The Fight Against Firefighter Cancer

By Angela Outhouse, RN, EMT, FASNY Health and Wellness Committee

It is becoming widely known that firefighters have an increased risk of developing certain cancers. Firefighters are exposed to toxins in smoke from the combustion of a variety of materials and chemicals. The National Institute of Occupational Safety and Health study of 2016 reported a 14% increased risk of firefighters dying from cancer when compared to the general public. Firefighters have a higher incidence of digestive, oral, respiratory, urinary cancers and malignant mesothelioma from asbestos exposure.

Since then, there has been an uptick in additional studies, an interest in sharing research, and incorporating the newest technologies and analysis. This has led to additional treatment options including targeted therapies, combination therapies which include immunotherapies and the like. Most importantly, cancer in the fire service is now a national conversation. New collaborations have been formed in order to share research and information among biotech, academic organizations, the technology sector and private and public entities.

The National Institute of Health developed the “All of Us” research program to obtain biological samples from 1 million firefighters in the U.S. to accelerate research. It has partnered with the Mayo Clinic, Baylor College of Medicine, the Broad Institute, University of Washington’s Northwest Genomic Center and research centers like Vanderbilt University Medical Center and several other California research centers in an effort to store, analyze and organize data as it relates to these cancers. Industry leaders from academia and cancer centers and companies like Pfizer and Genomic health bring industry leaders and researchers together with leaders from fire service organizations. Leaders like The International Association of Fire Fighters, The Miami Department of Fire and Rescue, Miami’s Sylvester Comprehensive Cancer Center’s Firefighter Cancer Initiative were among a few who participated. Firefighter Aid and Legislation was co-sponsored by Chris Collins (R-NY) and Bill Pascrell (D-NJ) with bi-partisan support and the Firefighter Cancer Registry Act of 2018 (H.R. 931) was signed into law on July 7, 2018, by President Donald Trump. This Law was to establish and maintain a volunteer registry of data for the incidence of cancer among firefighters and initiate long-term research. Multiple fire departments and the Center for Disease Control were to collaborate to collect data on the occurrence of firefighter cancers. These are among the multiple commitments to collaborate and participate in this fight by partnering up to help firefighters who risk their lives to save others.

On August 8, 2018, the National Volunteer Fire Council and the International Association of Fire Chiefs Volunteer and Combination Officers Section released the Lavender Ribbon Report – Best Practices for Preventing Firefighter Cancer. It outlines the 11 actions to mitigate the risk of cancer. In its introduction, it states: “Cancer is now recognized as one of the major killers of both career and volunteer firefighters, which we in the public safety community have only recently begun to admit. It is our duty to accept the need to change the safety culture as it relates to occupational cancer … this report provides information for the members of the response community on the actions necessary to protect ourselves from occupational cancer. We have named it the Lavender Ribbon Report since lavender is the symbol for general cancer awareness and represents all cancer.”

So, what can we do to help prevent cancer? Fires will continue, the contents of homes will continue to be modernized with chemicals that are toxic. We can take steps to mitigate exposure. The following is taken directly from the Lavender Ribbon Report. For the full report, follow the link at the end of this article. Here are the highlights …

Best Practice No. 1 – Full personal protective equipment (PPE) must be worn throughout the entire incident, including a selfcontained breathing apparatus (SCBA) during salvage and overhaul. If you didn’t already know, the skin is the body’s largest organ in surface area. In the Taking Action Against Cancer in the Fire Service’s white paper, it explains that “the skin’s permeability increases with body temperature; for every five-degree increase, absorption increases 400 percent.” US Department of Health and Public Services reports that “the neck area is one of the most likely areas of a firefighter’s body to become contaminated with potential carcinogens”.

Best Practice No. 2 – A second hood should be provided to all entry- certified personnel in the department. In a 2015 article from firerescue1.com, research was highlighted that showed “a large amount of exposure occurs to the vulnerable face and neck area that is not protected by the SCBA facepiece. The second hood is to make sure that firefighters don’t wear contaminated hoods after firefighting. Providing each firefighter with a second hood allows the firefighters to wash their contaminated hood while having the second one available for another emergency. Take-aways: Clean your hoods. Consider new multilayer hood designs. Take it off, as soon as you are out of the firefighting environment, remove the hood. The faster the hood is removed and the skin is cleaned, the faster those cancer-causing agents will be off the skin.

Best Practice No. 3 – Following exit from an immediate danger to life or health incident, while still on air, you should begin the gross decontamination of PPE using soapy water and a brush if weather conditions allow. PPE should be placed in a sealed plastic bag and placed in an exterior compartment of the apparatus or personally owned vehicle, thus keeping the off-gassing PPE away from passengers and self. This keeps the cab of the apparatus as clean as possible and to avoid transferring toxins and harmful products back to the fire station. It is extremely important to perform gross decon prior to leaving the incident.

Best Practice No. 4 – After completion of gross decontamination procedures as discussed above and while still on scene, the exposed areas of the body (neck, face, arms and hands) should be wiped off immediately using wipes, which must be carried on all apparatus. Use the wipes to remove as much soot as possible from exposed areas immediately. Takeaways: Wipes are effective but don’t replace a shower. Wipes should be used for immediate decontamination and a thorough shower and handwashing as soon as possible, “shower within the hour.” Exposures happen anywhere on the fireground, exposure can occur even during an exterior attack and hood should be kept in place during operations. Reducing exposure starts with prevention.

Best Practice No. 5 – Change your clothes and wash them after exposure to products of combustion or other contaminants. Do this as soon as possible or isolate in a trash bag until washing is available. All personnel exposed to products of combustion or any potentially harmful chemical or toxins, should complete a full personal decon as soon as possible, as listed above. Back at the station, PPE and turnout clothing need to be cleaned. A frontloading washer/extractor is best to limit damage caused by toploading washing machines. Proper drying is equally important. Note, upon returning from station, appropriate PPE and respiratory protection should be followed when removing contaminated PPE from the sealed bags. Further gross deconned if needed at this time, remembering to keep the inner liners dry and ready for response. The best option is extractor washers and commercial dryers as outlined in NFPA 1851.

Best Practice No. 6 – Shower as soon as possible after being exposed to products of combustion or other contamination. “Shower within the hour.” The days of arriving back to the station after a fire and having the top concern be to clean the fire apparatus are gone. The most pressing concern upon returning to the fire station is cleaning you. You are the most important tool on that apparatus, and you take the top priority of getting clean. The axes, halligans and pike poles can wait. You cannot! Allowing firefighters to get into their vehicles and return home to shower is not an acceptable practice. This results in firefighters contaminating their vehicle as well as their home. These are places where family members, possibly children, can be exposed unnecessarily. The ability for firefighters to shower prior to leaving the station and not carry the contaminants home should be the norm, not the exception. This may require modification to upgrade the station or purchasing portable showers, in the end, the cost is worth protecting firefighters and avoiding a painful and costly battle with cancer.

Best Practice No. 7 – PPE, especially turnout pants, must be prohibited in areas outside the apparatus floor (i.e. kitchen, sleeping areas, etc.) and should never be in the living quarters. To be 100% safe, even if the turnout gear has been decontaminated, you should not wear it in the fire station, with the exception of the bay, gear storage and decon areas. Online searches and training facilities can also provide sample documents and resources to help enforce this best practice. Currently, a large portion of training facilities are requiring firefighters to keep their PPE out of the classrooms and communal areas of their buildings. One agency that currently has a policy on this issue is the Westchester County Department of Emergency Services Training Facility in White Plains, New York. Their procedures explicitly state, “At no time is turnout gear to be worn into the classroom/office building. All turnout gear is to be removed outside of the glass entrance, gray doors, or garage doors. Turnout gear is to be kept outside or on the apparatus floor.”

Best Practice No. 8 – Wipes, or soap and water, should also be used to decontaminate and clean apparatus seats, SCBA and interior crew areas regularly, especially after incidents where personnel were exposed to products of combustion. Following a fire scene, the apparatus and equipment need to be thoroughly cleaned with appropriate cleansing wipes or soap and water in order to eliminate contaminants and stop continued exposure potential to the firefighters. Decontamination should be conducted immediately following an incident, especially when personnel were exposed to products of combustion. The use of cleansing wipes should also be used regularly to clean apparatus seats, SCBA and interior crew areas. Consider HEPA air filtration systems for inside cabs, create non-SCBA seats to prevent contamination for air packs entering the cab. Wipe down seat surfaces. Use external transverse compartments across the back of the cab to store SCBAs on a pullout board for easier access. Exterior compartments for storage of bunker gear with exterior access. A simple garden hose outlet on the pump panel for pressure regulated and temp-controlled water supply can be used for gross decontamination.

Best Practice No. 9 – Get an annual physical, as early detection is the key to survival. The American Cancer Society (ACS) states, “screening increases the chances of detecting certain cancers early, when they are most likely to be curable” (Cancer Screening Guidelines). The overall death rate from cancer in the United States has declined steadily over the past two decades, according to annual statistics reported by the ACS. The drop-in cancer mortality is mostly due to steady reductions in smoking and advances in early detection and treatment. Learn more at cancer.org.

Best Practice No. 10 – Tobacco products of any variety, including dip and e-cigarettes, should never be used at any time, on- or offduty. The negative health effects of tobacco aren’t reserved only for smokers. Tobacco use and the introduction of its chemicals into the body also exist through secondhand smoke, smokeless tobacco and now e-cigarettes, also known as vapor products. Early detection saves lives.

Best Practice No. 11 – Fully document all fire or chemical exposures on incident reports and personal exposure reports. The adage, “If you didn’t write it down, then it didn’t happen,” is never truer than in dealing with cancer in the fire service. Cancer does not present itself immediately after one is exposed to carcinogens. Thus, years later when the firefighter is diagnosed with cancer, the exact cause or procuring circumstances that exposed the individual to the harmful substances may be a long-forgotten memory. Therefore, it is important to have a process and to follow that process, to attempt to document as much detail regarding potential exposure, no matter the size of the incident or circumstance.

If your department is not following these best practices, please bring these suggestions to your department heads. Following these suggestions are the department’s best chance of limiting exposure to carcinogens and being proactive in the fight against cancer. Read the full report at nvfc.org/lrr and stay safe!