‘So many are dying’: Screening guidelines miss lung cancer among first responders
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Occupational exposure to carcinogens often is overshadowed by smoking as a risk factor for lung cancer, yet it has been linked to an estimated 30% of lung cancers. Moreover, those who experience this exposure, including first responders, frequently are missed by lung cancer screening guidelines from the U.S. Preventive Services Task Force.
“I’ve been studying low-dose lung CT as a screening modality for lung cancer for a long time,” Vershalee Shukla, MD, radiation oncology specialist at Vincere Cancer Center in Scottsdale, Arizona, told Healio. “When the National Lung Screening Trial released their data in smokers showing a survival benefit with lung CT, I thought it was an excellent opportunity to help people who are at high risk for lung cancer. Then, 2 months later, I happened to be reading an article about 9/11 and how they are now seeing more lung cancers then they see early on. So, I wondered: Why are we doing this only in smokers? We should be doing this with firefighters.”
That question motivated Shukla and colleagues to evaluate the adequacy of the current screening guidelines to diagnose lung cancer developed through occupational exposure, including among first responders. Their study affirmed the value of low-dose CT for detecting lung cancer among this population. Based on the strength of this study, Shukla was able to spearhead a change to the guidelines in her state of Arizona.
Shukla spoke with Healio about her findings, her experiences working with firefighters and the changing environmental hazards that may affect first responders.
Question: Why did you decide to undertake this study of first responders?
Answer: Because so many are dying. When I initially started doing this, I followed recommended guidelines, and therefore I was screening those aged 55 years and older. However, here in Arizona, we had firefighters who were diagnosed with lung cancer at age 39 years, or age 52 years. The firefighters pushed me and we got a grant, and we were able to subsidize the low-dose lung CTs and started doing them for those aged 40 years and older.
Q: What did your study reveal about the utility of low-dose lung CT for younger individuals?
A: With low-dose CT, I picked up a malignant thymoma in a 42-year-old and another primary lung cancer in a 48-year-old, so the study turned out to be worth it.
First responders are exposed to a lot of level-one carcinogens, such as benzene, arsenic, asbestos and many other toxins. We don’t know how these exposures cause cancer. So, it’s important for us to screen them. They are at risk for mesothelioma, as well, because they are often exposed to asbestos in older houses/buildings that burn. That is a very fatal disease. So, if we can catch these early, we can save lives.
Q: What does this suggest about the current practice of a chest X-ray every 5 years for this population?
A: By the time you pick up a lung cancer in a chest X-ray, it’s often too late to make a big impact. Another important factor is that the fires that firefighters deal with today are very different than those they fought 10 or 15 years ago, because of the flame retardants and so many synthetic products. The smoldering and the smoke, it just lingers on them.
Q: Are there any potential disadvantages to screening these individuals at earlier ages?
A: In Arizona, we have a lot of valley fever, which is a fungal infection seen in the lungs, so unfortunately, we have a lot of firefighters with nodules in their lungs. However, with the low-dose CT being safe, it allows me to follow these patients and make sure those nodules don’t turn into cancer. After 2 years or so, if these nodules are relatively stable, it’s very unlikely that they’re a cancer. I remind these firefighters that I’m probably going to find a nodule, but they shouldn’t worry. My job is to make sure that nodule doesn’t turn into cancer, and their job is to make sure not to worry about it.
Q: Do you think the lung cancer screening guidelines for first responders should be changed nationally?
A: For firefighters, yes. More and more states are starting to do this. It’s been happening across the country. First responders understand the risk for cancer from their job and we are fortunate they do it anyway. They just want their families to be taken care of if something should happen to them. So, they’re vulnerable people — the best people to take care of, for sure. – by Jennifer Byrne
For more information:
Vershalee Shukla, MD, can be reached at 7469 E. Monte Cristo Ave., Scottsdale, AZ 82560; email: drshukla@vincerecancer.com.
Disclosures: Shukla reports no relevant financial disclosures.