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Authors and Disclosures

Kenneth Hodson,1 Jason Waugh,1 Catherine Nelson-Piercy2

1
Directorate of Women's Services, Royal Victoria Infirmary, Newcastle upon Tyne, UK
2
Department of Women's Health, Kings College London, London, UK

Correspondence to
Kenneth Hodson Directorate of Women's Services, Royal Victoria Infirmary, Queen Victoria Road, Newcastle
upon Tyne, NE1 4LP, UK; kenneth.hodson@ac.uk

From Evidence-Based Medicine

Exposure to Diagnostic Radiation and Risk of Childhood Cancer
Overstated Risks Raise Unnecessary Concern

Kenneth Hodson; Jason Waugh; Catherine Nelson-Piercy

Posted: 12/05/2011; Evid Based Med. 2011;16(6):170-171. © 2011 BMJ Publishing Group

Abstract and Introduction

Abstract

Commentary on: Rajaraman P, Simpson J, Neta G, et al. Early life exposure to diagnostic radiation and
ultrasound scans and risk of childhood cancer: case-control study. BMJ 2011;342:d472.

Context

An association between in utero exposure to ionising radiation and childhood cancer, in particular leukaemia, was
first identified in 1956.[1] Subsequent studies have reported similar findings. [2 3] To date, all have retrospectively
interviewed mothers regarding exposure to diagnostic radiation and are therefore susceptible to recall bias. Little is
known about the effects of neonatal exposure to diagnostic radiation. The purpose of this study was to determine
whether exposure to diagnostic radiation and ultrasound in utero and during the first 100 days of life is associated
with childhood cancer.

Methods

A case-control study was chosen as childhood cancer is relatively rare in the UK, affecting 138. [6] per million
children under 14 years.[4] Cases were identified from the UK Childhood Cancer Study (UKCCS), a large
multicentre study of childhood cancer. For each case, two controls matched for sex and age from the same
population register were chosen. Parents of case and control children were questioned to determine social,
occupational and medical history. In utero and neonatal exposure to x-rays and ultrasound was determined from
medical records. Data were analysed to establish whether factors such as maternal age, smoking, socioeconomic
status, pregnancy order, pre-eclampsia, anaemia, multiple pregnancy, birth weight and admission to the neonatal
unit were potential confounders. Final models of analysis were adjusted for maternal age and birth weight.
Children with Down's syndrome were excluded from analysis because of the condition's known association with
leukaemia.

Findings

A small, non-statistically significant, increased risk for all cancers (OR 1.14, 95% CI 0.90 to 1.45) and leukaemia
(OR 1.36, 95% CI 0.91 to 2.02) following in utero exposure to x-rays was noted. Exposure to diagnostic
radiography in early infancy was associated with a similarly small, non-statistically significant, increased risk for
cancer (OR 1.16, 95% CI 0.83 to 1.62), leukaemia (OR 1.39, 95% CI 0.87 to 2.23) and lymphoma (OR 5.14, 95%
CI 1.27 to 20.78). There was no association between ultrasound and cancer risk.

Commentary

This study supports findings from previous studies which suggest an association between in utero exposure to x-
rays and childhood cancer. A large number of cases were studied, and elimination of confounding factors has been
attempted. Family history of cancer, however, does not seem to have been considered and is an obvious risk for
childhood cancer. The use of medical records eliminates recall bias but relies on accurate documentation of x-ray
exposure. It is fair to assume, however, that poor documentation is likely to affect cases and controls equally.

One should be cautious in accepting the conclusions of this study. It should be noted that the risks are small and
non-statistically significant. Given that the incidence of childhood cancer is low, the absolute risk increase is likely
to be minimal. As many of the ORs do not reach statistical significance, an alternative interpretation of the results
is that x-rays in pregnancy and early infancy are not associated with childhood cancer. Furthermore, the
conclusion that imaging in early childhood is associated with lymphoma is highly questionable given the small
number of children involved (seven) and the high incidence of prematurity and low birth weight in this group. It is
more likely that these factors play an influential role rather than x-ray exposure itself.

With advances in non-ionising diagnostic imaging techniques such as ultrasound and magnetic resonance, x-ray
examination of the abdomen or pelvis in pregnancy is rarely required. The majority of exposures in this study was
for pelvimetry, a practice that is now outdated. This study, therefore, does not apply to modern day imaging of
pregnant women. The authors are right to question whether CT is safe; however, they have ignored the fact that, in
pregnant women, this is usually limited to the chest and head, and conducted with lead shielding of the abdomen,
limiting fetal exposure considerably.[5] The benefits to the mother in diagnosing potentially fatal conditions such as
pulmonary embolism, subarachnoid haemorrhage and aortic dissection far outweigh the small, unquantified risk to
the fetus. Reluctance to image pregnant women is dangerous and is a contributing factor to maternal mortality. [6]
The conclusion that "caution is needed in the use of diagnostic radiation imaging procedures to the
abdomen/pelvis of the mother during pregnancy and in children at very young ages" can be viewed as potential
scaremongering and sends out the incorrect message that imaging in pregnancy and infancy is harmful when the
evidence does not support this.

References

1. Giles D, Hewitt D, Stewart A, et al. Malignant disease in childhood and diagnostic irradiation in utero.
Lancet 1956;271:447.
2. Wakeford R. Childhood leukaemia following medical diagnostic exposure to ionizing radiation in utero or
after birth. Radiat Prot Dosimetry 2008;132:166–74.
 3. Schulze-Rath R, Hammer GP, Blettner M. Are pre- or postnatal diagnostic X-rays a risk factor for
childhood cancer? A systematic review. Radiat Environ Biophys 2008;47:301–12.

4. Office for National Statistics. Cancer Statistics Registrations: Registrations of Cancer Diagnosed in 2007,
England. 2009:38.

5. Health Protection Agency. Protection of Pregnant Patients during Diagnostic Medical Exposures to
Ionising Radiation: Advice from the Health Protection Agency, The Royal College of Radiologists and the
College of Radiographers. London: RCR, 2009.

6. Centre for Maternal and Child Enquires. Saving mothers' lives: reviewing maternal deaths to make
motherhood safer: 2006–2008. BJOG: An International Journal of Obstetrics & Gynaecology 2011;118:1–
203.

Competing interests
KH is involved in a study utilising MRI during pregnancy. JW and CN-P have nothing to declare.
Evid Based Med. 2011;16(6):170-171. © 2011 BMJ Publishing Group