lower antibody response to vaccines, kidney and testicular cancer, pregnancy-induced hypertension and preeclampsia, and changes in liver enzymes. Although the epidemiologi- cal data might provide evidence for an asso- ciation, observed eects might or might not be clinically relevant depending on the eect size. Causal eects have not yet been estab- lished for PFAS exposures. Engaging With Patients About PFAS Concerns Clinicians can help patients with concerns about exposure to PFAS or other potentially harmful exposures through actively listen- ing and providing practical advice. Patients with concerns about PFAS can present with a known exposure and be asymptomatic; they could have signs, symptoms, or a diagnosis of a disease or health issue (e.g., high choles- terol); or they might live in a community with exposure concerns but not know if they were exposed. Clinicians can help patients identify and reduce exposures and promote standard age-appropriate preventive care measures. Unfortunately, no approved medical treat- ments are available to remove PFAS from the body. PFAS Information for Clinicians con- tains example strategies and resources to help assess and reduce exposures (ATSDR, 2024a). People exposed to PFAS may bring ques- tions to their clinicians about PFAS blood test- ing and clinical management based on PFAS blood levels. When approaching the decision to do a blood test for PFAS, ATSDR suggests that providers consider an individual’s expo- sure history; results of PFAS testing from the patient’s water supply, food sources, or other exposure routes; and whether blood test results could inform exposure reduction and health promotion. Dierent laboratories use dierent assays and might test for dierent PFAS. In situations where a community’s water or food supply are known to be contaminated by specific PFAS, clinicians can check if these PFAS are included in available laboratory tests. While PFAS blood levels do not predict future health outcomes, they might provide ben- efits to certain individuals. A test result could guide exposure reduction, provide greater recognition of PFAS-associated health eects, and possibly aord psychological relief from knowing one’s PFAS blood level. In deciding whether additional diagnostic evaluation is warranted, providers can con-
sider factors unique to the patient, including the patient’s risk for disease, whether health screening beyond the usual standards of care is appropriate, and the potential for unneces- sary further testing and treatment related to false positives from additional screening tests. While some screening protocols related to PFAS-associated health concerns are part of standard practice (e.g., for cholesterol, blood pressure in pregnancy), screening for oth- ers are not. Kidney cancer provides a case in point. Kidney cancer can cause (but does not always cause) blood in urine (i.e., hematuria). Urinalysis, an inexpensive and easy test to conduct, can detect hematuria. Many adults, however, will have hematuria on urinalysis due to benign causes, including menstruation, exercise, and urinary tract infections (Sharp et al., 2013). In the absence of an eective screen- ing test for kidney cancer, health professional organizations have not recommended screen- ing for kidney cancer, except in patients with a heritable syndrome that markedly increases the risk of kidney cancer (American Cancer Society, 2020; Gray & Harris, 2019). In epidemiologic studies examining PFAS and kidney cancer (Barry et al., 2013; Raleigh et al., 2014; Shearer et al., 2020; Steenland & Woskie, 2012; Vieira et al., 2013), the magnitude of the estimated can- cer risk is similar to other known risk fac- tors for kidney cancer that do not generally prompt additional screening, such as smok- ing (Cumberbatch et al., 2016), obesity (Adams et al., 2008), hypertension (Seretis et al., 2019), and male sex (Scelo & Larose, 2018; Siegel et al., 2022). While a urinalysis has minimal risk of harm, further evaluation for kidney cancer after a screening urinaly- sis detects hematuria can create more sub- stantial risk. The next steps might include, depending on risk factors, cystoscopy and an ultrasound of the kidneys, or a CT scan with contrast, (Barocas et al., 2020; Medi- cal Panel for the C-8 Class Members, 2013) with risks of urinary tract infection, radia- tion exposure, kidney injury from contrast, false positive test results, and overdiagnosis. Involvement of Environmental Health Professionals Environmental health professionals have valu- able expertise that can contribute to identify- ing, understanding, and reducing PFAS expo- sures. Environmental health professionals’
knowledge about local environmental PFAS contamination can inform clinical decisions and exposure reduction for patients. Spe- cifically, PFAS known to contaminate food or water supplies might be well known in pub- lic health departments but not in healthcare oces. Bridging this knowledge gap between environmental health and clinical practice can inform PFAS exposure reduction, including through guidance that environmental health professionals can provide on testing PFAS lev- els in private well water. Environmental health professionals can also share PFAS Information for Clinicians and other PFAS resources with clinicians. The PFAS Blood Level Estimation Tool (ATSDR, 2023) estimates blood PFAS levels based on drinking water exposure, which might be useful in cer- tain circumstances. The PFAS and Your Health website (ATSDR, 2024b) provides accessible information about PFAS and health, shares PFAS activities within ATSDR, and includes links to other PFAS resources. More broadly, the Environmental Health and Medicine Edu- cation website (ATSDR, 2018) provides an array of materials that can assist healthcare professionals with addressing patient concerns about environmental contaminants. Conclusion PFAS Information for Clinicians was developed to assist clinicians in engaging patients to help them understand PFAS exposures, develop exposure reduction strategies, and navigate clinical management decisions. Environmen- tal health professionals can help raise aware- ness among clinicians about PFAS and this resource, which complements their eorts to oer exposure reduction information to com- munities. Continued collaborations between public health laboratory scientists, environ- mental health professionals, and clinicians will remain essential to continued improvement in the prevention of PFAS-associated health risks. Research on PFAS and health continues to be done and provides greater insights into what health risks might occur with PFAS exposure. ATSDR will continue to update information for clinicians as the science on PFAS evolves. PFAS Information for Clinicians is avail- able on the ATSDR website at www.atsdr. cdc.gov/pfas/resources/pfas-information-for- clinicians.html, including a printable ver- sion. For PFAS-specific questions, email PFAS@cdc.gov.
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June 2024 • Journal of Environmental Health
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