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Life Redefined: Is “Weapons of Mass Destruction” an Overstatement?

Post Published: 09 November 2010
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Category: Column, Life Redefined, Thyroid Cancer in Young Adults Column
This post currently has 9 responses. Leave a comment

In my last article, Are We Becoming Weapons of Mass Destruction?, I wrote about my personal experience with radioactive iodine and my belief that we need stricter guidelines to protect those around us from being exposed to harmful radiation. I’m going to talk a bit more about this topic today and take a look at exactly what the United States Nuclear Regulatory Commission says about the radiation exposure from patients who receive I-131. Before I get into that, I need to provide you with a bit of background information.

In the United States, our I-131 dose is measured in millicurie (mCi). The SI unit of measurement is giga-Becquerel (GBq) and 100mCi=3.7GBq. OK, so mCi and GBq measure radioactivity. These measurements do NOT imply how much radiation will be absorbed by your body. If you have had external beam radiation, your dose may have been given in the unit Gray (Gy). This DOES imply how much radiation will be absorbed. The unit Gray measures the deposited energy of radiation. To get an idea of what a Gray is, here’s an example:  if you were to have an abdominal x-ray, you would receive about 1.4 milli-gray. If you were having external beam radiation for the treatment of lymphoma, you would likely receive somewhere between 20 and 40 gray. The next unit of measurement I want to introduce is the Sievert (Sv). The Sievert measures the biological effects of radiation. This measurement is also referred to as the “equivalent dose.”

OK, so “mCi”and “GBq” tell us the amount of radioactivity. “Gray” tells us how much radiation is absorbed. “Sievert” is an adjusted-Gray—it tells us the biological effects of the absorbed dose.

Are you tracking? There is a reason I’m telling you about all of these radiation units of measurement. When we’re talking about the potential harm that we’re causing to those around us after we have taken I-131, we’re talking about how many Sieverts they are receiving from us. We are talking about the biological effects the absorbed radiation has on their body. Now, let’s take a closer look at what the United States Nuclear Regulatory Commission states in the Code of Federal Regulations regarding the release of patients who have received a radioactive byproduct (eg, I-131):

a) A licensee may authorize the release from its control of any individual who has been administered unsealed byproduct material or implants containing byproduct material if the total effective dose equivalent to any other individual from exposure to the released individual is not likely to exceed 5 mSv (0.5 rem).

b) A licensee shall provide the released individual, or the individual’s parent or guardian, with instructions, including written instructions, on actions recommended to maintain doses to other individuals as low as is reasonably achievable if the total effective dose equivalent to any other individual is likely to exceed 1 mSv (0.1 rem). If the total effective dose equivalent to a nursing infant or child could exceed 1 mSv (0.1 rem) assuming there were no interruption of breast-feeding, the instructions must also include—

  1. 1. Guidance on the interruption or discontinuation of breast-feeding; and
  2. 2. Information on the potential consequences, if any, of failure to follow the guidance.

c) A licensee shall maintain a record of the basis for authorizing the release of an individual in accordance with § 35.2075(a).

d) The licensee shall maintain a record of instructions provided to a breast-feeding female in accordance with § 35.2075(b).

What this means is, the hospital is legally allowed to release patients receiving I-131 IF the total effective dose equivalent to any person as a result of exposure to the patient who received I-131 is not likely to be above 5 mSv.  The NRC provides a formula for calculating the expected total effective dose equivalent and this number should be calculated by an employee in your hospital’s nuclear medicine department prior to giving you the I-131. This guideline also says that the federal government mandates that the hospital provide patients with a list of WRITTEN guidelines to be followed upon release from the hospital IF the total effective dose equivalent to another person may exceed 1 mSv.

Did you catch that? If the biological effect of the absorbed dose that a person is likely to receive from being in contact with a patient who has received I-131 is calculated to be less than 1 mSv, the hospital is not required to provide you with any written instructions to minimize radiation exposure to others. Problem? I think so.

Members of the Society of Nuclear Medicine wrote a letter to the editor of the New York Times following all the hype in the news about patients who receive I-131 being a danger to those around them. They do bring up a valid point that risk versus benefit must be balanced. They bring up the valid point that if hospitalization was required for isolation, treatment may not be provided in a timely fashion as a result of a lack of available isolation rooms, staff, etc. They also reference a study (yes, just one study) that was published in the Journal of the American Medical Association that shows members of the same household of patients who received I-131 received less than the dose allowed by the NRC to the general public (5 mSv). However, this study is not without limitations. It does not consider the radiation exposure to household members from ingested I-131 (eg, drinking after a patient who received I-131). Additionally, the study did not control participants’ compliance to the guidelines (ie, wearing the dosimeters 24 hours a day to completely measure radiation exposure).

Perhaps what makes me consider this statement from the members of the Society of Nuclear Medicine to be meaningless more than anything else is their reference to I-131 as a “painless treatment.” I can only speak from personal experience, but my I-131 treatments have been anything but painless. In addition to the physical pain (extreme nausea, fried salivary glands), I also experienced emotional duress during the time I received treatment.

Yes, the topic of concern in the news is all about whether or not we should be hospitalized for isolation. But what is the real issue? I think it is lack of awareness. Do I want to be called a dirty bomb? No. But does being called a dirty bomb open my eyes to the severity of the issue? YES. I certainly do not think I can march into the office of the NRC and demand them to revise the guidelines. However, I do think that if I keep sharing my story I can raise awareness. And so can you. The more we speak out about these issues, the more awareness we raise. With awareness comes funding, with funding comes research, and with research comes answers.

So what do you think? Should we be provided with information and guidelines and precautions regardless of the dose of I-131 we receive? Is all of this an awareness issue? Do you take offense to being called a dirty bomb or a weapon of mass destruction?

Talk to me, peeps.

xo,

Joanna

Sources:

What is a Curie?

What is a Gray?

What is a Sievert?

10 CFR 35.75: Release of individuals containing unsealed byproduct material or implants containing byproduct material.

Nuclear Regulatory Commission Requirements for Expanded Definition of Byproduct Material; Final Rule

Society of Nuclear Medicine, Letter to the Editor, NYT

Journal of the American Medical Association: Radiation Exposure From Outpatient Radioactive Iodine (131I) Therapy for Thyroid Carcinoma

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9 Responses to “Life Redefined: Is “Weapons of Mass Destruction” an Overstatement?”

  1. HDinOregon says:

    Great article, Joanna.

    I don’t know if the US needs new (more stringent) rules and procedures. I’m not an expert, but i did appreciate that I didnt have to stay in hospital.

    Xo,
    HD

    • Thanks, HD!

      I, too, was grateful that I didn’t have to be in the hospital after receiving RAI. Hospital stays are never a vacation, that’s for sure. However, I think the lack of awareness regarding RAI is a problem that needs to be remedied.

      Thanks for sharing your opinion!

      Joanna

  2. Graves Situation says:

    “Dirty Bomb” and “Weapons of Mass Destruction” are inflammatory terms, for sure. They’re also attention-grabbing, which is important here. I don’t know of another treatment where the patient is actually radioactive (rather than irradiated) for a period of time. I assume doses used for uptake scans and other nuclear imaging are too small to be of much concern.

    How does money play into this? Hospitalizing someone for isolation purposes is expensive, especially when everything from their Kleenex to their shower water has to be treated as a biohazard or nuclear waste. I can’t imagine our “friends” at the insurance companies want to pay for this.

    Our families and pets don’t turn green or grow extra limbs with exposure to someone who has just had RAI, so it’s hard to show a direct effect on them. This makes it easier for the issue to be swept under the carpet.

    How do other countries, perhaps those without for-profit health care systems, perhaps those who have a record of acting to protect the common good, deal with this?

    With ANY medical treatment there should be a frank discussion of risks and benefits. Yes, all patients who receive RAI should be give a written list of recommendations and precautions. They should also be discussed with each patient, and the nuclear medicine people must be confident that the patient hears and understands them. You can’t just hand papers to someone who is upset, nervous, and being asked to swallow something handed to them by someone in a hazmat suit, and expect them to even remember they have the papers in their possession, much less to read them. Some will, others won’t.

    • Graves Situation, thank you for weighing in on this issue.

      I agree that money is an issue here. Hospitalizing someone for isolation is no cheap endeavor. Some patients request hospitalization for isolation, but their insurance won’t pay for it because it’s not viewed as necessary. And as you point out, there is not an abundance of research on this issue. If isolation can’t be provided, patients AT LEAST need to be provided with adequate information on precautions to take, side effects they may experience, and contact information for someone at the hospital who can answer any questions they may have once they get home.

      Thank you for sharing your opinion. This is where change begins.

  3. a bit un nerving to say dont they keep you in hospital in america after the rai over here in england they isolate for 3 days as my partners got to have it soon its so scarey this

    • Hi Michelle,

      The purpose of this article was certainly not to scare you, but to raise issue with the current guidelines. However, I understand that this is a scary time for you and your partner. Facing the unknown is not easy. If you have specific questions about what to expect after taking the RAI, please don’t hesitate to ask. If you would like, you can email me anytime: joanna@dearthyroid.org

      Please be assured that we are here for both you and your partner as you are dealing with all the changes that come about as a result of cancer.

  4. Linny says:

    VIDEO »More Video | Multimedia » please watch video attached here. In my opinion radition is a dangerous option for curing disease. I regret taking for my hyperthyroid and was misinformed and told it was safe. I believed without question thinking no one would give something to help me that was dangerous. It did not cure me. It left me without a thyroid and just made me a different kind of sick. No reports are likely to reach us because this is a business of making money more than a business of curing people. After treatment the insults to our questions of side effects further insult our logic and reality. Many report responses as “in our heads”…..although we know of
    storm possibilities and a likelyhood of making hyperthroid patients turn into hypothyroid patient, who then will depend on drugs {$} for being alive. These drugs are questionable as well with lawsuits and name changes and being served for many years without FDA approval. Asking for “natural” vs “unanatural” is poo~pooed and laughed at. One Dr. even suggested that Armour was a product of a “meat company”.
    The outrage I feel that this world is using a dangerous solution for people is beyond my words. The lazy~ass method is just a block to more research into BETTER solutions. This is a WAR PRODUCT. Comeon somebody get us something safe. Linny

    • Hi Linny! As always, thank you for sharing your opinion.

      I hear you loud and clear–treatment for one sick part of our body is often detrimental to another part. And no, neither the thyroidectomy nor the RAI are cures for thyroid cancer. Like you, I am now left with a chronic illness–I have no thyroid and I’m medicated into a hyperthyroid state. Unfortunately, I had to decide if I wanted to live with thyroid cancer or if I wanted to pursue treatment that may get rid of the cancer (thyroidectomy and RAI), but will undoubtedly leave me with other issues to deal with. Though the current treatment is not without limitations, I personally found it to be the lesser of the two evils.

      The more we speak out and raise awareness, the more change we can bring about. Thank you for speaking out about an issue that you find to be important!

  5. Jim says:

    The mass of I131 that was destroyed in your body as it decays is a similar process to that in any other WMD but on a significantly smaller scale. It’s only a weapon if you use it that way(with much less capability), expect most will not. Key point, the mass is not to be confused with a “mass of people”. Its just dry physics terminology for the missing part that turned into energy. Dangerous yeah. Manageable risk probably.

    I went through ablation in my case for thyroid cancer. Agree its no fun. Also had parotid glands plug up at a later date due to it. The hypoparathyroidism was special bonus which I am finding more troubling.

    That said I did worry about being a hazard to my driver or if we got into an accident being a spill.

    Nuc. Med did its best instruct me how to minimize that contact and clean up. They also advised that a few layers of drywall and distance would make a significant dint in the dose Grampa would get while he stayed. The kids and mom and the cats went to Grama’s before I got home. I was lucky to have that support.

    I think there are a lot of little things they sort of let you find out so your not worrying about that too.
    Doctors seem to follow a protocol with this, blinders on and rush you through the hoops. I think they should be more clear risks of RAI and give the option of surpressing it with the hormone. That also means more risk the scan won’t work and potentially return of cancer.

    There are many choices between bad options.
    I hear you when you say a different kind of sick though then again its not dead.

    As above, I think the lesser of evils. A hospital stay means more competition for treatment and risk for their employees that will continue to experience RAI patients daily unlike Grampa so would be likely to accumulate more long term effects.

    Cheers,
    J

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