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Cancer surgery causes climate change – Is it up because of it?


I can’t. I can’t.

From the Journal of Clinical Oncology.

In April 2021, President Biden pledged to drastically reduce greenhouse gas (GHG) emissions by 50% from 2005 levels by 2030. This ambitious agenda is certain to require significant changes. across the entire U.S. economy, including the healthcare sector. According to previous studies, the health care industry accounts for about 8.5% of total GHG emissions in the United States (the most in the world in per capita and absolute terms),first,2 and in recent years the delivery of cancer care has increasingly been included in decarbonization discussions.3,4 We believe that oncology surgeons are an important community in making related priorities for two reasons. First, due to the prevalence of consumable, heating, ventilating and air-conditioning (HVAC) systems, volatile anesthetic gases, and sterilization procedures, operating rooms (ORs) account for one in 70 % of hospital waste and three to six times more carbon use than a hospital as a whole, according to a 2017 life cycle analysis.57 In 2014, the anesthetic gases hydrofluorocarbon and chlorofluorocarbon emitted the equivalent of 3 million tons of carbon dioxide, with 80% of the emissions coming from desflurane alone.8,9 Second, carbon-intensive minimally invasive surgical approaches, i.e. laparoscopic and robot-assisted, have become the mainstay in the treatment of some cancers, such as uterine, for example. , pharynx, colon and prostate.ten15 For example, robotic hysterectomy is associated with a carbon footprint of 814 KgCO2e, which corresponds to a journey of 2,273 miles in a gasoline car.16 This is striking because the adoption of robot-assisted processes increased eightfold between 2012 and 2018.11 and overall minimally invasive surgery in the United States in relation to total CO2 emits 355,924 tonnes per year, making it the 198th national ranking among UN member states.17

https://ascopubs.org/doi/full/10.1200/JCO.21.02581

Here is the press release for this “publication”.

Two surgeons in training suggest some sustainable solutions to their energy-intensive discipline.

Peer-reviewed publications

MICHIGAN MEDICINE – UNIVERSITY OF MICHIGAN

Surgery matters for climate change
PICTURE DESCRIPTION: OPERATION ROOM PRODUCES 70% OF HOSPITAL’S Emissions, BUT TWO SURGEONS-IN-TRAINING HAS COME WITH SOLUTIONS TO REDUCE THAT NUMBER. see more
CREDIT: JACOB DWYER / MICHIGAN MEDICINE

In April 2021, during the Climate Leaders Summit, President Biden announced his goal of drastically reducing U.S. greenhouse gas emissions by 2030.

Victor Agbafe watching the address on TV. The University of Michigan Medical School student, who is also studying law at Yale, immediately texted several of his mentors, including Michigan Medicine general plastic surgery resident. Nicholas Berlin, MD, MPH, MS

The question that emerges from their messages is an important one: What role can the health community, which accounts for about 8.5% of U.S. greenhouse gas emissions, play in efforts to reduce greenhouse gas emissions? mitigating this climate change?

A year later, research led by Agbafe and Berlin pointed to some of the answers. Their paper describes how surgery, especially cancer surgery, contributes to climate change and suggests a number of solutions to combat the problem, from reducing waste to rethinking surgical care.

“Overall, these ideas are good for our planet,” Agbafe said. “But also unfortunately, surgery plays a disproportionate role in the carbon output and waste we create in medicine.”

Operating rooms are a huge producer of greenhouse gases for hospitals, accounting for 70% of waste and generating 3 to 6 times more carbon than the rest of the medical systems.

Berlin notes that cancer care is an obvious target for greener efforts in surgery, because it often involves a high level of care over a short period of time.

Additionally, energy-intensive minimally invasive surgeries, including robotic-assisted surgeries, have become common treatments for cancers ranging from colorectal and uterine to head and neck cancers. For example, a robot-assisted hysterectomy will produce as much carbon as driving more than 2,200 miles – the equivalent of a road trip from Ann Arbor, Mich., to Los Angeles.

“If we can reduce greenhouse gas production, we have an opportunity to extend patient life and expand access to timely care,” says Agbafe. “And we think it’s really important that the surgical community be proactive at that table.”

What else?

Agbafe says one of the most likely changes to be made in this area is to reduce waste.

This can be as simple as ensuring that anything thrown away before or during surgery is properly sorted and labeled as it is estimated that more than 90% of the waste OR does not meet the required standards for the type of trash that it ends up in. (The red waste bag in the ORs is only for items that have been in contact with bodily fluids, and disposal is much more expensive than clear disposal bags.)

Hospitals may also consider switching to some reusable or recyclable surgical gowns and equipment as there is no link between reusable instruments and hospital-acquired infections.

Some of the other proposals of this pair concern the optimization of the energy usage of the OR. Agbafe and Berlin point to recommendations from the American Society of Healthcare Engineering for installing energy-efficient lighting, scheduling preventive maintenance, and minimizing airflow into rooms that are not normally used. used as easy ways to green the system.

They write that the surgical supply chain could also be more efficient. Estimates show that 87% of surgical instruments are fitted for a surgery that is rarely used, so the production of a standardized list of tools needed for surgeries happens frequently. can cut the cost, waste, and energy required to sterilize and repack such instruments.

Moving more surgical supplies manufacturing facilities closer to hospitals – or sourcing from locally based suppliers – can also reduce OR’s carbon footprint.

“With some of the geopolitical events going on right now in Ukraine and with China and the competition there along with the effects of the pandemic there is an increasing emphasis on resilience in the supply chain. supply,” Agbafe said. “So the idea of ​​localizing our executive room supply chain is something the public has a lot of energy and political momentum to work towards.”

Re-imagine care delivery

But perhaps the broadest way that space oncology can cut greenhouse gas emissions is by changing the way surgical care is delivered, starting with the permanent provision of telemedicine.

“We think telemedicine is a great opportunity for us to reduce our climate impact and improve the quality of care by doing so,” Agbafe said. “During the pandemic, we have been using virtual care and if we can make that a routine aspect of cancer care for the pre- and post-operative period, that’s how we can make it happen. can reduce the climate impact of care delivery and make it more convenient for the patient”.

Reducing low-value care is another way to eliminate the carbon-generating activities associated with unnecessary scans, checks, and procedures.

This is a priority for UM, thanks Michigan Program in Value Enhancement – a partnership of Michigan Medicine and the University of Michigan Health Care Policy Institute aimed at improving the quality of care in the facility – and partnerships with Michigan Value Partnershipalso known as MVC, a collaborative quality initiative serving the entire state.

Last year, the two organizations collaborated on a research highlight how many routine tests are still done before surgery even though its value is low. Berlin is the first author.

“UM is considered one of the leading institutions that research low-value care and work to limit that type of care,” says Berlin. “But like so many other hubs, we are really just at the cusp of these initiatives. I predict big changes in the next 10 years. ”

Gas to gas (more sustainable)

Some sustainability changes may come sooner at Michigan Medicine.

For example, the Department of Anesthesiology recently launched the Green Anesthesia Initiative, or GAIA for short. Its mission: to become more environmentally conscious about the types and rates of anesthesia used by service providers, another area that Agbafe and Berlin say are ripe for improvement.

“This is a pretty hot topic of discussion right now in the field and I’ve been thinking about it for a while,” said George Mashour, MD, Ph.D., chair of the Department of Anesthesiology and the Robert B. Sweet Professor of Anesthesia at the University of Michigan School of Medicine. “Unlike other industries, I don’t think we require major disruption to make progress because fortunately we have options.”

Some of the inhaled gases frequently used for anesthesia are Class A offenders when it comes to greenhouse gas production. Nitrogen oxide, commonly known as laughing gas, is a greenhouse gas, a substance that depletes the ozone layer directly and does not dissipate from the atmosphere for more than a century after it is produced.

However, the inhaled anesthetic sevoflurane has much less impact on the environment than nitrous oxide and other common inhalers, so Mashour says it would be a good alternative.

“The overall goal is to move away from some of these serious culprits and start making better choices about what drug we take and then how we take it,” says Mashour.

He added: “Contributions to the greenhouse gas effect or to ozone depletion are partly related to the amount of gas being pumped out into the atmosphere and that is directly related to how much fresh air we flow. “For example, if we have 10 liters, we’re blowing a lot of anesthetic into the waste collection system and the atmosphere doesn’t need to be there.”

To that end, Mashour’s colleagues in the Department of Anesthesiology and Critical Care led a national initiative to try to reduce anesthetic gas flow rates through Multicenter perioperative outcome groupAnother quality initiative includes health centers around the country.

Mashour plans to roll out other elements of GAIA over a three to five year period.

“We can do better,” he said. “Right now, we’re starting the conversations, getting everyone involved, and making structural choices within the division to make it easier for everyone to do the right thing.”


JOURNEYS

Journal of Clinical Oncology

DOI

10.1200 / JCO.21.02581

RESEARCH METHODS

Comments / editorials

ARTICLE TITLE

Prescriptions for Climate Change Mitigation-Related Externalities in Cancer Care: A Surgeon’s Perspective

ARTICLE PUBLICATION DATE

March 25, 2022





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