Thousands of responders, workers, and volunteers participated in the rescue and cleanup efforts at the World Trade Center (WTC), the Pentagon, and the crash site near Shanksville, Pennsylvania during September 11, 2001 and ensuing months. Many workers and residents were exposed to an untold mix of asbestos, alkaline cement dust, pulverized building materials, and smoke, which research continues to link to health problems. The World Trade Center Health Program (WTCHP) was created by the James Zadroga 9-11 Health and Compensation Act of 2010, replacing 2 earlier 9-11-related health programs, to provide medical care for individuals affected by these events.

Renal & Urology News interviewed Michael Crane, MD, MPH, director of the WTC Health Program at Mount Sinai hospital, the largest of 6 Clinical Centers of Excellence administered by the National Institute for Occupational Safety and Health (NIOSH) that provide medical care for responders in the New York City metro area.

What should urologists and nephrologists know about the September 11 events and cancer?

Prostate, kidney, and bladder cancers are among the 10 most frequently diagnosed cancers among WTC responders. An August 2019 study in Molecular Cancer Research suggests respiratory exposure to WTC dust can induce inflammatory and immune responses in prostate tissue associated with cancer. In 2011, an early assessment of cancer outcomes published in the Lancet found that WTC-exposed firefighters had a 10% higher overall cancer incidence ratio than expected in the general male population and a 19% higher incidence than non-exposed firefighters.

Some providers have noted that WTC responders may have more aggressive cancers at a younger age than other patients, and this may be a factor in their strategies for follow-up. Clinicians at our institution take any sign or symptom of renal or urologic disease very seriously and coordinate care with appropriate specialists.

A news report cites a “big push” to find organ donors for those suffering from 9-11-related illnesses. What can you tell us about the need for kidney transplantation?

Experts say kidney cancer appears to be part of the wave of 9-11-related illnesses. It’s related to the exposure, there’s no doubt in my mind. We do seem to be having cancers picked up at a point where we can treat them effectively. I certainly support efforts to expand organ donation.

Currently, cancers are the only urologic/renal conditions that are covered under the WTC Health Program. However, WTC Health Program research grants are actively investigating renal disease in WTC responders, and these studies will inform the future course of the program. The Zadroga Act designates WTC-related conditions covered by the WTCHP and creates a procedure to expand that list of conditions.

WTC exposure is now associated with long-term cardiovascular disease risk. What are your thoughts?

According to a September 2019 JAMA Network Open study, firefighters who arrived at the WTC site the morning or afternoon of September 11, 2001 have a 44% and 24% higher risk of cardiovascular disease, respectively, than firefighters who arrived the next day or later. In addition, firefighters working at the site for 6 or more months have a 30% higher risk for cardiovascular disease than those who worked less time. Myocardial infarction, stroke, unstable angina, coronary artery surgery or angioplasty, and death from cardiovascular disease all fall under that umbrella.

The study authors suggest these findings reinforce the importance of long-term health monitoring for survivors of disasters like the September 11 attacks.

This well-crafted study is a demonstration of the enormous value of long-term follow-up research for our understanding of the health impacts of 9-11. The conclusion is spot on: We must continue the careful monitoring of the health status of these heroic responders.


Michael Crane, MD, MPH, director of the WTC Health Program at Mount Sinai hospital in New York City.


References

Cohen HW, Zeig-Owens R, Joe C, et al. Long-term cardiovascular disease risk among firefighters after the World Trade Center disaster. JAMA Network Open [published online September 6, 2019]. doi:10.1001/jamanetworkopen.2019.9775

Gong Y, Wang L, Yu H, et al. Prostate cancer in World Trade Center responders demonstrates evidence of an inflammatory cascade. Mol Cancer Res. 2019;17:1605-1612.

Zeig-Owens R, Webber MP, Hall CB, et al. Early assessment of cancer outcomes in New York City firefighters after the 9/11 attacks: an observational cohort study. Lancet. 2011;378(9794):898-905.

Melius JM. Medical care for workers exposed to the WTC disaster. Lancet. 2011;378(9794):854-855.

Push to find organ donors for those sickened at ground zero after 9/11 attacks. New York; New York. ABC News; September 9, 2018.