“It Would Break Your Heart”
Science vs. experience in a cancer cluster investigation
He calls it the best farmland in the world.
All around him, the dark soil of Central Maryland’s Frederick Valley rolls in meadows and hills over porous, fractured limestone.
On a late summer day as he stomps through grass and weeds along Shookstown Road in Frederick, Maryland, Bill Krantz says, “Take a look at the soybeans across the road. Look how big they are. You won’t see them that big in the Midwest.”
Krantz has spent most of his 79 years on the land. He swam and fished in the stream, listened to the bullfrogs croak at night, played in the shade of trees his granddaddy planted and baled countless tons of hay. Mostly though, he tended dairy cattle. “We didn’t go on vacation. We just milked,” he says.
At first glance, his pastoral Eden remains. The soybeans, the green hills and trees still stretch to the horizon, but history and geology offer a different reality. In 1944, as part of the war effort, the U.S. government claimed some of the Krantzes’ land as well as acreage from other families, dubbing it Area B. The 399 acres became part of the nearby Fort Detrick. The U.S. Army base, about 45 miles northwest of Washington, D.C., would become a center for biomedical research. From 1943 to 1969, work there would also include biological weapons development and testing.
The Krantzes occasionally glimpsed Area B’s research. They saw giant concentric circles cut into a field to measure the effect of the mysterious substances sprayed at the site. They remember smoke from burning pits rising above their houses at night. And Bill Krantz recalls the summer day in 1951 when some of his dad’s cattle suddenly died. (A recent Army report blamed an arsenic-based herbicide for the deaths of eight cows that August.)
Over the decades, Fort Detrick expanded, becoming a renowned research center and the county’s largest employer with 9,200 workers. While the base thrived, however, the Krantz family suffered repeated tragedies. Bill and his cousin Jim say that 13 of the 18 members of their extended family (in their 50s and older) were diagnosed with cancer. “My dad died of pancreatic cancer. My sister died of brain cancer. My wife died of ovarian cancer. My dog died—he was ate up with cancer. My cows had cancer. So they can’t tell me that they didn’t do something,” says Bill Krantz.
Jim Krantz points to the house Bill built in the 1970s (and lived in until his wife got sick) and two next to it and says an occupant of each had a rare blood disease. “Rare is not three in a row. Something caused that,” he says. “All three houses used well water.”
The Krantzes believe that the area’s groundwater was contaminated by the radiological materials, laboratory waste and drums of chemicals buried in Area B. An April 2012 EPA report noted that anthrax, phosgene (a poison gas) and radioactive carbon, sulfur and phosphorous were buried there. Agent Orange was tested on Area B as well. According to the EPA report, a 2004 Army effort to remove contaminated soil, chemical containers, gas cylinders and laboratory waste from disposal pit B-11 discovered “live pathogens,” causing the suspension of further removal efforts.
Fort Detrick declined comment for this article or a Bloomberg School case study, citing possible litigation. The Army did report in 2011 that $50 million had been spent on Area B cleanup and restoration efforts in the previous two decades and that “impermeable caps” had been placed over the dumpsites.
The possibility that chemicals from the base caused a cancer outbreak has roiled the Frederick community. Concerned citizens and public health experts (including Bloomberg School alumni) have sought answers to two deceptively simple questions: Is there a cancer “cluster” in Frederick? And, if so, is Fort Detrick the cause?
This is a story about the collision of personal experience, data, science and the hundreds of diseases known as cancer.
Each year in the U.S., cancer cluster concerns prompt more than 1,000 investigation requests. As people see neighbors and loved ones getting sick or dying from cancer, they naturally want to know the cause.
“Cancer clusters are perhaps one of the most difficult things I’ve ever done,” says Thomas Burke, PhD, MPH, a former New Jersey deputy health commissioner who has led several cluster investigations. “These are real people, real lives, real lost loved ones. And that’s the emotion that charges these investigations, and it makes it very difficult.”
The CDC defines a cluster as “a greater-than-expected number of cancer cases that occurs within a group of people in a geographic area over a period of time.” However, the public often sees it differently. They may hear of several cases of cancer in their neighborhood and think it’s a cluster. It’s probably not, says Burke, now associate dean for Public Health Practice and Training. First, different cancers are actually different diseases (likely with different causes), he says. Melanoma, for example, is quite different from leukemia or lung cancer. Second, cancer risk increases with age and occurs all too frequently among older people. The American Cancer Society estimates about one in two men and one in three women will develop an invasive cancer in their lifetimes.
When investigating a possible cluster, experts analyze data to uncover unusual cancer patterns. Do cases cluster in time and space? Are there more cases of a rare cancer than expected? Are cancers striking the young or otherwise healthy? Are there known carcinogens in the area? It’s a difficult task: Consider that it can take 20 or 30 years for cancer to develop after exposure. In the interim, an individual encounters innumerable other chemicals in water, air, their diet, the workplace and so on. “We’re starting at a scientific disadvantage,” says Burke. “For instance, if we have an outbreak of a foodborne disease, you can go to the refrigerators of people and see what they ate the night before. That’s not the case for 30 years ago when there may have been environmental exposure… that would lead to increased cancer incidence in a community.
"The difficulty involved is borne out in the scientific literature. Of the more than 400 investigations of perceived cancer clusters since 1990, only 13 percent found a statistically significant increase in the cancer rate, according to a 2012 article in Critical Reviews in Toxicology. And only one investigation found a clear cause. (That investigation found that “an excess in pleural cancers” in coastal South Carolina was due to asbestos-exposed shipyard workers.) And a CDC review of 108 investigations of perceived cancer clusters from 1961 to 1982 found that none could identify a cause, according to a 1990 American Journal of Epidemiology article.
Such long odds mean little to people like Carroll Rice, whose family, with deep roots in Frederick, has been decimated by cancer. Fourteen immediate family members have developed a rare form of leukemia, erythroleukemia. Thirteen have died from it. “In my way of thinking, if you’re part of our Rice clan, you gonna die with cancer,” Rice says. “It’s no question because all of the others have—with the exception of one. He had a heart attack.”
Rice says that the family’s cancer victims all descend from his grandfather, Charles “Tuff” Rice. They believe he developed the genetic mutation that’s been passed down through the family because he worked at Fort Detrick. Given the devastation visited upon his family, Rice is incredulous that the existence of a cluster is questioned, much less denied.
“Dammit, my family alone is a cluster,” he says.
Jennifer Peppe Hahn recalls long summer days playing in a natural spring in her friend’s backyard just east of Area B. From when she was a young girl until she got sick at age 12, Hahn and her friend splashed in the water, drank lemonade and invented adventures for their Barbies. They also may have been exposed to tetrachloroethylene (PCE) and trichloroethene (TCE).
In 1997, the Army found that levels of PCE (a chemical solvent linked to breast, lung and other cancers) spiked at 20,000 parts per billion (ppb) in the spring though the level returned to less than 1 ppb a month later. (The increase may have been caused by nearby excavation work in Area B.) The EPA’s maximum contaminant level of PCE for drinking water is 5 ppb. Hahn thinks the chemicals were in the spring long before monitoring began. Had she been warned, she says, she might not have become sick.
Hahn, now 39, was diagnosed with Hodgkin lymphoma in 1985 and suffered through a year of treatment that included radiation and the removal of her spleen. She later developed breast cancer. “I’ve spent my whole life getting very sick and in and out of the hospital,” says Hahn. “Now I have tumors in my thyroid. I have a mass on my pancreas that gets biopsied every six months, and I have no breasts. And I believe that this was all caused by environmental exposure that nobody will even do any critical thinking long enough to look into.”
For decades, people in Frederick appreciated the base’s economic engine but were wary of its secret work. Although bioweapons research ended in 1969 by order of President Richard Nixon, biomedical research by the Army, other agencies and companies continues at the base today.
Concern about the environmental exposures from Fort Detrick increased in April 2009, when the EPA added Area B to its National Priorities List (NPL), part of the Superfund cleanup program. The NPL designation initiated a raft of meetings, investigations, studies and remedies that will likely play out over more than a decade.
By June 2010, worry about a possible cancer cluster had spread through Frederick. Started by a concerned family, the Kristen Renee Foundation (KRF) began mobilizing people. It held large public meetings, placed newspaper ads and later conducted its own cancer survey.
After hearing the community’s concerns, Frederick County health officer Barbara Brookmyer, MD, MPH ’94, launched an investigation with the Maryland State Department of Health and Mental Hygiene (DHMH). In August 2010, she began a series of community meetings. At the first meeting, people vented decades’ worth of frustration for more than three hours. Brookmyer’s staff wrote down every question, solicited answers from the Army and other agencies and posted responses on the Department’s website. She also formed a Technical Advisory Committee (TAC) of concerned individuals like Hahn.
Clifford Mitchell, MD, MPH ’91, MS, director of the DHMH’s Environmental Health Bureau and a former Bloomberg School faculty member, analyzed data from the Maryland Cancer Registry, which collects cancer incidence information and patient demographics. “You’ve got specific addresses, you’ve got specific diagnoses and you’ve got really good clinical information,” he says. Without the registry, it would be almost impossible to know specific cancer rates (number of cases divided by the population at risk) in Maryland—and thus ascertain whether the rates near Fort Detrick are unusual.
However, like all cancer registries, the Maryland database has limitations. It does not, for example, track cancer cases before its 1992 inception. This concerned some residents because the registry would not include people who may have been exposed to carcinogens in the 1940s and 1950s and died from cancer by the 1980s. Hahn believes the registry misses the years when the cluster would have been most evident. “Just because there wasn’t enough efficiently available data does not mean there was not an issue,” Hahn says.
Mitchell acknowledges the issue but says there is no practical way to identify all the cancer cases from that era, track down people who have died or moved away, gather their health histories, determine population details, etc. The registry data, he says, is still the best data source given the circumstances.
While Mitchell pored over the data, KRF began to amass its own. Randy White, who founded KRF and named it after his daughter who died of cancer in 2008, says they spent more than $300,000 on a survey mailed to 30,000 people near Fort Detrick. From 15,000 responses, they said they learned of 1,200 cancer cases within 10 miles of the Fort. Although it was based on self-reported data (which is far from the scientific gold standard), the finding raised alarm among the public.
Brookmyer points out, however, that number is not remarkable given how many people were at risk. In fact, she says the cancer registry documented 1,059 cases within a 1-mile radius of Fort Detrick in just eight years. “If we’re talking about collecting cancer information spanning 40 years you’d expect in this area there would be more than just a 1,000 cases,” says Brookmyer. “So that’s one of the challenges: to make good use of the data and to be able to understand the rate.”
The long-awaited October 2011 report from DHMH and the Frederick County Health Department (FCHD) found that there were no statistically significant increases in specific types of cancer within 1 mile of Fort Detrick—except for lymphoma. Rates for lymphoma near Fort Detrick were higher than Maryland’s rates, but not higher than Frederick County’s, she says, adding that lymphoma rates will continue to be scrutinized as new data become available.
Few in the community were satisfied. “It is the saddest thing I’ve ever witnessed. You’ve got the state of Maryland trying to put together evidence that there is no cancer cluster,” says White. “I think it’s all smoke and mirrors to protect their ass. I think there’s a day of reckoning coming because the citizens of Frederick are tired of the song and dance, the pony show.”
Mitchell understands people’s frustration. They want to know if a specific exposure caused the cancer that’s afflicted them, and he can’t say for sure. “Sometimes it might be a family that has a genetic risk. Sometimes it might be that they are people who are very long lived and so they might have died of other causes, but they didn’t. … And after a while nature takes its course—something happens, and oftentimes that’s cancer,” says Mitchell. “At the end of the day, I can’t answer the question, ‘Can you promise me that this wasn’t an environmental exposure?’ What I can say is, this is what we know, this is what we don’t know. And I have to admit the limits of my own knowledge.”
From the front porch of his hilltop house, Bob Roberson can see Area B. The view may be idyllic, but Roberson is worried about what is below the ground, what chemicals may taint the groundwater and make their way into his home’s 500-foot deep well. He says the Army has tested his well water and deemed it safe. Roberson has his doubts, but he drinks it.
“I just hope the day doesn’t come when something down there gets out and we all regret that something wasn’t done before. I firmly believe that’s a possibility, and I don’t want to see that happen,” he says.
He was disheartened by the cluster investigation, but he continues to meet with Brookmyer and other TAC members. They are launching a case control study that compares cancer incidence among former students of an elementary school near Area B with those from another school farther away. He’s not optimistic. “I don’t think there’s ever going to be an answer of, yeah, Detrick caused these cancers. I don’t think that ever can be answered,” Roberson says.
In March 2012, a National Academy of Sciences committee essentially agreed with Roberson in its review of the cluster investigation and a 2009 report on Area B’s groundwater by the Agency for Toxic Substances and Disease Registry. The committee found there was simply not enough historical data on exposures and cancer incidence to determine whether or not people’s health was harmed by toxins from Area B’s groundwater. Given that lack of data, the experts said, additional studies “would not be useful.” DHMH and FCHD, meanwhile, will continue to examine lymphoma and total cancer rates in Frederick as more recent data are added to the Maryland Cancer Registry.
Existing data may not be conclusive for government experts, but personal experience suffices for Bill Krantz. He bitterly recalls his family’s and his neighbors’ losses. “I’m telling you they’ve lost their families and their loved ones and their children. To see this happen, and I did, it would break your heart,” he says.
As he walks among the high grass on the land his family once owned, Krantz mulls over the past and future at the same time. “You can’t bring people back to life, your loved ones. You can’t do that. And how many more are going to die, I don’t know.”