Radiation treatments prior to death may make a patient's body a little too hot to handle with regular crematorium procedures – and more attention needs to be paid to the issue of the proper management of such remains.
The matter came to light in a recent JAMA research letter, which reviewed the 2017 case of a cancer patient who had received radioactive treatment at the Mayo Clinic in Arizona prior to his death, and whose cremation led to contamination of the crematorium.
"It's not the second coming of Chernobyl or Fukushima, but it's unwanted, unnecessary radiation," Kevin Nelson, the radiation safety officer at Mayo Clinic in Arizona and one of the research letter's authors told The Arizona Republic
The JAMA letter and subsequent publicity – even alarm – surrounding it requires perspective, advised a statement from The American Association of Physicists in Medicine (AAPM) and the American College of Radiology (ACR).
It is important to remember several key points regarding the potential dangers, they advised, including:
- Radioactive materials are used routinely in medical practice to improve human health.
- The risk of harm to the crematorium operator is so small that it cannot be measured.
- Consensus guidelines from national (CDC and DOE) and international radiation protection and public health organizations provide clear guidance on how to identify radioactivity in patient remains and appropriately deal with the body of the decedent.
- Healthcare providers who administer radioactive material must have a designated Radiation Safety Officer whose credentials meet criteria established by the U.S. Nuclear Regulatory Commission. These individuals are often certified medical physicists or health physicists.
- The low-cost best practice of installing a simple radiation detector in hospital morgues, funeral homes and crematoriums would quickly alert staff to the presence of radioactivity. A certified medical physicist or health physicist has the expertise to determine when the measured radiation levels will have decreased to a level where it is safe to release the body to coroners, medical examiners, or mortuary services.
The research letter called the after-death challenge from radiopharmaceuticals “unique and often overlooked,” noting that "cremating an exposed patient volatilizes the radiopharmaceutical, which can then be inhaled by workers (or released into the adjacent community) and result in greater exposure than from a living patient."
"I don't think the risk from inadvertently cremating a body that might contain small levels of radiation is large. I think the risk is small," said Nelson, adding, "but what we're trying to do is reduce even those small levels of exposure as much as we possibly can. I think we have an onus in the community to try to do that."
The case involved a 69-year-old man who had been given intravenous lutetium Lu 177 dotatate for a pancreatic neuroendocrine tumor and then was admitted the next day to a different hospital for hypotension. He died from the pancreatic disease two days later and was cremated five days after his radiation treatment.
When Nelson and the patient's treating doctors found out – almost a month later – they alerted the crematorium and the Arizona Bureau of Radiation Control. A subsequent investigation of the facility's oven, vacuum filter, and bone crusher found “very low” levels of Lu 177. But the crematorium operator's urine was found to have levels of technetium Tc 99m, which Nelson thinks may have come from another cremated body.
"The question that this raises is, how frequently is this occurring?." Nelson noted to the Arizona paper, advising that, "when we look at exposure to members of the general public who don't know they are being exposed, that's another level of concern."
In some states, he said, procedures are different. In Florida, for example, the remains of patients who have had radiation treatments must either have the organs removed or the bodies stored until radioactive decay has cut the risks to acceptable levels.
"Just this morning I was in contact with the funeral home director where this occurred and in his industry this is getting a lot of notoriety," Nelson told the paper. "We want that discussion to happen. That was partially the reason we published this."
While present guidelines provide for safe handling of radioactive materials, in October, 2018, the EPA raised some alarm bells when it suggested questioning these current, decades-old guides that hold that any exposure to radiation places individuals at greater risk of developing cancer in their lifetime.
“The American Society of Radiologic Technologists is committed to optimal patient care that includes a focus on protection from unnecessary medical radiation,” Greg Morrison, ASRT associate executive director, told HCB News at the time
. “We strongly oppose any measure that would weaken radiation protection measures for patients, radiologic technologists and all other healthcare workers.”
First introduced in April, 2018, the Strengthening Transparency in Regulatory Science proposal directs regulators to consider alternative scientific viewpoints when establishing or adhering to regulatory standards, including evaluating various threshold models across the range of exposures when in contact with dangerous substances.
While not mentioning radiation directly, many interpret its language as including present radiation standards.