Effectiveness of skin cancer screening for individuals age 14 to 34 years.

BACKGROUND: Approximately 15 % of all cases of melanoma are diagnosed before age 35 years. In Germany, individuals ≥ 35 years are eligible for the national skin cancer screening program. The effectiveness of a population-based skin cancer screening in general and in particular for young adults is unclear. OBJECTIVES: Assessment of the effectiveness of a skin cancer screening program and of risk factors for detection of a melanoma/atypical nevus in the setting of a screening for the age group 14 to 34 years. METHODS: A total of 12,187 individuals age 14 to 34 years were screened in Saxony for skin cancer by a dermatologist in the program "Haut-Check 14-34 Jahre" of the AOK PLUS, a large German health insurance, between January and July 2009. Demographic, clinical and histopathological data and UV-exposure data were collected from each participant. Multivariate logistic regression models were used to assess risk factors for the detection of a (histopathologically confirmed) melanoma or atypical nevus. RESULTS: 2.8 % of the eligible individuals participated in the skin cancer screening program with women being more likely to do so. In 1 072 individuals (8.8 %) screening included at least one excision of a skin lesion leading to the diagnosis of melanoma in two participants, melanoma in situ in four persons, and atypical nevus in 641 persons. Use of tanning beds, higher age, number of nevi, and previous cutaneous excision were independent risk factors for the detection of a melanoma or atypical nevus. CONCLUSIONS: In 5.5 % of all cases skin cancer screening resulted in the excision of a malignant or atypical melanocytic lesion. It remains unclear what proportion of these cases would have been detected in routine care. The rate of excisions per newly diagnosed melanoma was 179 : 1. Further investigations are necessary to explore the reasons for this low diagnostic specificity. This study highlights the possibilities and limitations of routine data to evaluate screening programs and indicates the need to collect additional information on healthcare utilization behaviour.

[Compensation of damage in cancerology]. / Réparation du dommage en cancérologie.

In a few situations, the consequences secondary to a carcinological pathology require an assessment of damages for compensatory purposes. This is particularly the case when liable parties have been found to be at cause of the disease: occupational pathologies in the case of inexcusable employer's fault, exposure to a radioactive risk, for example in the context of full compensation for damages suffered by the victims of nuclear experiments performed by France, or lastly, in the after-effects of late diagnosis. This article does not discuss the imputability of cancer pathologies to an event, but it proposes an adaptation of methods for assessing damages, in an attempt to provide full compensation for damages.

Association between financial links to indoor tanning industry and conclusions of published studies on indoor tanning: systematic review.

OBJECTIVE: To assess whether an association exists between financial links to the indoor tanning industry and conclusions of indoor tanning literature. DESIGN: Systematic review. DATA SOURCES: PubMed, Embase, and Web of Science, up to 15 February 2019. STUDY SELECTION CRITERIA: Articles discussing indoor tanning and health were eligible for inclusion, with no article type restrictions (original research, systematic reviews, review articles, case reports, editorials, commentaries, and letters were all eligible). Basic science studies, articles describing only indoor tanning prevalence, non-English articles, and articles without full text available were excluded. RESULTS: 691 articles were included in analysis, including empiric articles (eg, original articles or systematic reviews) (357/691; 51.7%) and non-empiric articles letters (eg, commentaries, letters, or editorials) (334/691; 48.3%). Overall, 7.2% (50/691) of articles had financial links to the indoor tanning industry; 10.7% (74/691) articles favored indoor tanning, 3.9% (27/691) were neutral, and 85.4% (590/691) were critical of indoor tanning. Among the articles without industry funding, 4.4% (27/620) favored indoor tanning, 3.5% (22/620) were neutral, and 92.1% (571/620) were critical of indoor tanning. Among the articles with financial links to the indoor tanning industry, 78% (39/50) favored indoor tanning, 10% (5/50) were neutral, and 12% (6/50) were critical of indoor tanning. Support from the indoor tanning industry was significantly associated with favoring indoor tanning (risk ratio 14.3, 95% confidence interval 10.0 to 20.4). CONCLUSIONS: Although most articles in the indoor tanning literature are independent of industry funding, articles with financial links to the indoor tanning industry are more likely to favor indoor tanning. Public health practitioners and researchers need to be aware of and account for industry funding when interpreting the evidence related to indoor tanning. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42019123617.

Significance of radiation dose in medical imaging.

Publicized cases of errant high radiation exposure delivered to patients undergoing diagnostic imaging have led to heightened awareness and scrutiny of the costs and benefits of imaging by physicians, the public, and policymakers.The statistical risks associated with the ever-increasing utilization of modalities employing damaging ionizing radiation across the population are compounded by the development of the latest generation of devices, which are capable of delivering greater radiation doses than their predecessors for comparable diagnostic applications.This article reviews the fundamental concepts and risks of medical radiation exposure, trends in imaging utilization, and the role of radiologists and their physician colleagues in managing and appropriately utilizing imaging for patient diagnosis.

History of Dose, Risk, and Compensation Assessments for US Veterans of the 1966 Plutonium Cleanup in Palomares, Spain.

In 1966, about 1,600 US military men-mostly Air Force-participated in a cleanup of plutonium dispersed from two nuclear bombs in Palomares, Spain. As a base for future analyses, we provide a history of the Palomares incident, including the dosimetry and risk analyses carried out to date and the compensation assessments made for veterans. By law, compensation for illnesses attributed to ionizing radiation is based on maximum estimated doses and standard risk coefficients, with considerable benefit of the doubt given to claimants when there is uncertainty. In the Palomares case, alpha activity in urine fell far faster than predicted by plutonium biokinetic excretion models used at the time. Most of the measurements were taken on-site but were disqualified on the grounds that they were "unreasonably high" and because there was a possibility of environmental contamination. Until the end of 2013, the Air Force used low dose estimates derived from environmental measurements carried out well after the cleanup. After these estimates were questioned by Congress, the Air Force adopted higher dose estimates based on plutonium concentration measurements in urine samples collected from 26 veterans after they left Palomares. The Air Force assumed that all other cleanup veterans received lower doses and therefore assigned to them maximum organ doses based on the individual among the 26 with the lowest urine measurements. These resulting maximum organ doses appear to be sufficient to justify compensation to all Palomares veterans with lung and bone cancer and early-onset liver cancer and leukemia but not other radiogenic cancers.

[Mammography screening in Germany]. / Mammographiescreening in Deutschland.

Available data suggest that early detection of breast cancer by mammography screening can reduce mortality by about 25%. Intensified monitoring of women with a family history of breast cancer and regular general screening have recently been introduced in Germany. The screening program is expected to be fully established by 2008. Following its successful introduction (participation rates between 65 and 80%), the German screening program will be conducted and evaluated in accordance with the European guidelines. At least in the screening trials that were conducted prior to the now established screening program the quality criteria were more than fulfilled (e.g. cancer detection rate in Bremen 8.7, Wiesbaden 9.4, Weser-Ems region 8.3/1000). Additional parameters that can be taken into account for quality assurance are the overdiagnosis bias, lead time bias, length bias and selection bias. Moreover, there are some factors that are specific to the German program compared with the breast cancer screening programs already established in other countries. One of these is the intensified screening program for high-risk women (ca. 5% of all carcinomas) and as a result fewer women with an increased genetic risk of breast cancer will be represented in the general screening program. The German screening program involves only a few university centers and hospital-based physicians, which may have adverse effects on research and development as well as mammography training in the future. Therefore, the screening program should also provide for the investigation of new techniques or emerging techniques (e.g. CAD systems in screening mammography) in the future.

A new methodology for cost-effectiveness studies of domestic radon remediation programmes: quality-adjusted life-years gained within primary care trusts in central England.

Radon is a naturally occurring radioactive gas, high levels of which are associated with geological formations such as those found in Northamptonshire and North Oxfordshire in the UK. The UK's National Radiological Protection Board have designated both districts as radon Affected Areas. Radiation levels due to radon, therefore, exceed 200 Bq m(-3), the UK's domestic Action Level, in over one percent of domestic properties. Because of radon's radioactivity, exposure to the gas can potentially cause lung cancer, and has been linked to some 2000 deaths a year in the UK. Consequently, when radiation levels exceed the Action Level, remediation against radon's effects is recommended to householders. This study examines the cost-effectiveness of remediation measures in Northamptonshire and North Oxfordshire by estimating cost per quality-adjusted life-year gained in four Primary Care Trusts, organisations that play a key public health policy role in the UK's National Health Service. The study is the first to apply this approach to estimating the cost-effectiveness of radon remediation programmes. Central estimates of cost per quality-adjusted life-year in the four Primary Care Trusts range from 6143pounds to 10323pounds. These values, when assessed against generally accepted criteria, suggest the remediation programmes in the trusts were cost-effective. Policy suggestions based on the estimates, and designed to improve cost-effectiveness further, are proposed for the four Primary Care Trusts and the UK's National Health Service.

The Energy Employees Occupational Illness Compensation Program Act: new legislation to compensate affected employees.

Nurses make a bureaucracy work on behalf of clients. Occupational health nurses who are already versed in basic concepts applicable to EEOICPA--confidence intervals, occupational histories, exposure assessment, and dose response--can play constructive, caring roles in assisting claimants in securing benefits under this landmark program. Occupational health nurses know that chronically ill employees have a finite number of hours a week to make phone calls, visit providers, and advocate on their own behalf. Thoughtful referrals to occupational health providers who are both experienced and supportive can come from an occupational health nurse or a family physician. Involvement of university-based programs in projects to empower organizations representing EEOICP claimants would be a welcome development.

Evaluating for a geospatial relationship between radon levels and thyroid cancer in Pennsylvania.

OBJECTIVES/HYPOTHESIS: To determine whether there is an association between radon levels and the rise in incidence of thyroid cancer in Pennsylvania. STUDY DESIGN: Epidemiological study of the state of Pennsylvania. METHODS: We used information from the Pennsylvania Cancer Registry and the Pennsylvania Department of Energy. From the registry, information regarding thyroid incidence by county and zip code was recorded. Information regarding radon levels per county was recorded from the state. Poisson regression models were fit predicting county-level thyroid incidence and change as a function of radon/lagged radon levels. To account for measurement error in the radon levels, a Bayesian Model extending the Poisson models was fit. Geospatial clustering analysis was also performed. RESULTS: No association was noted between cumulative radon levels and thyroid incidence. In the Poisson modeling, no significant association was noted between county radon level and thyroid cancer incidence (P = .23). Looking for a lag between the radon level and its effect, no significant effect was seen with a lag of 0 to 6 years between exposure and effect (P = .063 to P = .59). The Bayesian models also failed to show a statistically significant association. A cluster of high thyroid cancer incidence was found in western Pennsylvania. CONCLUSIONS: Through a variety of models, no association was elicited between annual radon levels recorded in Pennsylvania and the rising incidence of thyroid cancer. However, a cluster of thyroid cancer incidence was found in western Pennsylvania. Further studies may be helpful in looking for other exposures or associations.

Radiation-associated disease: disease incidence and cost effectiveness of follow-up.

The organization, costs and outcome of a metropolitan area-wide recall campaign for patients irradiated for benign disease is documented. The campaing resulted in an increase in the number of thyroid malignancies discovered in both the irradiated and the nonirradiated population. The organization of the campaign cost $100,000. An estimated excess of 100 thyroid carcinomas were found in the 17 months following the campaign compared to the 17 months prior to the campaign in the Pittsburgh Standard Metropolitan Statistical Area. Of 150 patients who were radium exposed as infants and remained in the Pittsburgh area, 60% knew of their exposure only by direct hospital contact and were not reached by media public education. Seven of those 150 patients had thyroid carcinoma on 35 year follow-up, and 30% had some benign or malignant tumor.

The costs of radon mitigation in domestic properties.

The paper examines the costs of mitigating radon levels in domestic properties using data from the radon-affected county of Northamptonshire in the United Kingdom. Cost-effectiveness of mitigation is measured in terms of the total costs per lung cancers saved per year by mitigation expenditures. The results obtained match those reported in published theoretical estimates for proposed national mitigation programmes. Mitigation in domestic properties is shown to be more effective in reducing lung cancers than a mitigation programme designed for National Health Service workplaces in Northamptonshire, when all householders discovering radon levels above 300 Bequerels per cubic metre (Bq m(-3)) are assumed to implement mitigation strategies. In the United Kingdom, however, as elsewhere, only a small percentage of those finding raised radon levels proceed to mitigation. This reduces the effectiveness of mitigation programmes in domestic properties to levels matching those in the National Health Service workplaces. The paper confirms findings in studies from Europe and the United States that a significant proportion of householders with radon levels between 200 and 300 Bq m(-3) do not implement remedial work. The paper concludes with a range of policy proposals based on the results obtained.

Comparison of risk for pre- and post-remediation of uranium mill tailings from vicinity properties in Monticello, Utah.

Pre- and post-remedial action dose rates were calculated on 101 Monticello, Utah, properties included in the Monticello Vicinity Property Remedial Action Project. Dose rates were calculated using the RESRAD computer code, which indicated that 98% of the effective dose equivalent was contributed by external gamma radiation and radon emanation. Radium concentrations in pCi g(-1) were averaged for pre- and post-remedial action measurements; point sources were not included in the averages. The volume of the deposit was also used in the dose calculation. In all cases the dose was reduced, and at 77 properties the dose was reduced to 0.30 mSv y(-1) (Department of Energy ALARA recommendation). A paired t-test showed a significant reduction (p<0.05) between the pre- and post-remedial action dose rates, The average cost remedial action, number of persons per household, number of properties remediated, and the reduction of cancer mortalities through remediation resulted in an approximate cost of 11,000,000 per life saved by remediation of mill tailings.

Discounting in assessment of future radiation effects.

There is a question as to whether cancer fatalities to be experienced in the distant future as a result of radioactivity produced today should be treated on a par with those experienced now, or whether there should be discounting in analogy with accounting principles for money to be spent in the future. It is shown that recent trends in cancer cure rates justify about an 0.7% per yr discounting. Other rationales for discounting are developed. Money can, and always will be usable for saving lives; setting up a trust fund for future generations to use for this purpose is much more cost-effective than spending money now to reduce their exposure to radiation. The history of interest rates over the past 5000 yr indicates that at least 3% real annual interest can be expected. It may not be necessary to actually set up a trust fund as its purpose is largely accomplished by the decrease in the public debt when money is not spent. The trust fund approach is mathematically equivalent to discounting lives lost in the far future at 3% per yr. As an alternative to the trust fund, money can be invested in biomedical research. It is shown that per dollar spent, this is usually far more beneficial to the health of future generations than protecting them from radiation as that art is currently practiced, and for purposes of cost-benefit analysis, it corresponds to discounting lives lost in the future by a factor of the order of the number of years before they are lost; e.g. the number of lives calculated to be lost 1000 yr from now should be divided by 1000. Implementation of the biomedical research alternative requires only that about 0.1% of taxes from nuclear plants and 0.1% of government support for biomedical research be re-defined as contributions from nuclear plants to this research.

Cancer risk from the lifetime intake of Ra and U isotopes.

From extensive human data on the induction of skeletal cancers (bone sarcomas and carcinomas of the head sinuses) by 226Ra, 228Ra and 224Ra, the cumulative lifetime risk to 1 million people, each ingesting 5 pCi of a Ra isotope per day, was calculated to be nine bone sarcomas plus 12 head carcinomas for 226Ra, 22 bone sarcomas for 228Ra, and 1.6 bone sarcomas for 224Ra. Assuming that the risk per rad of average skeletal dose is equal for 226Ra and the U isotopes with half-lives exceeding 1000 yr and that the equilibrium skeletal content is 25 times the daily ingestion of 226Ra, but 11 times the daily ingestion of long-lived U, the cumulative life-span risk to 1 million persons, each ingesting 5 pCi per day of 233U, 234U, 235U, 236U or 238U, is estimated to be about 1.5 bone sarcomas. The U risk is not well established and additional research is needed on the metabolism of U in humans and its carcinogenicity in laboratory animals. These estimates assume linear dose responses. However, if incidence varies with the square of dose, virtually no induced cancers would be expected from these levels of radioactivity.

Estimated cost of person-Sv exposure.

The present paper summarizes work performed under contract to the Department of Energy and reported separately. This paper covers efforts to define a cost per person-Sv by determining a value for a societal life and coupling the result with the probability of death due to radiation exposure. The value of a societal life was estimated by examining wrongful death awards and settlements, amounts taken out in life insurance, amounts spent in the last year of life for the critically ill, lifetime earnings and investments, and other approaches and values found in related literature. The values of a societal life ranged from $600,000 to $7,000,000, with a value of $4,000,000 considered by the authors as a conservative average in terms of 1990 U.S. dollars. The associated costs per person-Sv thus determined were found to range from $18,000 per person-Sv to $630,000 per person-Sv ($180 per person-rem to $6,300 per person-rem), with a value of $200,000 per person-Sv ($2,000 per person-rem) taken as a conservative average.

The cost-effectiveness of residential radon remediation programmes: assumptions about benefits stream profiles over time.

A recent cost-effectiveness analysis of a residential radon remediation programme considered and highlighted many areas of uncertainty in the parameters chosen for the analysis. One assumption not challenged in the study was the benefits stream profile adopted. There are several different ways of loading the benefits in terms of life years into the cost-effectiveness model and several of these are explored and the results are reported in this study. The benefits profile depends upon the lead-time to cancer manifestation post environmental carcinogen (radon) exposure. The literature reviewed suggests that there are many options for loading benefits to radon-induced lung cancer prevention programmes. In this study, the alternative benefits stream profiles are explored and their implications for the cost-effectiveness ratio are examined. Adopting different benefits stream profiles to the model results in a range of cost-effectiveness ratios from 14912.90 pounds per life year gained to 52416.27 pounds per life year gained. The preferred model is reported where the life years gained are assumed to be equally distributed over the last 15 years of the 40-year time horizon of the analysis (Y25-40) and the corresponding cost-effectiveness ratio is 37,943 pounds per life year gained.

Claims based on exposure to ionizing radiation (prostate cancer and any other cancer)--VA. Final rule.

This document amends the Department of Veterans Affairs (VA) adjudication regulations concerning compensation for diseases claimed to be the result of exposure to ionizing radiation. This amendment implements a decision by the Secretary of Veterans Affairs that, based on all evidence currently available to him, prostate cancer and any other cancers may be induced by ionizing radiation. The intended effect of this action is to relieve veterans, or their survivors, seeking benefits under the provisions of the Veterans' Dioxin and Radiation Exposure Compensation Standards Act of the burden of having to submit evidence that a veteran's prostate cancer or any other cancer may have been induced by ionizing radiation.

Performance of functions under this chapter; claims for compensation under the Energy Employees Occupational Illness Compensation Program Act. Interim final rule; request for comments.

This document contains the interim final regulations governing the administration of the Energy Employees Occupational Illness Compensation Program Act (EEOICPA or Act), that provides lump-sum payments and medical benefits to covered employees and, where applicable, survivors of such employees, of the Department of Energy (DOE), its predecessor agencies and certain of its vendors, contractors and sub contractors. The Act also provides for the payment of smaller lump-sum payments and medical benefits to individuals already found eligible for benefits under section 5 of the Radiation Exposure Compensation Act and, where applicable, their survivors. The Department of Labor's (DOL) Office of Workers' Compensation Programs (OWCP) administers the adjudication of claims and payment of benefits under the EEOICPA, with the Department of Health and Human Services (HHS) calculating the amounts of radiation received by employees alleged to have sustained cancer as a result of such exposure and establishing guidelines to be followed in determining whether such cancers are at least as likely as not related to employment. The Department of Energy (DOE) and the Department of Justice (DOJ) are responsible for notifying potential claimants and submitting evidence necessary for DOL's adjudication of claims under the EEOICPA.

Characterization of exposures to workers covered under the U.S. Energy Employees Compensation Act.

Since the mid-1940s, hundreds of thousands of workers have been engaged in nuclear weapons-related activities for the U.S. Department of Energy (DOE) and its predecessor agencies. In 2000, Congress promulgated the Energy Employees Occupational Illness Compensation Program Act of 2000 (EEOICPA), which provides monetary compensation and medical benefits to certain energy employees who have developed cancer. Under Part B of EEOICPA, the National Institute for Occupational Safety and Health (NIOSH) is required to estimate radiation doses for those workers who have filed a claim, or whose survivors have filed a claim, under Part B of the Act. To date, over 39,000 dose reconstructions have been completed for workers from more than 200 facilities. These reconstructions have included assessment of both internal and external exposure at all major DOE facilities, as well as at a large number of private companies [known as Atomic Weapons Employer (AWE) facilities in the Act] that engaged in contract work for the DOE and its predecessor agencies. To complete these dose reconstructions, NIOSH has captured and reviewed thousands of historical documents related to site operations and worker/workplace monitoring practices at these facilities. Using the data collected and reviewed pursuant to NIOSH's role under EEOICPA, this presentation will characterize historical internal and external exposures received by workers at DOE and AWE facilities. To the extent possible, use will be made of facility specific coworker models to highlight changes in exposure patterns over time. In addition, the effects that these exposures have on compensation rates for workers are discussed.Introduction of Characterization of Exposures to Workers (Video 1:59, http://links.lww.com/HP/A3).