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Feb 3, 2022

Guest host, Dr. John Sweetenham, associate director for Clinical Affairs at UT Southwestern’s Harold C. Simmons Comprehensive Cancer Center, and Dr. Leticia Nogueira, a senior principal scientist in the Surveillance & Health Equity Science Department at the American Cancer Society, discuss the threat of climate change on cancer prevention and control efforts, and how oncologists can mitigate against the risks of climate change.


Dr. John Sweetenham: Hello. I'm John Sweetenham, the associate director for Clinical Affairs at UT Southwestern's Harold C. Simmons Comprehensive Cancer Center and guest host of the ASCO Daily News Podcast. Today, we'll be discussing the impact of climate change on cancer prevention and control efforts in the United States and beyond. Climate change has increased cancer risk through increased exposure to carcinogens after extreme weather events, such as hurricanes and wildfires.  

In addition, these major events disrupt cancer treatment, which has, until recently, poorly defined effects on cancer outcome. Dr. Leticia Nogueira, a senior principal scientist in the Surveillance & Health Equity Science Department at the American Cancer Society joins us today to discuss the threat from climate change and the importance of disaster preparedness and mitigation efforts by cancer centers. Our full disclosures are available in the show notes, and disclosures relating to all episodes of the podcast can be found at Dr. Nogueira, it's great to have you on the podcast today.  

Dr. Leticia Nogueira: Thank you. It's my pleasure to be here.  

Dr. John Sweetenham: Dr. Nogueira, when Hurricane Maria struck Puerto Rico in 2018, it closed several factories that provided life-saving IV fluids to US hospitals, causing shortages in cancer centers nationwide. That's really just one example of how an extreme weather event can compromise health care delivery. How is climate change impacting cancer outcomes today?  

Dr. Leticia Nogueira: Yes. Climate change is impacting not only the frequency, but also the behavior of extreme weather events, which makes it harder for communities and institutions to prepare and respond to these events. And disruptions in the supply chain, as we saw with Hurricane Maria, are just one example how extreme weather events can impact access to cancer care.  

As we saw recently with the tornadoes in Kentucky and the winter storms in Texas, extreme weather events can also damage medical infrastructure. And because cancer diagnosis and treatment can lead to several physical, psychological, and socioeconomic consequences, individuals who have been diagnosed with cancer have increased sensitivity to the health threats of climate change.  

Dr. John Sweetenham: Thanks. And you led a study, which was published in JAMA couple of years ago, that investigated whether hurricane disasters that occurred during the time that patients were receiving radiation therapy for nonsmall cell lung cancer were associated with the poorer outcome in that patient group. Could you comment on that study and, furthermore, maybe comment on whether you think that other modalities of treatment are also likely to be compromised by natural disasters?  

Dr. Leticia Nogueira: Yes, of course. In that study, we chose to focus on radiation therapy because it needs to be given daily, and it's highly dependent on electricity, which is frequently disrupted during hurricanes. But really, any cancer treatment modality is vulnerable to disasters that lead to power outages, supply chain disruptions, or damaged medical infrastructure, and that includes surgery, chemotherapy, immunotherapy, any cancer treatment modality.  

Dr. John Sweetenham: That's for sure. And I guess, also, I'm not sure whether you have any data specifically related to this, but I'd be interested to know if you have any information about the effects of these disasters on screening programs, for example, and the downstream consequences of that. That may be something that still requires study, but we'll be interested in your thoughts on that.  

Dr. Leticia Nogueira: Yes. That is definitely something that still requires studies. We currently don't have any publications evaluating the impact of extreme weather events on access to screening, which is a crucial stage towards the cancer care continuum. So, it starts with cancer prevention. Then, there is cancer screening, diagnosis, treatment, and survivorship. And at all of those stages, individuals have to interact with the health care system. And all of those stages are vulnerable to extreme weather events.  

Dr. John Sweetenham: Yeah. Yeah, I'm sure it's only a matter of time before folks really get into that because, in a way, there are parallels with the COVID-19 situation in terms of delayed screening and the potential effects of that. Some cancer centers have begun now to adapt to climate threats, and a good example of that might be by implementing plans for resilience to future flooding events.  

And I think many of us will vividly remember Hurricane Harvey, which had pretty devastating effects on a number of health care systems and facilities in the Houston area, including, of course, [The University of Texas] MD Anderson Cancer Center. Do you have any thoughts on whether these efforts have been successful and whether you think they're sustainable? And what do you think, for cancer centers in particular, are the most important elements of an effective disaster preparedness plan?  

Dr. Leticia Nogueira: Yes. [The Centers for Medicare & Medicaid Services] (CMS) requires that Medicaid- and Medicare-participating providers and suppliers develop emergency preparedness plans. However, it does not require these plans to be publicly available. So, we can't tell how many cancer treatment centers are compliant.  

Because these emergency preparedness plans are not shared, we also can't evaluate if these efforts have been successful, if they are sustainable, or have a pool of lessons learned from previous efforts to be able to identify the most important elements of an effective disaster preparedness plan. So, unless CMS makes these emergency preparedness plans publicly available, we just won't know.  

Dr. John Sweetenham: So, that's very interesting. So, if I understood you correctly, the disaster preparedness plans that health care institutions have are not publicly available. Is that correct? So, this isn't information which is readily available to researchers or anyone else who might have an interest?  

Dr. Leticia Nogueira: Exactly, yes. And that does not allow us to evaluate how well these are working and let other institutions learn from emergency preparedness plans that have been successful.  

Dr. John Sweetenham: Just carrying on that theme for one moment, are there any national benchmarks or standards that apply in that regard in terms of how those plans should look?  

Dr. Leticia Nogueira: CMS has guidelines about what should be included in those plans. However, there are no available data or guidelines about how each one of those guideline items need to be addressed for the emergency preparedness plan to be considered compliant.  

Dr. John Sweetenham: OK, interesting to know that. Just changing gear a little, one of the things that I have to confess I had not really thought about very much before I read your articles was the fact that the health care industry itself is a significant contributor to greenhouse gas emissions. And what do you think are the interventions that we, as cancer centers, could adopt to address some of the sources of greenhouse gas?  

Dr. Leticia Nogueira: Absolutely. So, all we have to do is look at our mission statements to realize we should be focusing heavily on climate change mitigation efforts. As a recent New England Journal of Medicine publication on decarbonizing the health care system stated, "Nowhere are the effects of climate change manifesting more clearly than in human health." And if we look at the health co-benefits of climate change mitigating efforts, this really is a no-brainer. The same air pollutants that cause the greenhouse effect also cause lung cancer and other health conditions.  

The health care system is the second most energy-intensive industry in the United States. Interventions aimed at improving energy efficiency and increasing use of environmentally responsible energy sources, ideally generated on site, cannot only reduce the environmental impact of cancer centers but also make them more resilient to power outages, which are becoming more frequent. Cancer centers can also switch to purchasing more environmentally responsible pharmaceuticals, medical devices, supplies, and even food. And, of course, they can reevaluate how much waste is generated and how the waste is processed.  

Dr. John Sweetenham: Thanks. Again, just switching gears slightly, it is clear, I think, to anyone who watches these events unfold in the media that, almost inevitably, there are health equity implications associated with climate change. And I know, on that theme, that you have been looking at the disproportionate impact of climate change on communities targeted for marginalization. Can you tell us a little more about this work?  

Dr. Leticia Nogueira: Yes, of course. Structural racism has concentrated in three conditions that determine vulnerability to climate change in communities that have been targeted for marginalization. These conditions are exposure, sensitivity to the health hazards of climate change, and decreased adaptive capacity. And our current project is looking at one extreme weather event at the intersection of all three, heat waves. As you probably know, government-sponsored racially discriminatory policies, such as redline, created a platform for systemic disinvestment in communities with large Black populations, leading to increased risk of exposure to climate hazards.  

Today, we see that historically redlined neighborhoods are disproportionately exposed to intra-urban heat, what is called urban heat islands. So that's the first one, increased exposure. But these racially discriminatory policies also led to uneven resource distribution in these communities, including limited access to full-service grocery stores, green spaces, and a clustering of alcohol outlets and tobacco marketing, leading to increased risk of developing chronic health conditions, which make you more sensitive to the health threats associated with heat waves, similar to how the health consequences of cancer diagnosis and treatment makes patients with cancer more sensitive to the health threats of climate change. So that's the second one, increased sensitivity.  

The last one is adaptive capacity. Material circumstances can restrict access to resources that are necessary to prepare, respond, and cope with climate hazards. Lack of properly insulated housing or access to air conditioning, for example, can limit the ability of individuals from communities targeted for marginalization to cope with heat waves. And individuals diagnosed with cancer are more likely to experience financial hardship. So, there's a parallel or an overlap here too.  

So, in this project, we are looking at the impact of heat waves and survival of individuals who have been diagnosed with cancer in large metropolitan areas of the United States and especially how individuals from communities targeted for marginalization might be more vulnerable.  

Dr. John Sweetenham: Yeah. On that note, as we wind up our discussion today, I mean, clearly, the solutions to the issues that you raise, these huge issues that you raise, are global, although we may begin with our own actions in the US, but also a long term—clearly, climate change—the fixes to climate change are very long term. But do you have thoughts on perhaps what we, in cancer centers in the US, could be doing right now as an initial step? You've mentioned disaster preparedness plans, and I take the point that that would be an important step forward, since it would incorporate reducing gas emissions and so on. But do you have any thoughts about what we should be doing immediately to begin to address this problem within our own centers and our own communities?  

Dr. Leticia Nogueira: Yes, of course. So definitely emergency preparedness plans if you are in a health institution is a good first step. You can also look at the energy sources that are consumed by your institution and your house. Are those environmentally responsible? And the amount of waste that is generated both at your institutions and at your community and how that waste is processed because, frequently, the waste ends up being stored and processed near communities that have been targeted for marginalization, which increases their exposure to health hazards.  

Another thing is to look at your purchasing processes at home and at your institution and how environmentally friendly the supply chain that leads to your consumer purchases might be impacting climate change.  

Dr. John Sweetenham: Well, thank you, Dr. Nogueira, for sharing your insights on this very important local and global problem and highlighting many important interventions for us to consider. It's certainly given us a lot of food for thought. So, thank you for joining us today.  

Dr. Leticia Nogueira: Thank you.  

Dr. John Sweetenham: And thank you to our listeners for your time today. If you enjoyed this episode, please take a moment to rate and review us wherever you get your podcasts.  



Dr. John Sweetenham 

Consulting or Advisory Role: EMA Wellness 


Dr. Leticia Nogueira: None disclosed.  


Disclaimer: The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.