International Action Plan for the Radiological Protection of Patients

Summary of the report of the Steering Panel meeting

Some participants of the third Steering Panel meeting

The third meeting of the Steering Panel on the International Action Plan for the Radiological Protection of Patients (IAPRPoP) was held in Vienna at the IAEA headquarters on 25-27 February 2008.

It was noted that every day of the year, throughout the world, radiation is used in an estimated more than ten million diagnostic procedures, one hundred thousand nuclear medicine procedures and for the radiation treatment of more than ten thousand patients. Ensuring radiation protection of patients worldwide is a huge and complex task, but considering that the medical use of radiation is by far the largest contributor of radiation exposure to the population from man made sources, it is important to deal with. The vision of the IAPRPoP is to coordinate international efforts, and to provide guidance, on the radiation protection of patients and the overall objective is to make progress in radiation protection of the patient as a whole

The Steering Panel was established in 2003 to keep under review the implementation of the activities under the Action Plan with a view to providing guidance, on a continuing basis, on the overall approach to the implementation of the IAPRPoP, and to make proposals for adjustments as may appear necessary. In previous two meetings held in 2004 and 2006, the Panel reviewed progress and made additional prioritized concrete recommendations for actions in particular on starting a new website on radiological protection of patients.

The panel realized that the medical radiation exposure, which had been the largest man-made source of radiation, has grown substantially larger over the last decade. While this has undoubtedly conferred benefits to a large number of patients, it also represents the largest opportunity to decrease unnecessary exposure of radiation exposure.

The panel also dealt with interdependence of patient exposure and occupational exposure. For example, during fluoroscopy, the exposure and dose to the patient has a physical relationship to occupational exposure. The marked increase in cardiovascular and other fluoroscopic interventional procedures potentially has more effect on occupational exposure than do practice changes that may occur in the operation of the nuclear fuel cycle. Occupational and public exposures from the use of radionuclides in nuclear medicine likely exceed other public radionuclide exposures (with the exception of radon). A significant fraction of 50 million patients with radionuclides following nuclear medicine procedures are released into the public annually. The inter-country mobility of the patients poses challenges in maintaining similar levels of radiation protection in all countries.

Current occupational dose limits and regulations on handling radionuclides do limit individual occupational exposure. This does not, and should not, imply limiting the number of examinations done, as better radiation protection practices can be employed and more technologists, radiopharmacists and physicians can become involved. Public dose limits are of value in designing facilities and releasing individual nuclear medicine patients, but again, they should not limit the total number of patients that can be released.

One must remember that the often quoted radiation protection paradigm of “lower radiation dose is better” is not applicable to patient exposure. There must be enough radiation dose to obtain useful diagnostic information or to cure a tumor. Too little dose is often as bad as too much dose.

Manufacturers and some regulatory agencies can limit the physical output of X ray tubes. However, they have little or no control over the number of medical examinations done or of the justification or optimization of those examinations. Exposure of specific patients is typically left predominantly to the judgment of professional societies and doctors. Medical exposure is typically voluntary and there should be individual justification balancing the potential risk versus benefit for a particular patient. Unfortunately, in most diagnostic situations, often neither the physician nor the patient has a good grasp of the possible radiation risks and there is often little evidence-based medicine on which to assess the potential benefit. Decisions are made on the basis of experience, expediency, gut feeling, patient urgency, and, unfortunately, sometimes monetary issues or other non clinical factors. The adherence to appropriateness criteria established by professional bodies and based on sound clinical judgment can be instrumental in reducing the influence of non clinical factors in the decisions.

All health care professionals involved in the use of radiation in health care together with radiation protection professionals have been involved in medical radiation exposure, yet there continues to be a marked increase in both the dose per person and the collective dose. This is not necessarily bad; however, it prompts an examination of the mechanisms and various levels at which there may be opportunities for improvement.

Summary of other points is given below:

• The IAEA has developed a dedicated website (http://rpop.iaea.org) for information on radiation protection of patients which is a resounding success. Even though this site has been in existence for only one and a half years, it is getting very high hits and is continuously being improved and updated.
• It has been known for decades that there is a wide variation in the dose used for a given medical examination. Over the last decade a major effort has been launched particularly in developing countries in the development and institution of the concept of diagnostic reference levels (DRLs). The DRLs represent implementation of a very powerful and major tool for improvement of radiation protection in medicine.
• Given the millions of persons involved in medical exposure around the world, there had been a serious problem in getting expert material on radiation protection to the end users. The IAEA has produced many training CDs which are now available free of charge and the material is freely downloadable from the above IAEA website.
• Lack of qualified personnel (particularly in medical physics) is a serious issue. This shortage can only be expected to increase in future years due to the increasing volume of medical exposures. Several organizations have been actively working on this issue but with limited success.
• With new technologies, there remains a need to maintain research on methods to improve radiation protection in medical practice and the impact of new technologies on improvement of radiation protection.
• There is a need for additional education on appropriate ordering of procedures involving radiation by referring clinicians. There should be appropriate communication with the patient as well as consideration of the patient’s doses, needs and requests.