Nasal Radium Treatments

[JMUCKERHEIDE@delphi.com]

Group,

Is everyone familiar with the nasal radium issue? The following is a CDC
report on the issue from a Sep 95 workshop. We are pursuing making sure this
is addressed thru the Gov's Advisory Council on Rad Protection. Stewart Farber 
has been pursuing this, originally re the submariners and airmen who were
"human experiments" for the treatment. 

Now we know that 500,000 to 2 million children were subjects to routine
treatments. There is indication of adverse effects, but also a Dutch study
that followed treated patients, but at about one-sixth the dose, showed no
adverse effects. A treatment series is about 2000 Rad locally. Many patients
had more than one treatment. I had previous indications that surrounding
exposures were higher than reported here, including up to 200 R to local
sections of the brain. We can pursue this info for more details if anyone is
interested. 

There is an argument that this population is not being pursued because it
again is expected to show the lack of linear dose effects. Also, very many of
the children exposed were done by the wholesale busload by Johns Hopkins, and
there is legal fear of raising the issue in this population. (The head of the
President's "Human Radiation Experiments" panel is a Professor of Ethics at
Johns Hopkins, and played a strong role in keeping this, the only truly
high-dose "human rad experiment" population (of a couple of thousand, though
there is a question of when the procedure was no longer experimental), from
being identified, and with recommendations to NOT notify or follow subjects
exposed (and noting, correctly, that the children so exposed were not
"experiments"). CDC and DOD have been fighting the effort to follow this
population. 

There is also indications of non-cancer effects that are not reflected in this 
report. 

Regards, Jim Muckerheide
jmuckerheide@delphi.com
Radiation, Science, and Health

=================================

Workshop on the Public Health Response to Nasopharyngeal Radium
Irradiation -- September 1995

     During September 27-28, 1995, a workshop entitled "Public Health
Response to Nasopharyngeal Radium Irradiation" was convened in New Haven,
Connecticut, to address issues regarding possible adverse health effects
of this former medical treatment. Workshop participants discussed the
strengths and weaknesses of possible epidemiologic studies. 

     From 1940 through the mid-1960s, nasopharyngeal (NP) radium was used
to treat hearing loss, chronic otitis, and other conditions in children
and was used to treat aerotitis media in submariners and aviators in the
military. The goal of this approach was to reduce swelling of enlarged
lymphoid tissue, which was believed to be a cause of both hearing loss and
aerotitis media. Treatment usually included insertion of an applicator
with a capsule of radium through each nostril and placement of the radium
near the eustachian tube opening for 8-12 minutes. 

     Workshop participants presented estimates of the numbers of persons
treated and of the doses to nearby organs. An estimated 500,000-2 million
persons may have received NP radium treatments. Radiation doses to nearby
organs were estimated on the basis of bilateral use in an adult of 50 mg
of radium sulfate in a 0.5-mm platinum capsule for 12 minutes per session
for three sessions. Estimates were 2000 rads to local tissue, 24 rads to
the pituitary gland, 5 rads to the brain, and 2 rads to the thyroid. 

     Based on a cohort study in Maryland of 904 exposed and 2021 unexposed
persons during 1943-1960, the risk for all head and neck cancers combined
was higher among persons who had received the treatment than among persons
who had not (1); however, this finding was based on small numbers of
cancers (three brain and one soft palate cancer) and was statistically
significant only after categories were combined. A cohort study in the
Netherlands of 2510 exposed and 2199 unexposed persons did not document a
statistically significant increase in head and neck cancers in the exposed
group (2). Follow-up studies of both cohorts are under way. 

     A panel of medical and public health experts and representatives of
veterans' and civilians' groups then discussed and provided comments for a
workshop report. The report encouraged CDC and the U.S. Department of
Veterans Affairs (VA) to collaborate on the following public health
activities: 

1. Continue the follow-up studies of existing cohorts, and if possible,
combine the data from these studies, include noncancer endpoints in the
follow-up studies, and evaluate the results of the follow-up studies
before considering an additional cancer incidence study of persons who
received NP radium treatments. Although studies of persons who self-report
exposure to the treatment are useful in generating hypotheses, such
self-reporting should not be the means of identifying formal
"case-subjects" in epidemiologic studies. 

2. Veterans who received NP radium treatments should be provided access to
the Ionizing Radiation Registry maintained by the VA and to priority
medical care at VA medical facilities. 

3. Rather than screening asymptomatic persons, physicians should be
educated about how to obtain more complete and accurate histories from
patients who received NP radium treatments. Subspecialists should be
provided specific information about NP radium exposure. 

Reported by: J Stolwijk, PhD, A Saftlas, PhD, Dept of Epidemiology and
Public Health, Yale Univ School of Medicine, New Haven. ML Fleissner,
DrPH, Connecticut Dept of Public Health. Association of State and
Territorial Health Officers, Washington, DC. S Mather, MD, Office of
Public Health and Environmental Hazards, US Dept of Veterans Affairs.
Radiation Studies Br, Div of Environmental Hazards and Health Effects,
National Center for Environmental Health, CDC. 


Editorial Note: Nasopharyngeal radium was one of several
radiationtreatments used to treat benign conditions before 1950. Other
approaches included use of external x-irradiation to treat hearing loss,
acne, tinea capitis, and enlarged thymus, and the use of radon and radium
to treat hemangiomas (3-7). When radium treatments were developed and
used, other options were either not available, were considered more
invasive, or involved external irradiation. Following the publication
during the 1950s of findings regarding long-term effects of radiation,
health-care providers reserved therapeutic radiation only for serious or
life-threatening conditions. 

     Because most of the radiation from NP radium was in the form of beta
particles, the highest dose was delivered to the soft tissue of the
nasopharynx, in which the background rate of cancer is low (0.6 per
100,000 persons) (8) and which has not been documented to be as sensitive
to radiation as thyroid or brain tissue. 

     In collaboration with workshop cosponsors, CDC plans wider published
dissemination of the proceedings of the workshop. The VA is seeking
legislation to provide veterans who received NP radium treatments with
access to the VA Ionizing Radiation Registry and priority medical care at
VA medical facilities. CDC, VA, and the Association of State and
Territorial Health Officers are developing a live satellite
videoconference for physicians on NP radium, which will be aired on
September 5, 1996, from 12:30 p.m. to 2:30 p.m. eastern daylight time. 

     Current studies do not indicate substantial increases in risks for
neoplastic or other disease among those who received NP radium treatments.
Because the workshop discussion discouraged medical screening, diagnostic
tests and procedures for asymptomatic persons are not warranted. However,
physicians may consider performing thorough head and neck examinations of
patients with a history of NP radium treatments. In addition, physicians
who provide care for patients aged greater than or equal to 35 years with
head and neck complaints should ask the patients whether they have a
history of NP radium treatments or other head and neck radiation. Persons
who recall being treated or believe they were treated with NP radium
should inform their physicians of the exposure. 

References

1. Sandler DP, Comstock GW, Matanoski GM. Neoplasms following
   childhood radium irradiation of the nasopharynx. J Natl Cancer Inst
   1982;68:3-8.

2. Verduijn PG, Hayes RB, Looman C, Habbema JD, van der Maas PJ.
   Mortality after nasopharyngeal radium irradiation for eustachian
   tube dysfunction. Ann Otol Rhinol Laryngol 1989;98:839-44.

3. Hempelmann LH, Hall WJ, Phillips M, Cooper RA, Ames WR.
   Neoplasms in persons treated with X-rays in infancy: 4th survey in
   20 years. J Natl Cancer Inst 1975;55:519-30.

4. Ju D. Salivary gland tumors occurring after irradiation of the
   head and neck area. Am J Surg 1968;116:518-23.

5. Lundell M, Furst CJ, Hedlund B, Holm LE. Radium treatment for
   hemangioma in early childhood: reconstruction and dosimetry of
   treatments, 1920-1959. Acta Oncol 1990;29:551-6.

6. Ron E, Lubin JH, Shore RE, et al. Thyroid cancer after exposure
   to external radiation: a pooled analysis of seven studies. Radiat
   Res 1995;141:259-77.

7. Viswanathan K, Gierlowski TC, Schneider AB. Childhood thyroid
   cancer: characteristics and long-term outcome in children
   irradiated for benign conditions of the head and neck. Arch Pediatr
   Adolesc Med 1994;148:260-5.

8. Ries LAG, Miller BA, Hankey BF, Kosary CL, Harras A, Edwards BK,
   eds. SEER cancer statistics review, 1973-1991: tables and graphs.
   Bethesda, Maryland: US Department of Health and Human Services,
   Public Health Service, National Institutes of Health, National
   Cancer Institute, 1994; NIH publication no. 94-2789.