CT and breast cancer risk: now is the time to act

And yet we continue to bombard our patients with x-rays.

I, for one, am becoming tired of the lack of diligence and abuse of imaging as a rule-out tool in situations when observation or a non-ionising alternative may be appropriate. CT is so readily available that clinicians use it as a crutch to hobble towards a diagnosis or away from a possible complication. Too often do we have are our arm twisted into performing a CT in the middle of the night so that a patient can be triaged to a specialty, sent home without adequate symptom control or a diagnosis. It is upsetting to follow up a case and see that although we have been told that a therapeutic procedure 'we would definitely perform tonight', it has never materialised despite the diagnosis in question being established by the imaging test. This is tantamount to perjury - would you hoodwink you patients so?

Be warned. We do not know the precise fallout of iatrogenic radiation exposure, but evidence is clearly increasing and the medical profession may one day have to face accountability. Radiologists are currently given the responsibility of being the gatekeeper of patient safety. So next time when a young female patient with pelvic pain has a normal CRP and WCC, do not get upset when a CT is refused at 2 am if an ultrasound is available in the morning.  Thinking of the chest - is a CTPA always necessary?  Is dissection really a probable (not just possible) diagnosis.  Perhaps part of the problem here is that we are lacking in other tests good enough to exclude life-threatening complications: we should toss D-Dimer overboard and save our Trusts some money, especially if we are going to ignore a negative result anyway! And don't get me started on the widened mediastinum! The threshold for imaging for CT immediately in such situations has slipped dangerously low.

Working towards a safe solution will require better communication and a better relationship between radiologists and referrers, who need to accept that they also have a duty to the patient not to unduly expose their patient to a cancer risk factor, for example so that a bed can be saved overnight instead of patient observation. Is that a price worth paying? This radiologist thinks that, in certain situations, it may be fair to watch and wait, not least to allow the patient to acheive some symptom control and be offered the chance to be seen in the morning by an experienced consultant.

We clearly also need strategies to reduce CT exposure, which will include a devloping a decent evidence base for the justification of its use (does repeat scanning in pancreatitis really change management?), as well as improved technologies to reduce dose. Perhaps we can take the lead from Paediatrics, where CT imaging is applied scarcely and with prudence...

Please excuse my passion on this topic, but for far too long has it been swept under the carpet. Together, devoid of fiscal and political motivation, we need to find the right balance for our patients.