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Abstract

Medicine has been intimately associated with ionising radiation since the discovery of x rays in 1895; the first adverse effects of radiation were observed in persons working in research and on medical staff using x rays. Consequently, in 1925, the first International Congress of Radiology considered the need for a protection committee, which was established at its second congress in Stockholm in 1928 and is known today as the International Commission on Radiological Protection (ICRP). The first ICRP recommendations in 1928 were devoted to the protection of medical staff in the use of x rays for diagnosis and radiotherapy, and radium for radiotherapy. Later, ICRP devoted increased attention to the protection of patients, starting in 1970 with Publication 16 on protection of the patient in x-ray diagnosis, followed by three reports on the broad areas of radiation medicine: diagnostic radiology, radiation therapy, and nuclear medicine. A major change was made at the end of the 20^th Century with the introduction of a series of short reports, focussed on specific problems and addressing specific medical practices. Since then, as many as 20 reports have been published on issues such as prevention of accidental exposure in radiotherapy, avoidance of radiation injuries from interventional procedures, managing radiation dose in digital radiology and computed tomography, protection in paediatric radiology, and many others.

Keywords

Radiation injuries Accidental exposure Protection in medicine

1. DISCOVERY OF RADIATION AND THE APPEARANCE OF RADIATION INJURIES

Just a few months after the discovery of x rays in November 1895 (Röntgen, 1895), x-ray dermatitis was observed in the USA. Similar observations soon occurred in several other countries, including the UK and Germany (Lindell, 1996; Clarke and Valentin, 2005). In 1896, the identification of radioactivity (Becquerel, 1896) and the subsequent discovery of radium (Curie, 1898) took place, which led to many further cases of radiation damage. However, these unwanted effects suggested the idea of inflicting damage at will on selected tissues, paving the way for radiation therapy (Lindell, 1996). The first proven cures of patients with cancer were in Sweden in 1899 (Mould, 1993).

X rays were used by military field hospitals as early as 1897. The number of x-ray injuries escalated during the First World War when primitive mobile x-ray equipment was used in the field. In the following 10 y, many papers were published on tissue damage caused by radiation.

However, during the first two decades following the discovery of x rays and radium, lack of knowledge about the risks caused numerous injuries, and early radiologists often used their own hands to focus the beam of their x-ray machines. In addition to tissue reactions, skin cancer as a result of such exposure was described within 6 y of the discovery of x rays (Frieben, 1902).

The deleterious effects on hands and skin could be gruesome (as evidenced by the amputated hand of the German radiologist Paul Krause at the Deutsches Röntgenmuseum in Remscheid). Unfortunately, it soon turned out that effects could be lethal, and the well-known monument to ‘x-ray and radium martyrs’ in Hamburg, erected in 1936 by the German Röntgen Society, carries the names of several hundred medical workers of many nationalities who died from radiation damage (Molineus et al., 1992).

In the early 1920s, radiological protection regulations were prepared in several countries, but it was not until 1925 that the first International Congress of Radiology (ICR) took place and considered the establishment of international protection recommendations.

2. THE FIRST 30 YEARS FOCUSSED ON PROTECTION IN MEDICINE BUT EXCLUDING PATIENTS

When the first ICR was held in London in 1925, the most pressing issue was that of quantifying radiation, and the International Commission on Radiation Units and Measurements was created, although it was then named the ‘International X-ray Unit Committee’. The growing concerns about the effects of ionising radiation being observed in the medical community were discussed, and the need for an international radiological protection committee was recognised. The second ICR was held in Stockholm in 1928, where what is now ICRP was established under the name of the ‘International X-ray and Radium Protection Committee’ (IXRPC). Rolf Sievert, at 32 y of age, became the first Chair of the Committee (Lindell, 1996; Clarke and Valentin, 2005).

The parent organisation was and still is the International Society of Radiology, although the field of work of ICRP has widened from protection in medical radiology to embrace all aspects of protection against ionising radiation. IXRPC was renamed in 1950, taking its current name. Its recommendations form the basis for more detailed codes and regulations issued by other international organisations, and regional and national authorities.

2.1. The early series of recommendations

The first report was issued in 1928 and focussed on the protection of professionals working in x-ray diagnostic and radiation therapy, including protection from x rays, radium salt, and emanations from the radium sources. The recommendations were based on time (limitation of working hours and vacations), distance, and shielding, with one section devoted to electrical safety which was a critical issue at the time. The subsequent series of recommendations incorporated protection from external x-ray beam orthovoltage therapy up to 200 kV and ‘telecurie therapy’. These recommendations were published as papers in various scientific journals in the fields of medicine and physics (Lindell, 1996).

2.2. Start of the current series of publications and widening the scope of radiological protection

In 1959, ICRP started its own series of reports with Publication 1 (ICRP, 1959). Medical exposure was recognised under the categories of exposure, but the report stated that ‘No recommendations are given with regard to the dose to the individual from medical exposure.’ The report further stated that ‘It is expected that improvements in equipment and techniques may considerably reduce individual exposures, but the ever-expanding use of x rays may well increase the world population dose.’ This statement is still valid today. It is interesting to note that, referring to occupational protection, Publication 1 (ICRP, 1959) stated that with ‘present maximum permissible exposure levels, no special treatment of radiation workers with respect to working hours and length of vacation is needed’. This represents a significant change with respect to the initial recommendations.

The widening of the scope of work was stated in 1950 in the following way: ‘Although the primary responsibility of the Commission has been to the radiological profession, it has had to widen its scope and has accordingly been active not only during the last two ICR but also in the intervening period.’ The widening of the scope of the recommendations implied the recognition that the first 22 y of existence of ICRP (1928–1950) had been focussed on radiological protection in medicine, namely occupational and public protection.

2.3. Start of patient protection

The protection of patients remained excluded from the scope of ICRP until Publication 9 (ICRP, 1966), which, citing the 1962 and 1964 United Nations Scientific Committee on the Effects of Atomic Radiation reports, recognised that measures can be taken to reduce medical exposure without loss of medically important information. Soon after this statement, the first Task Group charged explicitly with patient protection in x-ray diagnosis was established, which produced Publication 16 (ICRP, 1970). This report addressed the following topics, with recommendations that are still applicable today: properties of the radiation beam; size and position of x-ray beam; shielding; antiscatter grids; sensitivity of the recording system; processing control and recording of radiation exposure; and reduction in number of retakes. The report also included the following statement: ‘The establishment of efficient measures for patient protection will in no way impede the continuing development of radiological diagnosis. It may be stated that, without exception, such measures contribute to the highest standards of clinical radiological practice.’ The current principles of radiological protection were established in Publication 26 (ICRP, 1977): justification of practices, optimisation of protection, and dose limitation to individuals. Dose limitation is not applicable to patients.

2.4. Renaming Committee 3 as ‘Protection in medicine’

In 1977, the Commission renamed Committee 3 to become ‘Protection in medicine’. This decision reflected a significant re-orientation of priorities, explicitly including patient protection: ‘The Commission considers that its relationship to the ICR and its traditional contacts with the medical profession warrant the establishment of a committee specifically concerned with radiological protection in medicine. Matters requiring particular attention by the Committee include protection of the patient in radiodiagnosis and radiotherapy and protection in nuclear medicine.’ The Chairpersons of Committee 3 have been: 1977–1985, Charles B. Meinhold, USA; 1985–1993, Julian Liniecki, Poland; 1993–1996, Henri Jammet, France; 1996–2005, Fred J. Mettler, USA; 2005–2009, Claire Cousins, UK; and 2009 to date, Eliseo Vañó, Spain.

Once the protection of patients was explicitly part of the mission of Committee 3, a number of reports were devoted to it in the main areas of medical uses of radiation, namely protection of the patient in diagnostic radiology (ICRP, 1982), in radiation therapy (ICRP, 1985), and in nuclear medicine (ICRP, 1987). In addition, attention continued to be paid to occupational protection in medicine, as shown in Publication 57 on radiological protection of the worker in medicine and dentistry (ICRP, 1990).

2.5. Concise reports on particular issues for specific audiences

In 1997, under the chairmanship of Fred Mettler, Committee 3 recognised that ICRP reports were only known to regulators and radiological protection specialists in hospitals, and were hardly known to, or used by, the medical community. This realisation led to the decision to publish concise reports, addressing particular needs demanded by specific audiences within the medical community, worded in plain language understandable to these audiences but still consistent with ICRP terminology. The first documents addressed pregnancy and the use of radiation in medicine (ICRP, 2000a), avoidance of radiation injuries in interventional procedures (ICRP, 2001a), prevention of accidental exposure in radiotherapy (ICRP 2000b), radiological protection in computed tomography (ICRP, 2000c), reference levels in medical imaging (ICRP, 2001b), and a guide for medical practitioners called ‘Radiation and your patient’ (ICRP, 2001c).

This initial set of concise reports was soon followed by others that also focussed on specific topics such as protection in digital radiology (ICRP, 2004a), release of patients after therapy with unsealed radionuclides (ICRP, 2004b), prevention of high-dose-rate brachytherapy accidents (ICRP, 2005a), protection in brachytherapy for prostate cancer with permanent implants (ICRP, 2005b), managing dose in multi-detector computed tomography (ICRP, 2007a), prevention of accidental exposure with new external beam radiation therapy (ICRP, 2009a), education and training in radiological protection for diagnostic and interventional procedures (ICRP, 2009b), protection in fluoroscopically guided procedures outside the imaging department (ICRP, 2010), protection in cardiology (ICRP, 2013a), protection in paediatric diagnostic and interventional radiology (ICRP, 2013b), protection in ion beam radiotherapy (ICRP, 2014), and protection in cone beam computed tomography (ICRP, 2015a).

Some of these reports are accompanied by slide presentations, freely available from the ICRP website, for use by teachers in radiological protection, and some reports have been translated by professional associations into other languages, such as Chinese, French, Japanese and Spanish.

In addition, a more comprehensive report on radiological protection in medicine (ICRP, 2007b) in the traditional style was issued upon publication of the 2007 ICRP Recommendations (ICRP, 2007c), and the series of radiation doses to patients from radiopharmaceuticals has continued (ICRP, 2008, 2015b).

3. CURRENT WORK

Committee 3 is currently working on the following drafts: occupational radiological protection in brachytherapy; framework for justification in medical uses of ionising radiation; radiological protection in therapy with radiopharmaceuticals; occupational protection issues in radiation imaging guided interventions; diagnostic reference levels for diagnostic and interventional imaging; radiological protection in medicine related to individual radiosensitivity to ionising radiations; and radiation and your patient: a guide for medical practitioners.

4. CONCLUSIONS

Since its creation in 1928, ICRP has been intimately related to protection in medicine. It was born at ICR, in response to growing concerns about the effects of ionising radiation being observed in the medical community. During the first 22 y, its recommendations were devoted to protection of radiological professionals. In 1950, ICRP widened its scope to embrace other areas of protection, but in 1977, the Commission undertook a significant re-orientation of priorities, assigning Committee 3 the task to focus on radiological protection in medicine, including patients. Since then, a number of comprehensive reports have been devoted to patient protection in radiology, nuclear medicine, and radiotherapy, and many concise reports have addressed particular concerns of specific audiences within the medical community.

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