According to the statistics presented by the World Health Organization (WHO), with around 7.4 million deaths (around 13% of the total death) in 2004, cancer is the leading cause of death throughout the world (WHO, 2009). These levels are expected to rise further in future, 'with an estimated 12 million death in 2030' (WHO, 2009). There are more than 100 different types of cancer (Crosta, n.d.), among them the Lung cancer, stomach cancer, colorectal cancer, liver cancer and the breast cancer are the most common types. Tobacco is the most important risk factor for cancer, with nearly 1.3 million deaths per year just due to lung cancer alone (WHO, 2009).
At the primary level, human body consists of large number building blocks, called the cells. Under normal circumstances, new cells are formed by the body depending on the body requirement, in order to replace the dead cells. But sometimes, under abnormal conditions, there is an exponential (uncontrolled) increase in the formation and growth of new cells. The accumulation of these extra cells forms mass or lumps of tissues, called the tumor (National Cancer Institute, 2010). Most of the cancers, in general form tumors, but there are certain exceptions, like leukemia, that do not form tumors (in leukemia or blood cancer, the cancer cells hinder the normal blood functions due to abnormal cell disintegration in the blood stream (Crosta, n.d.)). The tumors can be of two types; benign tumor and malignant tumor. The benign tumors do not propagate to other sections of the body and have restrained growth (Crosta, n.d.), whereas the malignant tumor cells have the ability to invade into the surrounding tissues. Also the malignant tumor cells can escape from their initial location and spread to other sections of the body through blood or lymph. Only the malignant tumors are cancerous in nature. Therefore, the cancer has three distinctive properties that distinguish malignant tumors from benign tumors:
- Uncontrolled growth
- Invasive nature
- Metastasis (ability to spread to other sections of the body)
- Biological carcinogens, like certain bacteria, viruses or parasites.
- Physical carcinogens, which includes the high energy radiations (ionizing radiations).
- Chemical carcinogens, these include substances like tobacco smoke, arsenic (water contaminant), aflatoxin (food contaminant), asbestos etc.
These disorders in cells are the result of the interaction between the genetic factors and external agents (which are called carcinogens) (WHO, 2009). The carcinogens can be categorized as (WHO, 2009):
Another factor essential in the development of cancer is the age. According to the studies conducted by the Cancer Research UK, the risk increase predominantly with increasing age, with nearly 74% of the cases of cancer diagnosed in people aged 60 and above (Cancer Research UK, 2009).
Cancer Treatment Principle
In case of normal cells there is specific pattern of growth, division and death (orderly destruction of cells is called apoptosis) (Crosta, n.d.). It is known that the cancer is the result of the uncontrolled growth of cells which do not die (Crosta, n.d.), that is, the apoptosis process fails in the cancer cells. The cancer cells thus do not die and rather continue to grow, resulting in the formation of tumors. As the problem in the cancer cells lies in the DNA, therefore a possible treatment of cancer is the destruction of the DNA in cancer cells, leading to a self initiated destruction of the cells.
There are various methods used for the treatment of cancer depending upon the type of cancer. The most common types of treatment are (Fayed, 2009):
- Radiation therapy or Radiotherapy
- Biologic or Targeted Therapy
Radiotherapy, also referred to as radiation therapy, is one of the most common types of treatments used for cancer. It is the utilization of higher energy radiations like x-rays, gamma rays in order to kill cancer cells, treatment of thyroid disorder and even some blood disorders, in a particular section (effected part) of the body (Nordqvist, 2009). The high energy ionizing radiations can be produced using a number of radioactive substrates like 'Cobalt (60Co), Radium (228Ra), Iodine (131I), Radon (221Rn), Cesium (137Cs), Phosphorus (32P), Gold (198Au), Iridium (192Ir), and Yttrium (90Y)' (Howington, 2006).
The cancer cells have the ability to multiply faster than other body cells. The high energy ionizing radiations are more destructive towards the faster growing cells, and thus they damage the cancer cell more than the other body cells (Mason, 2008). These high energy radiations like gamma rays and x-rays; especially damage the DNA inside these cancer cells (or tumor cells) thereby annihilating the ability of the cells to reproduce or grow. Apart from treatment of cancer, radiation therapy is also used to shrink a tumor before being surgically removed (Mason, 2008).
Depending upon the method of irradiation, the process of radiation therapy is categorized into two forms (Mason, 2008):
External RadiotherapyIn this method (more common), the infected part of the body (tumor) is irradiated by high energy x-rays from outside the body.
Internal RadiotherapyFor this method, a radioactive substance are injected (or taken orally) into the body (close to the tumor) in the form of fluids. These substances, taken up by the cancer cells, radiate the tumor through internal beam radiation (or interstitial radiation) (Mason, 2008).
A careful planning is essentially required for radiation therapy, as over exposure can be critically dangerous to healthy tissues in the body. The ionizing radiations have side effects, therefore once the full dose of radiations is decided; the patient is given these radiations in the form of small doses in a series of therapy sessions (Cancer Research UK, 2009). Each small dose of radiation is called a 'fraction'. The gap between sessions provides the recovery time for the body, which may depend on the type of cancer and patient's health condition.
The area of the body that is radiated during the treatment is called the 'radiotherapy field' and the section inside the body that experiences the maximum exposure dose is called the 'target volume' (Cancer Research UK, 2009). The doctors decide the marginal area around the tumor that should be radiated to encapsulate any movement of the cancer cells. In order to accurately determine the position of tumor (or 'target volume'), body scans are done. Computed Tomography (CT) scans are done as a planning procedure, this provides vital information regarding the location of the tumor as well as the kind of treatment required by the patient (Cancer Research UK, 2009).
The radiotherapy treatment planning process can be divided into 6 major steps .
Computer Tomography (CT) Scan
The invention of Computer Tomography (CT) scanned is credited to Sir Godfrey Hounsfield in early 1970s, for which he along with Allen Cormack, was awarded the Nobel Prize in 1979 (Smith, n.d.). A CT scanner, also known as the Computed Axial Tomography (CAT) scanner uses X-rays to produce cross sectional images (or slices) of the body like a slice in a loaf of bread (FDA, 2010). The word 'tomography' suggests 'the process of generating a two-dimensional image of a slice or section through a 3-dimensional object (a tomogram)' (Nordqvist, 2009). These cross-sectional slides render an accurate picture of the size and location of the tumor along with the position of major organs in the body (Cancer Research UK, 2009). This would be essentially useful during the radiotherapy process, where these can be used to lower the dose of radiations on the organs.
It is known that in case of radiation therapy treatment, the doses are given in fractions over a certain period of time (to prevent major side effects), which may vary from few weeks to months. Thus, before each fraction of radiation dose, computed tomography (CT) scan of the patients is done to determine the exact location of the tumor or cancer cells. So in case the full dose has been divided into 30 fractions, then the patient has to undergo 30 CT scans, each before a fractional therapy.
The machine used for the radiation therapy planning is known as the 'simulator' (Cancer Research UK, 2009). The simulator identifies the position of the tumor and marks the position of radiation on the body with the help of light rays. The radiographer uses ink markers on the body before the actual radiotherapy is begun. These linear ink marks are used by the radiographer for positioning the machine for radiotherapy (Cancer Research UK, 2009). Simulators take the pictures (CT scans) in the form of X-rays, which locates the accurate tumor position for the radiographer to carry out the treatment. During a CT scan, it is essential that the person remains completely still so that the measurements are accurate. In order to insure the correct position supports like neck rest, chest board or arm pole are used (Cancer Research UK, 2009). In case of children it is ensured by giving proper sedatives.
Sometimes, under critical condition, extra measures are taken in order to prevent essential organs from being radiated during the therapy. These measures include injecting fluids or dyes which mark the position of vital human organs in the CT scan (Cancer Research UK, 2009). These markers may be given orally, through injections or rectally depending upon the requirement. Using this vital information from the CT scans, a treatment plan for radiation therapy is prepared. This plan indicates the position and direction of the radiations during the therapy, so as to minimize the exposure of healthy cells and organs.
The scans generated by a CT scanner are in the form of 2 dimensional (2-D) slides, but by the used of digital geometry processing they can be used to generate a 3 dimensional (3-D) images of the body (Nordqvist, 2009). This can be achieved by integrating all the slides (along the same axis) together using a computer system.
The CT scan can be understood as a technically advanced format of X-rays machines. The x-rays images are produced by the projection of a broad beam of x-rays on a film after passing through the body (Medindia, 2010). It provides a 2-dimentional projection of the body, where much of the information is lost. In case of CT scan, a thin beam of x-rays is absorbed by the detector after passing though the patient's body (Medindia, 2010).
Like the x-ray process, the CT scanning is a painless process for the patients but has been known to be accompanied with some side effects. These side effects may vary from the patient to patient depending upon the amount of radiation dose and health of the patient. The detailed discussion on the health effects of CT scanning has been discussed in the later sections of the project.
In order to understand the working of a computed tomography (CT) scanner it is essential to understand the properties of ionizing radiations (X-rays) used in the scanning process. The electromagnetic radiations are the arrangement of electric-field and magnetic-field vectors perpendicular to each other and also perpendicular to the propagation direction of the wave (Resnick et al., 2009). These Electromagnetic radiations have penetrating powers, which are directly dependent on the energy (or frequency) of these radiations. So that radiations with higher frequency have higher penetration powers. Therefore, on the basic the energy, the electromagnetic radiations are categorized as Non-ionizing radiations and Ionizing radiations.
Non-Ionizing radiations refer to the electromagnetic radiations which have energy lower than that required for an atomic ionization (MIT, 2001). The non-ionizing radiations include radio waves, micro waves, visible light etc. These radiations have lower penetration powers. Alternatively the Ionizing radiations are the high frequency radiations which have enough energy to knockout an electron from an atom and thus causing ionization (MIT, 2001). The Gamma rays and X-rays are the common type of ionizing radiations. Even the alpha particles and beta particles emitted in a nuclear reaction are ionizing radiations (MIT, 2001). Due to the higher energy they have higher penetration power than the non-ionizing radiations.
Principle of CT Scanning
The most important section of a Computed Tomography (CT) scanning is the interaction of the ionizing X-ray radiations with the living tissues in the body. When the ionizing radiations (X-rays) interact with the living tissues in the body, they break up atoms and molecules from the living tissues and disrupt chemical reactions within the body (Zamanian & Hardiman, 2005). The intensity of absorption of the x-ray radiations by the body varies depending upon the tissue coming in interaction. Different body tissues have different absorption power, where some are permeable to x-rays others are impermeable (Medindia, 2010).
It is due to this difference in the absorption ability of different sections of the body, which results in the generation of a graded pattern in the scans. High density tissues like the bones appear white in the scan while the soft tissues (like brain and kidneys) appear dark. The cavities (like the lungs) are seen as black sections in the scan (Medindia, 2010). Therefore, this gradation in the pattern can be used as method to distinguish different body organs depending upon their absorption capacity. This forms the basic principle behind the working of an X-ray scanning.
Radon (1917) was the first to develop the principles of computed tomography (CT) mathematically (Bushberg et al., 2002). According to Radon, with the help of infinite number of projections through an object, it could be possible to produce an image of an unknown object. In case of film imaging (as in conventional X-rays), a two-dimensional (2-D) projection of the body is generated on the film. Due to this, details in the dimension of the body along the direction parallel to the x-ray beam are lost. In order to overcome this drawback (only up to a certain level) projections can be taken along two directions; 'posteroanterior (PA) projection and lateral projection' (Bushberg et al., 2002) (as shown in Figure 4). Increasing the number of scans improves the amount of information but in critical and complex cases where much more details are required. For these critical cases, CT scan is done.
The CT scan provides the tomographical image, which is the picture of patient's body in the sections or slabs. The thickness of these uniform slabs may vary from 1 millimeter to 10 millimeter (Bushberg et al., 2002), according to the program, depending upon the requirement. Each CT image consists of an array of large number of pixels forming a two dimensional (2-D) image, which corresponds to the same number of three dimensional thin rectangular slabs called the 'voxel'. The voxels are the volume element whereas the pixels are the picture element (Bushberg et al., 2002).
Every ray from the X-ray source passes (transmits) through the patient before the transmission measurement is done by the detector. Intensity of the un-attenuated x-ray radiation emitted by the source is Io whereas the intensity of the attenuated radiation after transmitting through the patient is given as It. The intensities Io and It are related by the equation (Bushberg et al., 2002):
µ is the total linear attenuation coefficient of the tissue (Smith, n.d.).
t is the distance travelled by the radiation in the tissue i.e. the tissue thickness.
The coefficient µ is dependent on the atomic number and electron density of the tissues (Smith, n.d.). Higher the atomic number and electron density of the tissues, higher would be the attenuation coefficient (Smith, n.d.). This form the basic principle of CT scanning, that different tissues have different level of attenuation properties depending upon their atomic number and electron density. For every measurement, the overall attenuation coefficient is calculated using the above equation.
During a complete 360o scan, various transmission measurements for the intensity of X-ray photon are done. Using these intensity measurements specific attenuation values are allotted to every voxel (volume element). These attenuation numbers are directly proportional to the linear attenuation coefficient. The average of these attenuation values is called the CT number (Smith, n.d.). These values can be arranged on a linear scale, the units of which are called the Hounsfield units (HU).
The scale for modern CT scanners varies from approximately -1,000 to 3,000 HU. The attenuation scale is based on binary system and therefore the exact values range from -1,024 to +3,071, with a total of 4,096 (or 212) attenuation numbers. Here, the lower represent the black section while the higher values represent the white section of the CT image. On this scale the attenuation value of water is zero HU and that of air is -1,000 HU (Smith, n.d.). Both of these values act as the reference points.
Construction of a CT scanner
CT scanner is a complex machine, but the basic structure is simple. A common CT scanner has been shown in Figure 2. Two most important parts of a CT scanner are the X-ray source and detector. The source and detector are placed in a circular structure, which has a shape similar to a 'doughnut'. This doughnut shaped circular opening is called the gantry (RadiologyInfo, 2009), with an inner (opening) diameter varying from 60 cms to 70 cms. The X-ray source and detector are placed exactly (diagonally) opposite each other, so that the radiations emitted by the source pass through the body and the transmitted radiations are measured by the detector.
The x-ray source and detector system in the gantry is motorized to rotate around the patient for measurements in different projection angles. The rational speed of the system is adjusted according to the detectors ability to measure and convert the x-ray beam into electronic signal. Cobalt (60Co) is generally used as the source of x-rays in the CT scanners. The detector used in CT scanner consists of an array of detectors in a slightly curved shape (like a banana). This curved shape is especially useful in fan-shaped beam projects.
Two types of detectors are generally utilized in the CT scans; solid state or scintillation detector and Xenon gas detector (Reddinger, 1997). But the solid state detectors with scintillators like Cadmium Tungstate (CdWO4), yttrium, gadolinium ceramics etc are commonly used (Bushberg et al., 2002). The principle of the scintillation detector is that, when it is struck by a x-ray photon, it produces light. This light signal is then transformed to electrical signal with the help of photodiode. The Depending upon their structure, the detectors are categorized into two categories; single detector array and multiple detector array.
Another essential part of a CT scanner is the motorized examination table. The table is controlled to move in and out of the gantry during the scanning process. As the position of the x-ray source and detector is fixed therefore the section being scanned is controlled by the movement of the examination table. For a better scan it is necessary that the patient remains completely still. To insure this table is equipped with 'neck rest, chest board and arm pole' (Cancer Research UK, 2009).
The detector measures the intensity of the radiation and converts them into electrical signals. These raw signals are analyzed and manipulated by the computer to convert them into images which can be understood by the radiologists and the technicians. Multiple computers are required in a CT scanner. The main computer that controls the operation of the entire system is called the 'host computer' (Imaginis, n.d.). The computers and controls are located in a room adjoining the scanning room. This prevents the technicians and the radiographer from exposure to x-rays.
Scanning Procedure in a CT scanner
Initially the patient is positioned on the examination (or scanning) table in a flat upright posture (face towards the roof). In order to insure the correct and stationary position, straps and pillows may be used along the body. Once the patient is correctly positioned on the scanning table, the motorized table moves the patient into the circular opening of the CT scanner (FDA, 2010), which the x-ray radiations are projected on the patient from the scanning.
For a particular position of the x-ray source and detector, the rays from the source pass through a region called the 'projection' or 'view'. There are two different types of projection geometries that are used in CT scanning; 'parallel beam geometry' and 'fan beam geometry'. In the parallel beam geometry, the rays projected on the patient are parallel to each other whereas in fan beam geometry, the rays diverge from the source in the shape of a fan (Bushberg et al., 2002) as shown in Figure 7. The fan beam projections are the most commonly in used x-ray projections in the CT scanners.
The X-ray tube is attached with a collimator which controls the thickness of the fan beam. This thickness (of the fan beam projection) determines the width of the tissue slide in the scanning process. It is through the collimator that the slice thickness is varied between 1mm to 10mm (Smith, n.d.).
The x-ray source and detector rotate around the patient (for imaging) in a circular motion such that they always remain exactly (diametrically) opposite to each other (as shown in Figure 7). During the rotation the source keeps emitting x-rays which are attenuated after passing through the patient. For a single projection (or slice), the x-ray source and detector make a complete 360o rotation around the patient. During the rotation the detector takes a large number of snapshots of the absorbed X-ray beam at different projection angles. A single image may involve approximately 800 rays and there can be up to 1,000 different projection angles (Bushberg et al., 2002). Therefore for a single projection (one slice), the detector does nearly 800,000 transmission measurements (Bushberg et al., 2002). The scanning of a single projection generally takes around 1 sec (for axial CT scanners) (FDA, 2010).
Once all the transmission measurements (complete 360o) for a projection (or slice) are completed, the motorized table moves along the axis of the gantry so that the next slice of tissues forms the projection view. The process is continued till the complete required section of the body has been scanned. In the traditional CT scanners, the table moved on to the next projection ('slice') only when the scanning of the previous was completed. Such conventional type of scanning is called the 'axial' scanning. But in modern CT scanners, called the 'helical' or 'spiral' CT scanners, the rotation of the x-ray source and detector is accompanied with the uniform movement of the examination table, thus producing a helical projection. The helical CT scanning has been shown in Figure 9. These modern helical CT scanners are much faster than the traditional scanners due to continuous scanning process. They have been reported to take nearly half the time for scanning as compared to the traditional CT scanners.
In order to analyze and study the cardiac structure which is under constant motion, even helical CT is ineffective. For such applications a special CT scanner with an 'exposure time of 50ms and a maximum exposure rate of 17 images per second' are used (Smith, n.d.). These scanners, called the 'cine CT', freeze the cardiac motion due to extremely low exposure time resulting in a sharp image (Smith, n.d.). These scanners use electron beam to generate x-rays, thus are also known as Electron Beam Computed Tomography (EBCT).
In the CT scanning process large volume of data and operations are required to be processed, which is achieved with the help of multiple computers. The detector converts the intensity measurements of the attenuated x-rays in to electrical signals. The main computer, called the 'hub computer' processes these signals and converts them into an image. These images can then be analyzed for radiotherapy planning.
Computed Tomography (CT) has become an invaluable medical tool. It provides detailed 3-D images of various sections of the body like pelvis, soft tissues, lungs brain, blood vessels and bones (Nordqvist, 2009). Generally, CT scanning is the preferred method of diagnosing different types of cancers like liver, lungs and pancreatic cancers (Nordqvist, 2009). The tomographic images produced by the CT scan provide specific location and size of the tumor along with the details of affected tissues in the proximity of the tumor. This is especially advantageous in planning, guiding, and monitoring therapies like radiotherapy (FDA, 2010).
CT scanning has various benefits over other traditional diagnostic techniques; some of the benefits are (RadiologyInfo, 2009):
- It is non-invasive, painless and extremely accurate.
- A major advantage is the ability to identify and distinguish bones, soft tissues and blood vessels in the same image. It also provides real time images which cannot be done in conventional X-rays.
- This technique is fast and simple; and is extensively used to locate internal injuries after accidents.
- It is less sensitive towards patient movement as compared to MRI.
- CT scanning can be used on patients with medical implants unlike the MRI.
For an effective radiation therapy treatment, it is necessary that only the tumor is irradiated while minimum damage occurs to the surrounding health (normal) body tissues (Badcock, 1982). This is achieved with the help of CT imaging technique. In a study by Badcock (1982), 186 patients with various malignancies were studied and it was found that in nearly 39% of the treatment cases CT scanning was valuable in the assessment of the radiationdose calculation (Badcock, 1982). According to his study, CT scanner resulted in an alternation in target dose by more than 5%, (as compared to the traditional methods) in 27% of the patients (Badcock, 1982). The result has been shown in the table below.
The mean alternation was 6.5% of the target dose and usually resulted in reduction of dose per fraction by factors upto 35% (Badcock, 1982).
Even with these advantages, the adverse affect of the ionizing x-ray radiations cannot be neglected. Various experiments and researches have consolidated the fact that ionizing radiations like x-rays, gamma rays etc have adverse effect on living tissues. Zamanian & Hardiman (2005) have explained that when high energy ionizing radiations interact with living tissues they strip-off atoms and molecules from them. This disrupts the chemical reaction within the body and failure in organ functioning (Zamanian & Hardiman, 2005). The adverse effects of ionizing radiations were seen shortly after its discovery in 1890s, with a scientist involved in the study of radioactivity were reported with skin cancer in 1902. But is was not until 1944, that the role of radiations in causing leukemia in human was first documented, mainly in radiologists and physicists (Zamanian & Hardiman, 2005).
In recent years the use of x-rays has extensviely increased in medical field for diagonostic and treatment application. According to the U.S. Environmental Protection Agency, X-ray deveices are the largest source of man-made radiation exposure (US_EPA, 2007). According to NCRP Report No. 160 (2006), 'the average annual effective dose per individual in the US population, from all sources has increase from 1.7mSv in 1980s to 6.2mSv in 2006'. This increase is mainly attributed to the striking growth of high dose medical imaging procedures that utilize x-rays and radionuclides (NCRP, 2008). Such man-made devices include X-ray machines, CT scans etc. CT scans, especially result in high dose x-ray exposure, with nealy 100 times the exposure dose as compared to standard x-ray equipments (Coach, 2008).
Some of the major risks associated with CT scanning are:
- It is well documented that ionizing radiaitons like x-rays have the ability to cause cancer on exposure. Therefore, the CT dose in radiotherapy increase the probabilty of cancer in the future.
- Even though only 4% of the total x-ray examinations are CT scans, they account for more than 20% of the radiation dose to the population by medical x-rays (King Saud University, 2004).
- In general, the effective dose in a CT scan procedure ranges from 2 mSv to 10mSv, which is nearly equivalent to the amount of radiation that a person receive from the background exposures in three to five years (RadiologyInfo, 2009).
- A CT scan during preganacy make cause serious illness or even birth defects in the unborn baby (FDA, 2010).
- Children are more sensitive and vulnerable to x-ray exposures than the adults, therefore their CT scanning should be done only under extremely essential and necessary conditions.
- Women have higher risk of developing cancer in the lifetime, as compared to men under same levels of exposure (FDA, 2009).
In some rare situation of high-dose prolonged radiation exposure, the x-rays can cause adverse effects like 'skin reddening (erythema), skin tissue injury, hair loss, cataracts' etc (FDA, 2010).
In a study, Sawyer et al (2009) estimated the effective dose resulting from a cone beam CT scanning for planning of radiation therapy using thermoluminescent dosemeters (TLDs) for organ dose and using International Commission on Radiological Protection (ICRP) 60 tissue weighing factor (Sawyer et al., 2009). The results obtained for effective dose from TLD measurements and ICRP 60 weighting factor, for breast, pelvis and head simulation have been shown in the table below.
The scanning process results in the exposure of the normal tissues outside the treatment volume (Waddington & McKenzie, 2004). It is thus important to analyze the effect that the irradiation caused by the CT scanning process has on the patient's body. In a study, Waddington & McKenzie (2004) analyzed the propability of developing cancer from the irradiations caused by the extended field portal imaging techniques, the results of which are given in the table below (Waddington & McKenzie, 2004). In order to illustrate a real life situation, the calulations in the study were done for an average man with a height of 170 cms and weight of 70 kgs (Waddington & McKenzie, 2004). Therefore, these values may change depending upon the height, weight and tumor size of the patient.
Various studies have been done to statistically evaluate the effect of the ionizing radiations on the human health. These risks have severely amplified due to the rapid increase in the number of CT scans for diagnostic applications. CT scans form nearly 5% of all procedures used in diagnostic radiology in the developed countries (Wrixon et al., 2004). In U.S., nearly 70 million CT scans were done in 2007 as compared to just 3 million done in 1980 (Steenhuysen, 2009), this includes more than 4 million children in 2006 (Brenner & Hall, 2007). Thus, according to the NCRP Report no. 160, the average radiation dose per person has increased from 3.6 mSv in early 1980s to 6.2 mSv in 2006 (NCRP, 2008).
Steenhuysen (2009) has reported that 'the radiations from CT scans done in 2007 will cause 29,000 cancers and kill nearly 15,000' people in America (Steenhuysen, 2009). These stats explain the level of exposure caused by the CT scans. According to estimates by Amy Berrington de Gonzalez of the National Cancer Institute, 'one-third of the projected cancers will occur in people who were ages 35 to 54 when they got their CT, two-thirds will occur in women and 15 percent will arise from scans done in children or teens' (Steenhuysen, 2009). They also estimate that there would be 2,000 surplus cases of breast cancer due to the CT scans done in 2007. The children are especially more vulnerable to cancer largely due to longer life expectancy (more exposure in the lifetime) and the rapid developing nature of the tissues and system.
Even though CT scans add a lot of useful information in the diagnostic process but it is known that the CT scan of the chest exposes the patient to nearly 100 conventional chest X-rays (Preidt, 2009). Therefore, the radiation exposure from CT scans it much higher than that from the conventional x-rays.
Normally, people are exposed to radiations from natural resources on Earth. On an average, a person in United States receives a radiation dose of around 3 mSv per year just due to natural resources like radioactive materials and cosmic radiations from outer space (Radiology Info, 2009). These radiations, referred to as the 'background radiations', may vary from one region to another within a country.
In simpler terms, the radiation exposure from one chest x-ray is equivalent to the dose of radiations exposure experienced from natural environment (background radiations) in ten days (Radiology Info, 2009). The table below compares the effective radiation dose from various CT scans with the exposure from the background radiations.
CT scanners along with portal imaging systems are an essential part of radiation therapy. Therefore in addition to exposures from the radiotherapy, patients are also irradiated by these imaging systems (Harrison et al., 2006), which might contribute significantly to the total dose of the patient. According to Harrison et al (2006), the concomitant irradiation from the imaging systems may range from 5% to 10% of the total organ dose and can reach up to 20% for bone surfaces (Harrison et al., 2006).
Conformal radiotherapies are associated with an increased number of imaging operations for verification at different stages of the treatment (Harrison et al., 2007). Harrison et al (2007) have also analyzed the doses to critical organs (with higher cancer probability) for the realistic treatments of the larynx and breast including the doses from the concomitant CT and electronic portal imaging (Harrison et al., 2007). The results showed that the total dose to the critical organs due to imaging was in the range of 5% to 20% of the total dose but in case of bone marrow and bone surfaces this could reach up to 30%.
Based on the data on CT scan use and risk estimates, from 1991 to 1996, it has been estimated that 0.4% of all cancers in U.S. may be attributed to the radiation from the CT scans (Brenner & Hall, 2007). But with the rapid increase in the use of CT scans in recent year, the estimate may now be around 1.5% to 2.0% for the current data (Brenner & Hall, 2007).
Over the last decade there has been a rapid increase in the total number of CT scans, with over 70 million scans in 2007 in United States alone (Steenhuysen, 2009). According to the McKinsey Global Institute, an economic research group report (2007), from its invention in 1973, the CT scanners have grown largely in number, to nearly 24,000 machines in U.S. (Coach, 2008). This is almost equivalent to 81 CT scanners per million people in U.S. Only Japan has a higher CT scanner density with 91 scanners per million people (Coach, 2008).
There has been a question regarding the necessity of the CT scans being order by the doctors. While in some cases the CT scans have proofed to be life saving, in some other cases it is not necessary. According to Rubin, a Stanford University radiologist, "It's gotten into the culture of doctors" (Coach, 2008). In a research conducted by Highmark Blue Cross Blue Shield of Pennsylvania in 2000 (when the number of scans were half of today's total), 162,000 scans were reviewed and at least 30% were found to be either inappropriate or un-useful in contributing any information (Coach, 2008). According to the Health Physics Society, there is no evidence of any benefits from the whole body CT scans and believes that such radiation exposures are unjustified (Richard J. Burk, 2007).
Considering the vital information provided by the CT scanning along with the risks associated with it, it is necessary to keep the radiation dose to as small as possible, especially in case of children, who are more vulnerable to cancer that the adults. In this regard various recommendations have been proposed by the U.S. Food and Drug Association (FDA) to prevent unnecessary exposure during Computed Tomography scans (David W. Feigal, 2001).
- Optimized CT Settings. To prevent over-exposure it is necessary to change the CT scanning dose according to the patient's body structure (weight and diameter) and the scanning region.
- Reduction in Tube current. The radiation dose is directly proportional to the current in the x-ray tube. So the exposure can be reduced by reducing the tube current.
- Developing and using chart with optimized tube current based on patient weight or diameter and anatomical region of interest (David W. Feigal, 2001). Such charts can standardize the scanning process, thus preventing over exposures.
- Increasing table increment (axial scanning) or pitch (helical scanning). The amount of radiation exposure can also be reduced by increasing the table increment and pitch. According to FDA, by increasing the pitch from 1:1 to 1.5:1, the radiation dose can be decreased by 33%, without the loss of diagnostic information (David W. Feigal, 2001).
- Reduction in the number of multiple scans with contrast materials. Often scanning is done before, during and after injection of contrasting material. Such exposures can be reduced by pre-contrast images (David W. Feigal, 2001).
- Elimination of unnecessary CT scanning. CT scan should be referred only when necessary. Radiation exposure can be eliminated or reduced if other imaging techniques are used.
- Regular monitoring and inspection of the CT scanner machines. Such checks should be done to meet the standards of radiation exposure limits.
Other than this, even the manufacturers on CT scanners have worked on cutting down the radiation exposure and over the last 20 years they have been able to reduce the exposure by nearly 20 to 75% (Health Physics Society, 2009). The researchers have worked efficiently in finding methods to reduce the radiation dose due to the scanning process. Roxby et al (2009), in a research have documented that by introducing a copper filter (thickness, 0.15mm) in a Cone Beam Computed Tomography (CBCT), the dose on the phantom was reduced from 45 mGy to 30 mGy at the standard setting (Roxby et al., 2009). Even though the introduction of filter increase the noise but it does not affect the ability of identify soft tissues for the treatment verification purpose (Roxby et al., 2009).
In 2008, American Association of Physicists in Medicine (AAPM) published a CT radiation dose management report. The report recommended methods for standardization of reporting doses along with educating users on the latest dose reduction technology (Health Physics Society, 2009).
The imaging technology has advanced ever since the invention of Computer Tomography (CT) scanning. CT scans (also called the CAT scans) have revolutionized the diagnostic process in the field of medicine. This has especially been useful in the study of tumors and cancers. CT scanning can determine the exact location and size of the tumor along with the extent of damage it has caused to the nearby tissues. Even in the treatment of cancer through radiation therapy (or radiotherapy), CT scan are extremely useful.
But this revolution has come at a price of higher ionizing x-ray radiation exposure to the population. The adverse effects of CT scans (x-ray radiations) have come to light with the advancement in the understanding of the carcinogenic nature of low doses of radiations, especially for children (Brenner & Hall, 2007). There are two important factors that contribute to the higher vulnerability of children, firstly, children have longer life expectancy (they have large number of years for exposure) and secondly, they have a developing system with cells multiplying rapidly. This contributes to higher risk of cancer.
Another essential concern is the increasing number of CT scans in the recent years. In 2007 along, about 70 million CT scans procedures were conducted in United States (Steenhuysen, 2009). With just 3 million CT scans in 1980 (Steenhuysen, 2009), this number has multiplied many time over. According to reports, per person radiation dose due to medical x-rays has increased by about 500 percent since 1982 (FDA, 2009). From these results it is evident that there has been an increase in the number of unnecessary and unessential CT scans. The self requested CT scans by the patients has also been a key factor in the increasing number of CT scans in recent years.
In order to control such high radiation exposures, United States Food and Drug Association have proposed some guidelines and recommendation for the patients and the radiologist. These guidelines would limit and reduce the amount of radiation exposure due to CT scans especially in case of children. A chest CT scan provides an exposure equivalent to more than 100 conventional x-rays (Coach, 2008). Therefore, CT scan should only be done when necessary. Even measures like decreasing the tube current, increasing the pitch (for helical scanning) etc. can largely reduce radiation exposure.
The increasing radiation exposure among people is a cause of concern and should be controlled effectively. The radiologists and radiotherapists have to insure that CT scans are done only when necessary and when other low radiation alternatives are not applicable. As for people, they should work in collaboration with their physicians to insure that they are subjected to least amount of radiation exposure. Especially in case of children, additional attention must be given due to higher risk associated with radiation exposure.
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In the International System of Units, the sievert (Sv) or millisievert (mSv) describes equivalent or effective radiation dose. One sievert is equal to 100 rem. Rem is also the term used to describe equivalent or effective radiation dose (NCRP report). Also one sievert is equal to one Gray (Gy), which is the energy absorbed per unit mass. 1 Gy is 1 joule of radiation energy absorbed per unit kilogram (Brenner & Hall, 2007)