What are the Dollar Costs of Radon?
Through the efforts of many professionals and volunteers, the hazards of living with elevated levels of radon are becoming increasingly well communicated. A connection is gradually being made in the mind of the public between the amount of radioactive gas we breathe in over long periods of time and the incidence of lung cancer. Rightly so, these hazards are generally framed in terms of the loss of human life, with the U.S. Environmental Protection Agency’s estimate of 21,000 deaths per year in the U.S. being a generally accepted figure. [Refs. 1,2]
In this communication, a different tack is taken-- herein an attempt is made to quantify the dollar costs to the U.S. healthcare system using publicly available component data. This is offered in the spirit that if, collectively, we can do a better job at managing radon exposure; these dollar costs can be reallocated-- potentially moderating increases in the costs of private healthcare insurance and government-supported healthcare programs.
Since low-cost, no-risk screening of non-symptomatic individuals for lung cancer does not yet exist, it is clear more must be done in terms of prevention. Thus, it is argued that wider use of modern electronic methods for the continuous detection and visualization of radon levels needs to play a greater role in the public health response to the human and financial costs of radon.
What is Radon?
As a quick review, radon is a naturally occurring inert gas which unnaturally accumulates in our homes as the negative pressure “chimney effect” of temperature differential draws gases from the soil under our homes through cracks and penetrations in slabs and foundations. High-energy alpha and beta particles from the decay of radon and its solid daughter products can damage DNA in lung tissue, giving rise
over time to the incidence of lung cancer. If high levels of radon are detected in our homes, well-established and cost-effective mitigation techniques exist. Given soon enough knowledge of the problem, no one need be a victim.
A Simple Calculation
In the U.S., 228,820 new cases of lung cancer were diagnosed in 2019. [Ref. 3] The majority of these cases were diagnosed at Stage IV. There can be few symptoms that rise to the level of seeing one’s doctor early enough-- a persistent cough, shortness of breath, wheezing, hoarseness, or repetitive episodes of bronchitis or pneumonia are the usual triggers for office visits. The difficulty in treating lung cancer can be seen in comparing the number of new diagnoses in the U.S. per year to the number of lung cancer deaths in the U.S. per year (135,720 in 2019). [Ref. 3] The National Cancer Institute’s “SEER” database estimates the 5-year survival rates of small cell lung cancer (SCLC) and non-small cell lung cancer (NSCLC), independent of stage, at 6% and 24% respectively. [Ref. 3] The predominance of late stage diagnosis is tragically evident.
The U.S. Environmental Protection Agency has tried to estimate the fraction of U.S. annual lung cancer deaths that may be attributed to radon. This is not an easy thing to do, and the resultant quantification has not been received without controversy. [Ref. 4] Central to the estimate is a study of a population of miners who in the course of their work were exposed to elevated levels of radon for many years. Numerous correction factors needed to be applied to correlate their experience of lung cancer to that of the population at large. The result, now generally accepted, is that the number of annual U.S. lung cancer deaths due to radon is 21,000. Thus, 21,000/135,720 x 100 indicates 15.5% of all lung cancer cases may be attributable to radon.
The average lifetime cost of lung cancer diagnosis and treatment is available in the literature. In the U.S., this is approximately $282,000 per case. [Ref. 5] Of course, there is a wide variation, depending upon the interventions recommended and their effectiveness, but if we take this at face value, all information is now in hand to attempt an annual cost of the radon-induced incidence of lung cancer to the U.S. healthcare system:
(Diagnoses per year) x (fraction attributable to radon) x ($ per case) =
228,820 x (21,000/135,720) x 282,000 = $10 Billion/year*
*Statistics available in 2020 [Ref. 3] result in a higher cost than previous estimates
The result is big number-- especially for something that is to a great degree preventable. So, who pays? The answer is we all do, through private insurance premiums, through the taxes we pay that support Medicare and Medicaid, and out of our own pockets in the form of deductibles, co-pays, and charitable contributions.
How Can These Costs be Reduced?
Status quo efforts rightly focus on prevention. In the case of cigarette smoking, the leading cause of lung cancer, beginning in the 1960s concerted anti-smoking campaigns have substantially contributed to improved public health. Though messaging on radon has been but a fraction of that devoted to smoking, awareness of the need for testing our homes for radon has grown. What are largely the incumbent testing methods (plastic track detector chips and activated carbon packets-- both of which are exposed for a period of time and sent away to a laboratory for analysis) have made important contributions to prevention. In the search for what more can be done to reduce the societal costs of lung cancer, it is logical to examine the status of screening techniques.
Since diagnoses of lung cancer are most often made at later stages, to reduce overall costs, low cost non- (or minimally) invasive screening techniques are needed for use prior to the appearance of symptoms. For now, annual low-dose CT (computed tomography) scans remain the only approved method for screening of non-symptomatic individuals. Such screening involves the risky exposure to x-ray radiation at a level (1.4 mSv) equivalent to 14 chest x-rays and the false positive rate is significant (356 false positives if 1,000 individuals are screened each year for three years). [Ref. 6] Due to its costs and its risks, the Centers for Disease Control (CDC) guidelines are that low-dose CT scans are justified only for past or present heavy smokers in the 55 to 80 age bracket. Private insurance and Medicare pay (more or less) accordingly. Confirmation via visual bronchoscopy and biopsy remains necessary.
There is some promise worth noting toward screening tests employing breath analysis and “liquid biopsy” techniques. OneBreath, Inc. and Owlstone Medical, Inc. are start-up companies that focus on breath analysis. Cancers in lung tissue produce certain small molecule volatile organic chemical (VOC) markers, e.g.: 1-butanol and 3-hydroxy-2-butanone. [Ref. 7] In OneBreath’s version of such new technology, the patient exhales into an absorber cartridge at the point of care, which is later desorbed at a laboratory for analysis by gas chromatography. [Ref. 8] In Owlstone’s version, breath is absorbed over several minutes and desorbed into a gas stream flowing though what is known as a Field Assisted Ion Mobility Spectroscopy chip for artificial intelligence pattern recognition. [Ref. 9] In a completely different approach, there is much research on “liquid biopsy” techniques based on drawing blood samples and analyzing for ct-DNA (circulating tumor DNA) arising from apoptosis and necrosis of dying cells. [Refs. 10, 11] Despite continuing clinical studies, none of the above approaches will be in widespread use in the near term. False positives and false negatives remain a concern.
Thus, early diagnosis remains a remains difficult proposition, and for now it is reasonable that society must double-down on prevention.
What Else Can We Do?
Given the costs borne directly or indirectly by all of us, one might rightly ask how mush more can be done in promoting residential radon testing and mitigation activities?
The most cost-effective measures undoubtedly focus on education and communication. For instance, as part of patient intake, electronic heath records initiatives, Medicare annual physicals, and the like, we are generally asked about our smoking history. What if whether one’s home has been tested also commonly becomes part of such questionnaires? General practitioners need to be at the forefront of education on radon. Can more with done with pamphlets in waiting rooms-- possibly bearing discount coupons for detectors? How many people know that radon mitigation projects can be tax deductible if their doctor so advises?
One might think it in the interest of private health care insurance companies to reduce costs by incentivizing their insureds to reduce radon risks. However, given the nature of lung cancer, investments made by health insurers today (say in terms of rebates or reduced premiums upon evidence one’s home is tested) may have a decades long time lag prior to paying off in reducing their costs.
Lobbying for additional government regulation may be a logical way forward. Testing upon the transfer of title to homes is already practiced in 29 states. [Ref. 13] Requiring testing of schools, public buildings, and workplaces may make sense if bounded by some logical criteria. There are numerous resources for identifying legislation and the responsible agencies within individual states. [Ref. 14]
Non-profits and foundations may be interested in setting up library programs to lend electronic radon detectors and equip schools with detectors for science projects. As of 2020, Health Canada successfully operates such programs in 52 library locations, nearly all of which experience long wait lists. [Ref. 15] Lending periods are short (3-6 weeks), which runs counter to the modern understanding of the need for long term testing; however, the educational opportunity presented can be used to counteract any possible false sense of security arising from short-term tests.
Start the Discussion!
Continued on next page ...
What Are the True Costs of Radon to the U.S. Health Care System?
Peter C. Foller, Ph.D.
Ecosense, Inc.
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