On behalf of EFOMP, I thank the ICRP for the efforts provided in drafting this important document dedicated to radiological protection in PET and PET/CT. In our opinion, the document will represent a valuable support for professionals, regulators and various stakeholders in the practical application of radiological protection with regard to PET, PET/CT and PET/MRI systems and nuclear medicine facilities.
EFOMP agrees with the general structure and provides the following comments in the hope that they will help to improve the effectiveness and clarity of the document.
The title of the document is ''Radiological Protection in PET and PET/CT”. Since much space is also devoted to cyclotrons and PET/MR hybrid scanners, it would perhaps be useful to include these systems in the title as well.
Point 7) pag. 12, the list of professionals has some minor inaccuracies, e.g. maintenance engineers and clinical application specialists are not healthcare professionals.
Point 236) pag. 64, lines 2485-2493. For EFOMP, this part is very important and forms the basis for building a constructive and collaborative inter-professional relationship, which is necessary to make the radiological protection system effective in daily practice.
Please modify “physicist” with “medical physicist” where necessary in the text, for example in:
Point 252), pag. 70. This is an important aspect for the application of the radiological protection system: could the ICRP provide more details or references on how to carry out this individual risk estimation?
Point 289), pag. 78, line 2964. Please modify “nuclear medicine physicist” with “medical physicist”.
These two documents published by EANM and EFOMP might be interesting to describe and cite in the document
Point 442) pag. 116, lines 4292-4294 “There is a need for the individuals to work together as a team. Each have unique skills and the individuals within the team should have a mutual respect for the contribution that each makes.” The EFOMP agrees on the need to strengthen the medical imaging team "radiologist, medical physicist, registered radiologists assistants, radiologic technologists and all supervising physicians" (similar to the "optimisation team" described in previous ICRP documents). Without inter-professional collaboration and respect it is difficult to apply the optimisation principle in clinical practice.
Point 486) pag. 123, lines 4578-4580 “Annual Testing of the PET, CT or MRI subsystem of the scanner by a medical physicist trained in each of the specific subsystem is essential to a successful Quality assurance program” and point 489) pag. 123, lines 4594-4596. “Acceptance testing for a PET/MRI scanner should always be performed by qualified and knowledgeable medical physicists with expertise in both PET and MRI (AAPM, 2010; 4596 ACR, 2015).” These two points are crucial to ensure an effective and optimised use of the whole system. In general in the hospital there are many scenarios involving the simultaneous use of ionizing and non-ionizing radiation sources, for example, hybrid MR-LINAC and PET-MR systems, and medical physicists are actively involved in the safe and optimised management of all parts of the systems, for example by acting also as MR safety experts.
More generally, the medical world experiences a continuous evolution of technology, involving more and more different sources of physical agents (x-rays, electromagnetic fields, ultrasound, lasers, etc.) with the sole purpose of benefiting the patient. The safe and effective use of these devices increasingly involves medical physics units. EFOMP advocates an integrated and holistic approach of these different sources, in which responsibilities regarding the basic provisions to ensure safe, integrated, effective, and optimized use of the devices are clear. In fact, often the level of the optimisation and thus the effectiveness of the procedure (safety and clinical outcome), depends on how the actions dedicated to the use of all parts of the system are well coordinated and interconnected. Also for this reason, EFOMP welcomes the recent collaboration agreement between ICRP and ICNIRP, to foster a common approach to ionising and non-ionising radiation sources also in the medical field.
Notably, the EFOMP has recently updated one of its main statements, the Malaga Declaration [1]. In this document EFOMP recommends the establishment of medical physics units/departments, where all the necessary expertise is present to deal with all aspects of complex medical devices involving the use of different physical agents in an effective, coordinated and optimised manner. If the authors agree with this organisational model proposed by EFOMP, they could suggest in the document the creation of medical physics units/departments, to foster a holistic approach to managing the different sources of physical agents that are present in hybrid systems. This could also support countries where the shortage of medical physicists is more pronounced, to promote the improvement of staffing levels.
Punto 541) pag. 134, lines 5013-5021. “Publication 113 defines Medical Physicists as a Category 9, medical physicist 'specializing in radiological protection (RP), nuclear medicine, or diagnostic radiology' (ICRP, 2009). A medical physicist should have the highest level of training in radiological protection and, in many countries, is the one that, at institutional and facility level, will be overseeing the radiological protection program as a Radiation Safety Officer, ….A medical physicist will also undertake the equipment acceptance testing, and annual or periodic QC, as well as advise on optimisation of the dose for different protocols, working together with the remainder of the imaging team.” As it is correctly reported in this excerpt, in many countries medical physicists also act as Radiation Safety Experts/Officers. EFOMP, in the recently updated Malaga Declaration, published the following official position on this topic [1]:
Actions that ensure the radiation protection of workers and members of the public are often strongly interconnected with those dedicated to the radiation protection of patients (This aspect is also indicated in the ICRP document on radiological protection in PET and PET/CT currently open for consultation, e.g. at the point c pag. 8, point g pag. 9, point 5 pag. 11 and point 163 pag. 46). For example, the radiation exposure of workers in nuclear medicine and interventional radiology is strongly related to the patient’s absorbed dose. In this scenarios, the responsibilities of the Radiation Protection Expert (RPE) to protect staff and the public from the harmful effects of ionising radiation may not be aligned with those of the responsibilities of the Medical Physics Expert (MPE) to protect the patient; thus, the effectiveness of radiation protection depends on robust communication and liaison between RPE and MPE…. where the RPE is a MPE, radiation protection management that includes all the actions necessary to ensure radiation protection for all, is simplified and more effective. Accordingly, the 2006 Malaga declaration is updated as follows: …“The Medical Physics Expert (MPE) as defined in the directive 2013/59/EURATOM should be the healthcare professional to supervise and assume the responsibilities for radiation protection activities in hospital settings, including patients, working staff, members of the public and visitors. The Radiation Protection Expert (RPE) in hospital settings should be an MPE, since medical physicists have the highest level of radiation physics knowledge and training”. EFOMP recommends dividing national RPE registers into two groups:
“The minimum requirement for RPEs entering a national register for radiation protection in medical practices should be recognition as an MPE by the national authority.”
If the proposed organisational model is considered valid, the authors may cite this official EFOMP position in this part of the document.
Point 556) pag. 138. It could be appropriate to have specified here that medical physicists are healthcare professionals as indicated by the ILO-ISCO since 2008 [2, 3]. This is a very important point and can help countries where the profession is less developed to promote appropriate training programs.
Point 558) pag. 138, lines 5173-5178. Since the last years, the EFOMP is working to update the core curricula to become Medical Physics Experts (MPE) and to harmonise access to the MPE profession in Europe. In this regard, we would like to bring to the task group attention some recent documents, although they are focused on other medical physics sub-specialities (radiotherapy and artificial intelligence) [4, 5]. In fact, these documents contain up-to-date general information that can be applied also in the nuclear medicine field. In particular, in the last published core-curriculum [4], EFOMP suggests this training program to achieve the qualification of medical physics expert
If deemed useful by the TG, this training programme could be cited in or added to item 556) on page 138.
References
[1] Byrne B, et al. EFOMP Malaga Declaration 2023: An updated vision on Medical Physics in Europe. Phys Med. 2023;111:102620. doi:10.1016/j.ejmp.2023.102620
[2] https://www.ilo.org/public/english/bureau/stat/isco/docs/groupdefn08.pdf
[3] Nüsslin F, Smith P. Medical physics now classified internationally as a profession. Med Phys. 2011;38(8):i. doi:10.1118/1.3605469
[4] https://www.efomp.org/uploads/5fdfd8da-c219-4c1e-9a33-0678cf8c4021/Radiotherapy_cor_cc2022.pdf
[5] Zanca F, et al. Expanding the medical physicist curricular and professional programme to include Artificial Intelligence. Phys Med. 2021;83:174-183. doi:10.1016/j.ejmp.2021.01.069
[6] IAEA TCS-71. Guidelines for the Certification of Clinically Qualified Medical Physicists.
[7] IAEA TCS-56. Postgraduate Medical Physics Academic Programmes.