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Hilde Merete Olerud I Assessments of Patient Doses and Image Quality in X-Ray Diagnostics in Norway

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Hilde Merete Olerud I Assessments of Patient Doses and Image Quality in X-Ray Diagnostics in Norway NO9800042 NEI-NO--896 Hilde Merete Olerud I Assessments of patient doses and image quality in X-ray diagnostics in Norway 29-23 Assessments of patient doses and image quality in X-ray diagnostics in Norway Hilde Merete Olerud Norwegian Radiation Protection Authority (NRPA) Health Physics Department, P.O. Box 55, N-1345 0steris, Norway Submitted in partial fulfilment for the degree of Doktor ingeni0r Department of Physics The Norwegian University of Science and Technology, NTNU Trondheim Evaluation ofCT, or any dynamic medical technology, will never provide final answers. Findings will be open to interpretation. Individual values and judgements will always play a role. Decisions about the development, reimbursement, and use of new technologies will continue to be made, however imperfectly. The great challenge, embodied in CT but embracing all of medicine, is to bring policy and practice into line with knowledges Fineberg, 1978 Hilde M. Olerud: Patient doses and image quality in X-ray diagnostics in Norway Preface and acknowledgements This thesis is based on work carried out at the Norwegian Radiation Protection Authority (NRPA)(National institute of radiation hygiene until 15. April, 1993), where I have been employed since 1981. The Health physics department at the NRPA has performed surveys of examination frequencies and patient doses within X-ray diagnostics since the beginning of the eighties, and has in recent years also been dealing with assessments of image quality by means of qualitative and quantitative methods. I have taken part in these projects, and the results of this work are summarised in this thesis, which also describes the development of a phantom for ROC analysis in CT. The available methods for assessments of patient dose and image quality will be reviewed, and the survey results have been discussed in view of the radiation protection principles of justification and optimisation in medical radiology. I would sincerely like to acknowledge the following people for help and support: - professor Ame Skretting at the Norwegian Radium Hospital for scientific guidance and collaboration, - professor Tore Lindmo at the Department of Physics, NTNU, for establishing research level courses in medical physics in Norway, - my former boss, Jon Flatby, and my present boss, Gunnar Saxeb0l, for goodwill and collaboration, - my colleagues at NRPA for collaboration, and for taking over parts of my responsibilities while I was working on this thesis, - Aud Karin Carelius at the library of NRPA for kindness and assistance in obtaining relevant literature, - my colleagues at the other Nordic radiation protection authorities in the task group «X-ray diagnostics» for professional networking and inspiration, - and other professionals working in Europe who contribute within this field, especially to Gudrun Aim Carlsson at the Linkoping University in Sweden, and Hannelore Schibilla in the European Commission, as inspirations for female medical physicists. I would also like to thank my family for encouragement and support. Oslo, December 1997 mother and physicist wife, daughter and friend U NEXT PAQE(S) toft BLANK Hilde M. Olerud: Patient doses and image quality in X-ray diagnostics in Norway Abstract Results from other industrialised countries indicate that the annual number of diagnostic procedures approaches one for every member of the population, and in many cases the individual radiation doses are higher than from any other human activity. Furthermore, the doses to patients for the same type of examination differ widely from place to place, suggesting that there is a considerable potential for dose reduction. This motivated an investigation of the diagnostic use of X-rays in Norway. The trends in the number of X-ray examinations performed annually have been studied. The patient doses (all diagnostics) and image quality (mammography and computed tomography (CT)) have been assessed for various radiological procedures. This form the basis for the assessment of total collective effective dose (CED) from X-rays in Norway, and further risk estimates. The radiological practice has then been evaluated according to the radiation protection principles of justification and optimisation. Information on the number of various X-ray procedures performed annually has been collected every fifth year. Patient doses were assessed for common radiological procedures in a large number of hospitals, both to establish country mean values, and to study the distribution of doses. Patient doses were based on measurements free in air, or inside a phantom, and use of published conversion coefficients established by Monte Carlo simulations. Image quality was assessed based on (a) qualitative evaluations of the appearance of various test objects in technical phantoms (mammography), and (b) receiver operating characteristics (ROC) studies in CT, based on an anthropomorphic phantom developed for this study, giving a total performance measure (equipment and observer). During one decade, the total frequency of X-ray examinations has increased from 641 (1983) to 710 examinations per 1000 inhabitants (1993). Some conventional examination procedures have been replaced by new modalities utilising non-ionising radiation (ultrasonography, magnetic resonance imaging), but this decrease has been almost balanced by a significant increase in the number of CT, mammographic and angiographic procedures. Based on the 1993 examination frequency, the total CED was assessed to 3400 manSv (0.78 mSv/inhabitant). It is estimated that this radiation burden may cause about 100 excess cancer deaths annually. The frequency of CT examinations has doubled every fifth year, and did in 1993 represent 1% of the total number of examinations and 30% of the total CED. Based on recent calculations, the country mean effective doses for current radiographic examinations in the trunk region now range from about 0.1 mSv for chest examinations to 3.5 mSv for urography, depending on the number of projections. Fluoroscopic examinations range from about 2.5 to 6.5 mSv, depending on the contrast technique, fluoroscopy time, and the number of radiographs. Compared with previous patient dose data obtained before 1986, a tendency towards somewhat lower doses from conventional procedures was recognised, possibly caused by the introduction of more sensitive film/screen combinations. Based on questionnaires send to the local X-ray departments in 1994, the country mean effective dose from CT procedures was assessed to 2 mSv for head examinations, 10-13 mSv in the trunk region, and 4.5 mSv for lumbar spine examinations. This means that patient doses in CT are significantly higher compared to those from conventional examinations of the same body regions. These nation-wide surveys showed considerable spread in doses for the same type of examination performed at different hospitals. The ratio between the highest and lowest dose was typically in the order of ten for medium sized patients (70 kg). ui Hilde M. Olerud: Patient doses and image quality in X-ray diagnostics in Norway For medium sized breasts (4.5 cm), the average glandular dose (AGD) ranged from 0.7 to 2.0 mGy for grid techniques, and 0.4 to 0.8 mGy for non-grid techniques (45 mammographic units, 1994). There were also large variations in image quality (contrast, low contrast detectability, spatial resolution, visualisation of calcifications). According to the quality criteria set by the American College of Radiology, the image quality in almost half of the Norwegian laboratories was sub-optimal. The variations in patient dose and image quality could to some extent be explained by variations in the performance of film processing. The ROC phantom was shown to be useful to characterise perceived image quality in CT for old as well as modern scanners. Five laboratories were included in the study, and for the different exposure settings used as routine for studies of the liver, the weighted CT dose index (CTDIW) ranged from 15 to 31 mGy (1997). As judged from the corresponding areas under the ROC curves, three readers agreed that there was a significant difference in quality between the group of the three best images and the two ranked in the bottom. The two most modern scanners were associated with the best ROC results, and also gave the lowest doses. For each of the scanners, using the same slice thickness, a positive correlation was found between CTDIW and the area under the ROC curve. This pair of parameters may therefore be used for future optimisation of a specific CT procedure. However, significant intra- and inter-observer variations in the ROC results were found. The optimum choice of the number of test objects, the number observers, and the training of observers, must be investigated further, and statistical methods for distinguishing between different ROC curves must be developed. Generally, the methods for assessments of patient doses are well established, while the methods for assessments of image quality need to be further standardised in order to compare the performance of different equipment or laboratories. A need for development of phantoms for quality control of helical scanners was also recognised. Optimisation of mammographic procedures is of particular concern because of the recently started programme for screening of asymptomatic women in Norway, and the results of the present study indicate the importance of extensive quality control programmes in mammography. The optimisation of CT procedures is motivated by its significant contribution
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