptomatic• Pre op, low risk surgeryPre op, low risk surgery• Symptomatic low probability CADSymptomatic low probability CAD• Interpretable ECGInterpretable ECG

• Educate physicians (to educate their Educate physicians (to educate their patients)patients)



• Nuclear Cardiology Chair provided Nuclear Cardiology Chair provided seminar to medical departments and seminar to medical departments and grand roundsgrand rounds

• Phone calls to physicians when Phone calls to physicians when appropriateness of order is questionedappropriateness of order is questioned



Stress TestStress Test E (mSv)E (mSv)

Tc-99m SPECTTc-99m SPECT 15 15

Th-201 ChlorideTh-201 Chloride 35 35

Stress EchoStress Echo 0 0


NewslettersNewsletters


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 DoctorA Conversation with the Doctor

• Discuss appropriateness of tests:Discuss appropriateness of tests:

SestamibiSestamibi• Discuss cancer risk:Discuss cancer risk:

• Low risk of cancer, maybe 0.1%Low risk of cancer, maybe 0.1%

(BEIR VII incidence: 0.06% 65 yo male; (BEIR VII incidence: 0.06% 65 yo male;

0.25% 20 yo female)0.25% 20 yo female)• Risk of cardiac death is ~ 33%, likely Risk of cardiac death is ~ 33%, likely

higher in this patienthigher 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 ENDTHE END

Documents

2009 Villforth Lecture, CRCPD Annual Meeting, Columbus Ohio