Radioprotection 2019, 54(4), 303–307© SFRP, 2019https://doi.org/10.1051/radiopro/2019036

Available online at:www.radioprotection.org

ARTICLE

The fitness to work certificate in a worker exposed to ionizingradiation with an oncological disease: criteria and assessmentprocess

G. Taino1, E. Oddone1,2,*, G. Corona3, R. Foti2 and M. Imbriani1,2

1 Istituti Scientifici Maugeri IRCCS, Hospital Occupational Medicine Unit (UOOML), Institute of Pavia, Pavia, Italy.2 Department of Public Health, Experimental and Forensic Medicine, University of Pavia, Pavia, Italy.3 University Hospital, Modena, Italy.

Received: 6 May 2019 / Accepted: 12 September 2019

*Correspon

Abstract – To assess the fitness to work certificate i

n employees both affected by neoplasia and exposed toionizing radiation always represents a clinical and professional issue, as well as human and social. The aimof our study is to analyze the case of a 40-year-old clinician (woman, endoscopist, gastroenterologist) whounderwent left mastectomy and breast reconstruction with a tissue expander, professionally exposed toionizing radiation. Due to the presence of the BRCA1 gene mutation and the presence of breast and ovariancancer familiarity, the patient also underwent a prophylactic right mastectomy and bilateral oophorectomy.According to Italian legislation and international guidelines, several elements and criteria have been takeninto account to release the fitness to work certificate in this peculiar case of a female worker exposed toionizing radiation, resulting in a final positive indication.

Keywords: fitness to work / occupational exposure / cancer / radiation protection

1 Introduction

The ageing of working populations has many epidemio-logical consequences, including an increased incidence ofneoplastic diseases among several categories of workers. Thus,it is more frequent than in the past that the Approved Physician(i.e. the clinician licensed to carry out the health surveillance ofworkers exposed to ionizing radiation, “Autorizzato” accord-ing to Italian legislation definition) has to judge working fitnessin employees suffering from cancer and at the same time areexposed to ionizing sources. These lasts have been observed toincrease the risk of secondary cancer in different clinicalsituations, such as for instance in patients treated forhepatocellular carcinoma (Kim et al., 2014), and thus theuse of ionizing radiation has to be justified, optimized, andlimited (Giraud et al., 2009).

The assessment of the fitness to work certificate inemployees both affected by neoplasia and exposed to ionizingradiation always represents a clinical issue, as well as humanand social. For the occupational physician this process couldbe a challenging and delicate professional task (Taino et al.,2014; Malesani and Guglielmi, 2017). Our aim is to describethe process and conclusions of an exemplary case of a femaleworker who underwent left mastectomy, a prophylactic right

ding author: enrico.oddone@unipv.it

mastectomy and bilateral oophorectomy, who successivelywanted to return to work in a task professionally exposed toionizing radiation.

2 Materials and methods

According both to AIRM (Italian Society of MedicalRadioprotection) guidelines (AIRM, 2013) and to results ofprevious studies (Taino et al., 2014; Malesani and Guglielmi,2017), several elements have to be considered to carefullyanalyze a specific case in order to evaluate the assessment offitness in workers affected by neoplastic disease whose job taskinduces an exposure to ionizing radiation. Four different areashave been taken into considerations (Taino et al., 2014), andtheir features are presented in the following.

2.1 Characteristics of the neoplastic disease

–

Time since the neoplasia has elapsed from clinical onset(< 5 years or >= 5 years);

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neoplasia target organ; – histological type, degree of differentiation and TNMstaging of the neoplasm;

–

oncological prognostic judgment (probability of recoveryor recurrence at 5 years) after the ascertained clinical andinstrumental remission of the disease;

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–

rank of the neoplasm within the radioinducibility scale; – evaluation of the causal probability by using the“Probability of Causation” (PC) method.

This first partial judgment can be either favorable or notfavorable.

2.2 Health condition of the worker

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Presence of any coexisting diseases not directly related tocancer that can affect the overall health of the worker and/or influence the outcome or the ongoing recovery of treatedneoplastic disease;

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evidence of any previous chemo or radiation treatment thatcan make non-significant (or, conversely, counter indicate)an occupational exposure to ionizing radiation;

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worker psychological condition, important for identifyingan alternative work placement without risk from ionizingradiation, also suitable for the employee qualification;

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evaluation of worker qualification, his contract positionand career, and also the worker’s will regarding hisoccupational future.

This second partial judgment can be either favorable or notfavorable.

2.3 Work activities and tasks carried out by theworker

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Analysis of the work tasks performed within the specifictask, analysis of the prevention and protection measures inplace, risk extent in standard working conditions and inpotential exposure situations following an accidentalevent;

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radiation protection classification performed by thequalified expert (not exposed, B category, A category);

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type of potential exposure: partial external irradiation,global external irradiation, possible internal contamination(specific organs or apparatuses affected by possible internalcontamination);

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use of individual protection devices to avoid the exposureof the area of the previous neoplasm (for example thepossibility of using a suitable “collar” for thyroidprotection).

This third partial judgment can be either favorable or notfavorable.

2.4 Legislation and indications from the guidelines

Ministerial decree 2001 No. 488 lists a series ofphysiopathological conditions that although they do notexclude the fitness to work, they represent a case that mustbe assessed with particular attention by the physician duringthe health surveillance (ItalianMinistry of Health, 2011). ICRP103: the International Commission on Radiological Protectionapproved in 2007 new recommendations which replace theprevious ones (1991). In particular, the present recommenda-tions update the radiation and tissue weighting factors in the

quantities equivalent and effective dose and update theradiation detriment (ICRP, 2007). International Atomic EnergyAgency (IAEA, 2004) provide three guidelines: one containsrecommendations on professional radiation exposure con-ditions for which monitoring is required, both for the risk ofintroduction of radionuclides and for the risk of externalirradiation. Particularly, with reference to the subject of ourdiscussion, the document states that: “there is no reason whyemployees who have undergone radiotherapy have to beexcluded from work. Each worker must be evaluatedindividually, considering the type of treatment, the prognosisand other considerations related to health, will of the workerand type of work” (IAEA, 2004).

The explained elements of judgment (AIRM, 2013; Tainoet al., 2014), if analyzed and applied to the individual case,could represent a useful help for the elaboration of a suitabilityjudgment.

3 Case description

We analyzed the case of a 40-year-old doctor, endoscopistgastroenterologist, professionally exposed (category A) toionizing radiation, subjected to left mastectomy for an invasiveductal carcinoma [G3 pT1c (1.4 cm), N0M0] and breastreconstruction with a tissue expander. Due to the presence ofthe BRCA1 gene mutation and the presence of breast andovarian cancer familiarity, the patient was subjected to aprophylactic right mastectomy and bilateral oophorectomy(Finch et al., 2006; Rebbeck et al., 2009). In this clinical case,the criteria and the groups of elements of judgment proposed inthe scientific literature were considered (Tubiana, 2005;AIRM, 2013; Taino et al., 2014): characteristics of neoplasia;general condition of the worker; characteristics of the work atrisk; law references and guidelines on this subject.

The evaluation of the Probability of Causation (PC) wasnot considered, due to the low values of cumulative dose forthe total life-exposure of the worker.

At the end of the evaluation pathway (Appendix A) basedon the instructions found in the literature and explained also inthe Personal Health Record (PHR), the employee was judgedsuitable for the work of endoscopist gastroenterologist, activityto which she dedicated (and wished to dedicate) her entireworking life.

4 Discussion

Judging the fitness to work of an employee affected bycancer to perform work tasks at risk from ionizing radiation isvery complex and is always discussed between two extremeopinions, which are still acceptable today. One position issupported by many authors and by the ICRP (2007): thepotential occupational exposure to levels below the thresholdlimit for the workers exposed to ionizing radiation isconsidered as such, even in those with previous oncologicaldisease, not to be able to introduce a significant additional riskfactor of cancer, also considering the “bottom” of the so-called“spontaneous” or “natural” tumors. The other position (alsosupported by many authors (NCRP, 2001) and “prudentially”acceptable for the purposes of radioprotection), starting fromthe hypothesis of non-existence of a threshold dose for the

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induction of the phenomenon of carcinogenesis, supports thatis not possible guaranteeing a minimum level of acceptablerisk in people with negative-influencing pathologies in theirevolution from exposure to ionizing radiations.

Based on the analysis and study of the 4 groups ofelements of judgment proposed, it was possible to express, atthe end of the evaluation and decision-making process, afavorable final judgment regarding the fitness to work at riskof ionizing radiation, subject to a series of assessmentconditions and prescriptions that the current knowledge ofmedical physics and the latest technical acquisitions allow toimplement through a proactive and multidisciplinarycollaboration among the figures involved in prevention inthe workplace: occupational physician, “qualified expert”(medical physicist) and employer. The expression of anoverall favorable final judgment requires the positiveoutcome in the evaluation process of at least two of thefirst three groups of elements of judgment (concerning theneoplastic disease, the worker’s psycho-physical conditionsand the characteristics of the work at risk). The finaljudgment, after completing the purely medical and technicalanalysis, is then evaluated with respect to the normativeprovisions and scientific indications.

Regarding the factors related to the neoplasia, it should benoted that, if the Probability of Causation calculation (PC),based on the cumulated dose by total exposure, induces thehypothesis that the neoplasia is radio-induced, the physicianshould consider the possibility of further worker’s exposureto ionizing radiation, because, having already received asignificant dose, the observed neoplasia could be the first butnot the only one (AIRM, 2013). In the case of a positivecalculation of the probability of causation (PC), it will also bedesirable to proceed according to the law (Italian Law, 2005;Taino et al., 2017), the AIRM guidelines (AIRM, 2013) andthe criteria also present in the literature (Taino et al., 2013) tothe reporting of suspected professional origin. In theevaluation process, we considered the primary role thatshould be attributed to the psychological conditions of theworker (IAEA, 2004; Taino et al., 2014) compared to thecontinuation of a work activity with potential radiologicalrisk, as well as professional interest and career opportunitiesplaced by the worker in the work at risk. Today, more andmore frequently, there is the problem of the possibility andplausibility of ethics and legislation (not yet foreseen), inselected cases and in which the final overall opinion isfavorable, to propose an explicit consent signed by the workerto carry out work at risk. In relation to the psychologicalcondition of the worker, we always consider equally the factthat the work activity, beyond the economic and professionalaspects, represents in many cases for the worker a realpossibility of return to the “normal” life previously carriedout and a real form of “escape” from the concerns and thetherapeutic and follow-up constraints that the neoplasticdisease has involved or still requires. Let us not forget, in fact,that for the WHO the state of health of a person is not only theabsence of illness, but also a state of complete physical,psychological and social well-being.

5 Conclusion

According to Italian legislation and international guide-lines, several elements and criteria have been taken intoaccount to release the fitness to work certificate in this peculiarcase of female worker exposed to ionizing radiation, resultingin a final positive indication.

References

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Finch A et al. 2006. Salpingo-oophorectomy and the risk of ovarian,fallopian tube, and peritoneal cancer in women with BRCA1 orBRCA2 mutation. JAMA. 296: 185–192.

Giraud P, Henni M, Cosset JM. 2009. Risks of irradiation inhepatogastroenterology. Presse Med. 38(11): 1680–9 (French).

IAEA. 2004. Occupational radiation protection in the mining andprocessing of raw materials. Safety Standards Series. SpecificSafety Guides No. RS-G-1.6.

ICRP Publication 103. 2007. The 2007 Recommendations of theInternational Commission on Radiological Protection. Ann. ICRP.37(2-4).

Italian law 230/2005. 2005. Available from http://www.camera.it/parlam/leggi/05230l.htm.

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Appendix A Evaluation form and criteria used for the formulation of the fitness judgment.

Appendix A (Continued)

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Cite this article as: Taino G, Oddone E, Corona G, Foti R, Imbriani M. 2019. The fitness to work certificate in a worker exposed to ionizingradiation with an oncological disease: criteria and assessment process. Radioprotection 54(4): 303–307