Radioactive iodine treatment
New York Times
By MATTHEW L. WALD
Published: October 24, 2010
WASHINGTON — Doctors told Ann B. Maddox that she had thyroid cancer and that the cure was to swallow radioactive iodine, to kill the malignant cells. She traveled 500 miles from her home in Fayetteville, N.C., for treatment at Johns Hopkins Hospital in Baltimore.
Then began a problem: what do you do when you cannot go home and you are radioactive?
There are about 40,000 new cases of thyroid cancer a year, and most patients are treated with radiation, which makes them potentially dangerous to people around them for up to a week.
The question of where they should spend that time is drawing new concern from doctors, public health officials and regulators.
In 1997, the Nuclear Regulatory Commission dropped a requirement that such patients be quarantined in the hospital. Instead, patients can be released right after their treatment, when they are at their most radioactive.
And while most people go right home, one patient in New York boarded a bus for Atlantic City, N.J., and set off a radiation alarm in the Lincoln Tunnel. And about 5 percent of patients do what Ms. Maddox did: check into a hotel.
“There weren’t many choices, really,” said Ms. Maddox, who is 72. The night before her treatment, in 2003, she stayed with her daughter in Delaware, but her daughter was pregnant, and fetuses and children are especially vulnerable to radiation. Johns Hopkins had no place for her to spend the night, she said. Getting on an airplane was out of the question because of the dose of radiation she would give other passengers. And there was concern about what would have happened if, as many patients do, she vomited the radioactive contents of her stomach.
Instead, her husband, Bryce, booked a room at a hotel in Newark, Del. “I pretty much went in the back door,” Ms. Maddox said. When they hit the road the next day, heading home, she sat as far as possible from her husband, in the third row of seats in their Honda Odyssey minivan. “I’m sure we looked like we’d had some kind of spat,” she said.
Fortunately, like most thyroid cancer patients, she needed only a single dose of radiation to get rid of the cancer.
Scientists have estimated that, depending on the amount of radioactive drug given to a thyroid patient, a secondhand dose could exceed an average American’s annual level from all natural sources, and three or four times the safe level recommended for a pregnant woman.
One person alarmed about the situation is Representative Edward J. Markey, Democrat of Massachusetts, whose office has been studying the issue. He accuses the Nuclear Regulatory Commission of turning a blind eye to the problem.
“My investigation has led me to conclude that the levels of unintentional radiation received by members of the public who have been exposed to patients that have received ‘drive through’ radiation treatments may well exceed international safe levels established for pregnant women and children,” Mr. Markey said in a statement.
The Nuclear Regulatory Commission took up the issue at a meeting last Wednesday. James G. Luehman, a staff official who helps monitor the safe handling of radioactive materials used in medicine, said his agency might have made a mistake in dropping the quarantine requirement. The idea was that letting people return home to recuperate would cut costs, benefit the patients and allow doctors with no quarantine facilities to perform the treatment.
The agency knew that relatives and strangers would get a radiation dose from such patients, Mr. Luehman said, but it assumed that the doses to people like hotel clerks and chambermaids would be random and that no one was likely to be exposed repeatedly. He recommended that the commission study whether such patients tended to stay at certain hotels near major medical centers, but no conclusion about such a study was reached on Wednesday.
New York City has gone a step further. Last June, it advised radiologists and endocrinologists, “Do not advise patients to go to a hotel.” A few states have similar policies.
There are simple precautions that patients can take to reduce the risks sharply: stay several feet away from other people and keep them from contact with the patient’s saliva, urine and other body fluids.
Radiation from patients decreases both as the iodine dose is flushed out of their bodies and as it loses strength.
Many radiation experts doubt that radioactive thyroid patients represent a public health problem. “We’re talking about really small doses,” said Dr. Henry D. Royal, the associate director of nuclear medicine at the Mallinckrodt Institute of Radiology at Washington University, in St. Louis.
“Who is it going to harm?” added Dr. Royal, who is on the executive board of the American Nuclear Society. “Show me some measurement that you’ve made, that this really happens.”
But the issue has, in fact, stirred considerable concern among endocrinologists and others involved in nuclear medicine. Dr. Gregory A. Brent, the president of the American Thyroid Association, said that his group had spent two years trying to develop guidance for doctors on how to advise patients, but that there was no data about the risks of secondhand radiation to work from.
The risk seems hypothetical, he said. “You can imagine the pregnant woman working in a hotel, cleaning up urine,” he said. “One can generate scenarios. But from what we know and what has been looked at, that hasn’t been the case.”
The staff of Mr. Markey, who is chairman of the Energy and Environment subcommittee of the House Committee on Energy and Commerce, has been gathering reports of contamination. In Maryland and Massachusetts, for example, patients have put contaminated items in the trash, and the trucks that collected it set off alarms at dumps.
After thyroid treatment, patients are advised not to hug children or pregnant women, or to sleep next to another person, for several days — depending on the size of the dose.
They are even advised against eating chicken wings or whole apples, because the bones or the core will be contaminated with radioactive saliva.
Hospital isolation is still the practice in Europe. Patients can be hospitalized in the United States, but only if they try hard.
For example, Janis Lewis, of Roanoke, Va., took her 16-year-old daughter for an iodine dose in June, soon after thyroid cancer was diagnosed.
The girl, whose name Ms. Lewis asked not be published, gets motion sickness even in normal circumstances, she said, and she asked at the endocrinologist’s office if her daughter could be admitted overnight. She was told that was not possible, and that her medical insurance would not pay for it.
But Ms. Lewis eventually determined that her insurance would cover the expense if a doctor said hospitalization was medically necessary; but the hospital involved had no isolation rooms for thyroid cancer patients.
She gave up on that hospital. “I wasn’t comfortable driving her home three and a half hours in the car,” said Ms. Lewis, an occupational therapist.
Instead, she found another doctor, at Washington Hospital Center, in the District of Columbia, where her daughter stayed overnight, and did, in fact, vomit radioactive material all night.
Outpatient treatment is often appropriate, Ms. Lewis said, but “in some cases, it’s gone too far.”
