Kellerer, A. M. Electron Spectra and the RBE of X Rays. Radiat. Res. 158, 13–22 (2002).

For an assessment of the possible difference in effectiveness between mammography X rays and conventional X rays, the energy and LET spectra of the released electrons are examined. At photon energies below 20 keV and above 100 keV, the energy of the electrons increases with increasing photon energy, which implies that higher-energy photons produce less densely ionizing radiation and are therefore somewhat less effective per unit dose. However, in the intermediate energy range from 20 keV to 100 keV—the range that is relevant to medical diagnostics—the change from the photoelectric effect to the Compton effect causes a transient decrease of electron energies. The ionization density is therefore similar for 200 kVp X rays and 30 kVp mammography X rays, and the distributions of dose in LET suggest an RBE of 30 kVp mammography X rays compared to 200 kVp X rays of up to 1.3. This is in line with an earlier assessment by Brenner and Amols in terms of microdosimetric data, but it is strongly at variance with a recent claim that X rays for mammography are about four times more effective at small doses than conventional X rays and that they cause a correspondingly greater risk for breast cancer. Since LET need not be the only relevant factor, general response functions are examined here that specify—at low dose—the effect per electron of initial energy E and account, for example, for a particular role of the electron range. It is shown that, with any response per electron track that is a nondecreasing function of its starting energy, the low-dose RBE of the mammography X rays relative to the 200 kVp X rays must be substantially less than 2. The Auger electron that accompanies most photoelectrons, but only a minority of the Compton electrons, may increase the effectiveness of the mammography X rays somewhat, but it cannot explain the reported high values of the RBE.