How many times have you been excited to hear about a newly released study on firefighter cancer only to put it aside with the intention of getting back to it when you have time? It takes time to wade through the endless pages of scientific data to find the important facts, deposited here and there within the research, to let you know what you need to do, how to make it work for you and maybe even become an advocate for change in your department or with your crew.
Really, how many of us have the time or the expertise to actually become successful with that mission?
Enter the Firefighter Safety Through Advanced Research (FSTAR) program. FSTAR has gathered subject-matter expects to do the job of distilling research and data into its most useful takeaways.
One of the hardest areas of research is health and wellness. The research itself is complicated—and the outcomes may not be wholly understood until other research is completed. And the research changes. As science evolves, we learn more and we question earlier tenets.
This is true in the case of exposures and the causes of cancer in firefighters. We don’t fully understand the issues and challenges of exposures and cancer, but the research has told us enough to be very, very worried about the future health of all firefighters.
State of the Research
A search of FSTAR brings up 58 resources associated with cancer. In this article, we’re focusing on three studies, highlighting the key facts and takeaways from each.
Systemic Exposure to PAHs and Benzene in Firefighters Suppressing Controlled Structure Fires2 – This study found that even while wearing full protective ensembles, firefighters can have systemic exposures to polycyclic aromatic hydrocarbons (PAHs) and other aromatic hydrocarbons. PAHs are carcinogens found as a result of burning rubber or tar. Most fires found in simple residential homes have a risk of exposure to PAHs.
Cancer-causing PAHs can be absorbed through the skin during firefighting. They can also be inhaled due to incomplete or improperly worn PPE while close to a sources of exposure. PAHs can also be inhaled from the off-gassing of contaminated gear. Off-gassing can continue for several minutes after an exposure. Lastly, PAHs may be inhaled if the firefighter requires more air than the SCBA’s regulator can supply, causing pressure in the mask to temporarily become negative and allow combustion products to enter through a leak.
Exposure-response relationships for select cancer and non-cancer health outcomes in a cohort of U.S. firefighters from San Francisco, Chicago and Philadelphia (1950–2009)3 – This complex study of 19,309 firefighters from three urban U.S. departments reviewed exposure, mortality and incidence data from 1950 to 2009 to examine the relationship between occupational exposures and cancer.
The study found that the risk of lung cancer and leukemia increased with number of runs and fire hours, with fire hours having the strongest link to cancer in all exposure models within the study. Exposures after age 40 were more strongly related to lung cancer mortality than exposures occurring at younger ages.
The study verified that there is an exposure-response relationship between firefighting activities and certain types of cancer. Developing lung cancer and leukemia were of the highest risk.
The study also encouraged gathering and maintaining data on information such as length of employment, number of runs, and time spent on runs could be helpful in assessing the risk of developing cancer.
Cardiovascular & Chemical Exposure Risks in Modern Firefighting4 – The prerelease of the full study reviewed the acute physiological responses and toxic exposure markers of firefighters for 12 hours following their completion of a series of realistic, modern fire scenarios. The impact of different tactics (traditional interior attack versus a transitional attack) and different firefighting location/assignment (interior attack, outside operations, outside command, overhaul) were assessed. Measures such as skin cleaning and gross on-scene decontamination to mitigate these risks were also investigated.
The study sampled air from within the structure during active fire on one day, which showed hydrogen cyanide levels that were nearly seven times the Immediately Dangerous to Life and Health (IDLH) level. Benzene levels were found to be up to 15 times exposure limits. Several flame retardants and PAHs were detected on turnout gear items after use in a fire.
The study also found that gross on-scene decon with water/detergent and scrubbing was effective in bringing the PAH contamination to prefire levels. Regardless of whether or not the turnout gear was decontaminated, the off-gas levels returned to background levels within an hour.
Tactics to Minimizing Risk
Based on the research cited above, the fire service has begun to address ways to mitigate the risks of exposures. As we continue to push the boundaries of unknown and known, being cognizant of and cautious in facing these issues is critical. The fire service is adept at discussing and debating the effectiveness of tactics; the same discussion about minimizing exposure risks should be happening every day in your fire stations, between your crews and at every level of department leadership.
Based on the research, there are five areas to concentrate on for finding ways to mitigate the risk of exposures.
Fireground Exposures – The first area to focus on is the fireground. Wearing SCBA during all aspects of firefighting activities including size-up, ventilation and overhaul is critical. Not wearing SCBA in both active and post-fire environments is the most dangerous voluntary activity in the fire service today.
Minimize your exposure on the fireground by removing SCBA last. Prioritize minimizing exposure in rehab by designing protocols that place rehab away from the fire, by requiring firefighters to remove contaminated and possibly off-gassing gear and segregating it during rehab.
Wash hands thoroughly before eating any food and remove as much soot as possible from head, neck, jaw, throat, underarms and hands immediately and continually while on scene.
When returning from a fire and at the station, focus on maintaining separation from contaminated gear and have protocols in place that require firefighters to shower and remove soot after a fire scene exposure on a fire scene.
PPE – Understand that wearing dirty PPE is not a badge of honor. It’s a potential source of carcinogen exposure and should be treated with caution. Require your crews to check their entire protective ensemble at the start of every shift and after an incident. Have a program in place where complete, intensive inspections of PPE are regularly scheduled. When on a fire scene, do gross field decontamination of PPE to remove as much soot and particulates as possible. Decontaminate and wash PPE as often as possible. As the neck area is an area of concern, store additional hoods in rigs to switch out after each exposure to eliminate repeated or accumulated contamination. Change out and wash hoods so they can be ready for next response. Ensure facepieces are fitted properly by conducting F.I.T. testing as needed.
Station – While in the station or returning from a fire, the dangers of exposure may still be present. Make the station a clean zone by decontaminate fire apparatus interiors after fires, showering and changing clothes after returning from the fireground, store contaminated clothes in a protected environment until they can be washed, then wash clothes immediately or store in a protective environment until washing can occur. Ensure sleeping zones are clean by keeping exposed PPE, boots or other items out of the living and sleeping quarters. Consider instituting a sandals or a “crocs-only” policy.
Department Policies and Responsibilities – For chiefs and other department leaders, it is time to draw a line in the sand on exposures. As we don’t know the true ramifications of exposures, caution and vigilance is needed.
Build organizational and department systems that support a comprehensive culture and climate of safety.
Addressing policies on the proper inspection, maintenance, storage and cleaning of PPE. As one of the studies found that even firefighters wearing NFPA-compliant clean or new gear absorbed combustion products into their bodies, special care must be paid to PPE. Purchasing more than one hood for each firefighter, following programs such as “Wash Your Hood Sunday”, instituting PPE inspections the start of every shift are among the changes that can be made. For fire scene, chiefs should consider developing polices that emphasize exposure safety on-scene and while in rehab. In the station, decrease exposure by installing and using exhaust extractors and requiring clean, contamination-free living and sleeping quarters. Lastly, fire departments should track exposures that will provide data for firefighters in the future. Implement ways for your department to track fire-hours, fire-runs, and possible exposures.
Whenever possible, strive to follow standards such as NFPA 1582 and 1583. And of critical importance, advocate for annual medical exams. Exams will provide a baseline and ongoing source of relevant information should any of your firefighters become sick in the future. Early detection and care of cancers is raising the likelihood that many cancer patients will be able to enjoy a long, healthy life.
Individual, Environment and Lifestyle Choices – Limiting exposures to carcinogens may also require lifestyle changes and considerations. Remember that research shows that environment, including diet and lifestyle, causes up to 90% of all cancers5.
Do what you can to limit your exposures within the areas that you control - eliminate the use of all tobacco products (smoking and chewing), use sunscreen or sunblock, and reduce your exposures to second-hand smoke as much as possible. Never bring contaminated gear home or store it in your POV.
Finally, focus on your health and fitness. Take care of yourself and those around you in order to maintain a high level of job-ready fitness.
Stay in the Know
Read the research, start the discussion: FSTAResearch.org. FSTAR is funded by a Fire Prevention and Safety Grant award from FEMA’s Assistance to Firefighters Grant Program.
1. International Agency for Research on Cancer. (December 2007). "IARC Monographs Programme Finds Cancer Hazards Associated with Shiftwork, Painting, and Firefighting." Press release. Lyon, France: World Health Organization.
2. Fent, K. W., et al. (December 2013). “Evaluation of Dermal Exposure to Polycyclic Aromatic Hydrocarbons in Fire Fighters.” Health Hazard Evaluation Report No. 2010-0156-3196. Atlanta, GA: Centers for Disease Control and Prevention.
3. Daniels, R.D., et al. "Exposure-Response Relationships for Select Cancer and Noncancer Health Outcomes in a Cohort of U.S. Firefighters from San Francisco, Chicago, and Philadelphia (1950-2009)." Occupational and Environmental Medicine 72, no. 10 (October 2015): 699-706. doi:10.1136/oemed-2014-102671
4. Gavin P. Horn, et al. (Jan, 2016). Interim Report. “Cardiovascular & Chemical Exposure Risks in Modern Firefighting.” Illinois Fire Service Institute – IFSI Research - University of Illinois at Urbana-Champaign
5. Kang, D., et al. "Cancer Incidence Among Male Massachusetts Firefighters, 1987-2003." American Journal of Industrial Medicine 51, no. 5 (May 2008): 329–35. doi:10.1002/ajim.20549