The following factors increase the likelihood of the patient having a pulmonary malignancy: radiographic appearance of the lesion (size and lack of calcification), age, symptoms of cough and weight loss, hypercalcemia, absence of residence in or travel to an area endemic for coccidioidomycosis (southwest United States) or histoplasmosis (Ohio/Mississippi Valley), absence of fever or evidence of infectious disease, and negative PPD skin test. The latter does not rule out tuberculosis, but makes it less likely.
Initially, one or more of the following tests might be ordered:
search for previous chest radiographs for comparison
sputum studies for cytology and cultures (standard pathogens, fungus, acid-fast bacilli)
CAT scan
fiberoptic bronchoscopy with bronchial brushings and specimens for cytology and culture.
Additional tests would follow, depending on results of these initial studies. If a primary lung cancer is detected, a metastatic workup (scans of the brain, liver, adrenals, and bones) might be indicated.
The treatment issues for this patient are beyond the scope of this monograph, and treatment would not be recommended until further studies are completed. The patient should be referred to an oncologist and chest surgeon (if she is a surgical candidate) for evaluation before treatment. Depending on histologic type, local extension into adjacent anatomical structures, presence of metastases, and the general health of the patient, treatment options would include surgical excision, radiation, chemotherapy, and possibly immunotherapy.
Anyone who spends a significant amount of time in the home would be at risk. Data are inadequate to assess individual susceptibility to radon-induced lung cancer; however, possible reasons to be concerned about the patient's family members include her daughter's smoking habit, her grandson's young age, and possible asbestos and radiation exposure due to her husband's past history of shipyard work. The amount of time spent at home by each family member should be considered. You might be concerned about the patient's husband because exposures to asbestos, external radiation, and radon might increase his risk of lung cancer significantly. Because he is retired, he might spend more time at home indoors, thus increasing his duration of exposure to radon.
No. Everyone in the community will not be exposed to the same radon level. Regional geologic differences such as granite deposits and soil structure are major determinants of indoor radon concentration; however, local concentrations can vary greatly. Even assuming all homes in the community are built on the same geologic formation, the radon level in each home cannot be predicted. The only way to determine a home's radon level is to test the home. The construction and condition of each house and the source of water supply can vary. Even if the neighbors were exposed to the same radon levels, the neighbors would not be at equal risk of health effects. The risk of lung cancer to each occupant not only depends on the radon level, but also on the occupants themselves and their lifestyles.
The actions of radon and cigarette smoke are probably synergistic. For your patient's daughter, who is a smoker, the risk of dying from lung cancer is 10 to 20 times greater than if she did not smoke. It is not known how passive exposure to cigarette smoke affects the risk for lung cancer in relation to radon exposure.
In addition to building location, the factors that influence radon gas entry into a home are
type and condition of the foundation
pressure differences between the soil and the inside of the home
building materials used
air exchange rate or ventilation.
No. It is unlikely that the fetus would be affected by airborne radon, because alpha emitters act locally on the respiratory tract, and because there are no firmly established systemic effects.
It is unlikely that radon would play any role in the development of mesothelioma, because this is a malignancy of the pleural lining, not the lung. Smoking does not increase the risk for mesothelioma among asbestos workers.
The test kit should be placed in the lowest lived-in level of the home (e.g., the basement, if frequently used; otherwise, the first floor). It should be put in a room that is used regularly (like a living room, playroom, den, or bedroom), but not the kitchen or bathroom. The kit should be placed at least 20 inches above the floor in a location where it will not be disturbed-away from drafts, high heat, high humidity, and exterior walls.
As a health professional, you can
motivate all smokers to quit smoking
educate patients and act as a resource regarding radon risks
help families rank the risks of the many environmental pollutants they encounter
refer families to the health department, state radon office, or EPA for more information
relate to others your experiences in testing your own home
encourage detection and mitigation of radon when indicated
encourage appropriate building techniques for new construction.
There are no enforceable regulations to control indoor radon levels; therefore, no legal recourse exists. However, some communities have ordinances that require remediation before a house with elevated radon levels can be sold. EPA recommends mitigation if the indoor radon level is above 4 pCi/L; the national goal is to reduce indoor radon levels to outdoor levels (i.e., about 0.4 pCi/L). Clearly, the school's classrooms exceed these levels. Educating the community about radon might help motivate them to take remedial action.
