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Multicenter Study
. 2020 Jun 1;180(6):888-895.
doi: 10.1001/jamainternmed.2020.0950.

Evaluation of Medical Surveillance and Incidence of Post-September 11, 2001, Thyroid Cancer in World Trade Center-Exposed Firefighters and Emergency Medical Service Workers

Hilary L Colbeth  1   2 , Natalia Genere  3 , Charles B Hall  4   5 , Nadia Jaber  1 , Juan P Brito  3   6 , Omar M El Kawkgi  3   6 , David G Goldfarb  1   2 , Mayris P Webber  1   4   7 , Theresa M Schwartz  1   2 , David J Prezant  1   8 , Rachel Zeig-Owens  1   2   4
Affiliations
Multicenter Study

Evaluation of Medical Surveillance and Incidence of Post-September 11, 2001, Thyroid Cancer in World Trade Center-Exposed Firefighters and Emergency Medical Service Workers

Hilary L Colbeth et al. JAMA Intern Med. .

Abstract

Importance: Elevated incidence rates of thyroid cancer among World Trade Center (WTC)-exposed individuals may be associated with the identification of asymptomatic cancers during medical surveillance.

Objective: To examine the association between WTC exposure and thyroid cancer among Fire Department of the City of New York (hereafter, Fire Department) rescue/recovery workers as well as the association with medical surveillance.

Design, setting, and participants: This closed-cohort study classified the method of detection (asymptomatic and symptomatic) of thyroid cancers in 14 987 men monitored through the Fire Department-WTC Health Program diagnosed from September 12, 2001, to December 31, 2018. Age-, sex-, and histologic-specific Fire Department incidence rates were calculated and compared with demographically similar men in Olmsted County, Minnesota, from the Rochester Epidemiology Project using age-standardized rates, relative rates (RRs), and 95% CIs. The secondary analysis was restricted to papillary carcinomas.

Exposures: World Trade Center exposure was defined as rescue/recovery work at the WTC site from September 11, 2001, to July 25, 2002.

Main outcomes and measures: The outcomes evaluated comprised (1) number of incident thyroid cancers and their detection method categorizations in the Fire Department and Rochester Epidemiology Project cohorts; (2) Fire Department, Rochester Epidemiology Project, and Surveillance, Epidemiology, and End Results-21 age-standardized incidence rates of thyroid cancer; and (3) RRs comparing Fire Department and Rochester Epidemiology Project overall and by detection method categorization.

Results: Seventy-two post-9/11 Fire Department cases of thyroid cancer were identified. Among the 65 cases (90.3%) with a categorized detection method, 53 cases (81.5%) were asymptomatic and 12 cases (18.5%) were symptomatic. Median (interquartile range) age at diagnosis was 50.2 (44.0-58.6) vs 46.6 (43.9-52.9) years for asymptomatic vs symptomatic cases. Associated primarily with asymptomatic cancers, the overall age-standardized incidence of Fire Department thyroid cancers (24.7; 95% CI, 17.4-52.3) was significantly higher than the Rochester Epidemiology Project (10.4; 95% CI, 8.5-12.7) and Surveillance, Epidemiology, and End Results-21 (9.1; 95% CI, 9.0-9.1) per 100 000 person-years. Furthermore, the RR of thyroid cancer among symptomatic men in Fire Department cases was not significantly different from that of men in the Rochester Epidemiology Project (0.8; 95% CI, 0.4-1.5); however, the rate of asymptomatic cancers was more than 3-fold that of the Rochester Epidemiology Project rate (RR, 3.1; 95% CI, 2.1-4.7).

Conclusions and relevance: Excess asymptomatic thyroid cancer in Fire Department WTC-exposed rescue/recovery workers is apparently attributable to the identification of occult lesions during medical surveillance. Among WTC-exposed cohorts and the general population, these findings appear to have important implications for how thyroid cancer incidence rates are interpreted and how diagnoses should be managed.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Colbeth reported receiving grants from the National Institute for Occupational Safety and Health (NIOSH) for this work and other work. Dr Hall reported receiving grants from the NIOSH, grants from the National Cancer Institute, speaker’s fees from the University of California, Davis, and from the Johns Hopkins University during the conduct of the study; grants from National Institute of Aging, and personal fees from National Institutes of Health, personal fees from University of Iowa, and personal fees from Washington University St. Louis outside the submitted work. Ms Jaber reported grants from NIOSH during the conduct of the study; grants from the NIOSH outside the submitted work. Dr Brito reported receiving funds from the grant from the NIOSH for this work and other work. Mr Goldfarb reported receiving grants from the NIOSH, during the conduct of the study. Dr Webber reported receiving grants from the NIOSH during the conduct of the study and outside the submitted work. Dr Schwartz reported receiving grants from the NIOSH outside of this study. Dr Prezant reported receiving grants from the NIOSH during the conduct of the study. Dr Zeig-Owens reported receiving grants from the NIOSH during the conduct of the study and outside the submitted work. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Detection Method Categorization for Fire Department of the City of New York–Confirmed Thyroid Cancer Cases
Study population and detection method categorization criteria for Fire Department of the City of New York thyroid cancer cases.
Figure 2.
Figure 2.. Age-Standardized Thyroid Cancer Incidence Rates by Cohort and Detection Method
Bar graphs of the total age-standardized thyroid cancer incidence rate (per 100 000 person-years) among men are stratified by those aged 20 to 49 years at diagnosis (A) and those aged 50 years and over (B) from the Fire Department of the City of New York, Rochester Epidemiology Project, Rochester, Minnesota, and the US National Cancer Institute Surveillance Epidemiology and End Results–21 (SEER-21) registries. Data were age-adjusted to the 2000 US standard population.
Figure 3.
Figure 3.. Age-Adjusted Relative Rates (RRs) of Thyroid Cancer Overall, by Early and Late Period, and by Detection Method Comparing Fire Department of the City of New York With the Rochester Epidemiology Project
Relative rates, controlling for age group (in 5-year strata), comparing Fire Department of the City of New York and Rochester Epidemiology Project incident thyroid cancer rates, overall, by an early (September 12, 2001, to December 31, 2009) and late (January 1, 2010, to December 31, 2018) period and by detection method (asymptomatic and symptomatic). An RR greater than 1 indicates that the incidence rate of thyroid cancer is greater in the Fire Department compared with the Rochester Epidemiology Project, Rochester, Minnesota, and an RR less than 1 indicates that the incidence rate of thyroid cancer is greater in the Rochester Epidemiology Project.
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