Gelas M, Giraud M, Righi E, Tobajas L
Service Medical, Compagnie Générale des Matiéres Nucléaires (COGEMA), Velizy-Villacoublay, France.
Med Lav. 1994 May-Jun;85(3):193-204.
The principal directives on radiation protection (ICRP, EEC, national regulations) are the basis of a critical analysis of the concrete aspects, as typically found, of medical surveillance of exposed workers. It is shown how doctrinal, regulatory and legal hypertrophy produced by radiation protection often results in poor medical surveillance. This situation also arises by virtue of the rigid application of the ALARA principle (primary prevention) that considers workers in most cases as "virtually exposed". National regulations tend to privilege diagnostic exploration of deterministic damage, applying selective criteria to "slices" of the "state of health", whereas a global evaluation is required by the ICRP and by EEC regulations. In this context, there is a veiled intention, by now historically consolidated, to use such diagnostic tests as biodosimetric indicators. Another and persistent cause for concern is the practice of acquiring data on the radiosensitivity of some organs and systems for the (unlikely) occurrence of an accident. Instead, less consideration seems to be given to the early diagnosis of stochastic damage (leukemia and solid tumours). The physician has to confront not only the possible tumours due to occupational irradiation, but inevitably and prevalently (and often exclusively) the so-called "spontaneous" tumours that lead to an estimated mortality of 25% or more. Both radio-induced and spontaneous are in the end clinically observed in their globality, without distinction. In this context, medical surveillance undoubtedly acquires obligations with regard to tumour prevention (secondary prevention), considering also that sites with a high coefficient of risk of tumoral radio-induction basically coincide with the most frequently occurring cancers in the average population. Based on the above considerations, a diagnostic protocol is proposed that reconciles, with due economy but with the right balance, the real requirements of medical surveillance, reducing as far as possible undesirable effects such as "damage from excessive protection" (often of a formal character) and patient/physician delay, which is extremely dangerous for the early diagnosis of tumours.
辐射防护的主要指令（国际放射防护委员会、欧洲经济共同体、国家法规）是对受照工人医学监测具体方面进行批判性分析的基础。研究表明，辐射防护产生的理论、监管和法律上的过度发展往往导致医学监测不力。这种情况还源于对最优化原则（一级预防）的严格应用，该原则在大多数情况下将工人视为“实际受照”。国家法规倾向于优先对确定性损伤进行诊断性检查，对“健康状况”的“部分”应用选择性标准，而国际放射防护委员会和欧洲经济共同体法规要求进行全面评估。在这种背景下，利用生物剂量学指标等诊断测试存在一种由来已久且根深蒂固的潜在意图。另一个持续令人担忧的原因是，为了（不太可能发生的）事故获取某些器官和系统放射敏感性数据的做法。相反，对于随机损伤（白血病和实体瘤）的早期诊断似乎较少受到关注。医生不仅要面对职业照射可能导致的肿瘤，而且不可避免且普遍（往往是唯一）要面对所谓的“自发”肿瘤，这些肿瘤导致的估计死亡率高达25%或更高。最终，无论是辐射诱发的还是自发的肿瘤，在临床上都是作为一个整体被观察到，没有区别。在这种背景下，考虑到肿瘤辐射诱发高风险部位基本上与普通人群中最常见的癌症部位重合，医学监测无疑在肿瘤预防（二级预防）方面承担起了义务。基于上述考虑，提出了一种诊断方案，该方案以适当的经济性并保持正确的平衡，协调医学监测的实际需求，尽可能减少诸如“过度防护造成的损害”（通常是形式上的）和患者/医生延误等不良影响，这些对肿瘤的早期诊断极为危险。
