[Film leader] [Tone] [Film leader] [Tone] [University of Illinois, Medical Center Campus, Chicago Presentation] [X-rays... How Safe!!] [Narrator:] Studies have shownthat some cells and some organs of both humans and animals arehighly sensitive to radiation. Which cells and whichorgans can be most affected? X-rays How Safe. We'll answer those questionson today's Consultation. [Classical music] [Consultation] The University of Illinoisat the Medical Center Chicago brings you anotherprogram in this series and made possiblein part by a grant from GD Searle and company. Our guests from the Foodand Drug Administration are Dr. William Cole,associate director, Bureau of RadiologicalHealth, Rockville, Maryland, and Mr. JohnVillforth, director, Bureau of RadiologicalHealth, Rockville, Maryland. Moderator for thisprogram is Jack Righeimer. [Music, full then fades] [Jack Righeimer:] Welcome onceagain to Consultation. Fascinating program. I think all of us are goingto be very interested in or should be, if anyof us have ever had X-rays in the past year or so. This is a show which is goingto talk about that subject. As you heard, X-rays, how safe. Gentlemen, thank you forcoming from the Federal Drug Administration. We appreciate it. Mr. Villforth, let's-- X-rays, talking about thebroad subject of X-rays. That's very, very broad. What specifically are we goingto be talking about today? [Mr. Villforth:] Well,as you know, X-rays have been aroundfor a long time, and radiation has been withus in industry and university training programs andeducational efforts. But I think the most importantarea of radiation that we could talk about, the mostinterest to the public, is the one that concernsradiation in the healing arts-- X-rays used in diagnosis. This is a fascinatingsubject, one in which I think many of ourlisteners perhaps would appreciate understandinga little more about it. And I'd like to focus inon that particular subject, diagnostic X-rays. [Jack Righeimer:] We'll talkabout the medical aspect and the dental aspect. [Mr. Villforth:] Right,that's correct. Medical and dental. [Jack Righeimer:] OK. Could you definefor us-- we always do this on Consultation--could you define for us, what is radiation? [Mr. Villforth:] Well, it's alwaysa difficult subject to define, but in its simplestform, I think we can say that radiation isa form of energy in motion, and this energyin motion, when it passes through living material,the cells in our body, has the ability toaffect these cells, either rearrangethem, cause changes in the structure of the cell,or possibly kill the cell. And depending on theamount of radiation, quantity of radiation, andthe particular organs that are involved, the radiation cando various biological effects. And we all have differentsusceptibilities and responses to this radiation. [Jack Righeimer:] We're saying eachperson could relate differently to different radiations? [Mr. Villforth:] Depending on theorgans that are involved and the amount ofradiation, yes. [Jack Righeimer:] Dr. Cole,as Mr. Villforth said, X-rays, medicalX-rays, dental X-rays, this has been a thing with us. It's been with us for yearsand years and years and years and years and nobodyreally questioned whether there were any,in quotes, side effects, bad effects. Why all of a suddenare we concerned? [Dr. Cole:] Well Jack,we are concerned because in 1970, 108 millionpeople had one X-ray or more during that particular year. And as Mr. Villforthsaid, X-rays can produce somedamages to the body. And we divide this damagewhen it is produced-- and the risk is really minimal-- into what we callgenetic effects. The genetic effects arethose that will show up in subsequent generations. The ones that are of concernto the individual undergoing the X-ray examinationwe call somatic effects. These affects the body itself. For example, a woman undergoingan X-ray examination who is pregnant, the unborn childis more sensitive to radiation than, say, the mother herself. We are concerned about thistype of X-ray examination. We know that cells aredamaged by radiation, but we also knowthat cells recover. Some of their viability again,some of their normal existence after the radiation. One of the things thatreally bothers us most of all is what is the effectof low level radiation. That is, the type of radiationthat we get from the background and in particularfrom repeated X-ray examinations over the years. We really don't knowwhat the long term effect of this low level radiation is. For example, the questionof possible damage came up when Dr. Roentgenfirst discovered this modality when he must have had someconcern about possible damage, because the first X-rayfilm that was made was a film of his wife'shand rather than of his own. [Laughter] [Jack Righeimer:] Wouldn't eventake a chance himself. [Dr. Cole:] I guess not. I guess he decided that hewould have his wife's hand show up first. [Jack Righeimer:] Now, Ican understand when you mentioned using the exampleof a pregnant lady going in and having an X-ray becauseof the unborn child. Are we saying thereare certain parts of the body, certain organswithin the body, which can take X-rays betterthan other parts, therefore you can X-ray yourelbow 40 times more than you could your liver? I don't know, I'mjust using an example. [Dr. Cole:] That's right, Jack. Certain areas in certaincells of the body are more radiosensitive,that is they are damaged more easily andwith less amount of radiation than others. For example, we believe thatthe reproductive organs, or the gonads asthey're called, are more sensitive to the effectsof radiation than, say, the skin, for example. That doesn't mean that the skinis not sensitive to radiation, but less sensitive, let's say. The fetus, as I mentioneda moment ago, is certainly moresensitive to radiation, and at certain stagesof the pregnancy. In the first threemonths, we feel that the sensitivity is greaterthan it is in the last three months. [Mr. Villforth:] I thinkgenerally, Bill, we can say that themore rapid growing cells are the ones that aremore sensitive to radiation. This is why the skin is perhapsless sensitive than the blood supply system,which is a rapidly growing reproducing system. [Jack Righeimer:] Because we getradiation from the sun. [Mr. Villforth:] That's right. [Dr. Cole:] Naturalradiation we get. We speak of that asbackground radiation, Jack. We really live in a sea ofradiation to some extent. But today, of course,we're concerned about medical radiation. The second type of tissuethat we are concerned about is the bone marrow, where thered cells and the white cells are actually manufactured. The most sensitive cell, Ibelieve, is the white cell. This is the cell that reallyprotects us against infection. Or the thyroid gland inthe neck is another gland that we feel is moresensitive than other tissues. For example, weare concerned that the so-called annual routinefull mouth X-ray of the teeth possibly could exposethe thyroid gland, and we are concerned about that. And the lens of theeye is another organ that we're concerned about. It may be more sensitivethan other tissues. So that's about the differencein radio sensitivity. [Jack Righeimer:] OK, so there it is. So it's important toknow the part of the body that you are reallyX-raying and how often you should X-ray thatparticular part of the body. [Dr. Cole:] Yes. We think thatevery effort should be made to protect thereproductive organs in any type of X-ray examination. And this is very simply doneby the use of lead shields and the use of aproper technique, which we'll discuss a little later. [Jack Righeimer:] Now you'vebeen giving a case about the badness of X-rays,but X-rays must be good, because we've hadthem a long time and they do a wonderful thing asfar as diagnoses are concerned. So you better give theother side a little bit too. [Dr. Cole:] Well, I'm glad youasked that question, Jack. Because I personallyfeel that the benefits far outweigh the riskof this diagnostic test. For example, it's beencalculated that 70% to 80% of all the diagnoses thatare made in the United States today, either in the hospitalor in a doctor's office, are made or confirmed by theuse of X-ray examinations. For example, it wouldbe impossible to do any type of settingof fractures, for example, withoutthis modality. We calculate-- and I sawthis in one of our journals that there will be50,000 skiers who will have a fracture this year. This is just a small sample ofthe number of fracture cases that we see every year. Without X-ray, it would beimpossible to do and get a good result. [Mr. Villforth:] There's anelement of hazard, Jack, I think that I'dlike to mention, and that is the riskelement of radiation, and this is verydifficult to quantitate, but I think perhaps if I were touse the analogy with cigarette smoking, perhaps the viewerswould appreciate this. For example, weknow that radiation produces cancers, leukemias. It also wouldshorten our lifespan. We know that, forexample, cigarettes will increase the risk to cancer-- cancer of the lung. Now like cigarettes,we know that if we-- I mean, like insmoking cigarettes, we know that if wesmoke a certain amount, we may or may notget lung cancer. It's a risk. It's a risk that we,perhaps if we're smokers, are willing to take. Radiation risk is much the sameway, only the risk in this case may be imposed upon us by thephysician or the clinician. But the risks are statisticalor probabilistic as we say. For example, theamount of radiation that we might receive frommedical radiation, perhaps could increase the incidenceof certain diseases by maybe one in 10,000. That is, if 10,000people were to receive this particularX-ray, perhaps one might receive aparticular disease, a particular type of cancer. This is the order of magnitude. These are not specifics. But now if you look at thenumber of people in the United States receiving X-rays,and practically all of us, almost all 200 million ofus get it sooner or later. This means that one in10,000, times 200 million, it means that there'sprobably about 20,000 people in the United States who may begetting that particular disease or illness you see as aresult of the radiation. Whereas you as anindividual may only receive or have a probablechance of one in 10,000, which is a reasonable risk ifyou have a broken leg and are a skier asDr. Cole talked about. But when you use the totalpopulation of the United States, that means thereare perhaps 10, 20, or more thousand people with somesort of disease or illness perhaps caused by this radiationthat need to be treated. And I think that our job in theBureau of Radiological Health, the Food and DrugAdministration, along with our colleagues inthe state health departments and our colleaguesin the profession is to do the bestjob we can to keep the exposure from theseradiations as low as possible so that the risk is reduced. For example, if wecould reduce the dose to half of what itis today, we perhaps could cut that risk from onein 10,000 to one in 20,000. Instead of 20,000 peoplein the United States, maybe there's 10,000. In other words, thesaving of life or cancers of maybe 10,000 per year. [Jack Righeimer:] It is. Right. X-ray now has become a twoedged sword, good and bad. And it's up to an agencylike yours, Federal Drug Administration, toprotect us, the consumer. That's your job. I can't do that. It's up to you. Because I'm notqualified in that area. [Dr. Cole:] Jack,another example of what I considered a real benefitis in the use of pelvimetry. Pelvimety is anX-ray examination that is done on a pregnantwoman to find out whether or not she will be able todeliver the baby normally. Some years ago, this wasdone in approximately 20% of all the women that enteredthe general hospitals. Today that is less than 5%. So we feel that our effortsto educate the possible risk to the fetus have gone acrossthat this examination is now used in less than 5%. And also the physicians atordering this examination when it is really necessaryfor the safety and health of the childand the mother that we have advised that they havethis done in the last three months of the pregnancy. Because as I mentionedbefore, the fetus is less sensitive at that stage. [Jack Righeimer:] We're becomingmore sophisticated about X-rays and where they canbe used, when they can be used, why they can be used,and how they can be used. It's as simple as that. [Dr. Cole:] Right. [Jack Righeimer:] You useda term, and I think you'd better explain that. Low levels, highlevels, and all. And I'm a little confused. You said we're moreconcerned about low level. I would think you'd be moreconcerned about high level. [Dr. Cole:] Well, alow level radiation, as I mentioned, Jack, concernswith the type of X-ray examinations we arediscussing today. The diagnostic typeof X-ray examinations. This is low level radiation. [Jack Righeimer:] Oh, I see. Better semantics. [Dr. Cole:] Right. If we use X-ray in therapyor treatment of disease, this is consideredhigh level radiation. [Jack Righeimer:] Like cobalt. [Dr. Cole:] Cobalt, for example. Right. And where the dose ismeasured in thousands of rads, which is a term usedof the absorbed dose. So we're talking abouttwo different things. [Jack Righeimer:] The way Iassume the public can-- the public, we, consumer-- can get the minimum of riskand have the most benefit is by listening to and hopingthat what you are doing, the federal agencieslike the FDA is involved in working withthe physicians and radiologists so that we willhave a safer X-ray. [Mr. Villforth:] Our mainreason for existence is to reduce the unproductivequantity of X-radiation and optimize or get the mostbenefit out of the radiation that's used in diagnosis. [Dr. Cole:] Jack, if I couldhave that first slide, I think I might make apoint here on the benefits. [Elements of an X-ray slide] Now there are threeparts to this. The first is the soundmedical judgment. The second is goodradiographic technique. And the third isX-ray equipment. I will discuss themedical judgment and leave the other twoup to Mr. Villforth. Now in the taking ofan X-ray, a judgment has to be made by thepatient's physician as to whether or not thisexamination is indicated. [Jack Righeimer:] If it's necessary. [Dr. Cole:] Is it necessary? Correct. This is determined by thephysician's experience, by his educationin medical school, by efforts of agenciessimilar to our own, as to what are the indicationsfor this particular type of examination. So the firstdecision is made when an examination isto be done is made by the referring physician. And we call thismedical judgment. The type of examinationthat we don't like to see is when an X-ray examinationis done in a sense by or ordered by aphysician to protect himself from possible litigationat a subsequent time. The exact number of thesecases, how many of them are done in a yearis not really known. But we know that itis really too high. This is particularly truein various and sundry type of fractures. [Jack Righeimer:] In otherwords, what you're saying, it's the physician'sresponsibility to say that X-rayis important to have because I have to find outwhether or not this really is the problem. [Dr. Cole:] That's right. But as I said, alltoo frequently, he feels that ifhe doesn't repeat this examination at certain ormaybe too frequent intervals, such as a fracture of anankle in a cast, that it's possible it may besomething will slip and he later might be upfor possible malpractice litigation. So too frequently,these examinations are ordered for that purpose. This in our opinionis unnecessary. [Jack Righeimer:] I don't want peoplegoing to their physicians and have the broken legand he took two X-rays, and Dr. Cole said, hey, you'reonly supposed to be taking one. We got to clarify that. There may be a reason fortaking the second X-ray too. We're just saying ifthat is in the intention, the mind of thephysician, that's not the proper way of using X-rays. [Dr. Cole:] That's correct. Another one thatwe worry about too is when a patientor an individual makes a decision himself tohave an X-ray examination. We call this self referral. For example, ifan individual sees in the parking lot of theshopping centers the TB vans, he might be tempted togo in and have an X-ray examination of his chestwhen actually there's really no indicationthat this should be done. We feel that only thistype of examination should be done is when thereis a sound medical indication. [Jack Righeimer:] Yourphysician orders the fact that you need a chest X-ray. [Mr. Villforth:] I think it'simportant, Dr. Cole, to point out that thesechanges in judgmental factors are coming about mainly throughthe work of the professions. They're involving theeducational institutions to incorporate thesechanges, and you may mention a bit aboutthe pediatric fluoroscopy. I think this is a ratherdramatic example of changes that have taken place. [Dr. Cole:] Very good, John. Some years ago, Jack,it was almost a routine for a pediatricianto fluoroscope a child or aninfant on the table, just to check thesize of the heart, to check the expansionof the lungs. Well-- [Mr. Villforth:] Excuse me, I mightinterject that fluoroscopy delivers a much higher exposureto the individual than just regular radiography. So this is quite concern whenfluoroscopy would be used. [Dr. Cole:] This wasbrought to the attention of the pediatricians,and it was cranked back into the medical schoollevel that just what can you obtain from thistype of examination using the fluoroscope,and subsequently the American Academyof Pediatrics issued a statement to cautioningall pediatricians to only use this when it isabsolutely indicated, and where possible to use aX-ray film examination where the dose is much less thanit is with fluoroscope. With this type of thing thatwe think through education that we are making our point. [Jack Righeimer:] All of us,more and more educated. I've got to getto the technician. [Mr. Villforth:] I was goingto say, this ties in very nicely to thequestion of technique, because we're talking also abouttechnique and judgment that were used in thisparticular procedure. [Jack Righeimer:] What happens,if the physician makes a proper judgment, and we'regoing to assumption because I'm with physicians allthe time, therefore they make proper judgment. And they go on andmy technician maybe zaps me a little bit too much. That's a possibility, you know. I don't know. How do I know? [Mr. Villforth:] It'ssort of like you're deciding to take a picture ofyour child with your camera and that's your first judgment. The second pointof technique, you find out you left thelens cap on the camera or you have to retake the film. So our concern here is that theindividuals who are actually adjusting the machine, makingthe settings on the machine, and processing the film usethe best information to get the best quality radiograph. And all too frequently,we find that there's much room for improvement. You see there's probably 100,000technologists or technicians in the country who areresponsible for taking the X-rays. Most of these are notphysicians or technicians, and there's no real requirementin education for these. Only three statesright now have any sort of licensure laws forthese individuals. This means that in manycases, the individual may walk in off the streetand be activating the machine. So our concern is-- and one of the thingswe've been doing in the Bureau ofRadiological Health-- has been to place attentionat the educational levels, continuing educational levels,working with the states and the state societies oftechnologists to improve this. Yes. There are certain thingsthat we would emphasize. For example, making theproper selection settings on the machine justlike in your camera. If you decide totake the picture, you've got to make the properadjustments or the exposure's incorrect. And if the exposure'sincorrect, it may mean the film wouldhave to be taken over again. The picture would haveto be taken over again. Secondly, like in photography,if the film isn't processed properly, you may also havean ineffective picture. [Jack Righeimer:] So you'reupgrading action. [Mr. Villforth:] Yes. And then thirdly isanother interesting area. It's a process wecall collimation. Collimation is thatdevice or mechanism that we use whichlimits the X-ray beam to just the size of the film. Now if I could havethe first slide, I think that you'll be ableto see that on that slide, the top picture shows what wefacetiously call wall to wall radiography where the techniciandoes not bother to make the proper adjustmentsof his X-ray beam, and the beam covers all ofthe vital organs of the body in addition to the film. And of course that radiationwhich doesn't strike the film not only destroys some ofthe quality of the film but also has a riskof biological damage. So what we try toencourage is the technician to restrict the area of the beamto the same size of the film as shown in the bottom slide. [Jack Righeimer:] Right. In other words, just thatpoint you want X-rayed. [Mr. Villforth:] Right. [Jack Righeimer:] Usingyour same analogy, a little further aboutthe camera and so forth. What if my camera is lumped up? In this case, what if theequipment is lumped up? [Mr. Villforth:] That's the thirdpoint in the list of the three that we had on ourfirst slide, and I think this is extremelyimportant because here is an area where we have madesome considerable progress over the past few years. And I say we, I mean both theBureau of Radiological Health but perhaps more significantlyour colleagues in the state radiological health programsand certainly our colleagues in the profession,because here we can really place a lot ofcredit for the improvement. The equipment has beeninspected in most cases and is being inspectedto date by the state. The federal government has noauthority to inspect equipment in physician's offices. Now what we do have underthe recently passed Radiation Control for Healthand Safety Act is the ability to setperformance standards for new equipment, andwe have established performance standards. These were publishedin August of 1972 and will be effective forall new X-ray machines being manufactured after August 1974. This means all the X-rayequipment must meet certain performance standards. And if I may mention of theprevious slide of collimation, we have incorporated intothis performance standard a requirement that thistype of collimation be mandatory for new equipment. So that we hope thatwe will eliminate all of the extraneousradiation that was shown in the topof the previous slide. [Jack Righeimer:] So whatyou're saying, really, gentlemen, is the fact that nowyou've made a case for X-rays and the problems ofX-rays and the fact that there is somedanger but we're working towards the right end,and things are becoming much better and you're having certainprotective devices employed so that we the publicshouldn't be that scared. I don't want people togo around being scared. And one way we can stopthem from being scared, too, besides listeningto this program, I have some materialI can give away. And not I but the FederalDrug Administration is so happy to give this away. I don't know ifyou can see this. It's called-- oh,that's good, Jack. Look at that, right up. Radiology Health Protection andConsumer Radiation Protection. I'd be most happy to send boththese, both, to you, if you will write to us in thecare of Consultation, the University of IllinoisOffice of Public Information, post office box6998, Chicago, 60680. And you can get both copiesof these two pamphlets will give you an ideaof what is going on and what your FDA is doing foryou and why they're doing it. We only have about threeminutes left, gentlemen. And that's the reasonI thought I just wanted to say kind of sumup a little bit at the end there saying that you've madein the beginning kind of made a case to scare the heck out ofall of us that X-ray is coming and we're going to be worriedabout this and vital organs. And then you wenton, it was very good. You kind of refuted a lotof the things along the way. [Mr. Villforth:] To your questionabout the beneficial effects of radiation, of the diagnosticX-rays as Dr. Cole indicated. And the trend in the future isgoing to be, I'm sure, greater. Our data from thestudies that we've done show that theincreased radiation is being used at everincreasing amounts and hopefully for thebetterment of mankind. But at the same time,we must be concerned about this element of risk. And I think if I hadone point I would like the viewers to appreciate,its the fact that we do have an effectiveprogram, we do have an agency at the federallevel, and most of the states are involved at the state levelin doing something about this. Keeping this into perspective. We also are working withthe professional groups to bring the excessiveamount of radiation under some degreeof control, and I think we can be rather proudof the accomplishments that have been made to date. [Jack Righeimer:] Justone quick question. Dr. Cole, youindicated something about the mobile X-ray. It is not a good thing for us asindividuals to go in and select and say I want a chest X-ray. This should be leftup to your physician. [Dr. Cole:] Jack, thedynamics of tuberculosis have changed over thelast 25 to 30 years. And in some areasof the country, tuberculosis isalmost nonexistent. And it is for thisreason that people who themselves walkinto these vans and have an X-rayexamination, we think this is unnecessary X-rayexposure of that individual. And we issued a policy statementin February of this year recommending thatthis type of X-ray surveys of the generalpopulation be discontinued. Now the National Tuberculosisand Respiratory Disease Association in New York came outwith the same policy statement. So in a sense, weare recommended that this type ofsurvey be discontinued. [Mr. Villforth:] I think it'salso important to point out to the viewers that generally,the type of equipment that's used in these vans resultsin much higher exposure than the same kindof a procedure used in a hospital or aphysician's office. Perhaps as much as 10 to 100times more exposure than you would get for the same typeof diagnostic procedure in an office. Just by the natureof the equipment that's used inthese mobile units. [Jack Righeimer:] To get back to youthree points, the physician, the judgment, andthe type of equipment used and the technician. [Mr. Villforth:] And all ofthese come together. [Jack Righeimer:] Gentlemen,thank you very much. I want to thank you,ladies and gentlemen who watch Consultation. I hope that you've learnedsomething from this, know a little bit more about X-rays. Till we see you againon Consultation, the best of health. [Classical music] [X-rays... How Safe!!] [Narrator:] X-rays How Safe hasbeen a program in the series Consultation-- presented bythe University of Illinois at the Medical Center Chicagoand made possible in part by a grant from GDSearle and Company. Our guests from the Foodand Drug Administration have been Mr. John Villforth,director Bureau of Radiological Health, Rockville, Maryland,and Dr. William Cole, associate director, Bureauof Radiological Health, Rockville, Maryland. Moderator for thisseries is Jack Righeimer, coordinator of publicservice radio and television programming. This is Frank Sweeney. [Classical music] [Produced by: F. Keith Fearon] [Directed by: Sam Ventura] [Directed by: Sam Ventura] [Program organizer: Dr. Dorothy Dunn] [Program consultant: Donald C. Healton] [Production coordinator: Gloria Blasz] [Executive producer: Jack Righeimer] [Production Facilities, WFLD-TVField Communications] [University of Illinois at the Medical Centertv network, Univ. of ILL c 1973] [Fade to black] [Narrator:]The preceding programwas planned in cooperation with the Department ofHealth, Education, and Welfare Food and Drug Administration. [Fade to black] [Tone] [End film leader]