Screening firefighters for skin cancer
My brother was a firefighter in Chelsea, Massachusetts, an instructor at the Massachusetts FireAcademy, and a member of the hazmat team. At the age of 36, he was diagnosed with occupationalesophageal cancer. A year later, he lost his battle with cancer. During that year, I scoured themedical research learning as much as I could about occupational cancer in the fire service. Duringthe 1980s, Boston firefighters started to notice their fellow firefighters were developing cancer morethan their non-firefighter friends and relatives. These reports sparked the first firefighteroccupational studies. Massachusetts cancer registry data showed firefighters had the highestincidence of cancer, followed by police, and then all other occupations. Melanoma was found to beelevated in firefighters. Many other small studies worldwide appeared over the subsequent years.These studies lacked power and many studies were not statistically significant. In 2001, the WorldTrade Center disaster occurred. This event created a large cohort of first responders with a similarexposure, which rarely happens in the fire service. These individuals were then enrolled intolongitudinal cohort studies which continue today and investigate all aspects of health includingcancer.
Firefighters have unique occupational health risks due to their jobs. Chemical exposures increasethe rate of cancer, cardiovascular systems are stressed due to endorphin surges and physical labor,circadian rhythms are offset by shift work, pulmonary disease occurs from the inhaled irritants,traumatic events seen in car accidents can expose firefighters to infectious diseases and post-traumatic stress disorder.
American firefighters can be divided into career or volunteer. The majority of firefighters in theUnited States are volunteer. The career firefighters tend to be in cities and larger municipalities.These individuals are younger, tend to have previous military experience, and have insurancebenefits associated with their job. The volunteer firefighters have primary jobs in other fields whichmay or may not provide health benefits, they tend to be older and less physically fit. TheInternational Association of Firefighter (IAFF) union represents the career firefighters. IAFF line ofduty deaths from 2002-2020 are documented as 67% from cancer, 17% from cardiovascular events,and the rest are from trauma, burns, infections, etc.
In 2014, NIOSH conducted a cohort study of 30,000 firefighters from 1950-2009 in San Francisco,Chicago, and Philadelphia. This study found that firefighters were 9% more likely to develop cancerand the mortality rate was 14% higher than age-matched controls. Unfortunately, this study did notinclude melanoma. The Nordic study, which was also published in 2014, looked at 45 years of dataand found an elevated rate of cancer but more specifically, melanoma and prostate cancer occurredin firefighters aged 30-49 years of age. Other larger cohort studies and then meta-analyses havecontinued to show there is an elevated rate of cancer and melanoma in firefighters.
Firefighters are exposed to many different carcinogens which can include benzene, diesel exhaust,chloroform, soot, styrene, and formaldehyde to name a few. Soot contains known carcinogens, suchas polyaromatic aromatic hydrocarbons, which are forever chemicals and are not destroyed oreliminated with the high temperatures of a blaze but become aerosolized. These carcinogens arethen inhaled, ingested, and absorbed through the skin. Firefighters are tactical athletes, so thephysical demands and hot environment allows for increased pore size which in turn allows for theabsorption of these carcinogens. Firefighters report smelling like a fire for three days post the event.Urine and blood levels of PSH are elevated three-to-five-fold after a fire. Carcinogen exposures canvary depending on if the fire involves a house, a vehicle, a forest, or an industrial building; can varygreatly depending on where the firefighter is positioned in the attack of the fire. These carcinogenshave been found on personal protective equipment, within the cabs of the engines, and within thefire house. So, the exposure continues well after the fire has ended. Established protocols nowadvise firefighters to wipe the soot offtheir skin at the fire scene, wash PPE once they return to thestation, and PPE is now not allowed within the living quarters to reduce the carcinogen exposure.
Melanoma is the most important cancer diagnosis a dermatologist can detect. When considering allthe cancers a firefighter could develop, a melanoma can easily and efficiently be screened bydermatologists in health screenings held at fire stations or community centers. Firefighters do nottypically have care established with dermatologists. Males in America have the highest risk ofmelanoma and the majority of firefighters are male.
An annual full skin exam is essential for firefighters as the carcinogenic compounds have beenfound on their gear, and inside the engines and fire stations so their entire body is at risk ofdeveloping melanoma. Furthermore, many of the career firefighters have served our countryoverseas and have potentially been exposed to the carcinogens in the military such as fire pits.
I find the link between skin cancer and occupational exposures particularly fascinating. The majorityof melanomas are due to UV exposure from the sun. Not all melanomas are the same in terms ofthe DNA damage but also melanomas have been associated with some occupations such as infactory workers and electrical lineman. The melanomas seen in firefighters could signify a differentmechanism of DNA damage from the direct exposure of the carcinogens to the skin. Furtherresearch is needed to examine and possibly elucidate the mechanisms by which firefighters developmelanomas.
Volunteering is easy and so rewarding. Dermatologists can contact their state societies atwww.aad.org/member/advocacy/state/state-resources/society-toolkit-screenings, or checkout the AAD SPOT SkinCancer™ website at www.aad.org/member/career/volunteer/spotfor atoolkit and instructions for how to provide screenings. Additionally, the Firefighter Cancer SupportNetwork has an educational course geared to educating firefighters about the risks of cancer, howto screen for cancer, and the signs and symptoms of cancer.
Dr. Kannler is a Mohs surgeon for Northeast Dermatology Associates,practicing in North Andover, Massachusetts, and Manchester and Bedford, New Hampshire.
