Ionizing radiation protection and the linear No-threshold controversy: Extent of support or counter to the prevailing paradigm.

This study has developed a relationship that categorized radiation protection and allows for a proper, clear, and concise review of the different classifications in terms of principles of protection, dose criteria, categories, fundamental tools, exposure situations, applications and control measures. With the groundwork laid, advances of the linear no-threshold (LNT) model which has attracted attention in the field of radiobiology and epidemiology were examined in detail. Various plausible dose-response relationship scenarios were x-rayed under low-dose extrapolation. Intensive review of factors opposing the LNT model involving radiophobia (including misdiagnosis, alternative surgery/imaging, suppression of ionizing radiation (IR) research); radiobiology (including DNA damage repair, apoptosis/necrosis, senescence protection) and cost issues (including-high operating cost of LNT, incorrect prioritization, exaggeration of LNT impact, risk-to-benefit analysis) were performed. On the other hand, factors supporting the use of LNT were equally examined, they include regulatory bodies' endorsement, insufficient statistical significance, partial DNA repair, variability of irradiated bodies, different latency periods for cancer, dynamic nature of threshold and conflicting interests. After considering the gaps in the scientific investigations that either support or counter the scientific paradigm on the use of LNT model, further research and advocacy is recommended that will ultimately lead to the acceptance of an alternative paradigm by the international regulators.

Radiophobia Overreaction: College of Chiropractors of British Columbia Revoke Full X-Ray Rights Based on Flawed Study and Radiation Fear-Mongering.

Fears over radiation have created irrational pressures to dissuade radiography use within chiropractic. Recently, the regulatory body for chiropractors practicing in British Columbia, Canada, the College of Chiropractors of British Columbia (CCBC), contracted Pierre Côté to review the clinical use of X-rays within the chiropractic profession. A "rapid review" was performed and published quickly and included only 9 papers, the most recent dating from 2005; they concluded, "Given the inherent risks of radiation, we recommend that chiropractors do not use radiographs for the routine and repeat evaluation of the structure and function of the spine." The CCBC then launched an immediate review of the use of X-rays by chiropractors in their jurisdiction. Member and public opinion were gathered but not presented to their members. On February 4, 2021, the College announced amendments to their Professional Conduct Handbook that revoked X-ray rights for routine/repeat assessment and management of patients with spine disorders. Here, we highlight current and historical evidence that substantiates that X-rays are not a public health threat. We also point out critical and insurmountable flaws in the single paper used to support irrational and unscientific policy that discriminates against chiropractors who practice certain forms of evidence-based X-ray-guided methods.

Radiophobic Fear-Mongering, Misappropriation of Medical References and Dismissing Relevant Data Forms the False Stance for Advocating Against the Use of Routine and Repeat Radiography in Chiropractic and Manual Therapy.

There is a faction within the chiropractic profession passionately advocating against the routine use of X-rays in the diagnosis, treatment and management of patients with spinal disorders (aka subluxation). These activists reiterate common false statements such as "there is no evidence" for biomechanical spine assessment by X-ray, "there are no guidelines" supporting routine imaging, and also promulgate the reiterating narrative that "X-rays are dangerous." These arguments come in the form of recycled allopathic "red flag only" medical guidelines for spine care, opinion pieces and consensus statements. Herein, we review these common arguments and present compelling data refuting such claims. It quickly becomes evident that these statements are false. They are based on cherry-picked medical references and, most importantly, expansive evidence against this narrative continues to be ignored. Factually, there is considerable evidential support for routine use of radiological imaging in chiropractic and manual therapies for 3 main purposes: 1. To assess spinopelvic biomechanical parameters; 2. To screen for relative and absolute contraindications; 3. To reassess a patient's progress from some forms of spine altering treatments. Finally, and most importantly, we summarize why the long-held notion of carcinogenicity from X-rays is not a valid argument.

The LNT Issue Is About Politics and Economics, Not Safety.

The Sykes commentary advocates "a more sensible, graded approach for protection from low dose ionizing radiation" until the LNT dose-response issue is resolved. It urges scientists to stop criticizing the LNT model that links radiation to a risk of cancer and accept regulatory use of the threshold model to "protect" people, but with higher limits. It fails to mention the 120-year history of successful low-dose treatments of a wide variety of serious diseases, including cancers. The commentary ignores published evidence of a threshold at 1.1 Gy for radiogenic leukemia and a dose-rate threshold at about 0.6 Gy per year for lifespan shortening. LNT came from politicized science, replete with scientific misconduct and conflict of interest. Its acceptance created a false cancer scare that was likely intended to stop atomic bomb testing, but it has severely damaged human welfare. Many vitally important low-dose therapies were discarded when the radiation scare was disseminated in 1956. The rapid growth of nuclear energy ended with the media-inflamed public panic after the Three Mile Island accident in 1979. Extreme implementation of the precautionary principle made it uneconomic. Availability of a low-dose therapy for lung inflammation could have dramatically decreased the impact of the COVID-19 pandemic.

X-Ray Hesitancy: Patients' Radiophobic Concerns Over Medical X-rays.

All too often the family physician, orthopedic surgeon, dentist or chiropractor is met with radiophobic concerns about X-ray imaging in the clinical setting. These concerns, however, are unwarranted fears based on common but ill-informed and perpetuated ideology versus current understanding of the effects of low-dose radiation exposures. Themes of X-ray hesitancy come in 3 forms: 1. All radiation exposures are harmful (i.e. carcinogenic); 2. Radiation exposures are cumulative; 3. Children are more susceptible to radiation. Herein we address these concerns and find that low-dose radiation activates the body's adaptive responses and leads to reduced cancers. Low-dose radiation is not cumulative as long as enough time (e.g. 24 hrs) passes prior to a repeated exposure, and any damage is repaired, removed, or eliminated. Children have more active immune systems; the literature shows children are no more affected than adults by radiation exposures. Medical X-rays present a small, insignificant addition to background radiation exposure that is not likely to cause harm. Doctors and patients alike should be better informed of the lack of risks from diagnostic radiation and the decision to image should rely on the best evidence, unique needs of the patient, and the expertise of the physician-not radiophobia.

Are Restrictive Medical Radiation Imaging Campaigns Misguided? It Seems So: A Case Example of the American Chiropractic Association's Adoption of "Choosing Wisely".

Since the 1980s, increased utilization of medical radiology, primarily computed tomography, has doubled medically sourced radiation exposures. Ensuing fear-mongering media headlines of iatrogenic cancers from these essential medical diagnostic tools has led the public and medical professionals alike to display escalating radiophobia. Problematically, several campaigns including Image Gently, Image Wisely, and facets of Choosing Wisely propagate fears of all medical radiation, which is necessary for the delivery of effective and efficient health care. Since there are no sound data supporting the alleged risks from low-dose radiation and since there is abundant evidence of health benefits from low-doses, these imaging campaigns seem misguided. Further, thresholds for cancer are 100 to 1000-fold greater than X-rays, which are within the realm of natural background radiation where no harm has ever been validated. Here, we focus on radiographic imaging for use in spinal rehabilitation by manual therapists, chiropractors, and physiotherapists as spinal X-rays represent the lowest levels of radiation imaging and are critical in the diagnosis and management of spine-related disorders. Using a case example of a chiropractic association adopting "Choosing Wisely," we argue that these campaigns only fuel the pervasive radiophobia and continue to constrain medical professionals, attempting to deliver quality care to patients.

Radiophobia: 7 Reasons Why Radiography Used in Spine and Posture Rehabilitation Should Not Be Feared or Avoided.

Evidence-based contemporary spinal rehabilitation often requires radiography. Use of radiography (X-rays or computed tomography scans) should not be feared, avoided, or have their exposures lessened to decrease patient dose possibly jeopardizing image quality. This is because all fears of radiation exposures from medical diagnostic imaging are based on complete fabrication of health risks based on an outdated, invalid linear model that has simply been propagated for decades. We present 7 main arguments for continued use of radiography for routine use in spinal rehabilitation: (1) the linear no-threshold model for radiation risk estimates is invalid for low-dose exposures; (2) low-dose radiation enhances health via the body's adaptive response mechanisms (ie, radiation hormesis); (3) an X-ray with low-dose radiation only induces 1 one-millionth the amount of cellular damage as compared to breathing air for a day; (4) radiography is below inescapable natural annual background radiation levels; (5) radiophobia stems from unwarranted fears and false beliefs; (6) radiography use leads to better patient outcomes; (7) the risk to benefit ratio is always beneficial for routine radiography. Radiography is a safe imaging method for routine use in patient assessment, screening, diagnosis, and biomechanical analysis and for monitoring treatment progress in daily clinical practice.

Subjecting Radiologic Imaging to the Linear No-Threshold Hypothesis: A Non Sequitur of Non-Trivial Proportion.

Radiologic imaging is claimed to carry an iatrogenic risk of cancer, based on an uninformed commitment to the 70-y-old linear no-threshold hypothesis (LNTH). Credible evidence of imaging-related low-dose (<100 mGy) carcinogenic risk is nonexistent; it is a hypothetical risk derived from the demonstrably false LNTH. On the contrary, low-dose radiation does not cause, but more likely helps prevent, cancer. The LNTH and its offspring, ALARA (as low as reasonably achievable), are fatally flawed, focusing only on molecular damage while ignoring protective, organismal biologic responses. Although some grant the absence of low-dose harm, they nevertheless advocate the "prudence" of dose optimization (i.e., using ALARA doses); but this is a radiophobia-centered, not scientific, approach. Medical imaging studies achieve a diagnostic purpose and should be governed by the highest science-based principles and policies. The LNTH is an invalidated hypothesis, and its use, in the form of ALARA dosing, is responsible for misguided concerns promoting radiophobia, leading to actual risks far greater than the hypothetical carcinogenic risk purportedly avoided. Further, the myriad benefits of imaging are ignored. The present work calls for ending the radiophobia caused by those asserting the need for dose optimization in imaging: the low-dose radiation of medical imaging has no documented pathway to harm, whereas the LNTH and ALARA most assuredly do.

Dose Optimization to Minimize Radiation Risk for Children Undergoing CT and Nuclear Medicine Imaging Is Misguided and Detrimental.

A debate exists within the medical community on whether the linear no-threshold model of ionizing radiation exposure accurately predicts the subsequent incidence of radiogenic cancer. In this article, we evaluate evidence refuting the linear no-threshold model and corollary efforts to reduce radiation exposure from CT and nuclear medicine imaging in accord with the as-low-as-reasonably-achievable principle, particularly for children. Further, we review studies demonstrating that children are not, in fact, more radiosensitive than adults in the radiologic imaging dose range, rendering dose reduction for children unjustifiable and counterproductive. Efforts to minimize nonexistent risks are futile and a major source of persistent radiophobia. Radiophobia is detrimental to patients and parents, induces stress, and leads to suboptimal image quality and avoidance of imaging, thus increasing misdiagnoses and consequent harm while offering no compensating benefits.

Preserving the Anti-Scientific Linear No-Threshold Myth: Authority, Agnosticism, Transparency, and the Standard of Care.

The linear no-threshold (LNT) assumption is over 70 years old and holds that all ionizing radiation exposure leaves cumulative effects, all of which are harmful regardless of how low the dose or dose rate is. The claimed harm centers on the risk of future radiogenic cancer. This has been shown countless times to be fallacious, and hundreds of scientific studies-both experimental and observational/epidemiological-demonstrate that at low enough doses and dose rates, ionizing radiation stimulates an evolved adaptive response and therefore is beneficial to health, lowering rather than raising the risk of cancer. Yet the myth of uncorrected lifetime cumulative risk still pervades the field of radiation science and underlies the policies of virtually all regulatory agencies around the world. This article explores some of the motivations behind, and methods used to assure, the extreme durability of the LNT myth in the face of the preponderance of contrary evidence and the manifest harms of radiophobia. These include subservience to the voice of authority, tactics such as claiming agnosticism on behalf of the entire field, transparent references to contrary evidence while dismissing the findings without refutation, and seeking shelter behind the legally protective medical standard of care.

Epidemiology Without Biology: False Paradigms, Unfounded Assumptions, and Specious Statistics in Radiation Science (with Commentaries by Inge Schmitz-Feuerhake and Christopher Busby and a Reply by the Authors).

Radiation science is dominated by a paradigm based on an assumption without empirical foundation. Known as the linear no-threshold (LNT) hypothesis, it holds that all ionizing radiation is harmful no matter how low the dose or dose rate. Epidemiological studies that claim to confirm LNT either neglect experimental and/or observational discoveries at the cellular, tissue, and organismal levels, or mention them only to distort or dismiss them. The appearance of validity in these studies rests on circular reasoning, cherry picking, faulty experimental design, and/or misleading inferences from weak statistical evidence. In contrast, studies based on biological discoveries demonstrate the reality of hormesis: the stimulation of biological responses that defend the organism against damage from environmental agents. Normal metabolic processes are far more damaging than all but the most extreme exposures to radiation. However, evolution has provided all extant plants and animals with defenses that repair such damage or remove the damaged cells, conferring on the organism even greater ability to defend against subsequent damage. Editors of medical journals now admit that perhaps half of the scientific literature may be untrue. Radiation science falls into that category. Belief in LNT informs the practice of radiology, radiation regulatory policies, and popular culture through the media. The result is mass radiophobia and harmful outcomes, including forced relocations of populations near nuclear power plant accidents, reluctance to avail oneself of needed medical imaging studies, and aversion to nuclear energy-all unwarranted and all harmful to millions of people.

Radiologists: The Unsuspecting Subject Matter Experts.

The social and political climates are changing rapidly in the United States and the world at large. The threat of a chemical, biologic, radiologic, and/or nuclear event is a rising concern to many. The current Ebola crisis has shed light on health care providers' preparedness for such an event. Radiologists, including radiation oncologists, nuclear medicine specialists, and all radiology subspecialists are considered "subject matter experts" in this area and are likely to be called upon in response to a radiation incident. Although others, such as radiation safety officers, provide important expertise, the clinical leadership will be the responsibility of physicians and other health care providers. However, many radiologists are unaware that they are considered subject matter experts who may be called on to assist, should their local hospital's emergency department need to take care of casualties from a radiation incident. A mass-casualty situation with hundreds of patients would require the immediate assistance of all available medical providers. Radiologists are primed and positioned to take the lead in ensuring preparedness of their local hospital and community, through emergency planning for a radiologic incident, given their combined medical and radiation physics knowledge. Therefore, increasing the skills of radiologists first is the more prudent approach in such planning. This preparation can be done through understanding of the critical components of such scenarios: the threat, types of radiation incidents, contamination, detection, decontamination, and acute radiation syndrome and its treatment. Once the necessary knowledge supplementation has been completed, radiologists can participate in educating their fellow medical colleagues and health care staff, and assist in the radiation-related aspects of an "all hazards" emergency department response, decreasing "radiophobia" in the process.