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Why did my sister get lung cancer? When a non-smoker who hasn't lived or worked around smokers gets primary lung cancer, could it be because of radon gas in the home and-or a hereditary alpha 1 antitrypsin deficiency?


Primary cancer in the lungs ofnonsmokers is extremely rare. For this reason, we were shocked and incredulous when my sister, Dorothy, was given the diagnosis of bronchogenic adenocarcinoma. She had never smoked in her life, she had never lived with smokers, she had never even been exposed to smokers. Having lived in rural Iowa on a farm near a small town, she had never been exposed to any known pollutant.

After the disbelief and shock of hercancer diagnosis and the surgery, we began making inquiries about possible causes of lung cancer in nonsmokers. Of the 160,000 deaths from lung cancer each year, most are caused by smoking, either by the victim himself or by those around him. The affliction is rarely found in people who have had no association with tobacco.

We began searching for the possiblecause of my sister's lung cancer. She had the upper left lobe of her lung removed. If we could just find what caused the cancer to develop there, perhaps we could prevent a recurrence in her remaining lobes. If Dorothy has been doing something or breathing something that caused the lung cancer to develop, we would certainly want to find out what it is.

The Centers for Disease Controltells us that at present radon is the largest single cause of lung cancer in nonsmokers. The CDC has been frequently quoted as saying that this naturally occurring radioactive gas may be responsible for 5,000 to 20,000 lung-cancer deaths per year in the United States. I believe these figures, however, include those lung-cancer victims who not only breathed radon but also smoked. Radon trapped in cigarettes has long been a concern. It is known that smoking and radon exposure is worse than additive--it compounds the harm.

Radon rises from the ground invarying amounts in most parts of the country. It is harmless outdoors, but when it accumulates in high concentrations inside a house, exposure to it over long periods may be lethal.

Dorothy's family hung a charcoalbagradon detector in her basement for three days, and the radon level tested at 8.3 picocuries per liter, more than twice the level the Environmental Protection Agency has set as the action level--at 4.0 picocuries per liter or greater, the EPA recommends that steps be taken to reduce the amount of radon gas entering the home.

Further testing will be necessary todetermine the extent of the problem in Dorothy's home, but in the meantime, her family is investigating ways of lowering the radon level. Radon usually enters from the soil, so basements and crawl spaces exposed to open earth usually have the highest concentrations in a house. Lower pressure inside a house draws gas out of the soil; it seeps in through cracks and openings and is pulled up into the higher parts of the home.

Several features of Dorothy's basementmake it susceptible to radon problems: cracks in the concrete slab, hollow-block walls, a sump pump, and a wood-burning stove. The cracks in the floor can be sealed with silicone caulking, as can the joints between the floor and walls and openings around loose-fitting pipes. Sealing hollow-block walls is a more difficult problem; where the top of these blocks connect with the floor of the house, openings may be exposed, providing a passageway for radon from the soil through the hollow spaces in the blocks and into the living area. These blocks can be sealed with foam caulking and various other materials, but the task is difficult and probably requires professional help. Radon flow through concrete blocks and other porous building material can be greatly reduced with a carefully applied coat of waterproof paint or epoxy sealant on the interior side.

If done properly, sealing alone maybe sufficient to reduce the radon to acceptable levels in homes with marginal problems. Before-and-after tests with fan depressurization equipment and tracer smoke--or a good whole-house ventilation system and incense smoke--can show if all entries are sealed.

Sump pumps like the one inDorothy's basement are prime suspects for radon entry. These can be boxed up and sealed tight, then vented to the outside with a special fan. This can be a particularly effective means of radon control since it is drawing air from under the basement slab through the sump pipe and tile system, taking the radon outside before it seeps through the floor.

Increasing the air pressure in thehouse, particularly in the basement, is another way of reducing radon intake. When the pressure is lower inside the house than in the soil, a "chimney' effect is created, drawing gas upward like smoke up a chimney. Sealing the basement off between floors will help keep the pressure up and the radon contained downstairs. Fresh-air intakes on furnaces, dryers, and stoves (such as the one in Dorothy's basement) will prevent them from drawing air out of the basement and lowering air pressure. For more effective pressurization control, radon-control specialists like Retrotec USA can install a system that will pressurize the basement slightly, just enough to prevent radon from being drawn in.

Increasing the ventilation is a simple,inexpensive way to reduce radon levels in a home. The easiest way to do this is by opening windows on two sides of the basement; air will flow through and take radon out with it. Window fans can increase ventilation even more, but the fans must blow fresh air into the house; exhaust fans pulling air out may lower the interior air pressure and actually pull more radon out of the soil.

Of course, opening windows andblowing in fresh air will make Dorothy's house an icebox in the middle of an Iowa winter, so this isn't a practical long-term solution for her home.

The effectiveness of any of thesemethods of radon reduction depends upon the characteristics of the house, the route of radon entry, and the thoroughness of the work performed. Sometimes a single method may be sufficient, but often--especially where levels are high--several methods will need to be combined to reduce radon levels to acceptable levels. Professional consultation is probably a good idea before taking action.

We set out to learn more aboutradon in Iowa. Our son Paul, an engineer, helped put us in touch with a nuclear physicist in Iowa who had checked 42 homes in the Des Moines area. Three of the homes he checked were in the vicinity of Pella, where my sister lives. Thirteen of the 42 homes he checked had radon above 4 picocuries per liter, which the Environmental Protection Agency considers to be the action level for radon exposure.

In the December issue of the Postwe published a map prepared by the EPA that showed no high incidence of radon in Iowa. The caption beneath the map explained that even though some states didn't have shaded areas indicating high radon levels, this did not mean that no radon existed there. It might simply mean that the homes in the state hadn't been tested yet for the presence of radon. This was the case for Iowa.

When we found Paul's contact, Dr.Conrad Weisfenbach, in the physics department at Cornell College in Mt. Vernon, Iowa, he explained that no one particularly suspected Iowa. Areas with the highest radon concentrations are thought to be those that have large amounts of granite in the soil. Iowa has no granite, Dr. Weisfenbach explained, except for the glacial drift brought down from granite areas in Wisconsin.

Dr. Weisfenbach is not checking127 homes for the Linn County Health Department in Iowa. He explained that the latest concensus is that 1 out of 100 nonsmokers would get lung cancer from a lifetime (60 to 70 percent of his time) in a house that had 4 picocuries per liter of radon present. For every 4 picocuries per liter increase in radon, there is a 1 percent greater chance for lung cancer in the person breathing the radon-contaminated air during a lifetime of exposure. Dr. Weisfenbach explained that the EPA had recently adjusted this calculation to a 1 percent risk for every two picocuries per liter of radon over a lifetime's exposure. "What the EPA is saying,' he told us, "is that radon is the most important pollutant we've ever faced.'

We asked Dr. Weisfenbachmore about the levels in Iowa. "The highest levels that are found in Iowa are not nearly as high as the levels found in Pennsylvania, for example, or parts of New Jersey, where they've discovered 2,000 to 3,000 picocuries per liter on occasion,' he told us. "In central and eastern Iowa, levels may reach 15 or 20 picocuries per liter, and the average level in these parts of Iowa is higher than the estimated national average,' he said.

Of the 42 houses Dr.Weisfenbach tested, 13--or 31 percent--had levels higher than 4.0 picocuries per liter. The average level for houses in and around Pella was 2.1 picocuries per liter during the nine or ten months he had detectors in the houses. "And that did not include November, December, and January,' he added. "During those coldest winter months the radon levels are a little bit higher.

"Radon levels change with time,'Dr. Weisfenbach went on to explain. "They change when the atmospheric pressure falls or when the wind blows or when people ventilate their homes from the outside, such as in the summer. Radon levels are lower in the summer because there are more windows open.'

The EPA recommends that peoplemake a short-term, preliminary screening of their homes to detect potential radon problems. Charcoalcanister detectors are available commercially for quick, inexpensive testing, and more expensive alpha track detectors are good for longer tests. The three-day test using charcoal testers "is a good, quick check,' Dr. Weisfenbach said, "because if you've got thousands of picocuries per liter in your house, you want to know right away. You don't want to wait a year.' If preliminary tests indicate a potential hazard, more extensive testing should follow.

Dr. Weisfenbach hasbeen studying radon gas since 1979, when he began his work at the University of Maine. Maine has high levels of radon in some houses, and "radon in water in Maine is quite high, perhaps one of the highest in the nation,' he said. He pointed out that the concentrations of radon in water are not as important as the concentrations in the air. (Retrotec USA, a company selling devices for detecting radon in water, reveals that 40,000 to 50,000 picocuries per liter in water translates to approximately 4 picocuries in the air.) There is very little danger of high radon in city-water supplies, but water from deep wells may contain the gas.

The radon/lung-cancerpicture is still unclear; the only certainty is the need for more information. Determining the incidence of lung cancer in nonsmokers would help isolate cases caused by smoking from cases caused by sources such as radon.

We checked with an oncologistwho treated 64 cases of lung cancer in 1985. Of these cases, 62 were long-time cigarette smokers. One of the two nonsmokers was a woman who had lived most of her adult life with a husband who smoked four packs a day. He had died a few months earlier from a heart attack. The other nonsmoker had worked in an asbestos factory for many years. This oncologist said that in his entire career he has almost never seen primary lung cancer in a nonsmoker.

Dorothy's thoracicsurgeon, Dr. Hooschang Soltanzadeh at Methodist Hospital in Des Moines, could remember only two nonsmokers with primary lung cancer. He wasn't sure whether these patients had smoking histories, however. He has agreed to put us in touch with any future primary lung-cancer patients who have no history of smoking.

I asked a few oncologistswhether they believed that those who suffer from the hereditary alpha1 antitrypsin deficiency might be susceptible to lung cancer, just as they are sitting ducks for emphysema if the smoke.

The consensus seemed to beyes, it would be plausible, since they would have difficulty raising secretions from the lungs. This inability might also cause carcinogens to remain in the lungs, they theorized. Since my brother had severe emphysema at an early age from smoking and a cousin had also died from emphysema after smoking, it seemed logical to see if Dorothy's alpha1 antitrypsin is low.

Alpha1 antitrypsin is an antienzymethat protects the lung from proteases (protein-splitting enzymes) released from leukocytes (white blood cells). Trypsin is just one of the proteases that it protects against; it inhibits elastase and collagenase as well as other enzymes. It is speculated that recurrent inflammatory reactions related to infection and pollutants call forth white blood cells whose released proteases are free to cause damage to the lungs in people who lack the alpha1 antitrypsin.

About 1 in 4,000 people are bornwith a severe deficiency in alpha1 antitrypsin. About 1 in 20 may suffer from a milder form. The deficiency can have one of three results. One group seems to suffer no ill effects whatsoever. A second group may remain healthy for many years but in middle age may develop difficulty breathing due to emphysema. Small amounts of secondhand smoke that might not harm a typical person can be devastating for these people. The third and most severe result of an alpha1 antitrypsin deficiency is inflammation of the liver within a few weeks or months of birth, causing severe liver damage and perhaps even death for an infant. To my knowledge, alpha1 antitrypsin has not yet been prepared for replacement therapy for those who lack this anti-enzyme.

When emphysema runs in families,begins at an early age, or occurs in nonsmokers, a strong suspicion should arise that the patient suffers from an alpha1 antitrypsin deficiency. A standard test can determine this.

Obviously, a person with thiscondition should never begin to smoke. Smoking may lead to emphysema by the age of 40, but not smoking may delay the onset of emphysema until age 60. But does the person with little or no alpha1 antitrypsin get lung cancer more readily when exposed to cigarettes or radon? Could it be responsible for Dorothy's lung cancer and other rare instances of lung cancer in victims without the usual history of smoking? We checked our last Cancer Prevention Survey and found only two nonsmokers who had primary lung cancer. We are attempting to contact these patients or their families to find out about radon levels in their homes and whether there was any family history of alpha1 antitrypsin deficiency or symptoms such as severe emphysema in a nonsmoker or early severe emphysema in a smoker.

The SatEvePost Society willpay the cost of an alpha1 antitrypsin test and a radon charcoal detector test for any lung-cancer patient who never smoked or lived with smokers. We urge surgeons who have had such lung-cancer patients to put them in touch with the Society so we can send them a radon detector and information about the alpha1 antitrypsin test.

We have prepared a new survey fornonsmokers who have had lung cancer. In an effort to find more cases of primary lung cancer in nonsmokers to study, we urge any readers who have had primary lung cancer either themselves or in a family member to fill out the survey on page 59. Please fill it out for a relative, even if you do not have all the facts to answer each question. If a member of your family has died from lung cancer, it would help tremendously if you would make out the second part of the questionnaire on behalf of the deceased. In cases where it is not known if the cancer was primary or was metastasized (spread to the lung from other organs in the body), your loved one's physician would undoubtedly be happy to refer you to the pathologist who read the slides at the time the cancer was diagnosed. He could tell you whether your relative's cancer began in the lung or had simply spread to the lung. In this survey, we are interested in primary lung cancers that begin in the lung. Our goal here is to discover whether higher-than-normal radon exposure over a period of years has, indeed, caused primary lung cancer and whether hereditary alpha1 antitrypsin deficiency may have caused primary lung cancer. Your help may lead to more knowledge about the cause of lung cancer in nonsmokers.

Photo: Dorothy and Paul TerLouw never complain or lose courage because their Iowa farm is in jeopardy. Now the same faith in prayer keeps them in good spirits and optimistic that Dorothy's lungs will be healed. An active volunteer, Dorothy worked on experiments in blood clotting with pigs fed garlic. When their pastor travels, his children enjoy the TerLouw farm hospitality and Dorothy's superb cooking. Her grandchildren adore her.

Photo: This typical smoker's lung cancer is extremelyrare in nonsmokers. A peripheral lesion the size of a silver dollar was discovered on Dorothy's X-ray after she had noticed traces of blood in her sputum.

Photo: Dorothy's left upper lobe was removed and no cancer could be found in the remaining lung tissue. The only positive lymph nodes were contiguous to the lesion. Two weeks out of surgery she is back preparing food for Paul and his help in the field. Legions of friends pray for her recovery.

Photo: In an effort to find the cause of primary lung cancerin nonsmokers, the Post Society will pay for charcoal radon testing in homes of primary lung cancer victims who never smoked or lived or worked with smokers. Radon gas from soil beneath a house can enter through cracks and be trapped in basements.
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Author:SerVaas, Cory
Publication:Saturday Evening Post
Date:Jan 1, 1987
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