Perceptions of Preventable Cancer Burden Among US-Based Firefighters: A Mixed Methods Cross-Sectional Study.

OBJECTIVE: Characterize experiences with cancer and perceptions of the preventable cancer burden attributable to diet among firefighters. DESIGN: A cross-sectional survey was distributed to assess cancer history and perceptions of cancer. SETTING: US. PARTICIPANTS: US-based firefighters. MAIN OUTCOME MEASURE(S): History of cancer, perceptions of cancer, and perceptions of diet as a means to prevent cancer. ANALYSIS: Descriptive statistics and use of the Behaviour Change Technique Taxonomy v1 (BCTTv1) to evaluate qualitative responses. RESULTS: A total of 471 firefighters participated. Nearly half (48.4%) voiced they strongly agreed that they were at risk for cancer, whereas 44.6% agreed that changing diet could decrease cancer risk. The most common BCTTv1 codes focused on types of education, including "Instruction on how to perform the behavior" (45.1%, n = 189), followed by those centered on behavior execution (eg, "Action planning" [24.8%, n = 104]). Qualitatively, many were concerned about misinformation. CONCLUSIONS AND IMPLICATIONS: Firefighters acknowledge the role of diet in cancer risk and have a desire for knowledge and behavioral support (eg, goal setting) that includes an emphasis on evidence and tackling misinformation. This information should serve as the basis of future interventions that target diet.

Patterns of comorbid PTSD, depression, alcohol use disorder, and insomnia symptoms in firefighters: A latent profile analysis.

BACKGROUND: Firefighters are an at-risk population for multiple psychiatric conditions, including posttraumatic stress disorder (PTSD), depression, alcohol use disorders (AUDs), and insomnia. These disorders are likely to co-occur; however, patterns of comorbidity have scarcely been investigated in firefighters. We aimed to identify subgroups of comorbidity of PTSD, depression, AUDs, and insomnia in a nationwide population of firefighters in South Korea. METHODS: A total of 54,054 firefighters responded to an online survey. Latent classes of comorbidity were categorized using latent profile analysis (LPA) based on the symptom scores of PTSD, depression, AUDs, and insomnia. Analysis of variance was performed to compare the characteristics of the identified classes, and multinomial logistic regression was conducted to examine whether anger reactions, resilience, and number of traumatic events predicted class membership. RESULTS: The LPA identified four subgroups: minimal symptoms (n = 42,948, 79.5 %), predominant PTSD (n = 2858, 5.3 %), subthreshold symptoms and comorbidity (n = 7003, 13.0 %), and high symptoms and comorbidity (n = 1245, 2.3 %). Three comorbidity classes were defined based on severity and one class showed predominant PTSD symptoms. Number of traumatic exposures predicted predominant PTSD, while resilience and anger reactions predicted severity of comorbidities. LIMITATIONS: The cross-sectional design and usage of self-reported questionnaires are limitations of this study. CONCLUSIONS: The severity of PTSD, depression, AUDs and insomnia tend to correlate and co-occur in firefighters. Our findings highlight the need to assess comorbid symptoms in firefighters and need to reduce anger reactions and enhance resilience in those with multiple comorbidities.

Suicides among American Indian/Alaska Native firefighters: Data from the National Violent Death Reporting System, 2003 - 2017.

Suicide is a significant public health problem in the United States and disproportionally affects male American Indian/Alaska Natives (AI/AN). Suicide is particularly problematic among AI/AN firefighters who are more likely to report suicide ideation, planning, attempts, and risk compared to non-Hispanic white (NHW) firefighters. The aim of the current study was to compare non-Hispanic AI/AN firefighter and NHW firefighter suicide decedents by demographics and risk/precipitating factors using National Violent Death Reporting System data for 45 male non-Hispanic AI/AN firefighter and 588 male NHW firefighter decedents who died by suicide. Compared to NHW firefighter decedents, AI/AN firefighter decedents were significantly younger and had significantly higher odds of experiencing alcohol use problems and a recent death/suicide of a family member/friend. AI/AN firefighter decedents had significantly lower odds of documented mental health problems, documented diagnosis of depression/dysthymia, receipt of mental health treatment, or leaving a suicide note compared to NHW firefighter decedents. Results from this study may inform tailored suicide prevention and screening efforts among first responders with the goal of lowering suicide mortality among AI/AN firefighters and fire service as a whole.

Cancer incidence in World Trade Center-exposed and non-exposed male firefighters, as compared with the US adult male population: 2001-2016.

OBJECTIVE: To compare cancer incidence in Fire Department of the City of New York (FDNY) firefighters who worked at the World Trade Center (WTC) site to incidence in a population of non-WTC-exposed firefighters, the Career Firefighter Health Study (CFHS) cohort, and to compare rates from each firefighter cohort to rates in demographically similar US males. METHODS: FDNY (N=10 786) and CFHS (N=8813) cohorts included male firefighters who were active on 11 September 2001 (9/11) and were followed until death or 31 December 2016. Cases were identified from 15 state cancer registries. Poisson regression models assessed cancers in each group (FDNY and CFHS) versus US males, and associations between group and cancer rates; these models estimated standardised incidence ratios (SIRs) and adjusted relative rates (RRs), respectively. Secondary analyses assessed surveillance bias and smoking history. RESULTS: We identified 915 cancer cases in 841 FDNY firefighters and 1002 cases in 909 CFHS firefighters. FDNY had: higher rates for all cancers (RR=1.13; 95% CI 1.02 to 1.25), prostate (RR=1.39; 95% CI 1.19 to 1.63) and thyroid cancer (RR=2.53; 95% CI 1.37 to 4.70); younger median ages at diagnosis (55.6 vs 59.4; p<0.001, all cancers); and more cases with localised disease when compared with CFHS. Compared with US males, both firefighter cohorts had elevated SIRs for prostate cancer and melanoma. Control for surveillance bias in FDNY reduced most differences. CONCLUSIONS: Excess cancers occurred in WTC-exposed firefighters relative to each comparison group, which may partially be explained by heightened surveillance. Two decades post-9/11, clearer understanding of WTC-related risk requires extended follow-up and modelling studies (laboratory or animal based) to identify workplace exposures in all firefighters.

Dynamic Metabolic Risk Profiling of World Trade Center Lung Disease: A Longitudinal Cohort Study.

Rationale: Metabolic syndrome (MetSyn) increases the risk of World Trade Center (WTC) lung injury (LI). However, the temporal relationship of MetSyn, exposure intensity, and lung dysfunction is not well understood. Objective: To model the association of longitudinal MetSyn characteristics with WTC lung disease to define modifiable risk. Methods: Firefighters, for whom consent was obtained (N = 5,738), were active duty on September 11, 2001 (9/11). WTC-LI (n = 1,475; FEV1% predicted

Estimating Total Energy Expenditure for Fire-Fighters during Large Scale Disaster Response Training Using a Tri-Axial Accelerometer.

The present study was conducted to estimate total energy expenditure (TEE) of fire-fighters using tri axial-accelerometers in conjunction with an activity log survey on a large number of subjects undergoing training mimicking a large-scale disaster. Subjects were 240 fire-fighters participating in a two-day fire-fighting training dedicated to large-scale natural disasters. Data was analyzed by job type of activity group and the job rank, and by comparing the average. The average TEE of the total survey training period is about 3619 (±499) kcal, which is the same value of expenditure for professional athletes during the soccer game season. From the activity group, the rescue and other teams consumed significantly more energy than the fire and Emergency Medical Team (EMS) teams. From the job rank, Fire Captain (conducting position) consumed significantly lower energy than the Fire Lieutenant and Fire Sergeant. Furthermore, it was found that a middle position rank consumed the most energy. This research supports a need to reconsider the current rescue food (and protocols) to supplement the energy expenditure of fire-fighters. In addition, since there was a significant difference between the job type and the job rank, it is necessary to examine the energy amount and shape suitable for each.

SARS-CoV-2 antibody seroprevalence among firefighters in Orange County, California.

OBJECTIVES: We conducted serological SARS-CoV-2 antibody testing from October to November 2020 to estimate the SARS-CoV-2 seroprevalence among firefighters/paramedics in Orange County (OC), California. METHODS: OC firefighters employed at the time of the surveillance activity were invited to participate in a voluntary survey that collected demographic, occupational and previous COVID-19 testing data, and a SARS-CoV-2 immunoglobulin (Ig)G antibody blood test. We collected venous blood samples using mobile phlebotomy teams that travelled to individual fire stations, in coordination with an annual tuberculosis testing campaign for firefighters employed by OC Fire Authority (OCFA), and independently for firefighters employed by cities. We estimated seroprevalence and assessed several potential predictors of seropositivity. RESULTS: The seroprevalence was 5.3% among 923 OCFA personnel tested, with 92.2% participating. Among firefighters self-reporting a previous positive COVID-19 antibody or PCR test result, twenty-one (37%) did not have positive IgG tests in the current serosurvey. There were no statistically significant differences in demographic characteristics between cases and non-cases. Work city was a significant predictor of case status (p=0.015). Seroprevalence (4.8%) was similar when aggregated across seven city fire departments (42%-65% participation). In total, 1486°C fire personnel were tested. CONCLUSION: Using a strong serosurvey design and large firefighter cohort, we observed a SARS-CoV-2 IgG seroprevalence of 5.3%. The seroprevalence among OC firefighters in October 2020 was lower than the general county population estimated seroprevalence (11.5%) in August. The difference may be due in part to safety measures taken by OC fire departments at the start of the pandemic, as well as differences in antibody test methods and/or duration of antibody response.

Are there sex differences in physiological parameters and reaction time responses to overload in firefighters?

Male and female firefighters work side-by-side in the same in strenuous and risky conditions. Anthropometrics, physiological, and reaction time (mean of reaction time -MRT-, and errors made -E) parameters of 12 Female and 13 Male firefighters were compared. Effect of overload (step test with and without equipment) on the MRT and E were analyzed on 3 trials (T1 = 1-1s, T2 = 0.5-1s, T3 = 0.5-0.5s), compared with a pre-test condition (basal). T-test between males and females was applied to assess differences (p<0.05) in all parameters. ANOVA with repeated measures and Bonferroni on 3 conditions of step test between males and females was applied in reaction time variables. Between MRT and E, in T1, T2 and T3 trials and the 3 test conditions, ANCOVA models with interactions were used. Differences (p<0.05) in anthropometric, physiological and reaction time data emerged across groups, and on the 3rd trials (T3 vs T1 and T2) in reaction time parameters of each group. ANCOVA showed differences (p<0.001) in E among trials. Post hoc showed significant differences in T1vsT3 and T1vsT2. MRT x trial interaction was extremely significant (P<0.001). Implementing fitness and reaction time exercise programs is important to decrease the injury risk and increase work capacity in firefighters with reference to female workers.

Suicide Among the Emergency Medical Systems Occupation in the United States.

INTRODUCTION: Suicide claimed 47,173 lives in 2017 and is the second leading cause of death for individuals 15-34 years old. In 2017, rates of suicide in the United States (US) were double the rates of homicide. Despite significant research funding toward suicide prevention, rates of suicide have increased 38% from 2009 to 2017. Recent data suggests that emergency medical services (EMS) workers are at a higher risk of suicidal ideation and suicide attempts compared to the general public. The objective of this study was to determine the proportionate mortality ratio (PMR) of suicide among firefighters and emergency medical technicians (EMT) compared to the general US working population. METHODS: We analyzed over five million adult decedent death records from the National Occupational Mortality Surveillance database for 26 states over a 10-year non-consecutive period including 1999, 2003-2004, and 2007-2013. Categorizing firefighters and EMTs by census industry and occupation code lists, we used the underlying cause of death to calculate the PMRs compared to the general US decedent population with a recorded occupation. RESULTS: Overall, 298 firefighter and 84 EMT suicides were identified in our study. Firefighters died in significantly greater proportion from suicide compared to the US.working population with a PMR of 172 (95% confidence interval [CI], 153-193, P<0.01). EMTs also died from suicide in greater proportion with an elevated PMR of 124 (95% CI, 99-153), but this did not reach statistical significance. Among all subgroups, firefighters ages 65-90 were found to have the highest PMR of 234 (95% CI, 186-290), P<0.01) while the highest among EMTs was in the age group 18-64 with a PMR of 126 (95% CI, 100-156, P<0.05). CONCLUSION: In this multi-state study, we found that firefighters and EMTs had significantly higher proportionate mortality ratios for suicide compared to the general US working population. Firefighters ages 65-90 had a PMR more than double that of the general working population. Development of a more robust database is needed to identify EMS workers at greatest risk of suicide during their career and lifetime.

COVID-19 Vaccine Acceptability Among US Firefighters and Emergency Medical Services Workers: A Cross-Sectional Study.

OBJECTIVES: Estimate the point prevalence of COVID-19 vaccine acceptability among US firefighters and Emergency Medical Services (EMS) workers. METHODS: A cross-sectional study design was used to administer an anonymous online survey to a national non-probabilistic sample of firefighter and EMS workers. RESULTS: Among the 3169 respondents, 48.2% expressed high acceptability of the COVID-19 vaccine when it becomes available, while 24.2% were unsure and 27.6% reported low acceptability. Using the "high COVID-19 vaccine acceptability" group as the reference category, the groups with greater odds of reporting low acceptability included those: 30 to 39 years of age (odds ratio = 3.62 [95% confidence interval = 2.00 to 6.55]), Black race (3.60 [1.12 to 11.53]), Hispanic/Latinx ethnicity (2.39 [1.45 to 3.92]), with some college education (2.06 [1.29 to 3.27]), married (1.65 [1.03 to 2.65]), of current rank firefighter/EMS (2.21 [1.60 to 3.08]). CONCLUSIONS: Over half of US firefighters and EMS workers were uncertain or reported low acceptability of the COVID-19 vaccine when it becomes available.

Coccidioidomycosis outbreak among inmate wildland firefighters: California, 2017.

BACKGROUND: In California, state prison inmates are employed to fight wildfires, which involves performing soil-disrupting work. Wildfires have become more common, including areas where Coccidioides, the soil-dwelling fungus that causes coccidioidomycosis, proliferates. However, work practices that place wildland firefighters at risk for coccidioidomycosis have not been investigated. METHODS: On August 17, 2017, the California Department of Public Health was notified of a cluster of coccidioidomycosis cases among Wildfire A inmate wildland firefighters. We collected data through medical record abstraction from suspected case-patients and mailed a survey assessing potential job task risk factors to Wildfire A inmate firefighters. We described respondent characteristics and conducted a retrospective case-control investigation to assess coccidioidomycosis risk factors. RESULTS: Among 198 inmate firefighters who worked on Wildfire A, 112 (57%) completed the survey. Of 10 case-patients (four clinical and six laboratory-confirmed), two were hospitalized. In the case-control analysis of 71 inmate firefighters, frequently cutting fire lines with a McLeod tool (odds ratio [OR]: 5.5; 95% confidence interval [CI]: 1.1-37.2) and being in a dust cloud or storm (OR: 4.3; 95% CI: 1.1-17.4) were associated with illness. Two of 112 inmate firefighters reported receiving coccidioidomycosis training; none reported wearing respiratory protection on this wildfire. CONCLUSIONS: Wildland firefighters who use hand tools and work in dusty conditions where Coccidioides proliferates are at risk for coccidioidomycosis. Agencies that employ them should provide training about coccidioidomycosis and risk reduction, limit dust exposure, and implement respiratory protection programs that specify where respirator use is feasible and appropriate.

Predicting Posttraumatic Stress and Depression Symptoms Among Frontline Firefighters in China.

To investigate the prevalence and comorbidity rate of potential posttraumatic stress disorder (PTSD) and depression in frontline firefighters in China, as well as to analyze the related predictive factors for PTSD and depression, our study included 261 firefighters who completed assessments including the Demographic Data Forum, PTSD Checklist for DSM-5, Center for Epidemiological Studies Depression Scale, Chinese version of Perceived Stress Scale, and Perceived Social Support Scale. Among the participants, 1.9% and 11.9% were identified as having potential PTSD and depression, respectively. There was a 9.1% chance of comorbid PTSD among the depressed firefighters and a 60% chance of comorbid depression among the firefighters with PTSD. Perceived stress positively predicted both PTSD and depression; perceived social support negatively predicted both PTSD and depression. Whereas family exogenous support predicted both PTSD and depression, family endogenous support only predicted depression. In addition, PTSD was predicted by rank. Soldiers and sergeants demonstrated higher level of PTSD than officers. Future studies on mental health of firefighters should take factors like perceived stress, social support, and rank into consideration.

Prevalence of cardiovascular risk factors in a population of French firefighters.

Firefighters' activities increase the risk of sudden cardiac events. The main objective of this study was to describe the Loire firefighters' cardiovascular risk factors according to their cardiovascular risk and to their professional status. A retrospective study of the entire population of firefighters of the Loire department was conducted. Risk factors derived from the data collected during the occupational health follow-up medical examinations were described and the cardiovascular risk was assessed for 417 firefighters. The most frequent cardiovascular risk factors were: overweight and obesity (62.1%), high blood pressure (27.8%) and active smoking (16,1%). There were no significant differences between career firefighters and volunteers. The prevalence of risk factors for cardiovascular diseases is less than in the general population. Obesity remains the most common risk factor, especially among firefighters with high cardiovascular risk.

Younger, more senior, and most vulnerable? Interaction effects of age and job seniority on psychological distress and quality of life among firefighters.

OBJECTIVES: Firefighters are exposed to repeated traumatic events while the robustness of cumulative effects of repeated exposure to trauma on psychological distress among them are inconsistent. Considering the length of service and seniority are risk factors, the purpose of this study was to examine the effects of the interaction between age and seniority on psychological distress and quality of life among firefighters. METHODS: Participants were 229 firefighters of the Hualien County Fire Bureau in Taiwan who worked full time in response to emergency services and disaster rescues activities. Probable posttraumatic stress disorder (PTSD), depression, anxiety, agoraphobia, and quality of life were assessed among firefighters using psychodiagnostics questionnaires. Firefighters were stratified based on age into a young and a mature group, and based on length of service into a junior and a senior group, yielding four groups: "young-senior," "young-junior," "mature-senior," and "mature-junior." RESULTS: A majority of the firefighters were dissatisfied with their health condition. All the firefighters scored relatively lower at the social domain of their quality of life compared with physical, emotional, and environment domains. In the post hoc multiple comparison analysis, the young-senior firefighters were found to be most vulnerable to psychological distress, manifested in having a higher prevalence of, and suffering from more, severe probable PTSD, depression, anxiety, and agoraphobia symptoms than the other groups of firefighters. CONCLUSIONS: Age and job seniority have significant effects on psychological distress among firefighters. Being young and starting young to serve as a firefighter for a relatively long time is a significant risk factor for psychological distress. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Estimation of differential occupational risk of COVID-19 by comparing risk factors with case data by occupational group.

BACKGROUND: The disease burden of coronavirus disease 2019 (COVID-19) is not uniform across occupations. Although healthcare workers are well-known to be at increased risk, data for other occupations are lacking. In lieu of this, models have been used to forecast occupational risk using various predictors, but no model heretofore has used data from actual case numbers. This study assesses the differential risk of COVID-19 by occupation using predictors from the Occupational Information Network (O*NET) database and correlating them with case counts published by the Washington State Department of Health to identify workers in individual occupations at highest risk of COVID-19 infection. METHODS: The O*NET database was screened for potential predictors of differential COVID-19 risk by occupation. Case counts delineated by occupational group were obtained from public sources. Prevalence by occupation was estimated and correlated with O*NET data to build a regression model to predict individual occupations at greatest risk. RESULTS: Two variables correlate with case prevalence: disease exposure (r = 0.66; p = 0.001) and physical proximity (r = 0.64; p = 0.002), and predict 47.5% of prevalence variance (p = 0.003) on multiple linear regression analysis. The highest risk occupations are in healthcare, particularly dental, but many nonhealthcare occupations are also vulnerable. CONCLUSIONS: Models can be used to identify workers vulnerable to COVID-19, but predictions are tempered by methodological limitations. Comprehensive data across many states must be collected to adequately guide implementation of occupation-specific interventions in the battle against COVID-19.

Daytime sleepiness among Midwestern firefighters.

Excessive daytime sleepiness (EDS) is the most common symptom of sleep-disorders. Although high levels of EDS have been reported among firefighters, there is a limited understanding on EDS in firefighters. A cross-sectional survey was conducted in full-time firefighters (n = 275). The survey included the Epworth Sleepiness Scale to assess EDS, as well as other questions related to job characteristics, health history, and demographics. Firefighters reported inadequate sleep hours, extremely short sleep latencies, and high EDS higher than the general population. A majority of firefighters indicated a willingness to consult with a sleep professional. Risk factors associated with EDS included at least five years of professional experiences and depression diagnosis. Our findings suggest that EDS is widespread among firefighters. With increasing time on the job, frequencies of both obesity and EDS increase, which can have severe and compounding effects on health and safety.

An epidemiologic study of suicide among firefighters: Findings from the National Violent Death Reporting System, 2003 - 2017.

Suicide is a significant concern among fire service due to high rates of suicide behaviors. The aim of this study was to describe suicides among firefighters using national suicide death data. Data from the National Violent Death Reporting System for 722 firefighters and 192,430 non-firefighters were analyzed to compare sociodemographics and risk factors between firefighter and non-firefighter decedents; and among firefighters based on suicide means. A greater proportion of firefighter decedents died by firearm compared to non-firefighters. Firefighter decedents were less likely to have been diagnosed with depression, but more likely to have been diagnosed with post-traumatic stress disorder compared to non-firefighters. A greater percentage of firefighter decedents had a relationship or physical health problem prior to death, but a lower percentage had a history of suicide thoughts/attempts. Among firefighter decedents, multivariate analysis showed physical health problems and disclosing suicide intent predicted death by firearm. Greater awareness of risk factors, reduced access to lethal means, and ensuring access to behavioral health services may aide in decreasing suicide mortality in this population. These findings should be interpreted with caution due to limitations concerning report accuracy, generalizability, small female sample size, and inclusion of data only for lethal suicide attempts.

A prospective study of firefighters' PTSD and depression symptoms: The first 3 years of service.

Objective: Firefighters are an important sample of convenience to study traumatic exposure and symptom development. This study assessed trauma exposure inside and outside of fire service, diagnosed posttraumatic stress disorder (PTSD) and associated disorders using clinical interviews and self-report measures, then tested the hypothesis that trauma exposure would predict distress in firefighters over the first 3 years in service. Method: In total, 322 professional firefighter recruits were assessed during academy training and through their first 3 years of service. Diagnostic assessments were conducted by psychologists annually, and symptom checklists were completed by telephone every 4 months. Results: Firefighter recruits were exposed to approximately nine potentially traumatic events (PTEs) in the first 3 years of fire service, with 66% of these events occurring in the line of duty. Very few (3%) developed diagnoses of PTSD, major depression, or generalized anxiety disorder. Models of distress supported a trait model of distress. Distress was stable within individuals over time, and although those reporting more distress also reported more trauma exposure, variation in distress over time was not predicted by trauma exposure. Conclusions: Professional firefighters experience frequent exposure to potentially traumatic events during their early careers. This exposure, although large, does not result in a large proportion of mental health diagnoses. Distress was consistent and low, which provides evidence of the resilient nature of those selecting a career in emergency service. Future work is needed to understand the disconnection between the current rigorously collected prospective data and the existing literature regarding the increased risk of PTSD and associated disorders in fire service. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Comparing cancer risk estimates using occupational record linkage approaches in male Florida firefighters.

BACKGROUND: Firefighters have an increased risk of cancer, but variations in reported results could be due to differences in occupational case ascertainment. This study compares cancer risk estimates generated by identifying firefighters from their occupational title available in the Florida Cancer Data System (FCDS) versus identification by a linkage method between the FCDS and the Florida State Fire Marshal's Office. METHODS: Florida firefighter employment records (1972-2012; n = 109,009) were linked with FCDS data (1981-2014; ~3.3 million records), identifying 3760 primary cancers in male firefighters. Using the FCDS occupational data field we identified 1831 male cancer cases in those classified as firefighters, first-line supervisors of firefighting and prevention workers, fire inspectors, emergency medical technicians, or paramedics. Age and calendar year-adjusted odds ratios (aOR) and 95% confidence intervals for firefighters versus non-firefighters were calculated for both groups. RESULTS: For skin cancers the risk estimate for FCDS-indentified firefighters was substantially lower than in the employment-record-linked firefighters (aOR = 1.06; 0.87-1.29 vs. 1.54; 1.37-1.73), but for endocrine system cancers it was greater (aOR = 2.36; 1.77-3.14 vs. 2.08; 1.71-2.53). Remaining cancer risk estimates were in the same direction for the two samples except for lymphoma (aOR = 1.10; 0.90-1.34 vs. 0.86; 0.75-0.99). CONCLUSION: Reliance on occupational title in cancer registry records to characterize firefighter cancer risk may result in estimates that are over- or underestimated depending on cancer site. The authors recommend moving toward national linkages between cancer registries and certification or other administrative records, which are a vital resource for firefighter cancer research.