An Action Plan for Environmentally Sustainable Cancer Care

The effects of climate change on human health are considerable and wide-ranging. Severe weather events, temperature and precipitation extremes, sea-level rise, and increased pollution directly manifest in higher rates of cancer, infectious diseases, cardio-pulmonary disorders, and a variety of other illnesses.^1,2 Indirectly, climate change can worsen population health by increasing rates of poverty and food insecurity while damaging infrastructure and economic stability.

In the United States, many economic sectors have recognized their role in climate change and are reducing their greenhouse gas (GHG) emissions by shifting toward environmentally sustainable and resilient models that reduce carbon emissions, mitigate future climate impact, and are durable against the effects of climate change. Although the health care establishment has begun to acknowledge the health consequences of climate change,¹ it has yet to fully appreciate its role. Collectively, US health care produces approximately 10% of national GHG emissions, an increase of 28% over the past decade and greater than the whole United Kingdom.^1,2 The human cost of these emissions is substantial. Indeed, the 655 million metric tons of carbon dioxide equivalents produced by US health care translates into an annual loss of 470 000 disability-adjusted life-years,² commensurate with the annual loss of life in the United States due to leukemia or prostate cancer.³

Such assessments provide a clear basis for why the US health care system must direct significant resources to evaluate and improve its role in climate change. Within US health care, cancer clinicians have unique reasons and means to lead this effort. In this Viewpoint, we discuss these distinctive factors and provide an outline to create environmentally sustainable cancer care.

Motivations for Environmentally Sustainable Oncology Practice

There are many reasons why the US oncology community should lead the way in creating environmentally sustainable and resilient medical practice. First, oncology patients are particularly vulnerable to the effects of climate change. Increases in temperature, infectious diseases, pollution, and malnourishment each may have an outsized effect on those with compromised immunity and comorbid illnesses such as cancer.¹ The effects of extreme weather events also subject those with severe medical conditions, such as patients with cancer, to the most harm.

In addition, as patients are living longer both with their cancer and as survivors, oncology is necessarily broadening its focus to recognize previously over-looked patient health risks. Two such risks are financial toxicity and climate change, which can work together against patient health: financial toxicity increases rates of hardship and poverty,⁴ which can make affected persons less resilient against the effects of climate change. Simultaneously, climate change increases financial hardship, which is associated with higher rates of financial toxicity.^1,4 As we seek to minimize harms from oncology treatments, we must also recognize their unintended consequences, such as their environmental effects.

Beyond the direct benefits to patients with cancer, there are other reasons why oncology should lead the movement toward environmentally sustainable health care. The largest proportions of health care–related GHG emissions come from hospitals, physician services, and prescription medications.^1,2 These areas are central to cancer care and suggest that environmental improvements in oncology care may meaningfully affect overall health care emissions. Oncology care also exists at the intersection of medical, surgical, and radiation therapeutics. Therefore, the creation of an environmentally sustainable cancer care model would serve as an archetype for virtually any other medical specialty. In our view, oncology maintains a unique position of trust while being recognized as a leading force in scientific investigation. By positioning ourselves at the forefront of sustainable practice, we can have an outsized, positive effect on all of health care.

Creating Climate-Smart Practice

The path toward environmentally sustainable and resilient cancer care would begin by evaluating current practices. This involves using an established approach to determine GHG emissions across oncology processes and settings, evaluating the climate-related understanding and experiences of oncology patients and clinicians, and assessing the climate effects of oncologic health care policy. This comprehensive method would establish a baseline for improvement, highlight at-risk areas, and create short- and long-term goals for minimizing oncology’s contribution to climate change.

Determining the climate effects of oncology care would require a systematic assessment of GHG emissions from cancer research and practice. The term given to these analyses is the life-cycle assessment,⁵ in which a “life-cycle” indicates all activities performed across a process or product, from raw materials extraction until disposal. The criterion standard for many is the Greenhouse Gas Protocol,^1,5 an established and validated tool for measurement, management, and reporting of GHG emissions that provides benchmarks for comparisons across settings.¹

In the Greenhouse Gas Protocol, systems-level assessments can provide guidance for policy change and determine variability across regions, states, types of institutions, and models of oncology care. The protocol can also be tailored for smaller scales, such as an individual health care organization, hospital, or clinic. After establishing baseline GHG emissions, this framework can be used serially to assess new components and compare potential modifications. In addition to emissions reduction—and health promotion—such environmental assessments frequently provide fiscal benefits.^1,5 Unlike other cost-savings measures, which can reduce services or cause treatment delays, these savings are more ethically grounded and, in our view, more likely to collaboratively improve health.

Oncology-specific climate assessments include evaluating the environmental effects of oral chemotherapy waste, the potential benefits of replacing single-use plastics in cancer clinics, and the relative environmental consequences of different therapies. Cancer therapeutics are currently evaluated in their narrowest context: they only account for direct benefits and harms to treated patients. They do not consider the human harm potentiated by a treatment’s effect on the environment, nor do they place value on the health of the environment itself. While exchanging patient benefit for that of the environment may be a moral overreach for many, a middle ground that considers downstream human harms in addition to up-front toxicity is reasonable. Dilemmas will undoubtedly arise when treatment benefits and environment-induced population harms appear similar. The first step to addressing these problems is to recognize that these other harms exist and to perform research to quantify them.

These assessments, while essential, cannot create environmentally sustainable and resilient oncology practice without the support of patients and clinicians. This process should be a non-partisan effort and begins by objectively assessing climate-related awareness, opinions, and concerns. Akin to established methods of evidence-based treatment recommendation, the life-cycle assessment can help ascertain where knowledge gaps and misinformation exist and direct efforts for oncologist education and patient counseling. Much like cancer treatment, creating environmentally sustainable oncology care can be a process shared between patients and clinicians, relying on practitioners’ understanding of scientific evidence, best practices, and the input of their patients to collaboratively improve health. Although top-down policy will also be required, a grassroots effort will be key to creating a culture of evidence-based environmental sustainability.

Conclusions

Health care in the United States is a resource-intensive sector with environmentally burdensome processes. While climate change and its effects on human health are well studied, the effects of health care—and specifically cancer treatment—on the climate are not. For our oncology community to maintain its position at the forefront of medicine, we need to ensure that the treatments and facilities we provide encompass a holistic view of health care. Only by assessing and minimizing the environmental impact of the care we provide can we ensure that our overall goal to reduce all of cancer’s many burdens can be fully met.