APPEALS RESOLUTION OFFICER DECISION
DECISION NUMBER: 20240039
OBJECTING PARTY: worker
REPRESENTED by: WORKER REPRESENTATIVE
RESPONDENT: employer (not participating)
REPRESENTED by: self
HEARING: HEARING IN WRITING
HEARD by: l. mansueti, appeals resolution officer
DATED: APRIL 4, 2024
ISSUE
The worker objects to the Occupational Disease & Survivor Benefits (OD&SB) Adjudicator decision dated January 7, 2021, denying entitlement to benefits for right vocal cord squamous cell carcinoma (laryngeal cancer).
BACKGROUND
In November 2020, the worker was diagnosed with right vocal cord squamous cell carcinoma. The worker submitted a Worker’s Report of Injury/Disease dated November 17, 2020, indicating they attributed their cancer diagnosis to their occupation of firefighting. The worker had worked with the employer in various firefighting capacities for approximately 28 years.
The decision letter dated January 7, 2021, communicated there was no entitlement to benefits for laryngeal cancer under this claim. The worker objected to the January 7, 2021, decision. The operating area reconsidered and upheld the decision to deny entitlement under this claim, as per the reconsideration letters dated March 11, 2021, June 30, 2021, and May 12, 2023.
The worker continued to object to the decision dated January 7, 2021, and this is now the issue before the Appeals Services Division (ASD).
AUTHORITY
Workplace Safety and Insurance Act (WSIA), 1997, as amended Operational Policy Manual
Published
11-01-03 Merits and Justice 23-02-01 Cancers in Firefighters and Fire Investigators Administrative Practice Document: Weighing of Medical Evidence
October 12, 2004 July 4, 2018 February 2024
ANALYSIS
I have carefully considered all of the available information, legislation and relevant operational policies in reaching this decision. The worker representative provided a submission for my review and consideration. The employer is not participating in this appeal. For the reasons that follow, I find the worker is entitled to benefits for right vocal cord squamous cell carcinoma.
Employment & Exposure History
The record indicated the worker began their career as a Firefighter in 1988 and worked for the employer for approximately 28 years. They held a variety of positions including Firefighter, Fire Prevention Officer, Deputy Chief, and Fire Chief. The worker retired in 2016. Throughout their career, the worker attended fire scenes and post-fire suppression scenes.
Medical Evidence
The record indicated the worker’s medical issues commenced in April 2020, when they noticed their voice was hoarse. The hoarseness worsened over the summer, and they were referred to Dr. H. Caetano, Ear Nose and Throat (ENT) Specialist. On November 3, 2020, Dr. Caetano performed a micro laryngoscopy to obtain a biopsy of the right vocal cord lesion. Pathology from this procedure indicated the presence of squamous cell carcinoma, P16 negative. The worker was referred to Cancer Centre X.
A computed tomography (CT) scan of the neck and chest dated November 19, 2020, provided a suboptimal assessment due to the metallic streak artifact from dental hardware. There was evidence of right glottic squamous cell carcinomas, and no evidence of metastatic disease.
On November 20, 2020, the worker was assessed at Cancer Centre X. The consultation reports for this visit indicated the worker had worked as a Firefighter for over 28 years, and they were currently retired. The report stated the worker had a previous history of dysphonia, and in 2012, they had a superficial resection of dysplasia excised from the vocal cord. The worker was noted to be a non-smoker, and there was no family history of any head or neck cancer. In the past few months, the worker observed a return of dysphonia, and a lesion was observed on the right vocal cord. A micro laryngoscopy with biopsy was carried out, which showed evidence of squamous cell carcinoma. The worker was advised the options included transoral laser resection or primary radiation therapy.
The record indicated the worker underwent surgery on December 21, 2020, which consisted of microlaryngoscopy and CO2 laser resection of supraglottis involving the right false vocal cord. The worker saw Dr. Kim, Oncologist, on December 29, 2020, wherein adjuvant treatment was discussed, and it was decided the worker would undergo concurrent chemoradiation treatment. The worker received 35 radiation treatments and 3 rounds of chemotherapy.
On December 23, 2020, Dr. J. Razavi, Occupational Medical Consultant (OMC), reviewed the record and provided an opinion with respect to this case. It must be noted Dr. Razavi did not assess or treat the worker at any time. The OMC noted the worker was diagnosed with vocal cord dysplasia in 2012, and they underwent a repeat laryngoscopy for recurrence 2 years later, which was negative. In March 2020, the worker developed a hoarse voice, and on November 5, 2020, the surgical pathology report of a sample from the vocal cord showed evidence of right vocal cord squamous cell carcinoma. Dr. Razavi indicated established occupational causes for laryngeal cancer included strong inorganic acid mists and asbestos. Non-occupational causes include cigarette smoking and alcohol drinking. The OMC confirmed the worker’s diagnosis was laryngeal cancer, specifically right glottis squamous cell carcinoma. Dr. Razavi submitted the occupational medical/toxicological literature did not support the worker’s workplace exposures could be considered to be a significant contributor to the development of right vocal cord squamous cell carcinoma.
Dr. S. J. Hotte, Oncologist, submitted a letter dated February 24, 2021, in support of the worker’s claim for benefits. The letter indicated the worker had been their patient since December 31, 2020. Dr. Hotte indicated the worker had been diagnosed with a large, locally advanced cancer of the larynx (voice box), which required urgent chemotherapy and radiation treatments. Dr. Hotte submitted that these types of cancers are almost always secondary to excessive decades-long smoking. The worker, on the other hand, had been a lifelong non-smoker, thus it was extremely unusual for this type of cancer to occur in someone without significant risk factors. Dr. Hotte opined the worker’s employment as a Firefighter subjected them to significant inhalation of various toxic substances, thus their laryngeal cancer was almost certainly due primarily to occupational exposures. Dr. Hotte referenced a 2020 study that showed non-smoker Firefighters appear to have an eight-time increased risk for developing laryngeal cancers and that the likelihood is increased two-fold for each decade they worked as a Firefighter. Dr. Hotte indicated the study determined excess risk for Firefighters independent of any smoking history.
Dr. Razavi re-reviewed the record on March 4, 2021, in light of Dr. Hotte’s February 24, 2021, letter. The OMC surmised the new information provided by Dr. Hotte would not alter their opinion on the basis the study they referenced was a single study with a small sample size of individuals and the case-control type of study was hypothesize generating. The OMC placed more significant weight on the most quoted studies for firefighting, thus their opinion remained unchanged.
Dr. M. Pysklywec, submitted a report dated February 15, 2022, providing an opinion with respect to the work-relatedness of the worker’s laryngeal cancer. It must be noted Dr. Pysklywec did not assess or treat the worker; however, they had the opportunity to speak with the worker to obtain information regarding their occupational and medical history.
The worker informed Dr. Pysklywec they had worked with the employer from 1988 to 2016. For the first five years of their employment, they worked as a Firefighter in suppression. The worker recalled fighting numerous fires, and the exposures varied depending on the nature of the fires. Self-contained breathing apparatus (SCBA) was used; however, adherence to this practice was much less at the time than in recent years. The worker recalled being told specifically by captains in the past not to wear SCBA, and just go out and fight the fire. Dr. Pysklywec noted there was significant increased potential for inhalation exposure from reduced SCBA utilization. The worker also indicated hygiene practices were suboptimal as there was no cleaning of gear, and contaminated gear would be used repeatedly. The worker indicated they worked in prevention for the next five years. Their job duties involved investigations of fires, inspections, and other duties. The worker was on call, and they estimated they attended over a hundred fires during that period. They would attend fires that were either still burning or were out. After the fire was out, the worker would wander around the rubble during the overhaul and investigate the exposures. Dr. Pysklywec indicated the worker was exposed to significant inhalation exposure particularly from the off gassing of the overhauled materials. The worker worked as a Deputy Chief for the next 9 years; and the remaining 9 years, they held the position of Chief. During these 18 years, the worker was responsible for attending major fires in a supervisory capacity. They were typically supposed to be outside of the hot zone, but there would often be times conditions would change. The worker sometimes had to be closer to the fire, and perhaps do investigations. The worker did not have access to SCBA as these were not on the chief vehicles. The report, states, in part:
In its totality, [the worker] recounts 28 years of work in firefighting. He describes exposure across all of these roles of both fire contaminants and smoldering overhaul of toxins. Due to the unusual nature of his work, he was often unprotected as the roles were thought to have less direct exposure.
Dr. Pysklywec’s report indicated the worker was a non-smoker, with no past significant smoking history. The worker indicated they were a social drinker. There was no family history of laryngeal cancer. The worker denied engaging in any hobbies which would expose them to known toxins.
Dr. Pysklywec’s report includes an epidemiological review of studies pertaining to laryngeal cancer. Dr. Pysklywec indicated tobacco smoking was one of the strongest risk factors for the development of laryngeal cancer. Reference is made to International Agency for Research on Cancer (IARC), wherein four Group 1 laryngeal carcinogens are identified in humans – acid mists, alcohol beverages, asbestos, and tobacco smoking. With respect to firefighting and laryngeal cancer, Dr. Pysklywec referenced a number of cohort studies examining cancer amongst Firefighters. Dr. Pysklywec submitted the literature was rather equivocal in identifying a relationship between laryngeal cancer and Firefighting, which created challenges in understanding the firefighter epidemiology. Dr. Pysklywec noted there was considerable heterogeneity in exposures for Firefighters, depending on municipality, station, and specific fire experiences.
Dr. Pysklywec pointed to the worker’s experiences wherein they attended a number of fires without SCBA respiratory protection, and in their prevention role and as Deputy Chief and Chief, they attended and investigated fires including periods of overhaul with off-gassing of potential carcinogens. It was noted Firefighters may be exposed to number of known laryngeal carcinogens including but limited to asbestos from residential, commercial and industrial structures; as well as polyaromatic hydrocarbons (PAHs), as these are common given combustion in the process and the ubiquitous hydrocarbons from polymers in most fires. Dr. Pysklywec pointed to the fact the worker did not have any significant alternative risk factors for laryngeal cancer and no family history for this condition. It was also noted the worker’s tumour was P16 negative, which indicated lack of human papillomavirus (HPV) contributing to the malignancy. Finally, it was noted the worker was not exposed to any extraneous toxic substances from recreational activities, hobbies, or other incidental activities. Dr. Pysklywec opined the worker’s occupational exposures likely played a role in contributing to their laryngeal cancer diagnosis on the basis firefighting is known to be related to cancers, and the worker lacked any other obvious risk factor for laryngeal cancer.
Dr. Razavi re-reviewed the record on February 16, 2023, and provided a subsequent opinion as per receipt of the OHCOW report. Dr. Razavi maintained it was unlikely the worker’s laryngeal cancer is related to their occupation or exposures of firefighting. The OMC indicated that when IARC indicates the occupation of Firefighting is Group 1, it doesn’t mean that all cancers in Firefighters are caused by the occupational exposures of Firefighters, rather that certain cancers have been deemed to be causally associated with the occupation. Dr. Razavi indicated the Group 1 evaluation for occupational exposure as a Firefighter that were causally associated with firefighting were mesothelioma and urinary bladder cancer. There was limited evidence for causation for colon cancer, prostate cancer, and testicular cancers. As such, the OMC maintained laryngeal cancer was not considered to be causative or associated with firefighting or firefighting exposures. With respect to Dr. Pysklywec’s indication that the worker sometimes did not don SCBA while firefighting, the OMC reviewed the literature and surmised there was no increased risk for laryngeal cancer under these circumstances.
Assessment of the Evidence
Operational policy 23-02-01 states, in part:
If a firefighter or a fire investigator is diagnosed with a prescribed cancer on or after January 1, 1960, and meets the employment duration and additional criteria for the prescribed cancer, then the disease is presumed to be an occupational disease due to the nature of the worker’s employment, unless the contrary is shown.
In this case, the worker was diagnosed with laryngeal cancer in November 2020, and it is noted they received their diagnosis after having worked as a firefighter for 28 years. As enumerated in policy, the minimum duration of employment for prescribed cancers varies from 10 to 25 years, depending on the primary site of the prescribed cancer. In this case, the worker had worked as a Firefighter for approximately 28 years, thus I find the employment duration criterion has been satisfied. In order to qualify for the presumption, a worker must be diagnosed with a prescribed cancer. It is noted laryngeal cancer is not a prescribed cancer as per operational policy 23-02-01 (published July 2018). While I acknowledge the Ontario government expanded the presumption cancer coverage for eligible firefighters and fire investigators in 2023 to include pancreatic and thyroid cancers, it is noted laryngeal cancer is not included in this expansion.
In cases wherein a worker does not meet the presumption criteria, a decision is rendered based on the real merits and justice of the individual case in accordance with the general provisions of the Act, as outlined in section 119(1) of WSIA and operational policy 11-01-03, which states, in part:
Decisions related to occupational disease
When determining entitlement to a disease claim, a decision-maker considers the worker’s clinical condition and exposure at work, the up-to-date clinical and scientific information, any pertinent non-occupational factors, and all of the relevant policies.
It must be established that it is more probable than not the worker’s employment and/or exposure history caused or significantly contributed to the development of the medical condition for which benefits are being claimed. As such, the question to be determined is whether the worker’s occupational exposures throughout their 28-year career as a firefighter caused or significantly contributed to the development of the laryngeal cancer. If established, the above will generally be considered persuasive evidence that the worker’s employment made a significant contribution to the worker’s illness. A significant or material contributing factor is one of considerable effect or importance.
While the employer is not participating in this appeal, it is noted they also object to the denial of benefits under this claim. The employer is of the position entitlement ought to be granted to the worker for laryngeal cancer.
The worker representative submitted the worker’s laryngeal cancer is clearly linked to their workplace exposures throughout their career in fire service. They pointed to the fact the worker had a prior WSIB claim in relation to chemical exposure, in that they attended a fire at Company Z in November 2002, which was a result of a chemical mixture overflow. It was noted formaldehyde was one of the main ingredients involved in the incident, which caused the worker to experience airway irritation. The worker representative argued the worker was exposed to asbestos throughout their career, noting common asbestos-containing building materials included asbestos in buildings constructed before 1970. The worker representative submitted less significant weight should be placed on Dr. Razavi’s medical opinion on the basis they disregarded epidemiological research that demonstrated a causal link between firefighting and laryngeal cancer. The worker representative is of the position more significant weight ought to the medical opinions provided by Dr. Hotte and Dr. Pysklywec.
The record contains contrary medical opinions with respect to the work-relatedness of the worker’s laryngeal cancer. As per the Administrative Practice Document, Weighing Medical Evidence, the decision-maker is expected to assess and weigh each report in order to reach a decision. Consideration is given to:
The health care professional’s access to all the relevant medical records, including diagnostic reports available to review in order to obtain a complete understanding of the person’s relevant medical history and the injury process involved.
Timeliness of the medical examination in relation to the issue at hand.
Degree of the health professional’s knowledge of past and present medical history and its impact on the medical opinion.
Extent of the health professional’s knowledge and understanding of the injured or ill person’s employment environment in relation to ongoing impairment.
Expertise of those offering an opinion and relevance to the issue. Reference to relevant medical literature that supports the opinion and recommendations.
Evidence or opinion based on an examination of the injured or ill person. Evaluation of the person’s complaints and symptoms relative to the medical findings.
Well-explained and logical conclusion of opinion, including supporting medical findings.
In this case, I note Dr. Razavi, Dr. Hotte and Dr. Pysklywec had access to all the relevant medical records and facts of the case. It is noted Dr. Razavi did not directly assess, treat or communicate with the worker at any time; however, the OMC had the opportunity to review the claim file on three separate occasions, and provided a response to new medical reporting submitted to the record. It is noted the worker was a patient of Dr. Hotte since December 2020, thus they had the opportunity to direct assess and treat the worker. Finally, Dr. Pysklywec did not assess or treat the worker; however, they had the opportunity to speak with the worker and obtain additional information from the worker first hand.
I find all of the medical opinions were provided by knowledgeable and experienced health care professionals, with specialities and expertise in their respective fields. Dr. Razavi is an Occupational Medicine Specialist and is the current Chair for the Subspecialty of Occupational Medicine of the Royal College of Physicians and Surgeons of Canada. Dr. Razavi’s has expertise on disability management. Dr. Hotte is a Medical Oncologist, Associate Professor, Chair of the Department of Oncology Fellowship Program at McMaster University, and Chair of the Genito-Urinary Disease Site Group. Finally, Dr. Pysklywec is a Fellow of the Canadian Board of Occupational Medicine, Assistant Professor of the Department of Epidemiology and Biostatistics at McMaster University, holds a degree in Materials Engineering, and is the physician for the fire department of a large municipality. I am compelled by the fact Dr. Hotte directly assessed the worker, and I have placed more weight on the fact Dr. Pysklywec has a background in occupational medicine as well as experience and understanding of exposures and health issues specific to firefighters. I find the medical opinions provided in this case each made reference to medical literature to support their view, and a well-explained rationale was provided to substantiate their position.
In weighing the medical evidence, I have placed more significant weigh on the independent medical opinions provided by Dr. Hotte and Dr. Pysklywec. I am compelled by the fact the worker was a patient of Dr. Hotte, thus they had the opportunity to directly assess and treat the worker. As such, I find greater weight ought to be afforded to their expert oncological opinion. With respect to the worker’s laryngeal cancer diagnosis, Dr. Hotte stated, in part:
These cancers are almost always secondary to excessive smoking, usually for decades. [The worker] has been a life-long non-smoker and it would be EXTREMELY unusual for this type of cancer to occur in someone with his lack of risk factors. As you know, he has been a career fire fighter and has both fought fires directly and has inspected buildings once the fire was extinguished. Both of these activities can be subject to significant inhalation of various toxic substances which has been shown to be involved with the causation of many types of cancers.
Dr. Hotte further stated, in part:
As such, I am quite confident in my assessment that [the worker’s] current cancer is almost certainly due to primarily to this past occupational exposure.
Dr. Hotte’s sentiments are echoed in the OHCOW report prepared by Dr. Pysklywec. Dr. Pysklywec stated, in part:
In consideration of this, it is my impression that his work likely played a role in contributing to his laryngeal cancer. Firefighting is known to be related to cancers. [The worker] lacked any other obvious risk factor for laryngeal cancer. This would lead one to consider exogenous factors such as occupation in contributing to malignancy.
It appears Dr. Hotte and Dr. Pysklywec weighed and considered the worker’s occupational risk factors as well as non-work-related risk factors, including lack of smoking history and lack of family history of cancer, to form their expert medical opinion. It is noted Dr. Razavi placed greater emphasis on the scientific literature to form their opinion. Dr. Razavi maintained in each review that the medical/toxicological literature did not support the worker’s workplace exposures could be considered a significant contributor to the development of right vocal cord squamous cell carcinoma. As per the February 16, 2023, OMC review, the operating area asked Dr. Razavi to provide a response to the following question:
In your medical opinion, are there competing/non-work-related risk factors, in the absence of exposure that would cause/predispose the worker to have developed the illness?
Dr. Razavi’s responded, “In my scope of work, I am to discuss environmental and occupational factors. I will leave this to his treating specialists.”
According to the worker’s treating specialist, Dr. Hotte, the worker did not have any non-work-related risk factors that would cause or predispose them to the development of laryngeal cancer.
In review of the merits and justice of this case, I find there is sufficient evidence to support the worker’s 28-year career as a Firefighter likely caused or significant contributed to the development of right vocal cord squamous cell carcinoma. I accept the medical opinions provided by Dr. Hotte, the worker’s treating Oncologist, and Dr. Pysklywec, who both opined the worker’s occupation is more likely than not causally linked to their firefighting occupation given the likely inhalation of various toxic substances throughout their career as well as lack of personal risk factors. Based on the foregoing, I find on a balance of probabilities, the worker is entitled to benefits for laryngeal cancer.
CONCLUSION
I conclude the worker is entitled to benefits for right vocal cord squamous cell carcinoma (laryngeal cancer).
The worker’s objection is allowed.
DATED April 4, 2024
L. Mansueti Appeals Resolution Officer Appeals Services Division