On the morning of September 11, 2001, Elizabeth Cascio, an emergency medical technician with the New York City Fire Department, was in Queens directing a first responder training program, when the team got a call to mobilize to the World Trade Center. Her team arrived in a caravan of buses and ambulances just as the second tower collapsed.
At first it was "pitch black," Cascio recalls. "We couldn't see anything." A dust cloud swirled around them. "We were literally engulfed by it."
She recalls trying to hold her breath to avoid breathing in the fumes and dust. "We were walking through six to 10 inches of, like, concrete sand."
Cascio spent about a month at ground zero assisting the recovery efforts, and she was among the first responders who developed a cough. Then, in 2019, she received a cancer diagnosis that her doctors determined was linked to her exposure.
"The exposure [among first responders] was really dramatic," explains Dr. Michael Crane, a physician and environmental medicine professor at the Icahn School of Medicine at Mount Sinai, who also is the medical director of a clinic that delivers care to 9/11 first responders. "There were all kinds of carcinogens and combustion products," Crane says.
The contents of two skyscrapers including concrete, pipes, computers, were pulverized into burning ash laden with lead and other heavy metals. The plume of smoke that could be seen from space. "It was a real witch's brew," Crane says.
Increased cancer risks
It can take years, even decades, for cancers to develop. A study published in 2019 found that 9/11 first responders have an elevated risk of certain cancers, including a roughly 25% increased risk of prostate cancer, a doubling in the risk of thyroid cancer and a 41% increase in leukemia compared to the general population.
"When you hear the word cancer, it's a sobering moment, a scary moment," says Cascio, who is now chief of staff at FDNY. She says that 257 active and retired FDNY members have died of 9/11-related illnesses, including cancer.
But recent research has found that first responders are also more likely than the general population to survive their cancers, according to the results of a study published this summer in the American Journal of Industrial Medicine. Researchers compared cancer deaths among the first responders to cancer deaths in the population in the New York area.
"We found they were about 35% more likely to survive than the general population," explains Rachel Zeig-Owens, an epidemiologist at the Albert Einstein College of Medicine, and one of the authors of the study.
And the extent of the benefit is something the authors did not anticipate. "I was surprised by the magnitude of the benefit, says biostatician Charles Hall, a co-author of the paper.
Cascio got diagnosed with a rare, invasive cervical cancer that spread quickly. It has been determined that exposure to 9/11 could be a contributing factor for this type of cancer, along with multiple other rare cancers.
Her doctors came up with an aggressive treatment plan that included chemotherapy and radiation. She says the side effects of the treatment were really rough, she felt very sick and exhausted. But she responded well.
Midway through the treatment the results of a CAT scan buoyed her spirits. "The tumor had shrunk dramatically, very quickly," Cascio recalls. "I did feel relieved." She is now healthy and working full time at FDNY.
'Paid-for care is better care'
There are multiple factors that might explain the increased likelihood of cancer survival among 9/11 first responders.
For one thing, "it may be that they were healthier to begin with," says Zeig-Owens. The first responders were, on average, in their late 30s on the day of the September 11 attacks. And their jobs as firefighters and EMTS require a higher level of physical fitness, compared to people with sedentary jobs, she points out.
"The 'healthy worker' effect is real," agrees Mt. Sinai's Crane. But, another possibility is that the first responders are benefiting from the comprehensive screening and medical care offered through the World Trade Center Health Program.
Elizabeth Cascio is among approximately 80,000 people who are part of the federally-funded WTC Health Program, which provides monitoring and treatments for health conditions that are certified to be related to the September 11th attacks.
Crane, who is the medical director of the program, explains all of the medical care, including the treatments, are paid for by the program. "It may be indeed that paid-for care means better health care and better results and decrease in mortality," Crane says.
An important benefit of this "better health care" is that some cancers are found earlier.
"We also were noticing that they were diagnosed at earlier stages," Zeig-Owens says, which may lead to earlier treatment and might play a role in the improved survivability.
Cascio says she was very well cared for during her treatments. Being part of the WTC Health Program and part of the New York City Fire Department, she says there's a tremendous support network. For instance, she was offered transportation to and from her appointments. "You're not worried about, how do I pay for this? You're not worried about, how do I get to and from [my medical appointments]. So there's a lot of stressors that don't exist for us," she says.
The big unknown is whether 9/11 first responders will continue to beat the odds and survive their cancers at significantly higher rates. Crane says the rescue and recovery workers who were present on 9/11 are, on average, in their late 50's, and the "healthy worker" effect that has worked to their advantage may begin to dissipate as they hit retirement age.
But it's also possible that the comprehensive screening and treatment will continue to pay off.
"I think this is very exciting," Crane says. He hopes researchers continue to track the incidence of cancer among first responders, so the long-term impacts of early screening and comprehensive care can be documented. "This will really help answer a lot of questions," he says.
Cancer is always a hard diagnosis. But the evidence that there's an improved chance of survival among first responders is encouraging. "There is a lot of community rallying behind them," explains Zeig-Owens, and this may be an important part of the care.
"It is really nice to show that while they are being diagnosed with cancer at higher rates than the general population, they're able to survive those cancers," Zeig-Owens says. "That is a good feeling."
A MARTINEZ, HOST:
There were thousands of first responders, including firefighters and rescue workers, at the World Trade Center following the 9/11 attacks, and 20 years later, researchers have documented an increased incidence of several types of cancers. But a new study suggests there's reason for optimism. The first responders appear to be surviving their cancers at significantly higher rates. Now, the question is why? NPR's Allison Aubrey joins us. Allison, many of these first responders spent weeks at the ground zero site back in September of 2001. What were they exposed to?
ALLISON AUBREY, BYLINE: Well, just after the towers collapsed, the air was filled with smoke and debris - basically, all of the contents of two skyscrapers, all the concrete, glass, pipes, computers, you name it. Everything kind of pulverized and burning into ash, laden with all kinds of heavy metals, including lead and other toxins. I mean, many of us remember that plume of smoke and debris that could be seen from space. And Dr. Michael Crane, who is an environmental medicine expert at Mount Sinai, says there has never been anything quite like it.
MICHAEL CRANE: The exposure was really dramatic. And the dust - I mean, there was all kinds of carcinogens and combustion products and fibers and glass fibers and asbestos fibers. It was really a witch's brew.
AUBREY: And given what was in the air, A, there was definitely a concern early on that it could increase the risk of certain cancers.
MARTINEZ: Yeah. Now, what have doctors found? I mean, how much of an increased risk of cancer is there among these first responders?
AUBREY: You know, some of the most recent data suggests that the total number of cancers is only slightly elevated compared to the general population. But scientists have documented significant increases in certain cancers - a 25% percent increase in prostate cancer, a doubling in the risk of thyroid cancer and a 40% increased risk in leukemia. There are, in addition, a number of rare cancers linked to the exposure. I spoke to Elizabeth Cascio of the New York City Fire Department, who was diagnosed a couple of years ago. She told me about her experience on 9/11, arriving on the scene at the World Trade Center just as the second tower collapsed.
ELIZABETH CASCIO: You know, we were walking through 6 to 10 inches of concrete sand. And literally, the entire dust cloud that was in every direction - we were literally engulfed by it.
AUBREY: And she spent weeks at the site and breathed all of this in.
MARTINEZ: Yeah, that could not have been good. Did she have any health problems right off the bat?
AUBREY: You know, she was one of the first responders who developed a cough. That eventually went away. But then 18 years later, she received a diagnosis no one wants.
CASCIO: You know, when you hear the word cancer, it's a sobering moment. It's a scary moment. And the doctor was like, look; let's not get ahead of ourselves.
AUBREY: She was told that she had a tumor in her cervix. It was a rare invasive cervical cancer that could spread quickly. And her 9/11 exposure was likely a contributing factor.
MARTINEZ: Wow. That is rough. What's next, then - radiation, chemotherapy?
AUBREY: Yeah, she had both radiation and chemotherapy. She had a very aggressive treatment plan, and she says it was really rough. She was in severe pain, lots of side effects. But she responded very well. About halfway through the treatment, her doctors ordered a CAT scan, and she got some unexpected news.
CASCIO: Both oncologists were really happy. The tumor had shrunk dramatically, very quickly. And I did feel relieved. That, to me, was good news.
AUBREY: She finished her treatments, and now she's doing very well.
MARTINEZ: Wow. That's awesome. I mean, is this kind of experience typical?
AUBREY: You know, survival rates vary. Elizabeth is part of the World Trade Center Health Program, which is a federally funded program providing monitoring and treatment to first responders for conditions linked to the 9/11 exposures. There are thousands of responders and survivors in the program. And though some cancers are elevated, it turns out, quite surprisingly, that first responders are significantly more likely to survive their cancers. Here's Rachel Zeig-Owens of Einstein College of Medicine. She's just published a new paper that details the outcomes for first responders.
RACHEL ZEIG-OWENS: They were about 35%, 36% more likely to survive than the general population. And that is a good feeling.
MARTINEZ: So, Allison, could this be because they're finding the cancers earlier?
AUBREY: You know, that's certainly one explanation. They are finding some cancers earlier, perhaps due to more screening. And then these folks are getting incredible care. They work with nurses who help manage their cases. They can be driven to and from their appointments. They're getting the best treatments available. And it's all paid for, so there's no putting off appointments or treatments due to the expense. Elizabeth Cascio says she was incredibly well cared for.
CASCIO: There's a tremendous support network. You're not worried about, how do I pay for this? You're not worried about, how do I get to and from? So there are a lot of stressors that don't exist for us.
AUBREY: Being part of the fire department, she says, there's a whole community of people ready to help.
MARTINEZ: And I think it's safe to say that everyone's got their fingers crossed that this is something that can continue long term. Are they likely to continue to beat their cancers?
AUBREY: You know, I think that's the big question. And it's uncertain. I mean, the first responders were on average in their late 30s on the day of the September 11 attacks. Now they're in their late 50s. Firefighters and EMTs tend to be healthier than the population at large. They need to be pretty fit to do their jobs. So as they age, will they continue to beat the odds for surviving their cancers? It's not clear. Dr. Michael Crane, who is also medical director at the World Trade Center Health Program clinic, says time will tell.
CRANE: The really exciting thing is to kind of dream now of this study actually continuing on and maybe being done in another five years and another five years. And this will really help answer a lot of those questions.
AUBREY: You know, it goes without saying, A, that cancer is always a hard diagnosis, but this evidence that there is an improved chance of survival is encouraging.
MARTINEZ: Yeah, it is. That's NPR's Allison Aubrey. Allison, thanks.
AUBREY: Thank you.
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