Health effects associated with exposure to radioactively contaminated gold rings
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Number 6 June, 1984
Port-wine stain treated with laser
normal epidermis and dermis without evidence of cellular atypia.
R E F E R E N C E S
1. Noe J, Barsley S, Greer D, et al: Portwine stains and the response to argon laser therapy: Successful treatment and the predictive role of color, age, and biopsy. J Plast Re- constr Surg 65: 130-136, 1980.
2. Gilchrest B, Rosen G, Noe J: Chilling portwine stains improves the response to argon laser therapy. J Plast Re- constr Surg 69:278-283, 1982.
3. Ratz J, Bailin P, Levine H: COs laser treatment of portwine stains: A preliminary report. J Dermatol Surg Oncol 8:1039-1044, 1982.
4. Apfelberg D, Kosek J, Maser M, et al: Histology of portwine stains following argon laser treatment. Br J Plast Surg 32:232-237, 1979.
5. Finley J, Barsley S, Greer D, et al: Healing of portwine stains after argon laser therapy. Arch Dermatol 117:486- 489, 1981.
Health effects associated with exposure to radioactively contaminated gold rings Mark S. Baptiste, M.S., Richard Rothenberg, M.D., Philip C. Nasca, Ph.D., Dwight T. Janerich, D.D.S., Charles D. Stutzman, M.D., Karim Rimawi, Ph.D., William O'Brien, M.S., and John Matuszek, Ph.D. Albany, NY, Atlanta, GA, and Buffalo, NY
This study was designed to assess the health risks associated with exposure to radioactively contaminated gold rings. A group of 135 exposed individuals, who were identified through a statewide jewelry screening program, were studied to determine the frequency of carcinoma and other skin problems on the ring finger. Severity of skin problems increased with increasing length of wear. Forty-one of the exposures were associated with mild to severe skin problems. Nine of the individuals studied were diagnosed as having histologically confirmed squamous cell carcinomas at the site of exposure. The incidence of skin cancer on the ring finger was eleven times that expected for men and forty-five times that expected for women. These data indicate that physicians who have patients with skin lesions of the ring finger should be aware of the possibility of exposure to a radioactive gold ring. (J AM ACAD DERMATOL 10:1019-1023, 1984.)
Accepted for publication Dec. 22, 1983.
Reprint requests to: Mark S. Baptiste, M.S., Director, Cancer Epidemiology Unit, Rm. 557, New York State Department of Health, Albany, NY 12237.
Mark S. Baptiste, M.S., is director, Cancer Epidemiology Unit, Cancer Control Section, Bureau of Chronic Disease Prevention, New York State Department of Health, Room 557, Tower Bldg., N.A. Rockefeller Empire State Plaza, Albany/5IS-474-2460; Richard Rothenberg, M.D., is director, Bureau of Chronic Disease Prevention, New York State Department of Health, Albany; Philip C. Nasca, Ph.D., is director, Cancer Control Section, Bureau of Chronic Disease Prevention, New York State Department of
Health, Albany; Dwight T. Janerich, D.D.S., is director, Division of Community Health and Epidemiology, New York State De- partment of Health, Albany; Charles D. Stutzman, M.D., is medi- cal epidemiologist, Cancer Branch, Chronic Diseases Division, Center for Environmental Health, Centers for Disease Control, Public Health Service, U.S. Department of Health and Human Services, Atlanta; Karim Rimawi, Ph.D., is director, Bureau of Environmental Radiation, New York State Department of Health, Albany; William O'Brien, M.S., is associate radiological health specialist, New York State Department of Health, Buffalo; John Matuszek, Ph .D., is director, Radiological Sciences Institute, New York State Department of Health, Albany.
1020 Baptiste et al
Journal of the American Academy of
Reports of health effects associated with radio- actively contaminated gold jewelry began to ap- pear in the 1960s. 1-'~ Skin lesions, including squamous cell carcinoma, occurred at areas of di- rect, long-term skin contact with radioactively contaminated rings. One articIe documented the use of spent radon gold seeds to make the contam- inated ring worn by a person with dermatitis, ~ but the source of contamination has not been estab- lished for most of the rings discovered thus far.
In 1968, the New York State Department of Health sent notices to New York State medical journals advising physicians to have jewelry tested for radioactivity i f they saw patients with unex- plained skin reactions. During the period from 1968 through January, 1981, eleven reports of persons exposed to radioactive rings came to the attention of the State Department of Health. Of the eleven persons concerned, four developed skin cancer at the site of exposure, and the other seven all had moderate to severe dermatitis on the ring finger. In February, 1981, the Department initi- ated a campaign to find and remove from circula- tion any jewelry with radioactive contamination and to assess the public health impact. A more detailed account of the historical aspects of the problem has been published elsewhere.* Approx- imately 160,000 items of jewelry have been screened. Although public media campaigns cov- ered the entire state, the greatest public response occurred in the western New York area.
As a result of these screening activities, the De- partment o f Health has identified I77 contam- inated jewelry items and 155 exposed persons. All but six of these items originated or were repaired in western New York State or nearby Pennsylva- nia. Anecdotal reports indicate that contaminated rings have also been found in other areas, includ- ing Connecticut, Texas, Arkansas, Toronto, Ohio, Florida, and Germany.
Besides screening for and removing contam- inated jewelry from circulation, the Department was charged with estimating the health risk asso- ciated with exposure. The health effects survey described below was designed to provide data for making this assessment.
*New York State Department of Health: Report to the Governor and Legislature: Radioactive gold jewelry. Albany, NY, September, 1982.
The New York State Department of Health screening program has identified 155 persons exposed to jewelry contaminated with radioactive gold. The eleven ex- posed persons who had been identified by the depart- ment before the initiation of the screening program were excluded from analysis. Inclusion of these indi- viduals would bias the risk estimates since they came to attention because of the health problems being studied. Of the 155 persons identified by the screening program, fifteen were exposed to contaminated school pins and five to other types of jewelry not worn in direct contact with the skin. No health problems were associated with these items. These twenty items did not provide sig- nificant exposure and were excluded from the analysis. This analysis is thus limited to the 135 individuals ex- posed to contaminated gold rings.
The New York State Department of Health, in con- junction with the U.S. Department of Health and Human Services' Centers for Disease Control, con- ducted interviews to obtain information about the his- tory of the ring, duration of exposure, and selected sociodemographic characteristics. These factors, which included age, sex, and race, are associated with skin cancer risk and were controlled for in the risk estima- tion. Clinical data, including the occurrence of skin cancer, other skin disease, other cancer, general skin sensitivity indicators (e.g., color of eyes, hair, com- plexion, sensitivity to sunlight), and possible exposure to skin toxins or carcinogens were also collected. All skin cancers at the site of exposure were documented, with the patient's consent, through contact with the attending physician and/or through review of pertinent medical records. Less severe skin conditions were generally not treated by a physician, so that information on noncancerous conditions is based on patient re- sponse.
Five levels of health effects on the ring finger were identified: no disease, mild skin problem, moderate skin problem, severe skin problem, and skin cancer. Individuals were assigned to these categories on the basis of symptoms at the site of exposure to the ring. Persons with no symptoms were placed in the no dis- ease category. Persons with symptoms limited to erythema and/or pruritus were categorized as having a mild skin problem. The moderate skin problem cate- gory includes those with scaling, blistering, hy- perkeratosis, or hyperpigmentation. Persons with ul- ceration of the skin were classified in the severe skin problem group. The skin cancer group includes only cases confirmed through review of medical records. The average duration of exposure was calculated for each level of health effect.
Volume ! 0 Number 6 June, 1984
EXposure to radioactively c'ontaminated gold 1021
To estimate sex-specific standardized incidence ratios for carcinomas of the ring finger, it was neces- sary to calculate the "expected" incidence of these tumors in the exposed population. Data on skin cancer are not routineiy collected by the New York State Cancer Registry or other population-based registries. The best estimates of skin cancer incidence have been provided by Scotto et al, 6 who conducted a special survey of skin cancer in the United States during the years 1977 and 1978. Since the Scotto study excluded in situ forms of skin cancer, in situ cases in the present study were not included in the estimation of standard- ized incidence ratios.
The ring finger cancers observed among persons ex- posed to contaminated rings were all of the squamous cell type. Age-specific estimates of the expected num- bers of squamous cell carcinomas of the skin on the hand were calculated and compared with observed numbers to produce standardized incidence ratios for male and female patients in the study grou