The recent New England Journal of Medicine (NEJM) review article by Brenner and Hall [1] reviewed important concerns about the possible effect of radiation dose from CT scans on future population cancer risk, particularly in children. This article has been widely cited by local and national news media, and has brought this issue once again to public attention.

The Society for Pediatric Radiology strongly agrees with the article’s emphasis on the need to use CT only when medically necessary and to use patient-appropriate imaging protocols and exposure factors. However, we emphasize that the cancer risk estimates as stated in the NEJM article are not universally accepted and remain controversial [2,3]. Further, the CT scan techniques quoted from the NEXT survey are those reported for adult patients, yet 93% of respondents indicated that doses were modified for pediatric patients. The techniques quoted in the article are well beyond published standards for children [4,5] and fail to recognize that most pediatric imaging facilities perform CT scans employing techniques that result in substantially reduced radiation exposure.

The reasons for the rapid growth of the use of CT are more complex than suggested in the article. CT is an invaluable modality for children and adults; reasons for increasing use extend beyond faster scanning or use in appendicitis, and include the needs of our patients and colleagues in the complex world of pediatric healthcare. We agree with the authors that unnecessary CT scans should be avoided. However, we are concerned that the conclusions of the article on this subject were based on a non-scientific straw poll of an audience at a panel discussion [6].

The article only minimally acknowledges that CT scans in fact save lives and help to avoid unnecessary surgery. For example, exploratory laparotomies for many indications, such as trauma, are a thing of the past. Diagnostic information obtained from CT in clinically equivocal cases of appendicitis has been shown to decrease negative appendectomy rate and subsequent surgical morbidity [7]. It is a disservice to pediatricians, parents, and patients to de-emphasize these facts.

While the issues regarding the potential long-term risks of low-level radiation exposure continue to be explored, it is clear that CT scan use needs to be monitored and practice needs to continue to evolve as more scientific information becomes available. The Society for Pediatric Radiology has been, and continues to attend to this health issue with action.

The Society for Pediatric Radiology has a long-standing history of advocating responsible and safe imaging of children, adhering to the principles of ALARA (As Low As Reasonably Achievable) for radiation exposure during any imaging examination. The SPR is centrally involved in scientific and educational programs to promote improved safety and reduced radiation exposure for children undergoing CT scans. The SPR, through its R&E Foundation, sponsors research directed towards exploring further means of radiation dose reduction. The SPR sponsors annual ALARA conferences [8] with two additional sessions planned for this year [9], holds special sessions at national meetings addressing issues of radiation in pediatric imaging, and is partnered with the American College of Radiology in developing pediatric specific imaging guidelines, standards, and appropriateness criteria [10]. The SPR and the National Cancer Institute jointly issued a statement in August of 2002 promoting safe use of CT scans in children and is cited in Brenner and Halls’ article [11].

The NEJM article’s emphasis on the potential long-range risk for CT mandates the need to have a balanced discourse of the risks and benefits of CT in children. While the concerns raised deserve discussion and continued action, we must not lose sight of the significant improvements in the health and lives of children that CT has also brought.

The SPR remains committed to action that results in the safety and prudent use of pediatric medical imaging, and looks forward to being an active and central participant in future discussions to ensure that safe, high quality imaging is available to all children.

References and Links:

1. Brenner DJ, Hall EJ. Computed tomography: an increasing source of radiation exposure. N Engl J Med 2007;357:2277-2284.

3. Berrington de Gonzalez A, Darby S. Risk of cancer from diagnostic X-rays: estimates from the UK and 14 other countries. Lancet 2004;363:345-351

4. Boone JM, Geraghty EM, Seibert JA, Wootton-Gorges SL. Dose reduction in pediatric CT: a rational approach. Radiology 2003;228:352-360.

5. Cody DD, Moxley DM, Krugh KT, O’Daniel JC. Wagner LK, Eftekhari F. Strategies for formulating appropriate MDCT techniques when imaging the chest, abdomen, and pelvis in pediatric patients. AJR 2004;182:849-859.

6. Panel Discussion. Session I: Helical CT and cancer risk. Pediatr Radiol 2002;32:242-244

7. Applegate KE, Sivit CJ, Salvator AE et al. Effect of cross-sectional imaging on negative appendectomy and perforation rates in children. Radiology 2001;220:103-107

The Society for Pediatric Radiology
American Association of Physicists in Medicine
American College of Radiology
American Society of Radiologic Technologists

American Academy of Pediatrics
American Osteopathic College of Radiology
American Registry of Radiologic Technologists
American Roentgen Ray Society
Association of University Radiologists
Conference of Radiation Control Program Directors
National Council on Radiation Protection
Radiological Society of North America
Society of Computed Body Tomography and Magnetic Resonance

The statement was approved by the SPR Board of Directors.