Medical Surveillance Program For Uranium Workers In Grants, New Mexico

Prior to 1971, there were several clinical trials to evaluate programs for early detection of lung cancer. Among these, the Philadelphia Pulmonary Neoplasm Research Project,(3) the Veterans Administration Study published by Lilienfeld,(7) and the controlled trial of the Kaiser Foundation Health Plan showed an overall five year survival rate of 8% for newly detected cases (the same as the national statistic for unscreened patients). In 1971, the National Cancer Institute initiated three randomized, controlled mortality studies using lung cancer screening of persons at high risk (male smokers over 45 years old). The studies are being conducted at the Johns Hopkins University Hospital, the Mayo Clinic, and the Memorial Sloan-Kettering Cancer Center. The studies have slightly different designs in the combination of sputum cytology and chest x-rays. At the Mayo Clinic the study group is offered screening with sputum cytology and chest x-rays every four months, whereas the control group is advised to have an x-ray and cytology every year. No reminders are sent, and it is believed that only about 20% of the control group is screened. At Johns Hopkins and Memorial, both experimental and control groups are offered annual chest x-rays. The experimental group is additionally offered sputum cytology every four months.(5) At present all of the programs show that screening can detect cancers that are undetectible by other means. However, at this time mortality rates in the control and experimental groups are not significantly different in any of the three studies. OUR PROGRAM Our clinic is located in Grants, New Mexico and we provide most of the pre-employment physical examinations for the mines operating in the Grants area (Kerr McGee Nuclear, Homestake Mining, United Nuclear, Western Nuclear, and Ranchers). In the examinations, we obtain the previous mining history of the worker, a chest x-ray, a sample of sputum for cytological examination, and a blood sample. We also provide routine annual physical examinations of the workers, with special interest in the detection of bronchogenic carcinoma. In the early seventies, we did not have a definite surveillance program. We did not know whether we should have a program like the one started at Memorial or like the one started at the Mayo Clinic. After long consideration, we decided to have a program that does not demand a sputum cytology and chest x-ray every four months, but that allows as many chest x-rays and sputum cytologies as needed to diagnose lung cancer as early as possible. We believe that, if a screening method for cancer is to be optimally effective, it must detect the process at stages early enough for curative therapy. We order a test depending on the age of the miner, the race, the mining history, the smoking history, the radiation exposure levels, and the results of the previous chest x-ray and sputum cytology. With the help of the computer, we have a list of all the miners who should be watched closely because of age, race, mining history, smoking history, radiation exposure, etc. Examination of the miners is performed at our clinic, where all the records are kept. The sputum is collected there but examined in Grand Junction, Colorado, by Dr. Geno Saccomanno. There are two ways to collect sputum. The best way is to collect three consecutive morning samples. For this, we need the cooperation of the miners. They have to follow these instructions and mail the bottle containing the sample to Grand Junction. "Instructions for obtaining a good cough specimen" The enclosed plastic bottle contains a preservative solution, so do not empty out the liquid in it. When you go to bed, place the plastic bottle at your bedside where it will be handy in the morning. When you first get up in the morning (before breakfast) try to cough up some "phlegm" from deep in your chest, and spit it into the liquid in the bottle. Try coughing several times. If you have difficulty coughing, try inhaling deeply the steam from a teakettle (or home-type inhalator). Keep the amount of saliva (ordinary spit) that you put into the bottle along with the cough specimen as small as possible. Do not collect the "phlegm" or mucous that comes from the back of your nose. Put the cap back on the bottle, and shake it vigorously for two minutes. If the amount of material you have coughed up is quite small, then keep the bottle at your bedside for three or four days, and each morning try to add another cough specimen. After obtaining your cough specimen, repack the bottle in the mailing container, and attach the enclosed mailing label. It does not require any postage stamps. Unfortunately, some miners "forget" to mail the sample and end up with an incomplete physical examination. To avoid this some companies, like Homestake, request that we obtain the sample in our clinic by forcing cough and expectorant with a nebulizer machine. This method does not give as good a sputum sample as the previous one, but we do get a sputum sample for every miner. The policies of different companies, in regard to annual physical examinations are different. All