Editorial
Residential Radon and Risk of Lung Cancer in Never-Smokers
Radón residencial y riesgo de cáncer de pulmón en nunca fumadores
a Área de Medicina Preventiva y Salud Pública, Universidad de Santiago de Compostela, Santiago de Compostela, La Coruña, Spain
b CIBER de Epidemiología y Salud Pública (CIBERESP), Spain
c Servicio de Neumología, Hospital Álvaro Cunqueiro, Vigo, Pontevedra, Spain
d Servicio de Medicina Preventiva, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, La Coruña, Spain
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Globally, the percentage of total correct answers to multiple choice questions after watching the videos did not statistically improve, although there was a tendency towards improvement. Please refer to the text for more detailed information. *<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.05 (McNemar's exact test) comparison between pre and post videos; <span class="elsevierStyleBold">panel B</span>: evaluation of the video-based lectures. 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This evaluation revealed that video-based lecture #2 was ranked first in terms of pedagogical and teaching quality. White columns show the percentage (%) of votes that each video obtained from the students. Video-based lecture #2 was voted by 65% of the medical students as being the best. This was corroborated by the highest score the concomitant video-based lecture obtained; <span class="elsevierStyleBold">panel C</span>: questionnaire evaluating the value of the project. At the end of the eight video-based lectures, each medical student was asked to fill in a questionnaire composed of the following questions (Q): Q1: Do you find the video-based lecture helpful in the teaching of physiology?; Q2: Do you think the video-based lectures could eventually replace traditional classroom-based courses?; Q3: Do you find the video-based lecture helpful in the preparation of the National Board and Post-graduate Specialty Examinations for accessing medical postgraduate studies? The figure shows that all the recruited medical students (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>20) found the video-based lectures helpful in the teaching of respiratory physiology. Half of the medical students (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>10) thought that the video-based lectures could eventually replace official and traditional classroom-based courses, while 6 students thought the opposite (video-based lectures could never replace traditional classroom-based courses), and 4 students thought that video-based lectures could complement and eventually help elucidate the content covered by traditional classroom-based courses. 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Barros-Dios" "autores" => array:3 [ 0 => array:4 [ "nombre" => "Alberto" "apellidos" => "Ruano-Ravina" "email" => array:1 [ 0 => "alberto.ruano@usc.es" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Alberto" "apellidos" => "Fernández-Villar" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 2 => array:3 [ "nombre" => "Juan M." "apellidos" => "Barros-Dios" "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Área de Medicina Preventiva y Salud Pública, Universidad de Santiago de Compostela, Santiago de Compostela, La Coruña, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "CIBER de Epidemiología y Salud Pública (CIBERESP), Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Neumología, Hospital Álvaro Cunqueiro, Vigo, Pontevedra, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Servicio de Medicina Preventiva, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, La Coruña, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Radón residencial y riesgo de cáncer de pulmón en nunca fumadores" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Scientific evidence suggests that lung cancer (LC) in never-smokers is a different molecular entity to LC in smokers.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">1,2</span></a> The Lung Cancer Risk in Never-Smokers (LCRINS) study, a multicenter case control study competitively funded by the Government of Galicia, began in January 2011. Ten hospitals participated in 3 autonomous communities (Galicia, Asturias, and Madrid). The aim of the study was to determine LC risk factors in never-smokers, looking particularly at residential radon, and the initial results were published in <span class="elsevierStyleSmallCaps">Archivos de Bronconeumología</span> in 2012.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Six years later, this study has recruited more than 400 cases of LC in never-smokers with an equal number of controls, making it an important source of epidemiological data in this subgroup of LC cases. Moreover, the study provides a model that might serve as a basis for other multicenter studies, a highly desirable design in the investigation of rare diseases. The main findings of the LCRINS study, focusing primarily on residential radon, are highlighted and discussed below.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Residential radon is the second most important risk factor for LC after smoking, and the most important in never-smokers.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">4</span></a> Other significant risk factors for LC include certain occupations that involve exposure primarily to asbestos, polycyclic aromatic hydrocarbons (diesel exhaust), silica dust, or heavy metals, and environmental exposure to tobacco. However, only a small proportion of the population is employed in risk occupations (a risk that has decreased since environmental exposure to tobacco smoke among workers in the bar and restaurant sector has been eliminated). Environmental exposure to tobacco smoke is a quantitatively smaller risk than indoor radon, and is less ubiquitous.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Galicia, along with regions of Madrid, Extremadura and Castile-Leon, are areas with high radon concentrations, due to the geological characteristics of the subsoil. Other studies have suggested that the greatest numbers of cases of LC in female never-smokers occurred in the province of Ourense, which may be due to exposure to indoor radon, although this was not measured.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">5</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The World Health Organization sets the action level of radon at 100<span class="elsevierStyleHsp" style=""></span>Bq per cubic meter,<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">4</span></a> while the United States Environmental Protection Agency sets it at 148<span class="elsevierStyleHsp" style=""></span>Bq per cubic meter.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">6</span></a> The action level is understood as the lowest concentration at which radon significantly increases the risk of LC. These risk levels are based on a European study that included over 7000 cases and 14<span class="elsevierStyleHsp" style=""></span>000 controls and revealed a significant linear risk of developing LC due to exposure to residential radon, namely, a 16% increase in risk per 100<span class="elsevierStyleHsp" style=""></span>Bq/m<span class="elsevierStyleSup">3</span> increase in indoor radon concentration.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">7</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Most of the research performed on residential radon before the start of the LCRINS study had included cases of LC in smokers and former smokers. The LCRINS study confirmed that the risk of LC was also greater in never-smokers, and that this risk was significant at concentrations higher than 200<span class="elsevierStyleHsp" style=""></span>Bq per cubic meter<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">8</span></a> compared to the risk in subjects exposed to less than 100<span class="elsevierStyleHsp" style=""></span>Bq per cubic meter (OR: 2.42; 95% CI: 1.45–4.06), indicating that radon is a risk factor for LC. These results suggest that to induce LC, never-smokers must be exposed to higher radon concentrations than smokers. This study also showed evidence of an interaction between residential radon and environmental exposure to tobacco smoke. A detailed analysis of the cases reveals that subjects diagnosed before the age of 60 years were exposed to a higher concentration of residential radon than those diagnosed at older ages, suggesting that exposure to a very high concentration of radon could cause LC to develop earlier.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">9</span></a> Our analysis of histological types showed that residential radon appears to be more closely associated with small cell cancer and other less common histological types, such as large cell LC. Nevertheless, exposure to radon is associated with all histological types of LC in never-smokers.<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">10,11</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The LCRINS study also showed that there may be an association between residential radon and mutations or alterations in LC driver genes. We found no differences in residential radon concentrations between patients with and without EGFR mutations, but we did find close to significant differences in radon exposure in patients with the exon 19 deletion compared to patients with the L858R single-point substitution mutation, who were less exposed to radon (<span class="elsevierStyleItalic">P</span>=.057). We also found that subjects with ALK translocation had almost twice the radon exposure as subjects without ALK translocation, although the results were not significant<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">12</span></a> (the proportion of ALK-positive subjects is low). We will have to wait for the results of future studies to see if these findings are confirmed or not.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Genes conferring sensitivity to LC, such as GSTM1 and GSTT1, seem to modulate exposure to residential radon to a certain extent, and, similar to findings in smokers, studies performed in Galicia and other regions indicate that subjects with any of these gene deletions exposed to the same concentrations of radon had a greater risk of lung cancer.<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">13,14</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">In view of the accumulated evidence, we propose that scales predicting the risk of LC death or incidence should include exposure to radon, in addition to tobacco consumption and the many other variables that are already included, but which do not show the same degree of causal association as seen for residential radon.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">15</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Radon is a risk factor for LC, both in smokers and never-smokers. It should be considered as a cause of LC when this disease is detected in a never-smoker, particularly in areas with high exposure to radon. From a practical point of view, studies such as this highlight the usefulness of multicenter research in respiratory medicine for relatively unusual diseases such as LC in never-smokers or small cell LC, in which we began a similar study in 2015.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0055" class="elsevierStylePara elsevierViewall">The LCRINS study was partially funded by the Government of Galicia (10CSA208057PR). Part of the study was performed with a Fulbright grant for senior researchers awarded to Alberto Ruano Raviña (PRX14/00365). The protocol was approved by the Clinical Research Ethics Committee of Galicia (2010/295).</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">LCRINS investigators</span><p id="par0060" class="elsevierStylePara elsevierViewall">Carmen Montero Martínez (Corunna), Iria Vidal García (Corunna), Olalla Castro Añón (Lugo), Margarita Amenedo (Corunna), Antonio Golpe Gómez (Santiago), Francisco J González Barcala (Santiago), Isaura Parente Lamelas (Ourense), José Abal Arca (Ourense), Ángeles Rodríguez (Pontevedra), María Torres-Durán (Vigo), Virginia Leiro Fernández (Vigo), Mariano Provencio Pulla (Majadahonda), Rosirys Guzmán Taveras (Oviedo), Cristina Martínez (Oviedo) y María José Mejuto Martí (Ferrol).</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Funding" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "LCRINS investigators" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Ruano-Ravina A, Fernández-Villar A, Barros-Dios JM. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 6 | 2 | 8 |
| 2024 October | 49 | 22 | 71 |
| 2024 September | 54 | 15 | 69 |
| 2024 August | 72 | 40 | 112 |
| 2024 July | 44 | 27 | 71 |
| 2024 June | 59 | 36 | 95 |
| 2024 May | 101 | 30 | 131 |
| 2024 April | 64 | 33 | 97 |
| 2024 March | 63 | 22 | 85 |
| 2024 February | 59 | 21 | 80 |
| 2023 May | 1 | 0 | 1 |
| 2023 March | 12 | 3 | 15 |
| 2023 February | 55 | 27 | 82 |
| 2023 January | 36 | 28 | 64 |
| 2022 December | 86 | 32 | 118 |
| 2022 November | 72 | 23 | 95 |
| 2022 October | 81 | 57 | 138 |
| 2022 September | 48 | 31 | 79 |
| 2022 August | 40 | 47 | 87 |
| 2022 July | 32 | 42 | 74 |
| 2022 June | 38 | 42 | 80 |
| 2022 May | 55 | 35 | 90 |
| 2022 April | 44 | 38 | 82 |
| 2022 March | 54 | 45 | 99 |
| 2022 February | 45 | 36 | 81 |
| 2022 January | 66 | 45 | 111 |
| 2021 December | 58 | 53 | 111 |
| 2021 November | 55 | 45 | 100 |
| 2021 October | 51 | 56 | 107 |
| 2021 September | 43 | 48 | 91 |
| 2021 August | 46 | 41 | 87 |
| 2021 July | 53 | 34 | 87 |
| 2021 June | 42 | 39 | 81 |
| 2021 May | 45 | 48 | 93 |
| 2021 April | 125 | 123 | 248 |
| 2021 March | 67 | 29 | 96 |
| 2021 February | 31 | 22 | 53 |
| 2021 January | 55 | 20 | 75 |
| 2020 December | 45 | 21 | 66 |
| 2020 November | 42 | 24 | 66 |
| 2020 October | 40 | 16 | 56 |
| 2020 September | 34 | 14 | 48 |
| 2020 August | 33 | 13 | 46 |
| 2020 July | 32 | 26 | 58 |
| 2020 June | 23 | 13 | 36 |
| 2020 May | 30 | 17 | 47 |
| 2020 April | 42 | 24 | 66 |
| 2020 March | 18 | 13 | 31 |
| 2020 February | 34 | 17 | 51 |
| 2020 January | 33 | 18 | 51 |
| 2019 December | 43 | 16 | 59 |
| 2019 November | 40 | 20 | 60 |
| 2019 October | 22 | 13 | 35 |
| 2019 September | 19 | 9 | 28 |
| 2019 August | 31 | 22 | 53 |
| 2019 July | 29 | 19 | 48 |
| 2019 June | 23 | 10 | 33 |
| 2019 May | 30 | 18 | 48 |
| 2019 April | 294 | 31 | 325 |
| 2019 March | 35 | 19 | 54 |
| 2019 February | 39 | 28 | 67 |
| 2019 January | 24 | 28 | 52 |
| 2018 December | 34 | 33 | 67 |
| 2018 November | 58 | 19 | 77 |
| 2018 October | 85 | 37 | 122 |
| 2018 September | 45 | 12 | 57 |
| 2018 May | 41 | 5 | 46 |
| 2018 April | 24 | 12 | 36 |
| 2018 March | 36 | 16 | 52 |
| 2018 February | 56 | 19 | 75 |
| 2018 January | 69 | 23 | 92 |
| 2017 December | 77 | 26 | 103 |
| 2017 October | 1 | 0 | 1 |
| 2017 August | 1 | 0 | 1 |
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