Objectives: Given adverse health effects of climate change and contributions of the US health care sector to greenhouse gas (GHG) emissions, environmentally sustainable delivery of care is needed. We applied life cycle assessment to quantify GHGs associated with processing a gastrointestinal biopsy in order to identify emissions hotspots and guide mitigation strategies. Methods: The biopsy process at a large academic pathology laboratory was grouped into steps. Each supply and reagent was catalogued and postuse treatment noted. Energy consumption was estimated for capital equipment. Two common scenarios were considered: 1 case with 1 specimen jar (scenario 1) and 1 case with 3 specimen jars (scenario 2). Results: Scenario 1 generated 0.29 kg of carbon dioxide equivalents (kg CO2e), whereas scenario 2 resulted in 0.79 kg CO2e—equivalent to 0.7 and 2.0 miles driven, respectively. The largest proportion of GHGs (36%) in either scenario came from the tissue processor step. The second largest contributor (19%) was case accessioning, mostly attributable to production of single-use disposable jars. Conclusions: Applied to more than 20 million biopsies performed in the US annually, emissions from biopsy processing is equivalent to yearly GHG emissions from 1,200 passenger cars. Mitigation strategies may include modification of surveillance guidelines to include the number of specimen jars.

The effects of recent conflicting guidance on prostate-specific antigen (PSA) screening for prostate cancer during the past decade are not yet fully understood. In 2012, the US Preventive Services Task Force (USPSTF) issued a grade D recommendation against PSA-based screening for prostate cancer.^1,2 At the time, the guideline expressed moderate to high certainty that the harms of PSA screening outweighed the benefits.^3,4 In the subsequent period, the guideline was rapidly incorporated into practice, and there have been measurable decreases in rates of PSA testing and diagnostic biopsies, as well as the number of prostate cancers identified in the United States.^5-7 There are also increasing concerns that reductions in PSA testing associated with the USPSTF statement were temporally associated with increases in the incidence of prostate cancers diagnosed at an advanced or metastatic stage.^8,9

There are entrenched racial disparities in the diagnosis, treatment, and outcome of men with prostate cancer in the United States.¹ Black men are more likely to receive a diagnosis of prostate cancer, are less likely to receive guideline-concordant care, and experience a nearly 2-fold greater risk of cancer-specific mortality compared with White men. Recent analyses suggest that observed racial disparities in prostate cancer outcomes are wholly or, at least in part, attributable to factors that are associated with race, but only through generations of the legal, social, and medical (ie, “structural”) disadvantages experienced by Black persons in the US, and are not the result of immutable biological differences.^2,3 Race-based differences in prostate cancer care and outcomes also recapitulate other health disparities in the US associated with socioeconomic deprivation, geography, and timeliness and quality of care.⁴ For example, residential segregation, a form of structural racism resulting from discriminatory practices such as New Deal era “redlining” (intentional discriminatory practices enacted in a geographic area based on race or ethnicity), has been associated with race-based differences in prostate cancer detection and outcomes.^5-7 Thus, strategies to reduce race-based inequalities begin with broader acknowledgment of their existence and the processes that underlie their perpetuation.^8,9

Following significant expansions associated with the Patient Protection and Affordable Care Act (ACA) of March 2010, Medicaid has become the largest social insurance program and third largest payer in the United States, now providing health insurance to 1 in 5 US residents.¹ As Medicaid has long been an essential source of coverage for low-income, nonelderly US adults with cancer, implementation of the ACA has also led to increases in insurance rates, screening, and access to treatment.^2-8 Coverage has notably increased for historically disadvantaged populations of patients with cancer, including members of racial and ethnic minority groups, those residing in rural areas, and individuals with lower educational levels.^4,9 Despite improvements attributable to ACA expansion, infrastructural and financial constraints remain obstacles to timely and universal care.