Gary Flook served in the Air Force for 37 years, as a firefighter at the now-closed Chanute Air Force Base in Champaign County and the former Grissom Air Force Base in northern Indiana, where he regularly trained with aqueous film forming foam — AFFF, a frothy white fire retardant that’s 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 45, he got devastating news: He had testicular cancer, which would require surgery 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.
Studies have shown that firefighters — military and civilian — have been diagnosed with testicular cancer at higher rates than people in most occupations, often pointing to the presence in the foam of perfluoroalkyl and polyfluoroalkyl substances, the “forever chemicals” known as PFAS.
But the link between PFAS and testicular cancer among service members had never directly been proven — until now. A new federal study for the first time shows a direct association between PFOS, a PFAS chemical found in the blood of thousands of military personnel, and testicular cancer.
Using banked blood drawn from Air Force servicemen, researchers from the National Cancer Institute and the Uniformed Services University of the Health Sciences 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 drinking water.
The airmen with testicular cancer had higher serum levels of PFOS than those who hadn’t been diagnosed with cancer, according to study co-author Mark Purdue, an NCI senior investigator.
“To my knowledge, this is the first study to measure PFAS levels in the U.S. military population and to investigate associations with a cancer endpoint in this population,” Purdue said.
Not ‘just soap and water’
Old stocks of AFFF containing PFOS were replaced in recent decades by foam that contains newer-generation PFAS, which now also are known to be toxic.
By congressional order, the Defense Department must stop using all PFAS-containing foams by October 2024, but it can keep buying them until this October.
That’s decades after the military first documented the chemicals’ potential health concerns. A Defense Department study in 1974 found that PFAS was fatal to fish. In 1983, an Air Force report showed its deadly effects on mice.
Given its effectiveness, though, in fighting extremely hot fires, like those found in aircraft crashes and shipboard fires, the Defense Department still uses it.
If the military ever warned of its dangers, that was a rare occurrence, according to retired Air Force firefighter Kevin Ferrara and 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 accompanying description called 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. Beside the foam used for decades by firefighters and the military, the chemicals are found in makeup, nonstick cookware, water-repellent clothing, rugs, food wrappers and other consumer goods.
They don’t break down in the environment, and they 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 U.S. Geological Survey study estimated that at least 45% of U.S. tap water has at least one type of forever chemical.
Health and environmental concerns associated with the chemicals have spurred lawsuits and state and federal legislation targeting manufacturers and sellers of PFAS-laden products.
Flook is suing 3M and associated companies that manufactured PFAS and the firefighting foam, including DuPont and Kidde-Fenwal.
Congress has pushed the Defense Department 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 that’s not enough.
“How long has [DoD] spent on this issue without any real results except for putting some filters on drinking water?” said Jared Hayes of the Environmental Working Group, an advocacy group.
A mission to get screening
The federal Department of Veterans Affairs doesn’t recommend blood testing for PFAS, saying “blood tests cannot be linked to current or future health conditions or guide medical treatment decisions.”
That could change. In June, U.S. Rep. Dan Kildee, D-Mich., co-chair of the congressional PFAS Task Force, proposed the Veterans Exposed to Toxic PFAS Act, which would require the VA to treat conditions linked to exposure and provide disability benefits for those affected, including for testicular cancer.
There’s strong evidence exposure to PFAS is associated with health effects such as decreased response to vaccines, kidney cancer and low birth weight, according to a federally funded report last year by the National Academies of Sciences, Engineering, and Medicine. The nonprofit institution recommended blood testing for communities with high exposure to PFAS, followed by health screenings for those above certain levels.
It also said that, based on limited evidence, there is “moderate confidence” of an association between exposure and thyroid dysfunction, preeclampsia in pregnant women and breast and testicular cancers.
The new study of Air Force servicemen goes further, linking PFAS exposure directly to testicular germ cell tumors, which make up roughly 95% of testicular cancer cases.
Testicular cancer is the most commonly diagnosed cancer among young adult men and the cancer diagnosed at the highest rate among active military personnel, most of them male and 18 to 40 years old.
That age distribution and knowing AFFF was a source of PFAS contamination drove Purdue and USUHS researcher Jennifer Rusiecki to investigate a possible connection. Using samples from the Department of Defense Serum Repository of more than 62 million blood serum specimens from service members, researchers examined samples from 530 troops who later developed testicular cancer and those of 530 members of a control group. The blood was collected between 1988 and 2017.
A second sampling, collected four years after the first samples, showed the higher PFOS concentrations positively associated with testicular cancer.
Ferrara doesn’t have testicular cancer but has other health concerns he attributes to PFAS. He recalled working at Air Combat Command headquarters at Joint Base Langley-Eustis in Virginia in the early 2010s and seeing emails mentioning two types of PFAS chemicals: PFOS and perfluorooctanoic acid, or PFOA.
Even as growing evidence pointed to the chemicals in AFFF being toxic, “We were still led to believe that it’s perfectly safe,” Ferrara said.
When he had a desk job at Air Combat Command, no longer fighting fires, his exposure likely continued: Joint Base Langley-Eustis is among the five most PFAS-contaminated military sites, according to EWG, with groundwater at the former Langley Air Force Base registering 2.2 million parts per trillion for PFOS and PFOA.
According to the EPA, 40 parts per trillion would “warrant further attention,” such as testing and amelioration.
The Defense Department would not comment on the new study.
Air Force officials said the service no longer allows uncontrolled discharges of firefighting foam for maintenance, testing or training and “has replaced Aqueous Film Forming Foam, which contained PFAS, with a foam that meets Environmental Protection Agency recommendations at all installations.”
Both older-generation forever chemicals no longer are made in the United States. 3M, the main manufacturer of PFOS, agreed to start phasing it out in 2000. In June, the industrial giant announced it would pay at least $10.3 billion to settle a class-action suit.
Congress ordered DoD in 2019 to offer annual testing for all active-duty military firefighters and banned using PFAS foam by 2024.
According to Defense Department data, among more than 9,000 firefighters who requested the tests in fiscal year 2021, 96% had at least one of two types of PFAS in their blood serum, with PFOS the most commonly detected, at an average level of 3.1 nanograms per milliliter.
Readings between 2 and 20 ng/mL carry concern for adverse effects, according to the national academies. In that range, it recommends people limit additional exposure and screen for high cholesterol, breast cancer and, if pregnant, high blood pressure.
According to DoD, 707 active and former defense sites are contaminated with PFAS or have had suspected PFAS discharges. It’s in the early stages of a decades-long testing and cleaning process.
More than 3,300 lawsuits have been filed over AFFF and PFAS contamination.
DuPont and other manufacturers reached a $1.185 billion agreement with water utility companies in June.
But attorneys general from 22 states have urged a judge to reject the 3M settlement, saying it wouldn’t adequately cover the damage caused.
Flook declined an interview request. According to the 3M class-action lawsuit, his cancer wreaked havoc on his marriage, robbing him and his wife Linda of “affection, assistance and conjugal fellowship.”
U.S. Sen. Jeanne Shaheen, D-N.H., has reintroduced the PFAS Exposure Assessment and Documentation Act, which would require the Defense Department to test all service members — not just firefighters — at installations with known or suspected contamination as part of their annual health checkups as well as family members and veterans.
The tests, not covered by the military health program or most insurers, typically cost $400 to $600.
KFF Health News is a national newsroom that produces in-depth journalism on health issues.
