CT扫描和关于收益与风险的问题

IF 2.2 4区 医学 Q3 RADIOLOGY, NUCLEAR MEDICINE & MEDICAL IMAGING
Cynthia H. McCollough, Rebecca Millman
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Notably, the estimates are derived from risk coefficients published in BEIR VII—coefficients that were derived from very different populations, including populations with much higher doses than for CT.<span><sup>14</sup></span></p><p>While BEIR VII is an important document, there are considerable limitations to the risk coefficients it provides. Data based on human exposures to radiation are extremely limited, making it necessary to form risk estimates from a combination of data from higher dose exposures (well above 100 mGy) and animal and cellular studies, most of which were performed with radiation exposures on the order of Gy rather than the 10s of mGy used in medical imaging exams. More recent risk estimates from medical exposures (specifically CT) suffer from multiple limiting or confounding factors, including a lack of patient-specific dose estimates and medical records, increasing the uncertainty of any derived risk values.<span><sup>15</sup></span> Additionally, risk estimates derived from medical populations may suffer from what is known as reverse causality—did the CT cause a cancer or did the symptoms for which the CT was performed indicate a future cancer.</p><p>Importantly, the estimates in Smith-Bindman et al.<span><sup>9</sup></span> assume that a person's lifetime risk of developing cancer after having a CT scan is the same for a healthy person—where the exam is not justified—as it is for a sick or injured person needing a CT exam. 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The BEIR VII risk estimates were for individuals with full life expectancies and cancer rates similar to the general population<span><sup>18</sup></span> and do not apply to a patient population.</p><p>Mataac et al.<span><sup>19</sup></span> showed that only 50% of patients who receive multiple CT scans (and hence “high” doses) are alive 2 years after their CT scans. For these patients, the cause of death must be due to their underlying disease or injury since radiation takes much longer than 2 years to cause a solid cancer, typically from 5 to 40 years, and at least 2 years to cause a leukemia. Thus, patients in the Smith-Bindman cohort who received the highest doses had substantially decreased lifespans <i>before</i> having a CT scan and would likely die before any radiation induced injury could express itself.</p><p>Discussions of CT safety must consider an additional aspect of risk—the risk from medical decisions made without the information provided by a CT scan. 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Notably, the estimates are derived from risk coefficients published in BEIR VII—coefficients that were derived from very different populations, including populations with much higher doses than for CT.<span><sup>14</sup></span></p><p>While BEIR VII is an important document, there are considerable limitations to the risk coefficients it provides. Data based on human exposures to radiation are extremely limited, making it necessary to form risk estimates from a combination of data from higher dose exposures (well above 100 mGy) and animal and cellular studies, most of which were performed with radiation exposures on the order of Gy rather than the 10s of mGy used in medical imaging exams. 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Brenner et al. showed that patients with significant existing disease have a far lower risk of developing cancer from a CT exam than a person with no disease,<span><sup>16</sup></span> since a serious pre-existing condition (prior to the CT) can cause death before cancer from a CT would have time to develop. Hence, the estimates in the Smith-Bindman paper greatly overestimate radiation risk since the individuals in the study who received a CT scan already had symptoms or a diagnosis of some sort of injury or disease. Even Smith-Bindman has previously reported that among patients who received “high” CT doses (total effective doses ≥ 100 mSv over 5 years), 80% were ordered because of suspected or known malignancy.<span><sup>17</sup></span> Hence a great many of the CT exams included in the 2025 Smith-Bindman et al. study likely occurred in patients who already had cancer. 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引用次数: 0

摘要

计算机断层扫描(CT)发明于50多年前,被认为是20世纪最伟大的医学进步之一从诊断和治疗癌症患者到决定是否需要手术,医生们在无数的医疗场景中都依赖于CT。CT提高了诊断的准确性,降低了病人的死亡率。最近的一份出版物估计,在美国,高达5%的未来癌症可能是由CT扫描引起的。这篇论文,以及随后的媒体报道,强化了CT扫描是应该避免的有风险的医疗程序的观念。这种看法在很大程度上是由于一些相同的作者发表了类似的论文,以及大型媒体对这些论文的危言耸听的报道。因此,当患者质疑指定CT(或其他涉及电离辐射的检查或程序)的安全性时,包括医学物理学家在内的医务人员必须能够以令人放心和知情的方式讨论这个话题。为此,AAPM制定了一份交流指南,题为《辐射与医学成像:传达对主要问题的明确答案》。13该指南旨在帮助卫生专业人员向决策者、护理提供者、患者、家庭成员和公众解释医学成像的好处和风险。在这篇社论中,我们提供了更多的信息来回答有关CT致癌风险的问题。首先,必须指出的是,Smith-Bindman等人使用的方法在本质上基本上是数学的;他们假设CT和癌症之间存在因果关系,而不是证明它,他们也没有提供任何一个人因CT扫描而患癌症的直接证据。他们估计,与基于现代CT检查的器官剂量、进行的CT扫描次数和BEIR VII14器官风险系数(从100毫gy按比例缩小)的预期相比,每93,000次CT检查可能会增加103,000例癌症(0.1%)。值得注意的是,这些估计值是根据《第七次辐射评估报告》公布的风险系数得出的,这些系数来自非常不同的人群,包括剂量远高于ct .14的人群。虽然《第七次辐射评估报告》是一份重要文件,但它提供的风险系数有相当大的局限性。基于人体辐射照射的数据极为有限,因此有必要综合高剂量照射(远高于100毫戈瑞)以及动物和细胞研究的数据来形成风险估计,其中大多数是在以戈瑞为数量级的辐射照射下进行的,而不是在医学成像检查中使用的几十毫戈瑞。最近的医疗照射(特别是CT)风险估计值受到多种限制或混杂因素的影响,包括缺乏患者特定剂量估计值和医疗记录,增加了任何衍生风险值的不确定性此外,从医疗人群中得出的风险估计可能会受到所谓的反向因果关系的影响——是CT检查导致癌症,还是CT检查的症状预示着未来的癌症。重要的是,Smith-Bindman等人9的估计假设,一个人在接受CT扫描后患癌症的终生风险与一个健康的人(如果检查是不合理的)和一个生病或受伤的人需要接受CT检查的风险是一样的。Brenner等人的研究表明,患有严重疾病的患者通过CT检查患癌症的风险远低于没有疾病的人,16因为严重的疾病(在CT检查之前)可能会在CT检查导致癌症发展之前导致死亡。因此,Smith-Bindman论文中的估计大大高估了辐射风险,因为研究中接受CT扫描的个体已经有某种损伤或疾病的症状或诊断。甚至Smith-Bindman之前也报道过,在接受“高”CT剂量(5年总有效剂量≥100毫西弗)的患者中,80%是由于怀疑或已知的恶性肿瘤因此,2025年Smith-Bindman等人的研究中包含的许多CT检查可能发生在已经患有癌症的患者身上。BEIR VII风险评估是针对预期寿命和癌症发病率与一般人群相似的个体18,并不适用于患者群体。Mataac et al.19显示,在接受多次CT扫描(因此是“高”剂量)的患者中,只有50%的患者在CT扫描后2年还活着。对这些病人来说,死亡的原因一定是由于他们的潜在疾病或损伤,因为辐射需要比2年更长的时间才能导致实体癌,通常从5年到40年,至少2年才能导致白血病。因此,在Smith-Bindman队列中,接受最高剂量辐射的患者在接受CT扫描之前的寿命大大缩短,并且很可能在任何辐射引起的损伤表现出来之前死亡。 CT安全性的讨论必须考虑风险的另一个方面——在没有CT扫描提供信息的情况下做出医疗决定的风险。CT扫描指导医疗护理并改善健康结果。同一篇文章报道了接受CT扫描的患者中恶性肿瘤的发病率,发现接受高剂量CT扫描的患者中有7%是由于急性、危重疾病(如主动脉夹层、动脉瘤或高能创伤)而成像的,如果不能准确诊断和治疗,这些疾病有很大的死亡风险虽然不会立即危及生命,但其他适应症是指存在重大健康风险的情况,如胰腺炎、非急性血管疾病和手术失败(13%)如果没有来自CT扫描的诊断信息,这些患者的病情管理可能会更差,导致更糟糕的医疗结果。总之,CT的风险很小且未经证实,而益处是明确的。如果考虑进行CT检查的患者询问潜在的辐射风险,那么进行医学上合理的CT检查的巨大好处必须包括在讨论中。希望这里提供的信息可以帮助进行此类讨论。然而,所有这些信息都不能减少医学物理学家的责任,即确保CT检查针对患者的身体习惯和临床适应症进行优化。所有作者都审阅并批准了最终文件,并提供了编辑意见,符合ICJME对作者身份的所有要求。是西门子健康工程公司向该机构提供的一项研究资助的接受者,与这项工作无关。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
CT scanning and questions about benefit versus risk

Computed tomography (CT) was invented over 50 years ago and is considered one of the greatest medical advances of the 20th century.1 Physicians depend on CT in myriad medical scenarios, from diagnosing and treating cancer patients to determining whether a surgery is necessary. CT increases diagnostic accuracy and decreases patient mortality.2-8

A recent publication9 estimated that up to 5% of all future cancers in the U.S. may be caused by CT scans. The paper, and the ensuing media coverage, reinforced perceptions that CT scans are risky medical procedures that should be avoided. This perception is due in large part to similar papers by some of the same authors10-12 and the alarmist reporting of these papers by large media outlets.

It is therefore essential that medical personnel, including medical physicists, be able to discuss this topic in a reassuring and well-informed manner when patients question the safety of a prescribed CT (or other exam or procedure involving ionizing radiation). Toward that end, the AAPM produced a communication guideline entitled Radiation and Medical Imaging: Communicating Clear Answers to Top Questions.13 The guide was written to help health professionals explain the benefits and risks of medical imaging to policy makers, care providers, patients, family members, and the public. In this editorial, we provide additional information for answering questions regarding cancer risk from CT.

First, it must be noted that the methods used by Smith-Bindman et al.9 are fundamentally mathematical in nature; they assume a causal relationship between CT and cancer rather than prove it, and they provide no direct evidence of any single person getting cancer from a CT scan. They estimate 103 000 additional cancers might occur per 93 000 000 CT exams (0.1%) compared to what would otherwise be expected based on organ doses from modern CT exams, numbers of CT scans performed, and the BEIR VII14 organ risk coefficients (scaled down from 100 mGy). Notably, the estimates are derived from risk coefficients published in BEIR VII—coefficients that were derived from very different populations, including populations with much higher doses than for CT.14

While BEIR VII is an important document, there are considerable limitations to the risk coefficients it provides. Data based on human exposures to radiation are extremely limited, making it necessary to form risk estimates from a combination of data from higher dose exposures (well above 100 mGy) and animal and cellular studies, most of which were performed with radiation exposures on the order of Gy rather than the 10s of mGy used in medical imaging exams. More recent risk estimates from medical exposures (specifically CT) suffer from multiple limiting or confounding factors, including a lack of patient-specific dose estimates and medical records, increasing the uncertainty of any derived risk values.15 Additionally, risk estimates derived from medical populations may suffer from what is known as reverse causality—did the CT cause a cancer or did the symptoms for which the CT was performed indicate a future cancer.

Importantly, the estimates in Smith-Bindman et al.9 assume that a person's lifetime risk of developing cancer after having a CT scan is the same for a healthy person—where the exam is not justified—as it is for a sick or injured person needing a CT exam. Brenner et al. showed that patients with significant existing disease have a far lower risk of developing cancer from a CT exam than a person with no disease,16 since a serious pre-existing condition (prior to the CT) can cause death before cancer from a CT would have time to develop. Hence, the estimates in the Smith-Bindman paper greatly overestimate radiation risk since the individuals in the study who received a CT scan already had symptoms or a diagnosis of some sort of injury or disease. Even Smith-Bindman has previously reported that among patients who received “high” CT doses (total effective doses ≥ 100 mSv over 5 years), 80% were ordered because of suspected or known malignancy.17 Hence a great many of the CT exams included in the 2025 Smith-Bindman et al. study likely occurred in patients who already had cancer. The BEIR VII risk estimates were for individuals with full life expectancies and cancer rates similar to the general population18 and do not apply to a patient population.

Mataac et al.19 showed that only 50% of patients who receive multiple CT scans (and hence “high” doses) are alive 2 years after their CT scans. For these patients, the cause of death must be due to their underlying disease or injury since radiation takes much longer than 2 years to cause a solid cancer, typically from 5 to 40 years, and at least 2 years to cause a leukemia. Thus, patients in the Smith-Bindman cohort who received the highest doses had substantially decreased lifespans before having a CT scan and would likely die before any radiation induced injury could express itself.

Discussions of CT safety must consider an additional aspect of risk—the risk from medical decisions made without the information provided by a CT scan. CT scans guide medical care and improve health outcomes. The same article that reported rates of malignancy among patients receiving CT scans found that 7% of patients who received higher CT doses were imaged due to acute, critical conditions such as aortic dissection, aneurysm, or high energy trauma, where there is a significant risk of death if the condition is not accurately diagnosed and treated.17 While not immediately life-threatening, other indications were for conditions that pose substantial health risks, such as pancreatitis, non-acute vascular disease, and failed surgery (13%).17 Without the diagnostic information from a CT scan, these patients risk poorer management of their condition, leading to worse medical outcomes.

In summary, the risk from CT is small and unproven, while the benefits are unequivocal. If patients considering having a CT ask about potential radiation risks, the large benefits of undergoing a medically justified CT exam must be included in the discussion. Hopefully the information provided here can assist with such discussions. None of this information, however, diminishes medical physicists’ duty to ensure that CT exams are optimized for the patient's body habitus and the clinical indication.

All authors have reviewed and approved the final document and provided editorial input and met all ICJME requirements for authorship.

C.H.M. is the recipient of a research grant to the institution from Siemens Healthineers, unrelated to this work.

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来源期刊
CiteScore
3.60
自引率
19.00%
发文量
331
审稿时长
3 months
期刊介绍: Journal of Applied Clinical Medical Physics is an international Open Access publication dedicated to clinical medical physics. JACMP welcomes original contributions dealing with all aspects of medical physics from scientists working in the clinical medical physics around the world. JACMP accepts only online submission. JACMP will publish: -Original Contributions: Peer-reviewed, investigations that represent new and significant contributions to the field. Recommended word count: up to 7500. -Review Articles: Reviews of major areas or sub-areas in the field of clinical medical physics. These articles may be of any length and are peer reviewed. -Technical Notes: These should be no longer than 3000 words, including key references. -Letters to the Editor: Comments on papers published in JACMP or on any other matters of interest to clinical medical physics. These should not be more than 1250 (including the literature) and their publication is only based on the decision of the editor, who occasionally asks experts on the merit of the contents. -Book Reviews: The editorial office solicits Book Reviews. -Announcements of Forthcoming Meetings: The Editor may provide notice of forthcoming meetings, course offerings, and other events relevant to clinical medical physics. -Parallel Opposed Editorial: We welcome topics relevant to clinical practice and medical physics profession. The contents can be controversial debate or opposed aspects of an issue. One author argues for the position and the other against. Each side of the debate contains an opening statement up to 800 words, followed by a rebuttal up to 500 words. Readers interested in participating in this series should contact the moderator with a proposed title and a short description of the topic
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