Action 3: Implement measures to maintain radiation doses within diagnostic reference levels (DRLs).
“Diagnostic reference levels” refers to dose levels in medical radio-diagnostic practices for typical examinations for groups of standardized patients.
The European Council Directive 2013/59[vii] has been unanimously adopted by the Council of the European Union in 2013.
Each member state of the European Union is required by February 2018 to transpose the Directive into national legislation.
This legislation,
along with other professional and scientific guidance,
emphasises the use of diagnostic reference levels and the availability of dose-indicating devices in radiological imaging,
amongst other requirements.
From an Irish national perspective,
the medical exposure radiology unit (MERU,
Fig. 5 ,
Fig. 6 ) of the Health Service executive establish national DRLs.The first DRLs were published by the Irish medical council in 2004 based on RP 109[viii]. In 2004 the DRL for mammography was 4mGy/view.
This was revised in 2008,
with a DRL for screening and symptomatic mammography 5.75 and 4.70 mGy respectively,
although there was concern that these values were unreliable due to flawed methodology in acquisition and analysis of data as it was retrospectively established that the survey outcome was inconsistent with real practice.
A provisional draft of national DRL reference levels for 2016 has set the DRL at 2.7 mGy mean glandular dose (Two View)
The Medical Exposure Radiation Unit routinely audits the use of DRLs in a number of public and private centers in Ireland.
In 2015 the National radiation safety committee initiated a survey of DRLs to be carried out in 2017.
This survey will use information provided in the DICOM header information and QA data sets at each of the academic centers in 100 anonymised mammography studies.
This data will be made available to medical physicists involved in the National breast screening programme for analysis.
The expedience of the survey will be facilitated by the national integrated imaging system (NIMIS) which acts a PACS image repository for forty hospitals.
Action 4: Promote the use of up-to-date equipment and provide guidance on how to further reduce doses while maintaining image quality
Action 5: Establish a dialogue with industry regarding improvement of radiological equipment,
the use of up-to-date equipment and the harmonization of exposure indicators.
Current legislation (Euratom 97/43,
SI 478 2002 in Irish Legislation[ix]) requires that for the use ionizing radiation,
consultation with a medical physicist and practioner on the lifetime of the equipment is required,
with regular review of radiological equipment to assess its satisfactory performance and continuing utility.
Special attention is required to be applied to health screening programmes.
These provisions regarding equipment safety have not changed significantly in the most up to date EU legislation BSS EU 59/13.
Part of the National cancer screening programme,
Breastcheck,
has provided the springboard for many international publications concerning dose and image quality [x] [xi] [xii].The breast screening programme has encouraged collaboration with industrial partners in the development of new products around mammography image optimization and dose tacking.
The networks established through these programmes were also used to invite pioneers of novel mammographic techniques to Irish scientific meetings.
Further,
collaboration with tertiary level education centers,
for the well-established Masters in Mammography offered by the University College Dublin,
ensures that professional competence and expertise is maintained.
The Irish Department of Health is the competent authority in Ireland.
Following a 2015 review by the International Atomic Energy Agency (IAEA),
it has planned to transfer responsibility for the patient safety aspects of the legislation to an independent Health Information and Quality Body (HIQA).
HIQA aims to drive improvements in the quality and safety of healthcare and have produced numerous reviews and publications concerning mammography and breast screening.
For example in 2013,
HIQA established guidelines for symptomatic breast cancer services as well as producing health technology assessments on the role of mammography v MRI in breast screening for high risk women under 50years [xiii].