The use of ionizing radiation is one of the greatest medical discoveries of the last 120 years. Its use has vastly improved our understanding of the body's processes and functions and our ability to diagnose and to cure diseases.
Doctors use, for example, computed tomography (CT) scans, X-rays and positron emission tomography (PET) scans to help diagnose illnesses as diverse as heart disease and breast cancer. Ionizing radiation is also used to help cure many types of cancers and real-time X-ray imaging help doctors perform minimally invasive surgeries.
According to 2008 figures, every day ionizing radiation is used for the imaging of patients in more than 10 million diagnostic radiology procedures and 100 000 diagnostic nuclear medicine procedures, while more than 10 000 radiotherapy courses are started along with many therapeutic nuclear medicine procedures.
Ionizing radiation has undoubtedly been good for medical advancement and for patients' quality of life around the world. But ionizing radiation also carries a risk, and the deliberate exposure of an individual is justified only if there is a potential direct benefit.
This benefit versus risk balance is the main reason the IAEA is promoting its AAA (Awareness, Appropriateness, Audit) approach to radiation protection and safety, in an effort to get medical practitioners, nuclear regulators and medical facilities to take adequate care in the use of ionizing radiation in medicine.
To promote its AAA approach, the IAEA Radiation Safety and Monitoring Section held an event on 23 September during the IAEA's 58th General Conference, where Jim Malone, Professor of Medical Physics at Trinity College, in Ireland, and Lodewijk Van Bladel, Senior Radiological Protection Expert at the Federal Agency for Nuclear Control in Belgium gave presentations on the history, importance and benefits of using the AAA approach to improve patient radiation protection.
More than 40 regulators from around the world, who are responsible for managing radiation safety in their countries, attended the event.
AAA Basics
Awareness means that the physician or radiologist must understand the risks associated with exposing patients to various radiation doses, be able to evaluate whether the patient's condition and the potential knowledge and benefits gained from any procedure is worth the risk, and be able to communicate the potential risks and benefits to the patient.
According to Van Bladel, financial concerns are often important in determining in practice how many radiological procedures are requested. He said nuclear regulators, with their limited powers, cannot change this situation alone. He encouraged the regulators present to join forces with other stakeholders in government, medicine and education to address the problem.
Appropriateness means that each procedure using ionizing radiation should be suitable for the illness the patient is thought to have. Appropriateness criteria, or clinical imaging guidelines, are recommendations that inform the decision of the healthcare provider on which imaging test to perform or request, if any.
For example, many doctors request X-rays when patients complain of lower back pain, when such X-rays don't usually produce any useable information to explain the cause of the pain. Lower back pain not associated with sinister features can be managed without imaging as most will improve within weeks. Therefore such X-rays are not appropriate and should be avoided.
Lastly, (clinical) Audit should assess how well and how consistently the principles of Awareness and Appropriateness are being used in the clinical setting. The outcomes from audit must be integrated in the hospital/clinic's operating life.
Malone noted that though progress has been made, with several European countries and medical and radiological professional societies adopting the AAA approach, there is "still much more to do."
Our Role
The IAEA's efforts to improve radiation protection of patients stem from The International Action Plan (IAP) for the Radiological Protection of Patients, which was prepared and approved by the IAEA's governing bodies in 2002. The overall objective of this action plan is to make progress in the radiation protection of patients as a whole, noting that the involvement of international organizations and professional bodies are crucial to performing the actions and achieving the goals outlined therein.
The types of actions being taken under the IAP include: providing standards, training and guidance; facilitating knowledge exchange; providing direct technical assistance; and building awareness. Significant progress has been made over the years in addressing the optimization of radiation protection in medical exposures and increasing safety in medical exposures. Optimization involves, for example, ensuring that the equipment and procedures used produces good quality images for the purpose of the procedure, while transmitting the lowest possible radiation dose to the patient.
There has been less progress made in addressing the justification of medical exposure. Justification involves judging whether the procedure will potentially improve diagnosis or provide necessary information about the patient, and whether or not the procedure will potentially do more good than harm.