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A growing number of studies demonstrate that firefighters are exposed to more toxins and have higher rates of cancer relative to the general population.1,2 Recently, there has been an increase in the number of states adopting cancer presumption laws for firefighters, which most often fall under workers’ compensation. Presumptive legislation shifts the burden of proof to the employer; it holds the employer and insurer responsible for disproving that the cancer was unrelated to work as a firefighter. While these laws aim to compensate firefighters for the significant expenses associated with cancer diagnosis and treatment, many first responders are employed by municipalities or governmental divisions, and the financial burden of this legislation on local governments can be significant.3

In recognition of the increased risks associated with line-of-duty exposures, federal regulations were passed in 2010 and 2018 to secure funding for health complications in first responders and survivors of the 9/11 terrorist attacks and to develop and maintain a voluntary registry of the incidence of certain cancers in firefighters.4,5 There is no federal legislation directly addressing firefighter presumption law, and the state laws vary significantly. In an attempt to make these laws more accessible to the public, the First Responder Center for Excellence, which is a nonprofit organization providing education on and developing a research network committed to reducing first responder occupational illness, injury, and death, has summarized the presumptive legislation on their website.5 Additionally, the International Association of Fire Fighters (IAFF) Division of Occupational Health, Safety, and Medicine developed an information database of the current presumptive disability provisions in the United States and Canada.6

Every state in the United States has either passed or considered presumptive legislation for firefighters diagnosed with cancer; a total of 48 states and Washington, DC, have passed legislation, of which 31 states have passed the legislation under workers’ compensation (Table 29-1). The two remaining states without laws, Delaware7 and South Carolina,8 have bills under review by state legislators. Although nearly all states have passed presumptive laws to compensate firefighters or family members for cancers attributed to occupational exposures, the legislation varies significantly across state lines. Half of the states with presumptive laws cover volunteers, and 45% of states require proof of exposure to carcinogens. Firefighters must serve typically at least five years prior to their cancer diagnosis to be eligible for the presumption, although some states require six to ten years of service to qualify. A few states, namely Idaho,9 Montana,10 and New Mexico,11 require a specific number of service years based on the cancer diagnosis (Table 29-2). All but two of the states have passed presumptive legislation for specific cancer diagnoses, but these laws vary significantly in language and requirements, namely how many and which types of cancers may be covered, qualification criteria, and how long the presumption applies. The top five most commonly listed ...

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