Not long ago thyroid cancer patients who received a dose of radiation spent a day or two in the hospital. That's no longer the case, and one member of Congress thinks that poses a public health hazard.

Rep. Edward Markey (D-MA) points to a congressional analysis that he says backs up his point. It highlights the potential dangers to public health from patients who have been released from the hospital after being treated with radioactive materials for cancers and other diseases.

"Releasing radioactively 'hot' patients who may expose an unwitting public to potentially dangerous levels of radiation makes absolutely no sense," Markey said. "Yet that is exactly what the Nuclear Regulatory Commission's current policies allow." 

Markey, Chairman of the Energy and Environment Subcommittee of the Energy and Commerce Committee, also sent a letter transmitting the analysis to Nuclear Regulatory Commission (NRC) Chairman Greg Jaczko in advance of two meetings the NRC is having on the subject. In the letter, Markey calls on the NRC to revise its regulations to ensure that the public is protected against unnecessary exposure to radioactive patients.

1,000 subjects

The subcommittee's investigation, which drew from a survey of more than 1,000 thyroid cancer survivors' experiences, indicates that there is a strong likelihood that members of the public have been unwittingly exposed to radiation from patients who are discharged after being treated with radioisotopes.

The analysis found that these risks occurred because of weak NRC regulations, ineffective oversight of those who administer these medical treatments, and the absence of clear guidance and procedures to ensure that such exposures do not occur. 

Prior to 1997, most treatments for thyroid cancer and other disorders would have occurred on an inpatient basis. Other countries have similar rules, not just for the projection of the patient but for those who might come in contact with the patient immediately following the treatment.

In 1997, NRC revised its regulations to allow for patients treated with radioactive materials whose bodies are emitting high levels of radiation to be sent home, even if they live with young children or pregnant women, who are most vulnerable to such exposures. Patients can also be sent to hotels for recovery, even though hotel workers or other hotel guests may be unwittingly exposed. 

The subcommittee's survey collected about 1,000 responses in just over two weeks, Markey said.

According to the National Cancer Institute, 44,670 new cases of thyroid cancer will be diagnosed in 2010, and other thyroid disorders are also treated with radioactive iodine.  The survey results indicate that:

Radioactive patients

Nearly seven percent of all patients who are treated with radioactive iodine on an outpatient basis choose to go to a hotel or similar facility to recover where they contaminate sheets, bedspreads, and other common room surfaces and could also potentially expose pregnant hotel workers or children of guests -who are the most susceptible for developing cancer as a result of radiation exposure.  In 2007, a patient was discovered to have contaminated two individuals as well as the sheets and towels used in almost an entire hotel in Illinois.  

Seventy-five percent of these patients go to hotels with their doctor's knowledge.  The NRC's guidelines require physicians to perform individualized calculations to ensure that patients won't contaminate those they contact if they are released from the hospital, but these calculations can't be reliably performed for hotels (because there is no way to know who is sleeping on the other side of the wall, who the next hotel guest will be, or whether the hotel cleaning staff is pregnant).

Ten percent of the patients never received any education on ways to reduce exposure to pregnant women and children from the radiation they emit.  The NRC has chosen to depend on the adequacy of instructions given to patients to ensure that they don't expose others to radiation.  In a response to a previous letter Rep. Markey sent to Jaczko on this issue, NRC indicated that it believes the public is adequately protected, provided that "adequate instructions are given at discharge to patients and family members." Clearly, the assumption that the instructions provided to patients are adequate is not supportable.  

Correspondence with state regulators, who implement and oversee NRC regulations in 37 States, also indicated that concerns with radioactive contamination of public transportation systems (NJ) and waste landfills (MA, MD) are other confounding problems associated with the immediate discharge of patients after treatment with radioactive iodine. 

Markey says the NRC should immediately start a rulemaking to revise its 1997 regulations surrounding the treatment of patients with radionuclides, and ensure that these regulations are made to be consistent with and as protective of the most vulnerable populations as policies that are in place in other developed countries. Hospitalization should be mandatory for those patients who are treated with doses of I-131 above internationally accepted threshold limits. 

Further he says the new regulations should ensure that patients who are released from the hospital after treatment are prohibited from recovering from such treatments in hotels or taking taxis or public transportation in the days that immediately follow treatment, and that specific written and verbal guidance prohibiting such activities is provided both to medical licensees and to patients. 

Enforcement actions should be taken against medical licensees who fail to provide such guidance to patients, or otherwise fail to advise a patient planning to violate the prohibitions that the regulations do not permit such activities.  In cases where the patients cannot identify a suitable outpatient facility in which to recover, NRC regulations should mandate in-patient stays.