Climate Vulnerability and Cancer Incidence among U.S. Women: Who is most affected?

doi:10.21203/rs.3.rs-4720852/v1

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Climate Vulnerability and Cancer Incidence among U.S. Women: Who is most affected?

https://doi.org/10.21203/rs.3.rs-4720852/v1

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While climate change and its impacts have worsened in the U.S. over the past decade, associations between cancer incidence and regional climate change among women and racial minorities remains overlooked. U.S. states were divided into three climate impact categories (high, moderate, low) based on climate data from federal, insurance, and non-profit reports. We utilized United States Cancer Statistics data to identify 6,728,838 climate change-associated cancers (cutaneous melanoma, lung, breast) diagnosed from 2001-2019. Statistical analyses were then performed to examine incidence trends for these cancers. We found that high climate impact states experienced larger increases in cutaneous melanoma, lung, and breast cancer incidence compared to low climate impact states. Upon intersectionality analysis, breast cancer incidence in high impact regions increased among Black, Hispanic, and Asian women but decreased for White women. These incidence trends may continue to worsen unless actions mitigating climate change and its populational health impacts are undertaken.

Earth and environmental sciences/Climate sciences/Climate change

Earth and environmental sciences/Climate sciences/Climate change/Climate change impacts

Health sciences/Diseases/Cancer/Breast cancer

Health sciences/Diseases/Cancer/Cancer epidemiology

Health sciences/Diseases/Cancer/Lung cancer

Health sciences/Diseases/Cancer/Skin cancer

Health sciences/Oncology/Cancer

Climate Change

Climate Vulnerability

Cancer Incidence

Breast Cancer

Lung Cancer

Melanoma

Climate change is defined as the long-term average of the weather in a given location, specifically focusing on the type, frequency, duration, and intensity of the weather events.¹ Severe weather events such as hurricanes, atmospheric ozone depletions, and wildfires impact oncological healthcare outcomes through etiological pathways.¹ Moreover, the disruption of public resources, environmental exposure to ultraviolet (UV) radiation, introduction of environmental toxins, and air pollution also contribute to the increase in cancer incidences.²

Overall, cancer is the second most common cause of death in women.² Breast, lung, and skin (melanoma) cancer are identified as climate change-associated cancers due to the increasing risks associated with deleterious impacts of climate change.² Long term exposure to wildfire-related fine particles that are ≤ 2.5µm in diameter and those with greater oxidation potential is associated with increased risks for lung cancer.^3,4 Ozone layer depletion leads to UV radiation overexposure, one of the major risk factors contributing to the increasing incidences of skin cancer over the past five decades.⁴ Risks for breast cancer are associated with the increasing radiation and decreasing water vapor in lower altitude areas due to severe weather events.⁵ Moreover, decrease in access to healthcare caused by adverse weather events is associated with increased risks. For example, individuals diagnosed with cancer who experienced Hurricane Katrina had significantly decreased survival times.⁶ However, these regional studies do not emphasize the changes in cancer incidences and the impacts of climate change across the US as a whole over two decades.

The severe health impacts from climate change are identified in previous studies.² However, there is a lack of focus on cancer incidences within marginalized populations, with women being considerably more impacted.^7,8 Although lung cancer has a persistent high mortality rate, it presents a decreasing trend in men contrasting the increasing trend in women over the recent years.⁸ Moreover, even though climate change-associated weather events occur across the nation, racial/ethnic minority groups are significantly more vulnerable than others.^9,10 Additionally, historical redlining that led to lower tree canopy coverage is significantly linked to present-day unequal exposures to climate risks.¹¹ Intersectionality, a multi-axes framework considering both gender and race, has been previously overlooked in studies examining the effects of climate change on cancer incidences.^12,13 Thus, the aim of the study is to determine the association between cancer incidence and regional climate change among U.S. women.

Given the limitations of these prior reports, the objective of this study is to determine the association between cancer incidence and climate change among U.S. women from an intersectional perspective.

Climate Impact State Scores

The 13 states in the top 75^th percentile classified as high climate impact were as follows: Alabama, Arkansas, California, Florida, Georgia, Kansas, Louisiana, Missouri, North Carolina, Oklahoma, South Carolina, Texas, and Utah. The 13 states in the bottom 25^th percentile classified as low climate impact were: Alaska, Colorado, Hawaii, Illinois, Maine, Massachusetts, Michigan, Minnesota, New Hampshire, Pennsylvania, Rhode Island, Vermont, and Wyoming. The remaining 24 states were categorized as moderate climate impact regions (Figure 1).

Overall Demographics

From 2001-2019, there were 6,728,838 incident cases of climate change-related cancers diagnosed in women. Approximately 8.1% were cutaneous melanoma (N=543,051), 28.3% were lung and bronchus, and 63.6% were breast cancers. Regarding race, 80.1% (N=5,388,750) were non-Hispanic White patients, 9.7% were non-Hispanic Black (N=651,527), 6.1% were Hispanic (N=408,078), 2.9% were Asian (N=196,048), and 1.3% identified as other/unknown (N=84,425). Regarding age, 0.1% of patients were aged 0-19 years (N=5,168), 9.0% were 20-44 years (N=605,397), and 90.9% were aged 45 and above (N=6,118,263). Regarding stage, 52.5% of incident cancers were localized (N=3,535,800), 25.0% were regional (N=1,682,075), 16.7% were distant (N=1,122,529), and 5.8% were unknown (N=388,344).

Of all incident melanoma cases, 92.0% were White (N=499,709), 0.6% were Black (N=3,526), 2.8% were Hispanic (N=15,463), 0.4% were Asian (N=1,975), and 4.1% were other/unknown (N=22,378). Approximately 0.8% were aged 0-19 years (N=4,119), 22.2% were aged 20-44 years (N=120,668), and 77.0% were aged 45 years or older (N=418,175).

Of the lung and bronchus cases, 83.6% were White (N=1,594,939), 9.6% were Black (N=182,632), 3.8% were Hispanic (N=73,022), 2.2% were Asian (N=41,803), and 0.8% were other/unknown (N=15,049). Approximately 0.03% were aged 0-19 years (N=512), 1.7% were aged 20-44 years (N=32,734), and 98.3% were aged 45 years or older (N=1,907,445).

Of breast cancer patients, 77.0% were White (N=3,294,102), 10.9% were Black (N=465,369), 7.5% were Hispanic (N=319,593), 3.6% were Asian (N=152,270), and 1.1% were other/unknown (N=46,998). Approximately 0.01% were aged 0-19 years (N=397), 10.6% were aged 20-44 years (N=451,995), and 89.4% were aged 45 years or older (N=3,825,927).

Cutaneous Melanoma

From 2001-2019, cutaneous melanoma incidence increased by 1.59% per year from 13.87 to 18.23/100,000 (p=0.008). Regions with a high climate impact had greater increases in melanoma incidences compared to lower impact regions, with high, moderate, and low climate impacted states reporting incident increases of 2.82% (p=0.002), 2.37% (p<0.001), and 2.24% (p<0.001), respectively. Regarding stage, localized melanomas in high and moderate impact states respectively increased by 3.34% (p<0.001) and 3.31% (p<0.001) annually, whereas low impact states only increased by 2.21% (p=0.007). See Figure 2 for additional information.

The impact of climate change on cutaneous melanoma varied among different racial groups. White and Hispanic populations had respective annual increases of 2.85% (p<0.001) and 0.89% (p=0.03), while Black and Asian populations had annual decreases of -2.33% (p=0.02) and -2.88% (p=0.02). These decreases were largest in low climate impact for both Black (-2.67%, p=0.02) and Asian (-2.88%; p=0.02) populations. Specifically among the White population, melanoma incidences increased by 2.99% (p=0.001), 2.85% (p<0.001), and 1.80% (p=0.01) in high, moderate, and low climate impact states. See Table 1 for additional information.

Lung and Bronchus

Lung cancer incidence decreased in the United States by -0.73% per year from 54.97 to 48.12/100,000 over the study period (p<0.001). This annual decrease was greater in low climate impact states at -1.34% (p<0.001) and moderate impact states at -1.24% (p=0.004) compared to high impact states at -0.94% (p<0.001). Regarding distant stage disease, incidences had larger decreases among low (AAPC: -1.94%; p<0.001) and moderate impact states (AAPC: -1.86%; p<0.001) than high climate impact regions (AAPC: -1.15%; p=0.01). See Figure 3 for additional information.

While each racial group experienced decreases in incident lung cancer, these decreases were largest among Asian (-1.51%; p=0.02) and Hispanic populations (-2.24%; p<0.001) and lower among White (-0.91%; p<0.001) and Black populations (-0.82%; p=0.004) in high climate impact regions. See Table 1 for additional information.

Breast

From 2001-2019, breast cancer incidence decreased in the United States by -0.12% per year from 131.97 to 129.68/100,000 (p=0.001). Breast cancer incidences annually increased in high and moderate impact states at 0.34% (p=0.008) and 1.31% (p=0.002) but decreased in low impact states at -0.31% (p=0.03) per year. Regarding distant stage breast cancer, increases in incidence were smaller in low impact states at 1.37% (p<0.001) than moderate impact states at 1.99% (p<0.001) and high climate impact regions at 1.96% (p=0.02). See Figure 4 for additional information.

The impact of climate change on breast cancer varied among different racial groups. In high climate impact states, White populations experienced annual decreases of -0.52% (p<0.001) while Black, Hispanic, and Asian populations increased at 2.29% (p=0.001), 2.21% (p=0.003), and 0.90% (p<0.001) respectively. See Table 1 for additional information.

Please see additional information on cutaneous melanoma, lung and bronchus, and breast cancer incidence in Supplemental Table 1 and Supplemental Table 2.

In this report, our results suggested that climate change related cancer incidences increased in high and moderate climate impact states and decreased in low impact states. Our study additionally found that cutaneous melanoma and breast cancer incidences increased across the study period, whereas lung cancer incidences decreased. Regarding race, breast cancer incidence was greater among racial minorities in high climate impact regions the U.S.

Our study found that high climate impact states reported greater melanoma incidences when compared to low climate impact states. These findings suggest that factors related to climate change may contribute to these cancer incidence trends. Prior research indicates that climate change can impact the severity of UV radiation on human health.¹⁹ For example, stratospheric ozone depletion causes higher UV radiation penetration and warmer temperatures encourage outdoor activities.²⁰^,²¹^,²² This combination can increase the risk of developing melanoma. Additionally, higher temperatures during winter and spring seasons encourage people to stay outdoors longer, leading to higher received UV dosage leading to greater risk of skin cancer.²³

Furthermore, we found that White population had the highest increase in melanoma incidences. The increase in melanoma incidence among White populations can be attributed to a higher susceptibility to UV radiation, as a lack of eumelanin in fair skin types contribute to higher realized doses of ambient UV radiation exposure which increase melanoma risk.²⁴ Moreover, the rising popularity of tanning salons coupled with increased environmental UV radiation exposure exacerbates the risks of developing melanoma among White populations.²⁵ However, our study did not adjust for the potential confounders of the increased use of tanning salons and use of sunscreen and recommendations for annual screening by dermatological societies.

Lung cancer incidences were greater in high and moderate climate impact states and lower in low impact states. It is possible that climate change-related air pollution may affect lung cancer incidence. Although our results showed an overall decrease in lung cancer incidence, we did find there was a significantly lower decrease in incidence in higher impacted states. Shifting weather patterns due to climate change can cause prolonged droughts and decreased precipitation which lead to more frequent, severe, and widespread fires.²⁶ Prior reports indicate that these wildfires are associated with increased air pollution, and wildfire events and decreased air quality occur more frequently in high climate impact states.²⁷^,²⁸ Wildfires increase prolonged exposure to aerosolized fine particulate matter (PM) with acids and heavy metal byproducts, increasing lung cancer risks.²⁹^,³⁰^, With increased frequency of heat waves, there is worse ground level air quality that can potentially increase the risk of lung diseases and cancer.³⁰ In addition, risking temperature may lead to more indoor activity and more exposure to more exposure to pollutants such as second hand smoke.³¹ One study found elevated lung cancer incidence among those heavily exposed to ambient and household air pollution, particularly among nonsmokers and women.³²

While lung cancer incidence decreased overall, these decreases were not equally distributed. Racial minority groups experienced higher incidences compared to White populations, especially in severely climate impacted regions. This difference could be due to unequal exposure to air pollution due to systematic discrimination in redlining and neighborhood segregation.³³ One study found that socioeconomically disadvantaged neighborhoods were associated with increased lung cancer diagnosis.³⁴

On the other hand, it is conceivable that the racial and socioeconomic disparity in lung cancer risk may be due to differences in occupational exposure to harmful particles is further exacerbated by climate change-associated air pollution; this combination detrimentally increases lung cancer risks, with Black populations reporting higher occupational exposure influenced by systematic discriminatio.³⁵ Furthermore, we were unable to adjust for other factors such as socioeconomic status and impact living conditions and use of cigarettes and vaping.

In breast cancer, incidence increased in high impacted states and incidence dropped in low impacted regions. Ambient nitrogen dioxide and particulate matter 10 (PM10) concentration can cause deleterious genetic mutations that increase breast density and cancer risk.³⁶ Moreover, rising temperatures are associated with dose-dependent responses to increased absorption of these pollutants into the bloodstream that further increases breast cancer risk.³⁷

In addition, it is possible that temperature changes influenced by climate change may affect specific metabolic responses to EDCs, as studies have shown that the increasing ambient temperature has made model organisms more susceptible to cancer risks.³⁸ Higher temperatures can increase estrogen runoff and synthetic estrogen also potentially contribute to increasing breast cancer incidences in high climate impact states.³⁹ Increased estrogen exposure is associated with breast cancer in women, potentially through the proliferation of breast epithelial tissues.³⁹^,⁴⁰ Significant levels of environmental estrogen found in drinking, sewage, and irrigation water can be potentially made more harmful by the increasing temperature from climate change.⁴¹^,⁴² Additionally, heat stress is associated with decreased estrogen levels.⁴³

Climate change-related severe weather events can disrupt cancer screening facilities and oncology treatment centers that disproportionately affect disadvantaged communities. For example, while Hurricane Katrina impeded access to cancer care by disrupting transportation and depleting resources necessary for accessing cancer care.⁴⁴ Black residents in New Orleans accessed city infrastructures, including healthcare, much slower than White residents after Hurricane Katrina due to more severe housing damage from historic redlining practices.⁴⁵ These disparities in structural climate change recovery between racial groups could lead to disproportionate increase in cancer incidences among racial minorities. Our study found that Hispanic, Asian, and Black populations had statistically significant increases in breast cancer incidence in high impacted regions while White population had no change. Specifically in regions with a high climate change impact, breast cancer incidence decreased for White populations but increased for all other populations.

One limitation of this study is that data available from USCS is limited, and specific data on demographic information (e.g., socioeconomic states, income, occupation, education, genetic risk, trends in health screening and care, lifestyle factors) were not available. Additionally, data on cultural differences between U.S. states, such as diet and physical activity, that could potentially play a role in cancer development were unavailable. Moreover, this study is unable to find causational relationships between climate patterns and cancer incidences but rather a significant correlation between the variables.

Despite its limitations, our data found statistically significant associated trends and incidences of three specific climate change-related cancers by states with varying climate vulnerability and impact. Over a 19-year period study, we utilize national-level and state-wide data, making the results generalizable to U.S. women. Furthermore, the available racial data highlights the disproportionate impacts of climate change between racial groups, which increases the importance of caring for minority populations in climate change impacted states.

With the creation of the National Climate Task Force in 2022, the U.S. has been actively engaged with investing in renewable energy resources to combat climate change: its goals include reducing greenhouse gas emission 50-52% below 2005 levels in 2023, and to establish 100% carbon pollution-free electricity by 2035.⁴⁶ This research warrants further investigation with adjustment for socioeconomic and cultural factors to identify specific cancer risk factors among each climate region. This analysis provides potential guidance for state officials on environmental policies that attenuate the negative impacts of climate change, particularly among minority women. Lastly, studies are needed to validate our findings on a global scale.

Climate Impact Score

A climate impact score was calculated to determine the impact of climate change across all US states. This score was calculated by collecting climate change data on the number of severe weather events, climate change index scores, and state climate resiliency planning over the past two decades from publicly available reports from federal institutions, insurance companies, and nonprofit organizations.¹⁴^,¹⁵^,¹⁶^,¹⁷^,¹⁸

For each climate change data source, states were ranked on an 11-point scale from -5 to +5 to determine climate impact level. High climate impact states were defined as states with a greater frequency of severe weather events, higher climate change index ranking, and lower climate resiliency planning compared to the overall US, while low climate impact states were defined as states with fewer severe weather events, lower climate change index ranking, and higher climate resiliency planning compared to the overall US. The five states with the highest climate impact were given respective scores of +1 to +5 with +5 given to the state with the highest climate impact and +1 given to the state with the fifth-highest climate impact. The five states with the lowest climate impact were given respective scores of -1 to -5 with -5 given to the state with the lowest climate impact and -1 given to the state with the fifth-lowest climate impact. States that were not in the top or bottom five climate change categories were given a score of 0. Climate impact scores from each data source were added together to create an aggregate score for each US state. States that scored within the top 75^th percentile were designated as high climate impact states, and states within the 25^th percentile were designated as low climate impact states. States between the 25^th and 75^th percentiles were defined as moderate impact states.

Climate Change-Related Cancer Incidence

Data on climate change-associated cancers (breast, lung, and cutaneous melanoma) among women were obtained from the United States Cancer Statistics (USCS) database from 2001-2019. Cancer incidences in the overall US and states with high, moderate, and low climate impacts were analyzed. Race was categorized according to USCS guidelines: Hispanic, non-Hispanic Asian / Pacific Islander (NHAPI), non-Hispanic Black (NHB), non-Hispanic White (NHW), and other/unknown. Stage was categorized as localized, regional, distant, and unknown/other. Age was categorized as 0-19 years, 20-44 years, and 45 years or more. Nevada and Mississippi were excluded from all analyses as incidence data were not available.

Statistical Analysis

In order to be as statistically accurate as possible, the median statistically significant average annual percentage change was chosen to represent cancer incidence changes for each climate impact region. SEER*Stat 8.3.9.2 and Joinpoint regression program 4.9.0.0 were used to calculate cancer incidences and trends per 100,000. Average annual percentage change (AAPC) was used to describe trends. Age-adjusted incidences were adjusted by the U.S. 2000 standard population. P-values <0.05 were considered statistically significant. This study was exempt from IRB review as all utilized data were publicly available and deidentified.

ACKNOWLEDGEMENTS

The authors would like to thank the Denise Cobb Hale Chair and The Fisher Family Fund for their administrative support.

AUTHOR CONTRIBUTIONS

Conceived and Designed Experiments: CRJ, CIL, RLJ, DSK, JKC

Performed Experiments: N/A

Analyzed Data: CRJ, CIL, RLJ, NT, KD, AMG

Contributed Materials/Analysis Tools: CRJ, CIL, AMG

Wrote the Paper: CRJ, RLJ, NT, KD, DSK, JKC

CONFLICTS OF INTEREST

Dr. John K Chan has consulted for AstraZeneca, GlaxoSmithKline, Genmab/Seagen, Immunogen, Karyopharm, Merck, Mersana, Myriad, and Roche. Dr. Chan has received payment/honoraria for lectures and traveling support from AstraZeneca, Eisai, Genmab/Seagen, GlaxoSmithKline, Immunogen, Merck, and Myriad. He has also participated on an advisory board for AstraZeneca, GlaxoSmithKline, and Myriad. The remaining authors have no conflicts of interests to declare.

DATA AVAILABILITY STATEMENT

The datasets generated and analyzed during the current study are publicly available in the United States Cancer Statistics (USCS) database (https://www.cdc.gov/united-states-cancer-statistics/public-use/index.html).

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Table 1. Cutaneous Melanoma, Lung and Bronchus, and Breast Cancer Incidence by Race and Climate Impact Region in the United States

Cancer Type	Climate Impact Region By Race/Ethnicity	AAPC [2001, 2019]	95% Confidence Interval	P-Value
*CUTANEOUS MELANOMA*	WHITE
	High	2.99 [11.62, 16.58]	1.14, 4.86	0.001
	Moderate	2.85 [14.48, 22.38]	2.14, 3.58	<0.001
	Low*	1.92 [17.66, 27.66] 1.80 [18.63, 32.10]	0.52, 3.33 0.48, 3.14	0.010 0.010
	BLACK
	High	-2.33 [1.23, 1.04]	-4.20, -0.42	0.020
	Moderate*	-2.25 [0.66, 0.75] -4.02 [1.07, 0.68]	-4.34, -0.11 -7.43, -0.48	0.041 0.029
	Low	-2.67 [0.98, 0.60]	-4.88, -0.41	0.023
	HISPANIC
	High*	0.89 [4.27, 5.24] -5.77 [13.72, 4.60]	0.10, 1.69 -11.16, -0.05	0.029 0.048
	Moderate	-1.95 [3.57, 2.65]	-3.65, -0.22	0.030
	Low*	2.96 [1.17, 5.59] 2.04 [4.99, 7.73]	1.05, 4.90 0.34, 3.77	0.004 0.021
	ASIAN
	High*	0.10 [1.15, 1.33] -3.10 [2.36, 0.75]	-1.55, 1.79 -7.33, 1.32	0.9 0.2
	Moderate*	0.18 [0.50, 1.33] -1.09 [0.66, 0.57]	-2.37, 2.80 -7.33, 5.57	0.9 0.7
	Low	-2.88 [1.57, 1.64]	-5.26, -0.44	0.024
*LUNG & BRONCHUS*	WHITE
	High	-0.91 [64.81, 56.88]	-1.32, -0.50	<0.001
	Moderate	-1.34 [55.66, 41.99]	-1.87, -0.80	<0.001
	Low*	-0.87 [43.95, 46.44] -1.40 [47.89, 38.13]	-11.69, -0.44 -1.74, -1.06	0.041 <0.001
	BLACK
	High	-0.82 [50.33, 45.25]	-1.39, -0.26	0.004
	Moderate	-1.36 [53.11, 40.76]	-1.87, -0.85	<0.001
	Low	-1.34 [43.90, 41.50]	-2.39, -0.27	0.017
	HISPANIC
	High	-2.24 [26.50, 18.32]	-2.61, -1.86	<0.001
	Moderate	0.55 [27.75, 29.62] -5.99 [82.62, 42.66]	0.01, 1.08 -10.52, -1.23	0.046 0.017
	Low	3.53 [41.71, 88.31]	0.85, 6.29	0.012
	ASIAN
	High	-1.51 [25.97, 19.28]	-2.74, -0.27	0.020
	Moderate	2.65 [20.55, 38.10]	1.92, 3.39	<0.001
	Low*	3.60 [15.73, 29.52] 1.56 [17.85, 33.14]	11.43, 5.81 0.42, 2.72	0.003 0.010
*BREAST*	WHITE
	High	-0.52 [140.74, 129.09]	-0.80, -0.24	<0.001
	Moderate	0.40 [118.20, 122.80] 0.38 [141.65, 149.99]	0.18, 0.63 0.20, 0.57	0.002 <0.001
	Low	0.44 [143.20, 140.99]	0.05, 0.84	0.030
	BLACK
	High	0.96 [118.55, 136.96] 0.90 [108.52, 132.49]	0.67, 1.26 0.63, 1.17	<0.001 <0.001
	Moderate	0.80 [116.42, 132.85]	0.23, 1.38	0.009
	Low	0.18 [116.08, 123.97]	-0.47, 0.83	0.6
	HISPANIC
	High	2.29 [88.15, 91.70]	1.12, 3.47	0.001
	Moderate	1.31 [96.31, 96.63] 0.92 [96.10, 113.98]	0.56, 2.07 0.36, 1.47	0.002 0.003
	Low	1.16 [86.61, 104.51] 0.70 [97.86, 112.34]	0.60, 1.71 0.15, 1.26	<0.001 0.016
	ASIAN
	High	2.33 [67.92, 94.74] 2.21 [43.80, 89.77]	1.31, 3.37 0.83, 3.61	<0.001 0.003
	Moderate	2.08 [58.58, 83.07]	0.35, 3.84	0.021
	Low	1.16 [86.61, 104.51] 0.70 [97.86, 112.34]	0.60, 1.71 0.15, 1.26	<0.001 0.016
Nevada and Mississippi not included in analysis as data were not available. Oklahoma did not report cutaneous melanoma data. Incidences reported per 100,000. Statistically significant results bolded for ease of reference. AAPC: Average annual percent change *Even number of statistically significant AAPCs, therefore two values are presented instead of one

Competing interest reported. Dr. John K Chan has consulted for AstraZeneca, GlaxoSmithKline, Genmab/Seagen, Immunogen, Karyopharm, Merck, Mersana, Myriad, and Roche. Dr. Chan has received payment/honoraria for lectures and traveling support from AstraZeneca, Eisai, Genmab/Seagen, GlaxoSmithKline, Immunogen, Merck, and Myriad. He has also participated on an advisory board for AstraZeneca, GlaxoSmithKline, and Myriad. The remaining authors have no conflicts of interests to declare.

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Climate Vulnerability and Cancer Incidence among U.S. Women: Who is most affected?

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