Focusing on female firefighter cancer

Existing measures in place to offset firefighters’ increased cancer risk do not adequately address the variety and earlier onset of work-related cancers in women, suggests a recent international study.

Published in March 2023 in the journal Frontiers in Public Health, the peer-reviewed article “Cancer in Female Firefighters: The Clinicobiological, Psychological, and Social Perspectives” studied how demographics, life experiences and firefighting exposures impact cancer in female firefighters in Canada the United States and abroad, described the cancer characteristics reported by the women.

The research was based on a year-long survey of 1,344 active female firefighters from 2019 to 2020, mostly from Canada and the United States, along with a comprehensive literature review. Of those surveyed, 256 provided information on their cancer experience and were an average age of 39 at diagnosis. Commonly reported challenges included psychosocial, financial, physical and spiritual, along with lack of support from employers and insurers.

“This work makes an important contribution to the limited body of research available on female firefighter health,” noted Lori Moore-Merrell, DrPH, MPH, U.S Fire Administrator. “In the traditionally male-dominated career of firefighting, it’s not surprising that much of the research has historically focused on men’s health. The demographics are changing, however, and the research needs to keep up to provide the same degree of attention and care to all the men and women who help protect our communities.”

Based in B.C., the study team included Kenneth Kunz, Kate Turcotte, Samantha Pawer, Alex Zheng, Amanat Purewal, Alyssa Wellar, Shazya Karmali, Len Garis, Larry Thomas and Ian Pike. The authors brought their knowledge of injury prevention, firefighting, medicine and cancer to the work, with affiliations to the BC Injury Research and Prevention Unit at British Columbia Children’s Hospital, the School of Culture, Media and Society at the University of the Fraser Valley, Surrey Fire Service, and the Department of Pediatrics at the University of British Columbia, as well as expertise in medical oncology, molecular pharmacology and firefighter cancer.

The cancer research builds on earlier work on female firefighter injuries from the same study, published in May 2022 by Frontiers in Public Health in the peer-reviewed article “Female Firefighter Work-Related Injuries in the United States and Canada: An Overview of Survey Responses.”

Study details

Cancer continues to be a principal source of chronic illness and one of the leading types of all-cause mortality in Western nations. Numerous studies have confirmed an association between firefighting and cancer, but prior to the development of this study, none had included a large enough sample of women to draw specific conclusions regarding cancer risk for female firefighters.

As a result, data is lacking for a variety of parameters related to female firefighter cancers, such as types of cancers, means of clinical presentation, methods of diagnosis, tumour stages, tumour and tissue grading, and therapeutic strategies.

Like their male counterparts, female firefighters have been shown to develop cancer at rates substantially higher than the general public – as much as 24 to 64 per cent, studies have estimated.

In addition to cancers they have in common with men – such as melanoma, colorectal and thyroid – women are up to 100 times more likely to have breast cancer than men, and are vulnerable to many different forms of female-specific cancers such as endometrial, cervical, vulvar, vaginal, ovarian and fallopian tube cancers. Studies have also pointed to higher rates of miscarriage and delivery of low-birth-weight infants than the general population.

As a step toward closing the gap in female firefighter health data, the research team developed an online survey for female career and volunteer firefighters to gather information on the clinical, social, psychological and financial ramifications of a cancer diagnosis. The study was designed and interpreted by a medical oncologist and promoted through industry blogs, magazines, firefighting associations and fire/rescue research and health organizations.

Participants provided their consent and answered questions approved by the University of British Columbia Children’s and Women’s Research Ethics Board. The survey was available in English and French from June 7, 2019 to July 19, 2020, using REDCap electronic data capture tools hosted by the Provincial Health Services Authority in B.C.

Survey results were considered alongside a comprehensive literature review of relevant studies in the U.S. and Canada.

The toll of cancer

A total of 1,344 female firefighters from 12 countries responded to the survey, 92 per cent of those from North America. On average, respondents were 39.6 years old and had worked in the fire service for 14.5 years.

The 256 respondents who provided information on their cancer experience tended to be older – an average of 42.8 years old – and were more likely to be career fighters as opposed to volunteers, and hold positions such as Company or Station Officer, Driver or Engineer, or Chief Officer or Superintendent.

More of the respondents with cancer reported tobacco use than those without (32.8 per cent compared to 24.2 per cent), but there were no statistical differences in alcohol consumption, hormone use, family history of cancer, height, weight and body mass index.

The major types of cancer reported were breast (25.4 per cent), cervical (21.1 per cent), melanoma, (20.7 per cent), basal/skin cell (16.4 per cent), uterine, (14.8 per cent), colorectal (6.3 per cent), thyroid, (5.9 per cent) and ovarian (5.1 per cent). Of note are the higher percentages of cervical cancer and melanoma reported by the respondents than women in the general population.

About 42 per cent of the cancers were detected when the respondents sought medical attention for a symptom, 29.8 per cent during a routine health screen, 28.1 per cent during a specific cancer screen and 6.6 per cent by other means.

For about 46 per cent of those with cancer, the diagnosis had little to no impact on their daily lives, other than increased stress while waiting for test results. In these cases, their condition was precancerous or the cancer was either not invasive or had been detected early and treated quickly.

Other respondents reported a variety of challenges related to their cancer or treatments, including 33.2 per cent reporting psychosocial impacts (anxiety and impacts on personal relationships), 18.8 per cent reporting financial impacts (early retirement or medical costs), 6.6 per cent reporting physical impacts (pain, feeling ill, recovery, energy level, appearance or anatomical) and 6.3 reporting spiritual impacts.

When it came to reporting cancer to their employer, the leading concern (11.3 per cent) was about keeping health information private, followed by 7.4 per cent feeling vulnerable, seven per cent about being perceived as weak, 5.5 per cent about experiencing discrimination from supervisors and 5.1 per cent about losing credibility.

Of those who described barriers to reporting cancer in their workplace, common issues were lack of support from their employer or insurer – such as their condition being minimized or misunderstood – along with increased workplace stress, and the potential for having to engage in litigation with the fire service. Some respondents described added challenges with insurance and presumptive coverage for their cancers, including lack of coverage for female-specific cancers such as ovarian, while coverage was provided for male-specific cancers such as prostate.

The survey also collected information about the mental health impacts of firefighting, including issues specific to women, such as isolation from being the only female in a department, pressure to perform the same tasks as males, bullying or hazing, returning to work after maternity leave, and fertility issues.

Improving health outcomes for all firefighters

Cancer continues to take a high toll on firefighters – in fact, up to 85 per cent of all firefighter cancer deaths in Canada may be caused by occupational cancers, according to a study that followed Canadian firefighters from 2006 to 2015 and was conducted by researchers at the Injury Research and Prevention Unit at the University of B.C. and University of the Fraser Valley.

New insights on carcinogen exposure highlighted in the U.S.- based peer-reviewed Journal of Occupational and Environmental Hygiene may help change this distressing statistic.

Published in January 2023, “Effectiveness of Dermal Cleaning Interventions for Reducing Firefighters’ Exposures to PAHs and Genotoxins” by Jennifer L. A. Keir, Tracy L. Kirkham, Rocio Aranda-Rodriguez, Paul A. White and Jules M. Blais suggests that traditional decontamination methods have no impact on the levels of polycyclic aromatic hydrocarbons (PAHs) in the urine of firefighters.

These findings point to the need for measures that reduce firefighters’ initial exposure to toxins. Some potential solutions may be found in the journal’s August 2022 article “Hierarchy of Contamination Control in the Fire Service: Review of Exposure Control Options to Reduce Cancer Risk” by Gavin P. Horn, Kenneth W. Fent, Steve Kerber and Denise L. Smith.

Horn et al. identified a variety of evidence-based measures to better separate firefighters from toxins, including changes during emergency responses (including procedures and configuration of apparatus and fire stations), options for live-fire training including alternate fuels and virtual reality, revisiting materials used in flame retardants and personal protective equipment, switching to hybrid or electric vehicles, and enhancing public fire prevention education.

Canada’s lawmakers are also taking promising steps that could help save firefighter lives.

Bill C-224, a Private Member’s Bill sponsored by MP Sherry Romanado of Longueuil-Charles-LeMoyne in Quebec, is proposing a national framework for the prevention and treatment of cancers linked to firefighting.

At the moment, firefighters across Canada do not have receive the same level of cancer care because not all provinces recognize the full range of occupational cancers experienced by male and female firefighters.

Bill C-224 intends to raise awareness of all types of firefighting-related cancers, with the goal of improving access to cancer prevention and treatment across the country. The bill received third  reading in the House of Commons in March 8^th , 2023 and first reading by the Senate March 9^th 2023 , at time of publication and preceding  was  also considered by the Standing Committee on Health following presentation of the amended report in December 2022.

While these initiatives show promise in expanding the knowledge and awareness of the cancer risks faced by firefighters, continued and dedicated effort is required to address the imbalance of attention paid to female firefighter cancers and health.

“Early cancer detection and treatment saves lives. The survey results analyzed in this research article are an important addition to understanding the potential impacts of work-related exposures for female fire fighters.” said Victoria Lee, MD, MHP, MBA, CCFP, FRCPC, President and Chief Executive Officer, Fraser Heath Authority in British Columbia.

Read “Cancer in Female Firefighters: The Clinicbiological, Psychological, and Social Perspectives” in Frontiers in Public Health at: https://www.frontiersin.org/articles/10.3389/fpubh.2023.1126066/abstract

Larry Thomas is the Fire Chief for the City of Surrey B.C. and is an Executive Chief Fire Officer, ECFO and Chartered Manager, C. Mgr with 31 years’ experience. He has a background in Science from Simon Fraser University and Economics from Douglas College. Contact him at LSThomas@surrey.ca

Len Garis, Fire Chief (ret) for the City of Surrey, B.C., associate scientist emeritus with the B.C. Injury Research and Prevention Unit, adjunct professor at the University of the Fraser Valley, and a member of the Affiliated Research Faculty at John Jay College of Criminal Justice in New York. Contact him at Lwgaris@outlook.com

Ian Pike is a professor with the Department of Pediatrics in the Faculty of Medicine at the University of British Columbia, Director of the British Columbia Injury Research and Prevention Unit, Investigator for the BC Children’s Hospital Research Institute, and Co-Executive Director for the Community Against Preventable Injuries. Contact him at ipike@bcchr.ca