In part one of a two-part interview from ILCN’s series on climate change and the environment, Puneeth Iyengar, MD, PhD, and Edward Christopher Dee, MD, explore the environmental consequences of radiation therapy and other elements of cancer care. In part two, Dr. Iyengar, who is a radiation oncologist at Memorial Sloan Kettering Cancer Center (MSKCC), New York, and Dr. Dee, a third-year resident at MSKCC, will discuss how radiation schedules could be optimized to reduce environmental impacts without compromising efficacy or increasing toxicity.
ILCN: Can you describe the current clinical landscape of radiation therapy in cancer treatment?
Dr. Iyengar: Radiation has been used for oncologic management of cancers for more than 100 years, so it’s probably the oldest cancer therapy. Historically, radiation was delivered in small, discrete increments, because large doses can have profound side effects on normal tissues when delivered in fewer treatments. We began using small amounts of radiation daily and were able to spare the side effects associated with the normal tissues.
ILCN: Recent research has been revealing the environmental impacts of healthcare, including radiation therapy.1 How does radiation therapy contribute to healthcare-related carbon dioxide (CO2) emissions?
Dr. Iyengar: At the end of the day, this isn’t something our field talks about as much. That’s largely because patients with cancer need treatment, surgery, infusions, and radiation. Every trip a patient makes to receive treatment contributes to emissions, which is not ideal for the environment. Home-based infusions may be beneficial for reducing environmental impact and improving quality of life. Saving travel time is also extremely valuable for the patient.
Radiation is a little more complicated though. The radiation machines do use a lot of energy, but that is used to create the energy that is directed toward treating cancerous tumors. The machines are very large. You can’t have one at home, so patients must travel to these facilities to access therapy.
Dr. Dee: I think that’s the case with any medical treatment. They’re all associated with some sort of environmental cost. I think about the amount of plastic used in the operating room. I think the challenge there is how can we provide the same level of care while minimizing unnecessary waste?
I don’t think the implication that could theoretically be taken from that is that we should give less treatment because it’s not environmentally friendly. As physicians and oncologists, we must be patient-centric first in our approach.
ILCN: How does radiotherapy compare with other treatments from an environmental standpoint?
Dr. Iyengar: In terms of modality, surgery uses a lot of single-use plastics and disposable tools. Additionally, non-disposable tools such as scalpels must be sterilized, which requires heating and has an environmental impact. The disposal process for single-use items also requires energy and contributes to emissions. Systemic therapy infusion machines also use disposable needles and syringes that are used once.
A radiation machine can be used over and over again. I would say that radiation oncology is probably a cleaner therapy from that perspective. Radiation may have certain impacts on the environment, but, overall, it is probably less harmful than other options.
ILCN: How can oncologists or clinicians address environmental considerations with patients while ensuring safe and effective treatment?
Dr. Iyengar: That’s an incredibly complicated question. Most patients aren’t as concerned with environmental issues in that moment. Environmental issues go hand in hand with cost complexities and toxicities, but patients may not want to hear that either. They’ve paid into their insurance plans for years and want to receive the best care.
I think we should acknowledge that financial and environmental toxicities are a significant part of medical care. At the end of the day, we have to be driven by what is clinically best for the patient. If two equal treatments are equally effective, then you could raise other considerations. For instance, it’s not unreasonable to bring up environmental considerations with patients who are concerned about sustainability, if your out-of-pocket cost isn’t as significant, and the outcome will be the same.
Dr. Dee: I agree. When somebody is facing a cancer diagnosis, their primary concern is how do I get rid of this? Thinking about the 100-year sequelae of their treatment is probably the last thing on each patient’s mind.
I do think that there is something to be said for how we design innovations in our field. For example, when designing a surgical device, how do you package it? Do you need all the fancy packaging to keep everything sterile?
A lot of these devices come with unnecessary packaging that are thrown away. What do we use with these extra plastics, syringes, and other items that go into the treatment? The same can be said for drugs in medical oncology: How do we dispose of these?
I think, if anything, environmental sustainability could be more of an upstream approach that is taken into consideration when we design our technologies and trials.
Those are small but consequential considerations.
Reference
- 1. Lichter KE, Charbonneau K, Lewy JR, et al. Quantification of the environmental impact of radiotherapy and associated secondary human health effects: a multi-institutional retrospective analysis and simulation. Lancet Oncol. 2024;25(6):790-801. doi:10.1016/S1470-2045(24)00148-7
