Monday, March 2, 2020

Will patients accept x-rays without gonad shielding?

- Jennifer Middleton, MD, MPH

For decades, patients have come to expect shielding of their pelvises when receiving x-rays. This norm has been challenged by the radiology community over the last year as not only unnecessary but potentially harmful, and perhaps some of your patients have had a similar experience to mine where I was not offered a shield during an x-ray two weeks ago.

The American Journal of Roentgenology published "Patient Shielding in Diagnostic Imaging: Discontinuing a Legacy Practice" last year. In this review article, the authors discuss the original intent behind shielding - to lower the risk of germ-line mutations within gonads - along with decades of data showing no such risk has ever been substantiated. Additionally, shields can make it more difficult for radiologists to interpret x-rays, and the authors raise concern regarding most modern x-ray equipment's automatic exposure control settings, which may inadvertently increase the radiation dose in response to the presence of shielding. Since this article's publication, the American Association of Physicists in Medicine released a position statement asserting its agreement with discontinuing routine pelvic shielding during x-rays. Consequently, the US Food and Drug Administration is considering amending the regulations around x-ray shielding as are, according to this NY Times article, regulatory bodies in both Australia and Canada.

Patient acceptance of these changes may be more variable. Much of the lay public remains concerned about radiation safety; concerns about the safety of mammography contribute to its underuse for breast cancer screening, and a study by the US National Cancer Institute estimated that 65% of the general public worries about the safety of medical imaging. In an era where mistrust of medical care is already common, removing a perceived safety measure may be a sizable barrier for regulatory bodies and health systems to overcome. Preemptively anticipating our patients' concerns when ordering x-rays may be one first step for us as physicians; working collaboratively within our health systems to ensure that the decisions and messaging around this issue are scientifically based may be another.

And, of course, many patients still receive x-rays that are unlikely to be of benefit; a quick search of the AFP Choosing Wisely database reminds us that most pre-operative chest x-rays, imaging for acute low back pain, and x-rays for plantar fasciitis are not helpful. The AFP By Topic on Point-of-Care-Guides includes several evidence-based algorithms to guide your diagnostic imaging decisions as well.