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John Orchard

CT scans and X-rays increase risk of cancer – changing the goal posts in sports medicine

19 Sep, 12 | by Karim Khan

By John Orchard and Jessica Orchard

Two jaw-dropping papers from The Lancet 1 and BMJ 2 published in the past month should have a major effect on the practice of sports medicine.  They have clearly demonstrated that radiating scans in young people actually do lead to an increased risk of cancer later in life. Perhaps until 2012 this was a theoretical risk, but as of the publication of these landmark papers 1-3 we can be certain that the increased risk is not zero. There will be much more to come in this field over the next few years and it will dramatically change the landscape of radiology and all medical practice.

Pearce and colleagues’ study in The Lancet looked at the excess risk of leukaemia and brain tumours for children and young people exposed to CT scans. They found that children exposed to cumulative doses of 50mGy in CT scans may have triple the risk of leukaemia, and doses of 60mGy may have almost triple the risk of brain tumours1. Though this appears to be a massive increase in risk, the authors point out that these cancers are still relatively rare, causing an estimated one excess case of leukaemia and one excess brain tumour per 10,000 head CT scans. They are clearly cause for concern, as indicated by the fact that 12 other groups from 15 countries are studying the risk of scans on children3.

These Lancet findings are more striking when combined with the findings of Pijpe and colleagues’ GEN-RAD-RISK paper published last week in the BMJ2. This study showed that when women who carry a specific mutation associated with breast cancer (BRCA1/2), and who  were exposed to diagnostic radiation before the age of 30, had almost twice the risk of breast cancer (with a dose-response pattern). This study involved lower doses which we have previously considered fairly ‘safe’ (e.g. 4mGy from a single mammogram or shoulder x-ray). Therefore, BRCA1/2 carriers, with an already increased risk of a very common cancer, would be particularly at risk from exposure from radiating scans at a young age.

Why does this matter for sports and exercise medicine?

Sports and exercise medicine is a field in which most patients have many years of life expectancy remaining; it is also a field in which diagnostic imaging is very common. Imaging is often confined to the limbs but also involves the spine.  Importantly,  the GEN-RAD-RISK paper showed, for example, that shoulder X-rays in women with the BRCA1/2 mutation can increase the risk of breast cancer. This does not prove that a shoulder X-ray is unsafe for the entire female population, but because it is quite plausible, we need to reassess the use of radiating scans. The authors of this study have already recommended that women with the BRCA1/2 mutations should not get mammograms and it is hard to see how this recommendation will not soon be extended to all younger women, as mammograms are meant to be preventing deaths from cancer, not causing them.

Studies have not been published to look at, for example, the risk of  cancers in the abdominal cavity (e.g. bowel, ovarian) after lumbar spine CT scan, but again we have to presume from the existing knowledge that the increased cancer risk is not zero. In this case,  the unknown is the size of the increase in cancer risk (and not whether there actually is one). All tests (and treatments) in medicine need to consider benefits, risks and costs. On the benefit side, the test which gives the best information relevant to management needs to be identified. This can’t be done in isolation of the increased cancer risk of radiating scans, particularly in young or middle aged patients.

There will still be cases where a test that involves radiation is going to give preferred information to a non-radiating one – a classic example being in the knee of a 70 year old, where X-ray will tell what needs to be known in 95% of cases and MRI scan is generally an excessive use of imaging. However in scenarios where we used to recommend radiating tests (e.g. CT and bone scan to investigate for suspected pars stress fracture in an adolescent) we may need to quickly change to a recommendation of first line MRI scan to avoid increasing the risk of cancer. Health systems are going to need to change in scenarios where radiating tests are funded but non-radiating tests aren’t, because clearly it would raise ethical questions for a health system to be funding (offering a financial incentive) to have a test which can increase a patient’s risk of cancer when a non-risky test is available but unfunded.

Up to fifty years ago, some shoe stores used to perform X-rays on the spot to show whether a kid’s shoe was fitting well4 – this practice is now considered archaic.  Sensibly there is now an attitude in medicine that a pregnant woman should not receive an X-ray or CT scan if the information could be obtained in any other fashion. We are probably heading into an era where the same attitude needs to apply to all children and young people, for CT scan and even X-ray. Modalities such as MRI and ultrasound (and good old-fashioned clinical examination) will need to become more prominent in sports and exercise medicine, at the expense of radiating examinations. These studies highlighted in the blog will generate a demand for consensus meetings involving sports physicians, radiologists, radiation physicists, and epidemiologists among others to provide guidance for clinicians, professional bodies and patients. Depending on the recommendations made at consensus meetings, there should ideally also be a review of government/insurance funding arrangements to remove any financial incentives towards the inappropriate use of radiating scans.

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John Orchard is an Australian sports physician who has worked with numerous professional team sports. His sometimes controversial views are personal and not necessarily representative of organisations he is affiliated with. You can read more at www.johnorchard.comand/or follow @DrJohnOrchard on Twitter

Jessica Orchard is an Australian lawyer with qualifications in economics and public health, currently employed at the NSW Cancer Council. Her views in blogs are also personal and not necessarily representative of her affiliated organisations.

References

  1. Pearce MS et al. Radiation exposure from CT scans in childhood and subsequent risk of leukaemia and brain tumours: a retrospective cohort study. Lancet. 2012 Aug 4;380(9840):499-505.
  2. Pijpe A at al. Exposure to diagnostic radiation and risk of breast cancer among carriers of BRCA1/2 mutations:  retrospective cohort study (GENE-RAD-RISK).BMJ. 2012 Sep 6;345:e5660.
  3. Einstein AJ. Beyond the bombs: cancer risks of low-dose medical radiation. Lancet. 2012 Aug 4;380(9840):455-7.
  4. Bowden T. Frying one’s gonads for shoes. http://www.abc.net.au/unleashed/37598.html

Dr John Orchard on the “metal staples – no local anaesthesia” – discussion. Guest Blog.

18 Aug, 12 | by Karim Khan

 

 

 Interchange laws, bleeding and apparently dying players

@DrJohnOrchard

I am very interested to have read the Blog by Drs Fowell and Earl (http://blogs.bmj.com/bjsm/2012/08/17/closing-soft-tissue-wounds-rapidly-at-pitchside-a-role-for-metal-skin-staples-without-anaesthesia/) about the use of staples to close lacerations on the side of the pitch in football matches.

I used metal staples like this quite a few times myself in the early 2000s in rugby league and wrote up one of the cases in the BJSM (Orchard JW. Video illustration of staple gun to rapidly repair on-field head laceration.  Br J Sports Med 2004;38(4):e7). Now I still use staples as one of the options for closing wounds in rugby league players, although no longer do I do it on the sidelines. Shortly after the 2003 case (which was subsequently written up) a further case which was far more notorious occurred when I closed an eyebrow laceration on Michael De Vere in a rugby league State of Origin game

This was done on the pitch itself whilst a video refereeing decision was being made, meaning that the player didn’t leave the field – he didn’t miss any playing time at all. The video of the procedure, however, was captured on TV and shown to millions of viewers. The reaction to the vision was that the NRL (National Rugby League) banned the use of the staple gun outside the dressing room, meaning that players have to now leave the field to have a laceration closed.

The issue of management of lacerations is one which not only is of concern to team doctors – who must weigh up both (1) optimal medical treatment of an injury and (2) minimising loss of game time for players – but it now also needs to be a major concern for sporting administrators.

I cover some of the related issues in an Editorial in the August 2012 BJSM (Click here for: Orchard J. More research is needed into the effects on injury of substitute and interchange rules in team sports Br J Sports Med 2012;46:10 694-695). All sporting bodies should engage Medical Directors and medical/injury management concerns must to be prominent when considering existing and proposed new rules. Whether use of staple guns pitchside should be recommended in a sport depends on quite a few factors, including (but not finishing with) whether it will lead to unpleasant images on TV.

Blood management will be influenced by substitution rules

The sports rules for handling blood and the interchange/substitute laws clearly have a major impact on medical management. If the rules allow for “free” interchanges/substitutes for bleeding wounds (as per rugby union), then the player can be treated in the dressing room with minimal time pressure. However, this privilege (‘free’ substitution to respect the bloody player) can also lead to the distortion that it is advantageous for a team to have a player suffer a laceration (as they get an extra interchange in these circumstances). This, of course, is the scenario under which the “Bloodgate” affair arose. If it is disadvantageous for a team to have a player missing from action, then extremely rapid wound closure becomes a valuable priority. The challenge for all sports lies in balancing all of these concerns.

Practical implications of Fowell and Earl’s new data (blog, above)

I suspect that some football team doctors will look at the large case series of Fowell and Earl and decide that under the current FIFA rules (3 substitutes but no interchanges or “blood bins”) it makes sense to use staples on the side of the pitch, without local anaesthetic, for the uncommon scenario (in football) of a head laceration. History is in danger of repeating itself; this practice may be tolerated until children are exposed to it in their living rooms (e.g. by seeing a replay of it being done in an FA Cup final, for example).

More substitutes in football? (soccer)

A benefit of any debate on whether or not to ‘ban’ pitchside stapling in football will be that it should include a consideration about introducing an interchange player to the game itself. If soccer was to allowed 3 substitute players but also 1 roving interchange – the converse of the current ‘bench’ in the AFL (Australian Football League) – then a player could be interchanged off for 5 minutes for stapling/suturing to be done in the dressing room, without penalty to the team. It would also allow the player to be more thoroughly assessed for any co-existing concussion from the same blow to the head. This would fix an uncommon but consistent problem in the sport — how to deal fairly with the bleeding player.

It may also help fix a consistent but far more common problem – the exaggeration of minor injuries. If a player who was tapped on the shins and needed 2-3 minutes to recover was able to be interchanged off the field and temporarily replaced until this recovery, there wouldn’t be as much benefit in “playing dead” to stop the game if the temporary replacement could be made without hurting the team. A hybrid bench of substitute and interchange players (or one with a limited number of interchages rather than substitutes) probably leads to optimal injury management and perhaps even fewer injuries overall.

To close, I contend that the debate about what is best for a sport shouldn’t start with an argument of “this is how it’s always been done” but it should finish with “this is how we will make sure our sport gets the balance right between entertainment, fair play and optimal injury management”.

This Guest Blog relates to the BJSM Blog posted on August 16th – please scroll down.

John Orchard is an Australian sports physician who has worked with numerous professional team sports. His sometimes controversial views are personal and not necessarily representative of organisations he is affiliated with. You can read more at www.johnorchard.com and/or follow @DrJohnOrchard on Twitter

 

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