Lung Cancer Incidence after September 11, 2001, among World Trade Center Responders

Importance: Responders involved in rescue and recovery operations after the collapse of the World Trade Center (WTC) on September 11, 2001, were exposed to airborne carcinogens. Objectives: To examine the incidence of lung cancer after the WTC attacks and to compare the incidence of lung cancer among responders with varying degrees of exposure severity. Design, Setting, and Participants: In this prospective cohort study, data were collected between July 1, 2012, and December 31, 2023, from individuals who were enrolled in a medical monitoring program available to WTC responders residing on Long Island, New York. This study was restricted to people who survived and were followed up for incident lung cancer after a 10-year latency period. Exposures: Types and durations of exposures were based on responses to a detailed questionnaire about on-site work conditions, which included information about the type and duration of work, smells, and sights while working; exposure to dust; and the use of protective equipment. World Trade Center exposure characteristics and overall severity were measured as mild, moderate, and severe exposure using a validated approach. Main Outcomes and Measures: The incidence of lung cancer was the primary outcome. Diagnosis of lung cancer was ascertained following a standardized approach by trained clinicians, and diagnoses were verified by clinicians at the Centers for Disease Control and Prevention. Cox proportional hazards regression was used to estimate multivariable-adjusted hazard ratios. Result: Among 12334 eligible responders (mean [SD] age at study inclusion, 49.3 [10.2] years; 11213 men [90.9%]), 118 incident lung cancers were identified between July 1, 2012, and December 31, 2023 (incidence rate, 8.7/10000 person-years [95% CI, 7.3-10.5 person-years]). When compared with mild exposures, the incidence of lung cancer was higher among moderately (adjusted hazard ratio [AHR], 1.86 [95% CI, 1.19-2.91]; P =.007) and severely (AHR, 2.90 [95% CI, 1.69-4.99]; P <.001) exposed groups. Specific WTC exposures, including smelling fumes (AHR, 1.05 [95% CI, 1.01-1.09]; P =.007) or sewage (AHR, 1.03 [95% CI, 1.01-1.05]; P =.004), were also associated with higher incidence of lung cancer after adjusting for demographics and measures of tobacco use. Conclusions and Relevance: In this cohort study of WTC responders, the incidence of lung cancer was higher among those with greater exposure severity. Future studies may investigate specific WTC exposures and histologic changes and clarify the role of WTC exposure for prognosis.