The Largest Firefighter Cancer Study Continues and Expands The Three City Firefighter Cohort Study and the FDNY Cohort “Cancer Plus …..” David Prezant, MD, FDNY Chief Medical Officer, FDNY Special Advisor to the Fire Commissioner on Health Policy Director WTC Health Program Professor of Medicine Albert Einstein College of Medicine

Firefighting exposures includes known carcinogens Carcinogenic Agent Strong Association Suspected Association Aromatic Amines Bladder Prostate Metals Bladder, Lung, Skin, Soft Tissue Sarcoma, Nasal and Nasopharynx Brain/CNS, Renal, Liver, Biliary, Prostate, Pancreatic, Stomach Natural fibers/dust Laryngeal, Lung, Nasal and Nasopharynx Petrochemicals and combustions by-products Lung, NHL, Soft Tissue Sarcoma, Skin Bladder, Breast, Esophageal, Multiple Myeloma, Prostate Reactive chemicals Leukemia, Lung, NHL, Laryngeal, Liver, Biliary, Soft Tissue Sarcoma Breast, Nasal and Nasopharynx Solvents Leukemia, NHL, Liver, Biliary, Renal Brain/CNS, Lung, MM, Rectal, Hodgkin’s, Bladder, Esophageal Clapp RW, Howe GK, Jacobs MM. Environmental and occupational causes of cancer: a review of recent scientific literature. Lowell Center for Sustainable Production. Available from http://www.sustainableproduction.org; September 2005. Clapp RW, Howe GK, Jacobs MM. Environmental and occupational causes of cancer: A call to act on what we know. Biomedicine and Pharmacotherapy. 2007: 61;631-639.

Occupational Environ Med 2014

Chicago, Philadelphia, San Francisco Cancer NIOSH 3 City Cohort Study Chicago, Philadelphia, San Francisco Bladder * Brain Colon  Kidney Lung Melanoma Mesothelioma Multiple myeloma NHL Prostate Rectal Skin Stomach Testis Employed starting in 1950 Followed through 2009 Significant overall or in *specific age group

3 City Firefighter Cohort Firefighters from San Francisco, Chicago and Philadelphia NIOSH used roster information from the 3 departments to establish the cohort Dr. Daniels and colleagues studied cancer and mortality outcomes among these firefighters through 2009 FDNY/Albert Einstein College of Medicine received funding to continue follow-up for cancer and mortality We will match with state cancer registries We will contact the subset still alive to administer a questionnaire to obtain additional health information

Current status of the expanded study In July 2017 we received demographic information for San Francisco and Chicago. In December 2017 we received demographic information for Philadelphia and exposure history (runs etc.) on a subset of firefighters from each city.

Next steps Obtain death information from linkages to Social Security Administration and National Death Index NIOSH could not provide us with death data for cohort Assemble steering committee Chair: David Prezant Labor: Chicago, Philadelphia, New York & San Francisco Unions Fire Chiefs/Commissioners: Chicago, Philadelphia, New York & San Francisco Fire Departments NIOSH representative IAFF representative WTC Analytic Research Group representative Obtain cancer information from linkages to state cancer registries Outreach to alive members via mail, phone and email to complete the web-based questionnaire for additional health information Analyze results SSA is for vital status and death date NDI is for cause of death among those we know are dead (due to $ need to do it this way)

Demographics Source: Daniels RD, et al. Occup Environ Med 2014

Age as of 2018 – even if deceased All departments (N=29,992) San Francisco (N=5,313) Chicago (N=15,184) Philadelphia (N=9,495) Age group in 2018 (%) 20-29 4 (0.01) 4 (0.04) 30-39 1,001 (3.3) 115 (2.2) 472 (3.1) 414 (4.4) 40-49 2,972 (9.9) 551 (10.4) 1,593 (10.5) 828 (8.7) 50-59 4,231 (14.1) 754 (14.2) 2,581 (17.0) 896 (9.4) 60-69 4,382 (14.6) 729 (13.7) 2,310 (15.2) 1,343 (14.1) 70-79 3,903 (13.0) 752 (14.2) 1,458 (9.6) 1,693 (17.8) 80-89 3,097 (10.3) 400 (7.5) 1,911 (12.6) 786 (8.3) 90-99 3,794 (12.7) 795 (15.0) 1,936 (12.8) 1,063 (11.2) 100+ 6,593 (22.0) 1,214 (22.9) 2,914 (19.2) 2,465 (26.0) Note: contains deceased firefighters as we have not yet updated death status

All departments (N=29,992) San Francisco (N=5,313) Chicago (N=15,184) Philadelphia (N=9,495) Decade of hire (%) Before 1950 8,084 (26.9) 1,682 (31.7) 3,293 (21.7) 3,109 (32.7) 1950s 3,719 (12.4) 511 (9.6) 2,271 (15.0) 937 (9.9) 1960s 3,908 (13.0) 531 (10.0) 1,781 (11.7) 1,596 (16.8) 1970s 3,500 (11.7) 769 (14.5) 1,472 (9.7) 1,259 (13.3) 1980s 3,623 (12.1) 310 (5.8) 2,628 (17.3) 685 (7.2) 1990s 3,562 (11.9) 885 (16.7) 1,734 (11.4) 943 (9.9) 2000s 3,596 (12.0) 625 (11.8) 2,005 (13.2) 966 (10.2) Latest hire date 11/23/2009 5/26/2009 1/29/2009 Decade of retirement (%) 2,958 (9.9) 501 (9.4) 1,187 (7.8) 1,270 (13.4) 3,296 (11.0) 514 (9.7) 1,452 (9.6) 1,330 (14.0) 3,935 (13.1) 969 (18.2) 1,593 (10.5) 1,373 (14.5) 3,664 (12.2) 463 (8.7) 2,152 (14.2) 1,049 (11.1) 3,203 (10.7) 495 (9.3) 1,718 (11.3) 990 (10.4) 4,197 (14.0) 910 (17.1) 2,012 (13.3) 1,275 (13.4) Active (as of 1/1/2010) 8,739 (29.1) 1,461 (27.5) 5,070 (33.4) 2,208 (23.3)

Expanding the 3 City Firefighter Cohort We will add to the 3 City Firefighter Cohort the FDNY Cohort Greater Power to pick up Fire-related cancers Possible ability to distinguish WTC-related from Fire-related cancers All of above but for diseases of concern other than cancer such as COPD, etc.

Lancet 2011

FDNY Study Cohort (n=9,853) Active FDNY firefighters on 1/1/1996 Male White, black, or Hispanic Employed at FDNY for at least 18 months Had known WTC exposure status (exposed or unexposed) Were or would have been under age 60 on 9/11 Too few people who were over 60 and worked at WTC Our study was a longitudinal observational study, meaning we followed a group of firefighters starting in 1996 onward to see how many developed cancer. The group of firefighters we followed were: Active at the start of the study Male Whites, blacks and Hispanics The group was empolyed for at least 18 months Had known WTC exposure status And were or would have been less than 60 years old on 9/11 – this was because we had too few people who were over age 60 who also worked at the site.

FDNY Study Cohort Demographics ~1,000 not WTC Mean age @ 2018 ~ 60 Using the criteria just mentioned, we ended up with a sample of 9,853 male firefighters Most of whom were white and had never smoked (similar to the entire FDNY firefighter work force). On 9/11 their average age was 44 years old and only 15% of the cohort had retired.

FDNY WTC Exposure Demographics Number of WTC-exposed firefighters (N=8927*) FDNY exposure categories†—time of first arrival at WTC site Morning of 9/11 1600 (18%) Afternoon of 9/11 4409 (49%) Day of Sept 12, 2001 1616 (18%) Any day between Sept 13, 2001 & Sept 24, 2001 1211 (14%) Any day between Sept 25, 2001 & July 25, 2002 91 (1%) Common exposure categories—type of exposure on day of 9/11 Heavily exposed to the dust cloud 1702 (19%) Working on the pile but not heavily 4218 (47%) exposed to dust cloud Present but not working on the pile and 123 (1%) not heavily exposed to the dust cloud Not present in lower Manhattan on 9/11 2700 (30%) Missing type of exposure information 184 (2%) FDNY WTC Exposure Demographics 85% arrived day 1 or 2 Using the criteria just mentioned, we ended up with a sample of 9,853 male firefighters Most of whom were white and had never smoked (similar to the entire FDNY firefighter work force). On 9/11 their average age was 44 years old and only 15% of the cohort had retired.

Comparison Groups Compared to FDNY firefighters not at WTC (unexposed) Compared to the US population (general population) Rates by age group, gender, race, calendar year Can also compare to NYS and NYC populations - similar results, not published In Future will compare to the 3 City Firefighter Cohort To answer the study questions we compared cancer rates for firefighters at the WTC site to two groups Unexposed US population

Results All Cancers Exposed vs U.S. Population FDNY WTC-exposed Firefighters were up to 10% more likely to develop cancer than similar males in the U.S. population ~25 more cancer cases than expected With all cases: 10% increase means about 25 cases We found lung cancer rates were lower in the exposed population compared to the US population. This could be due to lower smoking rates among the firefighters compared to other similar Americans.

Delaying the date of diagnosis until the end of the study (2008): 19% increase  ~38 cases Corrected Incident Cancers - Delaying the date of diagnosis by 2 years  21% increase

Delaying the date of diagnosis until the end of the study (2008): 19% increase  ~38 cases Corrected Incident Cancers - Delaying the date of diagnosis by 2 years  21% increase

Specific Cancer Results Cancer site N FDNY (PY=61,884) SIR WTC Exposed All sites 263 1.10 (0.98 to 1.25) Lung 9 0.42 (0.20 to 0.86) Melanoma 33 1.54 (1.08 to 2.18) Prostate 90 1.49 (1.20 to 1.85) Thyroid 17 3.07 (1.86 to 5.08) Non-Hodgkin’s Lymphoma 21 1.58 (1.03 to 2.42) Multiple Myeloma ≤5 1.49 (0.56 to 3.97) Specific Cancer Results Note: Too few cases to achieve statistical power for any individual cancer analysis, but modest excess for Thyroid, Prostate, Colon and several Hematologic Cancers Lung is decreased – likely due to adjustment for smoking

Future FDNY Cancer Studies: Continued follow-up every 5 years Estimate future excess cancer burden in FDNY NIOSH non-WTC-exposed firefighter cohort Chicago, San Francisco, Philadelphia Biomarker precurser studies to identifdy cancer earlier Low Dose Chest CT Screening for Lung CA >5,000 persons with multiple scans Other Diseases of Interest It took decades of research to prove smoking causes cancer

Updated Number of Cancer Cases in the WTC-Exposed FDNY Firefighters 9/11/01 to 9/10/11

Updated WTC Cancers 2011 SIRs for Select Cancers with the US Male Population as the Reference and Correcting for Possible Surveillance Bias * Significant SIR This is a graph we have used to show the results from the Lancet paper to a lay audience. I LOVE THIS (MW)! CAN YOU ENLARGE?

WTC-exposed FDNY male firefighters compared to the 3 City Cohort male firefighters cancers diagnosed from 9/11/01-12/31/2009 Cancer type # FDNY Cases # 3 City Cohort Relative Rate Lower 95% CI Upper 95% CI All 345 443 0.96 0.83 1.12 Colon 14 21 0.73 0.33 1.59 Hematologic 40 41 1.04 0.64 1.71 Thyroid 17 3 3.82 1.07 20.81 Melanoma 1.69 0.93 3.13 Prostate 126 153 1.22 0.94 1.57 Lung 13 45 0.55 0.26 1.06

WTC-exposed FDNY male firefighters compared to the 3 City Cohort male firefighters cancers diagnosed from 9/11/01-12/31/2009 MGUS is a Multiple Myeloma pre-curser & is elevated in WTC exposed

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