1. 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

2. 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 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;

3. Occupational Environ Med 2014

4. 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

5. 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

6. 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.

7. 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 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)

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

9. 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

10. 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)

11. 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.

12. Lancet 2011

13. 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.

14. FDNY Study Cohort Demographics
~1,000 not WTC
Mean 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.

15. FDNY WTC Exposure Demographics
Number of WTC-exposed firefighters (N=8927*)
FDNY exposure categories†—time of first arrival at WTC site
Morning of 9/ (18%)
Afternoon of 9/ (49%)
Day of Sept 12, (18%)
Any day between Sept 13, 2001 & Sept 24, (14%)
Any day between Sept 25, 2001 & July 25, (1%)
Common exposure categories—type of exposure on day of 9/11
Heavily exposed to the dust cloud (19%)
Working on the pile but not heavily (47%)
exposed to dust cloud
Present but not working on the pile and (1%)
not heavily exposed to the dust cloud
Not present in lower Manhattan on 9/ (30%)
Missing type of exposure information (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.

16. 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

17. 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.

18. 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

19. 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

20. 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

21. 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

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

23. 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?

24. 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

25. 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

26. THANK YOU