This is the first of two stories about firefighters’ cancer risks.

Ben Brickhouse came to his career as a late bloomer. In December 2003, when he was 41 years old, he took a vacation to Asheville, North Carolina, and fell in love with the mountain town. He not only decided to stay but also to become a firefighter.

His plans to work 20 years and retire at 61 were upended by a routine physical in the summer of 2020: He had an off-the-charts level of prostate-specific antigen, or PSA, often a sign of prostate cancer. When further testing confirmed the disease, Brickhouse elected to have his prostate removed.

“I thought I was going to have the surgery, get healed, get better and go back to work,” Brickhouse said. “I was only expecting to be off for, like, 45 days.”

But after the surgery, his PSA measure never fell to zero and began to rise again. A scan confirmed that the cancer had spread to his lymph nodes. He would require three rounds of proton radiation therapy and two years of Lupron hormonal treatments, bringing his firefighting career to an end.

It wasn’t until he was medically retired and had sued the City of Asheville seeking workers compensation benefits that he learned about the link between the prevalence of cancer among firefighters and a widely used firefighting foam: Aqueous Film-Forming Foam, or AFFF. The foam contained toxic chemicals, called PFAS. He thought of the dozens of retired Asheville firefighters who had died of cancer over two decades and the half-dozen active-duty firefighters diagnosed with cancer since 2017.

Cancer forced firefighter Ben Brickhouse to retire from the Asheville Fire Department in North Carolina after 16 years. Brickhouse, shown at his garage workbench, sued the city for workers comp benefits, maintaining the cancer was job-related, and reached a settlement. Credit: Seth Maile for Public Health Watch.

He recalled the torrents of white, soap-like foam he had dispersed almost daily during his seven months of rookie training – and during monthly drills, continuing education courses and testing new equipment.

The foam would often leak from the fire trucks. “We would have to clean it up off the floor with a rag or whatever. It was actually concentrated at that point,” Brickhouse said. “I tried to wear gloves because it’s a heck of a thing to get it off your skin.” 

The Asheville Fire Department since has enacted tighter restrictions on exposure to AFFF foam, but still uses the foam to fight fires. Brickhouse wonders why it hasn’t been banned.

His question is a national one that has bedeviled firefighting leaders and crews, health experts and environmentalists for years. Growing research shows that high levels of PFAS chemicals may impair the immune system and cause kidney, testicular and other cancers. More recently, alarm has spread over the discovery that those same chemicals are found in firefighters’ protective suits, or “turnout gear,” posing more risks. But the PFAS-laden foam and gear remain in place at many firehouses even as cancer has become the leading cause of firefighters’ deaths, the International Association of Fire Fighters reported.

Earlier this year, the association revealed that of the 469 firefighters’ deaths in the United States and Canada classified as “line-of-duty,” or job-related, in the last two years, 348 – or nearly three-fourths – were cancer-related.

So why is the foam so hard to get rid of?

Discovery of a Miracle Foam

The AFFF story began more than 80 years ago when the first of a new class of fluorine chemicals was accidentally created by chemists at DuPont. The chemicals’ strong carbon bond made them virtually impenetrable and so slick that everything just slid right off. They also didn’t break down in the environment for many years.

DuPont patented one of the chemicals, named it Teflon and used it to make the first nonstick cookware. Other manufacturers followed suit, and before long, these so-called “forever chemicals” became everywhere chemicals found in numerous products, including make-up, shampoo, carpeting, paints, varnishes, clothing and boots.

Firefighting foam joined the lineup after one of the worst disasters in U.S. naval history. In 1967 the Navy deployed the USS Forrestal supercarrier to North Vietnam to provide additional airpower. A power surge caused a rocket to fire, which struck a fuel tank and exploded nine bombs. Skyhawk jet pilot and future U.S. Sen. John McCain narrowly escaped harm, but 134 sailors died and 161 were injured. The disaster prompted a wholesale makeover of the Navy’s firefighting practices.

The U.S. Navy destroyer USS Rupertus stood by to assist the aircraft carrier USS Forrestal as the Forrestal fought deck fires and explosions in the Gulf of Tonkin on July 29, 1967. The fire caused the Navy to overhaul its firefighting practices. Credit: U.S. Navy

Navy scientists had spent years working with 3M to develop a fire-suppressant foam. Military specifications required a “fluorinated surfactant” that would smother high-hazard liquid-fuel fires. 3M successfully developed the foam using PFAS chemicals. When mixed with water and discharged, it spread easily, extinguished fires more quickly and prevented them from relighting.

AFFF’s superior performance led the Department of Defense to mandate its use in all aircraft hangars, airfields and aircraft fueling stations. The Federal Aviation Administration adopted it for all commercial airports, and militaries and airports around the world embraced it as well.

Few questioned whether the miracle foam posed any dangers because relatively few outside of industry sources knew of the potential risks, and it stayed that way for years. Within a decade of its introduction, however, researchers began to realize there were serious, possibly harmful effects.

When Risks Became Known

As early as 1950, 3M researchers knew that PFAS chemicals attached themselves to proteins in human blood and persisted in the body. In later years, lab-animal studies showed that PFAS exposure was toxic and led to kidney and liver problems. By the early 1980s, a study of pregnant employees at DuPont, which also manufactured the foam, found elevated PFAS levels in their blood; among eight children born, two had birth defects. 3M, the initial AFFF manufacturer, didn’t publicly disclose the more than 1,000 internal PFAS studies it conducted or the results until decades later, said Jamie DeWitt, a toxicology professor at East Carolina University, who has studied the issue.

“Some of these companies had toxicity data they never published in the scientific literature until they had already made the decision to phase the chemicals out,” said DeWitt. “One of the first papers about their toxicity came out in 2004. 3M had made the decision to phase PFAS out of Scotchgard.”

In September 2022, a federal judge in the combined lawsuit of thousands of cases against PFAS manufacturers concluded that the U.S. government didn’t know the foam contained PFOS, a member of the PFAS family, until 2000, when 3M announced it would switch to a non-PFAS carbon chain in its products. 3M does not dispute that it didn’t disclose the foam contained PFAS but argued that it had developed the foam as a government contractor – a status that limits a manufacturer’s liability. Other chemical and foam manufacturers stepped in to fill the void left by 3M. PFAS-containing foam has not been manufactured since 2015, but chemical companies and fire departments still have large stockpiles of AFFF, and it’s still being used.

Meanwhile, evidence is mounting that PFAS chemicals in firefighting foam may cause cancer or, along with smoke and toxins from burning materials, heighten the risk of contracting cancer.

A landmark 2013 study by the National Institute for Occupational Safety and Health analyzed cancer rates among 30,000 Chicago, Philadelphia and San Francisco firefighters from 1950 to 2009. It found that firefighters have a 9% higher risk than the general U.S. population of being diagnosed with cancer and a 14% higher risk of dying of it.

In June, the World Health Organization’s cancer research group raised its classification of firefighting to “Group 1 – carcinogenic to humans”. Its review of studies found that firefighters are at greater risk of bladder cancer and mesothelioma as well as colon, prostate, testicular and skin cancers and non-Hodgkin lymphoma. The threats are complex, including emissions from fires, chemicals in foam and diesel exhaust.

The U.S. Agency for Toxic Substances and Disease Registry, however, has said more research is needed to determine how harmful PFAS chemicals are. Not all studies involved the same groups of people, same chemicals or same levels of exposure. There are thousands of man-made PFAS chemicals, and they are found in the blood of people and animals, as well as in food products, water, air, fish and soil around the world.

In December, 3M announced that by the end of 2025 it will stop manufacturing PFAS chemicals and discontinue use of them in its products, citing a “rapidly evolving external regulatory and business landscape.”

Tracking the Toll of Cancer

Alarmed by reports of toxic chemicals in firefighting foam, Shane Nantz, who’s been a firefighter for three decades in Mecklenburg County, North Carolina, began tracking cancer cases among local firefighters several years ago. Nantz is shown in turnout gear at The Palmer Building, a historic former firefighting training center owned by the Charlotte Firefighters Association; he is the union’s historian. Credit: Grant Baldwin Photography

Shane Nantz, a 51-year-old, second-generation Charlotte-area firefighter, closely watched a press conference on Nov. 4, 2021, held by North Carolina Attorney General Josh Stein. Stein was suing 14 AFFF manufacturers alleging PFAS contamination and failure to instruct their customers on how to safely use the foam or warn of potential harm.

Nantz believes his own family has been impacted. His father was diagnosed with kidney cancer three years ago. For several years before 2015, Nantz and his father were stationed at the Charlotte-Douglas International Airport, one of four sites that Stein’s office named in the lawsuit as having PFAS concentrations that far exceeded EPA recommendations.

“We all thought firefighters were dying of cancer because they were exposed to the products of combustion,” Nantz said. “But most firefighters at the airport generally didn’t go to a lot of fires so it didn’t make sense that they were dying of cancer at the same rates or higher than people who were going to structural fires all the time.”

Nantz came to believe that AFFF was the common denominator. Airport firefighters regularly used the foam in their many practice runs. He remembers being covered in foam for up to six hours at a time after a particularly large fire. When it was over, firefighters just rinsed themselves off with a hose. No one ever explained that being covered in foam posed a serious health threat, he said. They were told only that ingesting the foam might cause diarrhea.

Nantz has been tracking cancer diagnoses and deaths at the Charlotte Fire Department for several years. He dug through records and news reports and interviewed current and former firefighters to identify anyone who had acknowledged a cancer diagnosis.

When 35-year-old Seth Tinsley lost a six-year battle with brain cancer in 2016, he was the third Charlotte firefighter to succumb to cancer that year. In 2017, 43 active firefighters were diagnosed with cancer, Nantz found. Since 2020 there have been 10 cancer deaths in the department. “These are young folks, all under 50,” Nantz said. “We just watched them go down to nothing.”

Still, he doubts the numbers are complete. “Cancer is such a private thing, and many people don’t want to talk about it,” he said. “Years ago, we had people go to the hospital and have a tumor removed and come back to work four days later and not even tell anybody.” 

Resisting Regulation

Despite the increasing pressure to limit or ban AFFF, progress remains slow, said Pamela Miller, co-chair of the International Pollutants Elimination Network.

The Naval Research Laboratory has spent years trying to develop a fluorine-free replacement for AFFF foam. A 2020 report showed AFFF extinguishing fires in just under 30 seconds while the fluorine free foams took several seconds longer on average.

In Alaska, state Sen. Jesse Kiehl was rebuffed when in April 2022 he introduced a bill to more strictly regulate the chemicals, including banning AFFF foam at airports. The bill died without the legislature taking action.

Miller blames the chemical industry for much of the resistance.

“The powerful chemical lobby is influencing policymakers and pushing for its continued use,” she said. “Policymakers are so gullible they believe that there can’t be safe alternatives. Fluorine-free foams are effective, don’t create long-term harm and liability, and are being used at major airports, military installations and oil and gas facilities all over the world.”

Roger Klein, the PFAS expert panel coordinator for IPEN in Cambridge, England, said military standards are intentionally set to exclude the kinds of fluorine-free foams being used successfully in many other countries.

“One of the earliest substitutions was in a fire service in Queensland, Australia, which went completely fluorine-free in 2003,” Klein said. “In Europe, most fire brigades and fire departments are fluorine-free.” It’s the same for many military departments.

Klein said early versions of fluorine-free foam had formulation problems that sometimes caused fires to reignite, but those were overcome. “There is no excuse for saying that AFFF outperforms fluorine-free foam,” Klein said. “In many cases, it’s the other way around.”

In December 2019, Congress ordered PFAS to be phased out of military firefighting foams by 2024. In 2018, it directed the FAA to change its rules so that airports could switch to PFAS-free foams. The Navy is an exception: Ships at sea must continue to use AFFF until a fluorine-free foam meets certain requirements. The Pentagon plans to unveil specifications for a PFAS-free replacement in January. Despite the pledges and mandates, Dewitt, the toxicology professor, is skeptical that much will change in the next few years.

As things drag on at the federal level, 15 states have implemented bans or severely limited AFFF use. Legislation is pending in several others.

The shelf life of AFFF is 30-plus years. Many fire departments are reluctant to dispose of the foam because they have millions of dollars tied up in inventory that was purchased decades ago.

Departments also may not know how to get rid of the foam. The same qualities that make it effective also make it almost impossible to destroy. Dumping it could contaminate groundwater, and many states and the Defense Department have banned incineration because toxic emissions could travel downwind.

Battelle, an Ohio-based scientific nonprofit, received a temporary EPA permit to test out its “PFAS Annihilator” in North Carolina. Battelle uses a wet oxidation process that transforms organic materials into compounds it claims can be safely disposed of without leaving any forever chemicals. Battelle offers a new, eco-friendly foam.

Firehouse Culture

In the 1991 movie “Backdraft,” a sign on the wall of a Chicago firehouse sums up the attitude of many firefighters: “150 years of tradition unimpeded by progress.”

Some firefighters admit that macho attitudes and resistance to change have endangered their own health. Many used to remove their breathing apparatus as soon as a blaze was extinguished despite the smoke and toxins in the air. Firefighters routinely wore their turnout gear for hours after a fire, kept it in closed vehicles, and slept and worked out next to it. Many refused to wash it.

.“It was a badge of honor to have this nasty turnout gear,” said Nantz, the Charlotte area firefighter. “…There’s so much tradition in the fire service for things that really killed a bunch of us.”

In past years, firefighters typically let their protective suits, or turnout gear, get soiled and potentially toxic, as this 15-year-old photo of firefighter Shane Nantz at a Charlotte training fire shows. More firehouses now have the equipment to clean the gear on site, Nantz says. Clean or not, turnout gear may contain toxic PFAS chemicals. Credit: Provided by Shane Nantz.

The National Fire Protection Association has recommended more frequent cleaning and two sets of gear per firefighter. The Asheville Fire Department has been proactive in trying to reduce cancer risks. It was the first in the nation to funnel diesel exhaust out of the stations and one of the first in the state to require on-scene gear decontamination in addition to pre-employment and annual cancer screenings.

But those changes are potentially weakened by the fact that the gear contains the same chemicals firefighters want to ban in foam. A moisture barrier in the gear contains PFAS chemicals. Firefighters asked the national council to revise its standards to eliminate the barrier, but it declined, saying more study is needed. The International Association of Fire Fighters has advised wearing turnout gear only when necessary.

Retired firefighter Ben Brickhouse, of Asheville, North Carolina – shown in his garage at home – said many firefighters still are not aware of the cancer risks of their profession. He said he was clueless about it himself until a prostate cancer diagnosis. Credit: Seth Maile for Public Health Watch.

Brickhouse views the turnout-gear exposure as one more betrayal by his chosen profession. “You’re not thinking that the things that are essential to doing your job are going to hurt you,” he said.

Asheville and surrounding Buncombe County have reported 13 cancer cases to a state cancer registry over the last 18 months. Despite news and industry reports, Brickhouse said many firefighters are still in the dark. He recalls speaking to another firefighter at a colleague’s funeral who said he knew nothing about the high cancer rates in their profession.

Soon after settling his case with the city, Brickhouse developed a chronic sore throat that seemed immune to antibiotics, steroids and other treatment. A biopsy confirmed he had throat cancer, which he believes could stem from firefighting. He started radiation and chemotherapy and lost all sense of smell and taste. His salivary and mucus glands no longer work and he’s lost nearly 40 pounds.

Brickhouse advocates for more education and cancer screenings of firefighters and making all equipment and foam PFAS-free. The need is critical, he said, “so they don’t have to go through what I’m going through now.”

Melba Newsome is a contributing writer based in Charlotte, North Carolina. She frequently covers science, health and the environment.