Congress created September 11th Victim Compensation Fund, 49 USC § 40101, to compensate victims of the terrorist attack. Being a victim implies that the harm to be compensated was caused by the attack and its consequences. Understandably, many of the harms were acute injuries, but what about cancer? The latency period for most cancers are greater than 10 years, and the latency alone would suggest that persons who developed cancer within 10 years were not “victims,” but rather expected incidences of prevalent, chronic disease, or the result of much earlier exposures in the patients’ lifetimes.
Less than a year ago, the New York Times reported on a NIOSH report, which documented that there was little evidence upon which to rely, and what was available did not support conclusions of causality. See Anemona Hartocollis, “Scant Evidence to Link 9/11 to Cancer, U.S. Report Says,” N.Y. Times (July 26, 2011). The report appropriately noted that “[d]rawing causal inferences about exposures resulting from the Sept. 11, 2001, terrorist attacks and the observation of cancer cases in responders and survivors is especially challenging since cancer is not a rare disease.”
A few months later, the Times reported on an epidemiologic study of firefighters who were present at the World Trade Center in 2001. Sydney Ember, “Study Suggests Higher Cancer Risk for 9/11 Firefighters,” N.Y. Times (Sept. 1, 2011). According to the Times, the study:
“says firefighters who toiled in the wreckage of the World Trade Center in 2001 were 19 percent more likely to develop cancer than those who were not there, the strongest evidence to date of a possible link between work at ground zero and cancer. The study, published Thursday in the British medical journal The Lancet, included almost 10,000 New York City firefighters, most of whom were exposed to the caustic dust and smoke created by the fall of the twin towers. The findings indicate an “increased likelihood for the development of any type of cancer,” said Dr. David J. Prezant, the chief medical officer for the New York Fire Department, who led the study. But he said the results were far from conclusive. ‘This is not an epidemic’, he said.”
Well this is just bad reporting; the study said nothing of the sort. The study reported a non-statistically significant standardized incidence ratio for all cancer, of either 1.10 (95% CI 0·98–1·25), with a comparison group of the generalized U.S. male population, or 1·19 (95% CI 0·96–1·47), with unexposed firefighters as a comparison group, and corrected for possible surveillance bias. Here are the authors’ (including Dr. Prezant’s) published interpretation of the data:
“We reported a modest excess of cancer cases in the WTC-exposed cohort. We remain cautious in our interpretation of this finding because the time since 9/11 is short for cancer outcomes, and the reported excess of cancers is not limited to specific organ types. As in any observational study, we cannot rule out the possibility that effects in the exposed group might be due to unidentified confounders. Continued follow-up will be important and should include cancer screening and prevention strategies.
Rachel Zeig-Owens, Mayris Webber, Charles Hall, Theresa Schwartz, Nadia Jaber, Jessica Weakle , Thomas Rohan, Hillel Cohen, Olga Derman, Thomas Aldrich, Kerry Kelly, David Prezant, “Early assessment of cancer outcomes in New York City firefighters after the 9/11 attacks: an observational cohort study,” 378 Lancet 898, 898 (2011) [hereafter Zeig-Owens].
The Zeig-Owens study was a cohort of New York firefighters who had worked at the WTC in the immediate aftermath of the attack. The data neither ruled out chance nor bias and confounding as a basis for the reported risk ratios. The potentially toxic exposures at the WTC were only some of the exposures these men experienced over their careers. Comparisons with the general population are thus not terribly revealing, but the study also compared the firefighters with other firefighters who did not work at the WTC.
For firefighters, lung cancer is typically a concern, but the Zeig-Owens study reported that the WTC firefighters had a lower than expected incidence of lung cancer:
lung cancer 0.53 (95% CI 0.18 – 1.54)
Some cancers had an elevated SIR, which is also expected given that the study looked at dozens of different outcomes. Esophageal cancer was typical of the few that cancers that fell above 1.0; the SIR was 1.32, but the 95% confidence interval was huge, running from 0.12 to 14.53. Understandably the authors of the WTC study did not assert any causal conclusions.
The lack of causal conclusions and evidence did not ultimately stand in the way of politics. Last week, John Howard, the director of the National Institute of Occupational Safety and Health (NIOSH) issued his ruling that some 50 different types of cancer be added to the illnesses and injuries covered by the 9/11 Compensation Fund. Anemona Hartocollis, “Sept. 11 Health Fund Given Clearance to Cover Cancer,” N.Y. Times (June 8, 2012).
Not only is Howard’s report not based upon appropriate scientific conclusions of causality, it is a ghastly insult to those men and women who were truly victims of the attack. On virtually no evidence at all, Howard’s decision dilutes the fund for those truly injured. The extent of the dilution is disturbing; the decision will not only allow the victims and the heroic rescuers to apply for compensation for cancers, but it will allow residents and passerbys to do so, as well.
The Times quoted Dr. Howard as stating that the Zeig-Owens study provided “a strong foundation for a conclusion that some cancers had been caused by exposure to the WTC debris.” This is rubbish. Coming from the director of a supposedly scientific agency, the statement is shocking. As noted above, the lung cancer incidence ratio for WTC firefighters was lower than expected, compared to either non-WTC firefighters or the general male population. The presence of “known or potential carcinogens” in the debris hardly justifies compensation unless the exposures were at sufficient intensity and duration, with appropriate latencies, to have caused the claimed cancers. Howard’s report is shamelessly bereft of evidence to support bilking the compensation fund, and diverting compensation from true victims of the jihadist attack.
Although the Times ignored the primary data, it did acknowledge that Howard’s report, and the recommendation upon which he relied, seemed to be based upon “societal concerns that the cancer patients not be left out of the fund.” This is interest-group politics substituting for science.
The Times quoted Dr. Alfred I. Neugut, an oncologist and professor of epidemiology at the Mailman School of Public Health at Columbia University, as stating that the decision was “primarily motivated by concern for a sympathetic population,” and that “[t]he scientific evidence currently is certainly weak; whether future evidence bears out the wisdom of this decision will have to be seen.”
But “weak” is understatement. The Zeig-Owens study looked at dozens of organ cancers and subtypes; it was a huge exercise in data mining, which can best be described as hypothesis generating. Howard, however, decided to reject any semblence of evidence-based medicine:
“Requiring evidence of positive associations from studies of 9/11-exposed populations exclusively does not serve the best interests.”
So apparently positive associations are no longer required; compensation can be based upon negative associations, as was the case with WTC firefighting and lung cancer.
The Times cheered Howard’s decision in an editorial that followed quickly on the heels of the NIOSH report. “Ground Zero Cancers” (June 14, 2012). The Times acknowledged that “[s]ome experts still believe the evidence linking the Sept. 11 attacks to cancers is weak. But we have a moral obligation to ensure that those harmed by exposure at ground zero get the medical and financial help they need.”
But “weak” is a gross overstatement, and whence comes a moral obligation to help those not harmed by exposure at ground zero? Where is the morality of diluting the compensation fund for those who were truly victims. Howard’s report represents not only an abdication of the evidence-based world view, but profound disrespect for those were killed and maimed in this brutal attack.
Predictably, plaintiffs’ counsel have already urged mesothelioma patients to consider the fund. See “Lawyer Urges NYC Mesothelioma Sufferers to Explore Options after Decision Expanding 9/11 Fund,” New York, NY (PRWEB) (June 16, 2012) (“New York mesothelioma lawyer Joseph W. Belluck today said that 9/11 workers with mesothelioma should step forward to explore their eligibility for compensation in light of a federal ruling that greatly expands the scope of a $4.3 billion fund established to compensate and treat people exposed to toxic smoke, dust and fumes following the Sept. 11, 2001, terrorist attacks.”) No mesothelioma cases were reported as incident among the WTC exposed firefighters.
An internet search on ” cancer 9/11 compensation fund” turned up dozens of lawyer advertisements and websites urging cancer claims against the Fund.
