By Joseph Knitter
For many years prior to my retirement in 2022 as fire chief of the South Milwaukee (Wisconsin) Fire Department, we firefighters were subjected to periodic tuberculin skin tests.
The test is simple: A healthcare worker injects testing fluid (tuberculin) under the skin on the lower part of your inner arm. After 48 hours, the area is evaluated for swelling or a bump where the testing fluid was injected. If something does present, the healthcare worker measures the bump or swelling and tells you if your skin test reaction is positive or negative. Fortunately, my tests were always negative – no bump or swelling. However, in the days following my last test, I noticed that a rash had developed in the area around the injection site. I wasn’t concerned and simply ignored it.
As time went on, the rash would come and go, occasionally get irritated, but never completely disappear. Finally, after considerable urging by my wife, I contacted my personal physician. By then, several months had passed.
After checking out the rash, my physician believed it was a small patch of eczema or psoriasis that could have been the result of an injection site reaction from the TB skin test. He prescribed a topical ointment. After application of the ointment as directed, the spot seemed to get smaller, and irritation disappeared – at least for a while.
Weeks or even months would pass, and the spot would reappear. Reapplication of the ointment would cause it to lessen but, again, never totally disappear.
Fast-forward several months. I had been chosen to present one of my programs as a workshop at FDIC in Indianapolis. In one of the conference emails, I noticed that free skin cancer screenings would be offered in Lucas Oil Stadium. The screenings were provided by the Firefighter Cancer Support Network and the Center for Fire Rescue & EMS Health Research, funded by a generous grant from FEMA. I thought, why not? After all, I had the opportunity to be there at that time, they were free, and I was an outspoken advocate of cancer prevention, knowing that as a firefighter, I had a 21% higher risk of developing melanoma, the most severe type of skin cancer.
My passion for cancer prevention
My push for cancer prevention began in 2015 while I was fire chief. The diagnosis and eventual death of my 58-year-old brother from multiple forms of cancer caused me to pause and consider not only my own future but also that of the firefighters I worked with – and how I could impact them. Although my brother was not a firefighter and never fought a fire, he worked in an industry that exposed him to many of the very same chemicals that firefighters are exposed to on the fireground – benzene, toluene, acetone, etc.
In response, I established a program for my department called Firefighters Addressing Cancer Exposure (FACE). The program provided guidance to members based on best practices relating to cancer exposure reduction and included things such as not tolerating dirty (salty) gear or allowing firefighters to breathe smoke. While many of the best practices would seem like common sense, the program provided written guidance that not only served as important reminders to our personnel, but also stressed ownership and responsibility at each level of the organization. In addition, we provided tools and supplies on fire apparatus for on scene decontamination. What’s more, in 2017, the FACE Program was selected by the Safety Section of the Wisconsin State Fire Chief’s Association to receive the Safety Leadership Award.
Nonetheless, exposures still happened. I know in my case there were plenty of them, especially in days gone by where the use of SCBA and the education on the chemicals contained in the smoke and soot and gasses from fire was minimal. I always said it wasn’t a matter of if but when I would be affected by cancer. It sounds morbid to think that way, but it’s reality, and I always considered myself a realist. After all, I spent a lot of time in the “what if” business we call the fire service.
In addition, my family has an extensive history of cancer. My mom is a 30-plus-year breast cancer and skin cancer survivor, and both my dad and brother were diagnosed with multiple forms. To add to the equation, I spent a good portion of my 41 years in the fire service doing stupid stuff because we either didn’t know, didn’t care, or didn’t realize what we were breathing or being exposed to. So, knowing alI this now, I went online and registered for a screening.
Conference exam
Upon arrival for my exam appointment, I spent approximately 10 minutes completing paperwork and then it was on to the exam.
During the exam, which took only 15-20 minutes, a physician’s assistant (PA) closely examined me from head to toe. The PA was especially interested in what she identified as a non-healing lesion on the inside of my left forearm – the small patch that was previously evaluated by my personal physician. I informed her that it had been treated by my physician and he referred to it as an injection site reaction. Nonetheless, the PA strongly advised that I get it evaluated by a dermatologist.
So, upon my return from the conference, I reached out to my personal physician for a dermatologist recommendation and made an appointment for a skin cancer screening.
Cancer confirmed
During my visit with the dermatologist, I made sure he understood my work history and the increased cancer risks that firefighters face. Based on our conversation, I was confident that he seemed acutely aware of the increased risks we face.
[Download the Provider’s Guide to Firefighter Medical Evaluations]
The dermatologist focused on the spot on my forearm, and a biopsy was performed with a small sample of tissue taken from the spot for analysis. The dermatologist informed me he would send the sample to the lab and call me in several days with the results. Three days later, I received the phone call and, sure enough, the lesion was confirmed as squamous cell carcinoma (SCC). CANCER – the word no one wants to hear.
SCC is the second most common form of skin cancer. It can grow rapidly and metastasize (spread) to other parts of the body, including distant tissues and organs. However, fortunately, the dermatologist explained that my lesion was considered in situ, the medical term meaning confined to its site of origin – not invading neighboring tissue or gone elsewhere in the body.
The dermatologist offered three options for treatment:
- Total removal;
- A Mohs procedure, where the surgeon removes thin layers of skin one layer at a time and examines each layer under a microscope to determine if any cancer remains and continues until only cancer-free tissue remains); and
- A lengthy regimen of topical ointment as a form of chemotherapy.
After considerable discussion, I decided that total removal would be the best method of treatment.
Removal and recovery
Two weeks later, I was back in the office getting the lesion and a sufficient margin excised from my forearm. Because of the location on the forearm, a 2-inch oval-shaped incision was necessary in order to stretch the skin to cover the area from where the tissue was removed, which was originally less than half-inch in diameter. The excised tissue was then sent out to a lab for analysis and, luckily, all the tests came back saying the margins were clear – the cancer had been removed.
We had caught it early enough that it was localized to that one spot – there was no spread. We do not know if it would have spread and, if so, where – more skin, lymph nodes, organs, bones? Not everyone is or will be as lucky as me to find cancer while it is still localized.
Because of the location on the forearm, a 2-inch oval-shaped incision was necessary in order to stretch the skin to cover the area from where the tissue was removed, which was originally less than half-inch in diameter. The excised tissue was then sent out to a lab for analysis and, luckily, all the tests came back saying the margins were clear – the cancer had been removed.
Photo/Joseph Knitter
Considering cause
While we obviously can’t pinpoint a direct cause for my cancer, the dermatologist believes the injection site reaction may have weakened my skin’s ability to fight off infection at that site and the cancer took advantage of it. My 94 year-old mother has always said that everyone has cancer in their body and the cancer is just looking for a weakness to attack. Following that logic, my weakness was the injection site.
The dermatologist also commented on how my cancer was in a place not normally associated with SCC, which is typically found in areas exposed to the sun – tips of the ears, tip of the nose, lips, back of the neck, shoulders, outer arms/hands … and I don’t ever recall getting sunburned on my inner forearms.
Words of wisdom
My advice to you: Don’t think you are immune. Cancer doesn’t discriminate.
Do your homework. Pay attention to your bodies. Get screened – it may be the 15-20 minutes that saves your life.
And, to my fire service friends, CLEAN IS THE NEW SALTY. We know how many fires we go to. Don’t be a hero. Dirty gear, dirty helmets and dirty skin isn’t a sign of anything tough.
Paying it forward
One of my fire service passions is sharing information – paying it forward. Contained in many of my presentations is a slide that states my goal: “That one person leaves here today with one new idea, notion or thought that could save their life or the life of a brother or sister firefighter.” And I often share examples of people attending my presentations actually taking something away. In the case of this article, it was spurred on by a Facebook post sharing my cancer diagnosis. I didn’t share my experience to garner attention but rather upon the urging of my wife and several friends to serve as a lesson that I could pay forward – so now I share these lessons with you.
I never imagined that that post would get the traction it did. I received comments, private messages and text messages from people across the country sharing their stories, many of them thanking me for sharing my experience and acknowledging that it changed their outlook and gave them reason to seek more information or even schedule a screening.
So, please, do yourself, your family and your friends a favor – GET SCREENED. It could be your lifesaver.
Editor’s note: Firefighter Aaron Zamzow, host of FireRescue1’s Better Every Shift podcast, also took part in the free skin cancer screening at FDIC. Here’s a short video to show what the experience was like:
About the author
Joseph Knitter is a 41-year fire service veteran, retiring in 2022 as fire chief of the South Milwaukee (Wisconsin) Fire Department, where he served for 37 years. Knitter has an associate degree in fire science, a bachelor’s degree in fire service management, and is a graduate of the National Fire Academy’s Executive Fire Officer Program. Knitter previously taught fire certification classes for Milwaukee Area Technical College and continues to lecture on various topics throughout the area, and serves as a representative for the Wisconsin Technical College System Fire Service Training Office.