When the James Zadroga 9/11 Health and Compensation Act (P.L. 111-347) was signed into law in January 2011, among its aims was providing screening and medical treatment for the fire fighters, police officers, emergency responders and certain other survivors. More than $4 billion was authorized by Congress for the program. The adverse health conditions covered by the program for eligible participants were limited primarily to respiratory and mental health disorders. The list included the conditions that the responders and survivors were already suffering due to exposures at the World Trade Center site, such as asthma, chronic obstructive pulmonary disease, reactive airway dysfunction syndrome, chronic cases of rhinosinusitis, nasopharyngitis and laryngitis, as well as PTSD, major depression, substance abuse and anxiety disorders. (Eligible survivors of the 9/11 attacks at the Pentagon and Shanksville, PA sites were also encouraged to participate in the screening and medical treatment program.)
The Zadroga law contained a provision to allow the director of the World Trade Center Health Program, who is also the director of CDC’s National Institute for Occupational Safety and Health (NIOSH), to add new conditions to the list. Recommendations for those new conditions came be made by a periodic review of the scientific evidence, a petition, or the director’s discretion.
In September 2011, the program director received a petition from Senators Kirsten Gillibrand (D-NY) and Charles Schumer (D-NY), and Representatives Carolyn Maloney (D-NY), Jerrold Nadler (D-NY), Peter King (R-NY), Charles Rangel (D-NY), Nita Velazquez (D-NY), Michael Grimm (R-NY), and Yvette Clark (D-NY), requesting that cancer be added to the list of covered conditions. The petition referred to a study of cancer incidence in 9,853 men employed as New York City firefighters which was published that same month in Lancet. The authors of “Early assessment of cancer outcomes in New York City firefighters after the 9/11 attacks: an observational cohort study,” were cautious in the interpretation of their data which identified a modest excess cancer incidence (of any type) among the 8,927 firefighters classified as exposed when compared to the U.S. population.
The petition led the WTC Health Program director to request the expertise and recommendations of the program’s Scientific/Technical Advisory Committee (STAC) to
‘‘review the available information on cancer outcomes associated with the exposures resulting from the September 11, 2001, terrorist attacks, and provide advice on whether to add cancer, or a certain type of cancer, to the List specified in the Zadroga Act.’’
In April 2012, the STAC provided its findings to the WTC program director, noting:
“The STAC has reviewed available information on cancer outcomes that may be associated with the exposures resulting from the September 11, 2001 terrorist attacks, and believes that exposures resulting from the collapse of the buildings and high-temperature fires are likely to increase the probability of developing some cancers. This conclusion is based primarily on the presence of approximately 70 known and potential carcinogens in the smoke, dust, volatile and semi-volatile contaminants identified at the World Trade Center site. Fifteen of these substances are classified by the International Agency for Research on Cancer (IARC) as known to cause cancer in humans, and 37 are classified by the National Toxicology Program (NTP) as reasonably anticipated to cause cancer in humans; others are classified by IARC as probable and possible carcinogens. Many of these carcinogens are genotoxic and it is therefore assumed that any level of exposure carries some risk.”
The expert committee continued:
“Exposure data are extremely limited. No data were collected in the first 4 days after the attacks, when the highest levels of air contaminants occured, and the variety of samples taken on or after September 16, 2001 are insufficient to provide quantitative estimates of exposure on an individual or area level. However, the committee considers that the high prevalence of acute symptoms and chronic conditions observed in large numbers of rescue, recovery, clean up and restoration workers and survivors, as well as qualitative descriptions of exposure conditions in downtown Manhattan, represent highly credible evidence that significant toxic exposures occurred. Furthermore, the salient biological reaction that underlies many currently recognized WTC health conditions—persistent inflammation—is now believed to be an important mechanism underlying cancer through generating DNA-reactive substances, increasing cell turnover, and releasing biologically active substances that promote tumor growth, invasion and metastasis. Given that cancer latencies for solid tumors average 20 years or more, it is noteworthy that the published FDNY study of fire fighters showed a statistically significant excess in all-site cancer with only 7 years of follow-up.”
Based on the STAC’s recommendations, and following a public comment period,WTC Health Program director published a final rule on September 10 to amend the list of covered conditions. Effective October 12, 2012, that list will include 50 types of cancer, from malignant neoplasms of the bladder, colon, liver, lung, rectum, and stomach, to leukemia, lymphoma, myeloma and mesothelioma.