The Effect of Diagnostic, Therapeutic and Accidental Radiation on Children 1

The Effect of Diagnostic, Therapeutic and Accidental Radiation on Children

Kristen Johnson

December 5, 2018

Radiation Biology and Radiation Protection 4670

The Effect of Diagnostic, Therapeutic and Accidental Radiation on Children 2

Children’s Exposure to Diagnostic Medical Radiation and Cancer Risk: Epidemiologic and
Dosimetric Considerations

Linet MS, Kim KP, Rajaraman P. Children's Exposure to Diagnostic Medical Radiation and Cancer
Risk: Epidemiologic and Dosimetric Considerations. Pediatr Radiol. 2009;39 Suppl 1(Suppl 1):S4-
26.

Summary:

The exact etiology of pediatric cancer is unknown, but certain chemotherapy agents,

specific genetic disorders, and epidemiologic studies have repeatedly found an association

between exposure to diagnostic ionizing radiation during pregnancy and the risk of childhood

cancer in children. The risk of the offspring getting cancer later in life from diagnostic radiation

exposure depends on factors such as what trimester the mother is in, the number of films or

the amount of radiation the pregnant mother is exposed to, what imaging procedure is being

done and so on. Epidemiologic studies have been done to measure pediatric and lifetime

cancer risk from prenatal to early childhood exposures from ionizing radiation including

diagnostic imaging, computed tomography and and fluoroscopy.

In earlier years, there were a lot more obstetrical radiologic procedures before the

1970s when non-ionizing radiation imaging was introduced: sonography or ultrasounds. This

new technology resulted in a significant reduction of early life exposure of ionizing radiation to

pregnant women and their unborn children. But, sometimes these women need CT scans, or x-

rays if they have non-obstetric medical conditions such as renal colic, appendicitis and injuries

from trauma, etc. Many case-control studies have evaluated risks of pediatric cancer in

offspring of mothers who underwent diagnostic radiological examinations during pregnancy.

The Oxford Survey of Childhood Cancers (OSCC) case-control study in the UK first reported a
The Effect of Diagnostic, Therapeutic and Accidental Radiation on Children 3

statistical significance 1.6-fold and 2.1-fold mortality excesses in pediatric cancer (based on

1,299 total childhood cancer cases and 1,299 control children) comparing the offspring of

women who underwent diagnostic radiological medical exams and offspring of women who did

not undergo diagnostic radiological medical exams. Following up after 12 years, the OSCC

found a 6-fold more total childhood cancers (8,513 cases) for those mothers who underwent

diagnostic procedures while pregnant. Another case-control study was carried out in the U.S.

where investigators found a 1.4-fold and 1.6-fold increases in total childhood cancer deaths

(involving 556 pediatric cancer patients) between the offspring of women who underwent

diagnostic radiological medical exams and offspring of women who did not undergo diagnostic

radiological medical exams. These original U.S. findings were confirmed in an expansion that

included double the population of children coming to the same significant results. The OSCC

and other case-control studies went even further to assess the risks of particular exams of the

pregnant women and the cancers associated with their offspring.

This all comes down to these unborn fetuses and children being more sensitive to

radiation than the adult population. Also, the fact that they have a longer life expectancy, so a

longer time to show the cancer occurrence compared to adults. It is important to have reliable

research on estimates of radiation doses the fetus and child are receiving from common

diagnostic procedures and how they will be effected later in life.

Assessment:

Children’s Exposure to Diagnostic Medical Radiation and Cancer Risk: Epidemiologic and

Dosimetric Considerations is a peer-reviewed journal. This journal is a systematic review

The Effect of Diagnostic, Therapeutic and Accidental Radiation on Children 4

composed of secondary data from meta-analyses and past case-control studies. I thought this

was a very interesting and informing journal to read. As far as the research methods, they took

past data. But, I thought they did good as they compared multiple past studies to back up the

data with evidence. When reviewing the studies and sources they got their information and

records from, they seem to be very reliable sources. The journal was organized well and

divided up nicely, so it was easy to follow and read. This journal was both valid and reliable. It

was reliable because they compared multiple studies that came to the same conclusion. The

journal was valid because the sources used measured the effects of radiation on an offspring.

This is relevant to my clinical practice because it emphasizes the impact diagnostic

radiation, like our CT Simulations, can have on a pregnant woman and her offspring. It is so

important to ask the woman, if they are in child bearing age, if they are pregnant. In some

opinions, it should become a standard to make these women, of child bearing age, take a

pregnancy test. If a CT Simulation is necessary for radiation treatments for a pregnant woman

under extenuating circumstances, then there needs to be extra precautions. This would only

happen when the benefits of the CT scan clearly outweigh the potential risks. Depending on

the area of the scan and how far, or not far along they are, the doctor might recommend an

abortion. If they are scanning the pregnant mom’s head, for example, and are further along in

the pregnancy, they might be able to proceed making sure they aren’t scanning to far away and

might try to shield the abdomen with lead or a High-Z material.

The Effect of Diagnostic, Therapeutic and Accidental Radiation on Children 5

Radiation-Related Treatment Effects across the Age Spectrum: Differences and Similarities or
What The Old and Young Can Learn From Each Other

Krasin MJ, Constine LS, Friedman DL, Marks LB. Radiation-Related Treatment Effects Across the
Age Spectrum: Differences and Similarities or What the Old and Young Can Learn From Each
Other. Semin Radiat Oncol. 2010;20(1):21-9.

Summary:

The acute and late normal tissue effects from radiation treatments are what limits the

safe and therapeutically-optimal radiation dose for both adult and pediatric cancer. This is one

of the major clinical problems today; trying to limit these side effects from irradiating the

normal tissue, but also delivering enough dose to the tumor for cancer control. Tools like

conformal treatments vs IMRT treatments have increased our understanding on radiation

induced normal tissue effects. Adults and children have some similarities and differences when

it comes to common normal tissue effects. Studying the differences across the age spectrum

will advance the improvements of late normal tissue results for our patients.

When delivering radiation treatments to adults and pediatrics the concept is the same,

but there are normally different methods used for the differences in age. For both age groups

they have the same goal of getting a conformal and the prescribed dose to the tumor, while

sparing the normal tissues as much as possible. But, you also have other factors to consider like

life expectancy and the sensitivity of the tissues. It makes it harder to consider all of the

options and balance them all out. Some important factors to consider include field size, dose

per fraction, total dose, and the technique of delivering the dose. Normally children are

treated with smaller field sizes, smaller doses per fraction with an overall lower dose, and with

a conformal treatment or with IMRT instead of VMAT trying to limit the integral dose. This is
The Effect of Diagnostic, Therapeutic and Accidental Radiation on Children 6

not everything the doctors and treatment planning team takes into consideration, just some of

the important factors.

Late effects are also different in adults and children. In adults, late effects are normally

considered either to be present or absent; and normally appear in a relatively shorter time

compared to pediatrics. On the other hand, children, who are still growing and developing at

the time of treatment, can have a later onset of these late effects. Since these late effects

evolve overtime, the severity is normally graded in children and have follow-ups throughout

their life.

Two examples of late effects include radiation related lung effects, like pneumonitis,

and bone or skeletal effects from radiation therapy. With lung treatments, adults normally get

treated in the area where the cancer is, but in pediatrics their whole lung is most commonly

treated for metastatic Wilm’s or Ewings disease. It is important to measure the mean lung dose

and the volume of the lung receiving a certain amount of dose above threshold in both adults

and pediatrics. The probability of of getting these lung effects in adults depend on the health of

that patient and if they have any confounding health concerns. Rather most children do not

already have pre-exciting health concerns, like cardiac arrhythmia, COPD and and pulmonary

embolism. Understanding how the quality of life is affected beyond five years could support or

change the approaches to be used in the treatment. Bone, on the other hand, is not frequently

considered a dose limiting structure in adults, but is for pediatrics. Bones are still growing and

developing making them more sensitive in children. Possible toxicities include: fracture,

osteoradionecrosis, and growth retardation. For adults, the mandible is given special

consideration in H/N treatments because of the limited blood supply and its necessary function.
The Effect of Diagnostic, Therapeutic and Accidental Radiation on Children 7

Weight bearing bones also need consideration for adults and children because of the potential

necrosis or fracture. Also in children it is important to consider how treating bones could lead

to alterations in growth, potentially stunting their growth or leaving them with malformations.

For example, you would not want to treat half a vertebral body especially on a pediatric

patient. This could lead to scoliosis as they continue to grow and develop.

There are many important factors to consider when treating patients. But, there are

even more factors to consider when treating a pediatric patient. It is important to find the

perfect balance between tumor control and normal tissue effects. Children are growing and

developing and have sensitive tissues creating a challenge. They also have a better chance of

living to have to deal with the late effects.

Assessment:

Radiation-Related Treatment Effects across the Age Spectrum: Differences and

Similarities or What The Old and Young Can Learn From Each Other is a peer-reviewed journal.

This is a meta-analysis based on secondary research from research comparing pediatric and

adult radiation treatments. They had data from past patients comparing the likelihood of

getting a particular side effects for specific age ranges. Then, they came to their own

conclusions.

I think this was a well thought out journal. They made all their points and supported it

with data. The journal was very detailed when explaining what all extra planning takes place

when treating a pediatric vs an adult patient. This journal was valid because it measured what

it was suppose to: the differences in adults and pediatrics undergoing radiation therapy
The Effect of Diagnostic, Therapeutic and Accidental Radiation on Children 8

treatment and the side effects associated with each. This journal is also reliable because they

have data to back up their conclusions.

This article is relevant to my clinical practice because we treat adults everyday and

pediatric patients commonly. As a therapist, we are not in charge of coming up with the

treatment plans, but are a ‘last or final check’ meaning we are the ones to look at and review

the plans right before treatment. If something looks odd or different, we have the chance to

question or verify it right before treatment. We also are the ones in charge making sure the

child does not move during treatment, if they are not under anesthesia, making sure we are

treating were we are planned and not irradiating more normal tissue. When it comes to

pediatric radiation treatments, it is important to be extra careful.

The Effect of Diagnostic, Therapeutic and Accidental Radiation on Children 9

Pediatric Exposures to Ionizing Radiation: Carcinogenic Considerations

Kutanzi KR, Lumen A, Koturbash I, Miousse IR. Pediatric Exposures to Ionizing Radiation:
Carcinogenic Considerations. Int J Environ Res Public Health. 2016;13(11):1057. Published 2016
Oct 28. doi:10.3390/ijerph13111057

Summary:

After an exposure to ionizing radiation, children are at a higher risk for developing

cancer. When an accidental exposure of radiation happens, for example, the largest nuclear

disasters: Hiroshima and Nagasaki, children require more attention following the incident than

adults because of their developing bodies and longer life expectancies. Both of these disasters

proved ionizing radiation as a carcinogen, or a substance that is capable of causing cancer. It is

established that children are more sensitive to radiation than adults, particularly with a higher

risk for developing the following cancers after an exposure: leukemia, brain, breast, skin and

thyroid cancers. This is due to the children’s tissues being more sensitive and easily mutated.

But, also because of their longer life expectancy after the exposure and allowing time for these

cancers to develop.

Leukemia was the first radiation-induced cancer following the nuclear bombing.

Approximately 3% of the people after the Japanese atomic bomb developed leukemia. The

peak incidence of leukemia was between 6-8 years after the bombing and it was primarily in

children. Analysis in the Life Span Study of Japanese atomic bomb survivors found “the excess

relative risk (ERR, the proportional increase of risk) for leukemia in children under age 10 at the

time of exposure peaked at about 70 per Gy of irradiation, while the ERR among those who

were exposed at the age of 30 and older was around 2.” There was also a big increase in
The Effect of Diagnostic, Therapeutic and Accidental Radiation on Children 10

incidence for thyroid cancer following the radiation exposure. This was the most common solid

tumor developed after the exposure, specifically due to the thyroid gland still being developed

in children, therefore making the tissues very sensitive to radiation. Most of the children

affected were 5 or younger at the time of the exposure and developed the cancer at a peak of 5

years later. Lastly, the incidence of other cancers increased after the bombing, especially

breast, skin, liver, kidney, and ovarian cancer. They found that girls who were exposed to this

radiation incident as a kid were more likely to develop breast cancer later down the line as

women.

After much research, in 1982, the United States Food and Drug Administration approved

the use of potassium iodide as a protective agent against radiation exposure and decreases the

risk of thyroid cancer. This is to be used in the hours following an exposure and if you are

under the age of 15. It is important to limit the amount of radiation humans receive. We know

there is a direct correlation in the chances of getting cancer after an ionization exposure,

especially in children.

Assessment:

Pediatric Exposures to Ionizing Radiation: Carcinogenic Considerations is a peer-

reviewed journal. This is a meta-analysis based on secondary research about the bombings that

took place in 1945 at Hiroshima and Nagasaki in Japan. This journal showed evidence that the

bombings caused an increased rate in radiation-induced cancers in the people affected, but

more so in children. A critique I would give this journal is to give more compelling evidence and

more statistics to back up their research. It would be more convincing showing actual numbers
The Effect of Diagnostic, Therapeutic and Accidental Radiation on Children 11

of those adults who developed this cancer vs how many children developed this cancer vs how

many in total were effected by the radiation to show a baseline. The research from the journal

was valid because it was getting data from the two radiation bombings, Hiroshima and

Nagasaki, and measured the effects it had on children and adults. It measured what it was

suppose to measure. This journal is also reliable because they were able to show how the

radiation affected so many people, not just a few random ones. It showed consistency in the

results.

This is relevant for my clinical practice because it shows how important it is to limit

unneeded radiation doses as much as possible, but especially when you are dealing with

children. This can include doing imaging on children only when necessary, and keeping

radiation therapy doses smaller to limit the dose of radiation to the child’s normal tissue.

Hiroshima and Nagasaki were considered ‘accidents’ of ionizing radiation. This can be

important when handling live sources in Brachytherapy to make sure there are no ‘accidents.’

It is important to take all the precautions so no one accidently gets more dose than prescribed,

or the wrong source inserted for treatment, for the incorrect amount of time and so on. There

are many precautions in place to avoid radiation accidents from happening in Radiation

Therapy departments.
The Effect of Diagnostic, Therapeutic and Accidental Radiation on Children 12

References:

1. Krasin MJ, Constine LS, Friedman DL, Marks LB. Radiation-Related Treatment Effects
Across the Age Spectrum: Differences and Similarities or What the Old and Young Can
Learn From Each Other. Semin Radiat Oncol. 2010;20(1):21-9.

2. Kutanzi KR, Lumen A, Koturbash I, Miousse IR. Pediatric Exposures to Ionizing Radiation:
Carcinogenic Considerations. Int J Environ Res Public Health. 2016;13(11):1057.
Published 2016 Oct 28. doi:10.3390/ijerph13111057

3. Linet MS, Kim KP, Rajaraman P. Children's Exposure to Diagnostic Medical Radiation and
Cancer Risk: Epidemiologic and Dosimetric Considerations. Pediatr Radiol. 2009;39 Suppl
1(Suppl 1):S4-26.

Links: (Instead of attached articles)

Journal 1: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2814780/

Journal 2: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2843498/

Journal 3: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5129267/