Hello, and welcome to the Physics World Weekly
podcast, which is supported by Research
Laboratories.
I'm Hamish Johnston.
Our theme this week is diagnosing and treating
disease. How physicists
keep you safe during health care procedures.
This episode was created in collaboration with IPEM,
the Institute
of Physics and Engineering
in Medicine,
which owns the journal
Physics in Medicine and Biology.
Our guests are 2 medical physicists
working at the heart of the UK's
National Health Service
or NHS.
They are Mark Knight, who is chief health
care scientist
at the NHS Kent and Medway
Integrated Care Board,
and Fiammetta
Fidele,
who is head of non ionizing
radiation
at Geis and St. Thomas
NHS Foundation Trust in London.
They're in conversation with Physics World's Tammy Freeman,
and that's coming up after this message from
Research
Laboratories.
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Many of the health care procedures routinely delivered
in hospitals rely on the work of medical
physicists.
Medical physicists are responsible for developing and commissioning
advanced diagnostic and treatment systems.
They design radiotherapy plans that accurately target tumors,
make sure that the hospital's imaging equipment is
operating as expected, and much more.
But one of their most important tasks is
to ensure the safety of all these procedures
for the patient as well as the health
care staff.
To discuss how physicists keep you safe during
health care procedures,
I'm joined today by Mark Knight,
chief health care scientist at NHS Kent and
Medway ICB,
and Fiammetta Fidele,
head of non ionizing radiation at Guy's and
Saint Thomas NHS Foundation Trust.
Welcome both to the podcast.
Hello, Tammy.
Hello.
So looking at the safety of medical treatments,
one of the first things that comes to
mind is radiotherapy.
So this involves firing beams of ionizing radiation
at the patient to destroy cancer cells.
So how do the medical physicists ensure that
these treatments are safe?
For example, that the patient doesn't receive too
much radiation
and that the radiation only hits the tumor
and doesn't damage healthy parts of the body.
Thank you, Tammy. So I thought the best
way to look at this was to take
a step by step approach through the radiotherapy
process.
So we start with a scan, which will
show us precisely where the tumour is in
the patient and what shape it is.
And in the modern world, we might, use
a hybrid imaging technique to do this. So
a a CT scan perhaps which tells you
where the anatomy is combined with a with
a PET scan or an MRI scan, which
might tell you more about the dynamics of
the the tumor,
physiology.
So the the next stage is that a
clinician will outline the tumor,
to show us exactly where,
that is on the visual image, and then
they'll extend
the size of those margins a bit to
take account of microscopic
disease,
and uncertainties in the location of the tumor
that that would come about through all sorts
of,
things during the treatment process. So the patient's
bladder might be more full on one day,
which could affect the position of the prostate,
for example, in a prostate treatment.
And the next stage then is to take
a computerized treatment planning system,
to plan a bespoke
radiation treatment for every single patient. So based
on that scan,
the delineation of the tumor
volume, we would then use a series of
radiation beams to mathematically
model,
in a treatment planning system,
a radiation dose to that tumor. And and
the aim here then is to deliver the
prescribed radiation dose, which comes from our clinician.
We we want to deliver this much radiation
to exactly that shape, and size of tumor,
to,
and whilst minimizing the organs,
at risk,
radiation exposure. So for example, we know that
the bowel,
the spinal cord, for example, are much more
sensitive to radiation
than other organs, and so we would need
to ensure that, the dose is is minimized.
So on a on a conventional
radiotherapy treatment, we would use then a linear
accelerator or LINAC to deliver those radiation treatments
to the tumor.
And we've got lots of technologies available. So
for example,
tiny,
lead sheets, which are very
thick but very narrow, which can be used
to shape the radiation dose
coming out of the machine.
We can change the intensity
of the radiation,
and we can move the linear acceleration around
the patient while we deliver
the treatment. And all of that combines to
give us a very precise delivery
of radiation exposure to the tumor volume that
we've decided we need to treat from our
scans.
Okay. Great. So that's, I mean, that's a
super example of sort of physics based techniques
for, as you say, shaping the radiation and
planning where it needs to go exactly.
Now x rays are also used for diagnosing
medical conditions, and this includes
conventional x-ray scans,
CT images,
mammography.
Now here, the aim is very much not
to destroy any tissue, but to create images.
What are the potential risks of x-ray imaging,
and and how are these addressed?
So firstly, it's important to say that the
risk to individuals
from imaging with x rays are relatively small,
and it's important to keep those risks in
context.
So for example, we expose ourselves to risk
in everyday life through our day to day
activities such as traveling in a car and,
eating and drinking in excess of foods that
that may be bad for us.
And they they have risk to human health
as well, but we tend to not worry
about those so much as radiation risks,
because that's a bit of an unknown thing.
We we must remember as well that we're
exposed to background radiation
all the time,
which comes from the outside the Earth's atmosphere
and also in the food we eat and
the air we breathe. So humans have evolved
in an environment where we protect ourselves very
well against dionising radiation exposure.
A chest x-ray, for example, gives us the
same radiation exposure as a few days of
background radiation.
So the key to protection of patients,
is that each,
medical imaging procedure is justified
by an expert in medical imaging, and it
would only go ahead if the benefit to
the patient outweighs the risk from undertaking that
exposure, and that is a legal requirement.
Medical physics professionals
are closely involved
with the quality assurance of X-ray imaging equipment.
And during this process,
they'll review radiation dose, image quality,
and check that all of the radiation dose
saving devices for the patient are being used
in an optimal manner. And this process then
of balancing
the reduction of radiation exposure,
with the,
best image quality
is known as optimization.
Optimization is a huge part of our daily
work in medical physics. I should have said
before, of course, that it's exactly the same
in radiotherapy.
Our our physicists are closely involved with all
of the processes around inner accelerators,
the treatment planning processes,
and the scanning processes that go into delivering
that safe therapy.
And finally, we would reduce
risk further by ensuring that all of the
professionals connected
with each imaging procedure
are trained,
and they follow best practice guidelines. So that
would include our medical physics professionals who carry
out that quality assurance and optimisation
process,
on the x-ray equipment itself.
Okay. And and there's lots of other techniques
used for diagnostic imaging,
For example, ultrasound, which uses high frequency sound
waves to create images inside the body.
Now
if this technique just uses sound waves, are
there any safety concerns here? Fia, perhaps you
could answer this question?
Yes. Hi, Tommy. Good question. Yes. Ultrasound
still produces some effects in the body. It
produces some heat and can interact with gases
in the body, like, for example, the air
in the lungs.
But sonographers in UK
are trained to keep scanning times and as
well the level of the sound waves that
they use well below the levels that could
produce any of these effects. And so it's
perfectly safe to use. And the role of
the medical physicist is that to make sure
the scanners
are working as they say they're supposed to
work from manufacturers so that they can, keep
those levels within the limits sonographers
know.
Okay. And you also work with a treatment
technique called phototherapy,
and this uses UV light to treat skin
conditions.
So how do you make sure that patients
receive the correct dose to treat them and
not to cause harm?
Yeah. So phototherapy carbines are a bit like
huge,
UV ton inverts.
And
the point is that in that case, the
UV is being given to the patients for,
for treatment. But they need to have a
precise dose.
And what we do, we use light meters
to check the output of the cabins.
And then we can reassure the nurses, the
specialist nurses that usually deliver this treatment. So
what is the output of those units so
that they can make sure that they
register the dose, they track the dose, and
so they know when it's time to complete
the course of treatment for the patient?
Okay. So it sounds like in a lot
of these,
techniques that the medical physicist, one of their
big jobs is making sure that the equipment
is working safely.
But I guess, you can do that and
and and
there can still be issues.
So another imaging technique that's used all the
time in hospitals is MRI.
And MRI scanners present a unique hazard due
to their extremely strong static magnetic field.
And there have been reports of some serious
accidents caused by ferromagnetic
metal objects being pulled into the scanner.
So, you know, even if the scanner is
working perfectly, sometimes these accidents can happen. So
how do we present prevent this from happening?
So,
Tammy, linking to what we were discussing before
measurements, but then another big,
element of our job is training
training of the clinical teams.
So in MRI, for example, the at the
key prevention
is,
training the staff, making sure that all those
that can have access to MRI scanners,
have had specific training that let them know
of all the hazards that are connected
with this huge magnet being there.
And my colleagues that work in MRR, they
run periodic colleague training sessions in,
for geographers,
researchers,
everyone that might have access to that to
those scans.
2nd to training, there are the hazard control
prevention measurements. So there's labeling.
There's that indicates what are the higher risk
areas.
Whereabouts
you have the limits when you can carry
a magnetic objects?
And, again,
labeling of 8 entrances.
Everything that makes it easy in a high
pressure environment
for those operating it to know that that
it's,
their limit of operation.
Yeah. I mean, if if you if you
see an MRI scanning area, there there's loads
of big signs everywhere warning people to sort
of make sure they're not bringing any objects
near that they shouldn't. And then there's huge
yellow labels,
huge red labels on those pieces of equipment.
You know, the ones that, yes, it's fine.
That can go to ones that can't go.
So.
Okay. And then, I mean, I've seen sort
of issues with things like, you know, oxygen
cylinders being brought in that, that shouldn't be
there and, and being attracted to the magnet.
And obviously, as you say, training and making
sure everyone knows about these hazards,
that can help prevent that.
But what about if the patient have got
the patient has metallic implants that they can't
remove? So
if a patient has a pacemaker or a
cochlear implant, something like that, is that a
problem for MRI?
Yes. It is a problem, and this is
one of the biggest data that works for
the MRI physicist,
because they play a key role in advising
the clinical team.
First, they need to,
determine
whether that's how what's the classification
of that specific implant? So the newest implant
will be
as being MRI safe, so they can go
anywhere in an MRI environment.
Then there'll be the ones that are called
conditional, so they can be used under certain
conditions. And then there are the ones that
are called unsafe. So there are the ones
where it's not
recommended to have a patient in an MRI,
scanner.
And but also in those cases, it's always
a discussion between a multidisciplinary
team. So between the physics team and then
the consultant and the clinical team to discuss
the health benefit for the patient. Because you
might have a patient that has an implant
that is not one of those that is
MRI safe, but it's really important
for them to have their scanner.
And the likelihood of something happen comparing to
other implants might be lower if if it
makes sense. So it's always a balance. It'd
be like with ionizing radiation. There is always
a balance, and the physicists have a key
role in trying to explain
to the medical teams what are they,
the risk that they can,
can have.
Yeah. So it's the physicists working with the
clinicians to sort
of optimize
optimize it. Okay.
Now another area of health care, back onto
ionizing radiation. There's another area called nuclear medicine,
which includes things like PET, positron emission tomography.
And
here, the radioactive materials are actually introduced into
the patient's body for diagnosis
or for treatment.
How do we ensure patient safety here?
Thank you, Tammy. It's a it's a good
question. So, it's probably worth having a think
about how nuclear medicine and PET imaging work
initially. So so as you say,
radioactive substances
are typically labeled onto a pharmaceutical,
and that pharmaceutical is designed to target disease
processes in the body. So so we're all
familiar that when we take paracetamol or aspirin,
that's able to seek out the pain areas
and reduce the pain in that specific location.
So we call that a radiopharmaceutical,
and that's injected
into the patient,
and you would expect then that that concentrates
in the process where,
in the place where the disease process is
most strong. So,
when you then put that patient into a
camera or a or a scanner,
what you find is that the the areas
where the radiopharmaceutical
is concentrated will glow brighter than other areas,
and that allows us to see where the
disease,
is happening.
So,
in simple terms then,
medical physics professionals will be carrying out very
similar optimization
processes to those that we've discussed
before.
So,
very broadly ensuring that the minimum radiation dose
is given,
to allow for the production of diagnostic quality
images. But if we want to take a
bit of a deeper dive
into this, think about the physics a little
bit more,
we could think about,
how do we
design our radionuclide
diagnostic
processes
to minimize
that radiation dose. So let's let's take a
think for a for a moment about the
half life of the radioactive substance that we
use,
for our imaging.
This is quite critical.
It it takes up to 2 hours perhaps
to,
for the pharmaceutical to label onto the disease
process once it's inside the patient.
And during that 2 hour
time period, the radioactive substance is decaying.
So, obviously, if we use a radioactive substance
with a half life that's too short,
we we'll end up having to inject a
very high activity at the start of the
scan, which gives a high dose to the
patient. And similarly, if we give a radioactive
substance with a half life that's too long,
it will remain in the body for a
long time after the scan is finished. And
again, we'll deliver a high radiation dose to
the patient. So we need to optimise
our half life.
It's a similar argument with the energy of
the radiation emitted.
If we choose,
radio radioactive substance with an energy that's too
low,
then the gamma rays won't be able to
escape the body,
and they'll just deliver a radiation dose and
won't contribute to our useful image. But if
we choose an energy that's too high,
the gamma rays will pass straight through the
imaging equipment and won't contribute to the image
either. So we have to optimise
the radiation energy that we use. And again,
this is where our medical physics professionals come
in
and have a very interesting time thinking about
all of those different
physics processes that that make,
up the image. And if I could just
talk for a minute then about therapy, because
we also use radioactive substances in therapy.
It's a similar process. So we would either
inject,
or ask the patient to swallow a radioactive
substance
to treat,
medical condition, usually
cancer.
So common treatment, and this one dates back
to the middle of 20th century, is to
use radioactive
IID 131,
following the surgical removement,
removal of the thyroid
gland.
And so what happens is the iodine concentrates
in any remaining tissue that's left after the
surgery,
and it's a it's a great radioactive substance
for this purpose because it contains 2 elements,
beta
particles
that that are, of course, don't travel very
far in tissue. So they deliver a very
high dose to the thyroid tissue that's left
and minimize the radiation dose to other organs
in the body. So we destroy the thyroid
tissue that's left
and and spare the other tissues.
And it also contains a gamma emission, which
is quite useful because we can then use
that to image
any of that leftover thyroid tissue at the
end of the treatment.
So with that particular treatment, we use high
levels of radioactivity,
and the patient would need to remain in
a shielded bedroom with special bathroom and drainage
arrangements for a few days after receiving the
therapy.
Yeah. I mean, that, that was going to
be my next question. If the patient's got
a radioactive source of some sort inside them,
do they pose a risk to other people
and, and what's done about this?
That's absolutely right. So every medical procedure that
involves the use of radioactive
materials does carry a risk to members of
staff and, of course, to members of the
public.
So as you would imagine,
the procedures
are,
rigorously risk assessed.
So somebody will look at all of the
risks from that,
procedure. So we think about the external radiation
that comes from the radioactive substance. If the
patient travels home on the bus, for example,
someone will calculated what the radiation dose would
be to somebody sitting next to them on
the bus.
The radioactive substances are also excreted,
from the patient in in urine, in sweat,
saliva, for example. So we need to do
calculations to ensure that if those substances
get into, the environment,
that they're not going to give,
an exposure to members of the public that
are too
high.
So,
for our therapeutic
procedures,
the risk can be be higher still. And
for those procedures, we need a bespoke risk
assessment for each individual
patient.
So for example, in the iodine
therapy we we talked about earlier,
there, is a risk,
when the patient goes home
from the external radiation
and from contamination
from their urine and and bodily fluids.
So,
we would need to do a bespoke risk
assessment
for for them, and that will be based
on their own particular circumstances. So you can
imagine somebody who works as a park keeper
where they don't meet members of the public
very much, they're in a big wide open
space all day,
is much less risky than a primary school
teacher who's sitting very close to small children
all day. And then they would then go
home with a different set of restrictions on
their their own,
activities.
Okay. And, is this the same for brachytherapy?
Because that's it's slightly different, but it also
involves
putting radioactive sources inside people.
That's right. So,
for brachytherapy, it's probably worth having a think
about the difference between sealed and unsealed radioactive
sources to start with. So in our nuclear
medicine,
and PET procedures, we inject
unsealed sources, so they're liquid
radioactive substances. They're free to move around the
body and free to come out in our
bodily fluids. But in brachytherapy,
we use sealed radioactive sources where all of
the radioactivity
is encapsulated
inside,
for example, a metal capsule.
So, generally, there's no risk that those will
be released into the environment, and that whole
contamination
risk,
goes down,
to to 0.
Having said that,
the sealed source then can be thought of
a little bit like, an X-ray
source,
which which we would use in imaging or
in our linear accelerators.
The big difference is you can't switch it
off. It's radioactive. It's gonna be there until
it's decayed.
So we do have particular issues with a
brachytherapy.
For example, we would do a treatment where
a source goes into the patient
for, say, a 5 minute period and then
is withdrawn.
It's a very high activity sealed source,
but sometimes that source could become stuck,
and that poses a very big risk to
the patient,
and of course to to the staff. So
they have procedures in place with regular rehearsals
to make sure that if that does happen,
they're they're they're right ready to go or
the equipment's ready. The staff know exactly what
they're doing to go in and and do
that emergency source removal.
Okay. That's really interesting.
Now looking
ahead to the future,
researchers are continually developing sort of innovative new
medical techniques, both for diagnosis and treatment.
How do we ensure the safety of these
advanced
approaches when when they're first introduced into the
clinic? Maybe you could both comment on that.
So maybe before Mark comes in, what I
will say is not is not much different
from what is done for drug trials.
So before you introduce them in common use,
you need to test them under control,
technology trials.
And
and I don't know, you know, Mark, if
you wanna say a bit more about normally
the conditions we would do those tests.
Yes. We're doing,
trials. So,
essentially,
when we're introducing new technology, I think the
key is that we need to we need
to do it very carefully,
and in a very,
considered
manner.
So,
for first of all,
with any new technology,
we don't know at the start immediately how
how things are going to work,
and how they're gonna affect our patients. So
you do a very tightly controlled clinical trial
under those circumstances,
and and you would expect that there's ongoing
research,
and,
clinical trials into how do those technologies perform
over a period of time.
Then,
devices
you would expect to be
certified,
and regulated where where before they go into
use. So that is a a process where
the device is is rigorously examined,
and given a certification
to ensure that it's safe to use
on patients.
So again, you you would need expert
support
in the in the process of introducing this.
And I and I think to me, this
is where
multidisciplinary
approach comes in in healthcare.
For sure, you need your medical physics teams.
They're they're gonna be very well versed on
the the types of risks that might come
from these new technologies. They can,
do do, extensive calculations for you on on
what it might mean when we start to
use those in patients,
and and they will need to lurk work
alongside,
the doctors,
perhaps the radiographers who are delivering the treatments
as a multidisciplinary
group
to really understand how we're gonna best implement
that into our medical pathways.
And sometimes, if it's a diagnostic technique,
to be safe, what they will have to
do is they will have to give the
same exam they already give patients, and then
they would have to to use the new
device. So sometimes
they will inform the patients. They can accept
to take part in the trial or cannot
not accept to take part in the trial.
But if they're doing it, it's for future
benefit, and they will be, having to stay
a little longer. So,
again, most people are very happy to help
because, you know, they are are aware that
they're doing it for,
for the future of everyone.
Okay. And then,
also looking
ahead into the future,
can you comment on the use of artificial
intelligence
in medical procedures?
So AI is increasingly being touted for things
such as creating radiation treatment plans
or analysing medical images.
What do you think are the risks of
introducing AI into health care?
So AI is a hot topic. Course keeps
being is one of those
where we get all the ethical and all
the
questions.
In the end, like for other techniques,
is a matter
of controlled
trials
under expert guidance and under standardized
processes.
And
the point is
we can't just
have,
a black box
introduced in everyday use without knowing what that
black box is supposed to do when comparing
what what we have before.
But then again, there's bigger ethical issues. So
I don't know,
Mark, if you'd like to pop in.
Yeah. Thank you. So so I think it's
it's gonna be really important to make sure
that AI is introduced in an ethical manner.
So so one of the big concerns,
might be just as Fimeta said there,
we may not know exactly how the AI
is coming to its decisions,
because that that's the nature of the the
way in which these machines work.
And therefore, what we can look at is
the data that we've used to actually train
that
AI system
to make those decisions in the first place.
So if you look at example,
where we might be trying to diagnose,
medical conditions from chest X rays using an
AI system,
We have systems that have been trained
on on huge populations,
millions of patients,
but but in India. And and how do
we know that the population in India has
the same
anatomy, the same physiological,
conditions, the same,
medical conditions that we have in the UK.
So we may we may have an issue
there
with introducing a system that's been trained using
a different population
from our own. We we need to think
the same in the UK. We have a
wide range of nationalities.
We have, people of,
both sexes
in the UK. We we need to make
sure that when we train the systems, the
right data is used so that we get,
the the the right diagnostic
processes out. So again, I think, Fimete, you're
right. It's the ongoing research, the clinical trials,
and of course, incident reporting is really important.
If you have an incident
with a medical device,
and report that to the to the regulators,
it's something that then the whole,
world can learn from those mistakes, those errors,
and and fix it so that it doesn't
happen
again?
As far as AI is introduced
in this multidisciplinary
team with the contribution of the medical physicist,
the clinical engineers, but also the the team
the clinical teams are going to use them
is going to help us. Because in the
end, we have to think that in the
past, even some of the measure automatic measurements
that we use these days and some of
the technology that we use these days, they
were at those times equivalent of what AI
might be now. AI is just bringing this
to the to next level.
But on the other side, we know that
we are at the time of,
you know, time being pressured for time, being
pressured for
being able to see more patients, treat more
patients. So any tool that enables our clinicians
to reach those decisions in a quicker time,
it's it's going to be of of good
shape. So I'm one of those, and I
I don't know about Mark, but I'm one
of those that is very hopeful about AI,
but if done in a co design
way with
health care staff
and in in safe clinical trials.
I I agree. I I think that's absolutely
right. To to me,
I think if we were sitting here in
10 years' time having this discussion,
the the the world will have changed. It's
like when the the Internet was first introduced
in the early 19 nineties,
Maybe we didn't know what what we would
use that for, but but today, nobody can
imagine life without it. And I I imagine,
myself that this will be,
very similar.
Excellent. Well, it's, it's great to find out
what we may have to look forward to
in the future and also to, you know,
to learn about all the work that medical
physicists are doing to keep everyone safe. So
thank you both for joining me today.
Thank you.
Our pleasure.
That was Fiamada Fidele and Mark Knight in
conversation with Tammy Freeman.
That interview is produced in collaboration with IPEM,
which owns the journal
Physics in Medicine and Biology.
You can find the journal at IOP Science.
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Just click on the Physics World Live tab
at the top right of the home page.
I'm afraid that's all the time we have
for this week's podcast, which was produced in
partnership with IPEM.
Thanks to Fiammetta Fideli,
Mark Knight,
and Tammy Freeman for a fascinating
conversation.
And a special thanks to our producer,
Fred Iles.
And we would like to acknowledge the support
of RaySearch
Laboratories
for this podcast.
This podcast is supported by RaySearch Laboratories,
which unifies
industry solutions,
empowering healthcare providers
to deliver precise and effective
radiotherapy
treatment.
RaySearch's
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RayCare is an oncology
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It automates and streamlines
adaptive
oncology
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while securely guiding users
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Ray Intelligence
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This cloud based oncology
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Research products transform
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