Firefighter Cancer: The Massachusetts Experience

My younger brother, Peter, was a firefighter in Chelsea, MA, an instructor in the Massachusetts Firefighting Academy (MFA) burn building and a hazmat technician. He was selected to be trained as an instructor to teach the Firefighter Cancer Support Network (FCSN) course “Taking Action Against Cancer in the Fire Service.” The MFA was starting an initiative to educate and to try to reduce the incidence of cancer.

My brother received his stage 4 esophageal cancer diagnosis in July 2015, and he passed away in September 2016. As an older sister of a firefighter who died from cancer who is armed with multiple board certifications in internal medicine, dermatology and Mohs micrographic surgery and a master’s degree in public health, I was propelled on a mission: Peter’s death was wrong and signified an enormous gap in medical care.

Massachusetts takes action

In 2017, I began to offer free skin cancer screenings at the fire stations where Peter worked. These firefighters knew me, which made them more comfortable with the screenings. It didn’t take long for me to realize that my effort could be scaled to benefit firefighters across the entire state of Massachusetts.

To make this happen, I contacted the president of the Professional Fire Fighters of Massachusetts and educated him on the elevated risk of melanoma among firefighters. With his endorsement, I started to screen firefighters across the state on my own, free of charge.

Given Peter’s role as an instructor at the MFA, I scheduled a meeting with the academy’s director to discuss expanding the screenings and cancer education to recruits. This collaboration, along with support from Abby Baker, who is the MFA’s administrator, provided the administrative backing to scale the program. It eventually grew into a robust initiative that now reaches departments and municipalities across the state.

Cancer program in Massachusetts

The success of this initiative is the result of the teamwork of progressive thinkers: a strong union, a supportive fire marshal, an innovative fire academy and dedicated physicians. Together, we built a comprehensive cancer education and screening program that continues to expand and evolve.

Here’s how the program works:

Enrollment. A municipality contacts Baker to enroll in the cancer screening program.

Education. A trained instructor teaches the FCSN’s “Taking Action Against Cancer in the Fire Service” class at the local fire station. The class covers:

The carcinogenic risks that firefighters face.
The elevated cancer risk that’s particular to firefighters.
The importance of lifestyle choices in reducing cancer risk.
Stories of local firefighters who have battled cancer, to drive home the reality that it can happen to anyone.

Screenings. A board-certified dermatologist travels to the fire station to provide free skin cancer screenings through the American Academy of Dermatology’s (AAD) SPOT Skin Cancer program. If a suspicious lesion is flagged, Baker follows up with the firefighter to offer assistance in finding a dermatologist for further evaluation.

As part of the visit, we also educate firefighters about their overall cancer risks, what symptoms to look out for and how to seek care. We distribute resources, such as Dr. Michael Hamrock’s recommended screening list, the National Foundation for Cancer Research tracking app and the National Firefighter Registry for Cancer QR code.

However, we quickly discovered that many primary care providers (PCPs) were unaware of the unique cancer risks that firefighters face. Many firefighters reported that their PCP wasn’t engaging in the recommended cancer screening tests, because the lists of these screening don’t come from recognizable healthcare endorsements, so coding issues with insurance often arose.

The Massachusetts legislature was approached to create a fund through an earmark to provide free cancer screening for Massachusetts firefighters. Once the grant was obtained, the fire marshal, Hamrock and I determined that the best first screening tests to offer would be a low-dose lung CT scan and a prostate PSA blood test.

Reasoning

All firefighters should have a primary PCP who they see annually to check their blood pressure and to have a blood test, a urine test and, possibly, a chest X-ray, all of which are low cost.

An elevated blood pressure can detect hypertension, and interventions can be started to reduce the risk of a heart attack.

The blood test (complete blood count with differential) can detect a blood cancer, such as lymphoma and leukemia. It’s important to understand that blood cancers typically occur as early as three years after exposures. A blood chemistry panel can detect abnormal kidney function, abnormal liver function and high cholesterol, all of which can be reversed when detected early.

A urine test can detect microscopic blood, which could be a urinary cancer; sugar, which could be diabetes; and protein, which could be a few conditions, such as kidney failure.

Some PCPs are comfortable with evaluating skin for cancer.

The U.S. Preventive Services Task Force (USPTF) recommendations are used by PCPs to screen patients for cancer and other health conditions, but occupational exposures aren’t incorporated. Furthermore, there are no USPTF recommendations that are specific for the health risks of firefighters. When creating the cancer screening program in Massachusetts, we wanted to add screenings tests to detect known firefighter cancers, such as prostate cancer and melanoma, with PSA and the skin exam.

The other screening test that we opted to add was a low-dose lung CT scan. One trip to the scanner can provide a photograph of the thyroid to the top of stomach. This is the same test that American smokers receive to screen for lung cancer. (Ironically, firefighters are exposed at fire scenes to all of the same carcinogens that are found in cigarettes.)

In Massachusetts, firefighters could opt to pay out of pocket for the cardiac calcium score, as it is performed in the same scanner. So, one trip to the scanner could evaluate a firefighter for approximately 75 percent of causes of line-of-duty deaths.

The inclusion criteria for a firefighter to receive the low-dose chest CT scan and/or the PSA are:

Massachusetts resident.
40 years old or older.
Ten years or more in the fire service.
Have a PCP, because the results are sent to the firefighter and to a PCP.

From the onset of the program, it always was an option to pay out of pocket at the discounted price point for the above tests if the inclusion criteria weren’t fulfilled. (My brother wouldn’t have qualified but would have benefitted.)

Issues that might be encountered can include:

The PCP refuses to discuss findings with the firefighter because “I didn’t order this.”
It doesn’t include military exposure.
It doesn’t include cardiac calcium score.

Expansion/future

We added mammograms and ultrasound of organs and a specification to repeat the low-dose lung CT scan every 3–5 years to detect changes earlier or if symptoms develop, such as persistent cough. We modified the inclusion criteria to be 10 years in the fire service or age 40, not both.

Reflection

As I reflect on this journey, I have messages for every firefighter. Get an annual physical with your PCP. Look at your lab results and ask questions when something doesn’t seem right.

Perform regular self-exams for skin, testicular and breast cancer.

Know your numbers and understand your health.

Request the FCSN’s “Taking Action Against Cancer in the Fire Service” class for your department.

Take care of yourself after each fire call: Use wipes to clean soot off your skin, and shower as soon as possible. Eat antioxidant-rich foods, such as berries and broccoli.

Finally, please replicate our system, so firefighters can benefit as those who are in departments in Massachusetts do.