See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/49793204

Current Safety Practices Relating to I-131 Administration for Diseases of the

Thyroid: A Survey of Physicians and Allied Practitioners

Article in Thyroid: official journal of the American Thyroid Association · February 2011
DOI: 10.1089/thy.2010.0090 · Source: PubMed

CITATIONS READS

27 2,117

6 authors, including:

Lynn Burmeister Charlotte H Edinboro

University of Minnesota Twin Cities Exponent
65 PUBLICATIONS 2,591 CITATIONS 33 PUBLICATIONS 847 CITATIONS

SEE PROFILE SEE PROFILE

All content following this page was uploaded by Charlotte H Edinboro on 30 May 2014.

The user has requested enhancement of the downloaded file.

THYROID THYROID RADIOLOGY AND NUCLEAR MEDICINE
Volume 21, Number 2, 2011
ª Mary Ann Liebert, Inc.
DOI: 10.1089/thy.2010.0090

Current Safety Practices Relating to I-131 Administration

for Diseases of the Thyroid: A Survey of Physicians
and Allied Practitioners

Carol Greenlee,1 Lynn A. Burmeister,2 Robert S. Butler,3 Charlotte H. Edinboro,4 Shannon McIntyre Morrison,3
and Mira Milas;5 The American Thyroid Association Radiation Safety Precautions Survey Task Force

Background: There is little information about the individual safety instructions provided by healthcare pro-
fessionals to patients receiving radioactive iodine (I-131) therapy for the treatment of benign and malignant
thyroid disorders or about whether these instructions are consistent across medical specialties. Currently, no
national guidelines exist to standardize safety instructions related to I-131 administration. Here, we examine the
spectrum of I-131 safety practices in contemporary use.
Methods: Members of major societies of physicians and allied specialists who treat patients with thyroid dis-
orders were invited to complete a 27-question online survey about safety practices related to I-131 adminis-
tration. Data from questionnaires were analyzed by type of safety recommendation and grouped according to
provider specialty and geographic location.
Results: A total of 311 endocrinologists, surgeons, nuclear medicine radiologists, and allied health professionals
completed questionnaires. They indicated that patients often receive instruction from more than one treating
specialist. The decision to hospitalize a patient for treatment and the length of stay were determined by the
patient’s social situation and the dose of I-131 administered. Starting at I-131 doses between 259 and 1073 MBq (7
and 29 mCi), over 60% of respondents advised avoiding contact with children, sexual activity, and breastfeeding,
with the latter recommendation continuing beyond 48 hours after treatment. Personal hygiene, laundry, and
meal preparation precautions varied across respondents. Over 90% of respondents used serum or urine testing
to screen for pregnancy status. Precautions to delay parenthood were given more often to female than male
patients (90% vs. 60%), with a minimum recommended delay of 6 months. About 20% of respondents consid-
ered insurance coverage as a factor in selecting outpatient versus inpatient I-131 therapy, and this consideration
varied geographically.
Conclusion: A wide variety of safety recommendations are given to patients who receive I-131. To our
knowledge, this survey represents the first organized inquiry into safety practices related to I-131 administration.
The diversity of responses suggests an opportunity for multispecialty collaboration in defining more uniform
recommendations for patient safety instructions during and after I-131 treatment.

Introduction in the safety precautions recommended by the ATA com-

mittee members to patients receiving I-131. Precautions var-

I n 2006, the American Thyroid Association (ATA)

prepared a Position Commentary in response to a challenge
to the U.S. Nuclear Regulatory Commission’s guidelines for
ied from very minimal to very rigorous procedures, the choice
of which appeared to be based on tradition, local regulations,
level of personal concern, and payers’ acceptance or denial of
public safety regarding exposure to patients treated with ra- certain procedures. A survey was conducted to identify the
dioactive iodine (I-131) (1). During the preparation of that safety advice most commonly provided to patients and to
commentary, it became apparent that great diversity existed quantify the differences among current practices.

1
Western Slope Endocrinology, Grand Junction, Colorado.
2
Division of Endocrinology and Diabetes, University of Minnesota, Minneapolis, Minnesota.
3
Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio.
4
Health Sciences Group, Exponent, Inc., Menlo Park, California.
5
Department of Endocrine Surgery, Endocrinology and Metabolism Institute, Cleveland Clinic, Cleveland, Ohio.

151
152 GREENLEE ET AL.

The primary objective of the survey was to elicit informa- Medicine and the American Society for Therapeutic Radi-
tion concerning recommendations for I-131 safety protocols ology and Oncology, but, to our awareness, was not distrib-
for patients treated for hyperthyroidism, goiter, and thyroid uted further. A link to the survey was placed on the Web sites
cancer. A secondary objective was to identify differences in of The Endocrine Society and the American Association of
recommendations due to geographical location or profes- Clinical Endocrinologists. The survey was hosted by Survey-
sional association. The overall goal was to obtain a measure of Monkey.com, an online firm providing questionnaire
clinical safety practices related to I-131 treatment. To our services, including construction, hosting, and spreadsheet
knowledge, this is the first survey of its kind to capture con- summaries of responses. The responses were collected and
temporary clinical practices. Our hypothesis was that these maintained anonymously. Duplicate entries or incomplete
practices vary widely with clinician specialty. In reporting responses were screened and excluded on the basis of Internet
existing practices, we proposed to determine whether these Protocol addresses as a quality control measure. Not all re-
practices illustrate a need for the development of a common spondents answered every question, and some respondents
set of safety precaution recommendations to be provided to provided answers more than once. In these cases, only the first
patients, their families, and caregivers following I-131 ther- response attributable to an Internet Protocol address was in-
apy, because these are lacking in published literature (2–8). cluded in the analysis. If respondents chose more than one
answer for dosing questions, only the lowest dosage chosen
was counted. If ‘‘Do Not Advise’’ was selected, only that re-
Methods
sponse was counted. For some analyses, the respondents were
The questionnaire was developed by the members of divided into subsets based on role. Specifically, the data
the ATA Clinical Affairs and Public Health Committees with summarized in Tables 5 and 6 provide the responses of those
input from other ATA committees and individual mem- practitioners who administer or supervise the treatment of
bers. The survey consisted of 27 questions across a range of I-131, as the respondents who indicated that they only refer
topics, including participant demographics, safety protocols, patients for therapy did not elect to complete the question-
screening practices, procreation, consent forms, insurance is- naire on these topics to allow subset-to-subset comparisons.
sues, and precautions for isolation, human contact, and hy- Also, under each heading of the Results section, any subset
giene. Respondents were also invited to submit additional analysis according to a provider’s role is addressed directly in
general comments, and their personal or institutional example the context of the topic being presented.
of patient instructions for I-131 treatment. A summary of the Because the questionnaire was designed to quantify current
questionnaire is provided in Figure 1 and the questionnaire is practices, the focus of this survey was on the identification,
included as supplementary data S1 (Supplementary Data are rather than a critical evaluation, of differences. To this end, the
available online at www.liebertonline.com/thy). statistics provided in the tables were limited to simple counts
The questionnaire was included as a hyperlink in an e-mail and percentages relative to the total number of responses for
message to ATA members and to members of the American each question. Also, as noted in the Discussion section, be-
Association of Endocrine Surgeons, who were encouraged to cause the distribution of the survey was to a broad audience of
forward this e-mail to their colleagues. The survey was diverse specialists, it was not possible to quantify a response
also presented to the leadership of the Society of Nuclear rate as a percentage of any specific denominator. At the time

FIG. 1. Contents of the American Thyroid Association (ATA) I-131 safety recommendations survey.
I-131 CURRENT PRACTICES SURVEY 153

of survey distribution, there were 1300 members in ATA, 311 nologist from each of the geographic locations outside of
members in American Association of Endocrine Surgeons, North America (South America, Europe, Middle East, and
14,000 members in The Endocrine Society, and 6000 American Asia) provided a response; not all of these locations were re-
Association of Clinical Endocrinologists members. It was not presented in the group of surgeons and nuclear medicine
known how many clinicians are members of multiple orga- physicians. Professional affiliations identified by study par-
nizations. In addition, some members of each society are en- ticipants reflected their specialties, and many respondents,
gaged in basic research, in nonthyroidal fields (e.g., diabetes), particularly endocrinologists, were members of multiple as-
or may not prescribe or be licensed to administer I-131. As sociations (Table 2).
no single organization or professional group exists whose
membership deals exclusively with clinical practice using I- Nature of experience with I-131 treatment
131, estimating an appropriate denominator was not feasible.
Regardless of specialty, most respondents (75%, 219/293)
were involved in radioiodine treatment, between 10 and 100
Results
patients annually (Table 3). However, the personal adminis-
A total of 311 individuals participated in the survey. The tration or supervision of I-131 for hyperthyroidism, goiter, or
number of patients treated annually with I-131 was be- thyroid cancer varied depending on physician specialty.
tween 10 and 100 for the majority of respondents (219/311, Nearly all (93%) of the nuclear medicine physicians and 70%
70%), with an additional 46 specialists (15%) treating >100 of RSOs stated that they administered or supervised admin-
patients annually. Half of the respondents (156/311, 50%) istration of I-131 for hyperthyroidism, goiter, or thyroid can-
indicated that they personally administer and supervise the cer, whereas only 50% of the endocrinologists and 10% of the
I-131 treatment. Most (207/311, 67%) also designated that surgeons did so.
they themselves provided safety precautions related to I-131
therapy. Responses to questions contingent on the specialty Safety instructions pertaining to isolation,
of the practitioner administering or supervising I-131 therapy human contact, and hygiene
were analyzed for only those respondents who identified
Providers of safety instructions. Responses to the ques-
themselves by group, so that the advice tabulated reflected
tion regarding the source of safety instructions for the patient
opinions within each treating specialty, rather than that of all
and family members revealed that the patients received in-
specialists who refer patients for I-131 therapy.
structions from a variety of sources and often from more than
one source. The majority of endocrinologists (85%) provided
Demographic profile of the survey respondents
instruction personally and/or within their practices, but 79%
The majority of respondents (260/311, 84%) identified also believed that safety instruction was given to patients in
themselves as physicians and 51 (16%) were nonphysicians. the nuclear medicine department. In contrast, only 42% of
Medical specialties represented by the study respondents in- surgeons provided instruction personally, which may not be
cluded endocrinologists (195, 63%), surgeons (31, 10%), nu- surprising, given that 100% of the surgeons indicated such
clear medicine physicians (27, 9%), and a minority of others instruction was provided in the nuclear medicine department
(radiation oncology 2, pediatrics 3, unspecified 10). The ma- and 90% of surgeons identified their role as referring, rather
jority of physicians (62%, 161/260) were affiliated with uni- than directly treating, patients with I-131. Similar to the en-
versities. In contrast, the majority of radiation safety officers docrinologists, a high proportion of nuclear medicine physi-
(RSOs) were based in private practice (25/39, 66%). Non- cians provided instructions either personally or within their
physician respondents consisted primarily of RSOs (39, 13%) nuclear medicine department (21/27, 78%), with an addi-
and rarely of nurse practitioners (1) and radiation safety tional 37% (10/27) expecting further patient guidance from
program coordinators (1). RSO. The responses from RSOs revealed that 72% (28/39)
Most respondents (252/301, 84%; 10 did not specify coun- provided safety instruction to patients within their depart-
try of origin) were from North America, and 97% of the RSOs ments, and 74% of RSOs anticipated that radiation safety in-
were from the United States (Table 1). At least one endocri- struction would also be provided by the nuclear medicine

Table 1. Geographic Locations of 311 Respondents Participating in the American Thyroid

Association Survey of I-131 Safety Recommendations

Endocrinologist Nuclear medicine Surgeon RSO Other

Geographic area n % n % n % n % n %

North America
United States 148 76 19 70 25 81 38 97 7 70
Canada 6 3 2 7.5 0 0 0 0 0 0
Mexico 5 3 2 7.5 0 0 0 0 0 0
Othera 35 18 4 15 6 19 1 3 3 30
Totalb 194 27 31 39 10
a
The category ‘‘Other’’ included South America, Europe, Middle East, and Asia.
b
All respondents did not answer every question; 10 respondents did not state a country of origin.
RSO, radiation safety officer.
154 GREENLEE ET AL.

Table 2. Professional Association Affiliations of 311 Respondents Participating in the American

Thyroid Association Survey of I-131 Safety Recommendations

Endocrinologist Nuclear medicine Surgeon RSO Other

Professional association n % n % n % n % n %

American Thyroid Association 116 60 6 22 11 36 0 0 3 30

American Association of Clinical Endocrinologists 130 67 0 0 13 42 0 0 2 20
The Endocrine Society 156 80 1 4 5 16 0 0 4 40
American Association of Endocrine Surgeons 0 0 0 0 26 84 0 0 0 0
Society of Nuclear Medicine 6 3 26 96 0 0 10 26 1 10
American Society for Therapeutic Radiology and Oncology 1 0.5 1 4 0 0 3 8 1 10
Other professional association 34 17 6 22 6 19 34 87 1 10
Total number of physiciansa 194 27 31 39 10
a
All respondents did not answer every question; 10 respondents did not state professional association.
n, number of physicians who indicated they were members of the association in question.

department. Of practitioners who indicated that, in their at dose 1147–3663 MBq [31–99 mCi]; 20% at dose 3700–
clinical setting, more than one specialist provides safety in- 7363 MBq [100–199 mCi]; 30% at dose 7400–11,063 MBq [200–
structions to patients and their family members, the majority 299 mCi]; 32% at dose >11,100 MBq [ > 300 mCi]). However,
perceived that the recommendations from these sources were across all dose ranges, specialists frequently stated that the
comparable (Table 4). The proportion of those who indicated decision to hospitalize depended on the social situation; the
that recommendations were comparable, however, varied ATA questionnaire did not elaborate on what defines social
according to specialty type (Table 4A) and whether the situations in these circumstances, and neither did the re-
practitioner administers I-131 treatment (Table 4B). Of note, spondents. Likewise, for those recommending hospitalization
3%–11% indicated that recommendations were not compa- for doses over 3700 MBq (100 mCi), the length of stay was
rable, up to 16% did not know whether they were comparable, dependent on patient radioactivity measurements, according
and up to 45% provided written comments that could not be to 30% of respondents.
readily categorized, but rather expressed broadly what the Recommendations for quarantine at home showed the fol-
specialists do in their practice. lowing patterns: quarantine at home was never recom-
mended by 51% of respondents for I-131 doses 1110 MBq
Isolation precautions. To ascertain isolation precautions (30 mCi) and by 34% administering doses between 1147 and
for radioiodine treatment, survey questions asked were at 3663 MBq (31–99 mCi). For respondents who recommended
what dose and for how long patients were required to be that patients stay at home following treatment, the amount of
hospitalized, quarantined at home, and/or to stay at a hotel. time recommended for staying at home increased progres-
One-quarter (23%) of respondents indicated that they did sively from <1 day to 72 hours, as the dose of radioiodine
not use doses in the range between 7400 and 11,063 MBq (200– increased beyond 7400 MBq (200 mCi).
299 mCi), and 50% indicated that they did not use a dose of Recommendations for a hotel stay to avoid contaminating
11,100 MBq (300 mCi) I-131 or higher. At or below 1110 MBq the home were rarely made: over 80% of respondents never
(30 mCi), 72/104 (69%) of the respondents stated they never recommended a hotel stay for dose ranges below 11,063 MBq
hospitalize their patients (Fig. 2). At higher I-131 doses, pro- (299 mCi). This was corroborated by several questions that
portionally fewer specialists never hospitalize (28% at dose incorporated a choice for hotel stay.
1147–3663 MBq [31–99 mCi]; 15% at dose 3700–7363 MBq
[100–199 mCi]; 6% at dose 7400–11,063 MBq [200–299 mCi]). Human contact precautions. Ten questions focused on
Similarly, the percentage of specialists who specified a dura- recommendations about human contact distance precautions
tion of hospital stay increased with increasing doses of ad- following radioiodine treatment, with duration options of 24,
ministered I-131 (5% at doses <1110 MBq [ <30 mCi]; 19% 24–48, or >48 hours after I-131 therapy. Responses indicated

Table 3. Numbers of Patients Treated or Referred for I-131 Treatment by 311 Respondents Participating
in the American Thyroid Association Survey of I-131 Safety Recommendations

<10 10–100 >100

Physician type n % n % n % Totala

Endocrinologist 14 7 152 79 26 14 192

Nuclear medicine 2 7 15 56 10 37 27
Surgeon 4 13 27 87 0 0 31
Radiation safety officer 5 14 21 58 10 28 36
Other 3 43 4 57 0 0 7
a
All respondents did not answer every question: 293 of 311 responded to this question.
I-131 CURRENT PRACTICES SURVEY 155

Table 4. Responses to the Question ‘‘Are Safety Recommendations from Multiple Sources Comparable?’’
by 311 Respondents Participating in the American Thyroid Association Survey
of I-131 Safety Recommendations
(A) Responses Grouped by Specialty

Yes No Don’t know Other

Physician type n % n % n % n % Totala

Endocrinologist 123 77 10 6 13 8 14 9 160

Nuclear medicine 15 88 1 6 1 6 0 0 17
Surgeon 10 50 1 5 0 0 9 45 20
Radiation safety officer 24 86 3 11 0 0 1 3 28
Other 5 72 0 0 1 14 1 14 7
a
All respondents did not answer every question: 232 of 311 responded to this question.

(B) Responses Grouped by Whether Practitioner Administers or Supervises I-131 Treatment

Yes No Don’t know Other

Role in I-131 treatment n % n % n % n % Totala

Does not administer or supervise I-131 treatment 73 69 11 10 17 16 5 5 106

Administers or supervises I-131 treatment 97 83 4 3 7 6 9 8 117
a
All respondents did not answer every question: 223 of 311 responded to this question.

that there was little to no difference in the recommended Half of the respondents (49/106, 46%) recommended avoid-
precautions as the time from I-131 treatment increased (Table 5 ing public transportation following doses of radioiodine
provides responses for the first 24-hour interval). <1110 MBq (<30 mCi).
Most respondents (84/105, 80%) recommended avoiding Half of the respondents recommended the same precau-
children under age 2 for the first 24 hours following treatment, tions for the first 48 hours following treatment as for the first
beginning at doses of radioiodine <1110 MBq (<30 mCi). A 24 hours after treatment. Except for breastfeeding, contact
further 12% recommended this avoidance for all doses at or precautions beyond 48 hours were deemed to be unnecessary
above 1110 MBq (30 mCi). In addition, starting at the lowest by two to three times as many respondents as in the earlier
dose range of 259–1073 MBq (7–29 mCi), over 60% of re- hours following treatment. Half of the respondents continued
spondents recommended avoiding children under age 10 to recommend avoidance of breastfeeding on the third day
years, sexual contact, and breastfeeding. They also advised posttreatment (over 48 hours).
sleeping alone, maintaining a specific distance from people, At all time points, over 80% of respondents stated that they
and maintaining specific time/distance exposures, that is, the did not advise the patients to stay in a hotel and did not
length of time a person could spend within a certain distance recommend potassium iodide (KI) for family members.
from a treated patient. Our questionnaire did not elicit what
those time/distance instructions were for each respondent. Hygiene precautions. Eight questions involved hygiene
precautions following radioiodine treatment, including rec-
ommendations regarding laundry and dental habits as well as
food preparation. Fewer respondents indicated that they offer
advice on toothbrush disposal and use of gloves for food
preparation, compared with other precaution categories.
The hygiene precautions listed in Table 6 summarize pro-
vider advice for the first 48 hours after any level of I-131
treatment. The percentage of respondents who recommended
any one of the eight hygiene precautions was greater, by
margins of 1.3 or more, for those who actually administer or
supervise I-131 treatment, compared with any other practi-
tioners. Approximately half of those who offered hygiene
precautions in the first 24 hours following treatment did not
continue these precautions beyond 48 hours for patients
who had received I-131 in the dose range of 259–1073 MBq
FIG. 2. Type of isolation precautions according to treat- (7–29 mCi).
ment dose of I-131. The recommendation for hospitalization
includes any length of hospital stay. Dose of I-131 expressed Precautions relating to reproduction
in MBq are as follows: 1110 MBq (30 mCi); 1147–3663 MBq
(31–99 mCi); 3700–7363 MBq (100–199 mCi); and 7400– Pregnancy screening practices. Most respondents (151/
11,063 MBq (200–299 mCi). 168, 90%) indicated that they always screen for pregnancy
156 GREENLEE ET AL.

Table 5. Recommended Human Contact Precautions for the First 24 Hours After I-131 Treatment Provided
by 311 Respondents Participating in the American Thyroid Association Survey of I-131 Safety Recommendations

All doses All doses All doses

259–1073 MBq 1110 MBq 3700 MBq 7400 MBq Do not
Recommendation na (7–29 mCi) (30 mCi) (100 mCi) (200 mCi) advise

Avoid public transport? 106 49 (46.2%) 34 (32%) 10 (9.4%) 1 (1%) 12 (11.3%)

Avoid children
<Age 2? 105 84 (80%) 19 (18%) 0 (0%) 1 (1%) 1 (1%)
Ages 2–10? 103 69 (67%) 24 (23%) 3 (3%) 1 (1%) 6 (6%)
Maintain a specific distance 103 64 (62%) 23 (22%) 7 (7%) 1 (1%) 8 (8%)
with people?
Maintain a specific time/distance 103 68 (66%) 17 (17%) 7 (7%) 2 (2%) 9 (9%)
exposure?b
Stay in a hotel? 91 4 (4%) 6 (5%) 2 (2%) 3 (3%) 77 (85%)
Sleep alone? 104 64 (62%) 22 (21%) 10 (10%) 3 (3%) 5 (5%)
Avoid sexual contact? 101 69 (68%) 17 (17%) 7 (7%) 2 (2%) 6 (6%)
Avoid breast feeding? 89 58 (65%) 6 (7%) 0 (0%) 1 (1%) 24 (27%)
Recommend KI for family members? 94 0 (0%) 4 (4%) 1 (1%) 0 (0%) 89 (95%)

All respondents did not answer every question, and respondents could select multiple answers among the recommendations. If
respondents chose multiple dosages, only the lowest dosage selected was counted. If ‘‘do not advise’’ was selected, only that response was
counted. For example, most respondents (84/105, 80%) recommended avoiding children under age 2 for the first 24 hours following
treatment, beginning at doses of radioiodine between 259 and 1073 MBq (7–29 mCi). Another 18% recommended this avoidance start for all
doses at or above 1110 MBq (30 mCi).
a
Includes only respondents who answered yes (n ¼ 156 of 311, 50%) to the question ‘‘Do you administer or supervise administration of
I-131 for hyperthyroidism, goiter, or thyroid cancer?’’ All others were excluded (no ¼ 132, 42%; other ¼ 12, 4%; no response ¼ 11, 4%).
b
Defined as a specified length of time during which a person was within a certain distance from a treated patient.
KI, potassium iodide.

before giving I-131, with few doing this only sometimes (16, nancy tests (8/11, 73%). Few respondents (3.6%) accepted
9.5%); one respondent never did. Exclusion criteria for written consent of nonpregnancy status and few also (3.6%)
screening for pregnancy included hysterectomy (165/207, accepted verbal report of nonpregnancy.
80%) and self-report of celibacy (7.2%). In response to an The time between performing pregnancy screening and the
open-ended question regarding pregnancy screening, a few administration of I-131 was reported to be within 24 hours by
respondents answered that they also did not screen for 41% (82/198) and within 48 hours by 27% (53/198) of re-
pregnancy if the patient was clearly postmenopausal or over spondents. Few respondents (21/198, 11%) indicated that
age 55. they treated on the same day the pregnancy test was admin-
Pregnancy screening was primarily accomplished with a istered.
pregnancy test (179/194, 92%). Serum pregnancy tests were
most commonly employed by endocrinologists (111/156, Timing of parenthood after I-131. Only a subset of re-
71%), nuclear medicine physicians (14/16, 88%), and RSOs spondents who reported administering or supervising ad-
(15/23, 65%). Surgeons primarily reported using urine preg- ministration of I-131 treatment answered questions relating to

Table 6. Recommended Hygiene Precautions for the First 48 Hours After I-131 Treatment Provided by 311
Respondents Participating in the American Thyroid Association Survey of I-131 Safety Recommendations

All doses All doses All doses

259–1073 MBq 1110 MBq 3700 MBq 7400 MBq Do not
Recommendation na (7–29 mCi) (30 mCi) (100 mCi) (200 mCi) advise

Wash hands frequently? 102 72 (71%) 11 (11%) 3 (3%) 1 (1%) 15 (15%)

Dispose of toothbrush? 98 30 (31%) 13 (13%) 3 (3%) 1 (1%) 51 (52%)
Wash clothes/bedding separate from family? 101 56 (55%) 20 (20%) 7 (7%) 1 (1%) 17 (17%)
Wash dishes separate from family? 100 53 (53%) 18 (18%) 6 (6%) 1 (1%) 22 (22%)
Do not make food for other people? 98 50 (51%) 19 (19%) 7 (7%) 1 (1%) 21 (21%)
Wear gloves to prepare food? 92 23 (25%) 14 (15%) 4 (4%) 1 (1%) 50 (54%)
Sit to void urine and always flush twice? 95 78 (82%) 19 (11%) 4 (4%) 1 (1%) 2 (2%)
Special precautions if emesis/incontinence occur? 103 69 (67%) 16 (16%) 3 (3%) 1 (1%) 14 (14%)

All respondents did not answer every question, and respondents could select multiple answers among the recommendations. If
respondents chose multiple dosages, only the lowest dosage selected was counted. If ‘‘do not advise’’ was selected, only that response was
counted.
a
Includes only respondents who answered yes (n ¼ 156 of 311, 50%) to the question ‘‘Do you administer or supervise administration of
I-131 for hyperthyroidism, goiter, or thyroid cancer?’’ All others were excluded (no ¼ 132, 42%; other ¼ 12, 4%; no response ¼ 11, 4%).
I-131 CURRENT PRACTICES SURVEY 157

Table 7. Recommended Delay Time Before Pregnancy Following I-131 Treatment Provided by 311
Respondents Participating in the American Thyroid Association Survey of I-131 Safety Recommendations

1110 MBq 1147–3663 MBq 3700–7363 MBq 7400–11,063 MBq 11,100 MBq
Recommendation (30 mCi) (31–99 mCi) (100–199 mCi) (200–299 mCi) (300 mCi)

Respondents (n)a 108 106 106 94 89

1 month 3 (3%) 3 (3%) 1 (1%) 1 (1%) 0 (0)
3 months 14 (13%) 8 (8%) 9 (8%) 7 (7%) 7 (8%)
6 months 57 (53%) 57 (54%) 50 (47%) 36 (38%) 32 (40%)
12 months 20 (19%) 32 (30%) 40 (38%) 41 (44%) 40 (45%)
No routine recommendation 14 (13%) 6 (6%) 6 (6%) 9 (10%) 10 (11%)
a
All respondents did not answer every question.

recommendations restricting procreation after radioiodine practitioners. The impact of insurance coverage in the United
administration (108/156, 69%; Table 7). Of these respondents, States varied by geographical region (Fig. 4), with those
fewer provided responses to the questions regarding high- practicing in southern and western states responding that
dose-range treatments. The majority of respondents re- payer insurance had more influence on choices of inpatient
commended that female patients who received doses below versus outpatient I-131 care. The survey was not structured to
7400 MBq (200 mCi) wait a minimum of 6 months before at- identify other outcomes related to insurance coverage.
tempting pregnancy and at least 1 year for higher doses. At
least one-third of these respondents did not make recom- Other geographical and specialty-based variations
mendations to their male patients regarding delay times be- in I-131 precautions
fore fathering children (Table 8). When recommendations
Although no comprehensive pattern of differences emerged
were made, these were more often to wait for 6 months. The
about I-131 safety recommendations, practice patterns varied
proportion of respondents who chose to recommend a 12-
somewhat across specialty affiliations and geographic loca-
month delay until pregnancy increased incrementally as the
tions. Consent forms were more likely to be used by physi-
dose of I-131 treatment increased (e.g., 19% recommended
cians in the United States (72% vs. 38% for all other countries)
this for I-131 dose <1110 MBq [ <30 mCi], 38% for doses be-
and by nuclear medicine radiologists (88%) and RSOs (91%)
tween 3700 and 7363 MBq [100–199 mCi], and 45% for doses
than endocrinologists and surgeons (58% each). Nuclear
at or above 11,100 MBq [300 mCi], as shown in Table 7).
medicine physicians were more than twice as likely to provide
specific recommendations to male patients about delaying
Use of consent forms
child-bearing and more likely to advise a longer duration of
More than half (66%) of respondents stated that they use delay at each of the I-131 dose ranges than were endocrinol-
consent forms for I-131 administration (Fig. 3). Most consent ogists. This difference in recommendations between special-
forms provided information on pregnancy and breastfeeding ists did not exist for female patients and for either gender of
avoidance. Information on risk to salivary glands was also patients among those practicing within compared with out-
present on most consent forms. side the United States.

Impact of payer status or insurance coverage Discussion

on I-131 precautions
This is a unique multidisciplinary survey that addressed
The influence of insurance coverage on outpatient versus the topic of safety-related information provided to patients
inpatient care was felt to be a factor in decisions by 17% (26/ receiving I-131 treatment for thyroid disorders. It queried
155) of the United States and 20% (7/35) of non-United States how various professionals convey I-131 safety precautions at

Table 8. Recommended Delay Time Before Fathering Children Following I-131 Treatment Provided by 311
Respondents Participating in the American Thyroid Association Survey of I-131 Safety Recommendations

1110 MBq 1147–3663 MBq 3700–7363 MBq 7400–11,063 MBq 11,100 MBq
Recommendation (30 mCi) (31–99 mCi) (100–199 mCi) (200–299 mCi) (300 mCi)

Respondents (n)a 108 106 68 96 91

1 month 6 (6%) 2 (2%) 2 (3%) 2 (2%) 2 (2%)
3 months 14 (13%) 16 (15%) 13 (19%) 10 (10%) 8 (8%)
6 months 36 (33%) 36 (34%) 36 (53%) 30 (31%) 29 (32%)
12 months 8 (7%) 13 (12%) 17 (25%) 17 (18%) 15 (16%)
No routine recommendation 44 (41%) 39 (37%) 38 (56%) 37 (39%) 37 (40%)
a
All respondents did not answer every question.
158 GREENLEE ET AL.

mendations exist nationally among the various professionals

involved in the therapeutic administration of I-131. Our
analysis showed that most survey respondents provided little
consistency in practice patterns and radiation safety recom-
mendations from various sources, suggesting the potential for
patient and staff confusion. It may seem reasonable to expect
that, as the surgeons’ responses imply, all instruction ulti-
mately resides with a nuclear medicine department. But
clearly, neither the nuclear medicine radiologists nor the RSO
responders indicated that this actually occurs. Our question-
naire was not structured to confirm who ultimately does
provide such safety instruction.
An area of significant concern to patients receiving I-131
therapy is the site where that treatment will occur. Our sur-
vey showed that hospitalization was rarely recommended for
I-131 doses 1110 MBq (30 mCi). Hospitalization recom-
mendations were also influenced by the type of insurance
coverage and varied by geographic region within the United
States. For the dose range 1147–7363 MBq (31–199 mCi), the
recommendation to hospitalize was a function of patient ra-
dioactivity measurement and/or social situations, although
the survey did not inquire further about the specific thresh-
olds of radioactivity measurement or examples of social sit-
uations that prompt the recommendation to hospitalize
following I-131 treatment.
Another broad topic of concern to patients and providers
FIG. 3. Use and composition of consent forms for I-131 alike is the scope of contact precautions after I-131 treatment.
treatment. The types of recommendations reported included avoiding
children under age 10 years and sexual contact for the first
3 days following treatment, sleeping alone, maintaining a
a level of detail that, to our knowledge, had not been ac- specific distance from people, and limiting time spent with
complished in prior surveys or from predominantly the Uni- others. More respondents recommended contact precautions
ted States-based clinicians. Only few reports related to I-131 during the first 24 and 48 hours posttreatment than at 3 days
safety practices exist in the literature, some conducted in following I-131 treatment. Avoidance of public transportation
Europe with more limited scope of questions, smaller re- was most commonly recommended only for the first 24 hours
spondent numbers, and less multidisciplinary breadth (9,10). after treatment. Only 70% of respondents who provided
Based on the survey responses, our hypothesis was not re- safety precautions provided information to their patients re-
jected: I-131 safety practices do indeed vary widely. Radiation garding delaying starting a family. Recommendations rela-
safety instruction is presently available from a variety of tive to timing for future conception were given more often and
sources, and patients often receive information from more had more consistent precautions when treating women than
than one source. In this study, we confirmed the perception men. These patterns suggest a real need for defining more
from prior work (2,11,12) that notable differences in recom- consistent and clear recommendations for radiation safety
precautions. Such recommendations have the potential to
streamline the educational obligations of providers of I-131
treatment, enhance patient understanding, and reduce patient
anxiety related to daily activities following I-131 treatment.
Regardless of the administered radioiodine dose level,
staying in a hotel was not recommended by the vast majority
of respondents. This was determined through two questions,
one inquiring about the dose at which a hotel stay was re-
commended to avoid home contamination and the second
through the option of answering ‘‘staying in a hotel’’ as part of
human contact precautions; the majority of respondents in-
dicated that they did not advise this step. There is currently no
known policy for accommodating such patients that is stated
by the American Hotel and Lodging Association (13) and,
from anecdotal experiences described during the survey, no
mechanism for hotel management to be made aware that a
patient with recent I-131 treatment is a guest.
FIG. 4. Proportion of specialists who indicated that insur- Several limitations of the study can be identified. Re-
ance status influenced outpatient versus inpatient therapy spondents were self-selected, based on survey access and
with I-131. motivation to respond. Responses reflected the individual
I-131 CURRENT PRACTICES SURVEY 159

practices of respondents, which may not necessarily represent References

practices of other practitioners involved in radioiodine ad-
1. National Council on Radiation Protection and Measure-
ministration. These survey responses may also not represent
ments 2006 Management of Radionuclide Therapy Patients.
best practices for such treatment. We acknowledge that our NCRP Report No. 155. National Council on Radiation Pro-
study, similar to other online surveys, cannot provide an ac- tection and Measurements, Bethesda, MD.
curate total denominator of individuals who received the 2. Sparks RB, Siegel JA, Wahl RL 1998 The need for better
questionnaire but did not complete or return it. The enormous methods to determine release criteria for patients adminis-
membership rosters of the societies that received this ques- tered radioactive material. Health Phys 75:385–388.
tionnaire preclude this calculation and also make it cumber- 3. Grigsby PW, Siegel BA, Baker S, Eichling JO 2000 Radiation
some to model nonresponse bias in our study. This is the first exposure from outpatient radioactive iodine (131I) therapy
survey of its kind, with over 300 respondents from a variety of for thyroid carcinoma. JAMA 283:2272–2274.
disciplines, reflecting the interest and the reality of multidis- 4. Barrington SF, O’Doherty MJ, Kettle AG, Thomson WH,
ciplinary involvement with I-131 treatment. The study pro- Mountford PJ, Burrell DN, Farrell RJ, Batchelor S, Seed P,
vides a cross-sectional view of the I-131 safety instructions in Harding LK 1999 Radiation exposure of the families of
use today, with enough responses to reflect the wide variation outpatients treated with radioiodine (iodine-131) for hyper-
in I-131 safety practices. Although the study addressed dose thyroidism. Eur J Nucl Med 26:686–692.
ranges for radioiodine, no distinction was made between 5. Carey JL, Kumpuris TM, Wrobel MC 1995 Release of
treatments for hyperthyroidism, goiter, or thyroid cancer. patients containing therapeutic dosages of iodine-131 from
We did not inquire about recommendations beyond 3 days hospitals. J Nucl Med Technol 23:144–149.
posttreatment, and it is possible that recommendations 6. Ibis E, Wilson CR, Collier BD, Akansel G, Isitman AT, Yoss
RG 1992 Iodine-131 contamination from thyroid cancer pa-
against breastfeeding would extend beyond that time as a
tients. J Nucl Med 33:2110–2115.
function of higher treatment dose. Menopause and age were
7. Barrington SF, Anderson P, Kettle AG, Gadd R, Thomson
not options provided in the pregnancy screening exclusion
WH, Batchelor S, Mountford PJ, Harding LK, O’Doherty MJ
question, so it is possible these answers were underrepre-
2008 Measurement of the internal dose to families of out-
sented. We also noted that answers to questions involving patients treated with (131)I for hyperthyroidism. Eur J Nucl
dose ranges typically yielded fewer responses for the higher Med Mol Imaging 35:2097–2104.
dose ranges than the lower ranges, perhaps because respon- 8. Thomson WH, Harding LK 1995 Radiation protection issues
dents assumed their answers involving lower doses extended associated with nuclear medicine out-patients. Nucl Med
to the higher doses. A potential weakness of the question re- Commun 16:879–892.
garding staying at home was that it did not differentiate be- 9. Vaidya B, Williams GR, Abraham P, Pearce SH 2008
tween I-131 dose for outpatient treatment versus inpatient Radioiodine treatment for benign thyroid disorders: results
treatment (during which time, elimination and decay of ra- of a nationwide survey of UK endocrinologists. Clin En-
dioisotope was expected during hospitalization). To better docrinol 68:814–820.
define isolation practices in any future study, it would be 10. Monsieurs M, Thierens H, Dierckx RA, Casier K, De Baere E,
helpful to specify such details. De Ridder L, De Saedeleer C, De Winter H, Lippens M, van
In conclusion, we conducted a survey of groups of self- Imschoot S, Wulfrank D, Simons M 1998 Real-life radiation
selected respondents involved in the administration of ther- burden to relatives of patients treated with iodine-131: a
apeutic I-131. We observed a wide range of safety practices study in eight centres in Flanders (Belgium). Eur J Nucl Med
and recommendations and the perception of conflicting in- 25:1368–1376.
formation offered to patients. These differences may reflect a 11. Woodings S 2004 Radiation protection recommendations for
lack of best practices based on scientific data. Guidelines re- I-131 thyrotoxicosis, thyroid cancer and phaeochromocyto-
ma patients. Australas Phys Eng Sci Med 27:118–128.
flecting expert opinion, evidence-based decision-making, and
12. Dietlein M, Troche CJ, Moka D, Bausch V, Lauterbacj KW,
further investigation would be useful, and our survey results
Schicha H 1998 Consequences of new patient discharge
may provide an opportunity to stimulate development of
guidelines on the cost structure of radioiodine therapy.
such recommendations.
Nuklearmedizin 37:33–40.
13. American Hotel and Lodging Association. Available at
Acknowledgments www.ahla.com/. Accessed October 26, 2010.
The authors acknowledge the 2006–2009 American Thyr-
oid Association Clinical Affairs Committee, Public Health
Committee, and Radioactive Iodine Best Practices Task Force Address correspondence to:
members and administrative staff for their contributions. Carol Greenlee, M.D.
Western Slope Endocrinology
Disclosure Statement 603 28 1/2 Road
Grand Junction, CO 81505
The authors declare that no competing financial interests
exist. E-mail: mcgreenlee@bresnan.net

(Appendix follows ?)
 160 GREENLEE ET AL.

Appendix: American Thyroid Association I-131 also select that they do not advise a particular precaution and
Safety Recommendations Questionnaire submit a write-in comment.
1. What type of professional are you? (endocrinologist, 13. What human contact precautions do you advise on
nuclear medicine physician, radiation oncologist, sur- day 1 (first 24 hours) following I-131 treatment?
geon, pediatrician, internist, family practitioner, nurse 14. What human contact precautions do you advise on
practitioner, physician’s assistant, other-please speci- day 2 (24–48 hours) following I-131 treatment?
fy) 15. What human contact precautions do you advise on
2. Which professional associations do you belong to? day 3 and beyond (over 48 hours) following I-131
(American Thyroid Association, American Association treatment?
of Clinical Endocrinologists, The Endocrine Society,
For questions 16–18, respondents were asked to indicate what
American Association of Endocrine Surgeons, Society of
hygiene precautions were made for each of the dose ranges
Nuclear Medicine, American Society of Therapeutic
specified above for questions 10–12. The types of precautions
Radiology and Oncology, other-please specify)
queried included the following: cleanliness: wash hands fre-
3. In what state/country do you practice?
quently; cleanliness: dispose of toothbrush; cleanliness: wash
4. Do you refer patients with hyperthyroidism, goiter, or
bedding and clothes separate from family; cleanliness: wash
thyroid cancer to receive radioactive iodine? (yes/no/
dishes separate from family; food preparation: don’t make
other)
food for other people; food preparation: wear gloves to pre-
5. Do you administer or supervise administration of I-131
pare food; toilet use: sit to void urine and always flush twice;
for hyperthyroidism, goiter, or thyroid cancer? (yes/
waste/emesis clean-up. Respondents could also select that
no/other)
they do not advise a particular precaution and submit a write-
6. Please select the setting that you practice in? (academ-
in comment.
ic/university environment, ‘‘pure’’ private practice,
private practice with adjunct university appointment, 16. What hygiene precautions do you advise on day 1
other-please specify) (first 24 hours) following I-131 treatment?
7. How many patients a year do you treat with I-131 or 17. What hygiene precautions do you advise on day 2 (24–
refer for I-131 treatment? (<10, 10–100, >100) 48 hours) following I-131 treatment?
8. Who provides the safety instructions to the patient/ 18. What hygiene precautions do you advise on day 3 and
family? Check all that apply. (me/my practice, nuclear beyond (over 48 hours) following I-131 treatment?
medicine department, radiation safety department, 19. Do you screen for pregnancy before giving I-131 to
other-please specify) women? (always, sometimes, never, other-please
9. If you marked more than one in Q8, are the recom- specify)
mendations/instructions comparable? (yes/no/don’t 20. After screening for pregnancy, how much time before
know/other-please specify) giving I-131 treatment? (24 hours, 48 hours, other-
please specify)
For questions 10–12, the questions were posed in tabular form
21. What exclusions do you allow for not screening in
with the following I-131 dose ranges each having these an-
women of childbearing age? (hysterectomy, self-report
swer choices: hospitalized 24 hours, hospitalized 48 hours,
of celibacy, no exclusions, other-please specify)
hospitalized 72 hours, dependent on patient radioactivity
22. What tests do you use? (serum pregnancy test, urine
measurement, do not use this dose, never hospitalize, de-
pregnancy test)
pends on social situation, other. A space was also made
23. Which do you require? (pregnancy test results, written
available for write-in comments.
consent of no pregnancy, verbal report of no preg-
I-131 dose ranges were 1110 MBq (30 mCi), 1147–
nancy, none, other-please specify)
3663 MBq (31–99 mCi), 3700–7363 MBq (100–199 mCi), 7400–
11,063 MBq (200–200 mCi), 11,100 MBq (300 mCi).
For questions 24–25, respondents were asked to indicate how
10. At what doses do you hospitalize? long after I-131 to avoid child reproduction, for each of the
11. At what doses do you recommend a stay in a hotel to doses specified above for questions 10–12. The answer selec-
avoid contamination of home? tions included 1 month, 3 months, 6 months, 12 months, or
12. At what doses do you recommend that the patient stay that no routine recommendation was provided.
at home after treatment or after release from the hos-
24. How long do you recommend that female patient
pital as an inpatient?
avoid pregnancy after I-131 treatment?
For questions 13–15, respondents were asked to indicate what 25. How long do you recommend that male patients avoid
human contact precautions were made for each of the dose fathering a child?
ranges specified above for questions 10–12. The types of 26. Do you use a consent form (yes/no)? If yes, does it
precautions queried included the following: avoid public contain information about avoidance of pregnancy
transportation, avoid children under 2 years old, avoid chil- (yes/no), breast feeding (yes/no), risk of malignancy
dren 2–10 years old, stay in hotel, sleep alone, avoid sexual (yes/no), risk to salivary glands (yes/no), other
contact, maintain specific distance with people, maintain (please specify)?
specific time/distance exposure, breast feeding, use of po- 27. Does insurance affect choice of outpatient versus in-
tassium iodide to protect family members. Respondents could patient care? (yes/no/other-please specify)

View publication stats