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February - March 2003 |
An Ordeal with Cancer: Lessons Learned
In January of 2001, I was diagnosed with transitional cell carcinoma in my right renal pelvis. This is a deadly form of cancer if not caught early. What I would like to do in this article is briefly take you with me from the time I became aware of my sickness to my current situation with the law of presumption, the importance of documentation, and my battle with the City and County of San Francisco.
YOU HAVE CANCER . . . .
I had just finished my daily run and went to the gym for some weight training. I made a pit stop at the bathroom and noticed blood in my urine. I immediately went to my doctor’s office with a urine sample. The doctor termed it “gross hematuria,” which is a large volume of blood in the urine.
The following day my doctor sent me to the hospital for an ultrasound test of my kidneys and bladder. The renal pelvis of the right kidney showed some type of soft tissue mass. The next step was a CT scan that was conducted the following week. The CT scan confirmed that there was an intraluminal soft tissue mass in the right renal pelvis above the ureteropelvic junction most consistent with a cancer called transitional cell carcinoma or TCC.
Transitional cell carcinoma of the renal pelvis and ureter is a disease in which cancer cells are found in the tissues in the kidneys that collect urine (the renal pelvis) and/or in the tube that connects the kidney to the bladder (ureter). It is also the most common type of cancer found in the bladder. Hematuria (blood in the urine) is a common presentation. Generally, there is no palpable mass, and in some cases low back pain exists. In many cases, there are no signs or symptoms. This is a cancer of the genitourinary tract and a deadly cancer if not detected early.
Occupational chemical exposures are known to cause TCC. They include several aromatic amines, solvents, benzidine, PAH’s, coal tars and pitches, soot and oils, substances commonly encountered by firefighters, particularly at fires in commercial establishments. It has a latency period from as little as five years to 49 years and increases with duration of employment as a firefighter.
During my first 10 years on the job in San Francisco, there was no mandatory self-contained breathing apparatus rule. Many of us were exposed to a myriad of toxic chemicals. This also continues to this day to some extent during overhaul procedures when the SCBA is discarded.
Exposures at the firehouse, where we spend long hours, also may have an impact on our chances of getting cancer of the genitourinary tract, among other forms of cancer. Diesel exhaust from our apparatus, especially if the engines are run in closed houses without direct venting to outside air, may lead to high levels of diesel exhaust emission particulates that are most likely carcinogenic.
About me: I am a 28-year veteran of the San Francisco Fire Department, 52 years of age, and planning on retiring in February 2003. I am currently the captain of Rescue One and have worked at Rescue One for the last 12 years. (I have not returned to work since being diagnosed with TCC.) I have been in excellent physical condition throughout my career. I have always been a firm believer in keeping in top physical condition to meet the demands of the job. I have never smoked; no one in my family has ever smoked. My father had prostrate cancer in his early ’70s that was cured with radiation treatments; otherwise, there is no history of cancer in my family.
THE BIOPSY
I was sent to a urologist for a biopsy to confirm the findings of the CT scan. I was given a spinal block and watched the procedure on a TV monitor. A long tube with a camera was sent through my penis into the bladder through the ureter and finally into the renal pelvis of the kidney where an attempt was made to gather cells of the tumor. Once the procedure was completed and I gained feeling back in my legs, I was released to go home. Needless to say, I was in quite a bit of pain. A couple of days later the urologist advised me that they were unable to get any cells off the tumor—the procedure would have to be repeated.
At this time, the urologist I was seeing referred me to Dr. Marshall Stoller at the University of California, San Francisco (UCSF), who is one of the best surgeons in the business. It took three weeks to get into his office. This was taking a tremendous toll on me, mentally. Dr. Stoller performed the same procedure—still no cells. A third biopsy would be necessary. This time Dr. Stoller made a tiny incision in my back and was able to retrieve cells from the tumor. It entailed three days in the hospital. The results came back positive for TCC. Now it was time to get this alien bastard out of me. I was scheduled for surgery February 27, 2001—10 days after my 50th birthday.
Dr. Stoller was going to attempt to remove the entire kidney and ureter laparoscopicly, a procedure that is minimally invasive with a fairly quick recovery period. Unfortunately, during the surgery there were complications and the kidney and ureter were removed by a 10-inch incision through my abdominal wall. This meant a long, slow recovery period of at least three months. It was a very difficult hospital stay, which lasted seven days, as well as a very painful recovery. I did receive some good news—the tumor had clean margins and was confined to the renal pelvis. The big question remains, as with any cancer: what are the chances for reoccurrence? Transitional cell carcinoma can easily spread to the bladder so continual surveillance is necessary. For my first post-operative year, an unpleasant procedure called a “cystoscopy” would take place every three months. For the second year, the procedure would take place every six months. After the second year, the procedure is conducted annually. There was no chemotherapy or radiation necessary, besides chemotherapy and radiation have been shown to be ineffective if TCC spreads.
PRESUMPTIVE CANCER
From the very beginning of my ordeal with TCC, the officers at Station One put in countless hours documenting my exposures. This is something that I should have been doing throughout my career and something that every firefighter must do! Our union vice president, Joe Moriarity, contacted our Workers’ Compensation Department to set up an appointment with one of their qualified medical examiners. The appointment was made. I was to see a pulmonary specialist at the end of March. A pulmonary specialist?? At this point our department physician, Dr. Deborah Owen, contacted Workers’ Compensation and asked them to send me to a urologist. Their response was we are sending him to a pulmonary specialist who is also a cancer specialist. Union VP Joe Moriarity was also attempting to get Workers’ Compensation to send me to a urologist, but they refused. In the meantime, my work history documentation was completed. A report by Dr. Stoller was also submitted stating that he felt my exposures throughout my career were the cause of my cancer. This was also reflected in a report submitted by Dr. Piero Mustacchi at the request of Dr. Owen after reviewing all the documentation. Dr. Owen also submitted a report concluding “[m]y professional opinion is that Captain Stefani’s cancer is the result of an exposure he sustained while working for the SFFD. The occupational medical literature supports the association of genitourinary cancers in firefighters.” The documentation, the medical literature and the reports from Drs. Stoller, Mustacchi and Owen were all submitted to the City’s QME.
Joe Moriarity accompanied me on my visit to the QME. That day I went through six hours of testing. All the tests that were administered had to do with the condition of my lungs! It seemed that the pulmonary specialist they sent me to did not go over any of the documentation prior to my visit. A month later, the QME report was submitted stating “the overwhelming weight of medical literature . . . find no increased incidence of kidney cancer in fire fighters. The only risk factors . . . are cigarette smoking and perhaps excessive weight and the use of phenacetin analgesics.” My case was denied. Joe Moriarity and I sat down to talk. This was going to be a long battle.
At this point, I contacted Mr. Tom Kazarian, an excellent Worker’s Compensation attorney, who has had success with cancer cases prior to the presumptive law. Tom reviewed all the documentation, and we decided to file for a hearing before a State Workers’ Compensation appeals judge. My case was heard in September 2002, and no decision has been made as of this writing. At the hearing, Tom established exposures to a multitude of carcinogens to satisfy our burden of proof that the cancer was presumed to be job related. Tom also provided literature showing the possible connection between my exposures and TCC, as well as the doctors’ reports. The city attorney based her case on the report that was submitted by the city's QME, the pulmonary specialist. It will be up to the Workers’ Compensation judge to decide if the evidence presented proves there is a “reasonable link” between my cancer and the numerous exposures.
It is hoped that cancer will never be a problem in your career, but if the problem does present itself, prepare yourself for a possible battle. I cannot stress enough the importance of ongoing documentation throughout your career. The more you document, the easier it will be to establish the connection between your exposures and your illness. I was very fortunate to have my brothers at Station One work endless hours to provide the necessary documentation that I should have been compiling throughout my career.
Currently, I am healthy and back in top physical condition. I was at UCSF in early November and given a clean bill of health.
POSTSCRIPT
On November 21, 2002, a “Findings, Award and Order” and a 12-page “Opinion on Decision” was handed down by the Workers’ Compensation Appeals Board judge hearing the case stating:
“AWARD IS HEREBY MADE in favor of Anthony Stefani and against the City and County of San Francisco
(a) The applicant sustained a cumulative trauma injury/cancer of the right kidney arising out of and in the course of his employment as a firefighter by Defendant City and County of San Francisco.”
I will be happy to discuss the outcome of my case with other firefighters. I can be reached at alpinestef@earthlink.net. God bless all of you.
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