Risk of Cancer among Firefighters

Abstract

This proposal recommends that research be performed to determine whether firefighters are at increased risk for developing cancer and affirms that scientific evidence gathered through testing should devote a better understanding of the potential risk factors that concede to a firefighter developing cancer. The research shows there are numerous routes of exposure, such as chemical, radio frequency radiation, materials in different training scenarios, types of building construction, and even personal protective clothing that pose as a threat to firefighters. This research project suggests the need for further analysis on the risk of exposure to carcinogens and the need to develop better personal protective equipment. This documentation also suggests the need for changing the laws and procedures concerning workman’s compensation for exposures.

RISK OF CANCER AMONG FIREFIGHTERS

Introduction

Firefighters are considered by many to be America’s heroes. After all, they are running into burning buildings while everyone else is running out. Most people think that firefighters are only at risk of the dangers related to fire. However, firefighters face many other dangers, including, but not limited to, the chance of being run over, being in a building when it collapses, being exposed to dangerous chemicals, being shot, or being assaulted. David Millen (2009) stated, “Firefighting personnel experience stress each day in their work settings. Their ability to cope with stress affects their capacity to function effectively in emergency situations.” One must also take into consideration the health factors: stress, post-traumatic stress disorder (PTSD), depression, heart disease, suicide and cancer. Heart disease was once considered to cause the highest mortality rate among firefighters, but numerous studies both nationally and internationally have shown a remarkable interconnection between firefighters and the risk of developing different types of cancer.

Forty-five-year-old Kentucky firefighter Chris Miller, was diagnosed with lymphoma 10 years ago. He took four months off work, after spending six weeks in the hospital, received chemo causing him to lose 60 pounds, and to had go to rehab. In 2008, Keith Tyson retired after 34 years of firefighting in Miami when doctors found an aggressive form of cancer in his prostate. He explained that almost a third of his department has had some form of cancer in the past three years (Khazan, 2015).

According to the International Association of Fire Fighters (IAFF) (2015), about 60 percent of career firefighters will die “with their boots off,” because of cancer. The phase “with their boots off,” signifies when the firefighter dies somewhere other than on the scene of an emergency.   “The IAFF attributes 31 line-of-duty deaths (LODD) to cancer between 1993 and 2003. That number increased to 298 over the following decade among officers younger than 60” (Ujhely, 2015). These numbers may lower than the actual amount due too not have an adequate firefighter cancer registry that is linked to each state’s cancer registry databases. Each state is required to have a cancer registry but does not ask the occupation of the person being added to it.

The first study that revealed a higher incidence of cancer in firefighters was published in 1992. The participants were firefighters from Toronto, Canada. Although the study was originally undertaken to track cardiovascular disease, its greater impact was associated with the findings concerning firefighters and cancer” (Nelson, 2014). This study was originally performed to focus  on the number of cardiac related instances that have taken a toll on firefighter. As research was being performed, the researcher quickly realized the growing concern of the number of firefighters that developed cancer while on the job.

Grace LeMasters Ph.D., Professor of epidemiology at the University of Cincinnati, states: “Pinpointing the cause of cancer is extremely difficult because firefighters are not exposed to just one agent. They are exposed to multiple cancer- causing agents. Because of the multiple exposures and multiple routes of exposure – they inhale carcinogens and carcinogens are absorbed through the skin – it is also highly unlikely for firefighters to get only one type of cancer” (LeMasters, et al, 2006).

Often the firefighter does not even know they had an exposure, because there can be a latency period of 20 years or longer for some malignancies. Certain types of cancer may develop into a life-threatening illness faster than other types of cancer.

Research Statement

The research project that is being proposed will examine the risk of cancer among firefighters. It will identify certain causes of cancer such as carcinogens, radiations, contaminants, toxic fumes and chemicals. The risk of not knowing what may be waiting for them the next time the tone, signal that lets the fire department know they have a call, goes off for their next call leads to added stress and an increased chance of illness. Thus, raising the question, should the risk of developing cancer due to occupational exposure be considered as a work-related illness or injury for firefighters? The project will reveal different routes of potential exposure.

The importance of research in the risk of cancer in firefighters is needed for a better understanding of how this could possibly happen. The research will help give more insight of the types of cancer that a firefighter may develop. In addition, the research will specify certain precautions that a firefighter may take to help minimize the risk of cancer while on the job. As with any assignment, there may be complications. One of the obstacles standing in the way is the limited amount of information available. Also, certain websites may not be containing peer-reviewed articles, or it is lacking credibility, making some of the information not very reliable and scrutiny of the data will need to be taken to determine if the information is accurate.

Methodology

The research will be conducted using the University of South Alabama Library’s academic databases. Sage Journal, PUBMED, Wiley Online Library, EBSCO, WEBMED Central, Springer Link, Google Scholar, ERIC and SCOPUS were a few of the databases that were used to obtain reliable articles for this research. These databases offer a wide array of academic journals, peer review articles, and books that will be beneficial for the gathering of information. An example of the academic articles includes: Potential Health Effects Associated with Dermal Exposure to Occupational Chemicals (2014); Persistent organic pollutants including polychlorinated and polybrominated dibenzo-p-dioxins and dibenzofurans in firefighters from Northern California (2013); and (1992). Occupational Health Concerns of Firefighting (2013).

Some of the resources, or official documents, came from professional based websites that reference several of the academic journals and articles previously mentioned within this research project. Web based articles are from professional associations or organizations related to the fire service, such as International Association of Fire Fighters and International Association of Fire Chiefs. The magazine articles are from sources, such as Firehouse magazine and Fire Engineer magazine which offered a significant amount of data used in the research. Additionally, some of the data is from personal experiences that firefighters have encountered over the years of service.

The type of research that will be provided for this project will consist of a mixed method research. Mixed method research involves the mixing of quantitative and qualitative methods or other paradigm characteristics. Both the quantitative and qualitative methods of research will help to uncover large quantities of valuable data that is related to the research question. The quantitative research will provide statistical facts about the topic, while the qualitative research provides the bulk of the necessary data for the project. Also, some of the paradigm characteristics will come from the personal experience of firefighters. The use of this information will help provide more knowledge as to why the risk of cancer should be considered as an occupational hazard for firefighters. Therefore, allowing for the need to change workers compensation laws and medical benefits to the firefighters who have work related exposures without having to prove the origination at a specific fire.

Literature Review

Research concerning the risk factors of a firefighter developing cancer is somewhat limited, yet what has been found has had a great impact on the understanding of the different routes of exposure, namely the types of cancer, and the potential contaminants.  Most people think that firefighters are only at risk of the dangers of fire imposes on them. Since the attacks on the Oklahoma City Federal Building bombing and the World Trade Center (WTC) terrorist attack, fire departments have seen the effects of stress on firefighters which contributes to life changing response to physical and psychological stressors, such as anxiety, PTSD, depression, heart disease, suicide and cancer. Some people argue, with all that protective equipment, it’s not possible for a firefighter to get cancer, yet there are numerous routes of exposure that include chemicals, flame retardants, radios-frequency radiation, occupational exposure and even personal protective clothing that pose as a threat to firefighters.

Are Firefighters on the Frontline for Chemical Exposure?

According to the U. S. Environmental Protection Agency (2015), there are over 80,000 chemicals in use today, most of which are unregulated “Firefighters are on the front line of toxic chemical exposures, which has resulted in a disproportionate number of firefighters getting sick from diseases linked to chemical exposure” (Study Could Reduce, 2015). Due to the nature of certain chemicals like benzene, benzidine, dioxins, asbestos and formaldehyde that are being added to every day household items. Some of these items may include but be limited to sofas, mattresses, carpets, and vinyl. The probability of exposure to numerous carcinogens through various routes is highly likely and may occur simultaneously (Youakim, 2006).  These routes may include, but limited to, inhalation, absorption, ingestion, or even injection. The same items that make people’s lives comfortable, cozy, and convenient are manufactured with synthetic materials that create a noxious toxic smoke when burned. (See Table 6).

Smoke from fire contains numerous amounts of gases and vapors are extremely hazardous. “Firefighters are potentially exposed to countless numbers of gaseous and vaporous agents and also particles during the suppression of a fire. Chemical asphyxiants, such as carbon monoxide, hydrogen cyanide, and hydrogen sulfide, have been found to cause acute symptoms” (Laitinen, et al, 2012).  Large number of carcinogens remain within the air long after the fire is extinguished. Synthetic material may cause hundreds of times the amount of smoke than organic items from a century ago (Khazan, 2015). The darker or blacker the smoke appears; the more toxins are being burned off. These toxins become embedded on anything they encounter. Often settling in the lungs of those who breath them in.

Houses are being built out of wood that is soaked in chemical baths containing benzene and formaldehyde. According to the research literature, these carcinogens are the leading causes of the main types of cancer that were studied (Youakim, 2006). Timothy Rebbeck – Professor at Dana-Farber Cancer Institute and Harvard School of Public Health, stated, “Every substance, when it burns, changes its chemical structure, particularly when you burn something that’s synthetic or man-made, you’re creating strange compounds that we don’t know what they’ll do” (Khazan, 2015). This ultimately increases the potential threat of exposure, because the firefighter truly in unaware of every chemical, toxin or carcinogen that they encounter while battling any structure fire.

A study was conducted by Susan Shaw, a professor at State University of New York, in 2012 where firefighters had their blood drawn immediately following a fire. The firefighters blood contained two times the amount of perfluorinate chemicals as those who responded to the World Trade Center. Perfluorinate chemicals are commonly used as a non-stick coating agent. Their blood also contained three times the amount of flame retardants, for example chlorinated Tris, as found in the general population (Shaw, et al, 2013).

Do Firefighters Face Dermal Exposure?

The skin is the largest organ of the body and is composed of two layers, first being the epidermis. The epidermis is a thin, highly hydrophobic layer that provides a protective barrier. The second layer, dermis, is a thicker layer that contains sweat glands, hair follicles, blood vessels and nerves.  Dermal exposure is viewed purely in terms of percutaneous uptake of chemicals and occurs in a variety of occupations, such as farming, manufacturing and firefighting (Semple, 2004). There are three types of chemical-skin interaction of any dermal exposure. (See Table 4).

“First, the chemical may pass through the skin and contribute to the systemic load. Second, the chemical can induce local effects ranging from irritation through burns or degradation of the barrier properties of the skin. Lastly, the chemical can evoke allergic reactions through complex immune system response that can subsequently trigger responses in the skin at both the point of contact and at skin sites remote to the contact” (Semple, 2004).

According to the Bureau of Labor Statistics (BLS) in 2012, occupational skin exposures accounted for 34,400 cases of illnesses compared to 19,300 cases of respiratory illnesses which resulted in decreased productivity, increased medical expenses, and increased loss of work at the cost in excess of one billion dollars in the United States alone (Anderson, et al, 2014). When a person has a weakened immune system, the risk of developing cancer increases. When a chemical exposure is added to the dermal layer of the skin, it increases the odds of developing cancer dramatically. Unlike inhalation exposure there are no occupational exposure limits (OELs) for dermal exposure. “Pesticides, solvents and polycyclic aromatic hydrocarbons (PAHs) are some of the main chemical groups that have been recognized as posing health problems by dermal absorption” (Semple, 2004). Solvents are known to be toxic to several organs, such as the kidneys, the liver, and the nervous system, and may cause dizziness, nausea, vomiting, and irreversible damage to the central nervous system.

Gloves and protective clothing offer limited protection for dermal exposure when a firefighter encounters chemicals or carcinogens and often offer a false sense of security. (See Table 5). “With every five degrees that body temperature rises, skin absorption rates increase by as much as four-hundred percent” (Khazan, 2015). As soon as firefighters put on the gear, the psychological and physical demands of firefighter’s body increase along with the skin temperature and the rate of absorption.

Can Flame Retardants be Harmful?

Flame retardants (FRs) are used to reduce the catastrophic effects of fire on people, property and the environment. FRs work to delay the fire from spreading depending on their chemical makeup and interact in different stages of the fire cycle. FRs are used in a wide array of household products for instance rubber, textile coatings, resins, and polyurethane foams. The FRs are naturally released gradually into the environment as the product ages but are released more rapidly if the product is damaged by fire (Killilea, et al, 2017).  In a recent study the flame-retardant chemical, chlorinated Tris, was found in the blood and urine of fifteen of sixteen nonsmoking adults tested for the study (Ortiz, 2015).  Flame retardants are also on the personal protective clothing firefighters, welders, refinery workers wear on a daily basis.

Halogenated phosphate trimester tris (1,3-dichloro propyl) phosphate (TDCCP), is the leading flame-resistant chemical used in household products, has been found at a rate of >2ppm in household dust, and has also been found in high quantities in breast milk, adipose tissue, semen and urine (Killilea, et al, 2017). These chemicals are connected to adverse developmental, reproductive and carcinogen consequences. “The home environment is a major exposure area because those with the highest level of carcinogenic flame retardants in their urine also had high concentration of the retardant in dust in their homes” (Ortiz, 2015). The discovery of higher concentrations of TDCCP, has led to further research of breast, kidney, bladder, prostate, renal, and endocrine cancers in firefighters (Killilea, et al, 2017). “Evidence of chlorinated Tris is seen as especially problematic. The chemical was used to treat children’s pajamas, but its use for that purpose was discontinued in the 1970s after it was determined that it caused DNA mutations and posed a risk for cancer” (Ortiz, 2015).

Many household furnishing such as mattresses, couches, and recliners are made with flame retardant chemicals applied to the upholstery and the foam padding to help protect home owner in case of a fire. Although FRs can contribute to the disruption of the fire cycle, they pose a very high risk of carcinogen exposure to the home resident as well as the firefighters. Furniture can be made without adding flame retardant chemicals. Thus, when a person is buying new furniture, they should ask for it without the flame retardant.

How is Radio-Frequency Radiation a Possibility?

Firefighters also face the risk of developing radio-frequency radiation (RFR) exposure and electromagnetic field (EMF) exposure due to the use of two-way mobile communication radios that are found in the fire stations, fire trucks, and carried on each firefighter (Milham, 2009). Male and female firefighters are at higher risk for developing breast cancer due to increased exposure to RFR (Milham, 2009). This is partially because of the lapel microphone-speaker that is attached to the radio. The firefighter carries his radio on his belt which exposes him to a many RFR and EMF which can lead to various types of cancer, such as kidney, lung, pancreatic, liver, and intestinal.

“The upward turn of malignant melanoma incidence has been ecologically linked to the roll out of television and frequency modulation radio transmission in the 1950s with increased RFR exposure of populations” (Milham, 2009). Often police officers are exposed to various types of radio-frequency exposure do to holding a hand-help radar system in their lap. This puts them at a higher risk of developing bladder and testicular cancer. According to a 2003 National Institute of Occupational Safety and Health (NIOSH) report, the use of radios has shown an increase in RFR amongst firefighters. (Firefighters Radio Communication, 2003).

What are Some Occupational Exposures Firefighters Face?

Firefighters have been studied for evidence of chronic health effects considerably since the 1980s. Throughout their careers, firefighters perform numerous types of rescue work, along with the historical changes in firefighting activities, and the availability and use of personal protective equipment, all result in a wide range of exposures encountered by firefighters as a group (Youakim, 2006).

The New York City Fire Department (FDNY) experienced the danger first hand on September 11, 2001 with a terrorist attack on the World Trade Center (WTC). An extended study took place over several years with health information records of nearly 12,500 firefighters (See Table 2) from before and after the attacks (Zeig-Owens, et al, 2011). The study showed that the firefighters were exposed to aerosolized dust, lead, asbestos, pulverized cement, polycyclic aromatic hydrocarbons, dioxins, burning jet fuel, and diesel fuel. This analysis gathered information from numerous medical facilities and studied both ever-smoker, someone who is a smoker, and never-smoker, someone who has never smoked, candidates (Zeig-Owens, et al, 2011).

The field-work shows a consistency among different models that WTC-exposed firefighters have a higher cancer incident ratio than non-exposed firefighters (Zeig-Owens, et al, 2011). “An association between WTC exposure and cancer is biologically plausible, because some contaminants in the WTC dust, such as polycyclic aromatic hydrocarbons, polychlorinated biphenyls, and dioxins are known carcinogens. Although some contaminants could cause sickness directly, WTC exposure could also trigger chronic inflammation, through microbial infections, autoimmune diseases, or other inflammatory disorders, all of which have been reported as factors in oncogenesis, both experimentally and epidemiologically” (Zeig-Owens, et al, 2011). Many different types of cancer can lay dormant for many years and can affect the firefighter long after they were initially exposed.

Many studies highlight the mental health problems, such as PTSD, depression, anxiety, and substance abuse, that have been prevalent in many of the rescue and recovery workers (Crane et al., 2014). Numerous lay volunteers, who were not affiliated with any organization or occupations performing rescue efforts, were subjected to the dust cloud or witnessed the traumatic event unfold have also suffered from respiratory diseases, asthma, cancer, PTSD, and suicides.

What are the PTSD, Psychological and Sociological Effects?

There are numerous types of physical dangers and psychological stressors that firefighters face daily while on the job. Although no firefighter has a set number of callouts they will respond to, the firefighters in metropolitan or urban communities have a different workload than rural firefighters. Some of these incidents include medical emergencies, community disasters, explosions, hazardous material spills, commercial and residential structure fires (Regehr et al, 2000). Each of these emergencies can be very traumatic, not only on the people directly involved, but also on the first responders as well.

Firefighters, who normally work a 24-hour shift, often go from zero-sixty in about 0.5 seconds when the alarm is sounded for an emergency. They often face psychological and emotional risk because of the exposure of traumatic incidents and the stress factor placed on their bodies during a structural fire attack. Such events may lead to posttraumatic stress disorder (PTSD), causing physical and psychological disorders that has been linked to an increase in cancer, strokes, heart attacks, depression, suicides, anxiety, negative thoughts, and fear.

Emergency responders often suffer from depression, lack of cognitive functioning and /or second-guessing judgement which leaves them with recurring nightmares, flashbacks, and loss of appetite after responding to traumatic incidents (Regehr et al, 2000). Varvel stated, “Thus, research that identifies possible interventions to reduce firefighters’ perceived stress has the potential to save communities thousands of dollars as well as the property, and conceivably, the lives of both residents and firefighters themselves” (Varvel et al, 2007). There are six functionally different types of support to help alleviate some of the psychological stress firefighters may face which include: (1) attachment, (2) social integration, (3) reassurance of worth, (4) reliable alliance, (5) guidance, and (6) opportunity for nurturance (Varvel et al, 2007).

Research was performed in a midwestern city with a population of approximately 90,000 people, in which surveys were handed out to all members of the fire department and was described as “a study of workplace environment and the well-being of professionals in stressful occupations” (Varvel et al, 2007). Seven female and 29 male supervising officers were excluded, and the data from the remaining firefighters was collected. Ethnicity was not a contributing factor in the survey. The data evaluated describes the Perceived Stress Scale and the Social Provisions Scale used to measure the stress level and the social support level for firefighters, and the surveys were returned in sealed envelopes (See Table 3). The results suggest, “that reliable alliance (tangible help is available if needed), social integration support (feeling part of a group that shares interests, attitudes and activities), and reassurance of worth (skills and abilities are recognized) from supervisors were negatively associated with perceived stress and appear to bolster previous research indicating that this type of support is especially important when provided by workplace supervisors” (Varvel et al, 2007).

Social support interventions are generally effective but would be premature until underlying issues are addressed. Also, much more research is needed to discover the most effective way to help address the needs of these individuals in high-stress occupations.

“The complexity and demands of work, political influence, funding and scheduling increase the pressure and stress on firefighting personnel in their professional and private lives. Better training, education career counseling, and managerial duty updates will assist fire departments in their efforts to address social change” (Milen, 2009).

Firefighters should have different types of coping resources such as religious materials, physical fitness equipment, music, critical incident stress management (CISM), and critical incident stress debriefing (CISD) readily available. This will help reduce the memory disturbances, confusion, feelings of guilt, frustration, and emotional instability associated with PTSD.

According to Henderson et al (2016), The National Fallen Firefighters Foundation (NFFF) reported that fire departments are four times more likely, within a given year, to experience a suicide than a “traditional” line of duty death. Traditional line of duty death is a death that has occurred on an emergency scene. Many times, firefighters decide to self-medicate with alcohol or drugs as a coping mechanism. Other times, firefighters take more drastic measures, such as suicide, to take away the pain they have encountered from the tragic incidents.

The Firefighter Behavioral Health Alliance Website (www.ffbha.org) reports that 360 firefighters committed suicide between 2000-2013. “Fire departments need to adopt peer counseling or support programs that aim to recognize signs and symptoms of suicide risk and increase the willingness of firefighters to seek professional help (Henderson et al., 2016).” Battalion Fire Chief David Dangerfield with Indian River County Fire Rescue stated in his final Facebook post, “PTSD for a firefighter is real. If your loved one is experiencing signs, get them help quickly. Twenty-seven years of deaths and babies dying in your hands is a memory that you will never get rid of. It haunted me daily until now. My love to my crew. Be safe, take care. I love you all” (Hodges, 2016). Dangerfield made this post before shortly driving himself to a wooded area, making a 911 call to report where to find his body and committing suicide. Florida State University did a survey in 2015, where nearly half of the firefighters surveyed have thoughts about committing suicide, 19.2 % had suicide plans, 15.5 % had made suicide attempts (Hodges, 2016). The number firefighters facing suicide is alarming. The need of employee assistance programs to assist firefighter to cope with the stress or PTSD is in desperate need.

Do Training Scenarios Pose a Risk of Exposure?

Research has indicated that polycyclic aromatic hydrocarbons (PAHs) and volatile organic compounds (VOCs) have been found in high numbers in materials used in training scenarios. Through testing of 15 different PAHs on firefighters/smoke divers, biomonitoring was performed to determine the amount of exposure in modern and conventional simulators (Laitinen, Makela, Mikkola, & Hutto, 2012). This testing determined there was a 3-fold higher exposure in the conventional simulator as compared to the modern simulator (Laitinen, et al, 2012). The difference in the two simulators is that a conventional simulator uses burning materials such as chipboard or spruce wood, and kerosene or ethanol as an ignition source and is three-stories high built out of concrete. Whereas, the modern simulator burns propane and uses artificial smoke and is built two stories high out of steel.

Research explains how the biomonitoring was used to determine the amount of exposure the firefighters faced during the training scenario. This was done by performing a urine test before the scenario, then 6 hours after exposure and then again, the following morning. The results were 3-fold higher in the conventional simulator as compared to the modern simulator. The Hazard Index method is used for calculating and measuring the additive effects of VOCs in eye disorders or upper respiratory tract irritations. The experiment also stated the cancer risk was higher in the conventional simulator (Laitinen, et al, 2012). Laitinen states, “Firefighters are therefore exposed to a more toxic mixture of PAHs in conventional simulators than in modern simulators. This example described how occupational hygienic measurements can support the interpretation of biological monitoring results and risk assessments” (Laitinen, et al, 2012). Hydrocarbons are found is most petroleum base products and off-gas a lot of carcinogens. The artificial smoke is made often made from glycerin bases or glycol bases fluid combined with water and may present asphyxiation or breathing hazards, as well as irritation to mucus membranes.

Personal Protective Equipment is Meant to Protect, Right?

Firefighters wear a variety of personal protective equipment (PPE) which include fire retardant uniforms, Nomex hoods, turnout or bunker gear, leather gloves, leather steel-toed boots, helmets, and a self-contained breathing apparatus (SCBA) with mask. Firefighters used to have a “Badge of Honor.” This “Badge of Honor” has been associated with a soot-, smoke-, and contaminate-laden helmet with PPE- was ‘proof’ that the firefighter was not afraid of being on the front lines in the midst of the hottest of the battle” (Nelson, 2014). Even when worn as the manufacture recommends or properly donned, the PPE may still leave the firefighter vulnerable to potential exposure.

Firefighters are their own worst enemy when they do not wear their gear, not only fighting fire, but also when they go back into a smoldering structure to check for hidden flames or to gut the place, referred to as overhaul. Once the flames are extinguished, many of the firefighters do not wear all the PPE because it is hot, uncomfortable and weighs about 70 pounds. During this overhaul phase of the fire is when toxic levels of contaminants are at their highest. Even though the gear blocks some of the carcinogens, it does not fully eliminate the possibility of the firefighter being exposed. Gaps in the protective clothing often allows for smoke to travel to unprotected areas of the skin. Many times, while wearing the air mask of the SCBA the firefighter will sweat, and the mask will slip on his face causing harmful containments to enter and be breathed in.

An “Underwriters Laboratories’ (UL) study reaffirmed that firefighters are exposed to asphyxiants, irritants, allergens and carcinogens and noted that they are also exposed to ‘respirable particles in the ultrafine range (particles less than 0.1 micron in diameter), which have been detected in smoke” (Nelson, 2014). Many of these smoke particles penetrate the turnout gear and set on the firefighter’s skin where they can potentially be absorbed. “Some areas of skin are more permeable than others, specifically the face, the angle of the jaw, the neck, and the groin” (Taking Action Against Cancer, 2013). Some of the particles become lodged in the turnout gear which leads to cross contamination by the means of hand to mouth exposure. Each firefighter should perform a gross decontamination on their PPE before removing it. This is done using a booster hose from the firetruck to thoroughly rinse the PPE and SCBA before taking the gear off. Next, the firefighter should use some type of wipes such as Fire Wipes, to remove a great portion of the contaminates that penetrated through the turnout gear.

Tim Wall of the International Association of Fire Chiefs stated “Cancer does not discriminate between firefighters. This is a terrible problem that requires our full and immediate attention” (“Taking Action Against Cancer,” 2013). Volunteers routinely transport bunker gear in their vehicles, wear clothing contaminated from a fire into their homes and expose their families to the carcinogens. Volunteer firefighters often carry their gear in the trunks of their car or within the passenger compartment of their truck creating the off- gassing of toxins and carcinogens, especially when heated by the sun. Often when handling this gear, it causes hand-to-mouth cross contamination to occur because the firefighter does not think about his gear being contaminated with embedded carcinogens and fails to properly wash his hands.

Even the volunteer firefighter’s turnout gear should be carried back to the fire station on the fire truck, so the gear can be properly laundered according to National Fire Protection Association (NFPA) 1851 standards. NFPA 1851 titled Standard on Selection, Care, and Maintenance of Protective Ensembles for Structural Fire Fighting and Proximity Fire Fighting is the industry standard for selecting, maintenance, and care of firefighting turnout gear to reduce health and safety risks (Ballam, 2014). When the turnout is not properly sized, maintained, and cleaned this creates the potential threat of the gear not performing as it is intended. This could potentially increase the chance of injury, exposure or even worse – death.

Often, the PPE of career firefighters is stored in the truck bays of the station which causes the gear to absorb diesel fumes from firetrucks. On numerous occasions, oily residue from diesel exhaust can be found on turn-out gear, on surfaces within the living quarters and sometimes on the food in the refrigerator. Diesel exhaust systems are expensive, but many fire departments are beginning to install them in their stations to decrease the amount of diesel fume contaminants the firefighters are exposed to.

Would an Interdisciplinary Approach to Reduce the Threat?

The risk of cancer is great among the fire service and it will take an interdisciplinary effort to reduce the potential threat. “Cancer prevention is a broad field that crosses many disciplines; therefore, education efforts to enhance cancer prevention research focused on interdisciplinary approaches to the field are greatly needed” (Teegarden, et al, 2011). It is everyone’s responsibility from the firefighter, to the fire chief, to the hospitals, and all the way up to the elected city, county, state, and federal officials to take the proper precautions to eliminate these risks.

To help reduce the risk of exposure, firefighters first need to take proper steps to eliminate the contaminates they encounter. “Collaboration in health care is defined as health care professionals assuming complementary roles and cooperatively working together, sharing responsibility for problem-solving, and making decisions to formulate and carry out plans for patient care” (Fagin, 1992). Collaboration among firefighters is imperative to reduce the risk of being exposed. Firefighters should do everything they possibly can to protect themselves and their brother firefighter. One way is to make sure they wear all their PPE throughout the entire fire event. This includes the overhaul portions of the fire. Many times, firefighters feel that since the dark smoke has cleared, the hazards have gone away with them. SCBAs and turnout gear should be worn until firefighters are ready to leave the scene. Firefighters should shower as soon as possible after returning from a callout. They also need to keep a journal of each fire with a list of possible exposures.

The fire chief can “Identify operational enhancements and changes, set clear expectations and then enforce the policies – every time… Integrate cancer awareness and prevention into related training” (“Taking Action Against Cancer,” 2013).  The fire chief should examine standard operating procedures (SOPs) and enforce the use of SCBAs from the initiation of fire suppression activities until the completion of overhaul. There should be mandatory uses of commercial wipes and mandatory showers after returning to the fire station. Nancarrow suggests, “Ensuring that the necessary resources, infrastructure and training are available, as well as a mix of skills, competencies and personalities amongst team members” (Nancarrow, et al, 2013). He or she should also work with elected officials to ensure adequate funding for cancer awareness and prevention which includes equipment, annual physicals with cancer screening, and machines to adequately wash PPE and diesel exhaust systems for fire stations. CISM and CISD should be made mandatory for all firefighters after any traumatic event to alleviate stress and PTSD.

Local, State, and Federal fire academies need to adopt cancer awareness and prevention into the Firefighter 1 or Firefighter 2 curricula being taught.  Teegarden proposes, “A program that exposes students early in their academic careers to the broad field of cancer prevention, from basic science and engineering to behavioral and social sciences, is expected to enhance the students’ awareness of this crucially important area of research and how students can contribute both through their chosen career discipline and through interdisciplinary collaboration” (Teegarden, et al, 2011). By instilling interdisciplinary collaboration of cancer preventions to recruits in fire academies, the instructors are teaching the importance of working with other disciplines to help reduce the risk of cancer. The academy instructors need to set the example of not wearing the “badge of honor” by wearing clean turnout gear, hoods, and helmets. Proper decontamination of PPE should be taught to new recruits. The risk of cancer causing exposures should be stressed in every firefighting class. As well, cancer awareness and prevention classes need to be offered as part of the continuing education that is required by all firefighters.

The local doctors and medical facilities can take a proactive stance by offering cancer screenings, and educational opportunities to help educate their firefighters on different ways to help protect themselves. Nancarrow states, “An interdisciplinary approach relies on health professionals from different disciplines, along with the patient, working collaboratively as a team. The most effective teams share responsibilities and promote role interdependence while respecting individual members’ experience and autonomy” (Nancarrow, et al, 2013). Scientist working in the areas of molecular medicine, chemical biology, cancer biology, immunology, and epidemiology often collaborate with physicians to help develop new techniques to detect cancer at earlier stages. Because of the amount of risks, annual checkups for firefighters should include screening for cancer. Also, psychiatric services should be offered to alleviate the possibility of PTSD, social unattachment or suicide.

Solution

Harold Schaitburger, IAFF President was quoted as saying, “The connection between firefighting and cancer is real, and there is specific data to support our position. But we cannot stop there—we must continue to learn more, so we can prevent our members from contracting this horrible disease and help them if they do” (“Taking Action Against Cancer,” 2013). The majority of the research articles suggest the need for more extensive research and testing to determine the risk exposure of cancer and the need for better personal protective equipment.

Research shows the potential need to have workman’s compensation laws changed for work-initiated cancers (Milham, 2009). Some of the articles are even suggesting changing certain laws and procedures to better protect firefighters from work related risk of developing cancer. As evidence mounts that occupational exposures increase cancer risk, at least 33 U. S. states have adopted cancer presumptive laws (Anderson, et al, 2017). “Presumptive law presumes that a firefighter develops certain types cancer as a result of the occupation, making them eligible for benefits without having to prove a direct cause for the disease” (“Failing Our Firefighters,” 2015). Fourteen states do not acknowledge the connection between cancer and firefighting when it comes to worker’s compensation and medical benefits, and require the firefighter to prove the origination at specific fires. It is recommended that firefighters, fire departments, and fire advocates continue to research the potential cancer-causing effects firefighters face daily. With continued studies comes the advancement of better protective equipment and more safety standard operating procedures and standard operating guidelines to better protect the firefighters from the risk of cancer.

On September 13, 2017, the Senate of the United States passed H. R. 931 The Firefighter Cancer Registry Act of 2017. “The bill would create a national cancer registry for firefighters diagnosed with this deadly disease. The creation of this registry would enable researchers to study the relationship between firefighters’ exposure to dangerous fumes and harmful toxins and the increased risk for several major cancers” (Pascrell et al., 2017).

Congressman Chris Collins stated, “Unfortunately, firefighters see a higher rate of cancer than the rest of the public. This legislation will provide the Center for Disease Control and Prevention (CDC) the tools they need to improve their data collection capabilities on volunteer, paid-on-call, and career firefighters” (Pascrell et al., 2017). This bill stems from a National Institute for Occupational Safety and Health (NIOSH) study that was performed in 2015. This study determined that U. S. firefighters had a greater number of cancer diagnoses or cancer related deaths compared to the U. S. general population.

Pascrell announced, “The Firefighter Cancer Registry Act would: Develop a firefighter registry of available cancer registry data by existing State Cancer Registries; Create a registry that will contain relevant history, such as occupational information, years of service, number of fire incidents responded to and additional risk factors; Make de-identified data available to public health researchers to provide them with robust and comprehensive datasets to expand groundbreaking research; Improve our understanding of cancer incidences by requiring its administrators to consult regularly with public health experts, clinicians, and firefighters” (Pascrell et al., 2017).

The study verifies an increased risk of cancer because of occupational exposure that firefighters encounter. (See Table 1). The bill receives strong support from numerous fire service organizations and associations, as well as fire departments across the country.

Conclusion

Cancer comes in a variety of forms, such as prostate, breast, brain, lung, testicular, and colon, which are among the more than 100 types of cancer. Cancer does not discriminate based on age, gender, race, religion or profession. Firefighters have a greater risk of developing cancer than the general population of the United States. Cancer has been a risk to firefighters for many years. Many firefighters have known that the risk of developing cancer, while on the job, does exist, while others remain clueless and do not want to accept the facts about the potential threat. Several forms of cancer may lay dormant for an extended period, and the firefighter may not know that he or she has developed cancer until long after they have retired; often, not allowing them to enjoy their retirement.

Many fire departments are changing their fireground operation procedures about wearing all the gear, including SCBA’s the entire time while within what is considered the “Hot Zone” or within close proximity to the actual structure, vehicle, or dumpster that is on fire. Some departments are even considering making the firefighters wear SCBA’s on wildland (forest) fires. Some departments are changing standard operating procedures and guidelines making it mandatory to shower immediately after returning from a structure fire. This will help eliminate the number of carcinogens that remain on the firefighter for extended periods.

The thought of cancer as an occupational hazard is a growing concern among many firefighters as well as fire chiefs, fire departments, city governments and federal governments. Willing stated, “The company officer is the single most influential person concerning the team’s attitude, operations and willingness to change. But there is no excuse not to take every precaution against this devastating disease, from the first day on the job. A proactive attitude begins with leadership by example, and this starts with the company officer.” (Willing, 2014). Many of the professional organizations associated with firefighting are lobbying the federal government to impose stricter regulations on manufactures to help reduce or eliminate the number of carcinogens that are being used in everyday household products. They are also pushing for each state to impose the risk of cancer among firefighters as an occupational hazard. Thirty-three states have already adopted cancer legislation to provide workers compensation to firefighters should they develop cancer that is the result of an exposure while on duty. The House of Representatives have recently passed a bill endorsing a National Firefighter Cancer Registry.

Several manufacturers of firefighter turnout gear are working towards developing better protective equipment. Proper decontamination of the fire gear and the trucks will help to decrease the amount of cross-contamination firefighters face. More importantly, the firefighter needs to maintain a healthy life style by eating the right foods, avoiding sugary drinks and snacks, exercising, and decreasing the amount of stress in their lives to help decrease the chance of developing cancer.  Firefighters also need to have routine cancer screenings performed by their personal doctor. Lavelle divulged, “While we cannot wipe out cancer, understanding its nature and the special risk to firefighters allows us to take steps to reduce its occurrence and severity” (Lavelle, K. 2012).  There is no doubt in that firefighters face the risk of being exposed to carcinogens which could potentially lead to them developing cancer. This exemplifies even strong reasons why the risk of developing cancer due to an occupational exposure should be a work-related illness and/or injury. This would qualify the firefighter to receive worker’s compensation benefits.

The fact remains that a more intradisciplinary approach by combined efforts from scientists, engineers, medical personnel, psychologist, sociologist, biomedical engineers, firefighters, fire chiefs, community leaders and government officials working together to help protect the firefighters. The fire service cannot isolate itself to fight this battle of cancer alone. By building partnerships and relationships with other disciplines could lead to healthier firefighters and decrease the number of firefighters dying from such a horrible disease. The fire service needs the help from numerous other disciplines working together towards better research, better training, and better equipment to help ensure the health, safety and livelihood of the firefighters who risk their lives, 24 hours a day, 7 days a week and 365 days a year.

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