How Should Patients Potentially Exposed to Increased Levels of Radon Be Treated and Managed?

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• The clinical management of patients potentially exposed to increased radon levels.
• Appropriate referrals for positive findings during clinical assessment.

With radon, the most important preventive action is to minimize exposure to it. This requires appropriate measurement of environmental radon levels in the patient’s home to determine whether the levels are 4 pCi/L or more. If radon levels are at 4 pCi/L or more, recommendations to abate the increased exposure risk may include having the patient remediate radon levels in his or her home (reduction and abatement) to background, outdoor ambient air levels. More information on measuring and abating radon is available in “Annex I” at the end of this case study.

Patients potentially exposed to increased radon levels at home should have a clinical assessment. If clinical findings are positive, consider appropriate referrals.

Clinical care is based on findings from the initial clinical assessment and the health care provider’s clinical judgment. If a patient already has a respiratory condition, consider further testing, referral to a specialist, or both.

The following may increase the likelihood of the patient having a pulmonary malignancy:

• Radiographic appearance of a lesion (size and lack of calcification),
• Age,
• Sex (current or former women smokers are at higher risk).
• 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, which does not rule out tuberculosis, but makes it less likely.

Patient care based on the physician’s assessment may include further testing or, depending on the findings, additional referrals to an oncologist and chest surgeon. 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),
• LDCT scan, and
• Fiber optic bronchoscopy with bronchial brushings and specimens for cytology and culture.

If a primary lung cancer is detected, a metastatic workup (scans of the brain, liver, adrenals, and bones) might be indicated. Depending on histologic type, local extension into adjacent anatomical structures, presence of metastases, and the general health of the patient, treatment options may include surgical excision, radiation therapy, chemotherapy, and possibly immunotherapy. Again, specialist care and his or her recommended treatment plan should guide such treatment.

Referral to a specialist with expertise and experience treating lung disease is reasonable, given positive findings from the initial clinical assessment.

The patient should be apprised of the positive findings together with the reason for referral.

• Preventive steps can minimize exposure to radon.
• Preventive actions to reduce environmental levels of radon below 4 pCi/L include home remediation.
• Findings from the initial clinical assessment and the health care provider’s clinical judgment—including appropriate referral and follow up as clinically indicated—guide treatment and management of patients potentially exposed to increased radon levels.