Good afternoon, and welcome to Session 414, titled Cancer Control and Prevention in the Firefighter Workforce, Evidence from the Firefighter Cancer Initiative. My name is Alberto Caban Martinez, and I'm an Associate Professor of Public Health Sciences at the University of Miami, and we're really thankful to the ACOM and AOHC for the opportunity to present to you today some of the work that comes from the state of Florida in terms of cancer control and prevention. We put together a really interesting group of presentations that brings the breadth and scope of the different activities that we do for cancer control in the state of Florida. For our colleagues that are joining us remotely, please go ahead and feel free to put in your questions in the chat, and towards the end of our presentation, we've dedicated some time to answer questions from the room and from online. Before we begin, we'd like to dedicate this presentation to some of our Florida firefighters who recently passed away from cancer, as well as all firefighters in the U.S., Canada, and internationally that have suffered a disproportionate burden of different cancers. And these are some of our special firefighters from Florida that motivate us and inspire us to continue to push through and understand how we can reduce cancer burden within the U.S. Fire Service. So we've organized the presentation this afternoon with four items. The first one is we'll give you a really broad overview of the Firefighter Cancer Initiative in the state of Florida. So you have some background information there. Next, I'll invite Dr. David Lee up to the podium to speak to you a little bit about our dedicated Firefighter Cancer Registry and occupational epidemiology. So how do we know what cancers the firefighters are experiencing and how is that different from the general population? And then I'll return back to the stage and talk to you a little bit about how we do cancer exposure assessment and epigenetics within the first responder workforce. And then I'll invite my colleague, Dr. Natasha Sali, who will close us up talking about how firefighters do exposure reporting, how we do cancer education with them, and our newly kicked-off firefighter mobile van. So we have a lot to say, and hopefully we'll get through it in the next couple of minutes. So I'd like to begin by acknowledging our funding source. This work that we're presenting to you wouldn't have been possible without appropriation from the state of Florida, from the Florida Fire Marshal's Office, as well as all of the firefighters, including the Florida Firefighter Health and Safety Collaborative, and all the different Florida firefighter departments that support this research. So the Firefighter Cancer Initiative is home at the Sylvester Comprehensive Cancer Center. This is our NCI-designated cancer center at the University of Miami. And the initiative actually got started back in 2015. So we're about starting our eighth year where we've been devoting time, energy, and effort to understanding the question about why we see specific types of cancers more elevated in firefighters than in the general population. And it actually got started by the firefighters. The firefighters literally walked over from their local department to our cancer center and said, here are our insurance claims data to our senior leadership, and said, do we have a problem here? And after looking at some of those records, we did. And legislatively, the state of Florida legislature appropriates annually a certain amount of funds for us to be able to do this research, education, and service. And so the goal is really to understand and address the excess burden. And we use a community-based participatory research model. The firefighters tell us what they want to have investigated, and then we use our skills in science and in medicine to be able to design those projects. So to do that, we use a socioecological model to address many of the research projects that you see today. So in the center, I hope I don't click the wrong button. Of course, I would click the wrong button. In the center, you'll see that you have the individual with the knowledge, attitudes, and skills that they bring. These are our firefighters. And our research projects evaluates the impact of the interpersonal sphere. So how do coworkers and friends and family interact their experience with cancer? How the fire department and the individual fire stations impact that? The communities where they reside are these fire departments, rural, urban, and suburban, with the ultimate goal of impacting health policy, which I'll show in the state of Florida. We have now workman's compensation for select cancers based on a lot of the science that we've been able to contribute to that understanding. The projects we'll present to you this afternoon cross the continuum, what we consider the cancer control continuum. So some of the projects are dedicated to addressing prevention and how we can actually reduce it to begin with. Some of the projects cover early detection and diagnosis. Are there ways that we can detect these specific cancers earlier within the fire department or diagnose them a little bit differently? Also, the treatment, so cancer survivorship. If they are diagnosed with cancer, how do we help them navigate the cancer experience and burden? So there's a lot of different projects that happen at the FCI. And today, we've selected a handful to present to you. But there are projects that span epidemiologic efforts to understand the experience of the firefighters, like the annual cancer survey and aerial. Today, we'll be showing you our dedicated firefighter cancer registry led by Dr. David Lee. We'll show you how firefighters do individual reporting. We created an app that they told us how to create, called the exposure app, and they record their individual exposures. We have projects that span education and training on decontamination. So post scene, after the fire scene, how they can quickly decontaminate and remove carcinogen and their exposures. Survivorship, if they get diagnosed with cancer. We have a dedicated tumor bank. So any firefighter that's diagnosed with cancer, they can provide us with their tumor sample and we can compare those tumor morphology to, you know, non-firefighters and see if they're different. We have an industrial hygiene program where we do a lot of environmental sampling to understand the carcinogens that they come through and across as part of their fire response. Trying to do early detection led by my colleague, Dr. Sali, here, and then wellness and nutrition. So in the fire service, the topic of cancer has grown and grown. Originally, there was a lot of interest in cardiovascular disease as line of duty deaths. But more recently, as a profession, the firefighters have drawn a lot of increasing interest and attention into understanding why they're seeing elevated cancer rates for specific types of cancers more than others. I'm going to turn it over now to my colleague, Dr. David Lee, who's going to talk to you a little bit about our dedicated firefighter cancer registry, which is the way that we understand the different cancers to arise between the firefighters and the community. Thanks, Alberto. Okay. So there's been accumulating evidence as to the risk of cancer in the fire service. The International Agency for Research on Cancer is kind of like the worldwide definitive body that assesses data to determine if a particular chemical, for example, is carcinogenic and causally associated with subtypes of cancer. IARC has also looked at occupations, just a handful of occupations. In this particular volume, they looked at the occupations of firefighting, occupations that utilize shift work, and also painters in this particular volume. And in this initial comprehensive report, they noted that there were large variations of exposures across different fires, different firefighters doing different jobs. But they did see consistently increased risks for testicular prostate and non-Hopkins lymphoma. So around the same time, the first formal meta-analysis was completed with the existing 32 studies. This was published in JOEM back in 2006. And LeMasters et al concluded that cancers were probably elevated in firefighters for four cancers, multiple myeloma, non-Hopkins lymphoma, prostate, and testicular cancers. There have been a couple of updates to the original LeMasters report. And if we just look on this column here, basically what you can see, we've got the summary of the initial IARC report, then the LeMasters meta-analysis, and then some of the more recent meta-analyses. And you can see the list of candidate cancers that are possibly related to firefighting is actually growing. So I'm going to talk to you about our efforts in the state of Florida to understand cancer risk among firefighters. And we undertook, in partnership with the state fire marshal's office, we obtained certification records for all firefighters in the state of Florida going back to the 1972, and we needed to augment those records for some critical linkage variables like social security number, date of birth, and in some cases even gender, because the early records for firefighters, they didn't have a gender column because they were all men 20 years ago. Now we have roughly about 4% of the workforces, firefighting workforces, female. But we linked to this LexisNexis database, one of these companies that kind of, you know, has records, detailed records on all Americans, kind of scary, but we were able to get some critical information to augment our linkage file. And then we took that combined LexisNexis firefighter certification and linked to our cancer registry in the state of Florida, which I happen to be the project director principal investigator for that in the state of Florida. The registry is housed at the University of Miami and Sylvester Cancer Center. So we undertook this linkage and we basically, I won't go into all the details here, but we identified about 3,700 male firefighters with a cancer record and 168 female firefighters, and we were, we had done this linkage about 15 years prior and we picked up about triple the number of cancer cases when we did this more recently. So here are the primary findings from that linkage. Let me orient you to the figures here. We're reporting odds ratios here. Basically what we did was we compared firefighters as our cases and our controls where other cancers in the tumor registry that were reported to the registry and then we looked at occupation, were they a firefighter and were they not a firefighter? And so what we see is elevations in this case for male firefighters here, elevations, significant elevations for melanoma, prostate, testicular, thyroid, and we have a kind of a marginally significant finding here for late stage colorectal cancer. So this axis here is telling you the scale of the odds ratio association here. So for example, thyroid cancer was about twice as likely to be seen in firefighters versus all others in the registry. Testicular cancer about 1.5 and so on. Now for our smaller number of female firefighter cancers, we did see, we sort of confirmed what we saw for thyroid cancer in the men. We also see consistent association with melanoma. Here the, these bars here are the 95% confidence intervals and since we have so many male cancers, that confidence interval is not wide. But you can see our confidence intervals for the female firefighters were all much wider because of the smaller number of cases. In the case of brain cancer here, which was significantly elevated in the female firefighters, we report that with caution because it's based on less than 10 cases among female firefighters in the state of Florida. And you can see the confidence interval for that's pretty large. But we do see sporadic associations of increased risk of brain cancer in firefighters in other studies. So there may be a signal there for brain cancer as well. So from there we decided to take a look at the issue of multiple primary cancers. And that is essentially individuals that have a cancer diagnosis and then go on to have a second cancer diagnosis that is not a metastasis of that original identified cancer. So it's like a second cancer. And sometimes, unfortunately, people can have a third and even a fourth cancer over, diagnosed over the course of their, of their lifetime. Fortunately, those are relatively rare events. But there's been very little published to look to see if firefighters also are at increased risk of multiple primary cancers. So we, we took a look at this, this question in our next study. As I said, there's very little in the literature suggesting one way or another that, that this is a potential issue. But there was one important study published in Lancet in 2011 looking at the firefighters that were engaged in working the 9-11 incident in New York, New York City. As everyone is aware that, you know, we had the, the towers come down and there was a huge pile and the firefighters were, were working that pile for, you know, to find survivors and also just to find remains over long periods of time. So there were significant longitudinal exposures in that cohort. And for, for those firefighters, the risk of having an initial incident cancer, their first cancer, the odds ratio for that was, I believe, actually these may be relative risks, was 1.3 and the 1.32. But they also saw an increase about the same effect size for multiple primary cancers. So it was about a 30% elevation in the risk of, of, of developing multiple primaries. And the comparison groups in these studies were non-exposed firefighters. When I say non-exposed, of course, they are exposed, but they, they weren't exposed to 9-11. So this is like an added risk that, that particular cohort of firefighters were, were, were bearing and continue to this day. So we were interested to first answer the question, are Florida firefighters, are they at increased risk of multiple primary cancers? And if so, what is the type of, of second, third, and fourth cancers that firefighters may be diagnosed with? And so basically what we found was that there was a, a weak signal for an increased risk of, of developing a multiple primary, multiple primary cancers. In firefighters, that risk was about 14% over, over, you know, the second, third, and, and, and beyond in terms of multiple primary cancers. So we did see a, a weak signal there. It was just barely statistically significant. So you have to really, you know, interpret this with some degree of caution. But when we drilled down further and we looked at, okay, what were the, what were the second, third, and fourth cancers? And did we see any discernible patterns in the, in this occupational group? And in fact, we did. So these are, are relative risks for the development of a second, third, and fourth cancer. And of course, we're, what we're doing is we're comparing the Florida firefighters to everyone else in the registry who had second, third, and fourth cancers. And we got a clear signal here for, for melanoma. That for firefighters, they were roughly almost twice as likely to, if they were going to have a second, third, and fourth cancer, it was going to be melanoma. And it was pretty consistent across the second, third, and the fourth. And there are really no other consistent patterns there, other than I can point out that there, there was a significantly reduced risk of having prostate cancer as a multiple primary in firefighters relative to men in the state of Florida in general. Remember that prostate was one of our cancers, however, that was significantly elevated as a primary cancer. So I think it's, it's really noteworthy that we see this, this elevation in risk. And so we're seeing a very strong signal for, for melanoma as a cancer of concern for the, for the fire service. So basically, we, we concluded there that there's a slight increased risk in Florida firefighters for, for multiple primary cancers. And that the risk of melanoma as a specific cancer subtype is something that is, is of concern in this workforce. So, of course, we continue to do work in the area of, of skin cancer. We were interested in looking at, you know, the location of, of the cancers. And we sort of expanded our window in this study a little bit. Because so far, we've only been talking about career firefighters, those that are, are paid to, to fight fires. Well, there's a lot of volunteer firefighters out there as well. And in, and in many places, especially in rural part regions of the country, that's your only fire service are the volunteers. So they, they're an important group as well, even though they're not an occupational group technically. So we wanted to look at the cancer experience, the skin cancer experience in the volunteers as well. So we only had 68 cancers among the volunteers. And that's compared to 359 cancers among the career firefighters. And then we're making comparisons to these two groups against a much larger number of, of folks in the, in the cancer registry that were diagnosed with skin cancer. So we were interested in, in taking a, drilling down, since we've already demonstrated that skin melanoma was, was significantly elevated in, in career firefighters. We wanted to look at the specific subtypes of the, of the skin cancer as well. And we broadly grouped them into two categories of UV associated skin cancer and non-UV related skin cancers. And what we found for the careers firefighters was that they were at increased risk for both. And it was substantially elevated odds ratios here, 2.6 and 3.3.6 for the non-UV related melanomas. Because one of the hypotheses, of course, for this association with skin cancer and firefighters as well, maybe they're, you know, they're more exposed to the sun. As a function of their job, they might be more active than the general population. So on their leisure time, they're, they're out and they're being exposed. But, but we're basically seeing that even with the non-UV related cancers, non-UV related melanomas, there's a significant increase for the career firefighters. Again, we, now we have, talking about that much smaller group of volunteers, we did see something for the increased risk of development of UV related melanoma compared to the non-firefighters in the state of Florida. Pretty high point estimate here, but again, I caution everyone there because the confidence intervals are quite wide there, 1.3 to 22. So we have to be careful there. So we, this study, we concluded there were some variations in the location where firefighters were being diagnosed with skin cancer. And also, or perhaps more importantly, that the histological subtypes varied as well in terms of risk for both volunteer and career firefighters. So I'm going to now present some, some findings that supported the doctoral dissertation for one of our students in the epidemiology program she recently successfully defended. Her dissertation, this is one paper out of three that she wrote for that. And these results are not yet published, but are under, currently under review. So her topic was thyroid, this thyroid cancer risk that we had seen elevated in the Florida firefighters and in other studies as well. We, we, we again had this very strong association here in both men and women for increased risk of thyroid cancer. But if you look at the worldwide data, so this is a pooled summary estimates of, of all the studies, published studies worldwide. The, the, the point estimate here is 1.22, about a 22% elevation in risk associated with active firefighting. So we're getting much stronger signal here, but we have to, you know, this is a different design, the case control. These are standardized incidence ratios, which is typically how these risk estimates are calculated in these linkage studies. So, you know, we're going to hear more about the role of carcinogens, of course, as drivers of this risk in firefighters. But when we're talking about thyroid cancer, we need to bring in another class of exposures, and those are the endocrine disrupting chemicals that firefighters are exposed to. So examples of these are PBDEs and BPAs that are contained in different things that firefighters work with. So, for example, firefighting foams, which is a way to, you know, you spray it on these chemical fires to, you know, extinguish them when you can't use water. And so these exposures, I mean, they're exposed to it in their training, they're exposed to it when they're actually using these things out in fire scenes. And so, you know, the type of absorption routes for both these endocrine disrupting chemicals and the carcinogens, of course, is dermal inhalation and ingestion. And, you know, we've been tracking how these things kind of happen, they even follow them, these exposures, right into the firehouses themselves where they're living and sleeping. So this is work from another study that basically shows that these endocrine disrupting chemicals can be documented to be at higher levels in firefighters versus the general population. And so in this dissertation study, the question was, okay, we know that we've got this very, very high association of thyroid cancer in Florida, why do we have that? And we wanted to drill down and look at the histologic subtypes of thyroid cancer. And basically what we found is that firefighters are at an increased risk of papillary histologic subtype for thyroid cancer versus these other types. Fortunately, papillary as a subtype is less, you know, less bad, I forgot the technical term for that. But if you're going to have a thyroid cancer, papillary is probably a pretty good one to have. So that's one good takeaway. But basically what we did was we looked at the occupational histories and the cancer registry and we created groups of blue collar, white collar and service workers compared them to firefighters. And it's pretty consistent that the firefighters are much more, if they get a thyroid cancer diagnosis, they're much more likely that that's a papillary histologic subtype. We also found that our firefighters are diagnosed with cancer at a younger age than is typical in our cancer registry. It's pretty consistent either when we compare it to young versus middle-aged and, you know, older adults versus middle-aged adults. Now interestingly, we thought that we would see a difference in the stage at diagnosis in the firefighters. And we were thinking, we were hypothesizing that firefighters might be diagnosed at an earlier stage, just because they're more plugged into medical care. And there's actually these firms out there that will market directly to the firefighters because they know about their cancer, perceived cancer risk. And we'll market these, you know, whole body scans and other things to firefighters to sort of address this. So this raises a question that we might be picking up very early stage diagnoses. And we didn't find that at all. There's no statistical difference here in the odds of being diagnosed earlier versus later. So we concluded that the mean age of diagnosis was younger in firefighters than general population. And that the papillary histologic subtype was one that was predominate with regard to firefighters. They were, firefighters were also less likely to have rare undifferentiated subtypes relative to the other worker groups that we examined. And again, no significant difference in stage at diagnosis. And so, from there, we're going to invite Dr. Caban back up. And he's going to talk to us about some of the exposure studies. So I want to take a moment to embarrass Dr. Lee because I was his student 20 years ago. And he put me into this profession of occupational medicine. So the importance of mentoring at a young age, later on it turns out good, I guess. So thank you for your mentorship. Okay, so I want to show you how we measure the carcinogens out in the real, out in the real world. And so, I'll talk to you a little bit about what we use as a passive sampling device, these silicone-based wristbands. The first thing that I want to bring to your attention is that there's many types, as Dr. Lee alluded to, of carcinogenic exposures on the fire scene and during fire training activities. So firefighters train year-round on fire suppression activities and how you assess a fire, plus the regular fire response. And when they do this, they come across many different types of compounds, like benzene, toluene, xylene, as well as halogenated compounds, phthalates, PFAS. And we were interested in one particular called PAHs, or polycyclic aromatic hydrocarbons, which are products of combustion from regular organic materials. And so, when there's sort of incomplete combustion, you get a lot of these PAHs that are released into the environment, including even some semi-volatile compounds that can be like a vapor and move around through the environment. And so, our curiosity is, we know that these PAHs are carcinogenic, right? They carry an IR categorization of 2B. And so, our curiosity is, how do these firefighters, you know, are exposed to them? How do we measure them and sort of characterize them from there? So, what are some of the effects if you are exposed? Before I show you how we do that, if you internalize some of these PAHs, they are metabolized through different metabolic pathways. They can accumulate and cause damage. So, an example is like benzo-A-pyrene, which is well-characterized. It's a group one carcinogen. It goes in through different zeobiotic mechanisms, and ultimately, these metabolites can impact the DNA pathway and cause DNA damage. So, when we set up our experiments, we try to analyze the exposures of these carcinogens in a couple of different places. So, one is during the fire scene. We're also interested if these carcinogens are present or off-gas in their turnout gear. Do they move these carcinogens into the fire truck or engine, right? If they didn't do proper decontamination of their gear, post-fire scene, are they, you know, being like a fomite and transferring some of that from the fire scene, you know, back to their fire station and maybe their vehicle? Some firefighters, you know, put their gear in the back of their truck and may not be cognizant that it's off-gassing and actually impacting their family and spouse when they're driving with their car and their gear in the back. And so, we use this contamination cycle to get, to sort of set up our experiments. So, one of the technologies that we apply, we learned this from Dr. Anderson at Oregon State, is that you can actually use silicone-based wristbands as a passive sampling device. Really cool technology. Why? Because silicone as a polymer is porous. So, you see on the right-hand side, these were scanning electron micrographs that my medical student did. I made him do it for his capstone for his project and said, OK, let's take a look at these bands and see how useful they are at trapping some of these different carcinogens that are there. And so, you can see that on the surface, the bands are sort of porous, which is great because they're, you know, able to be trapped in the wristbands that we give to the different firefighters. So, once the wristbands are deployed with the firefighters, we just, you know, give them to them in a vial, tell them, OK, during your next 24 hours while you're on shift, wear the bands or if you're in a training exercise, wear the band and when you're done, you know, put it back in the vial. We bring those vials back to our laboratory at the university and then we begin an extraction process of the PAHs from those individual bands. And so, the first part, it goes, when the bands come out, they go through this device called the Dianex, which is a pressurized liquid extraction system, which is kind of like McDonald's operations, really fast. We can do a whole bunch of bands really quickly and be able to extract out of it what's concentrated in there and then make aliquots of it. So, we can use some of them for the immediate and then store some for later if we want to do other experiments with what the firefighter was exposed to at the time. Once the extraction is done, we put that liquid sample into gas chromatography mass spec and then we're able to analyze it for 16 priority EPA, polycyclic aromatic hydrocarbons that they come there and through the chromatogram, we're able to look for the signatures of the individual PAHs as they come out through the spectra. So, this is us out in the fields. This is City of Miami Fire. They're doing a fire training event. So, you can see the shipping containers where they have certain types of materials that they'll set on fire for different class A and class B burns. And we ask them to wear the wristbands, you know, we're sort of out on the perimeter, ask the firefighters to put on the wristband while they're in there. It goes to like 800, 1,000 degrees, you know, Fahrenheit of heat. And then, this is the firefighters after they finish their training exercise, which my colleague, Dr. Sali, will be talking about. They do now decontamination procedures to remove some of that soot. We know from science that if you use regular Dawn soap and water, you remove about 84% of the PAHs from that contamination. So, just basic will get you there. So, our experimental designs with the wristbands, as I alluded to, is usually during work shifts. I'm going to present to you the findings from one of those studies. We took 72 firefighters and we invited them to wear the wristband during a regular 24-hour shift, you know, like in real life. Just deploy them, show up at 6 in the morning. Before they start their shift at 7, please fill out a survey, wear the wristband, and then give it back to us on the next day at 7 a.m. So, here are the findings from that particular experiment. You can see the social demographic distribution of the firefighters from South Florida. So, on average, they're about 37 years of age, mostly male, 90. Largely Hispanic, because we're in South Florida, so we have a lot of Hispanic population. 83% were white Caucasian. And then you can see the ranks, right, because there's differences in ranks. And one of the things we're trying to understand is more the nuance, even for firefighters that are, say, are operating in the yellow zone, not in the red zone, in the immediate fire. Like, in the yellow zone, are you also exposed to these carcinogens, because they don't like to wear PPE in the yellow zone. They'll complain that it blocks their dexterity. And I tell them, like, look, I'm trying to protect you from cumulative exposure of PAHs. So, please consider the PPE. And so, we give them different ranks so we can see their exposure during that response. So, this very busy graph is just to show you among those 72 risk bands, all the different types of PAHs that we picked up. And you can see that some of the bands were completely saturated with some of the PAHs and some at different concentrations. So, there are variances in the PAHs that are picked up in any sample of bands. And then what we do is generate a heat map to be able to look at differences in the exposures based on what they do. So, in this, what I like to call the Mona Lisa of PAHs, is on the right side, firefighters that were exposed to a fire during their 24-hour shift. So, if they were on call those 24 hours and they responded to a fire, they're on the right side of the heat map. And then if they were not in a fire during their 24-hour shift, they're on the left side. The row is individual PAHs. And the column is a firefighter's risk bands. So, you can see based on the coloration that if you're blue, it was non-detected. And then if you're crimson red, you're about greater than 150 parts per billion of that particular PAH. And so, interestingly enough, you see that there are differences, but there are also similarities. So, what does that say about firefighters that didn't go to a fire that 24 hours and what they were exposed to? Remember, diesel exhaust in the fire station. They don't turn it off. Right? Here is the heat map for the training exercise. So, we gave firefighters that were in the training exercise risk bands. They're students, the rookies wore it, and then the instructors. The instructors are an interesting subgroup of the firefighters because they are repeatedly doused with the same exercise. Right? That instructor stays there for the two days or three days, rinse and repeat, but the students only do it one time. And so, we were curious if there are differences in the PAH type or concentration based on this type of exercise arrangement. So, we do see differences again and then some different similarities in those concentrations. We've also done experiments where we're trying to look at the epigenetics of the first responders through a blood sample. And so, basically through the epigenetics, we're trying to see if the on and off switches to certain pathways that lead to cancer are turned on or off with it. Because cancer has a long latency period, we want to see if we can look at early changes in biology. So, are these switches that up-regulate or down-regulate protein synthesis are being activated or disactivated as they are? And so, we did a blood sample on, I think it was like 94 firefighters total. And we divided them into firefighters that had high exposure and low exposure of carcinogen in the workplace. And we're able to identify in there that there were certain regions, CPG regions within the DNA that are specifically related to either tumor suppression or tumor activation were up-regulated. They were either methylated, meaning they were suppressed or they were non-low methylated and they were being up-regulated. And some of them, like for example, LY6G5C for tumor suppression inflammatory response, you can see were impacted. And so, this is now being allowing us to draw an early picture of some of the early changes in biology and not having to wait until a cancer diagnosis occurs. So, I'd like to invite my colleague, Dr. Sali, to talk a little bit about some of our clinical and cancer screening projects. Great, thank you. So, yeah, so as Dr. Kwan just mentioned, so we talked a little about the epidata, some exposure data, and now I'm going to tell you how we put these things into practice. So, the first thing I'm going to talk about is our personal exposure reporting mobile application. And so, you know, when we started in 2015, we did a lot of focus groups, a lot of interviews, really to try to understand the firefighters' experience, their perceptions, and really to just get an understanding of how many fires they had been on, what their exposures were. And so, when we're asking about their records, you know, many of them said, yeah, we don't keep those. Or, you know, someone keeps them somewhere but I have no idea. And you ask every firefighter, you know, can you tell me how many fires you've been on in the last year? Oh, I don't know. Who knows how many? And what have you been exposed to? Oh, everything. So, we really wanted to create something that we were getting actual metrics of how many fires are going on, what type of fire, what they're being exposed to, and then if they're doing any kind of decontamination after. So, what we created here, you know, this is a little bit of background about the work activity, I'm sorry, firefighters' work activities, collecting objective information, and then how this came about, developing the personal exposure reporter. So, in addition to us getting the information, it's really important for the firefighters to get that information. So, for many of our firefighters that we've met who unfortunately get a cancer diagnosis and they're talking with their oncologist and they're asking them about their exposures, they're giving them the same answers. You know, I've been exposed to everything. So, this really gives them something to track. The other thing is most states now, and Florida just received the cancer bill for presumption law. So, if a firefighter gets a certain type of cancer, we cover 23 cancers in the state of Florida, they will cover it under worker's comp. However, if you do get cancer, it's not just a free, here you go, here's your check. They wanna see records. They wanna see how many years you've been on the job, what exposures, really showing that your cancer is due to your occupation. So, with this, no matter where they work, if they go to a different department, if they change from a trainer to a volunteer, they always have their records with them. So, here are some of our research activities. You can see Dr. Barbara Millay who created this and tested it with firefighters. As we mentioned, everything we do is CBPR. So, from the questions, how they were created, what the options were, they were all given by the firefighter. In this preliminary data, we have 450 firefighter participants. This is what the application looks like. It's very simple and anyone can download it on both iPhone or Android. You go in, you create an incident report, and exactly what I had said, you click on your department, what type of fire it was, how long did it last, what did you do as far as tasks, were you the driver when you were in there, what did you do after for DECON, and then also what symptoms were you having post-fire. We've also added now for fire investigators as part of this and also for urban search and rescue. So, a little bit of background with the 951 user accounts, 98 agencies worldwide, and 664 reports. And so, what we found in the preliminary findings were that 80% of the reports had 100% completion rate. So, that's really important. So, that's showing you that it's pretty sure, it's to the point that they're not gonna start doing it and then stop doing it, because it's just a few questions. We did get people beyond Florida. So, we did get people throughout the country that are participating. 70% report wearing PPE during overhaul, except for brush fires. So, our wildland firefighters have reported not wearing PPE. 40% have reported no PPE decontamination after a fire incident. And then most frequently reported symptoms were headaches, coughing, and eyes burning. And so, with that, another piece of this we have is our cancer prevention education curriculum. So, again, when we started, really cancer was not talked about in the fire service. Really no one knew about it. And so, what we've done is we've been able to create a curriculum that's now being taught at the fire college. So, any new recruit or soon-to-be firefighter who's in the academy, they get a whole session or section on cancer prevention. So, again, taking information from focus group feedbacks, research findings, and then also hands-on decontamination. And so, what we're teaching them in the curriculum are different models. So, not only about their cancer risk, how they can reduce their cancer risk, how they can make organizational level changes, but then we're also teaching them about modifiable risk factors. So, when we first started, we really focused on DECON. Which you can see here on the third slide here, the tools for improvement. So, that gives them a step-by-step, when they're on a fire scene, how they DECON, where they go. And it's very specific. And I did not draw this, I did not write this. I created the curriculum, but this was by a firefighter. So, and that's what we tell them all the time. Like, we're studying firefighters, we've been doing it for almost eight years, but I'll never be a firefighter. So, I need them to tell me what's the best way to do it. The other thing that we did is we made it very interactive. By having slides that we show, like here at a scientific conference, is very different than educating a firefighter. So, I can't just have bullets of, you're exposed to polyaromatic hydrocarbons and PBDEs, because they'll look at me like, what are you talking about? So, we're able to show here that it's interactive. So, if they are reading this, they click on the couch, the couch starts burning, and then they say, when something like this burns, these are the type of chemicals that come off. Also, giving them examples about how they're being exposed, inhalation, absorption, and also ingestion, and how they can make those changes. So, one of the practices we've done, we've done a few different things. So, you can see there, here are the DECON practices, and so we've created multiple videos for our firefighters that they can watch. Again, very short snip, four minute max videos that they can get a step-by-step. We've also, you can see here, there's 4,500 green buckets, and so what is in these green buckets, we partnered with the State Fire Marshal's Office, that every fire station or fire department in the state of Florida will get a green bucket for every one of their apparatuses. And so, what's included in here is everything needed for DECON, and that is a hose, a cone, different types of hose nozzles. You can see these large bags, and so what it is, is after they DECON, they will take off their gear, which is wet, they will bag their gear, and then they will put it in an outside compartment. Because what was happening beforehand, one, they never washed their gear. So, when we first started, we learned that they went their whole careers without washing their gear or their helmet, because it was a badge of honor. It showed they went to a lot of fires, and that they were a tough firefighter. And so, by teaching them that that's always off-gassing, and you're being exposed, also, you may be going on all these calls that has nothing to do with the fire, no exposure, but you have 20 years of exposure on you that you're wearing, and you're still sweating, and that's absorbing into your body. And so, teaching a clean cab model, so everything stays on the outside of the cab. Before, they would just leave a fire, be full of soot, and everyone gets back in the cab, and transferring that to each other, as well as the next group that's coming in next day, that's not even on that fire. The other thing is showering within the hour. So, that's a practice and a motto that we've kind of set out that you would think, you know, of course, someone just went to a fire. They were in a, you know, 500-degree burning building, they're sweating, they're full of dirt. And so of course they're going to shower, but no, they don't. And so I said, well, why? And they said, well, because we're probably going to call in an hour. So if I can get a 30-minute nap, I'm going to fall asleep and then I'll go the next shower or the next fire. I'll shower at the end of the day. So teaching them to really get all that dirt off of them. And then creating educational materials. So we've done several materials like this that we've sent out both digitally, but also we have paper copies. But we've done everything from HPV, cervical cancer, melanoma, testicular cancer, all the cancers really that have been identified by Dr. Lee's work and now putting it out there. And so that's what we've really been doing in FCI, is how we can work together in our different groups and pillars and take the work from each other to then educate the firefighters. And so now moving on to one of our newest components of FCI and one of the most exciting is our mobile clinic. So we actually started a wellness and cancer prevention clinic specifically for firefighters about two and a half, three years ago. But it was a typical one just in our Cancer Center in brick and mortar. And so again, feedback from the firefighters, great idea, but we're not going to go. We don't go to the doctors to begin with, so why don't we go to your doctor? So what we've created is a mobile clinic. We've been able to take a sprinter van and turn it into a patient room. And we go to a fire station three days a week and do their annual physicals. So utilizing the current guidelines from NFPA 1582, American Cancer Society and the U.S. Preventive Services Task Force. And so the health concerns we know among the firefighters again is cancer, chronic disease, heart disease, physical activity, stress, trauma, women's health, infectious disease. So we try to create a place where they're able to get their annual physical, not only see us for cancer, but see us for all-around health concerns. And so what screening should be included as part of a firefighter annual exam? So what we do, our key component is a comprehensive history and physical exam. We do lab testing, vision and hearing, lung and heart, infectious disease, mental health, and then of course our cancer screenings. And so I'll leave this here. We can go through this. But really a head-to-toe assessment. This is being led by our nurse practitioner and our nurse navigator. We also have a physician on board, going through all the different standard screenings. So here's a little bit of a workflow. Our van goes to the fire station. We then follow up with telemedicine and then our doctors can see them for follow-up. Also with the mobile services we're meeting the health needs of the fire service, not only occupational health, family medicine and cancer screenings. And so here's a picture of the vehicle. And you can see the inside. We've got a patient table there. We've got everything set up there for an EKG. That's the outside. It's got an awning, thank you. On the outside we're able to set up with some of our research staff, so not only are they coming in for their annual physical, but we also are able to enroll them into some of our active studies. So it's increasing the accessibility, the utilization, decreasing the cost and decreasing the barriers to care. And so a little bit of data, I'll show you with our first department, Hialeah Fire Department, which is a department in Miami-Dade County. We've been going to them for the last few months. And so we can see here that my clinic visit, we had the FCI mobile clinic. We had two follow-ups, 125 new patients. When we were doing the brick and mortar we really only had 12 follow-ups, two new patients and then telehealth follow-ups for the year. So you can see an over 200% increase in getting access to care for our firefighters. The other thing we learned with this department is many of those firefighters, they hadn't seen someone in five years for an annual physical. So with the fire departments it's very department-by-department as far as what is mandated. Some require them to get annual physicals. Some require them to get it every other year. Some only for their hazmat crew. And some say we provide you insurance, it's up to you to get your physicals. And so here you can see just a bit of demographics. We had 92% that were male. The age ranges fell 15%, 15 to 29, and ranging 24 to 29% of middle-aged. Again we have a really high Hispanic population in Miami-Dade County, accounting for 63%. And 76% were white. And so as far as next steps, we really are looking to expand our services beyond where we are in Dade County. Also to receive funding for multiple vehicles. So Sylvester, our catchment area, is for four different counties in South Florida. So Monroe, Dade, Broward, and Palm Beach County. So our goal is really to take our model and move it throughout the different counties. Lastly I want to talk to you about is our National Firefighter Cancer Symposium. We've hosted it now for four years, and it's basically two days of the top scientists and researchers and firefighters in the country that come and give presentations. You can see there on the bottom we also partner with Sylvester for the Dolphins Challenge Cancer, which is the largest fundraiser with the NFL and the Miami Dolphins. It's a 5K but also a bike ride, and we've had a team of over 100 firefighters for the last four years, and they go and they walk in their gear. But I put this up here because if you go to the website, we have all the recordings there. So you can go and listen to all the presentations from this last year in Miami. And so thank you so much for your time and for listening. And so now I don't know what time, oh we do, we've got eight minutes for questions. We'll all come up here. So we have a few minutes for questions here in the room and online. So I'll moderate our online questions, and please feel free. Hi, good afternoon. I think you don't know me. I'm Florian, right? Correct. Later. Okay, later. Anyway, it's an amazing presentation. I will say, I really feel familiar with this. My question is ideally for Dr. Lee or Dr. Kavanagh. Even I don't know him personally. It's the first time. The population you include in your research. Dr. Perez, can you come a little closer to the mic? They were saying, it's just so they can hear. The population you include in your research, you mentioned Florida. Florida is not only Miami area. Correct. For a lot of South Florida. It's more than that. So the population you include in your research, you mentioned Florida. Correct. 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