malaysiakini: Lynas plant rushed ahead before radiation study.... by SM Mohamed Idris

Lynas plant rushed ahead before radiation study

SM Mohamed Idris
May 23, 2011, 1:46pm

 

 

The Lynas plant in Kuantan is unravelling into a nightmare. The lanthamide concentrates (rare earths) from Australia that Lynas will import into Malaysia contain thorium AND uranium, which suggests the processing in Kuantan will produce massive amount of radioactive wastes.

Further, there appears to be a serious disconnect in the entire review process of the Lynas plant. There seems to be two separate approval processes i.e. the Environmental Impact Assessment (EIA) under the DOE (Department of Environment) within the Ministry of Natural Resources and Environment(MNRE), and the Radiological Impact Assessment (RIA) under the Atomic Energy Licensing Board (AELB) within the MOSTI (Ministry of Science, Technology and Innovation).

Unknown to the public the poorly done Preliminary Environmental Impact Assessment (PEIA) for Lynas does not cover the radiation and health concerns. In fact, the PEIA does not explicitly mention the exclusion of radiation aspects from the scope of the EIA in its Introduction. Instead, the exclusion is specifically mentioned only in the later chapters e.g. in Chapter 8 on 'Summary and Conclusion' (page 8-13).

In addition, the PEIA mentions a Radiological Impact Assessment (RIA) but not in a clear manner. For example, in Chapter 2 of the PEIA, it states that, “The Malaysian Nuclear Agency [MNA], the radiological consultants appointed by Lynas are presently in the midst of determining radiation safety issues pertaining to lanthamide concentrate storage, handling and transport.”

At the end of Chapter 3, the PEIA states for the first time that wastes produced in the plant operations are radioactive and that their storage will be done according to the recommendations based on the MNA's 'Radiological Impact Assessment' carried out for the project (page 3-7).

The Lynas project was fast tracked for approval by the Pahang State DOE, within two or three weeks of submission. The DOE received the PEIA on Jan 21, 2008 and approved it in early February.

For such a complex project involving radiation hazards with a very vague waste management, storage and disposal proposal, the speedy approval raises serious questions.

This is especially when the PEIA was submitted and approved, the RIA on radiation safety issues was still in the process of being written by the MNA for submission to the AELB. In light of this, our concerns are as follows:

Firstly, how could the PEIA recommend the 'build' option (page 3-8) when the radiation safety issues have not been considered? How could the state DOE have approved the PEIA in such haste?

Note that in the PEIA, the waste management proposal is vague and inadequate. They include the following:

• the space for underground wastes storage cells is very limited due to the groundwater being extremely close to the surface;

• the ground is susceptible to subsidence as it is a former peat swamp area;

• the release of dangerous wastes into Sg Balok and subsequently into the sea;

• the dangerous and toxic radioactive wastes which are supposed to be carefully stored onsite in special ponds and storage cells but then schizophrenically proposed to be re-used as fertilisers, concrete, plasterboards, for roads, etc (page 5-58, 59).

Secondly, the fact that there is an RIA independent of the PEIA means that there are now two independent and parallel impact assessments in existence. This is setting a dangerous precedent in the entire review process.

Under Malaysia's environmental laws, the DoE is the primary coordinating authority on issues related to the environment and its impact on the well being of its citizens. The MNA and AELB are promoters of nuclear technology and this may give rise to conflicts of interests as MNA is the consultant that wrote the RIA for Lynas.

Thus, how effective will the DoE be in achieving its mandate to protect the environment and the well being of the people? How independent and autonomous is the DOE from the MNA-AELB?

Will DOE'S policies and decisions be subservient to the interests of the AELB? Will DoE have to relegate its role to the AELB in nuclear matters and issues related to radiation and its impacts? These questions have a crucial bearing on the credibility of the Lynas review process.

Thirdly, what is the RIA assessment and approval procedure under the AELB? While the general EIA process under the DOE is widely published and publicly available (e.g. on the DOE website), in comparison, the RIA process remains completely unknown and uncharted territory.

Which governmental agencies were on the RIA approval panel? What are the criteria for the RIA assessment? Why is the RIA or its contents not available for scrutiny by independent experts?

Fourthly, Lynas is required to apply to the AELB separate licences for siting, construction, importation of radioactive materials, onsite storage of radioactive wastes, temporary operation, and permanent operation. It is unclear if Lynas has all the licences to operate. AELB has said only siting and construction licences were approved.

Fifthly, the poorly done PEIA also lacks a proper socio-economic assessment. No costs-benefits assessment (CBA) was performed. The major reason given in the PEIA for the built option recommendation for the Lynas project is the large financial and economic benefits promised.

The lack of proper socio-economic analyses and CBA invalidates the recommended built option. For example, what are the values assigned for people's health, tourism, fisheries and other industries in the area and what happens when these are affected by the Lynas project?
One should also consider examples of the long-term health impacts of the Asian Rare Earth case in Perak, and the rare earths industry in China.

These are critical issues that need to be addressed concerning the Lynas project. Given the above, CAP and SAM recommend that:

• The Lynas project be stopped in order to address the issues, including the Wastes Management Plan, which an Australian mining expert reported as being 'yet to be disclosed by Lynas';

• A transparent, integrated assessment be done for projects requiring both EIA and RIA. This would prevent a PEIA or DEIA (detailed EIA) being approved while not knowing the full radiological safety impacts in an RIA;

• A DEIA be legally required for any project that requires an RIA, thus ensuring a more thorough review process. This is only logical, considering less hazardous activities require detailed environmental impact assessments. Further, unlike a PEIA, a DEIA makes public participation mandatory;

• Proper socio-economic analyses be a requirement for all EIAs, whether preliminary or detailed;

• Politicians (state and federal) should not make claims that controversial projects are safe as unqualified political endorsements make the project approval process political, very biased and dangerous.

SM Mohamed Idris is president of Consumers Association of Penang and Sahabat Alam Malaysia

Radiation Dose and Risks (another perspective...)

Radiation Dose and Risks (another perspective...)

Radiation is measured using the unit sievert, which quantifies the amount of radiation absorbed by human tissues.

Below are some facts about the health dangers posed by higher radiation levels:

- Japan's Chief Cabinet Secretary Yukio Edano had at one point said radiation levels near the stricken plant on the northeast coast reached as high as 400 millisieverts (mSv) an hour. That figure would be would be 20 times the annual exposure for some nuclear-industry employees and uranium miners.

- People are exposed to natural radiation of 2-3 mSv a year.

- A typical chest X-ray involves exposure of about 0.02 mSv, while a dental one can be 0.01 mSv.

- Exposure to 100 mSv a year is the lowest level at which any increase in cancer risk is clearly evident. A cumulative 1,000 mSv (1 sievert) would probably cause a fatal cancer many years later in five out of every 100 persons exposed to it.

- There is evidence linking an accumulated dose of 90 mSv from two or three CT scans with an increased risk of cancer. The evidence is reasonably convincing for adults and very convincing for children.

- Large doses of radiation or acute radiation exposure destroy the central nervous system and the red and white blood cells, leaving the victim unable to fight off infections. For example, a one sievert dose (1,000 mSv) causes radiation sickness such as nausea, vomiting, hemorrhaging, but not death. A single dose of 5 sieverts would kill about half of those exposed to it within a month.

- Exposure to 350 mSv was the criterion for relocating people after the Chernobyl accident, according to the World Nuclear Association.

"Very acute radiation, like that which happened in Chernobyl and to the Japanese workers at the nuclear power station, is unlikely for the population," said Lam Ching-wan, a chemical pathologist at the University of Hong Kong.

Sources: the New England Journal of Medicine, World Nuclear Association and Taiwan's Atomic Energy Council

Plain Film X Rays

Single Radiographs	Effective Dose, mrem (mSv)
Skull (PA or AP)1	3 (0.03)
Skull (lateral)1	1 (0.01)
Chest (PA)1	2 (0.02)
Chest (lateral)1	4 (0.04)
Chest (PA and lateral)5	6 (0.06)
Thoracic spine (AP)1	40 (0.4)
Thoracic spine (lateral)1	30 (0.3)
Lumbar spine (AP)1	70 (0.7)
Lumbar spine (lateral)1	30 (0.3)
Abdomen (AP)1	70 (0.7)
Abdomen6	53 (0.53)
Pelvis (AP)1	70 (0.7)
Pelvis or hips6	83 (0.83)
Bitewing dental film6	0.4 (0.004)
Limbs and joints6	6 (0.06)

Doses Received Undergoing an Entire Procedure

Complete Exams	Effective Dose, mrem (mSv)
Intravenous Pyelogram (kidneys, 6 films)1	250 (2.5)
Barium swallow (24 images, 106 sec fluoroscopy)1	150 (1.5)
Barium meal (11 images, 121 sec fluoroscopy)1	300 (3.0)
Barium follow-up (4 images, 78 sec fluoroscopy)1	300 (3.0)
Barium enema (10 images, 137 sec fluoroscopy)1	700 (7.0)
CT head1	200 (2.0)
CT chest1	800 (8.0)
CT abdomen1	1,000 (10)
CT pelvis1	1,000 (10)
CT (head and chest)5	1,110 (11)
PTCA (heart study)6	750-5,700 (7.5-57)
Coronary angiogram6	460-1,580 (4.6-15.8)
Mammogram6	13 (0.13)
Lumbar spine series6	180 (1.8)
Thoracic spine series6	140 (1.4)
Cervical spine series6	27 (0.27)

Dose	MSCT	Conventional angiography
Mean effective radiation dose (mSv)	14.7	5.6

Multislice computed tomography (MSCT) using a 16-slice scanner delivers more than twice the radiation than conventional angiography

Radiation and Risk - Compilation from various sources

Radiation and Risk

How much radiation do we get?

The average person in the United States receives about 360 mrem every year whole body equivalent dose. This is mostly from natural sources of radiation, such as radon. (See Radiation and Us ).

In 1992, the average dose received by nuclear power workers in the United States was 300 mrem whole body equivalent in addition to their background dose.

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What is the effect of radiation?

Radiation causes ionizations in the molecules of living cells. These ionizations result in the removal of electrons from the atoms, forming ions or charged atoms. The ions formed then can go on to react with other atoms in the cell, causing damage. An example of this would be if a gamma ray passes through a cell, the water molecules near the DNA might be ionized and the ions might react with the DNA causing it to break.

At low doses, such as what we receive every day from background radiation, the cells repair the damage rapidly. At higher doses (up to 100 rem), the cells might not be able to repair the damage, and the cells may either be changed permanently or die. Most cells that die are of little consequence, the body can just replace them. Cells changed permanently may go on to produce abnormal cells when they divide. In the right circumstance, these cells may become cancerous. This is the origin of our increased risk in cancer, as a result of radiation exposure.

At even higher doses, the cells cannot be replaced fast enough and tissues fail to function. An example of this would be "radiation sickness." This is a condition that results after high doses to the whole body (>100 rem), where the intestinal lining is damaged to the point that it cannot perform its functions of intake of water and nutrients, and protecting the body against infection. This leads to nausea, diarrhea and general weakness. With higher whole body doses (>300 rem), the body's immune system is damaged and cannot fight off infection and disease. At whole body doses near 400 rem, if no medical attention is given, about 50% of the people are expected to die within 60 days of the exposure, due mostly from infections.

If someone receives a whole body dose more than 1,000 rem, they will suffer vascular damage of vital blood providing systems for nervous tissue, such as the brain. It is likely at doses this high, 100% of the people will die, from a combination of all the reasons associated with lower doses and the vascular damage.

There a large difference between whole body dose, and doses to only part of the body. Most cases we will consider will be for doses to the whole body.

What needs to be remembered is that very few people have ever received doses more than 200 rem by accident. With the current safety measures in place, it is not expected that anyone will receive greater than 5 rem in one year. Radiation risk estimates, therefore, are based on the increased rates of cancer, not on death directly from the radiation.

Non-Ionizing radiation does not cause damage the same way that ionizing radiation does. It tends to cause chemical changes (UV) or heating (Visible light, Microwaves) and other molecular changes. Further information can be found at:

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Risk

How is risk determined?

Risk estimates for radiation were first evaluated by scientific committees in the starting in the 1950s. The most recent of these committees was the Biological Effects of Ionizing Radiation committee five (BEIR V). Like previous committees, this one was charged with estimating the risk associated with radiation exposure. They published their findings in 1990. The BEIR IV committee established risks exclusively for radon and other internally alpha emitting radiation, while BEIR V concentrated primarily on external radiation exposure data.

It is difficult to estimate risks from radiation, for most of the radiation exposures that humans receive are very close to background levels. In most cases, the effects from radiation are not distinguishable from normal levels of those same effects. With the beginning of radiation use in the early part of the century, the early researchers and users of radiation were not as careful as we are today though. The information from medical uses and from the survivors of the atomic bombs (ABS) in Japan, have given us most of what we know about radiation and its effects on humans. Risk estimates have their limitations,

1. The doses from which risk estimates are derived were much higher than the regulated dose levels of today;
2. The dose rates were much higher than normally received;
3. The actual doses received by the ABS group and some of the medical treatment cases have had to be estimated and are not known precisely;
4. Many other factors like ethnic origin, natural levels of cancers, diet, smoking, stress and bias effect the estimates.

What is the risk estimate?

According to the Biological Effects of Ionizing Radiation committee V (BEIR V), the risk of cancer death is 0.08% per rem for doses received rapidly (acute) and might be 2-4 times (0.04% per rem) less than that for doses received over a long period of time (chronic). These risk estimates are an average for all ages, males and females, and all forms of cancer. There is a great deal of uncertainty associated with the estimate.

BEIR VII risk estimates for fatal cancer are similar to the values from BEIR V, but they also estimated incidence rates, which were about 50% of the fatal cancer rate.

Risk from radiation exposure has been estimated by other scientific groups. The other estimates are not the exact same as the BEIR V estimates, due to differing methods of risk and assumptions used in the calculations, but all are close.

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Risk comparison

The real question is: how much will radiation exposure increase my chances of cancer death over my lifetime.

To answer this, we need to make a few general statements of understanding. One is that in the US, the current death rate from cancer is approximately 20 percent, so out of any group of 10,000 United States citizens, about 2,000 of them will die of cancer. Second, that contracting cancer is a random process, where given a set population, we can estimate that about 20 percent will die from cancer, but we cannot say which individuals will die. Finally, that a conservative estimate of risk from low doses of radiation is thought to be one in which the risk is linear with dose. That is, that the risk increases with a subsequent increase in dose. Most scientists believe that this is a conservative model of the risk.

So, now the risk estimates. If you were to take a large population, such as 10,000 people and expose them to one rem (to their whole body), you would expect approximately eight additional deaths (0.08%*10,000*1 rem). So, instead of the 2,000 people expected to die from cancer naturally, you would now have 2,008. This small increase in the expected number of deaths would not be seen in this group, due to natural fluctuations in the rate of cancer.

What needs to be remembered it is not known that 8 people will die, but that there is a risk of 8 additional deaths in a group of 10,000 people if they would all receive one rem instantaneously.

If they would receive the 1 rem over a long period of time, such as a year, the risk would be less than half this (<4 expected fatal cancers).

Risks can be looked at in many ways, here are a few ways to help visualize risk.

One way often used is to look at the number of "days lost" out of a population due to early death from separate causes, then dividing those days lost between the population to get an "Average Life expectancy lost" due to those causes. The following is a table of life expectancy lost for several causes:

Health Risk	Est. life expectancy lost
Smoking 20 cigs a day	6 years
Overweight (15%)	2 years
Alcohol (US Ave)	1 year
All Accidents	207 days
All Natural Hazards	7 days
Occupational dose (300 mrem/yr)	15 days
Occupational dose (1 rem/yr)	51 days

You can also use the same approach to looking at risks on the job:

Industry type	Est. life expectancy lost
All Industries	60 days
Agriculture	320 days
Construction	227 days
Mining and quarrying	167 days
Manufacturing	40 days
Occupational dose (300 mrem/yr)	15 days
Occupational dose (1 rem/yr)	51 days

                ___________________

These are estimates taken from the NRC Draft guide DG-8012 and were adapted from B.L Cohen and I.S. Lee, "Catalogue of Risks Extended and Updates", Health Physics, Vol. 61, September 1991.

Another way of looking at risk, is to look at the Relative Risk of 1 in a million chances of dying of activities common to our society.

• Smoking 1.4 cigarettes (lung cancer)
• Eating 40 tablespoons of peanut butter
• Spending 2 days in New York City (air pollution)
• Driving 40 miles in a car (accident)
• Flying 2500 miles in a jet (accident)
• Canoeing for 6 minutes
• Receiving 10 mrem of radiation (cancer)

Adapted from DOE Radiation Worker Training, based on work by B.L Cohen, Sc.D.

The following is a comparison of the risks of some medical exams and is based on the following information:

• Cigarette Smoking - 50,000 lung cancer deaths each year per 50 million smokers consuming 20 cigarettes a day, or one death per 7.3 million cigarettes smoked or 1.37 x 10^-7 deaths per cigarette
• Highway Driving - 56,000 deaths each year per 100 million drivers, each covering 10,000 miles or one death per 18 million miles driving, or 5.6 x 10^-8 deaths per mile driven
• Radiation Induced Fatal Cancer - 4% per Sv (100 rem) for exposure to low doses and dose rates

Procedure	Effective Dose (Sv)	Effective Dose (mrem)	Risk of Fatal Cancer	Equivalent to Number of Cigarettes Smoked	Equivalent to Number of Highway Miles Driven
Chest Radiograph	3.2 x 10-5	3.2	1.3 x 10-6	9	23
Skull Exam	1.5 x 10-4	15	6 x 10-6	44	104
Barium Enema	5.4 x 10-4	54	2 x 10-5	148	357
Bone Scan	4.4 x 10-3	440	1.8 x 10-4	1300	3200

Adapted from information in Radiobiology for the Radiologist, Forth Edition; Eric Hall 1994, J.B. Lippincott Company

Typical scan doses (Wikipedia)

Examination	Typical effective dose (mSv)	(millirem)
X-ray Personnel security screening scan	0.00025	0.025[19]
Chest X-ray	0.1	10
Head CT	1.5[20]	150
Screening mammography	3[12]	300
Abdomen CT	5.3[20]	530
Chest CT	5.8[20]	580
CT colonography (virtual colonoscopy)	3.6–8.8	360–880
Chest, abdomen and pelvis CT	9.9[20]	990
Cardiac CT angiogram	6.7-13[21]	670–1300
Barium enema	15[12]	1500
Neonatal abdominal CT	20[12]	2000

So, in summary, we must balance the risks with the benefit. It is something we do often. We want to go somewhere in a hurry, we accept the risks of driving for that benefit. We want to eat fat foods, we accept the risks of heart disease. Radiation is another risk which we must balance with the benefit. The benefit is that we can have a source of power, or we can do scientific research, or receive medical treatments. The risks are a small increase in cancer. Risk comparisons show that radiation is a small risk, when compared to risks we take every day. We have studied radiation for nearly 100 years now. It is not a mysterious source of disease, but a well-understood phenomenon, better understood than almost any other cancer causing agent to which we are exposed.

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Doses

The following is a comparison of limits, doses and dose rates from many different sources. Most of this data came from Radiobiology for the Radiologist, by Eric Hall or BEIR V, National Academy of Science. Ranges have been given if known. All doses are TEDE (whole body total) unless otherwise noted. Upon revision, SI units will be added. Units are defined on our Terms Page. The doses for x-rays are for the years 1980-1985 and could be lower today. Any correction or comments can be sent to us at: RIN Webmaster

Also, see Calculator for Medical Radiation Exposure.

Doses from various sources

Limits for Exposures	Exposure	Range
Occupational Dose limit (US - NRC)	5,000 mrem/year
Occupational Exposure Limits for Minors	500 mrem/year
Occupational Exposure Limits for Fetus	500 mrem
Public dose limits due to licensed activities (NRC)	100 mrem/year
Occupational Limits (eye)	15,000 mrem/year
Occupational Limits (skin)	50,000 mrem/year
Occupational Limits (extremities)	50,000 mrem/year
Source of Exposure
Average Dose to US public from All sources	360 mrem/year
Average Dose to US Public From Natural Sources	300 mrem/year
Average Dose to US Public From Medical Sources	53 mrem/year
Average dose to US Public from Weapons Fallout	< 1 mrem/year
Average Dose to US Public From Nuclear Power	< 0.1 mrem/year
Coal Burning Power Plant	0.165 mrem/year
X-rays from TV set (1 inch)	0.500 mrem/hour
Airplane ride (39,000 ft.)	0.500 mrem/hour
Nuclear Power Plant (normal operation at plant boundary)	0.600 mrem/year
Natural gas in home	9 mrem/year
Average Natural Background	0.008 mR/hour	0.006-0.015 mR/hour
Average US Cosmic Radiation	27 mrem/year
Average US Terrestrial Radiation	28 mrem/year
Terrestrial background (Atlantic coast)	16 mrem/year
Terrestrial background (Rocky Mountains)	40 mrem/year
Cosmic Radiation (Sea level)	26 mrem/year
Cosmic Radiation (Denver)	50 mrem/year
Background Radiation Total (East, West, Central US)	46 mrem/year	35-75 mrem/year
Background Radiation Total (Colorado Plateau)	90 mrem/year	75-140 mrem/year
Background Radiation Total (Atlantic and Gulf in US)	23 mrem/year	15-35 mrem/year
Radionuclides in the body (i.e., potassium)	39 mrem/year
Building materials (concrete)	3 mrem/year
Drinking Water	5 mrem/year
Pocket watch (radium dial)	6 mrem/year
Eyeglasses (containing thorium)	6 - 11 mrem/year
Coast to coast Airplane roundtrip	5 mrem
Chest x-ray	8 mrem	5 - 20 mrem
Extremities x-ray	1 mrem
Dental x-ray	10 mrem
Head/neck x-ray	20 mrem
Cervical Spine x-ray	22 mrem
Lumbar spinal x-rays	130 mrem
Pelvis x-ray	44 mrem
Hip x-ray	83 mrem
Shoe Fitting Fluroscope (not in use now)	170 mrem
Upper GI series	245 mrem
Lower GI series	405 mrem
Diagnostic thyroid exam (to the thyroid)
Diagnostic thyroid exam (to the Whole Body)
CT (head and body)	1,100 mrem
Therapeutic thyroid treatment (dose to the thyroid)	10,000,000 mrad
Therapeutic thyroid treatment (dose to the whole body)	7,000 mrem	5,000-15,000 mrad
Earliest Onset of Radiation Sickness	75,000 mrad
Onset of hematopoietic syndrome	300,000 mrad	100,000 to 800,000 mrad
Onset of gastrointestinal syndrome	1,000,000 mrad	500,000 to 1,200,000 mrad
Onset of cerebro-vascular syndrome	10,000,000 mrad	>5,000,000 mrad
Threshold for cataracts (dose to the eye)	200,000 mrad
Expected 50% death without medical attention	400,000 mrad	300,000 to 500,000 mrem
Doubling dose for genetic effects	100,000 mrad
Doubling dose for cancer	500,000 mrad	(8% per Sv, natural level at 20%)
Dose for increase cancer risk of 1 in a 1,000	1,250 mrem	(8% per Sv)
Consideration of therapeutic abortion threshold (dose in utero)	10,000 mrem
SL1 Reactor Accident highest dose to survivor	27,000 mrem
Three Mile Island (dose at plant duration of the accident)	80 mrem

Miami Herald: Some health screenings may do more harm than good

Some health screenings may do more harm than good

Just excess radiation, one doctor says.

• Photo

Common diagnostic screenings
STRESS TEST
• For women older than 50 and men older than 40 embarking on a strenuous exercise program. Also for those with shortness of breath or chest pain.

BLOOD TESTS
High sensitivity-C-reactive protein -- indicates inflammation of the arteries.
Lp(a) -- for those with a strong family history of early cardiovascular disease.
ApoB -- to help evaluate risk of cardiovascular disease. Dr. Arthur Agatston recommends it when the total triglycerides are high and the HDL (good cholesterol) is low.
PSA -- the American Urological Association says it should be offered to men 40 or older who have a life expectancy of at least 10 years; others suggest a baseline screening at 50. Not for men over 75. Early findings in two screening studies had conflicting results: a European study found it cut the death rate by 20 percent; an American study found no benefit.

GENETIC TESTS
ApoE -- indicates genetic risk for Alzheimer's disease. For those who are concerned about or have a family history of the memory disorder.
Parkin and lark2 -- mutations in these genes indicate a risk for Parkinson's disease. Geneticist Jeffery Vance suggests that those with a strong family history, where multiple generations had Parkinson's, should ask their doctor about these genetic tests.

DIAGNOSTIC SCANS
Mammograms -- to detect breast cancer in women, baseline test at age 40, then annually. Not recommended for younger women because their breast tissue is too dense and breast cancer is relatively rare in that age group. After age 70, at discretion of the patient and her doctor.

BY KATHRYN W. FOSTER, Miami Herald, 03 Nov 2009

... Tests can tell if we have a high risk of prostate cancer, Alzheimer's, Parkinson's disease and various genetic disorders. CT scans can examine every inch of our bodies.

Are all these tests wise for a healthy adult? While mammograms and blood pressure readings have become part of annual checkups for most Americans, the explosion in preventative health exams has triggered a debate over which tests are necessary and which ones simply drive up the cost of health care -- or actually harm a patient.

Some doctors warn that certain screenings may do more harm than good because they expose the body to unnecessary radiation or raise questions that lead to further, invasive probing. Research suggests that some CT scans increase the risk of radiation-induced cancer.

"There are [genetic] tests that could be run on all of us,'' says Dr. Jeffery M. Vance, chairman of the University of Miami's Dr. John T. Macdonald Foundation Department of Medical Genetics. But "you need to understand why you're doing it. Make sure it's answering the question you want answered.''
CT scans are "being used for all sorts of diagnostic purposes not envisioned in the past, such as detecting heart disease, [conducting] virtual colonoscopies,'' says Dr. Jeffrey Neitlich, chairman of the Department of Radiology at Mount Sinai Medical Center.

"Patients shouldn't be scared away from CT scans if they need them, but shouldn't have them routinely.''

A study in the August New England Journal of Medicine suggests that as many as 4 million Americans a year are exposed to high doses of radiation from diagnostic scans, with a nuclear heart stress test called the myocardial perfusion scan being the single biggest contributor.

TOTAL-BODY SCANS
Particularly worrisome to Neitlich are full-body scans on healthy people. There has been ``no scientific publication demonstrating that a whole-body CT scan has any impact on life expectancy or quality of life. Therefore, at least at the current time, it's just excess radiation without any proven benefit,'' he says.

While cancer screenings are often life-saving, not all the information is helpful. Among the possible drawbacks, according to the U.S. Preventive Services Task Force:
• Results that falsely indicate cancer, leading to additional tests and worry.
• Failure to find an existing cancer so that the patient ignores symptoms while the disease continues unchecked.
• Detecting slow-growing or non-fatal cancers, leading to treatment that could have been avoided.

PROSTATE CANCER
The American Cancer Society no longer recommends routine PSA blood tests, saying doctors and patients should discuss the implications first.
"Some prostate cancers grow so slowly that they would likely never cause problems. Because of an elevated PSA level, some men may be diagnosed with a prostate cancer that . . . would never have caused any symptoms or lead to their death,'' the ACS writes in its online screening guide.

HEART TESTS
There's disagreement about which tests should be given. Dr. Michael Ozner, director of Wellness and Prevention for Baptist Health South Florida, recommends three blood tests that include the ApoB ("predictive of who's going to have a heart attack'') and the LP(a), which can help detect heart and vascular disease.

But South Beach Diet doctor Arthur Agatston, an associate professor at UM's medical school, recommends the ApoB only ``if the total tri-glycerides are high and the HDL [good cholesterol] is low.'' He also uses advanced blood tests, CT scans and even genetic tests.

Dr. Melissa Tracy, head of UM's cardiac rehab, would try other treatments before ordering the ApoB or the Lp(a).
"For the average person, we don't have evidence-based medicine that treating an elevated ApoB or Lp(a) leads to a positive outcome,'' she says.

Ozner's third recommendation is the high-sensitivity CRP blood test, to tell "whether arteries are inflamed,'' Studies have shown that people with elevated CRP levels and normal cholesterol were at increased risk of a heart attack, he says.

"In the past we've treated cardiovascular disease like a plumbing problem,'' Ozner says. "Now we know it's not a cholesterol storage disease, but a chronic inflammation disease. We have three tests that are very important to uncover hidden risks, yet people are bombarded with ads to get 64-slice CT scans.''

Ozner, whose book The Great American Heart Hoax: Lifesaving Advice Your Doctor Should Tell You About Heart Disease Prevention (But Probably Never Will) was published last year, calls the 64-slice heart CT scan for healthy people ``one of the biggest hoaxes perpetuated on the public.

"All that does is gives the patient an inordinate amount of radiation and sends people down the slippery slope to more and more medical intervention,'' he says. "If you're a man or woman in the ER with the proverbial elephant on your chest, I'm all for CT scans'' and other interventions.

A recent study found the median level of radiation in a heart CT scan is equal to 600 chest X-rays, although the levels varied widely.

"There are a lot of different ways to do cardiac CT scans. You can take two different centers and get twice the radiation at one as at the other,'' says Mount Sinai's Neitlich.

ALZHEIMER'S
As for Alzheimer's disease, many diagnostic tools are in the works. The ApoE gene test is already available.

Vance warns against genetic testing by mail, partly because some of the factors detected by these tests raise alarms when the risk really isn't that high.

"The results are misleading,'' Vance says. "It's important to have it done with a genetic counselor or a doctor to discuss what it means . . . Other than the very rare mutation, there is no test that's going to tell you 100 percent that you'll get Alzheimer's.''

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Screening for Prostate and Breast Cancers

Have the benefits been overstated?

Screening for prostate and breast cancers has been promoted heavily in the U.S., and annual screening costs are US$20 billion for just these two cancers. 

Lifetime diagnoses of prostate cancer were made in 1 of 11 white men in 1980; in 2009, the risk is 1 in 6. 

For breast cancer, risks were 1 in 12 in 1980 and 1 in 8 in 2009. 

Authors of a highly publicized JAMA review now challenge the value of such intensive screening.

If screening accurately identifies cancer at an early treatable stage, the incidence of localized cancer should increase after screening is implemented, and the incidence of metastatic cancer should decline. Because this pattern has occurred for neither breast nor prostate cancer, screening simply might identify low-risk non–life-threatening cancers that then are treated inappropriately with aggressive therapy. 

By comparison, screening for colon and cervical cancers has led to significantly fewer cases of advanced disease. The observed decline in prostate cancer–related mortality in the last 20 years probably is not attributable to screening but, rather, to aggressive new adjuvant therapies.

The costs associated with screening are substantial. 

For breast cancer, avoiding 1 cancer-related death requires annual screening of more than 800 women (age range, 50–70) for 6 years, which generates hundreds of biopsies and overly aggressive treatment for many patients with low-grade cancers.

The authors recommend greater focus on identifying new biomarkers that differentiate low- and high-risk cancers, minimalist approaches that are appropriate for treating patients with low-risk cancers, better tools to guide physicians and patients in informed decision making, and a greater focus on prevention and screening in high-risk patients rather than broad indiscriminate screening.

— Thomas L. Schwenk, MD
Published in Journal Watch General Medicine October 29, 2009

Reference: Esserman L et al. Rethinking screening for breast cancer and prostate cancer. JAMA 2009 Oct 21; 302:1685.