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"When the doctor told Alexandria Cody she needed to have a CT scan &amp;quot;right now,&amp;quot; she and her husband headed straight for a hospital near their Hopkins, MN, home. They were worried about the cost \u2014 they&amp;#039;d had no health insurance since Cody, 55, had been laid off from her job as an administrative assistant and her husband had retired from a car dealership. But the doctor&amp;#039;s tone was so urgent, they didn&amp;#039;t question the order. Cody had battled a nasty cold for weeks, and now, on Christmas Eve 2008, she was in agony. The doctor at the urgent-care clinic thought she&amp;#039;d probably broken a rib from the coughing and, to be sure, had taken an X-ray. That&amp;#039;s when he said, &amp;quot;We&amp;#039;ve spotted something else in there,&amp;quot; describing a bump on her rib.  One CT scan \u2014 and $788 \u2014 later, the couple found out that the &amp;quot;bump&amp;quot; was a cracked rib \u2014 exactly what the doctor had thought when he examined her. It would heal, and meanwhile, he prescribed painkillers.  Cody is still angry. The test was expensive, worrying \u2014 and, she believes, almost certainly unnecessary. The physician&amp;#039;s own exam and clinical judgment had told him what was wrong, but these days, it seems, &amp;quot;doctors put all their faith in CT scans,&amp;quot; she says.  Statistics back her up. About 70 million CT scans are performed each year in the United States, double the number done just 10 years ago. Among young and middle-aged patients, more women than men have had them; nearly one in five women (19 percent) ages 45 to 64 has had at least one CT scan in the past year. That&amp;#039;s up from 13 percent in 2004 \u2014 a 46 percent jump. No one argues that the technology \u2014 which takes 3-D pictures of soft tissue and bone so detailed they can reveal abnormalities as small as a grain of rice \u2014 has saved countless lives by helping doctors diagnose serious illnesses or injuries. CT scans can also lead to more effective treatment, and can spare patients painful exploratory surgeries. Scanning patients with abdominal pain, for example, reduced the number of unnecessary appendectomies in women 45 and under from 42.9 percent in 1998 to 7.1 percent in 2007, a recent Duke University Medical Center study found.  But CT scans deliver radiation \u2014 a whopping dose compared with regular X-rays \u2014 that can, down the road, make people very sick. Experts say that many doctors are now far too quick to order scans, and that at least one-third \u2014 maybe up to half \u2014 are unnecessary. &amp;quot;We have been doing too many CT scans, and we continue to do too many,&amp;quot; says Howard P. Forman, M.D., a professor of diagnostic radiology and public health at Yale.  There need to be better guidelines, as well as a willingness on the part of doctors to follow those rules. But don&amp;#039;t count on that happening soon. It&amp;#039;s hard for the medical world to undo something that&amp;#039;s become so routine \u2014 and so lucrative. That&amp;#039;s why it falls to you to protect yourself. And that begins with understanding the risks as well as the benefits of scans. OK Today, Cancer Tomorrow?  Because the CT unit rotates around the body, taking multiple cross-sectional images, scans expose you to far more radiation than a traditional X-ray. One scan of the chest, for example, can give a dose equivalent to more than 100 chest X-rays, says David Brenner, Ph.D., a professor of radiation biophysics at Columbia University Medical Center who has conducted pioneering research on the hazards. And although doses vary depending on the type of scan, the machine itself, and the center performing it, even low-dose exposures can ultimately lead to cancer. With radiation, the risk accumulates \u2014 it rises higher with each scan you have over your lifetime, explains Rita Redberg, M.D., a cardiologist at the University of California, San Francisco, Medical Center. And there&amp;#039;s nothing you can do to reverse it: &amp;quot;In 10 to 20 years, when we see the increased cancers, it&amp;#039;ll be too late for those people.&amp;quot;  The numbers are frightening. Last year, scientists at the National Cancer Institute predicted that about 15,000 Americans would die of cancer from the CT scans given in a single year. In their study, that year was 2007, and the number of scans has continued to rise since then.  Some people are more vulnerable than others. Children, whose cells are still dividing in their developing bodies, face higher risks. The danger is also greater for women \u2014 radiation may be more concentrated in those with smaller frames. And breast tissue is especially susceptible to radiation, says Dr. Redberg. Where your scan is matters, too: Nearby organs are at greatest risk. A heart scan, for example, increases the risk of lung or breast cancer, while a head scan raises the risk of thyroid cancer. Although the chance of getting cancer from a single CT scan is small \u2014 one in 1,000, for example, for a 30-year-old woman who has an abdominal-pelvic scan \u2014 some people with chronic conditions such as Crohn&amp;#039;s disease or kidney stones, or those with multiple health problems, may undergo a dozen or more scans over their lifetimes. Kim Curran, 46, a third grade teacher in Cary, IL, has had at least nine CT scans in the past five years as doctors have tried to diagnose strange nodules on her lungs. These growths first showed up on a chest X-ray taken when Curran&amp;#039;s asthma flared up and doctors wanted to rule out pneumonia. Now, as the nodules have gotten smaller \u2014 some have disappeared altogether \u2014 they suspect she had an infection that burned itself out. Real Anxiety from False Alarms  The very technology that makes CT scans so valuable is also what makes them problematic. The machines take such refined pictures that, beyond troublesome growths, they can find lesions, cysts, and other abnormalities that pose no threat to your health. This happens so often that doctors have dubbed these findings &amp;quot;incidentalomas&amp;quot; \u2014 abnormal growths, most often benign, that are found incidentally by a CT scan or other imaging test. A CT scan of the abdomen can pick up kidney cysts, for example, that have little or no chance of becoming cancerous or causing any other health problem. Yet once a suspicious spot has been detected, doctors often feel compelled to do further tests \u2014 in part because they worry about a malpractice suit if they don&amp;#039;t follow up. Patients may face biopsies, or even surgeries, all the while tormented by the worry of what could be growing inside them.  That&amp;#039;s what happened to Stephanie Dutchen, who has gone through years of uncertainty and anxiety due to such a finding. In 2007, Dutchen, then 24, went to the doctor because of an intense pain on her right side. She thought she was probably suffering from a kidney stone. Her physician thought so, too, and he sent her immediately for a CT scan. The test showed a small stone in her kidney. But it also showed something else: a strange dark shadow on Dutchen&amp;#039;s liver. Over the course of a year, Dutchen had an ultrasound and then three MRIs, but her doctors still didn&amp;#039;t know what the penny-size lesion was.  A liver specialist suspected it was a type of benign tumor that rarely poses a danger, but, to make sure, recommended that Dutchen undergo a biopsy. &amp;quot;Let&amp;#039;s just go in and get a piece of it,&amp;quot; she recalls the doctor saying. &amp;quot;Just going in&amp;quot; sounds simple enough, but the procedure required the insertion of a long needle into her rib cage, which left Dutchen feeling uncomfortable for two weeks. Worse, though, was the conclusion. The lesion, the specialist reported, was &amp;quot;probably benign.&amp;quot; She recommended more tests, but given what Dutchen had already gone through, it took her nearly two years to make the appointment. Although she once believed she&amp;#039;d want to know if something was wrong with her body, after having endured so much uncertainty, she said, &amp;quot;I sometimes wished I&amp;#039;d never had that CT scan.&amp;quot;  Defending Themselves (and Their Wallets) In a recent survey of more than 100 physicians, 74 percent of those questioned significantly underestimated a patient&amp;#039;s risk of getting cancer from a single abdominal-pelvic CT scan. And asked how much a patient&amp;#039;s exposure to radiation influenced their decision to order the test, 17 percent said it had no influence at all. Part of the problem is that physicians tend to view CT scans in the same light as other radiologic procedures, like X-rays, even though radiation doses may be hundreds of times higher. Also, they aren&amp;#039;t thinking about a cancer that might happen years in the future. If you have severe belly pain or an aching shoulder, &amp;quot;you \u2014 and your doctor \u2014 aren&amp;#039;t worried about 10 or 15 years out,&amp;quot; says Dr. Forman. &amp;quot;You&amp;#039;re worried about today.&amp;quot; It&amp;#039;s bad enough that patients are exposed to radiation when scanning might actually be helpful. But study after study has found that many scans don&amp;#039;t benefit the patient. Last year, for example, when a team of researchers from the University of Wisconsin-Madison reviewed 978 abdominal-pelvic studies that had been done on 500 men and women, they concluded that 52 percent of the patients had gotten unnecessary scans.  Could there have been a profit motive at work? The researchers raised that possibility in their report. Certainly imaging centers have become profit centers for many hospitals and physicians. Even doctors who aren&amp;#039;t radiologists \u2014 cardiologists, gastroenterologists, orthopedists, and others \u2014 have installed CT scanners in their offices. And, having spent upwards of a million dollars on a device, they&amp;#039;re going to find ways to cover their investment. Indeed, many physicians now count on the hefty fees they earn from scans for a significant portion of their income. In 2006 (the most recent figures), cardiologists received roughly 36 percent of their Medicare revenues from CT scans and other imaging tests, a 57 percent increase since 2000, reported federal auditors, who had been asked by members of Congress to look into the matter.  Even when patients are referred to outside imaging clinics by their physicians, the reason may not be purely medical. Federal statutes prohibit doctors from giving or receiving money or other kickbacks in exchange for the referral of patients, but physicians continue to try to skirt the law. In 2008, Fred Steinberg, M.D., a radiologist in Palm Beach County, FL, agreed to pay $7 million to settle allegations that he had given financial inducements to doctors to send patients to his clinics for scans and had also performed scans that the patients did not need. He denied wrongdoing. Similar cases have been brought by federal fraud investigators against a medical-imaging clinic in New Jersey and two doctors in New York State.  And last year, Open Advanced MRI clinics of Illinois agreed to pay $1.2 million to settle charges that they had paid kickbacks to doctors who sent patients their way for MRIs. The company denied wrongdoing. Her purpose in bringing the lawsuit, said Lisa Madigan, the Illinois attorney general, went beyond the illegal activities of this one group; she wanted to send a message that &amp;quot;medical professionals cannot engage in schemes to line their pockets at the expense of providing the best patient care.&amp;quot; Looking for Trouble There are times, of course, when the benefits of a CT scan greatly outweigh the risk of a future cancer. If doctors believe you&amp;#039;ve had a stroke or could be suffering from a blood clot, for example (say, you can&amp;#039;t catch your breath after getting off a 12-hour flight), the test might swiftly find the cause of your illness and help you get the proper treatment. The same is true if you&amp;#039;ve had a serious injury.  Far more questionable than such diagnostic scans are those used to screen healthy patients who have no symptoms of cancer, heart disease, or any other medical problem. These tests are promoted as giving health-conscious people peace of mind (with the claim that if something is found, it may well be at an earlier and more treatable stage). Sometimes doctors suggest that patients get these scans, but often people sign themselves up, thinking they are taking a step toward better health. They may, instead, bring on big problems. Lung Scans In 2002, Carol Smith,* a speech therapist from just outside Atlanta, saw a promotional spot on television inviting former and current smokers to join an early-lung-cancer-detection study that involved getting two CT scans. Although she&amp;#039;d given up smoking years before, she suggested that both she and her husband sign up for the clinical trial. &amp;quot;I thought, &amp;#039;Wouldn&amp;#039;t it be nice to find out our lungs were nice and pink?&amp;#039;&amp;quot; Smith recalls. Instead, doctors found a lesion in her lung, which, after other tests, required a surgical biopsy. &amp;quot;I was scared to death,&amp;quot; says Smith. &amp;quot;And it was hard on my family, too. They thought I was going to die.&amp;quot; The lesion turned out to be benign, but Smith ended up in the hospital for almost two weeks, some of it in intensive care because of complications from the surgery that included trouble breathing, intense pain, and a bad reaction to a pain medication that she had been given.  Such complications are not uncommon in the kind of surgery that Smith underwent. In fact, up to 44 percent of patients have serious complications, and 5 percent die \u2014 although her doctors never told her about these statistics.  When Smith got home, she was in severe pain and needed oxygen on and off to breathe. Now, eight years later, she still doesn&amp;#039;t have the full use of her left arm \u2014 the result of an incision made in her chest that cut through muscle. Smith regrets ever having signed up. &amp;quot;They wanted to follow up every year with another CT scan, but I said no,&amp;quot; she reports.  Clinical trials like the one Smith and her husband volunteered for are part of an effort that began in the early 1990s to see if CT scans could help save former and current smokers&amp;#039; lives. Since lung cancer is usually detected when it&amp;#039;s already advanced, too late for it to be cured, the hope was that if tumors were found and treated early, more patients would survive. *Name changed for privacy. The effort got a big push in 2006, when a group of researchers led by Claudia Henschke, M.D., then a professor of radiology at Weill Cornell Medical College in New York City, published results showing that yearly low-dose scanning could prevent up to 80 percent of lung-cancer deaths. These findings, published in the New England Journal of Medicine, were immediately criticized by other scientists, who questioned the study&amp;#039;s design. Critics also pointed out that the scans appeared to be overdetecting lung tumors; that is, that they were finding cancers that likely would never have harmed the patient \u2014 and that this led to overly optimistic survival figures. In 2008, an even bigger uproar ensued: The New York Times reported that the 2006 Weill Cornell study had been partly funded by the Vector Group, which owns cigarette maker Liggett Group. Cigarette companies would love it, of course, if their products were not so deadly, something early detection of cancer seemed to be promising.  Since then, the controversy has grown even more intense. Last year, researchers from the National Institutes of Health raised concerns about too many suspicious but ultimately harmless spots turning up in lung screening; as many as a third of 1,610 volunteers in the CT arm of the study had such false-positives after two annual exams, they announced. Trials of these lung scans are continuing, but neither the American Cancer Society nor the U.S. Preventive Services Task Force recommends the tests for smokers or former smokers who are healthy and have no symptoms. Heart Scans While doctors and hospitals may promote CT scans of the heart as a way to prevent heart attacks and strokes, so far scientists have not been able to show that healthy people getting these scans have fewer heart attacks. One reason heart scans aren&amp;#039;t terribly useful for screening healthy people: By age 50, most people have plaque buildup in their arteries. Yet this is not necessarily a threat. Heart attacks occur when bits of the plaque break off and create a clot that stops blood from getting to the heart. A CT scan can&amp;#039;t determine whether that will happen, says Dr. Redberg.  For patients showing up in the emergency room with chest pain, doctors are still divided over whether CT angiography is better than more traditional care, which often includes a stress test and possibly a conventional angiogram, long the gold standard in diagnosing heart disease. This last test, which involves the injection of an iodine-based radioactive dye, is more invasive than a CT scan because doctors must insert a catheter into a blood vessel in the groin.  But studies have shown that the results from CT angiograms can be misleading or even wrong. A 2008 study of 360 Dutch women and men found that in roughly 50 percent of patients, CT heart scans had identified coronary blockages that actually weren&amp;#039;t there \u2014 a &amp;quot;mistake&amp;quot; revealed by the conventional angiograms the volunteers also underwent.  The radiation from these tests is particularly worrisome. In a 2007 study, Andrew J. Einstein, M.D., a Columbia University Medical Center cardiologist, estimated that a 40-year-old woman would have a one in 284 chance of getting cancer over her lifetime due to the radiation from a single CT angiogram.  Although doctors have recently found ways to greatly reduce the radiation a patient receives from heart scans \u2014 indeed, one new technique that takes pictures during a single heartbeat can cut the dose by up to 91 percent \u2014 it&amp;#039;s still questionable whether patients without chest pain or other symptoms of heart disease can benefit from them, says Dr. Redberg.  Virtual Colonoscopy A colonoscopy \u2014 the fasting, the bowel-cleansing drugs taken the day before, then sedation while the doctor inserts a probe \u2014 is never a pleasant experience. So when clinics began to offer noninvasive CT scans of the colon, many patients were interested. And doctors hoped it would prompt more people to get screened.  The catch: You still need to undergo the fasting and bowel prep. And virtual colonoscopy is not as effective at finding small precancerous polyps. While the traditional test misses up to 27 percent of polyps, with virtual scans, &amp;quot;you&amp;#039;re lucky if you pick up half of polyps five millimeters and smaller,&amp;quot; says Steven H. Itzkowitz, M.D., professor of medicine at the Mount Sinai School of Medicine in New York City. Dr. Itzkowitz coauthored a recent summary article that compared traditional colonoscopy and CT colon screens.  Though some argue that anything that size is the equivalent of finding nothing, there are rare cases where very small polyps can quickly become cancerous, says Dr. Itzkowitz. Also, when a CT scan does find a polyp, you must undergo a regular colonoscopy to remove it. (With the traditional test, it can all be done in one procedure.) Last year, citing &amp;quot;inadequate&amp;quot; evidence of appropriateness, Medicare announced it would not cover the cost of virtual colonoscopy.  View to the Future Frightening stories of patients accidentally receiving excessive doses of radiation during diagnostic brain scans (see &amp;quot;Megadoses, Mega-Worries,&amp;quot; below) or while being treated for cancer have drawn greater attention to the risks of scans. As a result, Congress, the FDA, various medical societies, and individual experts and hospitals have all recently called for new safeguards. In March, the American Medical Association announced its support for developing ways to better quantify the cumulative exposure patients receive in medical settings and for educating physicians on ways they can limit such exposure.  That starts with not ordering unnecessary scans in the first place. The American College of Radiology and other groups have created guidelines to help determine which patients can benefit from specific diagnostic scans. Not every woman who hits her head needs a brain scan, for example, but those with the most serious injuries can be saved by one. Critics argue, however, that not enough doctors follow the guidelines. &amp;quot;The more we can encourage physicians to use them or to explain why they&amp;#039;ve decided not to follow them, the better off we&amp;#039;ll be,&amp;quot; says Dr. Forman.  Your doctor may not be listening yet \u2014 which is all the more reason you need to be. Ask questions, discuss the radiation dose, talk about alternatives. And don&amp;#039;t go ahead unless you&amp;#039;re totally convinced it&amp;#039;s necessary.  How Much Radiation Are You Really Getting in Your CT Scan? 1 CT head scan = 30 chest X-rays 1 CT chest scan = 119 chest X-rays 1 CT abdomen scan = 234 chest X-rays  Source: Rebecca Smith-Bindman, M.D., UCSF Medical Center Megadoses, Mega-Worries The risks from properly done CT scans are troubling enough. But what if mistakes are made? Imagine if you learned months after your test that it had been done incorrectly \u2014 and that you&amp;#039;d been given an excess dose of potentially cancer-causing radiation. Last year the FDA found that 375 people received up to eight times the expected dose during CT brain perfusions, scans that show how blood is flowing in the brain and that are done in cases of suspected stroke. One facility performed 260 of these scans over a period of 18 months (Cedars-Sinai Medical Center in Los Angeles); between 50 and 60 occurred at one location in Alabama, and the remainder were at other L.A. County hospitals. No &amp;quot;root cause&amp;quot; for the accidents has been found yet, says the FDA.  In light of these accidents, as well as some well-publicized treatment overdoses, medical groups are now calling for more careful training and supervision of the people involved in scanning. &amp;quot;In some states, hairdressers are better regulated than people who perform medical radiation procedures,&amp;quot; Sandra Hayden, a radiation therapist at M.D. Anderson Cancer Center in Houston, told Congress in February.  More sophisticated technology will also help. The industry association for scanners, Medical Imaging &amp;amp;amp; Technology Alliance (MITA), has recently committed to new, additional safeguards, including pop-up alerts when doses are higher than usual and a way for imaging centers to set their own maximum dose limits. These features will be included on new products and applied as upgrades on some older machines, with a number of the changes happening by the end of this year, says MITA&amp;#039;s executive director, David Fisher.  \u2014Marnie Soman The Come-Ons Some imaging centers know just how to exploit your worst health fears. These tout the benefits of CT scans for people who think they&amp;#039;re healthy, but could be harboring a dangerous disease.  &amp;quot;A $99 lung scan could save your life! It&amp;#039;s a closer look that could make all the difference.&amp;quot;   \u2014Reid Hospital &amp;amp;amp; Health Care Services, Richmond, IN &amp;quot;Could these deaths have been prevented? The cases listed here are real people, people who are not with us today, people who might still be here today if only they had an EBT heart scan...If only.&amp;quot;   \u2014Advanced Body Scan of Newport, Newport Beach, CA &amp;quot;Help save your life in seven minutes. HeartSaver CT can uncover heart disease...years before you exhibit symptoms.&amp;quot;   \u2014Texsan Heart Hospital of San Antonio &amp;quot;Introducing...Integrated Virtual Colonoscopy. Don&amp;#039;t take a risk with your life.... Get screened \u2014 The Integrated Way&amp;quot;   \u2014Colon Health Center of Delaware, Newark, DE &amp;quot;You Don&amp;#039;t Know What&amp;#039;s Inside Until You Look.&amp;quot;   \u2014Health View Center for Preventive Medicine, Tustin, CA  If Your Doctor Orders a Scan  Ask why it&amp;#039;s necessary. What does she hope to learn, and how might that affect your treatment? See if there are alternatives. Bring up your concerns about the dangers, and stress that you want to go to a facility skilled in limiting radiation exposure. Check out the clinic. Those that are accredited by the American College of Radiology are most likely to have qualified staff and use the safest procedures. You can search for accredited clinics in your area at acr.org/accreditation/accreditedfacilitysearch.  Request a shield. You want to protect your breasts, reproductive organs, and thyroid.  Pregnant? Just say no unless your life is in danger. A Brown University study found that though scans during pregnancy are still rare, the number that moms-to-be undergo has more than doubled in the past 10 years. Ask even more questions if the scan&amp;#039;s for your child. Make sure it&amp;#039;s vital and that a pediatric setting is used. Keep a list. Because the danger from radiation is cumulative, tell your doctor how many other CT scans you&amp;#039;ve had over the years.  Try to get a digital version of your completed scan. That way, if you change doctors, you&amp;#039;ll have a copy and won&amp;#039;t have to duplicate the test. "^^<http://www.w3.org/2001/XMLSchema#string>
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