Objective To assess the cancer risk in children and adolescents following exposure to low dose ionising radiation from diagnostic computed tomography (CT) scans. Design Population based, cohort, data linkage study in Australia. Cohort members 10.9 million people identified from Australian Medicare records, aged 0-19 years on 1 January 1985 or born between 1 January 1985 and 31 December 2005; all exposures to CT scans funded by Medicare during 1985-2005 were identified for this cohort. Cancers diagnosed in cohort members up to 31 December 2007 were obtained through linkage to national cancer records. Main outcome Cancer incidence rates in individuals exposed to a CT scan more than one year before any cancer diagnosis, compared with cancer incidence rates in unexposed individuals. Results 60 674 cancers were recorded, including 3150 in 680 211 people exposed to a CT scan at least one year before any cancer diagnosis. The mean duration of follow-up after exposure was 9.5 years. Overall cancer incidence was 24% greater for exposed than for unexposed people, after accounting for age, sex, and year of birth (incidence rate ratio (IRR) 1.24 (95% confidence interval 1.20 to 1.29); P<0.001). We saw a dose-response relation, and the IRR increased by 0.16 (0.13 to 0.19) for each additional CT scan. The IRR was greater after exposure at younger ages (P<0.001 for trend). At 1-4, 5-9, 10-14, and 15 or more years since first exposure, IRRs were 1.35 (1.25 to 1.45), 1.25 (1.17 to 1.34), 1.14 (1.06 to 1.22), and 1.24 (1.14 to 1.34), respectively. The IRR increased significantly for many types of solid cancer (digestive organs, melanoma, soft tissue, female genital, urinary tract, brain, and thyroid); leukaemia, myelodysplasia, and some other lymphoid cancers. There was an excess of 608 cancers in people exposed to CT scans (147 brain, 356 other solid, 48 leukaemia or myelodysplasia, and 57 other lymphoid). The absolute excess incidence rate for all cancers combined was 9.38 per 100 000 person years at risk, as of 31 December 2007. The average effective radiation dose per scan was estimated as 4.5 mSv. Conclusions The increased incidence of cancer after CT scan exposure in this cohort was mostly due to irradiation. Because the cancer excess was still continuing at the end of follow-up, the eventual lifetime risk from CT scans cannot yet be determined. Radiation doses from contemporary CT scans are likely to be lower than those in 1985-2005, but some increase in cancer risk is still likely from current scans. Future CT scans should be limited to situations where there is a definite clinical indication, with every scan optimised to provide a diagnostic CT image at the lowest possible radiation dose.

Objectives: To establish local diagnostic reference levels (LDRLs) at the Royal Children's Hospital (RCH) Melbourne, Parkville, Australia, for typical paediatric CT examinations and compare these with international diagnostic reference levels (DRLs) to benchmark local practice. In addition, the aim was to develop a method of analysing local scan parameters to enable identification of areas for optimisation. Methods: A retrospective audit of patient records for paediatric CT brain, chest and abdomen/pelvis examinations was undertaken. Demographic information, examination parameters and dose indicators—volumetric CT dose index (CTDIvol) and dose–length product (DLP)—were collected for 220 patients. LDRLs were derived from mean survey values and the effective dose was estimated from DLP values. The normalised CTDIvol values, mAs values and scan length were analysed to better identify parameters that could be optimised. Results: The LDRLs across all age categories were 18–45 mGy (CTDIvol) and 250–700 mGy cm (DLP) for brain examinations; 3–23 mGy (CTDIvol) and 100–800 mGy cm (DLP) for chest examinations; and 4–15 mGy (CTDIvol) and 150–750 mGy cm (DLP) for abdomen/pelvis examinations. Effective dose estimates were 1.0–1.6 mSv, 1.8–13.0 mSv and 2.5–10.0 mSv for brain, chest and abdomen/pelvis examinations, respectively. Conclusion: The RCH mean CTDIvol and DLP values are similar to or lower than international DRLs. Use of low-kilovoltage protocols for body imaging in younger patients reduced the dose considerably. There exists potential for optimisation in reducing body scan lengths and justifying the selection of reference mAs values. The assessment method used here proved useful for identifying specific parameters for optimisation. Advances in knowledge: Assessment of individual CT parameters in addition to comparison with DRLs enables identification of specific areas for CT optimisation.

Background: Computed tomography (CT) scans make substantial contributions to low-dose ionizing radiation exposures, raising concerns about excess cancers caused by diagnostic radiation. Methods: Deidentified medicare records for all Australians aged 0–19 years between 1985–2005 were linked to national death and cancer registrations to 2012. The National Cancer Institute CT program was used to estimate radiation doses to the brain from CT exposures in 1985–2005, Poisson regression was used to model the dependence of brain cancer incidence on brain radiation dose, which lagged by 2 years to minimize reverse causation bias. Results: Of 10 524 842 young Australians, 611 544 were CT-exposed before the age of 20 years, with a mean cumulative brain dose of 44 milligrays (mGy) at an average follow-up of 13.5 years after the 2-year lag period. 4472 were diagnosed with brain cancer, of whom only 237 had been CT-exposed. Brain cancer incidence increased with radiation dose to the brain, with an excess relative risk of 0.8 (95% CI 0.57–1.06) per 100 mGy. Approximately 6391 (95% CI 5255, 8155) persons would need to be exposed to cause 1 extra brain cancer. Conclusions: For brain tumors that follow CT exposures in childhood by more than 2 years, we estimate that 40% (95% CI 29%–50%) are attributable to CT Radiation and not due to reverse causation. However, because of relatively low rates of CT exposure in Australia, only 3.7% (95% CI 2.3%–5.4%) of all brain cancers are attributable to CT scans. The population-attributable fraction will be greater in countries with higher rates of pediatric scanning.