PFAS Information for Clinicians From ATSDR

Introduction

Communities around the U.S. have been concerned about possible health effects from per- and polyfluoroalkyl substances (PFAS) exposure. Individuals with PFAS-related concerns have sought support and guidance from healthcare providers. In response to these concerns, the Agency for Toxic Substances and Disease Registry (ATSDR) has developed many resources directed at PFAS exposures and health and is leading seminal research studies to better understand PFAS health effects.

In early 2024, ATSDR released PFAS Information for Clinicians. The information is intended to enable more productive conversations between clinicians and patients around PFAS exposures and promote informed and individually tailored decisions around PFAS exposure reduction, PFAS blood testing, and clinical management of PFAS exposures (Agency for Toxic Substances and Disease Registry [ATSDR], 2024a). Drawing on PFAS Information for Clinicians, this column reviews PFAS properties and health effects, raises considerations that clinicians might discuss with patients who have PFAS concerns, and explores the contributions that environmental health professionals can make.

PFAS Background

PFAS is a family of thousands of synthetic chemicals that all contain a partially or fully fluorinated carbon chain. Since 1999, the National Health and Nutrition Examination Survey (NHANES) has measured certain PFAS in blood samples from people living in the U.S. Nearly everyone in the U.S. has measurable amounts of PFAS in their blood; however, some communities with PFAS contamination of water or food can have higher average blood PFAS levels than the levels observed in NHANES (ATSDR, 2021, 2022). Communities near facilities that have manufactured, used, or handled PFAS—including airports, factories, military bases, or incinerators—are often where elevated blood PFAS levels are found (ATSDR, 2021, 2022).

In communities affected by PFAS-contaminated water, drinking water can be the main source of PFAS exposure. Food can also be contaminated, including food grown on farms where PFAS-contaminated sewage sludge was applied or fish from PFAS-contaminated water bodies. Ingesting residue or dust from PFAS-containing consumer products or other sources can also result in PFAS exposure. Most PFAS are not volatile, so inhalation is not a typical exposure route. Certain PFAS can transfer in utero through the placenta and breastmilk into infants and children.

The PFAS Toxicological Profile from ATSDR (2021) provides a comprehensive evaluation and summary of toxicological and epidemiological information on PFAS. ATSDR evaluated the available epidemiological data and found that the preponderance of evidence suggested associations between certain PFAS exposure and increases in cholesterol levels, small decreases in birth weights, lower antibody response to vaccines, kidney and testicular cancer, pregnancy-induced hypertension and preeclampsia, and changes in liver enzymes. Although the epidemiological data might provide evidence for an association, observed effects might or might not be clinically relevant depending on the effect size. Causal effects have not yet been established 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 listening 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 cholesterol); 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 treatments are available to remove PFAS from the body. PFAS Information for Clinicians contains example strategies and resources to help assess and reduce exposures (ATSDR, 2024a).

People exposed to PFAS may bring questions to their clinicians about PFAS blood testing 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 exposure 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. Different laboratories use different assays and might test for different 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 benefits to certain individuals. A test result could guide exposure reduction, provide greater recognition of PFAS-associated health effects, and possibly afford psychological relief from knowing one’s PFAS blood level.

In deciding whether additional diagnostic evaluation is warranted, providers can consider 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 unnecessary 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 others 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 effective screening test for kidney cancer, health professional organizations have not recommended screening 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 cancer risk is similar to other known risk factors for kidney cancer that do not generally prompt additional screening, such as smoking (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 urinalysis detects hematuria can create more substantial 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; Medical Panel for the C-8 Class Members, 2013) with risks of urinary tract infection, radiation exposure, kidney injury from contrast, false positive test results, and overdiagnosis.

Involvement of Environmental Health Professionals

Environmental health professionals have valuable expertise that can contribute to identifying, understanding, and reducing PFAS exposures. Environmental health professionals’ knowledge about local environmental PFAS contamination can inform clinical decisions and exposure reduction for patients. Specifically, PFAS known to contaminate food or water supplies might be well known in public health departments but not in healthcare offices. 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 levels 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 certain 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 Education 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. Environmental health professionals can help raise awareness among clinicians about PFAS and this resource, which complements their efforts to offer exposure reduction information to communities. Continued collaborations between public health laboratory scientists, environmental 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 available on the ATSDR website at www.atsdr.cdc.gov/pfas/resources/pfas-information-for-clinicians.html, including a printable version. For PFAS-specific questions, PFAS@cdc.gov.

Biographies

CAPT Arthur Wendel

Linda Hansen

Aaron Bernstein