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Mass Fireghters Cancer Study

Mass Fireghters Cancer Study

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Cancer Incidence Among Male Massachusetts Firefighters, 1987–2003
Cancer Incidence Among Male Massachusetts Firefighters, 1987–2003

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AMERICAN JOURNAL OF INDUSTRIAL MEDICINE 51:329–335 (2008)
Cancer Incidence Among Male MassachusettsFirefighters, 1987–2003
Dongmug Kang,
 MD
,
 PhD
,
1
Letitia K. Davis,
 ScD
,
2
Phillip Hunt,
 PhD
,
2
and David Kriebel,
 ScD
3
Background
 Firefighters are known to be exposed to recognized or probablecarcinogens. Previous studies have found elevated risks of several types of cancers in firefighters.
Methods
 Standardized morbidity odds ratio (SMORs) were used to evaluate the cancer risk in white, male firefighters compared to police and all other occupations in the Massachusetts Cancer Registry from 1986 to 2003. Firefighters and policewere identifieby text search of the usual occupation field. All other occupations included cases withidentifiable usual occupations not police or firefighter. Control cancers were those not associated with firefighters in previous studies.
Results
 Risks were moderately elevated among firefighters for colon cancer (SMOR
¼
1.36, 95% CI: 1.04–1.79), and brain cancer (SMOR
¼
1.90, 95% CI: 1.10– 3.26). Weakerevidence ofincreased risk was observed for bladdercancer (SMOR
¼
1.22,95% CI: 0.891.69), kidney cancer (SMOR
¼
1.34, 95% CI: 0.90–2.01), and Hodgkin’slymphoma (SMOR
¼
1.81, 95% CI: 0.72–4.53).
Conclusions
 These findings are compatible with previous reports, adding to theevidence that firefighters are at increased risk of a number of types of cancer.
 Am. J.Ind. Med. 51:329–335, 2008.
2008 Wiley-Liss, Inc.
 KEY WORDS: firefighter; cancer; SMOR; police; surveillance
INTRODUCTION
Firefighters are known to be exposed to recognizedor probable carcinogens. These include benzene, polycyclicaromatic hydrocarbons, benzo(
a
)pyrene, formaldehyde, chloro-phenols,dioxins,ethyleneoxide,orthotoluidine,polychlorinatedbiphenyls,vinylchloride,methylene chloride,trichloroethylene,dieselfumes,arsenic,andasbestos[Bendix,1979;Treitmanetal.,1980; Fitzgerald et al., 1986; Froines et al., 1987; Brand-Rauf etal.,1988,1989;Jankovicetal.,1992;BurgessandCrutchfield,1995;MoenandOvrebo,2001;Austinetal.,2001a,b;Cauxetal.,2002].In the past several decades, a number of studies on therelationship between firefighters and cancer have beenconducted [Brownson et al., 1987; Vena and Fiedler, 1987;Heyer et al., 1990; Sama et al., 1990; Demers et al., 1992;Guidotti, 1993; Aronson et al., 1994; Burnett et al., 1994;Tornlingetal.,1994;Guidotti,1995;Barisetal.,2001].Afterreview of the studies, several authors [Golden et al., 1995;Bogucki and Rabinowitz, 2005] suggested that leukemia,non-Hodgkin’s lymphoma, multiple myeloma, brain andbladder cancer have strong evidence, and rectal, colon,stomach, prostate cancer, and melanoma have weaker butplausible evidence of association with firefighting. However,there remain important inconsistencies in the strength of 
2008Wiley-Liss,Inc.
1
DepartmentofPreventive and Occupational Medicine,Pusan National University Schoolof Medicine,Busan,Korea
2
OccupationalHealthSurveillanceProgram,MassachusettsDepartmentofPublicHealth,Boston,Massachusetts
3
DepartmentofWork Environment,UniversityofLowell,Lowell,MassachusettsContractgrantsponsor:NationalInstituteforOccupationalSafetyandHealth,CooperativeAgreement; Contractgrantnumber:U60/OH008490.*Correspondence to: Dr. Letitia K. Davis, Occupational Health Surveillance Program,Massachusetts DepartmentofPublic Health,250 WashingtonStreet,Boston,MA 02108.E-mail: letitia.davis
@
state.ma.us.Accepted 31October 2007DOI10.1002/ajim.20549.PublishedonlineinWileyInterScience(www.interscience.wiley.com)
 
evidence reported by other authors. Guidotti [1995] con-cluded that lung, colon, rectum, and genitourinary tractcancers including kidney, ureter, and bladder, have strongevidence, while brain cancer has inadequate evidence of anassociation with firefighters. Haas et al. [2003] reviewedall cancers combined, lung cancer and brain cancer, andreported that only the standardized mortality ratio of braincancer was consistently higher in firefighters. Other recentstudiesshowtheassociationoffirefightingwithothertypesof cancer including laryngeal [Muscat and Wynder, 1995], lip,nasopharynx, pancreas, soft tissue sarcoma, and Hodgkin’sdisease [Ma et al., 1998], testicular [Bates et al., 2001; Stanget al., 2003], male breast cancer, and thyroid cancer [Maetal.,2005].Hencetherecontinuestobeaneedforadditionalstudiesontherelationshipsbetweencancersandfirefighting.Cancer patterns among firefighters in Massachusettswere reported previously for the period 1982–1986 [Samaet al., 1990]. We used the same dataset, the MassachusettsCancer Registry, to study cancer among firefighters for aconsiderablylongerperiod—the17yearsfrom1987to2003.Wehavealsostudiedawiderrange ofcancer sitesthanSamaand colleagues.
MATERIALS AND METHODSExposed and Unexposed Groups
Subjects were white male cancer cases in the Massa-chusetts Cancer Registry newly diagnosed in 1987 through2003 by all Massachusetts acute care hospitals and onemedical practice association. (Additional physicians’ officesand pathology laboratories began reporting in 2001; Radia-tion Therapy Centers in 2002.) Non-Massachusetts residentsand those aged under18 years at the time of diagnosis wereexcluded. There were too few female firefighters to permitanalyses of cancer incidence.Usual occupation and industry, defined as the longest jobheld, were used to define exposure groups. These data aregathered by cancer registrars in each hospital, and are enteredinto the Registry as narrative text. Cases for which no usualoccupation was specified were excluded. ‘‘Firefighters’’ wereidentified by searching the usual occupation text field forthestrings:‘firema(e)n,’‘firefighter,‘firelieutenant,‘firechief’’ or ‘‘fire captain.’ To eliminate peoplewhoworked forfire departmentsbutwere not involved directly in firefighting,‘‘fire inspector,’’ ‘‘investigator,’’ and ‘‘dispatcher’’ were ex-cluded. Also, workers who are called ‘fireman’in otherindustries, such as foundry workers, stationary fireman, andboilerfireman,wereexcluded.Volunteerfirefighterswerealsoexcluded. Two comparison groups were used: police and allCancerRegistrycasesforwhomanyoccupationalinformationwas reported (other than firefighter or police). Police weredefined by searching usual occupation for text stringsincluding: ‘‘policeman,’’ ‘‘police chief,’’ ‘‘sheriff,’’ ‘‘correc-tional officer,’’ ‘‘prison guard (officer),’’ ‘‘security,’’ ‘‘policedetective,’‘‘policesecurity,’’‘‘marshal,’’‘‘lawenforcement,’’‘constable,’’ ‘FBI,‘police investigator,‘court guard(officer),‘‘probation,‘‘deputy,’‘prisonwarden,and‘jailguard (officer).People who were employed in a policedepartment but had another job title such as maintenance,electrician etc., and police belonging to private organizations(campus, college, private guard) were not included. Caseswhose usual occupation information listed both police andfirefighterwereclassifiedasfirefighters.Becauseofextremelysmall numbers, cases and comparison subjects with raceAfrican American (3.1%), ‘Other’(1.1%) and ‘unknown’race (1.8%) were excluded.
Cancers of Concern
We identified all cancers for which evidence of anassociation with firefighting has been reported. We per-formedaPubMedsearchfortheyears1966–2006,usingkeywords ‘‘firefighter’’ and ‘‘fireman,’’ cross-referenced with‘‘cancer.’’ After the web search and assembling articles, thereference sections of the articles were reviewed. Included inour list of cancers of concern was any site for which atleast two studies reported observing a relationship withfirefighting.Twenty-fivecancerswere regardedascancers of concern.EachcanceranditsICD-O-3codesarefollows:Lip(0–9), Buccal cavity (30–69), Nasopharynx (110–113,118–119), Pharynx(140–142, 148), Esophagus (150–159),Stomach (160–169), Colon (180, 182–189, 199), Rectum(209), Liver (220–221), Pancreas (250–259), Larynx (320–329), Lung (340–349), Skin melanoma (ICD-O-3 440–449 and histology type 8,720–8,780), Soft tissue sarcoma(470–479, 490–499), Breast (500–509), Prostate (619),Testicle(620–629),Kidney(649),Bladder(670–679),Brain(710–719),Thyroid(739),Leukemia(histologytype9,800–9,948), Non-Hodgkin’s Lymphoma (histology type 9,590–9,596, 9,670–9,596, 9,727–9,729, 9,827), Hodgkinslymphoma(histologytype9,650–9,667),MultipleMyeloma(histology type 9,731–9,732).
Confounders
Hospital registrars record age, gender, and smokingstatus,alongwithdetailedinformationonthetumor,histology,staging, etc. After January 1, 1996, current cigarette, cigar/ pipe, and smokeless tobacco users were differentiated in theMCR.Current,ex-,andnevertobaccouseofanykindareusedin the analysis. Age and smoking were studied as potentialconfounders in these analyses.
Analysis
Because of numerator-only data of this study, thestandardized morbidity odds ratio (SMOR) was used to
330 Kang et al.
 
measure associations between firefighting and specificcancer types. The SMOR expresses the ratio of the odds of having the cancer of interest among firefighters to the oddsamong the unexposed group (either police or all knownoccupations). It can also be thought of as the ratio of thenumber of cases of cancer observed among firefighters tothe number expected, were the firefighters to experiencethe same cancer risk as the comparison population. Themethod requires not only an ‘‘unexposed’’ group, but alsoa comparison set of cancer sites not identified as cancers of concern as described above [Checkoway et al., 2004]. TheSMOR is less biased than the Proportional Mortality Ratio(PMR), which is an alternative method often used whendenominator data are not available [Miettinen and Wang,1981; Park et al., 1992]. SMORs were calculated usinglogisticregression,permittingcontrolforconfoundersofageand smoking status [Smith and Kliewer, 1995]. Each cancersite was compared individually to the comparison cancerswitheachofthetwounexposedreferentgroups.Associationswere also calculated in three age strata: 18–54, 55–74 and75
þ
, the same groupings used in the previous report [Samaet al., 1990]. Analyses were performed using SAS v. 9.1.
RESULTS
Among the 258,964 eligible cancer cases (white maleresidents of Massachusetts equal or older than 18 years of age, registered in Massachusetts in the 17 year period from1987 to 2003), 161,778 (62.5%) had a usual occupationlisted, of which 2,125 were firefighters (1.3%). The distri-bution of firefighters, police, and other occupations, by ageat diagnosis, smoking status, and specific cancer type arepresented in Table I.SMORsforthecancersofconcernareshowninTableII,using both unexposed groups, after adjusting age andsmoking status. Results with the two different unexposedgroups were fairly similar, which gives confidence that therewasnoimportantbiasfromthechoiceofoneortheother.Onenotablediscrepancywastheresultsformelanoma;comparedto police, there was a reduced risk among firefighters(SMOR
¼
0.65, 95% CI: 0.44–0.97), while the firefightersand the all occupations comparison group had quite similarrisks (SMOR
¼
1.04, 95% CI: 0.77–1.42).Forclarity,wefocusfurtherpresentationofresultsonthepolice comparison group. There were moderate elevationsinriskforcoloncancer (SMOR
¼
1.36,95%CI:1.04–1.79),and brain cancer (SMOR
¼
1.90, 95% CI: 1.10–3.26).Weaker evidence of increased risk among firefighters wasalso observed for bladder cancer (SMOR
¼
1.22, 95% CI:0.89–1.69), kidney cancer (SMOR
¼
1.34, 95% CI: 0.90–2.01), and Hodgkin’s lymphoma (SMOR
¼
1.81, 95% CI:0.72–4.53).AgestratifiedSMORsprovidedsomeadditionalinsightsinto the elevated risks described above (Table III). Theelevated colon cancer risk occurred only among the 75
þ
agegroup (SMOR
¼
1.73, 95% CI: 1.06–2.84), while braincancer risk appeared elevated across all age groups, withwide confidence intervals because of the smaller numbers ineach stratum. Bladder cancer was only moderately elevatedineachagegroupwithnoclearpattern.Hodgkin’slymphomarisk was highest in the youngest age stratum, but withwide confidence interval. The pattern of risks for melanomaacross age strata again showed divergent results dependingupon which unexposed referent group was used. Using thepolice referent, the firefighters appeared to have lowerrisk across all age groups, but particularly in the oldestgroup (SMOR
¼
0.35, 95% CI: 0.13–0.91). In contrast, thefirefighters had
 higher 
risk than the all occupationsreferencegroup, in the youngest age stratum (SMOR
¼
1.82, 95% CI:1.09–3.04) (data not shown).
DISCUSSIONStrengths and Limitations of Registry-Based OccupationalCancer Studies
Registry-based studies of occupational risks have manywell-recognized limitations [Checkoway et al., 2004]. Onelimitation is the underreporting of occupational information,which was available for approximately 62.5% of all cases inthe period under study. Thus there were quite likely othercasesofcanceramongfirefightersandpoliceofwhichwearenot aware. This numerator-based analysis method (the totalnumber of firefighters from which the cases came cannot bedetermined) would produce biased risk estimates if the
TABLEI.
 DistributionofCancerCasesbyAge,SmokingStatus,andCancerSite Among Firefighters, Police, and Other Occupations in Massachusetts,1987^2003
Firefighters PoliceOtheroccupationsn % n % n %
Age*
<
55 330 15.5 531 19.2 30,663 19.555^75 1,257 59.2 1,633 59.1 87,429 55.775
þ
 538 25.3 599 21.7 38,798 24.7Smokingstatus
a
Non-smoker 500 27.9 625 26.5 38,734 30.1Pastsmoker 834 46.5 1,063 45.1 53,011 41.1Currentsmoker 461 25.7 671 28.4 37,148 28.8Missing 330 404 27,997Total 2,125 100.0 2,763 100.0 156,890 100.0
Massachusetts Cancer Registry.*
<
0.05.
a
Cases with unknownsmoking status are not included in percent distribution.
Cancer Incidence Massachusetts Firefighters 331

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