FOCUS ON RADON-INDUCED LUNG CANCER PREVENTION O N CO LO GY AN N UAL R EP O RT

Transcription

1 FOCUS ON RADON-INDUCED LUNG CANCER PREVENTION O N CO LO GY AN N UAL R EP O RT

2 TABLE OF CONTENTS TABLE OF CONTENTS CONTAINS ACTIVE HYPERLINKS. CLICK ON THE AREA OF INTEREST TO BE TAKEN TO THAT PAGE. CLICK BACK TO TABLE OF CONTENTS AT THE TOP OF ANY PAGE TO RETURN HERE. Lung Cancer in Kentucky...1 Risk Factors for Lung Cancer...2 Facts about Radon...3 Cancer Committee Prevention Report...7 Collaboration with the Kentucky Radon Program to Raise Radon Awareness and Increase Home Radon Testing to Reduce Radon-Induced Lung Cancer Multidisciplinary Lung Cancer Care at Baptist Health Lexington... 9 Lung Cancer Screening and Early Detection Who should be screened for lung cancer with a low dose computed tomography scan?...12 Incidental Lung Nodule Clinic...13 Lung Cancer Conference...13 References...15

3 LUNG CANCER IN KENTUCKY In 2017, the American Cancer Society estimates 222,500 new cases of lung cancer and 155,870 deaths from the disease (ACS, 2017). Lung cancer is the second most commonly diagnosed cancer and the leading cause of cancer death in both men and women in the United States. Unfortunately, Kentucky leads the nation in both incidence and mortality rates with an estimated 4,830 new cases and 3,560 deaths from lung cancer in 2017 (ACS, 2017). The area of the state most affected by lung cancer is the Appalachian regions, with the majority of counties having incidence and mortality rates higher than the non-appalachian regions (Kentucky Cancer Registry, 2017). At Baptist Health Lexington, lung cancer has been and continues to be one of our top 2 cancer types diagnosed and/or treated (Figure 1). While lung cancer accounts for approximately 25% of all cancer deaths, the disease remains highly preventable. Eliminating exposure to tobacco smoke and reducing exposure to radon has the potential to reduce the incidence and mortality from lung cancer. This report will highlight Baptist Health Lexington s involvement in implementing strategies identified by the Kentucky Cancer Consortium to reduce the incidence and mortality rate of cancers related to environmental carcinogens, with a focus on radon. In addition, our multidisciplinary approach to lung cancer care including our Lung Navigation program, our Lung Cancer Screening Program, our Incidental Lung Nodule Clinic, and our Multidisciplinary Lung Cancer Conference, will be featured. FIGURE 1 Lung Cases Diagnosed and/or Treated at BHLEX Number of Cases Trachea,bronchus,lung- small Trachea,bronchus,lung- NSC BAPTIST HEALTH LEXINGTON / 2017 ONCOLOGY ANNUAL REPORT / PAGE 1

4 RISK FACTORS FOR LUNG CANCER SMOKING: Tobacco smoke is the leading cause of lung cancer and 80% of lung cancer deaths are attributed to smoking (ACS, 2017). Use of tobacco is likely to blame for the high incidence of lung cancer in our state as the prevalence of smoking in Kentucky continues to be higher than the national average. Approximately 25.9% of Kentucky adults identified themselves as current smokers, compared to the 17.5% of U.S. adults (The Kentucky Behavioral Risk Factor Survey 2015 Annual Report). RADON: Radon gas exposure is the second leading cause of lung cancer. Exposure to radon is associated with an approximately 15,400-21,000 cases of lung cancer each year in the U.S. (Committee on Health Risks of Exposure to Radon (BEIR VI), N.R.C., 1999). Of the estimated cases, approximately 2,900 occur in individuals who have never smoked tobacco (Environmental Protection Agency [EPA], 2017). OTHER RISK FACTORS Various environmental and occupational exposures are also risk factors for lung cancer. Examples include secondhand smoke, asbestos, air pollution, and diesel exhaust (ACS, 2017). BAPTIST HEALTH LEXINGTON / 2017 ONCOLOGY ANNUAL REPORT / PAGE 2

5 <<< B A C K <<< TO TA B L E O F C O N T E N T S FACTS ABOUT RADON Radon is a naturally occurring, colorless, tasteless, odorless radioactive gas released from the normal decay of uranium found in rocks and soil and is found in every region of the United States. Radon is found in outdoor and indoor air. Exposure to radon is largely due to high concentrations of radon in the home. A difference in air pressure inside a home and the soil surrounding the home acts as a vacuum, drawing radon indoors (EPA, 2016b). Radon accumulates indoors when the radon gas enters the home through cracks in walls, basement floors, foundations and other openings, and becomes trapped in the home (EPA, 2016a). When radon is inhaled, radioactive particles may be deposited in the lungs, irradiating cells in the airways and increasing the risk of lung cancer (EPA, 2016a). The landscape of Kentucky is known for its high occurrence of karst, which is the term used to describe a landscape that is formed by the erosion of bedrock that leads to the development of sinkholes, sinking streams, large springs, and caves. In Kentucky, the karst development is primarily the result of water dissolving the limestone and dolomite rock types. In addition to the potentially hazardous landscape, karst is known to be associated with relatively high concentrations of radon which may enter a home that has been built on the landscape. A recent study which analyzed geological rock formations and known radon values in north central Kentucky found that geologic formation categories with the highest average radon measurements were found in central Kentucky (Hahn, 2015). A synergistic effect exists between tobacco smoke and radon. Those who smoke and are exposed to radon have a nearly ten-fold greater risk of developing lung cancer (EPA, 2016a). The risk of developing radon-induced lung cancer increases with higher levels of radon exposure (EPA, 2016a). Daniel kw Bo Par o ay Parkway Pennyrile Pur ch as Cumb ay Parkw d erlan Pa r k way Mountain y Parkwa y e ck Western Kentu Blue Parkw Pa r k w a y Pa rk y wa Grass ay her Natc Parkway Audu bon ne Karst Randall L. Paylor and James C. Currens KARST OCCURRENCE IN KENTUCKY B A P T I S T H E A LT H L E X I N G T O N / O N C O LO G Y A N N U A L R E P O R T / PA G E 3

6 RADON GETS IN THROUGH: 1) Cracks in solid floors 2) Construction joints 3) Cracks in walls 4) Gaps in suspended floors 5) Gaps around service pipes 6) Cavities inside walls 7) The Well Water RADON TESTING In the United States, radon is measured in picocuries per liter of air (pci/l). A picocurie is one trillionth of a Curie, disintegrations per second. Therefore, picocuries per liter is the measure of radioactive decay of radon in one liter of air. Radon is naturally occurring and approximately 0.4 pci/l of radon is found in outdoor air, while the average indoor radon level is approximately 1.3 pci/l (EPA, 2016a). Testing one s home for radon is the only way to know one s risk from radon exposure. In January 2005, the U.S. Surgeon General issued a national health advisory warning about the dangers associated with breathing indoor radon. The advisory encouraged all Americans to test indoor radon levels and mitigate when appropriate (US Department of Health and Human Services, 2005). The EPA estimates that one in every 15 homes nationwide has a high radon level, and recommends homeowners take action to reduce their home radon level when the value is 4 pci/l or greater (EPA, 2016b). Illustration courtesy of the EPA The Kentucky Radon Program, a division of the Kentucky Department for Public Health, is a member of the Kentucky Cancer Consortium and offers short-term radon test kits to Kentucky residents free of charge. These short-term radon test kits are made available at many county health departments located throughout the state or can be requested from the Kentucky Radon Program by calling Low cost do-it-yourself test kits are also available through the mail and at many hardware stores. In addition, a qualified radon tester can be hired to test homes and buildings for radon. Generally, there are two ways to test for radon (1) short-term testing and (2) long-term testing. BAPTIST HEALTH LEXINGTON / 2017 ONCOLOGY ANNUAL REPORT / PAGE 4

7 SHORT TERM TESTING: Several types of detectors can be used for short-term radon testing (i.e., Charcoal canisters, alpha track, electret ion chamber, continuous monitors, and charcoal liquid scintillation detectors). Short-term tests remain in homes for 2-90 days depending on the device being used. Short-term testing is ideal for those who need results quickly, however, it is less likely than a long-term test to give a year-round average radon level. LONG TERM TESTING: Two types of detectors are used for long-term radon testing (i.e., alpha track and electret detectors) and remain in the home for more than 90 days. The use of a long-term radon detector provides a reading that is more likely to tell a home s year-round average radon level than a short-term test. THE EPA SUGGESTS: When testing for radon it is important to follow the instructions that come with the chosen test kit. When utilizing a short-term test kit, windows and outside doors should be closed at least 12 hours before beginning the test and remain closed as much as possible during the testing period. Heating and air conditioning systems may be used, but fans and other machines that bring in outside air should not be operated during testing. Short-term testing should not be conducted during unusually severe storms or periods of unusually high winds. Regardless of the type of testing kit utilized, it is recommended that detectors be placed in the lowest lived-in level of the home, in a room that is regularly used, but not a kitchen or bathroom. Detectors should be placed at least 20 inches above the floor in a location where it won t be disturbed. Once the testing period is complete, the detector should be sealed in the packaging provided and sent to the lab specified on the package for analysis. Results from a long-term test provide residents with a reading that resembles the home s year-round average radon level. When short-term test results are 4 pci/l or higher, it is recommended that the resident followup with either another second short-term test (if results are needed quickly) or a long-term test. If the results of a long-term test, or if the average of the first and second short-term test is 4 pci/l or higher the EPA recommends fixing the home. BAPTIST HEALTH LEXINGTON / 2017 ONCOLOGY ANNUAL REPORT / PAGE 5

8 RADON MITIGATION While there is no safe level of radon exposure, the use of various methods to mitigate radon when radon levels are at or above the EPA s recommended action level of 4 pci/l is a primary prevention strategy for the prevention of lung cancer (EPA, 2016b). The primary method used to reduce radon levels in homes is through the use of a soil suction radon reduction system. This system works by using a fan to draw radon from below the home and vent it through a pipe, to the outside air above the home where it is quickly diluted. Installation of this system can reduce the radon level in a home by up to 99%. The EPA suggests that the cost of mitigation is similar to other common home repairs and varies depending upon the radon reduction method employed, and the size and design of the home (EPA. 2016b). A list of certified radon mitigation professionals within the state of Kentucky can be found on the Kentucky Association of Radon Professionals website Locator.html. Vent pipe BAPTIST HEALTH LEXINGTON / 2017 ONCOLOGY ANNUAL REPORT / PAGE 6

9 CANCER COMMITTEE PREVENTION REPORT Collaboration with the Kentucky Radon Program to Raise Radon Awareness and Increase Home Radon Testing to Reduce Radon-Induced Lung Cancer BACKGROUND As the nation s leader in both incidence and mortality from lung cancer, reducing radon exposure is of particular interest to the state of Kentucky. The Kentucky Cancer Consortium (KCC) has set priority goals to reduce the burden of lung cancer within the state. Seventy organizations, including Baptist Health, work together to implement the Cancer Action Plan for Kentucky (CAP). Within the 2016 CAP, the KCC identified four prevention goals, one being Reduce the incidence and mortality rates of cancers related to environmental carcinogens, with a focus on radon. Strategies to achieve this goal include, but are not limited to: (1) Support the Kentucky Radon Program in their efforts to increase public awareness of the potential dangers of high radon levels in homes and workplaces; (2) Encourage Kentuckians to test their home for radon through short-term kits available through the Kentucky Radon Program; (3) Educate the public on the risks of high radon levels and the benefits of mitigation and the EPA recommended action levels; (4) Educate healthcare providers about radoninduced cancer risk and the link between radon and tobacco smoke in increasing the risk of lung cancer. PREVENTION ACTIVITY In January of 2017, Baptist Health Lexington held a two-day health fair to provide education to employees about various cancers. Baptist Health Lexington collaborated with the Kentucky Radon Program to educate employees on the risks associated with exposure to radon and tobacco smoke on the development of lung cancer. County-level radon infographic handouts developed by the University of Kentucky BREATHE program were distributed. The infographics provided easy-to-read information on radon, the dangers of combined tobacco and radon, and information on testing homes for radon. During the health fair, employees were offered free short-term radon test kits provided by the Kentucky Radon Program. BAPTIST HEALTH LEXINGTON / 2017 ONCOLOGY ANNUAL REPORT / PAGE 7

10 RESULTS In total, 186 home radon test kits were distributed to employees. Twenty-one kits (11%) were returned for analysis (Figure 2). Of those returned, four were unable to be analyzed (reason unknown). Of the remaining 17 kits analyzed, radon values were between 0.7 pci/l and 33.4 pci/l. Eleven of the 17 kits (65%) had values above the EPA s action level of 4 pci/l (Figure 3). CONCLUSION Testing indoor air for radon is necessary to determine one s exposure risk, yet evidence has shown that despite public awareness of radon, the proportion of people who have completed home radon testing remains low (Eheman, 1996; Wang, 2000). In Kentucky, it is estimated that annually, less than 1% of homes complete radon testing (Hardwick, 2017). While we had hoped for a higher completion rate, this prevention event in which Baptist Health Lexington in partnership with the Kentucky Radon Program, offered education on the health consequences of radon FIGURE 2. Completion rate of home radon tests distributed at the employee health fair. Total Test Kits Analyzed Total Test Kits Taken but Not Analyzed and provided free short-term radon test kits to those in attendance, was thought to be a good initial attempt at working towards meeting one of the Kentucky Cancer Consortium s Cancer Action Plan prevention goals. FIGURE 3. Measured home radon values n= 17. Red line indicates the Environmental Protection Agency s recommended action level (4 pci/l) BAPTIST HEALTH LEXINGTON / 2017 ONCOLOGY ANNUAL REPORT / PAGE 8

11 MULTIDISCIPLINARY LUNG CANCER CARE AT BAPTIST HEALTH LEXINGTON LUNG NURSE NAVIGATOR In February of 2016, Sara Barker, BSN, RN, OCN, joined the Baptist Health Lexington cancer care team in the role of Lung Nurse Navigator. As the Lung Cancer Nurse Navigator, Sara serves as a personal resource for patients and families, ensuring that all needs are met and barriers to care are addressed. In addition, Sara works with the multidisciplinary team to coordinate and facilitate lung cancer care, from suspicion of a lung nodule to diagnosis and beyond. With more than 12 years of experience caring for oncology patients in Central Kentucky, and specialty nursing certification as an Oncology Certified Nurse (OCN ) Sara has been instrumental in developing the Lung Cancer Screening Program and facilitating weekly lung cancer conferences in which lung cancer cases are presented to a multidisciplinary team. Sara works closely with several specialty physicians including those in the Baptist Health Medical Group medical oncology and pulmonary practices as well as radiation oncologists and cardiothoracic surgeons. Sara is the coordinator for the Lung Nodule Clinic at Baptist Health Lexington, which began in December of This weekly Lung Nodule Clinic is an effort to identify patients with suspicious lung findings, navigate referrals to specialists for appropriate assessment and plan recommended follow-up. With more efforts toward early detection such as Low Dose Lung CT Screenings and the Lung Nodule Clinic, the Lung Cancer Nurse Navigator role is providing more focus on access and coordination to expert care in an effort to make a meaningful impact on lung cancer prevention, diagnosis and survival. Sara is also very involved in community education, lending her expertise to the Central Kentucky community by participating in the Lexington KY Free to Breathe 5K and coordinating the Baptist Health Lexington Shine a Light on Lung Cancer celebration. She is also a leader in Baptist Health Lexington s participation with events such as the American Cancer Society Relay for Life and the Leukemia and Lymphoma Society Light the Night event. SARA BARKER, RN, BSN, OCN 1700 NICHOLASVILLE ROAD CANCER CENTER LEXINGTON, KY HEALTH TALK VIDEO BAPTIST HEALTH LEXINGTON / 2017 ONCOLOGY ANNUAL REPORT / PAGE 9

12 LUNG CANCER SCREENING AND EARLY DETECTION Sadly, a diagnosis of lung cancer comes with a dismal prognosis. The 5-year relative survival rate for lung cancer is 15% for men and 21% for women (ACS, 2017). Lung cancer screening in asymptomatic, highrisk patients has the potential to reduce mortality from lung cancer by identifying lung cancer in its earliest stages when the disease is more responsive to treatment. Early detection with the use of low-dose spiral CT (LDCT) has been shown to reduce lung cancer Baptist Health Lexington CT Lung Cancer Screening Locations 206 Bevins Ln., Georgetown 1740 Nicholasville Rd., Lexington 100 Southland Dr., Lexington 1775 Alysheba Way, Lexington 100 Providence Way, Nicholasville 107 Meridian Way, Richmond BAPTIST HEALTH LEXINGTON / 2017 ONCOLOGY ANNUAL REPORT / PAGE 10

13 mortality by approximately 20% compared to standard chest x-ray (ACS, 2017). Based on results from the National Lung Screening Trial published in the New England Journal of Medicine (NEJM) in August 2011, the US Preventive Services Task Force (USPTF) recommends annual screening for lung cancer with lowdose computed tomography in adults aged years who have a 30 pack-year smoking history and currently smoke or have quit within the past 15 years. The American Cancer Society (ACS) has endorsed a process for lung cancer screening that includes shared decision making between clinicians who have access to high-volume, high-quality lung cancer screening programs and current or former smokers who are 55 to 74 years of age, in good health, and have at least a 30 pack-year history of smoking. In February of 2015, the Centers for Medicare and Medicaid Services (CMS) began providing national coverage for low dose CT lung cancer screening for eligible Medicare beneficiaries. ADDRESSING BARRIERS IN ORDER TO DETECT LUNG CANCER EARLY A lung cancer screening program was first implemented at Baptist Health Lexington in Annually the volume of lung cancer screenings completed continues to grow, however utilization remains low (see Table 1.) Potential barriers to utilization of lung cancer screening were evaluated by the Baptist Health Lexington Cancer Committee. In 2017, our Lung Nurse Navigator (LNN) worked with hospital administration, Epic electronic medical record team members, a primary care physician representative, and the oncology medical director to determine ways in which our electronic medical record could be utilized to facilitate the ordering of LDCT in eligible patients. Various applications within the system are now being used to allow for easy identification of eligible patients and minimize barriers to ordering LDCT. In addition, our LNN participated in various activities to educate both physicians and the public on criteria for LDCT, common billing information, and follow-up services offered through Baptist Health Lexington which includes Lung Nurse Navigation and Lung Nodule Clinic. In addition, the LNN and a pulmonologist participated in a Baptist Health Health Talk to discuss lung cancer screening and raise awareness of this important early detection opportunity. TABLE 1 Baptist Health Lexington LDCT Lung Screening Program by the Numbers Jan-Oct 2017 Number of persons requiring < 12 month follow-up scan Number of Lung Cancers Diagnosed Total number of persons scanned BAPTIST HEALTH LEXINGTON / 2017 ONCOLOGY ANNUAL REPORT / PAGE 11

14 WHO SHOULD BE SCREENED FOR LUNG CANCER WITH A LOW DOSE COMPUTED TOMOGRAPHY SCAN? Lung cancer screening is recommended in high-risk individuals in order to find disease early, before symptoms are present, possibly making it easier treat. According to the United States Preventative Services Task Force and the Centers for Medicare and Medicaid Services, anyone meeting the following criteria should have LDCT lung cancer screening: Between the ages of years of age with commercial insurance or with Medicare (Medicare covers until age 77) Currently smoking or smoker who quit within the past 15 years, and Smoked at least one pack of cigarettes a day for 30 years or more (30-pack year history) Would consider treatment if diagnosed with cancer Absence of any signs of lung cancer such as unexplained weight loss, cough with unknown cause or bloody sputum. HOW DO I CALCULATE MY PACK-YEAR HISTORY? A pack year is a way to measure the amount a person has smoked over a long period of time. To determine your pack-year history, multiply the number of packs of cigarettes smoked per day by the number of years you have smoked. For example: 1.5 packs of cigarettes per day x 17 years 25.5 pack years Yearly LDCT screening is recommended as long as the above criteria are met. There are risks involved with lung cancer screening so it is recommended that all individuals considered at high-risk talk to his/her doctor and discuss the risks and benefits. FOR QUESTIONS ABOUT LUNG CANCER SCREENING CONTACT: SARA BARKER, RN, BSN, OCN BAPTIST HEALTH LEXINGTON / 2017 ONCOLOGY ANNUAL REPORT / PAGE 12

15 INCIDENTAL LUNG NODULE CLINIC In December of 2016, Baptist Health Lexington began offering a Lung Nodule Clinic to connect incidental lung nodule patients with appropriate follow-up care. Finding a spot on a patient s lung can cause concern. The Lung Nodule Clinic at Baptist Health Lexington monitors, diagnoses, and treats patients with identified lung nodules. In the Lung Nodule Clinic, lung experts from several medical disciplines work together to create tailored treatment plans for each patient. Early detection of lung cancer is the main goal. The patient s family doctor will be kept up-to-date throughout follow-up. Detailed information on the development of this clinic was included in the 2016 annual report. OUR SERVICES INCLUDE: Quick access to appointments Continuity of care by the same team of providers Ongoing communication with referring providers Patient education and resources provided by the nurse navigator Access to advanced imaging and procedures Close support from related disciplines including pulmonary, radiology, thoracic surgery, medical oncology and radiation oncology LUNG NODULE CLINIC is held weekly on Tuesdays at Baptist Health Medical Group Pulmonary & Critical Care Medicine 166 Pasadena Drive, Suite 100, Lexington, KY TO MAKE AN APPOINTMENT for the weekly clinic call or contact SARA BARKER, RN, BSN, OCN LUNG CANCER CONFERENCE At Baptist Health Lexington, a multidisciplinary approach to lung cancer care is utilized. Our multidisciplinary team includes: Medical oncologists Thoracic surgeons Radiation oncologists Interventional radiologists Pulmonologists Pathologists Palliative care team members Genetic counselors Oncology dietitian Chaplains Clinical research coordinators Lung cancer nurse navigator Cancer registry The multidisciplinary approach allows for input from various healthcare professionals on the care provided to patients. Lung cancer conference meets weekly to discuss individualized treatment options for patients with lung cancer. Conferences allows for team members to review patient s history and diagnosis, provide input and concur with how the patient should best be treated. The frequency of conferences allows patients to receive the multidisciplinary feedback in a timely fashion. BAPTIST HEALTH LEXINGTON / 2017 ONCOLOGY ANNUAL REPORT / PAGE 13

16 REPORT ON COMMUNITY EVENTS Free to Breathe Run/Walk: Held annually in November. Sponsored by Free to Breathe and the Lung Cancer Research Foundation, a partnership of lung cancer survivors, advocates, researchers, healthcare professional and industry leaders whose mission is to improve and save lives by funding groundbreaking research for the prevention, diagnosis, treatment and cure of lung cancer. Shine A Light on Lung Cancer: A free event held annually in November. Sponsored by the Lung Cancer Alliance. The event s mission is to provide hope and inspiration to all impacted by lung cancer and those who are at risk. This year s event was hosted by Baptist Health Lexington and held on November 16 from 5:30-7 p.m. at Baptist Health Lexington Cancer Center. BAPTIST HEALTH LEXINGTON / 2017 ONCOLOGY ANNUAL REPORT / PAGE 14

17 REFERENCES American Cancer Society. Cancer Facts & Figures Atlanta: American Cancer Society; Hardwick, C. (2017, March 17, 2017). [Kentucky Radon Program]. Kentucky Cancer Registry. ( ). Age-Adjusted Cancer Mortality Rates in Kentucky. Lung and Bronchus; By Appalachian Region. Retrieved from ky/?datasource=mort Kentucky Cancer Registry. ( ). Age-Adjusted Invasive Cancer Incidence Rates in Kentucky. Lung and Bronchus; By Appalachian Region. Retrieved from info/ky/?datasource=mort United States Department of Health and Human Services. (2005). Surgeon General Releases National Health Advisory on Radon [Press release]. Retrieved from radon/assets/surgeon_general_radon.pdf. Kentucky Department for Public Health (KDPH) and the Centers for Disease Control and Prevention (CDC). Kentucky Behavioral Risk Factor Survey (KyBRFS) Data. Frankfort, Kentucky: Cabinet for Health and Family Services, Kentucky Department for Public Health, [2015]. Kentucky Cancer Consortium. (2016). Cancer Action Plan, a blueprint for cancer prevention and control in our state. Retrieved from canceractionplan.pdf Committee on Health Risks of Exposure to Radon: Biological Effects of Ionizing Radiation VI (BEIR VI), National Research Council. (1999). Health effects of exposure to indoor radon. Washington, DC: The National Academies Press. US Environmental Protection Agency. (2016a). A citizen s guide to radon. The guide to protecting yourself and your family from radon. Retrieved from files/ /documents/2016_a_citizens_guide_to_radon.pdf US Environmental Protection Agency. (2017). Health risk of radon. Retrieved from US Environmental Protection Agency. (2016b). Consumer s guide to radon reduction. How to fix your home. Retrieved from consumers_guide_to_radon_reduction.pdf Hahn, E.J., Gokun, Y., Andrews Jr., W.M., Overfield, B.L., Robertson, H., Wiggins, A. & Rayens, M.K., (2015). Radon potential, geologic formations, and lung cancer risk. Preventive Medicine Reports. 2, Eheman, C., Ford, E., Staehling, N. & Garbe, P. (1996). Knowledge about indoor radon in the United States: 1990 national health interview survey. Archives of Environmental Health, 51(3), Wang, Y., Ju, C., Stark, A.D., & Teresi, N. (2000). Radon awareness, testing, and remediation survey among New York state residents. Health Physics, 78(6), Aberle, D.R., Adams, A.M., Berg, C.D., Black, W.C. et al. (2011). Reduced lung-cancer mortality with low-dose computed tomographic screening. New England Journal of Medicine, 365(5): Jemal, A. & Fedewa, S.A. (2017). Lung cancer screening with low-dose computed tomography in the United States 2010 to JAMA Oncology, 3(9): BAPTIST HEALTH LEXINGTON / 2017 ONCOLOGY ANNUAL REPORT / PAGE 15