The NRC and how nuclear is regulated

The current practice for controlling ionizing radiation exposures is ALARA – (As Low As Reasonably Achievable). This practice is based on acceptance of the 1950s vintage assertion that all exposure to radiation, down to a single low energy gamma ray, carries a greater than zero probability of causing a genetic mutation that might result in…

The current practice for controlling ionizing radiation exposures is ALARA – (As Low As Reasonably Achievable). This practice is based on acceptance of the 1950s vintage assertion that all exposure to radiation, down to a single low energy gamma ray, carries a greater than zero probability of causing a genetic mutation that might result in either a hereditary defect or cancer.

Some medical imaging professionals who use diagnostic tools employing radiation or radioactive materials believe that they should acknowledge and accept that patients have a legitimate reason to be concerned about radiation. By assuring the patient that they do everything they can to avoid exposures, they believe patients are reassured. ALARA means that their care provider is taking the smallest risk possible while still obtaining information needed to help them avoid even greater risks.

Other imaging professionals accept the evidence supporting their understanding that doses associated with proper medical imaging procedures are far below the doses that might cause harm. They believe that the policy of emphasizing ALARA principles contributes to patient concerns and may even cause some patients to avoid needed procedures.

In January, the journal Medical Physics published a Point/Counterpoint debate on this controversy with the following proposition.

Advocating for use of the ALARA principle in the context of medical imaging fails to recognize that the risk is hypothetical and so serves to reinforce patients’ fears of radiation.

Colin G. Orton Ph.D. Professor Emeritus, Wayne State University, provided the proposal and the discussion introduction. Jeffry A. Siegel, Ph.D. argued for the proposition. Cynthia H. McCollough, Ph.D. argued against the proposition. Both debaters provided brief opening statements and a single round of rebuttals responding to the other’s opening statement.

For the Point/Counterpoint section of Medical Physics, this is the standard stopping point. As a result of existing policy and technical limitations, the Medical Physics editor rejected follow-up contributions related to the published discussion.

According to correspondence made available to Atomic Insights, the journal editor recognizes that some discussions deserve a mechanism for continued engagement, additional points and further interaction with people who might not have been initially invited to provide their views. He even acknowledged that this topic is one that deserves additional exchanges, so he might revisit his rejection decision after making alterations to the current web site software.

While that journal is developing the technical capability to host such discussions, authors of the rejected letters decided that the Atomic Insights comment feature might provide an interim solution.

As a continuation of the excellent debate started by Drs Siegel and McCollough here are additional contributions.

J. J. Bevelacqua

Bevelacqua Resources

Dear Editor,

This correspondence addresses the Point/Counterpoint debate by Drs. Jeffry A. Siegel and Cynthia H. McCollough on the use of the ALARA principle in medical imaging.1 The as low as reasonably achievable (ALARA) principle is based upon the linear no-threshold hypothesis (LNTH) that assumes low doses of ionizing radiation are harmful and should be minimized. Using superficial arguments, LNTH/ALARA appears to be a beneficial philosophy, but upon examination of relevant data and experience, it accomplishes a result that is opposite to its intent2-6. In attempting to protect patients from an imagined detriment, the arguments fostered by Dr. McCollough limit the use and application of a vital diagnostic tool.

Dr. McCollough defends ALARA in medical imaging by extrapolating the observed carcinogenic effect of high-dose radiation to the low-dose range used in medical imaging. She notes, “current biological and epidemiological evidence cannot definitively prove that low doses of radiation are safe”. This statement inherently relies on the flawed LNTH and its ALARA derivative. As such, it fails to acknowledge studies observing a reduction of cancers following low-dose rate exposures7 and publications that illustrate significant flaws in the LNTH3,7,8.

As applied to medical imaging, Siegel1 and Siegel and coworkers2 succinctly outline the fallacy of the LNTH and its illegitimate ALARA progeny. These authors note that credible evidence of imaging-related carcinogenic risk at low absorbed dose (2 observe that the LNTH and associated ALARA concepts are fatally flawed and focus only on molecular damage while ignoring protective, organismal biologic responses. The societal harm caused by the LNTH and ALARA has been well documented1-8.

The LNTH also affects acceptance of the use of radiation and radioactive materials and causes the ALARA concept to create harm rather than the presumed benefit. These concepts create a world in which ALARA becomes A Law against Radiation Applications, and radiophobia is continually reinforced.

Radiophobia has inhibited research using low-dose radiation in the detection, prevention, and treatment of cancer and other diseases. Unwarranted fears caused by belief in the LNTH have also effectively inhibited research involving unique applications of radiation and radioactive materials. These applications include the use of low-dose radiation as a treatment protocol.

Patients have refused computed tomography scans and physicians are not prescribing these procedures because the LNTH/ALARA dogma has created concern for the subsequent radiation detriment. This fear could result in missed diagnoses because imaging doses are too low to produce adequate tissue resolution6.

LNTH/ALARA induced radiophobia promotes increased regulations of radiation and radioactive materials. The associated costs to implement compliance further dampen the expansion and use of radiation and radioactive materials. Regulations affect consumer, medical, industrial, healthcare, and research applications and result in significantly increased costs with very limited benefit.

Dr. Siegel provides a rational argument for rejecting the LNTH/ALARA fallacy. I hope that his arguments will cause professionals to challenge poor science and facilitate the use radiation and radioactive materials to benefit society.

REFERENCES

• Siegel JA, McCollough CH, Orton CG. Advocating for use of the ALARA principle in the context of medical imaging fails to recognize that the risk is hypothetical and so serves to reinforce patients’ fears of radiation. Medical Physics. 2016:n/a-n/a.
• Siegel JA, Pennington CW, Sacks B. Subjecting Radiologic Imaging to the Linear No-Threshold Hypothesis: A Non Sequitur of Non-Trivial Proportion. J Nucl Med 2017; 58:1–6.
• Doss M, Little MP, Orton CG. Point/Counterpoint: low-dose radiation is beneficial, not harmful. Med Phys. 2014; 41(7): 070601-1 – 070601-4.
• Calabrese EJ. On the origins of the linear no-threshold (LNT) dogma by means of untruths, artful dodges and blind faith. Environmental Research. 2015; 42: 432- 442.
• Bevelacqua JJ. Health Physics: Radiation-Generating Devices, Characteristics, and Hazards. Wiley-VCH, Weinheim (2016).

Cohen MD. Point: Should the ALARA Concept and Image Gently Campaign Be Terminated? Journal of the American College of Radiology 2016; 13(10): 1195-1198.

• Doss M. COUNTERPOINT: should radiation dose from CT scans be a factor in patient care? No. Chest. 2015;147(4)874:877.
• Sacks B, Meyerson G, Siegel JA. Epidemiology without Biology: False Paradigms, Unfounded Assumptions, and Specious Statistics in Radiation Science (with Commentaries by Inge Schmitz-Feuerhake and Christopher Busby and a Reply by the Authors). Biological Theory. 2016;1-33.

Author: Bill Sacks, Ph.D., M.D.

Retired physicist and diagnostic radiologist

To the Editor: This is a comment on the recent Point/Counterpoint debate published online regarding use of the ALARA principle in medical imaging between the two medical physicists, Jeffry A. Siegel and Cynthia H. McCollough (https://doi.org/10.1002/mp.12012).

Dr. McCollough begins her Opening Statement by referring to the ICRP’s principles for medical radiation protection, but offers them as though they were “The fundamental principles” without questioning them. The two ICRP principles are justification and optimization: first, that the use of any ionizing radiation must confer medical benefit, and second, that the lowest dose necessary for diagnostic quality must be used.

The justification is unarg