PROSTATE CANCER Addressing the Intersection of Climate Change and Cancer: A Roadmap to Action for Urological Care Providers

By: Alexander P. Cole, MD, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, Center for Surgery and Public Health, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts; Hari S. Iyer, ScD, MPH, Rutgers Cancer Institute of New Jersey, New Brunswick, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey | Posted on: 19 Sep 2023

It is difficult to overstate the impacts of anthropogenic climate change on natural ecosystems, including direct and indirect influences on human health.1,2 As members of a comparatively small surgical subspeciality, urologists may feel isolated and limited in their ability to confront the large-scale public health challenges posed by climate change. Nonetheless, there is growing evidence for links between climate change, environmental health, and numerous urological diseases.3-5 A recently convened working group at the National Cancer Institute discussed challenges and potential solutions to climate related impacts on cancer care and outcomes.6 We believe that the urological community must also adapt and identify ways our specialty can help meet these challenges.

Our objectives here are to (1) describe the links between planetary health (the health of humans and the natural systems that support our health), climate change, and cancer, (2) describe the challenges facing the provision of prostate cancer care in the era of anthropogenic climate change, and (3) outline steps to address and mitigate the major impending climate change–related challenges of urological cancer care.

Impacts of Climate Change on Urological Patient Outcomes

Climate-related changes have well-known impacts on natural ecosystems, which may increase exposure to environmental risk factors that influence urological cancer incidence (see Figure).7 Extreme weather events (eg, flooding, hurricanes) can inundate sites contaminated by pollutants with water, spreading carcinogenic chemicals into drinking water sources and agricultural sites.8-10 Endocrine-disrupting chemicals which are widely used in industrial manufacturing, such as per- and polyfluoroalkyl substances, have been linked with several cancers, including prostate, testes, and kidney.11

Figure. Hypothesized pathways linking climate change to urological patient outcomes.

Higher prostate cancer incidence and worse outcomes have been observed in regions with lower overall environmental quality (eg, higher pollution exposure, social and racial disadvantage).12,13 Regarding heat and sun exposure, prostate cancer risk may be higher among those with frequent lifetime sunburns (OR 4.30, 95% CI 1.7-11.2) and higher general sun exposure in adulthood per week (OR 2.03, 95% CI 1.09-3.81).14

Emerging research suggests that access to green spaces (such as parks and tree cover) may influence health outcomes, including prostate and other cancers. Changes in biodiversity, habitat loss, and reductions in greenspace could lead to poorer survival in urological cancer patients. Men with lower access to greenspace may experience exacerbation of carcinogenic inflammatory pathways, higher prevalence of inflammation-related pathology in prostate tumors, and higher prostate cancer–specific mortality.15-17

Climate Change, Extreme Weather, and Impacts on the Health System

Climate-related natural disasters such as hurricanes, wildfires, and other extreme weather events will be far more common in the warming planet.18 Alongside direct health impacts of these events (eg, heat stroke, dehydration, drowning), extreme weather events can indirectly impact patient outcomes through disruptions to care delivery.19 Both Hurricane Katrina and Hurricane Sandy led to hospital closures, lack of staffing, medication shortages, and interruptions of coordinated cancer care.20 Recent hurricanes in Puerto Rico caused shortages of IV fluids, which impacted clinical care thousands of miles away from the site of the hurricane.21,22 Rural health centers—often the sole option for their patients—are already facing high rates of closures and loss of the rural physician workforce.23,24 These same hospitals are already often underresourced, and therefore may be particularly susceptible to climate-related disruptions which could accelerate small hospital closures.25

What Can We Do as Clinicians and Researchers?

Tying urological oncology to planetary health co-benefits

Many health behavioral change recommendations also mitigate adverse impacts of climate change on natural systems. Encouraging plant-based diets is one such strategy of particular relevance to urologists.5,26 Diets high in meat and low in fruits and vegetables are associated with greater risk of the top 3 urological malignancies including prostate, bladder, and renal cancer.27-29 Meat-heavy diets are a risk factor for stone disease; reducing dietary meat consumption could offer relief to those with recurrent urolithiasis.30

On a global scale, livestock farming is a major contributor to greenhouse gases, which, in turn, drives more extreme weather and heat waves (with many of the downstream effects listed above). At the societal level, animal agriculture drives ecosystem-level changes, including loss of biodiversity and reductions in greenspace, which, as noted earlier, may increase risk of prostate cancer–related mortality.16 Animal agriculture also contributes to antibiotic resistance: of the over 30,000,000 pounds of antibiotics used in the United States, 80% are in livestock farming. Of these, most end up in soil and water where they encourage antibiotic resistance: a significant source of sepsis after prostate biopsies.31

Numerous companies (Impossible, Beyond) are bringing plant-based meat substitutes to market, and tasty, nutritious cuisines that offer health benefits are already available (for example, the world-renowned “Mediterranean Diet” is associated with greenhouse gas reductions that closely align with targets).32 Reducing environmental impact does not require 100% adoption of plant-based diets: researchers from the UK estimated that merely optimizing diets to comply with the WHO recommendations (including decreasing red meat consumption by 38% and increasing nonstarchy vegetables by 56.4% for men) would lead to a 17% reduction in greenhouse gas emissions from that country.33

Reduce waste and advocate for a sustainable health delivery system

The US health system is the second most carbon-intensive industry in the United States.34 Encouraging hospitals to reduce their energy consumption will decrease fossil fuel usage while potentially benefitting patients and the health system as a whole. Strategies to increase efficiency by eliminating unnecessary testing, reducing costly and nonindicated services, reducing administrative burden, and efficiently sharing information all have the potential to streamline care while improving quality and sustainability.35

Many physicians are respected community leaders. An example of this is physicians who are partners in group practices or who serve on hospital leadership boards. Leveraging trust from community members to advocate for policies that offer cancer and climate co-benefits is one way for physicians to shape values in this critical area.

Introducing sustainability protocols into health care delivery could address a perennial challenge: wasteful spending on health care in the United States. Our team has identified evidence for unwarranted variability and high costs in prostate cancer care.36,37 While much work in these areas has emphasized the benefits to the health system of reducing the costs of prostate cancer care, the very factors that contribute to high costs (administrative spending, variability in procedures, failures of care delivery, and low-value interventions) also contribute significant energy and carbon costs.

Building sustainable health care systems does not always require sacrifices in efficiency, and may more closely align with goals already held by physicians. In the clinical sphere, proposals that encourage faster operating room turnovers, increased use of virtual health visits, and reduction in administrative workload are likely to be popular with the physician work force and can reduce carbon emissions. For, example, a recent analysis found that transitioning to telehealth visits could result in a significant 40- to 70-fold decrease in carbon emissions while increasing patient and provider satisfaction.38

Build a climate-adaptive health system

Physician leaders must respond to growing climate change–imposed stresses to the health system. The Centers for Medicaid and Medicare Services currently requires that providers have an emergency preparedness plan.6,39 Unfortunately, these plans are not publicly available and although the body of literature is growing, limited data are available to understand disruptions in cancer care after natural disasters and how to respond to them.40 A recent report of National Cancer Institute–designated cancer centers revealed that only 17 (24%) provided emergency preparedness information regarding climate-driven disasters on their public websites.41 Climate disasters may force patients and treatment to be moved to different locations, with disruptions lasting days or months. Additional recommendations include having a communication plan so that patients know who to contact following a disaster, sharing plans across state lines and across institutions, and providing a centralized system for cancer care in case of emergencies.

Conclusions and Future Directions

In closing, we argue for a urology-focused research agenda to clarify links between cancer and climate change (see Figure). The medical and scientific community can promote research into these key areas and support funding initiatives. Public health scientists have responded to major public health challenges from AIDS to smoking. We must remain confident that our commitment to our patients and communities, along with our expertise in caring for patients and understanding the causes of their illnesses, will allow us to generate the knowledge, policies, and adaptations needed to mitigate the harms of climate change.

We encourage the urological community to reflect on the changes we must make to our behaviors, clinical practices, and health system in the era of climate change and to identify strategies to meet these challenges for us and our patients.

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