[Intl_DxMedPhys] Heads up on NEJM paper on radiation exposure in peds and hematologic cancer risk

Wed Sep 24 17:06:16 EDT 2025

Ditto.

Too many sites still do multiphase when they should not, use the same dose on all phases of multiphases when this isn’t needed, and still have high doses for protocols that can/should be lower. And this is just dose. Too many sites also scan too slow when they could be scanning faster. There is a ton of uncompleted optimization work out there. Non overlapping slices…

Some of you know I work with this UCSF group, on projects outside the scope of cancer risk type studies. The data they have is really interesting and I found it a useful and important project when I worked with them to  assess how optimized for speed CTPA protocols were https://urldefense.com/v3/__https://ajronline.org/doi/abs/10.2214/AJR.24.32323__;!!KGKeukY!0fjA8epsu4q-ptnKI5eDGF0U9pZGzUX8WcUCxoS2NG5-sKfptUcuIZVCdbS6E8flUqIJgLz0QQJvLIr57bfzidCsfO24NWl2eSXtKf93fFl6Iu4FRA$ 

The need for better technical expertise on protocols will only increase with photon counting scanners becoming more prevalent. We usually never worry about focal spot size for optimizing image quality in the energy integrating world, now with photon counting we must.

Moving the needle away from pigeon holing physics away from being paid only for compliance is good for us at the end of the day. We need to identify gaps in training for meaningful protocol optimization. Most residencies don’t get very far into this, the focus for CT is on passing an ACR phantom and learning how to babysit a dose monitoring system (I know there are more competencies of course…but I think you get my point, how many residencies have integrated meetings with ct techs and rads on a regular basis to work on protocols?). I am often frustrated when I test scanners out of my department, and only get paid for the report, when I look through their pt browser and see all sorts of stuff that doesn’t make sense (like mA always maxxed out, or bx being done using dx protocols, or scans using 1 sec rotation and only going up to like 200 mA on a modern scanner) but there is no incentive for the sites to pay for having me help those issues… This should be flipped, we should get paid to do protocol optimization, and only spend time doing testing a minority of the time.

At UW we ran our first CT protocol optimization workshop this summer (not advertised outside UW, here is a link https://urldefense.com/v3/__https://ctecc.radiology.wisc.edu/ct-pow/__;!!KGKeukY!0fjA8epsu4q-ptnKI5eDGF0U9pZGzUX8WcUCxoS2NG5-sKfptUcuIZVCdbS6E8flUqIJgLz0QQJvLIr57bfzidCsfO24NWl2eSXtKf93fFnU_8a16w$  ) but we will be expanding to anyone to attend next year and doubling capacity to 60 people. I hope to help others learn the art of protocol optimization. As suggested on this listserv, I also believe protocol optimization is a concrete way we can help mitigate issues with radiation dose. >From years trying to get other sites to adopt a universal optimized protocol from outside their own site (our UW GE protocols), I learned it is easier to get a camel through the eye of a needle than for a site to adopt someone else’s CT protocols. Sites will always want to do stuff their way, so we need to help our own community be knowledgeable on how to assist them in this effort.

-stick

Timothy P. Szczykutowicz, Ph.D., DABR
Professor
Departments of Radiology, Medical Physics and BME
University of Wisconsin Madison
Cell# 1-716-560-7751<tel:(716)%20560-7751>
Office# 1-608-263-5729
he/him/his

From: Intl_dxmedphys_wd_osu_list <intl_dxmedphys_wd_osu_list-bounces+tszczykutowicz=uwhealth.org at lists.osu.edu> On Behalf Of Rebecca Milman via Intl_dxmedphys_wd_osu_list
Sent: Wednesday, September 24, 2025 3:34 PM
To: Dave Jordan <dave.jordan at gmail.com>
Cc: intl_dxmedphys_wd_osu_list at lists.osu.edu
Subject: Re: [Intl_DxMedPhys] Heads up on NEJM paper on radiation exposure in peds and hematologic cancer risk

WARNING: This email appears to have originated outside of the UW Health email system.
DO NOT CLICK on links or attachments unless you recognize the sender and know the content is safe.
Dave: FWIW, I agree completely. Rebecca Milman On Wed, Sep 24, 2025 at 11: 03 AM Dave Jordan via Intl_dxmedphys_wd_osu_list <intl_dxmedphys_wd_osu_list@ lists. osu. edu> wrote: From a clinical physicist standpoint, let’s try a thought experiment. 
Dave: FWIW, I agree completely.

Rebecca Milman

On Wed, Sep 24, 2025 at 11:03 AM Dave Jordan via Intl_dxmedphys_wd_osu_list <intl_dxmedphys_wd_osu_list at lists.osu.edu<mailto:intl_dxmedphys_wd_osu_list at lists.osu.edu>> wrote:
>From a clinical physicist standpoint, let’s try a thought experiment. Suppose that regardless of the quality of the science or our criticisms of it, the essential conclusions of this paper will end up driving or guiding our field. I do think
>From a clinical physicist standpoint, let’s try a thought experiment. Suppose that regardless of the quality of the science or our criticisms of it, the essential conclusions of this paper will end up driving or guiding our field. I do think that will end up happening to some extent, given the “first-mover” effect of this research having been published with high visibility in one of the top journals not just in radiology but all of medicine. Any responses from professional organizations will be reactive and much less visible than the paper itself.

Given that background, what can we, and should we, do about it as medical physicists proactively, *before* that decision is made for us and we are forced to react? I believe we will make better decisions proactively than what would be forced upon us by knee-jerk action of less-expert authorities, and you can bet that hospital presidents and physician leaders (I’m talking CMOs, not Radiology chairs) are going to want to “get in front of this."

This paper isn’t going to spell the end of CT by any means. Even if you accept the risks described in this paper as accurate, the medical benefits when a scan is medically appropriate are several orders of magnitude larger.

However, if we don’t want to get dragged down by a barrage of questions and challenges about radiation dose, we could approach this by assuming the paper is right, deciding what we would do if that were the case, and taking proactive steps to address those concerns and make improvements. Then instead of reacting and being jerked around by the inevitable questions, we’re in a position to say “thanks, we’re aware of it, already working on it, and here’s what we’ve done/are doing.” This lets us stay in the driver’s seat to maintain image quality and diagnostic utility instead of getting swept along in the obsession with reducing and avoiding radiation dose.

---
On Sep 24, 2025 at 10:40 AM -0400, Gao, Yiming via Intl_dxmedphys_wd_osu_list <intl_dxmedphys_wd_osu_list at lists.osu.edu<mailto:intl_dxmedphys_wd_osu_list at lists.osu.edu>>, wrote:

Hi Kai, I think there are many unanswered questions for this published paper. Here are my thoughts: Apparently they used the UF/NCI phantom library to match patients to phantoms and compute organ and effective doses. They mentioned “missing
Hi Kai,

I think there are many unanswered questions for this published paper. Here are my thoughts:

  1.  Apparently they used the UF/NCI phantom library to match patients to phantoms and compute organ and effective doses. They mentioned “missing height or weight” in both US and Canadian exams, and the matching process is yet based on height and weight. They filled in the missing data with median values, but the questions are: (1) how much percentage of the dataset is missing height and weight, (2) have they tried different filling methods and compared the outcome, (3) can they use effective diameter instead of height & weight for matching and how different the outcome would be?
  2.  They mentioned exams missing CT acquisition parameters and just filled them randomly by using a multilevel random effects model, so again (1) how much percentage is missing the parameters, (2) have they tried different models and (3) can they use a different filling method.
  3.  They mentioned “One U.S. site was unable to abstract individual CT dose”. I’m assuming they are talking about CTDIvol here, so again (1) how much percentage is missing CTDIvol, (2) how did they fill in the missing data for CTDIvol. They also mentioned a “random forest model” which filled in missing technical parameters, so is it the same model as the “multilevel random effects model” in point 2?

In terms patient demographics, CT acquisition parameters, and CTDIvol (“CT dose”), there are many unanswered questions and their models for filling the missing parameters are unclear and unverified. I wonder how this paper got through the reviewers and editors…

Best wishes,
Yiming Gao,
Assistant Attending Physicist,
MSKCC

From: Intl_dxmedphys_wd_osu_list <intl_dxmedphys_wd_osu_list-bounces+gaoy1=mskcc.org at lists.osu.edu<mailto:mskcc.org at lists.osu.edu>> On Behalf Of Yang, Kai, PhD via Intl_dxmedphys_wd_osu_list
Sent: Wednesday, September 24, 2025 9:52 AM
To: Mark Supanich <Mark_Supanich at rush.edu<mailto:Mark_Supanich at rush.edu>>; Jerry Thomas <jerry.thomas at ascension.org<mailto:jerry.thomas at ascension.org>>
Cc: intl_dxmedphys_wd_osu_list at lists.osu.edu<mailto:intl_dxmedphys_wd_osu_list at lists.osu.edu>
Subject: Re: [Intl_DxMedPhys] [EXTERNAL] Re: Heads up on NEJM paper on radiation exposure in peds and hematologic cancer risk

Hi everyone, as I am reading through the appendix 1 for that paper, it turned out that they didn't even have most of the real dose data, but other than "guessing it out"? Below is the exact text, would love to hear what others think. 
Hi everyone, as I am reading through the appendix 1 for that paper, it turned out that they didn't even have most of the real dose data, but other than "guessing it out"? Below is the exact text, would love to hear what others think. 
Hi everyone, as I am reading through the appendix 1 for that paper, it turned out that they didn't even have most of the real dose data, but other than "guessing it out"? Below is the exact text, would love to hear what others think.

<image001.png>

<image002.png>
________________________________
From: Intl_dxmedphys_wd_osu_list <intl_dxmedphys_wd_osu_list-bounces at lists.osu.edu<mailto:intl_dxmedphys_wd_osu_list-bounces at lists.osu.edu>> on behalf of Jerry Thomas via Intl_dxmedphys_wd_osu_list <intl_dxmedphys_wd_osu_list at lists.osu.edu<mailto:intl_dxmedphys_wd_osu_list at lists.osu.edu>>
Sent: Monday, September 22, 2025 12:11 PM
To: Mark Supanich <Mark_Supanich at rush.edu<mailto:Mark_Supanich at rush.edu>>
Cc: intl_dxmedphys_wd_osu_list at lists.osu.edu<mailto:intl_dxmedphys_wd_osu_list at lists.osu.edu> <intl_dxmedphys_wd_osu_list at lists.osu.edu<mailto:intl_dxmedphys_wd_osu_list at lists.osu.edu>>
Subject: Re: [Intl_DxMedPhys] [EXTERNAL] Re: Heads up on NEJM paper on radiation exposure in peds and hematologic cancer risk

Mark and Baojun, Great points. Both need to be in a letter to the editor. Unfortunately, the reviewers of this paper failed to do their job. -- They were either, biased in favor of the paper's conclusions, busy and did not read the paper
        External Email - Use Caution
Mark and Baojun,

      Great points.  Both need to be in a letter to the editor.  Unfortunately, the reviewers of this paper failed to do their job.  -- They were either, biased in favor of the paper's conclusions, busy and did not read the paper critically, or were reviewing work that they were not qualified to review.  Regardless this paper will be quoted, so it is now imperative that a letter to the editor be written.  I would enjoy reading the response to the letter. --- especially the support for hormesis that Mark pointed out.

Jerry Thomas, MS, FAAPM, DABR, CHP, DABSNM
Diagnostic Medical Physicist / Radiation Safety Officer
Ascension Via Christi Hospitals Wichita
Wichita, KS  67214

Phone:  316-268-5958  (office)
            240-447-1014  (cell)

On Fri, Sep 19, 2025 at 3:18 PM Mark Supanich via Intl_dxmedphys_wd_osu_list <intl_dxmedphys_wd_osu_list at lists.osu.edu<mailto:intl_dxmedphys_wd_osu_list at lists.osu.edu>> wrote:
An interesting note on this is that they also could have claimed that low levels of ionizing radiation have a positive impact on hematologic cancer rates. They cancer incidence rate (cases per 10,000 in their cohort) was lower for groups receiving
An interesting note on this is that they also could have claimed that low levels of ionizing radiation have a positive impact on hematologic cancer rates. They cancer incidence rate (cases per 10,000 in their cohort) was lower for groups receiving between 5-15 mGy dose to the bone marrow than the group with no medical imaging. Their own calculated ERR was even <1 for the 5-10 mGy group.

I wonder why the headlines aren't: "exposure to low levels of ionizing radiation protects children from blood cancer"?
[Beaming face with smiling eyes]

________________________________
From: Intl_dxmedphys_wd_osu_list <intl_dxmedphys_wd_osu_list-bounces at lists.osu.edu<mailto:intl_dxmedphys_wd_osu_list-bounces at lists.osu.edu>> on behalf of Li, Baojun via Intl_dxmedphys_wd_osu_list <intl_dxmedphys_wd_osu_list at lists.osu.edu<mailto:intl_dxmedphys_wd_osu_list at lists.osu.edu>>
Sent: Friday, September 19, 2025 1:01 PM
To: intl_dxmedphys_wd_osu_list at lists.osu.edu<mailto:intl_dxmedphys_wd_osu_list at lists.osu.edu> <intl_dxmedphys_wd_osu_list at lists.osu.edu<mailto:intl_dxmedphys_wd_osu_list at lists.osu.edu>>
Subject: Re: [Intl_DxMedPhys] Heads up on NEJM paper on radiation exposure in peds and hematologic cancer risk

Rush Email Security

This email originated from outside of RUSH. Do not click links or attachments unless you recognize the sender and know that the content is safe. RUSH will never ask for user ID information via email.
If we replace “accumulative dose to bone marrow” with “total number of blood draws or hospital visits,” the relationship would likely still hold. By the authors’ reasoning, one could then conclude that blood draws or hospital visits cause cancer?!

If we replace “accumulative dose to bone marrow” with “total number of blood draws or hospital visits,” the relationship would likely still hold. By the authors’ reasoning, one could then conclude that blood draws or hospital visits cause cancer?!

In reality, children who undergo multiple CT examinations typically do so because of more severe or complex medical conditions. These patients are inherently predisposed to more hospital encounters and already have a higher baseline risk of hematologic malignancies, independent of imaging. The causal inference presented by the authors is deeply flawed and misleading.

Thanks,

Baojun

From: Intl_dxmedphys_wd_osu_list <intl_dxmedphys_wd_osu_list-bounces+baojunli=bu.edu at lists.osu.edu<mailto:bu.edu at lists.osu.edu>> On Behalf Of Mark Supanich via Intl_dxmedphys_wd_osu_list
Sent: Wednesday, September 17, 2025 6:35 PM
To: intl_dxmedphys_wd_osu_list at lists.osu.edu<mailto:intl_dxmedphys_wd_osu_list at lists.osu.edu>
Subject: [Intl_DxMedPhys] Heads up on NEJM paper on radiation exposure in peds and hematologic cancer risk

Hi all, Just a heads up that NEJM published a paper from Smith-Bindman et al this afternoon. https: //www. nejm. org/doi/full/10. 1056/NEJMoa2502098?query=featured_home It’s an observational study of 3. 5+ million peds looking at cumulative

Hi all,

Just a heads up that NEJM published a paper from Smith-Bindman et al this afternoon. https://urldefense.com/v3/__https://www.nejm.org/doi/full/10.1056/NEJMoa2502098?query=featured_home__;!!KGKeukY!0fjA8epsu4q-ptnKI5eDGF0U9pZGzUX8WcUCxoS2NG5-sKfptUcuIZVCdbS6E8flUqIJgLz0QQJvLIr57bfzidCsfO24NWl2eSXtKf93fFn3DLO84Q$ <https://urldefense.com/v3/__https:/secure-web.cisco.com/1Pif7c1GVQLMo413q8lyswy_kWQJLqJ3cKx0nQGFkr6roy5XKcaHcgKgfMCEavkXWhlxS8ojxDPVSFGiV159HoqVJmU1jBGSWxEki9pZnNPgFOXuWFFH2cPJ9iESxUtrQHf_ftWuSrAwDenu0XEKs0so3Lp9yPyDyGAV3HvnkyA-TrzcHTi9F93RdM-0fHk1giADz-zhQumMlFKwrrYAqW8VJgUXlHogYD3wj7r1dcf4yGekHSraexmKvdaXr30d08r8i_6QvavJrM510aQFokDAKVMk1V0aM93CarLhqDapQA4xODAM2K6B2mOQ4qdXk/https*3A*2F*2Furldefense.com*2Fv3*2F__https*3A*2Fwww.nejm.org*2Fdoi*2Ffull*2F10.1056*2FNEJMoa2502098*3Fquery*3Dfeatured_home__*3B*21*21KGKeukY*211m_oRWHMFCepm1fT1RIhzq46cPRXjfbhAvYKAO_5iNUOWD5mqN0G-iBdtAZYZy1h5_JOVRouzbgwoLM5N75lJAFaFMiQA3UTRzxHR2RjJ7wH4P8*24__;JSUlJSUlJSUlJSUlJSUlJSUl!!KGKeukY!yZPKhr2mTtVY5J4oB8YS20iVqEevZH1nS-QKS-tCkHtFL4ZXioOOitfyVAfuZc3I629AInOtdaqGr5XvVbxPsz36b87UQ_8neCrfjdqCRxIWHw$>

It’s an observational study of 3.5+ million peds looking at cumulative exposure to ionizing radiation, particularly focused on bone marrow dose, and increased risk of hematologic cancer incidence. Their results claim an increased incidence of cancer in patients with exposure to imaging, and demonstrate a cummulative dose effect. They claim their results are not likely due to reverse causation as they have reasons for exams and symptoms of these cancers were not common reasons for exams. They also note their results are inline with the EPI-CT study. Of note, it appears that they looked at imaging from 1996-2017 – so much of the imaging likely occurred on imaging equipment without many of the modern dose reduction features.

This is sure to get media play and parents will certainly have questions as the media coverage develops. Continuing to focus on the judicious use of imaging, the benefits of diagnostic imaging to answer clinical questions, and the fact that modern imaging equipment adapts to patient size and uses optimized radiation will be key talking points.

>From the paper: “By the end of follow-up, 7.5% (280,548 of 3,724,623) of all the children and 9.2% (272 of 2961) of those in whom a hematologic cancer developed had received a cumulative dose of at least 1 mGy.”

<image003.png>

There is a lot to look at in this paper and the supplemental materials, so more information/analysis is sure to come.

--

Mark P. Supanich, Ph.D., DABR, FAAPM (he/him)

Director – Diagnostic Medical Physics

Rush University System for Health

Associate Professor & Vice Chair for Physics and Informatics

Rush Medical College Department of Diagnostic Radiology and Nuclear Medicine

<image004.png>

CONFIDENTIALITY NOTICE:
This email message and any accompanying data or files is confidential and may contain privileged information intended only for the named recipient(s). If you are not the intended recipient(s), you are hereby notified that the dissemination, distribution, and or copying of this message is strictly prohibited. If you receive this message in error, or are not the named recipient(s), please notify the sender at the email address above, delete this email from your computer, and destroy any copies in any form immediately. Receipt by anyone other than the named recipient(s) is not a waiver of any attorney-client, work product, or other applicable privilege.
The information in this e-mail is intended only for the person to whom it is addressed.  If you believe this e-mail was sent to you in error and the e-mail contains patient information, please contact the Mass General Brigham Compliance HelpLine at https://urldefense.com/v3/__https://www.massgeneralbrigham.org/complianceline__;!!KGKeukY!0fjA8epsu4q-ptnKI5eDGF0U9pZGzUX8WcUCxoS2NG5-sKfptUcuIZVCdbS6E8flUqIJgLz0QQJvLIr57bfzidCsfO24NWl2eSXtKf93fFnwQWdq-g$ <https://urldefense.com/v3/__https:/www.massgeneralbrigham.org/complianceline__;!!KGKeukY!yZPKhr2mTtVY5J4oB8YS20iVqEevZH1nS-QKS-tCkHtFL4ZXioOOitfyVAfuZc3I629AInOtdaqGr5XvVbxPsz36b87UQ_8neCrfjdoHCfnxpQ$> .

Please note that this e-mail is not secure (encrypted).  If you do not wish to continue communication over unencrypted e-mail, please notify the sender of this message immediately.  Continuing to send or respond to e-mail after receiving this message means you understand and accept this risk and wish to continue to communicate over unencrypted e-mail.
=====================================================================

Please note that this e-mail and any files transmitted from
Memorial Sloan Kettering Cancer Center may be privileged, confidential,
and protected from disclosure under applicable law. If the reader of
this message is not the intended recipient, or an employee or agent
responsible for delivering this message to the intended recipient,
you are hereby notified that any reading, dissemination, distribution,
copying, or other use of this communication or any of its attachments
is strictly prohibited. If you have received this communication in
error, please notify the sender immediately by replying to this message
and deleting this message, any attachments, and all copies and backups
from your computer.

Disclaimer ID:MSKCC
-------------- next part --------------
An HTML attachment was scrubbed...
URL: <https://lists.osu.edu/mailman/private/intl_dxmedphys_wd_osu_list/attachments/20250924/2628c400/attachment.html>