A U.S. military firefighter for 32 years, Kurt Rhodes trained and performed his duties with aqueous film forming foam, or AFFF — a highly effective fire suppressant that he never knew contained PFAS chemicals, now known to be harmful to human health.
New federal research links testicular cancer in U.S. service members to the "forever chemicals," adding to a growing body of evidence of the dangers they pose. Rhodes lives in fear that he, like many of his colleagues, will get sick.
"It's kind of like a Russian roulette," he said. "Are you going to get the cancers or are you going to be one of the lucky ones who doesn't?"
The chemicals in the firefighting foam are suspected to have polluted more than 700 active and former military installations as well as thousands of towns across the U.S., potentially exposing millions of people to long-term health risks, say the scientists and public health experts who study the chemicals. The contamination was the result of industrial spills, dumping, and firefighting.
The new testicular cancer findings, as well as new requirements to fund PFAS testing in some communities, have firefighters like Rhodes on edge.
Many have sought recently developed blood serum tests to determine their cumulative levels of perfluoroalkyl and polyfluoroalkyl substances, or PFAS. But it's unclear what they should do with those test results, given there are no medical treatments to remove PFAS from the body.
"It is stressful, especially when you know there is a chance of cancer," said former Air National Guard firefighter Jeffrey Warrick, noting he has a worrisome skin condition he believes was caused by PFAS exposure. It worsens in warm weather, he said, and "freaks me out."
In 2020, Congress required the Department of Defense to offer active-duty military firefighters blood tests for PFAS, thousands of compounds dubbed "forever chemicals" because they accumulate in the human body and don't break down in the environment. Some states followed suit or even preceded the federal legislative action.
Indiana passed a bill effective July 1 that establishes a biomonitoring pilot program to provide PFAS blood testing for 1,000 of the state's firefighters. New Hampshire requires insurers to cover PFAS blood tests, and a bill introduced in Maine this year would do the same.
But while the tests have been a major step forward in understanding the scope of the issue across the country, medical providers often aren't sure how to interpret the results.
Breaking the code
The National Academies of Sciences, Engineering, and Medicine issued preventive medical guidance last year for those whose test results confirm a level of PFAS chemicals in their blood meriting concern.
The national academies recommended that patients with readings between 2 and 20 nanograms per milliliter limit additional exposure and screen for high cholesterol, breast cancer, and, if pregnant, high blood pressure. At 20 ng/mL and above, the report recommends further assessment.
But even with these published guidelines, finding doctors knowledgeable about interpreting the blood test results and inferring the possible health effects of PFAS exposure can be slow going.
Kevin Ferrara, a former Air Force firefighter who now advocates for military personnel and firefighters, said they simply want their physicians to be more educated on PFAS contamination and its health consequences.
"Firefighters really need to concentrate on their jobs, not 'How do I decipher my blood tests?'" Ferrara said. "Physicians should have a basic understanding of PFAS, and they simply don't."
To muddy matters further: With so many types of PFAS, not all of them show up in the blood tests. Some compounds manifest elsewhere, such as in organ tissue or other parts of the blood, said Neil McMillan, the International Association of Fire Fighters' director of science and research.
"These PFAS blood panels are complicated," McMillan said. "The results you get back may not show the full picture of your body burden."
Graham Peaslee, a University of Notre Dame professor who studies PFAS, said he knows of seven civilian and military firefighters who have had a rare form of brain cancer, glioblastoma, three of whom resided in South Bend, Indiana.
The aggressive disease has only sparsely been studied and its causes are not understood, although scientists suspect environmental exposures may be to blame.
"What's really interesting is it's [about] a one-in-a-million disease," Peaslee said. "There aren't 7 million firefighters in this country. How was that possible?"
State Rep. Maureen Bauer, a Democrat who authored the Indiana PFAS testing bill and represents South Bend, said the program was inspired in part by those firefighters who died of brain cancer.
"Blood testing is providing one more useful bit of information," Bauer said. "If you're exposed, but you don't know what your levels are, if you have fertility issues, high blood pressure, thyroid problems, that could all go back to your blood levels."
Guarding against risks
Ned Calonge, who is the associate dean for public health practice of the Colorado School of Public Health and co-authored the national academies' report, said that taking proactive measures in communities with known high exposure, such as among firefighters and military service members and their families who lived on bases, is particularly important.
"It depends on how much different states have paid attention to it," Calonge said. "I wouldn't say that we've advanced very far in terms of clinician education in the area of the PFAS exposure."
Congress passed legislation last year that gave medical benefits and disability compensation to federal firefighters who develop one or more of 16 health conditions within 10 years of service. The illnesses include 14 types of cancer, chronic obstructive pulmonary disease, and cardiovascular events such as heart attack and stroke that occur within 24 hours of engaging in their jobs.
But firefighters want to learn how to prevent these illnesses from taking hold. Because PFAS chemicals accumulate in the body, older people typically have higher levels than younger people. Men tend to have higher levels than women, which researchers attribute to menstruation helping eliminate the chemicals from the body.
Over time, if people limit exposure, PFAS levels in the blood can slowly drop as the chemicals are excreted. For example, PFOS, the legacy chemical found in AFFF that's no longer used, has a half-life in humans of 4.8 years. While researchers estimate that everyone has some level of PFAS in their bodies, Calonge said, people with levels above 20 ng/mL in their blood should particularly avoid additional exposure.
Although full avoidance may be nearly impossible — these chemicals can be found in nonstick cookware, industrial lubricants, cosmetics, and even food wrappers — those with high amounts of known exposure should consider filtering their drinking water and removing stain-resistant carpet, water-repellent clothing, and other PFAS-containing household goods from their homes, Calonge said.
Experts point to reverse osmosis filters under a kitchen sink or at the tap as the most effective way to remove PFAS from drinking water, but the systems can be expensive, putting them out of reach for some Americans. Some tabletop water filters seem pretty effective, too. The American National Standards Institute and NSF have certified water filters from 15 manufacturers for the reduction of select PFAS chemicals.
Holding out hope
While there are no known treatments for the buildup of PFAS chemicals in one's body, an Australian study published last year found that firefighters with high levels of PFAS reduced their levels by 10% over a year when they donated blood every 12 weeks and by 30% if they donated plasma every six weeks.
Jeff Burgess, a University of Arizona Health Sciences researcher, seeks to duplicate the findings and take it a step further — determining whether a reduction in PFAS levels yields lower cardiovascular and cancer risk.
The plan is to enroll 1,500 firefighters in the study who will donate blood or plasma for a year, monitoring for DNA methylation cancer biomarkers.
As for the ethics of letting firefighters with known PFAS contamination contribute to the nation's blood banks, Burgess noted that nearly everyone in the U.S. is thought to have some PFAS in their bodies and that, given chronic shortages, the need for donated blood outweighs the risks.
"From my perspective, the benefits of giving blood, even though it has some degree of PFAS in it, are much greater than the potential harm from the PFAS that people might receive because, again, blood products can be lifesaving," Burgess said.
Citing the Australian study, Nicole Maul, director of media relations for the American Red Cross, which manages standards and quality control for the blood banks, said further study is needed to determine whether donations by firefighters have any "clinical implications."
"No study has shown a detrimental effect of such substances in blood for donors or recipients," Maul said. "The Red Cross and the FDA work together to ensure the blood supply is as safe as possible, and individuals should not worry about the safety of donating or receiving blood."
A Department of Defense spokesperson said Aug. 29 that the Pentagon uses the Centers for Disease Control and Prevention's Agency for Toxic Substances and Disease Registry to guide its firefighter PFAS testing program and develop information it provides to personnel, including military physicians, on the potential health effects of PFAS.
"It is not possible yet to distinguish PFAS exposures by DoD personnel in their occupational setting from those they may experience from consumer products, so much of the information provided is general PFAS health effects information," said Peter Graves, chief of media operations for the Defense Health Agency. "The DoD will update occupational health provider fact sheets when ATSDR updates their PFAS clinical guidelines and develop or incorporate available PFAS training modules for healthcare providers, as appropriate."
Graves added that the Defense Department is interested in the outcomes of ongoing health studies by the Agency for Toxic Substances and Disease Registry as well as toxicology assessments by the Environmental Protection Agency and noted that the Pentagon supported the testicular cancer study by allowing use of the Department of Defense Serum Repository and including it in the Pentagon's Congressionally Directed Medical Research Programs.
CDMRP research projects are not requested by the Pentagon in its annual budget, but instead are supported by extra money that Congress gives the department to manage research projects that members deem necessary to advance medical science and promote the health of the armed forces.
Rhodes, the veteran military firefighter, said he has high hopes for the University of Arizona research and would like to see more studies done on reducing PFAS exposure as well as the illnesses linked to PFAS. He also wants Congress to extend the health and disability benefits for a lifetime for those illnesses.
"I put my life on the line for 30 years for people I didn't know, and I did it willingly," he said. "That is every firefighter's mindset. Now we are asking for a little bit. There's something out there killing us. Keep researching and don't give us pushback when we want testing. Make it easier for us."
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 This article was reprinted from khn.org, a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF - the independent source for health policy research, polling, and journalism.
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