By: Tony Stefani
“You have cancer”—three mind-numbing words that now seem to resonate throughout the entire firefighting profession.
On Jan. 6, 2001, I was out on a long morning run. With about one mile left, I had to stop and walk. This had never happened to me before. I was exhausted. I got back to the gym, went to the john and pissed blood. I headed straight to my doctor’s office and within a few weeks was diagnosed with Transitional Cell Carcinoma (TCC) in my right renal pelvis, a rare form of cancer normally found in 1 in 100,000 people. At the time, I was the captain at San Francisco Fire Department Rescue 1, located in Station 1, and was just about to turn 50 years old with 27 years on the job.
I was extremely fortunate to be referred to a brilliant urologist at the University of California San Francisco (UCSF). On my first office visit he asked me if I smoked or if I worked in the chemical industry. My response to both was “no.” I told him I was a firefighter. He looked up at me and said, “So you do work in the chemical industry”—a profound statement that I will never forget and one that every firefighter must realize. He performed a radical nephrectomy removing my right kidney and ureter and basically ended my career fighting fires.
Within a couple of years, two more firefighters at Station 1 were diagnosed with TCC of the bladder. I told my doctor what was happening and his response was, “this is very unusual and should be looked into as soon as possible.” It also seemed like we were attending funerals on a monthly basis of firefighters succumbing to some form of this insidious disease. We all knew something had to be done.
I arranged a meeting with the Executive Board of San Francisco Firefighters Local 798 expressing my concerns as to what seemed to be elevated rates of cancer in our department. I presented my idea of forming a non-profit foundation to address the issue of rising cancer rates; the idea was welcomed with open arms. I stressed the importance of establishing a foundation that would be its own entity, not part of the administration and run by a president and board of directors who would be decision makers. I also met with the department administration and explained the idea and the concept behind the foundation. We were all in agreement. Within a week I got a call from Tom O’Connor, then-vice president of Local 798. He told me the union board had authorized a $100,000 donation to get the foundation started. Tom began working with attorneys to get our non-profit status. Within six months the San Francisco Firefighters Cancer Prevention Foundation (SFFCPF) was a registered 501-3c with the State of California and the board of directors was established with executive positions filled.
The first order of business after the by-laws were in place was to send out a department-wide survey to both active and retired San Francisco firefighters to get an idea of how many had been affected by the disease. There was no cancer database, no cancer registry of any kind, so we had no clue what the numbers were. Approximately 775 retired firefighters responded to the questionnaire and there were 237 active cases of cancer. This number does not include the number of firefighters who had lost their lives to the disease. Among active firefighters, approximately 665 responded and there were 33 active cases. It was time to get to work.
The mission statement of the SFFCPF can be summed up in a few words: “We are dedicated to the early detection and prevention of cancer in both active and retired San Francisco firefighters.” At the time the foundation was established, we had two consulting physicians from UCSF on our board. We sat down with them and explained our concerns about the rising rates of cancer in our department and need for science-based studies. We wanted to establish a direct link to elevated rates of cancer and toxic exposures in our profession.
First study focused on bladder cancer
With bladder cancer on the rise in the department, we decided to conduct a department-wide voluntary screening that would include retired firefighters. We teamed up with the Department of Urology at UCSF to conduct the study. We knew going into this study there would be one stumbling block…the department administration had recently put in place a “zero tolerance” policy for alcohol and drug abuse. They had the right to do random urine tests if there was reasonable cause to believe someone was using. We had to assure the firefighters that by no means was their urine sample going to be used for anything except the study. We gained their confidence and our first major study was underway. We teamed up with Dr. Marshall Stoller, professor and vice chairman of the Department of Urology at UCSF, and his colleague Dr. Kirsten Greene.
Close to 1,000 active and retired San Francisco firefighters took part in the study. Urine samples were collected, tested for hematuria and then tested for a specific protein in the urine known as NMP-22. Elevated levels of this protein can possibly indicate bladder cancer. Two retired firefighters and one active firefighter tested positive for both hematuria and elevated levels of NMP-22 in their urine. Follow-up with their doctors confirmed that all three had TCC. Two of them had TCC of the bladder and one had TCC of the right renal pelvis. At the time the test was administered, none of these three were aware that they had cancer.
This was definitely an eye opener for all of us. Dr. Greene presented the study along with her concerns of higher rates of bladder cancer in firefighters at the annual American Urological Association meeting in 2007. What did we learn from this? We came to understand how toxic chemical exposures can have a negative impact on the genitourinary system. Once the filters of the kidneys pass fluid into the bladder, toxins that remain in the fluid can cause cellular changes in the bladder eventually causing cancer. Since 2007, we have offered the screening every other year catching six more firefighters with various forms of cancer.
The SFFCPF has also offered fecal immunochemical tests to both our active and retired firefighters in conjunction with UCSF. In San Francisco we recommend that every firefighter starting at the age of 40 take part in this screening.
Exposure to flame retardant chemicals
In 2009, our foundation was contacted by Arlene Blum, PhD, Biophysical Chemist, Visiting Scholar at UC Berkeley’s Department of Chemistry. She expressed her concerns to us about the toxicity of flame retardant chemicals and our elevated rates of cancer. Everyone is exposed to these toxins but firefighters really take a hit as was revealed in the HBO documentary, “Toxic Hot Seat.” After a working fire, flame-retardant chemicals (polybrominated biphenyl ethers—“PBDE’s”) off-gas both furans and dioxins. These cancer-causing chemicals bio-accumulate in our bodies. We became very concerned so we conducted our own study with Dr. Susan Shaw. After two separate working fires, 12 firefighters agreed to give blood samples to see if they had elevated levels of PBDE’s. This pilot study showed that our firefighters had levels of PBDE’s 60% higher than the general population. The study was peer reviewed and published in Chemosphere. What did we learn? The importance of SCBA’s during overhaul and the need for immediate gross decontamination before leaving the scene.
In 2010, we were contacted by the National Institute for Occupational Safety and Health (NIOSH) and invited along with Chicago and Philadelphia fire departments to take part in a first-of-its-kind study looking at the causes of death in firefighters dating back to 1950. The study cohort was close to 30,000 firefighters, the biggest study cohort in the history of the profession. We were told up front by the NIOSH epidemiologists not to expect elevated rates of cancer in our profession since we were considered a “healthier work group.” We thought otherwise.
In 2013, NIOSH published its findings. The study found firefighters to have higher rates of the following cancers: oral cancers, respiratory cancers, digestive system cancers, cancers of the genitourinary system, twice the rate of malignant mesothelioma and higher rates of prostate cancer in men under the age of 65. What did we learn? There is a direct link to our profession and higher rates of cancer. With hard scientific evidence in place from SFFCPF studies showing the correlation between toxic chemical exposures on the job, San Francisco Mayor Ed Lee signs into law the Firefighters Cancer Presumption Law for San Francisco firefighters.
In 2012, a department survey found that we have six times the rate of breast cancer in our female firefighters in the 40- to 50-year-old age group. A collaborative project with the Labor Occupational Health Program at the University of California Berkeley was put in place and a breast cancer summit was held with major institutions invited. The Women Firefighter Biomonitoring Collaborative was formed to examine toxic exposures that may disrupt the body’s normal hormone function—a first-of-its-kind study dealing with the health of our female firefighters. Preliminary results will be published this year.
After the diagnosis
Once a firefighter is diagnosed with cancer and a pathology report is made available, our foundation’s research/navigator, retired firefighter and cancer survivor Jeff Malone, will assist the firefighter step-by-step through this very difficult time. After a course of treatment is recommended by the treating physician, he will refer the firefighter to UCSF, Stanford or possibly as far away as M.D. Anderson in Texas for a second opinion. Jeff will arm the firefighter with a list of pertinent questions to ask the doctor, so by the time the firefighter walks out of the doctor’s office he or she will have a much better understanding in the decision-making process. He will then help decipher treatment protocols made available and assist in finding the most successful treatment options. They are supported every step of the way.
We have played a role in advocacy as well. We have a deep concern about a chemical industry that is basically unregulated. I have had the opportunity to give testimony at both state legislative committees and Congressional committees in Washington D.C. about overhauling the Toxic Substances Control Act of 1976. Since the law was passed only 200 of the original 60,000 chemicals have been tested for safety. Today there are over 80,000 chemicals and the EPA has required very few of these to be tested. We are basically the canaries entering the cave.
The future of SFFCPF
This year we celebrate the 10-year anniversary of our foundation. Our short-term goals have been accomplished but the job is far from done. We have lost over 200 active and retired firefighters since the foundation’s inception. At this time, close to one in two firefighters in San Francisco are contracting some form of cancer. These numbers are unacceptable. We now look forward to mid- and long-term goals. On the immediate agenda is a pilot study underway that we have funded at UCSF to evaluate the key flame-retardant compound effect in human cell models of human disease. The aim of the study will be to determine the toxicity of known flame-retardant compounds in human cell culture models and to evaluate the effects of possible counter measures in the prevention or reversal of toxicity of these chemicals. The outcome will not only greatly benefit firefighters but also the general population.
We also have to take a seriously look at the culture of our profession. We all have a tremendous amount of pride in what we do as well as a strong sense of infallibility with a love for tradition. Do we continue to aggressively attack fires? In my opinion, absolutely, but we must also consider the long-term effects if we do not protect ourselves.
Two years ago I gave the eulogy at Captain Dan Armenta’s funeral. Dan was the captain of Engine 1, one of the busiest engine companies in the United States. Dan and I grew up together in the city and were friends since the age of five. Dan was the fifth firefighter at Station 1 to contract TCC, and the third from our firehouse to lose his life to this insidious disease. He left us in the quiet of a hospital room surrounded by family and friends. He died with his boots off, but he did not die in vain.
His voice and the voices of the men and women of our profession who have lost their lives to cancer will continue to resonate in our minds giving us the strength to continue to push for peer-reviewed scientific research showing the direct link to cancer from on-the-job toxic exposures. Our profession must reach the point where our civic leaders can no longer turn their backs on the evidence produced and where every municipality adopts firefighter cancer presumptive legislation.
ANTHONY STEFANI started with the San Francisco Fire Department in 1974. The 28-year veteran retired as the captain of Rescue 1 in 2003. He has an associate's degree in fire science, is a blackmask certified diver and holds a number of technical rescue certifications, including surf and cliff rescue and served as an instructor for Rescue Systems I and II. After being diagnosed with Transitional Cell Carcinoma in 2001, he founded the San Francisco Firefighters Cancer Prevention Foundation and now serves as president.