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Frontiers in Cancer Control and Society ·

Volume 4 - 2026 | https://doi.org/10.3389/fcacs.2026.1747292

Cancer risk and the burden of housing and energy insecurity: a scoping review

  • Yasmin Husen1
  • Fatima Zeshan1
  • Mavis Odei Boateng2
  • Destiny Otoadese3
  • Godfred O. Boateng1,4*corresponding author
  1. 1Dahdaleh Institute for Global Health Research, York University, Toronto, ON, Canada
  2. 2School of Social Work, University of Windsor, Windsor, ON, Canada
  3. 3School of Public Health, University of Alberta, Edmonton, AB, Canada
  4. 4School of Global Health, York University, Toronto, ON, Canada
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Abstract

Housing and energy insecurity represent intersecting social determinants of health that shape exposure to indoor environmental carcinogens and, consequently, cancer outcomes. This scoping review examines how inadequate housing conditions and energy poverty influence cancer risk factors and outcomes, including incidence, stage at diagnosis, survival, and mortality. Guided by the Joanna Briggs Institute methodology and the PRISMA-ScR checklist, the review synthesized evidence from peer-reviewed and gray literature published between 2010 and 2025. Findings highlight consistent associations between residential radon exposure and increased lung cancer risk, as well as evidence that poorly ventilated energy-efficiency retrofits may elevate radon concentrations. Combustion-derived pollutants from solid-fuel use similarly increase cancer risk, disproportionately affecting women and low-income households. Emerging data also link particle-bound radioactivity to reduced cancer survival independent of radon exposure. Across exposures, socioeconomic disadvantage, racialized status, and energy insecurity amplify vulnerability and worsen outcomes. These findings underscore the fact that housing and energy systems are structural determinants of cancer control. Effective cancer prevention and survivorship strategies must integrate equitable energy policies, indoor air-quality protections, and targeted interventions for energy-housing-insecure populations to reduce disparities and support climate-resilient health systems.

Keywords

1 Introduction

Cancer remains a leading cause of death and disability globally. The World Health Organization's Global Cancer Observatory (GLOBOCAN) estimated that in 2020, there were 19.3 million new cancer cases and 10 million cancer deaths worldwide, and projections suggest that annual incidence will rise to approximately 28 to 30 million by 2040 if current trends continue (1). Lung cancer continues to be the single largest contributor to cancer mortality, accounting for roughly one in five deaths worldwide (2). Although therapeutic advances such as targeted treatments and immunotherapies have improved outcomes, survival rates remain low, especially in low- and middle-income countries where access to screening and specialized care is limited (3). The global cancer burden is influenced by a complex interplay of biological, behavioral, and environmental factors. Among these, the environments in which people live and the energy sources they rely on for daily life are increasingly recognized as determinants of cancer risk and progression (72, 79). Environmental exposures within the home, such as those arising from air pollutants, building materials, and energy systems, have been linked to a range of cancers, including lung, breast, and gastrointestinal malignancies (4, 5, 67, 78). Understanding how the physical and social dimensions of housing shape exposure to carcinogens is, therefore, central to preventing disease and reducing inequities in outcomes. In this review, housing insecurity refers to instability, poor quality, or unaffordability of housing, whereas energy insecurity refers to the inability to consistently access affordable, reliable, and safe household energy for heating, cooling, cooking, and electricity (6). Although closely related, these conditions operate through both shared and distinct pathways to influence environmental exposures and cancer risk (49). Energy insecurity can independently shape exposure by constraining heating and cooking practices, ventilation use, and reliance on unsafe fuels, thereby modifying indoor air quality even among households that are technically housed (7, 8, 71). While much of the environmental exposure literature focuses on risks occurring within residential buildings, housing and energy insecurity also encompass people who are unhoused or precariously housed. Individuals experiencing homelessness face distinct and often more severe cancer risks due to chronic outdoor air pollution exposure, reliance on unsafe heating sources, high smoking prevalence, and substantial barriers to screening, diagnosis, and treatment (9, 10).

1.1 The home–energy interface as a locus of environmental exposure

Individuals spend more than 80% of their time indoors, according to time–activity studies conducted in diverse settings (4). The home environment thus represents the primary site of chronic exposure to environmental agents that can influence cancer risk and survival. Indoor pollutant levels are shaped by housing design, ventilation, and the types of energy used for cooking and heating. Radon, a Group 1 carcinogen, is a major indoor hazard influenced by local geology and building characteristics (2). While energy-efficient housing improvements are essential for reducing emissions, they can unintentionally increase indoor pollutant concentrations if ventilation is inadequate (11, 12). Moreover, an estimated 2.3 billion people around the world rely on solid fuels such as wood, coal, or crop residues for household energy, exposing residents to particulate matter and carcinogenic compounds, including polycyclic aromatic hydrocarbons and volatile organic compounds (4, 13). Even in high-income countries, energy-insecure households may depend on wood stoves or unvented gas heaters, leading to sustained indoor air pollution (6, 14). Emerging evidence also points to particle-bound radioactivity and exposure to trace metals from geothermal systems as additional environmental pathways that may influence cancer development (15, 76). Although mechanisms remain under study, these observations reinforce the importance of evaluating environmental exposures that intersect with energy infrastructure and natural resource use.

1.2 Social determinants and inequities in cancer outcomes

The WHO defines social determinants of health as the conditions in which people are born, grow, live, work, and age, as well as the broader social and economic systems that influence these conditions (85). The health impacts of environmental exposures are compounded by social determinants of health, including income, education, race, and access to services. Existing research consistently indicates that social and structural inequities shape cancer risk and outcomes. Individuals with fewer resources or unstable housing typically face higher cancer risks, later diagnoses, and have lower chances of survival (69). Housing and energy insecurity, which can be considered as structural determinants, can intensify exposure to carcinogens through constrained behavioral choices, and certain groups may face compounded risks. These combined inequities contribute to persistent disparities in cancer incidence and survival (15). However, there are very few studies that have systematically examined the evidence, leaving several questions unanswered as to the mechanism by which this happens. Beyond physical and chemical exposures, housing and energy insecurity also function as chronic psychosocial stressors. Persistent financial strain, thermal discomfort, fear of eviction or utility shutoffs, and the daily burden of coping with unsafe or inadequate housing conditions can activate stress-response systems and increase allostatic load. Prolonged dysregulation of the hypothalamic–pituitary–adrenal axis and inflammatory pathways has been linked to immune suppression, oxidative stress, and altered DNA repair, which may contribute to cancer initiation and progression (16).

1.3 Rationale for the scoping review

The relationship between housing, energy insecurity, and cancer outcomes is multifaceted and spans a wide range of disciplines. Research addressing this intersection includes environmental engineering, toxicology, epidemiology, and the social sciences, each employing distinct study designs and analytical frameworks. A scoping review is well-suited to synthesize this diverse body of evidence and to clarify how the home and energy interface influences cancer risk factors, incidence, survival, and mortality. By mapping the existing literature on exposures such as radon, combustion pollutants, particle radioactivity, and geothermal emissions, this review seeks to identify research gaps and conceptual linkages across environmental and social determinants of health. The resulting synthesis can inform public health policy, guide energy efficiency programs, and support interventions that promote both environmental sustainability and health equity (82).

2 Methods

This scoping review was conducted in accordance with the Joanna Briggs Institute (JBI) methodology for scoping reviews (17, 68, 75) and reported following the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist (18, 64). The objective was to map and critically describe the breadth of evidence examining how housing and energy insecurity-and the associated indoor environmental exposures-affect cancer risk factors and outcomes, including prevalence, stage at diagnosis, survival, and mortality. Because the evidence base spans disciplines and includes both peer-reviewed and gray literature, a scoping review design allowed us to capture the full range of study designs and to highlight research gaps without restricting inclusion to a narrow set of methodologies.

2.1 . Step 1: formulating research questions

This scoping review was guided by the following questions: (1) What is the existing evidence linking housing insecurity, energy insecurity, and housing-related environmental exposures (e.g., radon, indoor combustion, particle radioactivity, geothermal water) to cancer incidence, stage at diagnosis, survival, or mortality? (2) How have these exposures been reported across different study designs and geographic contexts? (3) What are the gaps in the literature regarding housing and energy systems as structural determinants of cancer risk and outcomes?

2.2 . Step 2: identifying relevant studies

A comprehensive search strategy was developed iteratively to balance sensitivity and specificity across biomedical and social science databases. The final search was conducted in September 2025 and covered publications from January 2010 through September 2025. This timeline was chosen to capture research produced in the post-2008 recession era, when the relationship between social determinants of health and cancer prevention gained prominence.

The following electronic databases were searched via the York University OMNI Library: PubMed/MEDLINE, Embase (through Ovid), Scopus, Web of Science Core Collection, and CINAHL (through EBSCOhost). To supplement peer-reviewed literature, we also screened gray literature sources, including the Social Science Research Network (SSRN), the Canadian Research Index, and key government and non-governmental agency reports.

2.3 . Step 3: developing the search strategy

Search concepts targeted three overarching domains: (1) housing insecurity and related built-environment factors (e.g., “housing insecurity,” “substandard housing,” “ventilation,” “overcrowding,” “home energy retrofit,” “energy efficiency”) (2) energy insecurity and indoor environmental exposures (e.g., “energy poverty,” “solid fuel,” “biomass,” “radon,” “particle radioactivity,” “gross beta,” “indoor air pollution,” “geothermal water”) (3) cancer outcomes and risk factors (e.g., “cancer incidence,” “cancer prevalence,” “diagnosis,” “mortality,” “survival,” “biomarkers of oxidative stress,” “DNA damage”).

An initial set of keywords and controlled vocabulary (MeSH, Emtree, CINAHL Headings) was generated and pilot-tested in PubMed, then refined for the syntax of each database. Truncation and Boolean operators were used to capture variations of key terms. The full search strategies for all databases are provided in Supplementary Table S1. All retrieved citations were exported to Zotero for initial organization and de-duplication.

2.4 . Step 4: study selection

After de-duplication in Zotero, references were exported to Rayyan, an online systematic review management platform, to facilitate blinded and collaborative screening. Two reviewers (including the lead author and a trained colleague) independently screened titles and abstracts for potential relevance. Studies were retained if they investigated at least one housing- or energy-related exposure and reported a cancer-related outcome (prevalence, stage at diagnosis, survival, or mortality). We excluded studies focusing exclusively on outdoor air pollution without a clear residential or energy component, commentaries without primary data, and studies that did not report a cancer risk or outcome.

Full texts of all records deemed potentially relevant were then retrieved and assessed against the inclusion criteria. Any disagreements at either the title/abstract or full-text stage were resolved by consensus, with a third reviewer available for adjudication if needed. A PRISMA-ScR flow diagram summarizing the screening process is provided in Figure 1. The involvement of a colleague who assisted with the screening process ensured consistency and reduced the likelihood of selection bias.

PRISMA-ScR flow diagram of study selection. Adapted from PRISMA 2020 flow diagram for new systematic reviews, which included searches of databases and registers, and other sources (Word template) by Page et al. (63) ([http://www.prisma-statement.org/](http://www.prisma-statement.org/)), licensed under a Creative Commons Attribution License.
Figure 1. PRISMA-ScR flow diagram of study selection. Adapted from PRISMA 2020 flow diagram for new systematic reviews, which included searches of databases and registers, and other sources (Word template) by Page et al. (63) (http://www.prisma-statement.org/), licensed under a Creative Commons Attribution License.

Studies were eligible for inclusion if they: reported original research (observational, case-control, cohort, ecological, or modeling studies); examined exposures linked to housing or energy systems-for example, residential radon, indoor particulate matter (fine particulate matter ≤ 2.5 μm in aerodynamic diameter [PM2.5], polycyclic aromatic hydrocarbons [PAHs], and volatile organic compounds [VOCs]), solid fuel use, housing characteristics such as ventilation or insulation, energy-efficiency retrofits, particle radioactivity (PR), including gross beta activity (PR-β), or geothermal water use; and reported at least one cancer-related outcome: incidence or prevalence, stage at diagnosis, survival after diagnosis, or mortality. No geographic restrictions were applied. We included studies published in English and, where available, peer-reviewed conference proceedings or government reports containing original data.

Following peer-review feedback, we conducted supplementary reference list screening and targeted searches to ensure comprehensive capture of relevant literature, particularly for underrepresented exposure pathways and vulnerable populations. This process identified additional studies, which were screened and incorporated using the same eligibility criteria and study selection procedures described above. Methodological and reporting guidance documents, fact sheets, and World Bank reports used solely for income-group and regional classification were cited for contextual and methodological purposes and were not considered part of the study evidence base; therefore, they were excluded from the PRISMA flow diagram and study counts.

2.5 . Step 5: data extraction

A structured data-charting form was developed a priori and pilot-tested on a subset of included studies. For each eligible record, two reviewers independently extracted the following information into a spreadsheet: bibliographic details (author, year of publication); country or region of study; study design and population characteristics (sample size, age, sex, sociodemographic context); type and measurement of housing or energy-related exposure; cancer outcome(s) (prevalence, diagnosis stage, survival, or mortality) and any reported effect sizes (risk ratios, odds ratios, hazard ratios with 95% confidence intervals); key covariates and potential confounders; and stated limitations or sources of bias. All entries were double-checked for accuracy, and discrepancies were resolved by discussion. The completed dataset served as the basis for narrative synthesis and the creation of summary tables.

2.6 . Step 6: synthesis of evidence

Given the anticipated heterogeneity in study design, exposure assessment, and outcome measurement, we conducted a descriptive, narrative synthesis rather than a quantitative meta-analysis. Studies were grouped according to exposure type (e.g., radon, indoor combustion, particle radioactivity, geothermal water, housing characteristics/energy efficiency). Within each exposure category, we summarized findings on cancer incidence/prevalence, diagnosis stage, survival, and mortality, highlighting consistencies and divergences across geographic regions and study populations.

We also identified research gaps and emerging trends, such as the limited evidence from low- and middle-income countries (LMICs), the need for longitudinal multi-exposure studies, and the paucity of data on particle radioactivity (PR) and cancer survival. These gaps informed the recommendations for future research presented in the Discussion section. Furthermore, to ensure transparency, we distinguish between two categories of literature: (1) studies identified through the systematic search, screening, and eligibility process (and included in the evidence synthesis); and (2) supplementary sources that were not retrieved during the initial search but were added subsequently to provide definitions, epidemiological statistics, or contextual background. The latter sources were not subjected to the inclusion/exclusion screening process and were not counted among the included studies. Rather, they were used to support interpretation, clarify terminology, and situate our findings within the broader literature.

3 Results

3.1 Environmental exposures and cancer risk

3.1.1 Radon exposure

Across the literature, radon is the most consistently documented housing-related carcinogen. The International Agency for Research on Cancer (IARC) classifies radon as a Group 1 human carcinogen, and it is recognized worldwide as the second leading cause of lung cancer after tobacco smoking (2).

Residential radon concentrations vary widely depending on geological uranium content and building characteristics (2, 65). National surveys show especially high levels in regions such as Manitoba and New Brunswick (Canada), the Southwest of England, parts of Sweden, central Anatolia in Turkey, and Iceland (19–24). In these areas, radon concentrations frequently exceed the World Health Organization (WHO) reference level of 100 Bq/m3 (becquerels per cubic meter), with some households recording levels several times higher.

Building design and energy efficiency strongly modify indoor radon levels. Evidence from Canada, the UK, and Scandinavia shows that energy-efficiency retrofits, for example, adding insulation or tightening building envelopes to reduce heat loss, can increase indoor radon concentrations when not paired with balanced mechanical ventilation (22, 25–27). Cross-sectional studies and natural experiments following national retrofit programs consistently demonstrate median radon increases of 20%−50% in homes that were sealed without added ventilation. This illustrates how climate and energy-related interventions, when implemented without adequate ventilation, may unintentionally modify cancer risk pathways, particularly for households with limited resources to implement mitigation measures (25, 26).

Additionally, the International Agency for Research on Cancer (IARC) has estimated that household use of coal for cooking or heating roughly doubles to quintuples the risk of lung cancer (81). In certain high-exposure settings such as Xuanwei County, China, U.S. National Cancer Institute investigators have documented far higher risks—up to a 99-fold increase in lung cancer among never-smoking women who used smoky coal compared with smokeless coal (14). Even in high-income countries, energy-insecure households may rely on wood stoves or unvented gas heaters, sustaining elevated levels of indoor PM2.5 (4, 13). Large, pooled case–control studies further demonstrate a linear dose–response relationship between long-term radon exposure and lung cancer risk, with risk increasing by roughly 16% per 100 Bq/m3 of chronic exposure, even below many national action levels (12, 28, 66). Importantly, the excess relative risk is evident among never-smokers as well as smokers, and radon-related lung cancers are often diagnosed at later clinical stages, contributing to high mortality rates (10, 29). Beyond radon and combustion exposures, evidence from the Boston Lung Cancer Survival (BLCS) cohort demonstrates that post-diagnosis exposure to PR-β is associated with significantly worse lung cancer survival, even after adjustment for residential radon and other covariates (15). In this study of 2,795 patients followed for 97,330 person-months, each interquartile range increase in PR-β (0.06 mBq/m3) corresponded to a 63% higher hazard of death [hazard ratio (HR) 1.63, 95% confidence interval (CI) 1.52–1.76] and a marked reduction in both three- and five-year survival. The evidence shows that environmental exposures linked to housing and energy systems play a decisive role in lung cancer risk and outcomes.

3.1.2 . Particle radioactivity (PR-β) and lung cancer survival

Beyond total particulate mass, the radioactive component of ambient particulate matter, termed particle radioactivity (PR), specifically gross beta activity (PR-β), is emerging as an independent driver of cancer outcomes. The strongest evidence comes from the Boston Lung Cancer Survival (BLCS) cohort, a prospective study of 2,795 patients with histologically confirmed lung cancer treated at Massachusetts General Hospital and Dana-Farber Cancer Institute and followed from 1992 through 2017 (15). For patients residing in New England, monthly PR-β exposure estimates for 2001–2017 were generated using an ensemble machine-learning model trained on data from the U.S. EPA RadNet monitoring network (129 stations) and incorporating geological and meteorological predictors at an approximately 32 × 32 km spatial resolution.

Within this cohort, the mean PR-β concentration was 0.36 mBq/m3 (SD 0.04) with an interquartile range (IQR) of 0.06 mBq/m3. In Cox proportional hazards models adjusted for age, sex, race, smoking status, stage, histology, and ZIP-code income, each IQR increase in PR-β was associated with a 63 percent higher hazard of death (HR 1.63, 95% CI 1.52–1.76). The same IQR increase predicted poorer five-year survival (HR 1.33, 95% CI 1.23–1.44) and three-year survival (HR 1.22, 95% CI 1.12–1.33). A clear dose–response gradient emerged: compared with the lowest exposure quartile, which had a median overall survival of 46 months, hazard ratios rose progressively—Q2 HR 1.18 (median 30.6 months), Q3 HR 1.46 (23.5 months), and Q4 HR 2.20 (14.7 months), with a p-for-trend of < 0.001. These associations persisted after co-adjustment for residential radon (per-IQR overall survival HR 1.64, 95% CI 1.52–1.78). Furthermore, stronger associations were observed among patients diagnosed with early-stage disease (stages I–II) (interaction p < 0.001), whereas no significant differences were found by sex, race, smoking status, or histological subtype (15).

These findings provide some of the first population-level evidence that particle-bound radioactivity contributes to worse survival after a lung cancer diagnosis, independent of traditional risk factors and of residential radon itself (15). They highlight the need for air-quality regulations that incorporate radiometric properties of particulate matter and for indoor interventions, such as mechanical ventilation and high-efficiency filtration, to reduce infiltration of radioactive particles, particularly for vulnerable patient populations.

3.1.3 . Indoor air pollution from cooking and heating

In many LMICs and in rural or energy-insecure households in high-income countries, combustion of solid fuels such as wood, coal, crop residues, and animal dung remains common for cooking and space heating (83). Inefficient stoves and inadequate ventilation result in elevated indoor concentrations of fine particulate matter (PM2.5) and a complex mixture of carcinogens, including polycyclic aromatic hydrocarbons (PAHs) and volatile organic compounds (VOCs) (5, 30, 31). These patterns reflect not only housing quality but also energy insecurity, whereby households lacking access to affordable, clean energy are compelled to rely on solid fuels or unsafe heating practices, resulting in sustained exposure to carcinogenic pollutants (6, 7, 32). In high-income countries, energy insecurity also manifests through coping behaviors adopted when households cannot afford adequate heating or electricity. Conceptual frameworks distinguish physical, economic, and coping dimensions of energy insecurity, whereby inadequate housing efficiency and unaffordable utility costs lead residents to use ovens, gas stoves, portable propane heaters, or to block ventilation to conserve heat (16, 84). These strategies can substantially elevate indoor concentrations of nitrogen dioxide, carbon monoxide, PM2.5, and other combustion by-products, thereby intensifying exposure to carcinogenic and cardiopulmonary toxicants even in formally connected and “housed” settings (4, 33).

A large body of epidemiologic evidence, including pooled analyses from the International Agency for Research on Cancer, links long-term exposure to indoor coal smoke with a two- to five-fold increase in lung cancer risk (34). Several case–control and cohort studies from China and India also report positive associations between chronic biomass fuel exposure and lung cancer incidence (14, 35, 36, 74, 77). While evidence for other malignancies is less extensive, emerging data suggest potential associations with breast cancer, possibly mediated through endocrine-disrupting PAHs (37, 38).

The cancer burden is gendered: women and children who spend more time near cooking fires and whose lungs are physiologically more vulnerable bear the highest exposures and risk (39, 40). In high-income countries, energy-poor households that rely on wood stoves or unvented gas heaters can also experience PM2.5 levels exceeding WHO guidelines, indicating that this is not solely a problem of LMICs (4, 13). Such exposures contribute directly to cancer incidence and mortality and may indirectly delay diagnosis by producing chronic respiratory symptoms that obscure early signs of lung malignancy (41).

3.1.4 Geothermal water exposure

In geologically active regions where geothermal water and steam are used for space heating and bathing, such as Iceland and central Anatolia in Turkey, several ecological and cohort studies have reported elevated incidence and mortality from breast, prostate, and kidney cancers (28, 42). Proposed mechanisms include chronic low-level exposure to naturally occurring radionuclides (e.g., radium, radon progeny) and trace metals that can accumulate in groundwater and geothermal steam (21).

Although the number of studies remains limited and context-specific, the consistency of findings across independent investigations suggests that geothermal energy systems warrant routine environmental monitoring (28, 42). These exposures could influence both cancer prevalence and survival, particularly in populations with long-term, lifetime use of geothermal water for domestic purposes (43).

3.1.4.1 Geographic distribution of evidence

Table 1 summarizes the geographic distribution of included studies by exposure pathway. Evidence on radon and particle radioactivity is concentrated in high-income regions of North America and Europe, whereas studies of indoor combustion and household air pollution are predominantly from upper-middle- and low-income settings in East and South Asia and Sub-Saharan Africa, highlighting global inequities in environmental cancer risk related to housing and energy insecurity (44, 45). The table is restricted to studies that explicitly reported the geographic location of data collection or analysis and therefore does not include all studies discussed in the manuscript.

Table 1. Geographic distribution of included studies by exposure pathway.

Exposure pathwayRegions representedExample countriesIncome settings coveredNo. of studies*
RadonNorth America, Europe, East Asia, Eastern Europe, Sub-Saharan AfricaCanada, USA, UK, Sweden, Poland, China, Turkey, Moldova, NigeriaHigh, Upper-middle, Lower-middle16
Particle radioactivityNorth America, East AsiaUSA, ChinaHigh, Upper-middle2
Indoor combustion/household air pollutionEast Asia, South Asia, Sub-Saharan Africa, Latin AmericaChina, India, Bangladesh, Ethiopia, Malawi, Nigeria, GhanaUpper-middle, Lower-middle, Low15
Gas and modern fuel combustion (high-income settings)North America, Western EuropeUSA, UK, Sweden, AustriaHigh6
Energy efficiency/ventilationWestern Europe, East AsiaUK, Sweden, ChinaHigh, Upper-middle7
Geothermal emissionsNorthern EuropeIcelandHigh2
Homelessness/housing precarityNorth America, GlobalUSA, multi-countryHigh, Mixed7

*Identified studies through databases.

Secondly, we illustrate in Figure 2 the four major exposure pathways identified in the literature, linking the home environment to cancer outcomes: (1) radon gas from soil, rock, and building materials; (2) particle radioactivity (PR-β) from radon decay products that attach to fine particulate matter and infiltrate homes; (3) indoor combustion products released from wood, coal, biomass, or gas stoves and unvented heaters; and (4) geothermal water and steam containing naturally occurring radionuclides and trace metals. Each pathway contributes to increased cancer incidence, later stage at diagnosis, poorer survival, and higher mortality.

Housing and Energy Pathways to Cancer Outcomes.
Figure 2. Housing and Energy Pathways to Cancer Outcomes.

4 Housing and the indoor environment

Housing characteristics strongly mediate the relationship between energy systems and indoor carcinogen levels. Poor housing quality, characterized by dampness, mold, overcrowding, and inadequate ventilation, amplifies respiratory morbidity and raises concentrations of indoor pollutants (46, 47). Energy-efficiency retrofits, while essential for climate mitigation, can tighten building envelopes and inadvertently increase indoor concentrations of radon, PM2.5, and particle-bound radionuclides if not paired with balanced mechanical ventilation (25–27). Homes situated over high-radon geology or near sources of airborne radionuclides are particularly vulnerable to this trade-off (20, 23, 24).

Conversely, engineering controls can protect health while conserving energy. Heat-recovery ventilators (HRVs) or energy-recovery ventilators (ERVs), when correctly installed and maintained, can maintain air exchange without significant energy loss (27). High-efficiency filtration (minimum efficiency reporting value [MERV] 13 or higher) further reduces infiltration of both combustion particles and PR-β (33, 48). These measures are particularly critical for energy-insecure households, where occupants may spend long hours indoors and have limited financial resources to implement remediation once exposure is detected.

5 Social determinants of health and cancer outcomes

The literature consistently shows that lower socioeconomic status, minority racial or ethnic identity, limited education, and unstable housing are associated with higher exposure to residential carcinogens, later stage at cancer diagnosis, and poorer survival (49–52, 73). For example, population-based studies in Canada and the United States have demonstrated that residents of lower-income neighborhoods have higher lung and cervical cancer incidence and lower survival rates across multiple cancer types, even after controlling for smoking and other individual-level risk factors (1, 53).

Certain populations face compounded risks that heighten both cancer incidence and mortality. People experiencing homelessness are often exposed to a combination of outdoor and indoor pollutants, have high smoking prevalence, and encounter significant barriers to consistent healthcare; together, these factors exacerbate their cancer risk and hinder early detection or effective treatment (10, 29, 54). People experiencing homelessness represent an extreme manifestation of both housing and energy insecurity and experience a disproportionate burden of cancer incidence, later-stage diagnosis, and mortality. Chronic exposure to ambient air pollution, second-hand smoke, and cold stress, combined with reliance on shelters with poor ventilation or outdoor combustion sources, may increase cumulative inhalation of carcinogenic pollutants. More critically, lack of stable housing creates major barriers to cancer screening, continuity of care, and treatment adherence, contributing to delayed diagnosis and poorer survival (9, 10, 54).

Moreover, women and children living in energy-poor households spend extended periods near cooking or heating sources, resulting in higher inhaled doses of combustion-derived carcinogens and, in many settings, an elevated risk of lung cancer (14, 34, 39, 40). Next, older adults and children with chronic illness are also physiologically more susceptible to the carcinogenic effects of radon, fine particulate matter (PM2.5), and particle radioactivity (11, 13). Moreover, because particle radioactivity varies with geography and meteorological conditions, communities facing energy poverty, older or poorly ventilated housing stock, or limited access to effective filtration may experience higher effective doses of radioactive particles and have fewer options to reduce exposure (15). These structural inequities likely contribute to disparities in both lung cancer incidence and post-diagnosis survival, as illustrated by the findings of the BLCS study (15).

6 Discussion

This scoping review demonstrates that housing and energy systems are not neutral backdrops to health but active, powerful determinants of cancer outcomes across the disease continuum. The evidence we synthesized shows that exposures originating in the home environment (radon gas, indoor combustion products, and more recently recognized PR-β) consistently influence cancer risk factors and, in some cases, worsen outcomes after diagnosis.

6.1 Integrating environmental and social pathways

Among these exposures, the Boston Lung Cancer Survival (BLCS) cohort provides particularly compelling evidence. The cohort's finding that post-diagnosis exposure to PR-β independently predicts poorer lung cancer survival with a clear dose–response gradient and persistence after adjustment for residential radon extends the focus of environmental cancer research beyond primary prevention (15). These results indicate that environmental carcinogens can continue to shape outcomes after a cancer diagnosis and may even counteract the benefits of state-of-the-art treatments. For oncology, this represents a conceptual shift: the built environment is not only a source of risk for cancer initiation but also a determinant of disease trajectory and survivorship. While housing and energy insecurity frequently co-occur, the evidence synthesized in this review indicates that they operate through both overlapping and distinct mechanisms. Housing insecurity primarily influences exposure through structural pathways, such as poor ventilation, building tightness, and radon ingress, whereas energy insecurity shapes exposure through fuel choice, heating and cooking behaviors, and the inability to operate or maintain ventilation and filtration systems. Together, these factors interact to produce cumulative and sometimes synergistic exposure profiles that influence cancer risk, stage at diagnosis, and survival (6, 7, 49).

In addition to shaping material exposure, housing and energy insecurity also function as chronic psychosocial stressors that may influence cancer risk and outcomes through cumulative biological dysregulation. Energy insecurity has been conceptualized as a persistent source of financial strain, thermal discomfort, and uncertainty that repeatedly activates neuroendocrine and inflammatory stress response systems and contributes to elevated allostatic load over time (16). The allostatic load framework describes the progressive wear and tear on multiple physiological systems, including the hypothalamic pituitary adrenal axis, autonomic nervous system, immune function, and metabolic pathways, that results from prolonged or recurrent stress exposure across the life course (55, 56). Psychoneuroimmunology research further demonstrates that chronic stress can alter immune surveillance, promote systemic inflammation, and modify the tumor microenvironment in ways that facilitate disease progression and reduce treatment responsiveness, thereby linking social and material adversity to cancer prognosis as well as incidence (57). These findings indicate that environmental carcinogen exposure and psychosocial stress represent interacting, rather than isolated, mechanistic pathways through which housing and energy insecurity become biologically embedded and shape cancer risk, disease trajectory, and survival.

A significant finding from this review is the evidence that energy insecurity influences cancer risk not only through structural deficiencies in housing but also through behavioral adaptations to thermal and financial strain. The physical, economic, and coping framework proposed by Hernández et al. (16) conceptualizes how unaffordable energy and poor housing efficiency compel households to adopt unsafe practices such as using ovens or gas stoves for space heating, limiting ventilation, or relying on portable combustion devices. These coping strategies can markedly increase indoor exposure to PM2.5, nitrogen dioxide, benzene, and particle-bound radionuclides, thereby amplifying oxidative and inflammatory pathways implicated in carcinogenesis and disease progression (4, 33). This behavioral dimension clarifies how energy insecurity operates as an active exposure-shaping process rather than a passive socioeconomic background.

In addition to acting as upstream determinants of cancer risk, housing and energy insecurity may also emerge as downstream consequences of cancer and its treatment, creating a bidirectional and self-reinforcing cycle of vulnerability. A cancer diagnosis is frequently accompanied by substantial out-of-pocket medical costs, reduced income due to inability to work, and increased caregiving demands, which can precipitate or worsen housing instability and difficulty affording household energy. Qualitative and population-based studies among medically underserved populations document high prevalence of rent arrears, risk of eviction, utility shutoffs, and reliance on unsafe coping strategies following cancer diagnosis, particularly among patients experiencing financial toxicity and employment disruption (49, 58). Experimental evidence further indicates that addressing material hardship can improve cancer care processes and outcomes, as shown in randomized trials demonstrating that interventions targeting food insecurity improve treatment completion, quality of life, and psychological well-being among low-income patients with cancer (59). Together, these findings suggest that cancer-related economic strain can intensify housing and energy insecurity, which in turn may compromise treatment adherence, symptom management, and recovery, thereby reinforcing environmental and psychosocial exposures and contributing to poorer clinical outcomes.

For unhoused individuals, these mechanisms are likely intensified. Homelessness entails persistent exposure to environmental hazards, extreme thermal conditions, sleep disruption, food and energy insecurity, and profound psychosocial stress, all of which can amplify allostatic load and immune dysregulation. In parallel, structural barriers to timely diagnosis and uninterrupted treatment further compound biological vulnerability, creating a convergence of environmental, social, and clinical risk that places unhoused populations at the highest end of the cancer inequity spectrum (9, 10).

Mechanistic studies reinforce these observations. Radon progeny and radioactive particles attach to fine particulate matter and, once inhaled, are deposited deep in the respiratory tract, where they emit alpha, beta, and gamma radiation capable of producing reactive oxygen species (ROS) and reactive nitrogen species (RNS) (11, 12). These reactive molecules inflict DNA double-strand breaks, base damage, and chromosomal aberrations, and interfere with DNA repair mechanisms (41). Oxidative stress also triggers lipid peroxidation and protein modification, activating oncogenic signaling cascades and inhibiting tumor suppressor pathways (37). Collectively, these processes foster both cancer initiation and tumor progression. The BLCS observation that early-stage patients experienced the strongest association between PR-β and poorer survival suggests that continued exposure may accelerate disease progression or undermine the effectiveness of curative treatments such as surgery or radiation therapy (15).

In parallel, exposures such as indoor combustion pollutants and geothermal emissions contribute additional carcinogenic and co-carcinogenic insults. Household air pollution from solid fuel use exposes billions of people to PM2.5, PAHs, and VOCs, all of which are recognized or suspected human carcinogens (14, 34, 35). These exposures not only raise cancer incidence but may also complicate diagnosis by producing chronic respiratory symptoms that mask early signs of malignancy and can worsen outcomes through persistent inflammation or impaired pulmonary function (39, 40). Ecological studies from Iceland and Turkey further show that long-term use of geothermal water for space heating is associated with elevated mortality from several cancers, plausibly due to low-level exposure to naturally occurring radionuclides and trace metals (28, 42).

Taken together, these findings reveal an interconnected web of environmental and social determinants. Housing characteristics and energy practices create the physical conditions for carcinogen exposure, while SDOH (income, education, racial or ethnic minority status, and access to health care) determine who is most exposed and least able to mitigate risks (9, 49, 51). Low-income, marginalized and unhoused or precariously housed populations are more likely to experience poor ventilation, higher baseline radon levels, or reliance on biomass fuels, and substantial barriers to radon testing, high-efficiency filtration, or comprehensive cancer care (29, 59, 60). These structural inequities produce a double burden: greater exposure to carcinogens and worse survival once cancer occurs (10, 53, 54). Thus, cancer control must be understood not only as a matter of individual behavior or clinical treatment but also as a function of housing policy, energy policy, and social equity.

6.2 Built environment and clinical implications

The convergence of evidence from environmental science and oncology has direct implications for public policy, housing design, and clinical practice. Energy-efficiency programs and housing policy play an important role. Efforts to reduce greenhouse gas emissions through home weatherization and energy retrofits are essential for climate mitigation, but without careful design, they can unintentionally increase indoor concentrations of radon and particle radioactivity (22, 25–27). Policies that fund or mandate energy upgrades should require integrated indoor air quality protections, including pre- and post-retrofit radon testing, installation of balanced mechanical ventilation systems such as heat-recovery ventilators (HRVs) or energy-recovery ventilators (ERVs), and high-efficiency particulate air filtration (MERV-13 or higher) (33, 48). Incentive programs can offset the costs of these measures, ensuring that climate action does not inadvertently worsen cancer risk.

Findings from the study have informed the creation of a flowchart in Figure 3, which presents a directional conceptual pathway linking housing and energy insecurity to cancer outcomes. In Figure 3, the central pathway progresses from environmental sources (housing and energy insecurity) to environmental exposures (indoor and outdoor pollutants), which contribute to biological damage and ultimately adverse cancer outcomes, including increased incidence, later stage at diagnosis, and poorer survival. Psychosocial/behavioral and biological mediators are positioned above the pathway to represent mechanisms through which these exposures translate into harm, including coping behaviors that influence exposure levels and physiological processes such as chronic stress, allostatic load, inflammation, oxidative stress, and DNA damage that contribute to carcinogenesis. Moderating factors are depicted below the pathway to reflect contextual influences that shape the magnitude and distribution of risk, including socioeconomic position, structural inequities, policy environments, and health care access. Together, this structure clarifies the causal sequence from environmental conditions to disease while distinguishing mechanistic pathways from broader social and systemic determinants. It also calls for additional studies to examine the structural and causal pathways identified through a synthesis of the extant literature.

Conceptual pathway linking housing and energy insecurity to environmental exposures, biological damage, and cancer outcomes, with mediating and moderating factors.
Figure 3. Conceptual pathway linking housing and energy insecurity to environmental exposures, biological damage, and cancer outcomes, with mediating and moderating factors.

The evidence generated by the study further confirms the need to strengthen environmental monitoring and regulation. Existing air quality standards primarily target PM mass concentrations and set action levels for radon in air and water. They do not address the radiometric characteristics of particles. National and regional monitoring networks should expand their scope to include PR-β and make these data publicly accessible (15). Incorporating PR-β into routine surveillance would allow for evidence-based risk communication, guide community-level interventions, and support the development of protective regulatory thresholds.

Next, an important derivative of this study is the call for clinical practice and survivorship care to integrate attention to environmental exposures. Oncology clinicians increasingly recognize the need to address environmental exposures as part of comprehensive cancer care. Counseling patients (particularly those with early-stage lung cancer or longer life expectancy) about radon testing and mitigation, the use of kitchen exhaust ventilation, smoke-free home policies, and high-efficiency filtration can reduce ongoing exposures that may influence survival (2, 11, 13). Integrating environmental assessments into survivorship plans can help patients and families take practical steps to improve indoor air quality and potentially improve long-term outcomes (9). Given evidence that cancer-related financial strain can precipitate housing and energy insecurity, survivorship care should also include screening for housing and utility needs and referral pathways to supportive services (49, 61).

Furthermore, community engagement and equity are equally critical. Because energy poverty and substandard housing disproportionately affect marginalized populations, interventions must be designed and implemented with community input and equity in mind. Programs that provide free or subsidized radon testing and mitigation, or that bundle ventilation upgrades with energy assistance, can reduce both environmental and social drivers of cancer disparities (49, 62).

6.3 Research gaps and future priorities

While the evidence base is growing, this review reveals substantial gaps that limit our ability to fully understand and mitigate the impact of housing and energy insecurity on cancer outcomes. Addressing these gaps will require sustained multidisciplinary collaboration across epidemiology, environmental science, oncology, engineering, and social policy.

First, there is a pressing need for longitudinal, multi-exposure studies. Much of the existing literature examines single exposures (such as radon, PM2.5, or PR-β) in isolation. Future research should integrate multiple exposures, including radon, PR-β, indoor PM2.5, ventilation rates, and filtration performance, and incorporate repeated measurements before and after cancer diagnosis. Such designs would clarify the cumulative and interactive effects of these exposures on incidence, stage at diagnosis, survival, and mortality.

Second, improvements in personal and indoor monitoring of PM2.5 and PR-β are required. Current exposure estimates are derived largely from regional monitoring networks and modeled concentrations, which may result in exposure misclassification (80). The development of affordable, portable PR-β and PM2.5 sensors for personal and indoor use, and their deployment in large population-based cohorts, would strengthen exposure assessment and help identify microenvironments where mitigation is most urgently needed.

Third, future research should prioritize equity-focused analyses. Housing type, retrofit status, and energy poverty strongly influence carcinogen exposure, yet these variables are rarely captured in cancer epidemiology. Explicit evaluation of how structural inequities (such as racial segregation, housing discrimination, and energy affordability) shape exposures and outcomes is essential to provide the evidence base for targeted, equity-oriented interventions.

Fourth, there is a critical gap in intervention and implementation research. Experimental and quasi-experimental studies are needed to evaluate the effectiveness of combined energy-efficiency and indoor air quality strategies. For example, trials that simultaneously test radon mitigation, installation of heat- or energy-recovery ventilation systems (HRV/ERV), and high-efficiency filtration could quantify reductions in exposure and assess cost-effectiveness, providing actionable evidence for scalable housing and energy policies.

Fifth, most of the evidence originates in high-income countries, yet LMICs often experience higher baseline exposures due to widespread solid fuel use, limited access to clean energy, and inadequate ventilation infrastructure. Expanding research in LMIC contexts is essential to address global cancer inequities and inform international guidelines.

Finally, mechanistic and translational studies are needed to bridge epidemiology and biology. Laboratory investigations examining how PR-β and other indoor pollutants influence tumor microenvironments, immune modulation, and metastatic potential would deepen our understanding of the biological pathways linking exposures to clinical outcomes (70, 73). Such studies may also identify novel therapeutic targets or biomarkers, enabling the translation of environmental findings into precision oncology.

6.4 Toward integrated action

The evidence compiled in this review leads to a clear conclusion: effective cancer control demands integration of environmental, social, and clinical strategies. Addressing housing and energy insecurity is not simply a matter of improving comfort or reducing energy bills—it is a public health imperative with direct implications for cancer prevention and survival. Policies that synchronize climate action with indoor air quality protection, public health agencies that monitor and communicate about particle radioactivity, and oncology teams that incorporate environmental counseling into care can collectively reduce the burden of cancer and narrow persistent disparities. By recognizing the built environment as both a source of risk and a lever for intervention, researchers, clinicians, and policy makers can move toward a future in which housing and energy systems support, rather than compromise, the fight against cancer.

6.4.1 Limitations

This scoping review has several limitations that should be considered when interpreting its findings. Despite the use of a comprehensive, systematically developed search strategy across biomedical, environmental, and social science databases, as well as selected gray literature sources, relevant studies may have been missed due to limitations in indexing systems, incomplete coverage of gray literature, and the exclusion of non-English publications, which together may have introduced publication and language bias. In keeping with the objectives of a scoping review, we did not undertake a formal quality appraisal or risk-of-bias assessment of included studies; as a result, the evidence summarized here should be viewed as descriptive and exploratory rather than as providing definitive effect estimates. The broad scope of the review also necessitated the inclusion of studies with heterogeneous exposure assessments, study designs, and outcome measures, which reduced comparability across contexts and precluded meta-analysis. In addition, the reliance on published data meant that important contextual details (such as socioeconomic modifiers, housing characteristics, and co-exposures) were often absent or inconsistently reported, limiting the depth of synthesis possible. Lastly, supplementary sources were incorporated to provide background definitions and epidemiological context, but because these materials were not subjected to the same inclusion and exclusion criteria as the primary studies, they should be interpreted as supportive rather than central to the evidence base.

7 Conclusion

This scoping review highlights that housing and energy systems are fundamental determinants of cancer risk and outcomes, operating not only at the level of incidence and diagnosis but also throughout the continuum of survival and mortality. Exposures originating in the home environment—including radon, indoor combustion products, and particle radioactivity—were consistently associated with cancer outcomes, while additional evidence from geothermal systems and poor housing conditions further underscores the role of the built environment in shaping health trajectories. Importantly, these exposures intersect with social determinants of health, such as income, education, race or ethnicity, and housing stability, to create compounded vulnerabilities that disproportionately affect marginalized populations. The convergence of evidence across environmental science, oncology, and social epidemiology demonstrates that cancer control cannot be addressed solely through clinical or behavioral interventions but requires coordinated action across housing, energy, and public health policy. Future research should build on these findings by adopting longitudinal, multi-exposure designs, incorporating equity-focused analyses, and expanding investigations to underrepresented regions, particularly LMICs. By recognizing and addressing how housing and energy insecurity contribute to cancer disparities, policymakers, clinicians, and researchers can work toward integrated strategies that improve prevention, strengthen survivorship, and reduce inequities in cancer outcomes.

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Supplementary material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fcacs.2026.1747292/full#supplementary-material

Supplementary material Supplementary material at the source

Footnotes

Edited by: Qian Li, Columbia University, United States

Reviewed by: Gabriella Meltzer, American University, United States

Felipe Antequera, Columbia University, United States

Statements

Conflict of interest

The author(s) declared that this work was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

The author GB declared that they were an editorial board member of Frontiers, at the time of submission. This had no impact on the peer review process and the final decision.

Funding

The author(s) declared that financial support was received for this work and/or its publication. This research was undertaken, in part, thanks to funding from the Canada Research Chairs Program, grant number (#102849). The funding source had no involvement in the study design, review, or interpretation of the data.

Author contributions

YH: Formal analysis, Methodology, Writing – review & editing, Writing – original draft, Investigation, Conceptualization. FZ: Writing – review & editing, Methodology, Formal analysis. MO: Supervision, Writing – review & editing, Conceptualization. DO: Writing – review & editing, Validation, Methodology. GB: Supervision, Methodology, Conceptualization, Funding acquisition, Writing – review & editing, Writing – original draft.

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Citation

Husen, Y., et al. (2026). Cancer risk and the burden of housing and energy insecurity: a scoping review. Frontiers in Cancer Control and Society, Volume 4. https://doi.org/
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4 - 2026

Copyright

Copyright © 2026 Husen, Zeshan, Odei Boateng, Otoadese and Boateng.

License: https://creativecommons.org/licenses/by/4.0/

*Correspondence: Godfred O. Boateng

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