Screening firefighters for skin cancer
First Person
By Christine Kannler, MD, FAAD, October 1, 2022
DermWorld’s First Person column offers Academy members the opportunity to share their personal reflections about how dermatology is changing and how they’ve adapted.
Firefighters have unique occupational health risks due to their jobs. Chemical exposures increase the 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 the United 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 insurance benefits associated with their job. The volunteer firefighters have primary jobs in other fields which may or may not provide health benefits, they tend to be older and less physically fit. The International Association of Firefighter (IAFF) union represents the career firefighters. IAFF line of duty 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 cancer and the mortality rate was 14% higher than age-matched controls. Unfortunately, this study did not include melanoma. The Nordic study, which was also published in 2014, looked at 45 years of data and found an elevated rate of cancer but more specifically, melanoma and prostate cancer occurred in firefighters aged 30-49 years of age. Other larger cohort studies and then meta-analyses have continued to show there is an elevated rate of cancer and melanoma in firefighters.
AAD SPOT Skin Cancer
The SPOT Skin Cancer initiative helps reduce the incidence of skin cancer and saves lives by building shade structures, providing free skin cancer screenings, and installing sunscreen dispensers. Learn more about how you can get involved at SPOT Skin Cancer or email screenings@aad.org.
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, such as polyaromatic aromatic hydrocarbons, which are forever chemicals and are not destroyed or eliminated with the high temperatures of a blaze but become aerosolized. These carcinogens are then inhaled, ingested, and absorbed through the skin. Firefighters are tactical athletes, so the physical demands and hot environment allows for increased pore size which in turn allows for the absorption 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 can vary depending on if the fire involves a house, a vehicle, a forest, or an industrial building; can vary greatly depending on where the firefighter is positioned in the attack of the fire. These carcinogens have been found on personal protective equipment (PPE), within the cabs of the engines, and within the fire house. So, the exposure continues well after the fire has ended. Established protocols now advise firefighters to wipe the soot off their skin at the fire scene, wash PPE once they return to the station, 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 all the cancers a firefighter could develop, a melanoma can easily and efficiently be screened by dermatologists in health screenings held at fire stations or community centers. Firefighters do not typically have care established with dermatologists. Males in America have the highest risk of melanoma and the majority of firefighters are male.
An annual full skin exam is essential for firefighters as the carcinogenic compounds have been found on their gear, and inside the engines and fire stations so their entire body is at risk of developing melanoma. Furthermore, many of the career firefighters have served our country overseas 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 majority of melanomas are due to UV exposure from the sun. Not all melanomas are the same in terms of the DNA damage but also melanomas have been associated with some occupations such as in factory workers and electrical lineman. The melanomas seen in firefighters could signify a different mechanism of DNA damage from the direct exposure of the carcinogens to the skin. Further research is needed to examine and possibly elucidate the mechanisms by which firefighters develop melanomas.
Volunteering is easy and so rewarding. Dermatologists can contact their state societies, or check out AAD SPOT Skin Cancer™ for a toolkit and instructions for how to provide screenings. Additionally, the Firefighter Cancer Support Network has an educational course geared to educating firefighters about the risks of cancer, how to screen for cancer, and the signs and symptoms of cancer.
To learn more, visit the Massachusetts Fire Academy, and the Firefighter Cancer Support Network.
Dr. Kannler is a Mohs surgeon for Northeast Dermatology Associates, practicing in North Andover, Massachusetts, and Manchester and Bedford, New Hampshire.
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