Preston L. Williams Jr., a lieutenant with the D.C. fire department who advocated for extended cancer coverage, personalized his helmet to include the symbol to promote prostate cancer awareness. (Katherine Frey/The Washington Post)

Sitting before the D.C. Council in a crisp blue dress shirt, Lt. Preston L. Williams Jr. recounted the day he was first diagnosed with the cancer that was slowly killing him.

It seemed to be “the longest day of my life,” when “time stood still,” the firefighter said in advocating for new health and retirement benefits he wouldn’t live to see.

Over a five-year period, Williams was diagnosed three times with prostate cancer. He said he believed he was sickened by the fumes and chemicals that leached into his skin and seeped into his lungs during his more than 20 years battling fires.

He testified in 2012. He died in February 2016, only months before the nation’s capital joined a growing number of jurisdictions stating that because certain cancers in firefighters occur at such high rates, they should be presumed to come from on-the-job exposure.

Laws in nearly 40 states, including Maryland and Virginia, have expanded medical, workers’ compensation and disability coverage for such cancer cases, and departments across the country are revamping training and how they handle gear to try to reduce risks.

“This is the hidden hazard and the silent killer in the fire service,” said Matthew Miller, a Prince George’s County firefighter and cancer survivor who is developing cancer-prevention and safety reforms at his department. “We’re seeing just how bad the problem is.”

The memorial booklet for Preston L. Williams Jr. shows him in his dress uniform and the firehouse where he worked draped in black. (Katherine Frey/The Washington Post)

This month, a bill to create a national registry of firefighters diagnosed with cancer was introduced with bipartisan support to help track and research the issue, and in January, Ohio’s governor signed into law a measure extending firefighters’ coverage for workplace cancers.

In October, the National Fallen Firefighters Foundation added names of firefighters who died of cancer to its memorial honoring line-of-duty deaths for the first time since the foundation’s creation in 1992, with 24 cancer deaths among the 112 deaths in 2015.

Yet with awareness comes anxiety from municipal governments, which are concerned about setting a precedent for other public employees and triggering spiraling costs.

The National Council on Compensation Insurance, which tracks workers’ comp proposals and legislation nationally, counted almost 90 first-responder cancer presumption bills in 2016. That number is already at 70 in the first six weeks of 2017.

Protracted legal battles have been fought to establish the workplace links to a cancer or expand the cancers covered as occupational hazards. This month, the Washington state Supreme Court sided with two firefighters whose insurance claims about melanoma had been denied as not tied to their jobs.

Cancer studies in emergency responders began in earnest after the Ground Zero cleanup after the 9/11 attacks in New York.

In 2015, the Centers for Disease Control and Prevention released the final results of what is currently the largest study of cancer risk among career firefighters ever conducted in the United States. The study of about 30,000 firefighters over a 60-year span showed that compared with the general population, firefighters on average are at higher risk for certain kinds of cancer — mainly oral, digestive, respiratory, genital and urinary cancers.

The CDC also found that firefighters who were exposed to more fires than their peers experienced more instances of lung cancer and leukemia, said Robert Daniels, the principal investigator of the project and a research epidemiologist at the National Institute for Occupational Safety and Health.

The risks come on many fronts, research has indicated.

Fires carry soot and smoke from high-toxin synthetic material and electronics. Exhaust fumes from diesel fire engines present a hazard. The protective gear that insulates firefighters from heat and flames also raises body temperatures, opening pores to absorb chemicals.

Concerned with the results of the CDC study — and similar research coming out of Norway and Australia — fire departments and firefighters unions nationwide revamped safety policies.

“Smoke on your gear and smoke on your helmet used to be a sign that you’re an experienced firefighter,” said Lt. Sarah Marchegiani of the Arlington County Fire Department. “But now people just recognize it’s a hazard and not worth it.”

Tubes are hooked to fire engine exhaust pipes in District stations to vent fumes outside, said Kenneth Crosswhite, a deputy fire chief. Heavy protective jackets, helmets and pants are washed after every call, he said, and the city is looking to contract for professional decontamination services.

Within the next few months, Prince George’s County plans to equip firefighters with a second set of personal protective equipment so fresh gear will always be on hand.

Amy Dant, a firefighter in Montgomery County, carries her gear to a locker in Rockville. (Bonnie Jo Mount/The Washington Post)

Last year, Montgomery County issued an order that firefighters keep wearing protective breathing gear even after flames are out as they open walls and ceilings and search for leftover hot spots. The order cited “the growing scientific information linking cancer to firefighting.”

The county also has low-tech strategies, said Jill Captain, a physician for Montgomery’s Fire and Rescue Occupational Medical Services. Among those, firetrucks carry plenty of baby wipes for firefighters to use to clean their skin after a fire is out but while they are still at a scene.

Political fights over cost

At the same 2012 hearing where Williams asked that benefits be expanded, a city official warned about costs and untangling whether lifestyle or family history might have determined a firefighter’s path to cancer. It was the kind of standoff repeated across the country since.

Paul Quander, then the deputy mayor for public safety, also testified that many firefighters have second jobs, some at rural fire departments that might not practice the same standards for decontamination.

“We’re going to be responsible for future health-care costs that might not be due to working for the District of Columbia,” Quander said.

Local governments often are “vocal opponents because it is a cost issue” and “they have to be financially solvent,” said Peter Burton of the National Council on Compensation Insurance, who added that the cancer presumption laws are among the top issues his organization has been monitoring since 2016.

A single leukemia claim could cost $3 million over an individual’s lifetime, said Alexandria Deputy Fire Chief Jeffrey Merryman, who runs health, safety and risk management for his fire department. One firefighter there has received benefits under the state’s presumptive cancer law, and two others have the disease.

In Prince George’s County, 29 retired and sworn firefighters have filed occupational cancer claims since 2012, including Lt. Chris Hill, who died last year of brain cancer.

“It was really scary,” said his wife, Jennifer Hill. “Not only was he fighting this battle he’s never going to win . . . but he was unsure about his retirement and whether his family would have enough to survive” after he died.

Municipalities fear funding individuals who may have developed cancer regardless of whether they were firefighters, according to a report produced for the National League of Cities in 2009.

Across the country, firefighters suffering from cancer and their families have engaged in contentious legal fights with local governments questioning who should be on the hook financially. In Philadelphia, a three-judge panel in October determined a retired firefighter could not claim workers’ comp benefits for his prostate cancer because he could not prove that he got sick from exposure on the job.

Amy Dant, a master firefighter for Montgomery County, was diagnosed with thyroid cancer in 2012. There is a keen awareness of the cancer risks posed by the job, she said. (Bonnie Jo Mount/Washington Post)

Amy Dant became a volunteer firefighter in Montgomery in 1995, when she was 19, and a paid firefighter in 2002. A routine checkup at the county’s medical services unit detected a problem with her thyroid that was diagnosed in 2012 as cancer.

Her type of cancer was not one that the state’s workers’ compensation program would presumptively say was a result of her job, Dant said, leaving her and her union to battle for benefits she ultimately received.

Around fire stations, there is keen awareness of cancer risks on the job, she said.

“Today’s attitude is totally different,” Dant said.

The nonprofit Firefighter Cancer Support Network said it has provided assistance and one-on-one mentoring to thousands of firefighters and their families since the organization was started in 2005. But because awareness is fairly new, it is difficult to determine exactly how many have died or been diagnosed with work-related cancer, said Bryan Frieders, president of the network and a deputy chief with the fire department in Pasadena, Calif.

In the District, Williams, who grew up in Northeast Washington, became a voice for firefighters with cancer.

Williams helped in New York after the 2001 terrorist attacks. A restaurant owner whose basement he cleaned gave him a bottle of wine, but Williams couldn’t wash off the soot when he took it home, recalled his widow, Katrina Williams.

He then realized the hazards of his job, and it prompted a family rule that is still enforced: no shoes in the house.

Less than 16 years into the only job he ever cared about, Williams, then 40, discovered he had cancer. It went into remission, then returned, then went into remission again only to return once more.

Legislation granting D.C. firefighters full early retirement and coverage for eight types of cancer — leukemia, breast, throat, prostate, ovarian, testicular, pancreatic and rectal — passed the council in 2012, but it took until 2016 to get it funded, with up to $7 million a year authorized. Williams died before the money for the bill came through.

Katrina Williams pauses as she talks about her late husband, Preston L. Williams Jr., who died just over a year ago. (Katherine Frey/The Washington Post)

Katrina Williams said her husband was heartened when the cancer bill passed but frustrated by the lengthy refusal to fund it, leaving him and others without benefits he had championed.

She still has the dingy white helmet her husband wore, adorned with two small blue ribbons for prostate cancer awareness and covered with soot from his final fire.

“We have to pay a debt,” Katrina Williams said, “to the people who save our lives.”

Dan Morse and Mandy McLaren contributed to this report.