KFF Health News — Gary Flook served in the Air Force for 37 years, as a firefighter at the now-closed Chanute Air Force Base in Illinois and the former Grissom Air Force Base in Indiana, where he regularly trained with aqueous film forming foam (AFFF) — a frothy white fire retardant that is highly effective but now known to be toxic.

Flook volunteered at his local fire department, where he also used the foam, unaware of the health risks it posed. In 2000, at age 45, he received devastating news: He had testicular cancer, which would require an orchiectomy followed by chemotherapy.

Hundreds of lawsuits, including one by Flook, have been filed against companies that make firefighting products and the chemicals used in them.

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And multiple studies show that firefighters, both military and civilian, have been diagnosed with testicular cancer at higher rates than people in most other occupations, often pointing to the presence of perfluoroalkyl and polyfluoroalkyl substances (PFAS) in the foam.

But the link between PFAS and testicular cancer among service members was never directly proven — until now.

new federal study shows a direct association between perfluorooctanesulfonic acid (PFOS), a PFAS chemical, and testicular cancer. Using banked blood drawn from Air Force servicemen, researchers at the National Cancer Institute (NCI) and Uniformed Services University of the Health Sciences (USUHS) found strong evidence that airmen who were firefighters had elevated levels of PFAS in their bloodstreams and weaker evidence for those who lived on installations with high levels of PFAS in the drinking water. And the airmen with testicular cancer had higher serum levels of PFOS than those who had not been diagnosed with cancer, said study co-author Mark Purdue, a senior investigator at NCI.

“To my knowledge,” Purdue said, “this is the first study to measure PFAS levels in the US military population and to investigate associations with a cancer endpoint in this population, so that brings new evidence to the table.”

In a commentary in the journal Environmental Health Perspectives, Kyle Steenland, a professor at Emory University’s Rollins School of Public Health, said the research “provides a valuable contribution to the literature,” which he described as “rather sparse” in demonstrating a link between PFAS and testicular cancer.

More studies are needed, he said, “as is always the case for environmental chemicals.”

Not ‘Just Soap and Water’

Old stocks of AFFF that contained PFOS were replaced in the past few decades by foam that contains newer-generation PFAS, which are also known to be toxic now. By congressional order, the Department of Defense (DoD) must stop using all PFAS-containing foams by October 2024, though it can keep buying them until this October. That’s decades after the military first documented the chemicals’ potential health concerns.

DoD study in 1974 showed that PFAS was fatal to fish. By 1983, an Air Force technical report showed its deadly effects on mice.

But given its effectiveness in fighting extremely hot fires, like aircraft crashes and shipboard blazes, the DoD still uses AFFF in operations. Rarely, if ever, had the military warned of its dangers, according to Kevin Ferrara, a retired Air Force firefighter, as well as several military firefighters who contacted KFF Health News.

“We were told that it was just soap and water, completely harmless,” Ferrara said. “We were completely slathered in the foam — hands, mouth, eyes. It looked just like if you were going to fill up your sink with dish soap.”

Photos released by the Defense Visual Information Distribution Service in 2013 show personnel working in the foam without protective gear. The description calls the “small sea of fire retardant foam” at Travis Air Force Base in California “non-hazardous” and “similar to soap.” “No people or aircraft were harmed in the incident,” it reads.

There are thousands of PFAS chemicals, invented in the 1940s to ward off stains and prevent sticking in industrial and household goods. Along with foam used for decades by firefighters and the military, the chemicals are in makeup, nonstick cookware, water-repellent clothing, rugs, food wrappers, and myriad other consumer goods.

Also known as “forever chemicals,” PFAS do not break down in the environment and do accumulate in the human body. Researchers estimate that nearly all Americans have PFAS in their blood, exposed primarily by groundwater, drinking water, soil, and foods. A recent US Geological Survey study estimated that at least 45% of US tap water has at least one type of forever chemical from both private wells and public water supplies.

Health and environmental concerns associated with the chemicals have spurred a cascade of lawsuits, plus state and federal legislation that targets the manufacturers and sellers of PFAS-laden products. Gary Flook is suing 3M and associated companies that manufactured PFAS and the firefighting foam, including DuPont and Kidde-Fenwal.

Congress has prodded the DoD to clean up military sites and take related health concerns more seriously, funding site inspections for PFAS and mandating blood testing for military firefighters. Advocates argue those actions are not enough.

“How long has [the DoD] spent on this issue without any real results except for putting some filters on drinking water?” said Jared Hayes, a senior policy analyst at the Environmental Working Group. “When it comes to cleaning up the problem, we are in the same place we were years ago.”