Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 
Home Print this page Email this page Small font size Default font size Increase font size Users Online: 105


 
 Table of Contents 
EDITORIAL
Year : 2010  |  Volume : 33  |  Issue : 3  |  Page : 88-93  

Dr AK Ganguly Memorial Oration


Raja Ramanna Fellow, Department of Atomic Energy, Mumbai, India

Date of Web Publication22-Oct-2011

Correspondence Address:
K S Parthasarathy
Raja Ramanna Fellow, Department of Atomic Energy, Mumbai
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


Rights and PermissionsRights and Permissions
  Abstract 

Dr. K.S. Parthasarathy is the recepient of IARP-Dr. A.K. Ganguly Memorial Oration Award-2010 This is the text of the Oration delivered at the 29th IARP National Conference (IARPNC-2010) on Recent Advances in Radiation Dosimetry, held during 3-5 February, 2010 at Mumbai.

Keywords: Diagnostic radiation procedures, safety assessment, regulatory control


How to cite this article:
Parthasarathy K S. Dr AK Ganguly Memorial Oration. Radiat Prot Environ 2010;33:88-93

How to cite this URL:
Parthasarathy K S. Dr AK Ganguly Memorial Oration. Radiat Prot Environ [serial online] 2010 [cited 2022 Jan 17];33:88-93. Available from: https://www.rpe.org.in/text.asp?2010/33/3/88/86261


  1. Introduction Top


At the very outset, I wish to place on record my deep appreciation and gratefulness to the office bearers of the Indian Association for Radiation Protection (IARP) for inviting me to deliver Dr A K Ganguly Oration this year. Dr Ganguly was an outstanding scientist.

After securing a Ph.D from Calcutta University, Dr A K Ganguly worked with Prof John L. Magee at the University of Notre Dame, Indiana, USA. He joined the Department of Atomic Energy (DAE) in 1956 as Head of the Radiation Hazards Control Section. A chemist by training, he progressed into an outstanding environmental scientist committed to the protection of people and environment.

He set up a fine group of health physicists to cover the entire nuclear fuel cycle. He guided them on topics such as fission physics, radiation shielding, environmental impact of nuclear installations etc. They did outstanding work. I came into close contact with Dr. Ganguly during 1973-1978 and later during 1984 while he chaired the AERB's Advisory Committee for Safety Research Projects and Programmes.

During late 1972, he held a review of the activities of the Directorate of Radiation Protection (DRP). Some of us felt that he was a bit harsh!! He appreciated my presentation on the special problems in enforcing safety in medical radiation procedures. I thought that it is appropriate to chose "Safety in medical radiation procedures: developments over the past four decades" as the topic for the AKG Memorial Oration this year.


  2. Medical Radiation Procedures Top


The medical radiation procedures included radiotherapy using Co-60 units, Accelerators and brachy therapy units (manual and remote after-loading) and diagnostic radiology procedures including those with conventional X-ray equipment, CT units, dental, mammography and interventional radiology equipment and nuclear medicine.

Over the years, the regulatory control over radiotherapy equipment in India has been established satisfactorily. I intend to cover mostly the regulatory control diagnostic X-ray equipment in this lecture.

During the late 70s, Dr Ganguly encouraged me to write popular science articles while many others discouraged me! You may recall that writing articles in newspapers was then considered a risky venture. On my return from the UK, where I went as a Colombo Plan Study Fellow in the University of Leeds, I was shocked to see the abject negligence with which medical X-ray equipment is handled in India.

During my formative years in the DRP, I accompanied many senior officers and learnt how to carry out radiological protection surveys of medical X-ray installations. During the 60s, the officers from the erstwhile DRP used to prepare booklets giving all the details of measurements done during the surveys. These were remarkable source books for those who cared to read them.

Later, I led several teams of officers to survey X-ray installations. These were purely voluntary efforts. Except some indirect enabling provisions in the Radiation Protection Rules 1971, there was no mandatory provisions for formal regulatory control of medical X-ray installations, though every one new that these sources exposed large sections of the populations to avoidable radiation exposure. I got my medical physics training under Professor F W Spiers, a pioneering medical physicist who contributed significantly to make radiation protection of medical sources a respectable activity.

While I discussed the radiation protection issues with Dr Ganguly, I suggested that there is a growing need to inform the members of the public about radiological protection issues, particularly in the field of diagnostic radiology.

"Who prevents you from doing it?" Dr. Ganguly asked

I wrote the first article in the evening newspaper called "The Mail" published from Chennai. It was titled "Medical X-rays: A note of caution, (The Mail May 14, 1977). It described the status of radiation safety in medical X-ray installations. We sent different versions of the article and brief ideas from it to other publications. Nearly 60 dailies, monthlies and other publications published different versions of the article. It included "Caravan", Eves weekly", Readers Digest among others. It was translated into Tamil, Kannada, and Marathi & Malayalam. The Deccan Herald (July 3, 1977) published the best version.

The article described the status of radiation safety in medical X-ray installations. The items covered were: Crowding in X-ray room; Improper planning; lack of protective accessories among others. The article listed the deficiencies observed in nation- wide surveys of medical X-ray installations


  3. Radiation Safety Status 1957-1983 Top


Regulatory control of medical X-ray equipment and installations was purely voluntary for the first few decades. Though it was advisory in nature, it covered radiological safety surveys of a few thousand institutions in different States. Though the agency offered advice on safety improvements, there was no dedicated follow up on these programmes to verify whether the institutions implemented them.

Erstwhile DRP conducted over a few years several short term training programmes on safety aspects in the medical applications of ionizing radiation. The agency also offered a personnel monitoring service based on film badges for a few thousand institutions. The service included over exposure investigations as and when they were identified in the institutions.

DRP and later, the Division of Radiological Protection, Bhabha Atomic Research Centre (DRP/BARC) developed systematic procedures for quality assurance of X-ray equipment used in the field. It also fabricated some of the essential tools to carry out the studies.

The legal frame work for regulatory control of medical X-ray equipment and installation was virtually non existent. Atomic Energy Act 1962 (33 of 1962) referred to the regulatory control in the use of radiation generating plant by rules. There was no immediate follow up on implementing this provision. Radiation Protection Rules 1971 (RPR 1971), the first set of rules for enforcing special provisions for radiation safety promulgated under the Atomic Energy Act did not refer to medical X-ray units. This may be because of the lack of resources to initiate effective measures to control this important source which was being used virtually unbridled across the nation.

RPR 1971 did contain regulatory control of radiation installations. For this, the RPR 1971 gave powers to the competent authority to specify surveillance procedures for radiation installations. The competent authority was expected to identify the radiation installations. RPR 1971 did not also refer to regulatory control of nuclear fuel cycle facilities including nuclear power plants. This may be because these facilities are owned and operated by the Central Government. RPR 1971 specifically referred to issuing licences to users of radioactive substances.

As soon as the Atomic Energy Regulatory Board was set up in November 1983, there was a suggestion that AERB should focus it's attention on regulatory control of medical X-ray units primarily because radiation safety in nuclear facilities was being effectively implemented by the Safety Review Committee of the Department of Atomic Energy (DAE/SRC). As per the constitution of AERB, DRP/BARC was expected to assist AERB in enforcing radiation safety in radiation installations out side DAE. DRP carried out this function mainly by organizing a few training programmes and conducting surveys. DRP also carried out the assessment of genetically significant dose to the population by measuring the gonadla doses to patients undergoing X-ray examinations in different hospitals located in different States.


  4. AERB'S Efforts Top


At the very out set, AERB identified the legal infirmities in initiating the programme. Pending revision of RPR 1971, the Board issued a gazette notification prescribing the surveillance procedures for medical applications of radiation, 1989 (GSR 388 dated June 3, 1989) under Rule 15 of RPR 1991. It also issued a safety code on diagnostic X-ray equipment and installations. AERB published a Safety Manual:  Atlas More Details of Reference Plans for Medical Diagnostic X-ray Installations 1986.

These documents covered essential steps to initiate an effective radiation safety programme in the use of medical X-ray units. AERB assisted BIS in publishing the following standards:

Standard for Diagnostic X-ray Equipment (Part-III): Radiation Safety IS-7620, 1995

Standard for Dental X-ray Equipment: Radiation Safety IS-13709 (1993)

Dr A K De, the first Chairman of AERB initiated several steps to kick-start the programme. In 1986, AERB organized a national seminar on "Radiation Exposures in Medical X-ray Practices: Consequences and Control" in Mumbai. The invitees included the Directors of Health Services, Directors of Medical Education, Secretaries of the Departments of Health and Family Welfare, Director General from the Directorate General of Health Services (DGHS), officers from the Bureau of Indian Standards, X-ray manufacturers and Vendors, radiological safety officers among others. After two days' deliberations, the seminar recommended that AERB should start a centralized X-ray control programme.

The Board set up a task group which reviewed the safety status in the use of medical X-ray equipment in the country and made suitable recommendations. Dr Arcot Gajraj, eminent radiologist and former Director of Bernard Institute of Radiology, Chennai chaired the task force which had representation from AERB, BARC and DGHS. The Board implemented several recommendations of the task group. These included type approval of X-ray equipment, organization of training courses and publication of a code and a Manual. Type approvals which examine the built-in safety features of X-ray equipment started systematically. AERB sent the list of type approved X-ray equipment to various States.

AERB sent it's own survey teams to a few hospitals in Mumbai. These teams confirmed that the safety status is not satisfactory. AERB offered funds to several hospitals to carry out radiological safety surveillance of a few thousand X-ray units. The programme was in two phases. In the second phase, the researchers from hospitals in different parts of the country measured radiation doses in typical X-ray examinations. There were wide variations. But they were mostly within the Guidance Levels recommended by the International Atomic Energy Agency (IAEA). But this is not enough; we must ensure that the doses are As Low As Reasonably Achievable (ALARA), without losing clinical benefits.

There was considerable improvement in the safety status in India. There is renewed awareness in the field. All over the world, including India, the safety measures in medical radiation procedures appear to be not receiving due attention.

I would like to draw your attention to a series of articles published in the New York Times recently; the latest one was in January 2010. They referred to mishaps in radiotherapy.

The news got wide media coverage as it was published in the mainstream media. IAEA and ICRP published documents on such mishaps in 2000. In 2003, I gave a lecture on the topic at the Annual meeting of the Association of Radiation Oncologists of India (AROI) at Cochin. I wrote two articles in the Hindu; they were titled "Accidental exposures in radiotherapy (The Hindu, March 4, 2004) and "Errors in radiation treatment of cancer" (The Hindu July 15, 2009).


  5. Safety Status 1993-1996 Top


While reviewing the progress in the implementation of a comprehensive radiation safety programme in the field of diagnostic radiology, we saw that it was a daunting task. We did not know how many units were available in the country. Dr. A Gopalakrishnan who took over as Chairman, AERB initiated steps to carry out a nation-wide survey of diagnostic X-ray units.

AERB entered into an MOU with Council of Industrial Research (CSIR) and Defence Research and Development Organization. AERB with the support of DRP/BARC trained 125 officers from DRDO and CSIR to carry out a basic survey of X-ray installations nation wide. These officials were located in different States. They visited X-ray units in their area and collected very important basic information on the type of units, shielding materials used, and qualifications of the staff among other details.

Before starting the project, Chairman, AERB contacted district authorities on the programme seeking their support. He made use of the nation-wide NICNET service for the purpose. For the first time, AERB could collect safety-related details of over 30,000 X-ray units. AERB initiated some follow up to correct the obvious deficiencies observed in the survey. The programme revealed that nearly 30% of the Units are above 15 years old. It also highlighted the need for providing more detailed recommendations to those who operated the Units. The survey once again confirmed various safety related issues.

AERB prepared a list of institutions State-wise. This was useful for further follow up with State Governments. The need for decentralizing the regulatory efforts became obvious


  6. Directorate of Radiation Safety Top


Kerala State showed interest to start an independent agency to enforce the radiation safety guidelines of AERB in the X-ray installations in the State. This was the outcome of the discussions I had with the medical physicists and radiological safety officers at the Regional Cancer Centre (RCC), Thiruvanathapuram. (Late) Dr T P Ramachandran played a key role in the negotiations. Whenever any question on radiation safety in the State was raised by anyone it was invariably referred to RCC for comments.

Earlier, there were proposals to decentralize regulatory control of medical X-ray installations by asking the help of State Governments. It did not progress much. When the proposal came from Kerala, Dr. A. Gopalakrishnan the then Chairman, AERB held discussions with Shri Gopalkrishna Pillai, the then Secretary, Department of Health and Family Welfare, Government of Kerala. I assisted them by providing the technical inputs. Government of Kerala set up a committee to prepare a project document. Shri P K Ghosh and I served in the Committee. Kerala Government issued a gazette notification setting up the Directorate of Radiation Safety (DRS); the committee report was a part of the notification. The Board reviewed the project document and suggested some changes. AERB submitted the proposal (to delegate some authority to the State Government) to the Atomic Energy Commission which approved it in one of it's meetings.

AERB delegated the authority to inspect the X-ray installations in Kerala to DRS by exercising the powers vested in it under the Radiation Protection Rules 1971. AERB is currently trying to popularize the project in other States. The project document serves as a bench mark in carrying out further follow up with other States


  7. Arrival of New Technology Top


Arrival of modern CT Units and interventional radiology units call for greater attention as these deliver relatively high radiation doses to the patients. Admittedly these are very useful diagnostic tools if they are used in clinically indicated cases. In such instances, the benefit from imaging exceeds any possible radiation harm. In view of the possibility of the patient receiving high radiation doses, the quality assurance procedures for them must be diligently applied. Atomic Energy (Radiation Protection) Rules 2004 which graded the regulatory documentation as per the risk potential of the practice has included CT scan units and interventional radiology equipment in the highest category of licensing.

My tryst with CT scan units started more or less with the time these units were commercially available. Professor Bill Spiers, my guide for Ph.D at Leeds University announced the advent of CT in June 1972 in our journal club shortly after a meeting of the British Institute of Radiology. I recall that he invited an obscure professor to talk about CT. The lecture was disappointingly boring! He spoke on the mathematics of image construction used in CT. We never thought that CT will develop into such a unique diagnostic tool.

CT helps to plan and assess the results of surgery. It helps to plan and administer radiation treatments for tumours. CT is very useful to carry out cardiac studies. Though, there are controversies surrounding it's use in some instances as the required, clinical justification is yet to come, the clinical trials now going on may settle the issues surrounding it's use in scanning patients suffering from different disease conditions


  8. Surge In CT Use Top


There was a surge in the uncontrolled use of CT equipment in all advanced countries. Since insurance companies do not reimburse money unless the procedure is prescribed as an acceptable standard, many physicians tend to encourage patients to undergo CT scans which are personally-initiated. This procedure became very controversial and in UK the personally-initiated CT scan procedures themselves came under scanner. The UK Committee on Medical Aspects of Radiation, COMARE published a report on the topic on December 19, 2007; A few physicians were marketing CT use to give peace of mind to the patients! COMARE demanded that CT scanning of asymptomatic individuals should be stopped; the committee noted that it is not possible to optimize exposure parameters for whole body CT.

It was found that of the 62 million CT exams done in the USA in 2007, 30% are unnecessary. An AERB funded study limited to Tamil Nadu indicated that 2140 patients undergo CT exam daily; they use 127 CT scan units. For 2000 units in India assuming that they are in use for 300 days per year, the annual exams in the field of CT scanning will be about 10 million.

One of the important observations was that the same exposure factors are used for children as for adult in many countries. The resulting radiation dose is 5 times high. Children are more sensitive to radiation as their cells are in the growing stage. Also effects may manifest because of their longer life. If an old patient is exposed, he may die before the adverse effect, if any, due to radiation manifests itself.

Use of improper technique factors for examining children and related issues were covered in eight papers in the American Journal of Roentgenology in 2001. The US Food and Drug Administration) published an advisory on the topic in November 2001. AERB brought the advisory to the notice of over 400 CT centres in December 2001.


  9. What Can Operators Do? Top


X-ray operators/technicians must use separate technique factors for children. By appropriate measures they can reduce dose to the children by a factor of 5 or more. It is most essential that they must choose appropriate selection of image reconstruction parameters. The technicians must record the doses and the exposure factors.

Realizing the safety significance of paediatric imaging, 13 professional societies started "Alliance for Radiation Safety in Paediatric Imaging" as a proactive measure. These included the American Association of Physicists in Medicine, the National Council for Radiation Protection, the American College of Radiology, the American Society of Radiation Technologists and Society of Pediatric Radiology; Radiological Society of North America among others, The Image Friendly Alliance got endorsement from 52 associations.

An AERB funded study revealed that 2.8% of the examinations are paediatric. This works out to be about 2.8 lakhs per year; another study showed that 12% of studies in a in a single centre was pediatric. Internationally 11% of examinations are shown to be paediatric. An AERB funded survey found that 32 out of 71 units only had paediatric protocol. On this basis, it is estimated that 1.53 lakhs children in India get excess dose annually. High doses are given to patients due to negligence, improper work practices and lack of knowledge of radiation safety.


  10. If Roentgen Visits Us Now! Top


A few weeks ago, in a PTI feature, I wrote about the possibility of Professor Roentgen visiting us in a hospital. We have to tell the old professor that medical imaging is done at times to improve the bottom lines of the budgets of some institutions; "Not for medical sense but for business cents" some one commented! Some physicians advertise to get more patients. They scare "the worried well", at times with anecdotes of rare findings. At times, CT Screening is done without any scientific evidence of clinical benefit. Radiation doses are received as extra bonus!


  11. CT Advertisement Top


In one of the TV programmes, Oprah Winfrey, the well known TV anchor gets a blanket assurance "Your heart is perfect," from Dr. Andrew Rosenson, a cardiologist who did a CT scan of her heart.

He says. "You have the heart of a 19-year-old." If you know how influential Oprah is among vast sections of women in USA you may realize the advertising potential of such a programme.

Bill Clinton, former President of USA experienced chest pain; it was a fit case for intervention. Pro-CT specialists argued that Bill Clinton must have gone for CT screening, so that his condition would have been known earlier. He had undiagnosed heart disease. For those who knew the disadvantages of CT screening, the suggestion is not appealing. You may have to screen thousands of symptom-less patients to identify one for whom the test will be beneficial. In such instances, we must also consider the harm due to X-ray exposures.

Two hospitals in Mumbai advertised CT Scanning of symptom-less persons. Among other indications, they asked those who over work should undergo CT scans. The Mumbai Mirror, a daily published a colourful advertisement. `Know in time,' the heading splurged in bold letters, `Heart study in 8 seconds.'

An advertisement in The Times of India intoned that `Now discovering the state of your heart vessels is as quick and easy as having a cup of tea.' The advertisements persuade a potential patient to believe that a computed tomography (CT) procedure to evaluate the heart would be beneficial. Any CT procedure is unjustified, if it is not medically necessary.

One of the clinics invited people with some "universal" risk factors ("stress", erratic life style, long working hours, "pressure") for the test!. Any city dweller may suffer any one or more of the risk factors listed. The Clinic aimed at mass screening of patients. I wrote about it as a rapid response feature in the British Medical Journal. Times of India quoted me extensively based on my BMJ article. I also published an article titled "CT screening unjustified" in The Hindu (January 5, 2006). Roentgen may react!

Another hospital owning a CT Scan Unit claimed a correlation between conventional angiography and CT angiography based on one patient! The hospital cleverly used a letter from a member of the faculty of PGI, Chandigarh for propaganda. I took it up with him. He responded and promised to withdraw it.

CT angiography cannot replace conventional angiography at present. CT angiography gives false positives (10%) and wrong diagnosis (15%).

In USA some physicians formed a special group called Society for Heart Attack Prevention and Eradication (SHAPE). They wanted to follow their own guidelines in cardiac screening. Their guidelines were not supported by professional associations.

It is interesting to realize certain events in USA to appreciate the background. CT companies sold 5000 CT units at $2 million apiece. Owners have vested interests. Centers for Medicare and Medicaid Services (CMS) in USA tried to control the proliferation of CT angiography and lost. Intense lobbying by physicians and manufacturers led to the intervention by 79 members of the House of Representatives against the case made by CMS.

Cardiologists and radiobiologists are currently trying to push an "anti radiation pill". It is very intriguing to note that the promoters of the pill are cardiologists and radiobiologists.

There is no clear scientific evidence that the pill works; the promoters are suggesting arbitrary protocols and dosage for the pill. The company markets two types of pills one for radiation workers and aircrew and another for patients and air passengers!

The British Medical Journal has accepted my feature article on the pill (Recently, I received a rejection note from the BMJ informing me that they cannot publish the paper as they received legal opinion against publishing it. The libel laws in the UK are very stringent. The development showed the soft underbelly of a commercial publication!)


  12. Mammography, Interventional Radiology Top


Another important area of concern in radiation protection is mammography. AERB funded BYL Nair Hospital to carry out a project which involved radiological protection survey of over 30 institutions carrying out mammography. The project revealed many correctable deficiencies. Overall safety status in this field is not satisfactory. In some cases, the mean glandular doses to patients were found to be high. There were also high rejection rates of tests leading to repeat examinations. AERB must review the project to set the conditions right.

Interventional radiology is yet another area of importance. A few workshops revealed several problems. AERB must concentrate their efforts on this unregulated area. Cardiologists have virtually no training in radiology. IAEA has shown that some of them suffer from pre- cataract conditions. The radiation doses to cardiologists carrying out interventional radiology procedures tend to be high. It is difficult to train these groups which are extremely busy in their profession. AERB must organize awareness programmes at the conferences of cardiologists. All over the world the progress in regulatory control of this field is very slow.


  13. Articles in Newspapers Top


It became clear that there is a need to inform public about the safety status of CT and pediatric radiology internationally. It is essential that since professional associations are not taking any interest in the area, public should be informed about various factors. With this end in view, I have published a series of popular science articles on the topic.

  1. CT scan risk to children (The Tribune, December 20, 2001)
  2. CT: reducing risk to children (The Hindu, February 8, 2007)
  3. Image gently, bring down CT dose to kids (The Hindu March 6, 2008)
  4. Scientists find direct link between CT scan and cellular damage (The Hindu, August 18, 2009)
  5. Angiography: CT not as effective as conventional (The Hindu Dec 18, 2008)
  6. Routine use of CT to screen for lung cancer risky (The Hindu, September 13, 2007)
  7. Using CT for screening unjustified (The Hindu January 5, 2006)
  8. Routine CT screening can be dangerous (The Tribune Oct 17, 2002)
  9. Do cancers soar with CT scans (The Hindu, Nov 6, 2007)
  10. CT scans: safety issues (The Tribune, January 4, 2008)


I also continued to provide updates whenever any journal published new information on the topic.


  14. Conclusions Top


CT is a very useful technique; but it is not without risk; risk is small; we need not take the risk if it is not essential. Before scanning, parents must ask whether the technologists are using separate adjustments of technique factors for children. If the unit does not have them, they may request the physician to refer the child to another unit which has the facility. Accept the scanning with a unit without child protocol only in a life and death situation. Then the risk from excess dose will be less than the immediate risk. All installations must follow Atomic Energy (Radiation Protection) Rules 2004 and AERB safety codes in letter and spirit. The rules cover the need for Type approval, QA and, licence. In view of the potential for high doses, CT Units need a licence to operate.

In conclusion, I would like to pay my homage to Dr. Ganguly who was a mentor for those who accepted radiation protection as a mission. Because of his insistence, radiological protection in the field of industrial gamma radiography became the first area which was covered by notable and effective regulatory frame work.. RPR 1971 along with the "Surveillance procedures for industrial gamma radiography, 1980" provided this frame work. Dr Ganguly often stressed the safety significance of medical radiation procedures particularly diagnostic radiation procedures. We have done a lot. But we have miles to go to reach the final goal.




 

Top
   
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
1. Introduction
2. Medical Radia...
3. Radiation Saf...
4. AERB'S Efforts
5. Safety Status...
6. Directorate o...
7. Arrival of Ne...
8. Surge In CT Use
9. What Can Oper...
10. If Roentgen ...
11. CT Advertisement
12. Mammography,...
13. Articles in ...
14. Conclusions

 Article Access Statistics
    Viewed2591    
    Printed123    
    Emailed2    
    PDF Downloaded342    
    Comments [Add]    

Recommend this journal