Distinct Prostate Cancer Survival Outcomes in Firefighters: A Population-Based Study.

Introduction: Survival outcomes for prostate cancer among specific occupational groups prone to regular medical check-ups vis-à-vis the general population have been understudied. For firefighters, a demographic subject to rigorous medical evaluations, possessing above-average medical expertise, and exposed to specific carcinogens of interest, prostate cancer survival in the US has never been studied. Methods: We conducted a retrospective study, utilizing data from the Florida Cancer Data System spanning 2004 to 2014, coupled with firefighter certification records from the Florida State Fire Marshal's Office. Our study cohort consisted of 1058 prostate cancer cases among firefighters as well as prostate cases for the Florida general population (n = 150,623). We compared cause-specific survival between the two using Cox regression models adjusted for demographics and clinical characteristics, including PSA levels, Gleason scores, and treatment modalities. Results: Firefighters demonstrated a higher five-year cause-specific survival rate (96.1%, 95% CI: 94.7-97.1%) than the general population (94.2%, 95%CI: 94.1-94.3%). Overall, firefighters' diagnoses were established at younger ages (median age 63 vs. 67 in the general population), exhibited a higher proportion of localized stage cancers (84.7% vs. 81.1%), and had a greater utilization of surgery (46.4% vs. 37.6%), a treatment modality with a high success rate but potential side effects. In multivariable analysis, firefighters displayed a survival advantage for localized stage (adjusted hazard ratio [aHR] = 0.53; 95%CI: 0.34-0.82). However, for regional or distant stages, firefighters aged 65 and above exhibited a higher risk of death (aHR = 1.84; 95% CI: 1.18-2.86) than the general population. Conclusion: Firefighters experience enhanced prostate cancer survival, primarily in cases diagnosed at localized stages, likely due to increased PSA testing. Nonetheless, for regional or distant stage, survival among older firefighters' lags behind that of the general population. Further investigations are warranted to unravel factors influencing the development of aggressive disease beyond PSA and Gleason scores in this population, as well as to assess the impact of a higher rate of surgical treatment on firefighters' quality of life.

Lung cancer survival among Florida male firefighters.

Introduction: Lung cancer is a leading cause of cancer incidence and death in the United States. Although most firefighters are fit and do not smoke, they are exposed to many known carcinogens during and in the aftermath of firefighting activities. Comprehensive epidemiologic investigations on lung cancer survival for both career and volunteer firefighters have not been undertaken. Methods: Data from the Florida Cancer Data System (1981-2014) were linked with firefighter certification records from the Florida State Fire Marshal's Office to identify all patients of this occupational group; lung cancer cause-specific survival data were compared with other occupational groups using Cox regression models with occupation as the main effect. Adjusted hazard ratios (aHR) and 95% confidence intervals (95% CI) were calculated. Results: Out of 210,541 male lung cancer cases diagnosed in Florida (1981-2014), 761 were firefighters (604 career, 157 volunteer). Lung cancer death was similar between volunteer (75.2%) and career firefighters (74.0%) but lower than non-firefighters (80.0%). Survival at 5 years was higher among firefighters (29.7%; career: 30.3%; volunteer: 27.4%) than non-firefighters (23.8%). In a multivariable model, compared with non-firefighters, firefighters have significantly higher cause-specific survival (aHR = 0.84; 95% CI: 0.77-0.91; p < 0.001). However, there were no significant survival differences between career and volunteer firefighters (1.14; 0.93-1.39; p = 0.213). In a separate multivariable model with firefighters as the comparator, other broad occupational groups had significantly lower cause-specific survival [white collar: 1.11 (1.02-1.21); blue collar: 1.15 (1.05-1.25); service: 1.13 (1.03-1.25); others/unknown: 1.21 (1.12-1.32); all p-values < 0.02]. Conclusion: Lung cancer survival is significantly higher among firefighters compared with non-firefighters, but there is no significant difference between career and volunteer firefighters. Improved survival for firefighters might be due to a healthy worker effect, lower smoking prevalence relative to other worker groups, and possibly superior treatment adherence and compliance. Many firefighters are cross-trained as EMTs/paramedics and possess a level of medical knowledge that may favorably impact treatment engagement and better navigation of complex cancer care.

A comparative analysis of histologic types of thyroid cancer between career firefighters and other occupational groups in Florida.

BACKGROUND: Florida Firefighters experience a higher risk of thyroid cancer than non-firefighters. This study examines whether the histologic types and tumor stage of thyroid cancer is different among firefighters compared to other occupational groups. METHODS: Eligible cases were firefighters (n = 120) identified in a linkage of Florida Cancer Data System (FCDS) registry records (1981-2014) and Florida State Fire Marshal's Office employment and certification records, and non-firefighters classified into: blue-collar (n = 655), service (n = 834), white-collar (n = 4,893), and other (n = 1,789). Differences in thyroid histologic type (papillary, follicular, and rare/other less common forms of thyroid cancer), tumor stage, and age at diagnosis were evaluated using multinomial logistic regression models comparing blue-collar, service, white-collar, and other occupational groups with firefighters. Univariate odds ratios as well as odds ratios adjusted for age, gender, race, tumor stage, and year of diagnosis (aOR) and 95% confidence intervals (95%CI) were reported. RESULTS: Service (aOR = 4.12; 95%CI: 1.25-13.65), white-collar (aOR = 3.51; 95%CI: 1.08-11.36), and blue-collar (aOR = 4.59; 95%CI: 1.40-15.07) workers had significantly higher odds of being diagnosed with rare histologic types of thyroid cancer vs papillary type compared to firefighters. Service (aOR = 0.42; 95%CI: 0.27-0.66), white-collar (aOR = 0.39; 95%CI: 0.26-0.59), blue-collar (aOR = 0.36; 95%CI: 0.23-0.56), and other (aOR = 0.34; 95%CI: 0.22-0.53) occupational groups have a significantly lower odds of being diagnosed with rare vs papillary type at a younger age (30-49 years) vs 50-69 years compared to firefighters. However, stage at diagnosis was not significantly different among occupational groups. CONCLUSION: Firefighters diagnosed with thyroid cancer experience a higher odds of papillary compared to rare histologic types of thyroid cancer relative to other workers; there is no evidence of an increased odds of late-stage diagnosis in firefighters relative to other worker groups. Firefighters may benefit from routine screening and active surveillance of suspected thyroid tumors especially given the excellent treatment outcomes available for those diagnosed with early-stage papillary thyroid tumors.

Integration of Cancer Screening Data into Routine Cancer Surveillance Systems: A Florida Pilot Project.

Introduction: Integration of screening data into routine cancer surveillance systems can create more robust data systems to inform cancer prevention and control activities. Currently, state central cancer registries do not routinely collect breast and cervical cancer screening data as part of state cancer surveillance activities. Florida conducted a pilot study involving: (1) linkage of breast and cervical cancer screening data from the Florida Breast and Cervical Cancer Early Detection Program (FBCCEDP) from 2009 to 2021 to the Florida Cancer Data System (FCDS) database to capture screening data for matched cancer cases in the FCDS; and (2) evaluation of the feasibility of developing a population-based breast and cervical cancer screening surveillance system by capturing electronic screening data from private health care providers. Methods: In 2018, the FCDS worked with the Florida Department of Health to identify data partners for the 5-year cancer screening pilot project funded by the Centers for Disease Control and Prevention. Engagement of project partners required extensive review of available screening data; data standards and formatting; data transmission schedules and methods; and processing procedures. The FCDS developed a database to integrate multiple source data sets into a single database whereby linkage to the central cancer registry could be performed. Results: The FCDS worked with Suncoast Health Systems, a clinical practice in the Hillsborough region of Florida, and the FBCCEDP to evaluate data availability, standardization of data sets, and data submission schedules for the pilot project. Extensive meetings and data reviews were conducted with both partners in the first phase of the project. The FCDS developed automated data processing procedures to integrate the data into a single cancer screening database and then linked records to the central cancer registry data set. Discussion: Registry collaboration with the FBCCEDP and Suncoast team on data quality and standardization has produced positive results. The project required extensive review of data and produced many lessons learned for development of a cancer screening surveillance system. Our pilot project depended on partnership building, commitment to data quality, and consistency in data submission practices.

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.

Cancer risk among career male and female Florida firefighters: Evidence from the Florida Firefighter Cancer Registry (1981-2014).

BACKGROUND: Firefighters are at increased risk for select cancers. However, many studies are limited by relatively small samples, with virtually no data on the cancer experience of female firefighters. This study examines cancer risk in over 100,000 career Florida firefighters including 5000 + females assessed over a 34-year period. METHODS: Florida firefighter employment records (n = 109 009) were linked with Florida Cancer Data System registry data (1981-2014; ~3.3 million records), identifying 3760 male and 168 female-linked primary cancers. Gender-specific age and calendar year-adjusted odds ratios (aOR) and 95% confidence intervals for firefighters vs non-firefighters were calculated. RESULTS: Male firefighters were at increased risk of melanoma (aOR = 1.56; 1.39-1.76), prostate (1.36; 1.27-1.46), testicular (1.66; 1.34-2.06), thyroid (2.17; 1.78-2.66) and late-stage colon cancer (1.19;1.00-1.41). Female firefighters showed significantly elevated risk of brain (2.54; 1.19-5.42) and thyroid (2.42; 1.56-3.74) cancers and an elevated risk of melanoma that approached statistical significance (1.68; 0.97-2.90). Among male firefighters there was additional evidence of increased cancer risk younger than the age of 50 vs 50 years and older for thyroid (2.55; 1.96-3.31 vs 1.69; 1.22-2.34), prostate (1.88; 1.49-2.36 vs 1.36; 1.26-1.47), testicular (1.60; 1.28-2.01 vs 1.47; 0.73-2.94), and melanoma (1.87; 1.55-2.26 vs 1.42; 1.22-1.66) cancers. CONCLUSION: Male career firefighters in Florida are at increased risk for five cancers with typically stronger associations in those diagnosed younger than the age of 50, while there was evidence for increased thyroid and brain cancer, and possibly melanoma risk in female firefighters. Larger cohorts with adequate female representation, along with the collection of well-characterized exposure histories, are needed to more precisely examine cancer risk in this occupational group.

Availability and accuracy of occupation in cancer registry data among Florida firefighters.

OBJECTIVES: Occupational exposures significantly contribute to the risk of adverse cancer outcomes, and firefighters face many carcinogenic exposures. Occupational research using cancer registry data, however, is limited by missing and inaccurate occupation-related fields. The objective of this study is to determine the frequency and predictors of missing and inaccurate occupation data for a cohort of career firefighters in a state cancer registry. METHODS: We conducted a linkage between data from the Florida Cancer Data System (1981-2014) and the Florida State Fire Marshal's Office (1972-2012). The percentage and the odds of having a firefighting-related occupation code in the cancer record were calculated, adjusting for other occupation and cancer-related factors. RESULTS: Among 3,928 career firefighters, nearly half (47%) were missing a registry-dervived occupation code and only 17% had a firefighting-related code. Males were more likely to have a firefighting-related code (OR = 2.31;95%CI: 1.41-3.76), as were those with more recent diagnoses (OR1992-2002 = 2.98;95%CI: 1.57-5.67; OR2003-2014 = 11.40;95%CI: 6.17-21.03), and those of younger ages (OR45-64y = 1.26;95%CI: 1.03-1.54; OR20-44y = 2.26;95%CI: 1.73-2.95). CONCLUSIONS: Accurate occupation data is key for identifying increased risk of advserse cancer outcomes. Cancer registry occupation fields, however, are overwhelmingly missing for firefighters and are missing disproportionally by sociodemographic and diagnosis characteristics. This study highlights the lack of accurate occupation data available for hypothesis-driven cancer research. Cancer registry linkage with external occupational data sources represents an essential resource for conducting studies among at-risk populations such as firefighters.

Factors Associated With Receipt of Radiation Therapy for Rectal Cancer.

PURPOSE: Appropriate treatment for cancer is vital to increasing the likelihood of survival; however, for rectal cancer, there are demonstrated disparities in receipt of treatment by race/ethnicity and socioeconomic status. We evaluated factors associated with receipt of appropriate radiation therapy for rectal cancer using data from the Florida Cancer Data System that had been previously enriched with detailed treatment information collected from a Centers for Disease Control and Prevention Comparative Effectiveness Research study. This treatment information is not routinely available in cancer registry data and represents a unique data resource. MATERIALS AND METHODS: Using multivariable regression, we evaluated factors associated with receiving radiation therapy among rectal cancer cases stage II/III. Our sample (n=403) included cases diagnosed in Florida in 2011 who were 18 years and older. Cases clinically staged as 0/I/IV were excluded. RESULTS: Older age (odds ratio=0.96; 95% confidence interval, 0.94-0.97), the presence of one or more comorbidities (0.61; 0.39-0.96), and receipt of surgical intervention (0.44; 0.22-0.90) were associated with lack of radiation. CONCLUSIONS: In this cohort of patients, sociodemographic factors such as race/ethnicity, insurance status, and socioeconomic status, did not influence the receipt of radiation. Further research is needed, however, to understand why aging, greater comorbidity, and having surgery present a barrier to radiation therapy, particularly given that it is a well-tolerated treatment in most patients.

Linking the National Health Interview Survey with the Florida Cancer Data System: A Pilot Study.

Cancer registry data are vital for the surveillance of cancer trends, but registries are limited in the number of data items that can be collected for hypothesis-driven research. Linkage with other databases can add valuable information and is a potentially effective tool for increasing our understanding of and identifying the causes of cancer and health disparities along the cancer continuum. We conducted a pilot study to link data from the 1981-2010 Florida Cancer Data System (FCDS) with data from the 1986-2009 National Health Interview Survey (NHIS). The NHIS data contain important information on sociodemographics, screening behaviors, comorbidities, risk factors, health care access, and quality of life, which are not available from FCDS. The linkage resulted in a total of 6,281 linked cases. After removing cases with a first cancer diagnosis before 1981 (prior to FCDS creation) or missing date of diagnosis information, there were 1,908 cases diagnosed with cancer prior to their NHIS interview and 4,367 cases diagnosed after their NHIS interview. The enriched data set resulting from the linkage allows us to evaluate risk factors associated with developing cancer as well as conduct analyses on cancer survivorship issues and mortality. This pilot study demonstrates the feasibility and utility of a linkage between cancer registries and national health surveys, while also acknowledging the cost and challenges associated with such linkages.

Linkage of 1986-2009 National Health Interview Survey with 1981-2010 Florida Cancer Data System.

BACKGROUND: National survey data linked with state cancer registry data has the potential to create a valuable tool for cancer prevention and control research. A pilot project-developed in a collaboration of the Centers for Disease Control and Prevention's National Center for Health Statistics (NCHS) and the Florida Cancer Data System (FCDS) at the University of Miami -links the records of the 1986-2009 National Health Interview Survey (NHIS) and the 1981-2010 FCDS. The project assesses the feasibility of performing a record linkage between NCHS survey data and a state-based cancer registry, as well as the value of the data produced. The linked NHIS-FCDS data allow researchers to follow NHIS survey participants longitudinally to examine factors associated with future cancer diagnosis, and to assess the characteristics and quality of life among cancer survivors. METHODS: This report provides a preliminary evaluation of the linked national and state cancer data and examines both analytic issues and complications presented by the linkage. CONCLUSIONS: Residential mobility and the number of years of data linked in this project create some analytic challenges and limitations for the types of analyses that can be conducted. However, the linked data set offers the ability to conduct analyses not possible with either data set alone.

Enhancing cancer registry data for comparative effectiveness research (CER) project: overview and methodology.

Following the Institute of Medicine's 2009 report on the national priorities for comparative effectiveness research (CER), funding for support of CER became available in 2009 through the American Recovery and Re-investment Act. The Centers for Disease Control and Prevention (CDC) received funding to enhance the infrastructure of population-based cancer registries and to expand registry data collection to support CER. The CDC established 10 specialized registries within the National Program of Cancer Registries (NPCR) to enhance data collection for all cancers and to address targeted CER questions, including the clinical use and prognostic value of specific biomarkers. The project also included a special focus on detailed first course of treatment for cancers of the breast, colon, and rectum, as well as chronic myeloid leukemia (CML) diagnosed in 2011. This paper describes the methodology and the work conducted by the CDC and the NPCR specialized registries in collecting data for the 4 special focused cancers, including the selection of additional data variables, development of data collection tools and software modifications, institutional review board approvals, training, collection of detailed first course of treatment, and quality assurance. It also presents the characteristics of the study population and discusses the strengths and limitations of using population-based cancer registries to support CER as well as the potential future role of population-based cancer registries in assessing the quality of patient care and cancer control.

Enhancing central cancer registry treatment data using physician medical claims: a Florida pilot project.

BACKGROUND: To capture the complete first course of therapy and cancer incidence, given the shift in cancer care from the hospital to the private physician practice, central cancer registries (CCRs) in the United States are actively pursuing cancer reporting from ambulatory providers. The 837 medical health claim is a national standard which CCRs can use to capture and translate data into standardized cancer reporting for surveillance. METHODS: The Florida Cancer Data System conducted a pilot project with a large medical oncology practice to transmit electronic claims from 2011 to 2013. Using the logic and platform developed under a previous National Cancer Institute (NCI) contract, claims were consolidated and translated into standardized cancer registry codes. Consolidated physician claims were compared against gold standard data from the practice electronic health record (EHR) and evaluated for enhancement to registry data. RESULTS: A total of 623 patient tumor cases were collected from the practice EHR and matched to the physician claims data, and to the original cancer registry record. The claims captured 256 cases (41 percent) with chemotherapy, compared to 28 percent in the registry data set, and 45 percent in the gold standard EHR data set. Combining physician claims with registry data produced 280 cases (45 percent) with chemotherapy. The physician claims plus the registry cancer chemotherapy treatment data produced 92 percent agreement, 92 percent sensitivity, and 91 percent positive predictive value. Claims added 103 cases, or 16.5 percent, to the total chemotherapy received. CONCLUSIONS: Physician medical claims data capture chemotherapy information not otherwise reported by hospitals, and is a standardized and efficient mechanism for cancer reporting.

Cancer registry enrichment via linkage with hospital-based electronic medical records: a pilot investigation.

BACKGROUND: Hospital electronic medical record (EMR) systems are becoming increasingly integrated for management of patient data, especially given recent policy changes issued by the Centers for Medicaid and Medicare Services. In addition to data management, these data provide evidence for patient-centered outcomes research for a range of diseases, including cancer. Integrating EMR patient data with existing disease registries strengthens all essential components for assuring optimal health outcomes. OBJECTIVES: To identify the mechanisms for extracting, linking, and processing hospital EMR data with the Florida Cancer Data System (FCDS); and to assess the completeness of existing registry treatment data as well as the potential for data enhancement. METHODS: A partnership among the Florida Department of Health, FCDS, and a large Florida hospital system was established to develop methods for hospital EMR extraction and transmission. Records for admission years between 2007 and 2010 were extracted using ICD-9-CM codes as the trigger and were linked with the cancer registry for patients with invasive cancers of the breast. RESULTS: A total of 11,506 unique patients were linked with a total of 12,804 unique breast tumors. Evaluation of existing registry treatment data against the hospital EMR produced a total of 5 percent of registry records with updated surgery information, 1 percent of records with updated radiation information, and 7 percent of records updated with chemotherapy information. Enhancement of registry treatment information was particularly affected by the availability of chemotherapy medications data. CONCLUSION: Hospital EMR linkages to cancer disease registries is feasible but challenged by lack of standards for data collection, coding and transmission, comprehensive description of available data, and the exclusion of certain hospital datasets. The FCDS standard treatment data variables are highly robust and complete but can be enhanced by the addition of detailed chemotherapy regimens that are commonly used in patient centered outcomes research.