“When It Comes to Heat, I Retreat”: Heat Impacts and Adaptation Practices Among People with Cancer

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Ashad-Bishop, Felicia O. Casanova, Mayra Cruz, Nkosi Muse, and 9 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7482903/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Across the US, increasingly prevalent heat extremes pose diverse threats to population health and well-being. Due to sensitivities from age-related declines in thermoregulation, elevated prevalence of comorbidities, drug-induced dehydration and fatigue, as well as decreased disposable income, people with cancer are recognized as particularly susceptible to heat impacts. Yet, little empirical research has focused on this population. Our objective was to understand heat impacts, coping mechanisms, and adaptation practices among people with cancer. This qualitative study used semi-structured interviews of adults with a history of cancer in South Florida. Between May 2024 and January 2025, a total of 20 participants across 18 unique zip codes were interviewed, and data were analyzed using rapid qualitative methodology. Four key themes reflected ongoing challenges related to how people with cancer experience and adapt to heat in the region: (1) heat interacts with health status to adversely affect quality of life among people with cancer, (2) increased cooling needs result in significant lifestyle adjustments, (3) patient-provider communications are underutilized opportunities to discuss heat risks and heat-responsive health-promoting behaviors, and (4) social support facilitates heat adaptation. Our findings indicate that heat exposure leads to prominent health impacts among people with cancer, as well as a prioritization of access to cooling despite financial and social consequences. This need to stay cool often decreased quality of life due to social withdrawal, but quality of life impacts were mitigated by social support. Our findings indicate that heat exposure may differentially affect people with preexisting conditions such as cancer, leading to social withdrawal and maladaptive behaviors, which indicates a need for heat adaptation policy tools to be tailored to the unique needs of medically vulnerable populations. Future research should seek to further our understanding of behavioral changes among people with chronic disease in response to heat exposure, specifically across regions with chronic heat and humidity. Cancer Survivors Extreme Heat Quality of Life Heat Adaptation Social Support Figures Figure 1 Introduction In much of the continental United States, the prevalence of heat hazard extremes have been increasing over at least the past 60 years (Habeeb et al., 2015 ; Vose et al., 2017 ). Across the country’s diverse physical geography and climate (Beck et al. 2023), such heat hazards are experienced differently—from more persistent, chronic heat in the lower subtropics (Cruz et al., 2025 , Wodzicki et al., 2024), to an increased frequency and duration of extreme temperatures at midlatitudes (Heeter et al., 2023, Lyon and Barston, 2017). In addition, extensive urbanization has further intensified hazards via the urban heat island effect, amplifying heat risks in cities that house most of the U.S. population (Muse et al., 2024 , Li et al., 2025, Tadros et al. 2021). Heat hazards have well-documented health consequences, including associations with increased incidence of respiratory, heart, and infectious diseases, poor mental health, hospital admissions, injuries, and deaths (Bobb et al., 2014 ; Bunker et al., 2016 ; Ebi et al., 2021 ; Ellis, 1972 ; Nori-Sarma et al., 2022 ). These impacts are amplified among people with heat-sensitive chronic health conditions (Ebi et al., 2021 ), especially older adults who suffer impaired thermoregulation in response to extreme temperatures (Bunker et al., 2016 ; Kohon et al., 2024 ; Millyard et al., 2020 ). In the United States in 2025, there will be an estimated 2 million new diagnoses of cancer, a common chronic illness that requires costly, coordinated, and multidisciplinary care (Siegel et al., 2025 ). Further, over 18 million people with a history of cancer in the United States (Siegel et al., 2022 ; Tonorezos et al., 2024 ) are at disproportionate risk of heat negatively impacting their health due to the prevalence of comorbidities that are independently associated with risk of heat-related illness (Fowler et al., 2020 ; Hassan et al., 2023 ; Sarfati et al., 2016 ; Stoltzfus et al., 2020 ). Further, common oncology treatments can induce dehydration and fatigue, warranting precaution regarding sun, heat, and humidity exposure from both healthcare providers and patients (Blakely et al., 2019 ; Glassock et al., 1977 ; Sarhill et al., 2001 ; Vassal et al., 1987 ). Despite these risks to the burgeoning number of people bearing the burden of cancer in the United States, there are few studies considering how people with cancer are being impacted by, coping with, and adapting to the increased frequency and severity of elevated heat and humidity. Residents of South Florida, a region where high temperature and humidity co-occur throughout a significant part of the year (Clement et al., 2023 ; Cloutier-Bisbee et al., 2019 ; McAllister et al., 2022 ), are impacted in unique and complex ways to seasonally high levels of elevated heat and humidity (Cruz et al., 2025 ; Turek-Hankins et al., 2025 ). The objective of this qualitative investigation was to assess the impacts of chronic heat on health, quality of life, and healthcare access among 20 people with a history of cancer in South Florida. Methods & Materials Study Participants Participants included 20 people with a history of cancer, defined as having ever been diagnosed with cancer, living in South Florida, a region of the US that suffers persistent and varied heat exposure (Clement et al., 2023 ). Participants were recruited from 1) two ongoing clinical studies in which participants provided their consent to be contacted for future research studies and 2) University of Miami’s clinical research recruitment website, UMiamiHealthResearch.com. Both clinical studies had distinct aims from the current qualitative study. First, we conducted a telephone screen to recruit participants from ongoing clinical studies who met the following inclusion criteria: 1) being 18 years of age or older, 2) residing in South Florida (Miami-Dade, Broward, Monroe, or Palm Beach County), and 3) having a history of a cancer diagnosis or treatment. Participants were excluded if they were unable to provide consent or unable to speak in either English or Haitian Kreyol. Enrollees who were interested and eligible were consented, interviewed either virtually or on-site, and compensated $ 100. The study was conducted in Miami, FL. All study procedures were reviewed and approved by the Institutional Review Board at University of Miami. Data Collection Interviews were completed either virtually or on-site between May 2024 and January 2025 and audio-recorded using Zoom. Prior to any study activities, participants provided verbal consent to participate (following IRB-approved study procedures). Our consent protocol involved a study team member reading participants consent information, which informed them of the study objectives and procedures, risks and benefits of participating, the voluntary nature of their participation in the study, their right to withdraw from the study, data confidentiality and storage, and contact information for the study PI and overseeing IRB. After indicating verbal consent to participate, the study team member proceeded to ask a brief series of demographic questions prior to their interview. The demographic survey included questions about housing, income, education, employment status, age, sex and gender identity, and race/ethnicity. After the demographics survey, participants completed semi-structured interviews with one of four trained study staff in English (n = 16) or Haitian Kreyol (n = 4). A semi-structured interview guide (~ 45–60 minutes) developed by KCB, MC, and KJM guided the interviews. The Haitian Kreyol translation of the interview guide was forward and back translated by two separate individuals bilingual in English and Haitian Kreyol and approved by the IRB. The interview guide, which was iteratively adapted as we analyzed initial insights using grounded theory techniques (Charmaz, 2006 ), explored the domains of heat impacts and access to care, social impacts and adaptation practices, and bill consciousness. During the interviews, participants were asked to describe (1) their medical history and any electricity-dependence considerations for current treatments, (2) their experiences of extreme heat, including physical and mental health impacts pre- and post-diagnosis, access to healthcare resulting from heat impacts, and conversations with health professionals about heat interactions with cancer treatments, (3) the ways they cope with and adapt to extreme heat, including social networks and support programs, and (4) any financial tradeoffs necessary to manage medical bills and energy needs for cooling. The complete sociodemographic survey and interview script are provided in the eMethods Supplement. Upon completion of the interviews, data were securely stored using a university-approved Cloud platform that only the study team could access, as approved in our IRB protocol. Qualitative Analysis Rapid qualitative analysis, an established approach for expedited, rigorous implementation research, was employed to analyze the data collected for the current study (Nevedal et al., 2021 ) from May 2024 to March 2025. Our rapid qualitative analysis involved the following steps, in accordance with the methodology established by Hamilton and Finley (Hamilton & Finley, 2019 ). First, KCB and EB developed an “interview summary” template in Microsoft Word based on the interview guide, accompanied by written instructions for completion of interview summaries. KCB trained all team members on how to use the interview summary template to systematically document key insights and quotations from each interview. Then, KCB, EB, FC, MC, and JR followed a standardized process for completing and auditing interview summaries for each interview. Each interview was summarized directly from audio recordings by two independent team members using the interview summary template, then each interview summary was reviewed by the lead author. Key insights and quotations from interviews completed in Haitian Kreyol were translated and documented in English by bilingual team members. Next, KCB and FC transferred key insights and quotations to a matrix summary in Microsoft Excel, allowing team members to view participant responses within each domain. Once the first ten interviews were completed and summarized, the data were transferred to the matrix summary document, where KCB, EB, and FC began analyzing data to identify emergent themes. Each analyst independently reviewed the data comprising the matrix summary to identify and define emergent themes and illustrative key quotations. Inconsistencies in themes identified across analysts were discussed among the study team until consensus was reached. The remaining ten interviews were summarized upon completion and integrated into the matrix summary. We continued to interview participants until saturation, or the point where no additional themes emerged, was reached. A final thematic summary document was developed based on the analysis of the matrix summary. All participants are referred to by pseudonyms in the reported results. All authors reviewed and agreed on the accuracy of the findings as reported in this manuscript. Results Sociodemographic Profile of Study Participants Overall, participants lived across Miami-Dade and Broward Counties (80% Miami-Dade, 20% Broward), across 18 unique zip codes. Participants were predominantly 45–64 years old (55%) or 65 years of age or older (35%), with the largest racial/ethnic groups being Black (Non-Hispanic) (60.87%), Black (Hispanic) (17.39%), White (Hispanic) (8.7%) and White (Non-Hispanic) (8.7%). In terms of housing tenure, participants reported being renters (40%) or property owners (35%) or having other less formal arrangements, such as living with relatives or subleasing (25%). Most reported having 2–4 people in the household (60%). Most had retired from the workforce (40%) or were on medical leave (25%), and separately, 35% of participants reported an annual household income of less than $ 30,000. All of our participants had health insurance (100%), whether employer-sponsored (25%) or subsidized healthcare programs for low-income individuals and families (45%). The sociodemographic profile of our study population is described in Table 1 . Table 1 Participant Characteristics Characteristic No. (%) Participants (n = 20) Housing Tenure a I own my home 7 (35) I rent a room in a home 5 (25) I rent my home 8 (40) Housing Type a Apartment, condo, or multiplex 10 (50) Houseless or in transition housing 1 (5) Room in a single-family home or house 2 (10) Single family home or house 7 (35) Number of Residents in Home a 1 5 (25) 2–4 12 (60) 5 or more 3 (15) Household Annual Income a Less than $ 30,000 7 (35) $ 30,000 to $ 60,000 4 (20) $ 60,000 to $ 90,000 5 (25) More than $ 90,000 4 (20) Health Insurance Coverage a Any other type of health insurance or health coverage plan 4 (20) For people 65 and older, or people with certain disabilities 5 (25) Insurance purchased directly from an insurance company 2 (10) Insurance through a current or former employer or union 5 (25) Medical Assistance, or any kind of government-assistance plan for those with low incomes or a disability 3 (15) VA (enrolled for VA Health care) 1 (5) Employment Status a Full-time 5 (25) Medical leave 5 (25) Part-time 2 (10) Retired 8 (40) Age a 25–44 2 (10) 45–64 11 (55) 65 and older 7 (35) Gender a Cisgender woman or female 8 (40) Cisgender man or male 11 (55) Trans/non-binary 1 (5) Race & Ethnicity b White (Non-Hispanic) 2 (8.7) White (Hispanic) 2 (8.7) Black (Non-Hispanic) 14 (60.9) Black (Hispanic) 4 (17.4) American Indian or Alaska Native (Non-Hispanic) 1 (4.3) a Self-identified by participants from closed-ended questions. b Self-identified by participants from closed-ended questions. Racial identity was not limited to one selection, resulting in a total number greater than the number of participants. No participants identified as Asian, Native Hawaiian, or Pacific Islander. Four themes emerged from our rapid qualitative analysis reflecting how heat exposure is affecting people with cancer: (1) heat interacts with health status to adversely affect quality of life among people with cancer, (2) increased cooling needs result in significant lifestyle adjustments, (3) patient-provider communications are underutilized opportunities to discuss heat risks and heat-responsive health-promoting behaviors, and (4) social support facilitates heat adaptation. The primary themes are presented along with the related subthemes and their descriptions in Table 2 . Table 2 Study Themes, Subthemes, and Descriptions Primary Theme Subtheme Description Heat Interacts with Health Status to Adversely Affect Quality of Life Among People with Cancer This theme encompasses participant descriptions of the way that heat interacts with their cancer diagnoses and comorbidities to impact quality of life and heat adaptation needs. Increased Cooling Needs Result in Significant Lifestyle Adjustments Heat Avoidance as a Coping Mechanism This theme describes short-term strategies to meet increased cooling needs among participants and experiences with the expenses associated with those adjustments. Medical and Cooling Expenses Are Equally Prioritized as Lifestyle Adjustments Patient-Provider Communications Are Underutilized Opportunities to Discuss Heat Risks and Heat-Responsive Health-Promoting Behaviors Infrequent Conversations with Healthcare Providers About Heat This theme relates to participant interactions with medical providers, including aspects of patient-provider conversations and how heat exposure influences adherence to physician recommendations. Limited Adherence to Doctor-Recommended Health Protective Behaviors Social Support Facilitates Heat Adaptation Lack of Financial Support for Expenses Associated with Cooling This theme relates to participant experiences with heat adaptation, including financial and social support for cooling. Social Support as a Means of Adaptation Heat Interacts with Health Status to Adversely Affect Quality of Life Among People with Cancer All of our study participants reported being impacted by heat either before or after their cancer diagnosis. Whereas 14 (70%) participants reported that heat impacted their physical or mental health prior to their cancer diagnosis, the remaining 6 (30%) reported impacts that began after their cancer diagnosis. Among our study participants, there was substantial variability in comorbidity burden and consequent pre-diagnosis vulnerability to heat exposure; This variability contributed to differences in the way that participants attributed post-diagnosis heat impacts to interactions between their cancer diagnosis or treatment and heat. Among our study population, only 3 (15%) of participants self-reported cancer as the sole chronic disease they were managing. Participants reported comorbidities including physical health issues such as type 2 diabetes, HIV, high blood pressure, thyroid disease, rheumatoid arthritis, osteoarthritis, kidney disease, hypertension, and autoimmunity, as well as mental health issues such as bipolar disorder and generalized anxiety. These conditions had ranging impacts on participants’ experiences with heat sensitivity, from both the conditions themselves and the corresponding treatments. A prostate cancer survivor, here forth referred to as Miles, reported that before his cancer diagnosis, prolonged heat exposure led to exhaustion. Post-diagnosis, he can only stay in the heat for 30–45 minutes, with prolonged heat exposure leading to loss of mental acuity. Another person undergoing treatment for prostate cancer, here forth referred to as Leon, who was similarly impacted, shared that the heat “sucks the life out of him.” Anita, who was admitted to the hospital for a heat-induced seizure reported: I can’t have heat exposure with my medications. Some of them bring out hives, rashes, so I can’t, that’s the first thing they told me [after the incident]. So, if you like to be outside in the sun, you can’t. So, I haven’t. Conversely, a less heat-impacted breast cancer survivor, here forth referred to as Ayra, described experiencing mild heat intolerance both pre- and post-diagnosis but shared that she did not see a connection between heat intolerance and cancer: I did not correlate heat and humidity with our cancers. I correlate our food and our water because it’s easily consumed. This highlights that although heat impacts were widespread among our study population, they were not always mentioned as being a result of or exacerbated by chronic health conditions or treatments. Still, from the commonality of heat impacts emerged a shared sentiment that avoiding the heat and staying cool was not only a priority, but a necessity. Increased Cooling Needs Result in Significant Lifestyle Adjustments Heat Avoidance as a Coping Mechanism Many of our participants reported staying cool as a necessity, and a shared sentiment was that a comfortable temperature had to be maintained no matter the cost. The cost was not exclusively financial, participants also described staying cool to the detriment of time spent outdoors and social participation. This resignation to adapting to heat impacts, despite the cost, was described by Billie, a breast cancer survivor: “The heat isn't going anywhere, we must resign ourselves to it." Participants shared that to avoid heat exposure, they initiated lifestyle adaptations including only leaving the house early in the morning or late at night when temperatures aren’t as extreme, scheduling and traveling to medical appointments in the morning before the heat peaks, and near constant use of air-conditioning, ice packs, cool and protective clothing, and fans. Michael, who is managing prostate cancer, kidney disease, and hypertension, shared: "I know the side effects of heat stroke can be very serious and with my co-morbidities I don't want to fool with it, so I stay out of the heat as much as possible." A common theme among participants’ accounts of heat adaptation practices was withdrawal from social participation. Leon recounted a general lack of social interactions that require time spent outside: "If there is going to be a line for an event, I avoid it. If there comes time for voting, I registered for an absentee ballot to avoid possibly being an hour outside…When it comes to heat, I retreat!” and James, a prostate cancer survivor, stated: "I might go outside 30 minutes to an hour at most. I'm basically inside all day. Staying cool is what it's all about for me." Medical and Cooling Expenses Are Equally Prioritized as Lifestyle Adjustments Due to the consensus regarding the importance of cooling, we sought to understand whether tradeoffs were being made between elevated medical and cooling expenses. No tradeoffs for electricity or medical bills were reported, but elevated medical bills led participants to cut down on recreational expenses. A shared sentiment that emerged was a resignation to a new reality of having to forgo other daily costs for essential expenses such as food and housing. Marian, who is managing breast cancer, high cholesterol, and hypertension, shared: "Sometimes I want to do something or buy something to eat, but I have no money left because I have to cover the expenses related to my illness." Most participants did not articulate in what ways they were at financial capacity, but expressed having to borrow from their 401K or retirement, borrow money from family members, and pursue additional revenue streams such as additional jobs or pawning personal items. Ayra expressed the taxing financial implications of chronic disease: I call cancer a Gucci disease, a designer disease, it’s costly. Despite social withdrawal, our study population reported consistent interactions with healthcare providers due to the sensitive nature of the health conditions they are managing. Patient-Provider Communications Are Underutilized Opportunities to Discuss Heat Risks and Heat-Responsive Health-Promoting Behaviors Cancer is a complex disease that requires coordinated, multidisciplinary, and often multisite care. Two subthemes emerged related to patient-provider interactions as opportunities to communicate around heat risks and opportunities to mitigate heat-related health impacts. Infrequent Conversations with Healthcare Providers About Heat Our study found that despite frequent and consistent interactions with a range of healthcare providers, there were limited reports of provider-initiated conversations about heat. Of the nine participants who reported having a heat-related conversation with a healthcare provider, only six of those conversations were provider-initiated. The conversations that were reported mostly centered interactions with medications and medical devices. Patient-initiated conversations, which were usually in response to an adverse health event, were reported as poorly received. Anita, who is managing recurrent lymphoma, recounted an experience where she attempted to initiate a conversation about heat sensitivity, "I have told them [about heat sensitivity]. One nurse told me it’s menopause.” Anita was later admitted to the emergency room due to a heat-induced seizure. Grace, a breast cancer survivor, also mentioned initiating a conversation about heat sensitivity where she did not feel heard. Eventually, her doctor offered therapeutic intervention for hot flashes. In contrast, male participants in this study reported provider-initiated conversations about heat that were accompanied by lifestyle recommendations including avoidance of heat exposure, the importance of hydration, apparel recommendations to support cooling, and vitamin supplementation due to inadequate sun exposure. Interestingly, participants that reported patient-provider conversations also reported seeking care for symptoms of heat-related illness, which indicates the importance of these interactions in mitigating potential negative health outcomes including physical and mental illness, morbidity, and mortality. Limited Adherence to Doctor-Recommended Health-Protective Behaviors Participants often cited difficulties adhering to doctor-recommended health-protective behaviors such as physical activity. Those who were committed to adherence reported walking and working out indoors, but the majority of participants reported a lack of adherence because of heat avoidance or lack of convenience. Ray, who has conversed with his cardiologist about heat risks and does all of his physical activity indoors when it is hotter outside, shared, The only person that I’ve had the discussion with is my cardiologist because he looks after my hypertension...That’s tied to me going up stairs and keeping myself in the kind of condition that I can get some exercise in. James, on the other hand, spends most of his time indoors and limits his physical activity, "Yea, I can [go walking], but I don’t want to go out there in that heat. If I do do it, I can’t walk around but one time. I usually do like 3 or 4 [laps]...but it’s too hot for all that. and Anita, who has medication-induced heat sensitivity, shared a similar sentiment, They [the doctors] sent me to walk everyday but to tell you the truth of where I live there’s no parks close by and the heat, it doesn’t let me, so I don’t get no exercise. Moreover, Grace described how extreme heat compounded the fatigue she already faced as a cancer survivor and influenced her to forego a doctor’s appointments to avoid heat exposure: yeah, actually, I have. I'm thinking about, because sometimes I have skipped doctor's appointments, and sometimes it's because I quite literally don't want to get in the shower. And I'm so disgusting like, too tired to get in the shower. So I reschedule. From these data, a clear opportunity emerged to provide heat-responsive recommendations for health-protective behaviors that may further positive cancer outcomes. Social Support Facilitates Heat Adaptation The heat adaptation theme described the ways that people supported their increased cooling and medical needs. Three specific subthemes were evident in the participants’ accounts regarding support for lifestyle changes, including financial adjustments, which were necessary to accommodate increased cooling and medical needs. Lack of Financial Support for Expenses Associated with Cooling Very few people reported the receipt of financial support for cooling despite some knowledge of support programs, most financial support was received for medical bills. All of our study participants were covered by medical insurance, which lessens the burden of medical expenses. However, a common sentiment discussed was the burden of reconciling medical bills and other healthcare expenses with insurance and healthcare systems, which made it difficult to plan for medical expenses. The unpredictable nature of medical expenses was a sharp contrast to the expected, elevated expenses associated with cooling. Yet even among the participants who reported some knowledge of financial support programs, very few (2; 10%) applied or received any consistent support. This internalized responsibility for expenses seemed to underlie patient-initiated lifestyle changes unless social support networks were present. Social Support as a Means of Adaptation In the absence of financial support for elevated medical and cooling expenses, a common patient-initiated lifestyle change was withdrawal from social participation to avoid heat. However, strong social networks were able to attenuate the consequences of social isolation. Louis, a prostate cancer survivor who is also managing diabetes, did not report lifestyle changes because of his love of the outdoors, describing: “We [he and his wife] both figure out, you know, if we need to take ice, or whatever, or I try to make sure I have, you know, things that can help me. Portable fans, you know, ice packs, you know, little things that I know that I may need. If I’m gonna be in the sun long I try to make sure I have a cooler or a bag full of stuff.” Ray shared a diverging sentiment since he spends most of his time indoors in the AC, stating: “She [my wife] would tell you that she’s literally freezing. You know it’s uncomfortable for her, but it’s very comfortable for me.” The willingness of family and friends to sacrifice personal comfort for the comfort of the participants was commonly reported. Further, social support ranged from familial support for cooling, transportation, medical expenses, and emergencies to health-system mediated support for physical and mental well-being. However, only one participant reported social support that was specifically offered to mitigate potential heat impacts on healthcare access. Anita, who had a history of skipping medical appointments due to heat-related fatigue, explained, So I don’t miss appointments, they come pick me up in an Uber. These patient experiences suggest many opportunities for programs and policies to mitigate heat impacts, including physical health, mental health, and financial burdens, on population health among people with cancer. As heat intensifies, opportunities may present to encourage healthcare access for regularly scheduled visits, as well as unexpected visits for heat-related illnesses, among this extremely sensitive population. Discussion This is, to our knowledge, the first qualitative assessment of how heat negatively impacts quality of life among people with cancer and patterns health-protective behaviors to mitigate heat exposure in a chronically hot and humid region. We found that our study population reported prevalent experiences of deleterious heat impacts patterned by both cancer and comorbidities that are independently associated with sensitivity to heat exposure. The common sentiment was that cooling became a necessity, and our participants adapted to increased cooling needs through staying indoors and constant use of air conditioning. Despite reports of elevated electricity costs due to increased cooling needs, there was little reported awareness of or receipt of assistance from energy assistance programs. Due to their health status, participants reported consistent and frequent interactions with healthcare providers. These patient-provider interactions emerged as underutilized opportunities to discuss heat risks and maladaptive coping strategies, including withdrawal from social and physical activities that require time spent outdoors. Previous literature on heat impacts among people with chronic disease has largely focused on chronic diseases with biological determinants of vulnerability such as cardiovascular disease, diabetes, mental health conditions, kidney diseases, and respiratory disorders (Ebi et al., 2021 ; Kenny et al., 2010 ; Vaidyanathan, 2020 ). Though it has been posited that people with cancer are particularly sensitive to heat impacts due to the physical, psychological, and socioeconomic consequences of cancer diagnosis, treatment, and survivorship care (Hassan et al., 2023 ), very little is known about the ways that heat hazards impact quality of life among this population and how people with cancer cope and adapt. So, although previous studies have not specifically studied heat impacts and strategies for coping and adaptation among people with cancer, our data represents an expansion of an emerging body of literature on climate, aging, and health. Cancer is most prevalent among people over the age of 50 years (Siegel et al., 2025 ), the same population that is also at the greatest risk of heat-related mortality due to physiological challenges, including decreased capacity for thermoregulation which may be exacerbated by treatment-induced heat intolerance (Jung et al., 2023 ; Millyard et al., 2020 ). A recent study found that two-thirds of people diagnosed with cancer had at least one comorbidity at the time of their diagnosis (Fowler et al., 2020 ). Similarly, our study population reported a range of comorbidities including chronic conditions that are independently associated with sensitivity to heat exposure (Gao et al., 2022 ; Layton et al., 2020 ; Liu et al., 2022 ; Qu et al., 2023 ). These varied, intersecting health conditions interacted with chronically elevated heat and humidity in South Florida to increase financial stress, disrupt social networks, and decrease quality of life. In these ways, these impacts ring similar to the mechanistic framework established by Zuelsdorff & Limaye (2024). However, our findings diverge from this framework in a few crucial dimensions. Common coping strategies reported among our study participants were staying indoors at home and constant use of air conditioning and, consequently, withdrawing from social and physical activities to avoid heat exposure. Social isolation has adverse impacts on the health of people with cancer, including cancer mortality (Wang et al., 2024), and conversely, social support and interaction positively impact quality of life among people with cancer by enhancing resilience and optimism (Ruiz-Rodríguez et al., 2022 ). Our finding that social support facilitates heat adaptation aligns with previous studies that establish the importance of social support in preventing treatment and follow-up related quality of life declines among people with cancer. Previous studies have largely delineated social support into three types: emotional, instrumental, and informational support (Ruiz-Rodríguez et al., 2021 ). While this study did not explicitly ask about these delineated types of social support, emotional and instrumental support from family and friends, which have been positively associated with quality of life among people with cancer, were the predominant types of social support reported in this study. While each type of support has a unique function (Ruiz-Rodríguez et al., 2022 ), our findings revealed a crucial gap in informational support from healthcare providers. Patient-initiated health-protective behaviors, including social isolation and lack of adherence to doctor-recommended physical activity that require time spent outdoors, were reported to be effective in mitigating heat exposure. Notably, while these maladaptive behaviors serve to minimize stress related to heat exposure in the short term, they can ultimately serve to worsen overall health and well-being (Thiamwong et al., 2024 ). Heat-responsive, health-protective lifestyle recommendations from healthcare providers may increase quality of life among people with cancer through informational support. Other clinical interventions for heat risk communication could include the identification of social, physiological, and environmental factors that increase the possibility of negative health risks, with referrals to responsive resources (Sorensen & Fried, 2024 ). It is crucial to note that despite the promise of patient-provider communication as a co-beneficial heat and health intervention, there are well-documented institutional, environmental, and personal challenges associated with the delivery of such tailored, patient-centered care (Kwame & Petrucka, 2021). Additionally, behavioral interventions are often more effective when incentivized by financial support and structural changes that can reduce area-level heat build-up and reduce the need for artificial cooling (Johar et al., 2025 ). Importantly, social withdrawal and lack of patient-initiated conversations with healthcare providers were attributed to the financial burden of elevated medical and electricity costs without the receipt of financial support. Despite expressed need, there was little reported awareness of or receipt of assistance from the few energy assistance programs available in South Florida such as the federally funded low-income home energy assistance program (LIHEAP) or the locally funded Florida Power & Light Care to Share Program. All of our study participants were insured, which serves to decrease the financial burden of medical care in a multi-payer health system. Our study participants reported simultaneous experiences of financial toxicity associated with cancer diagnosis and treatment (Carrera et al., 2018 ; Khan et al., 2023) alongside increased energy demands, highlighting an important intersection of energy insecurity, climate, and health previously described by Jessel et al. ( 2019 ). Greater adoption and use of air conditioning is a commonly reported and highly effective response to increasing climate change. However, previous literature has reported barriers to the adoption of this strategy including cost and reliance on electricity, as well as a lack of acclimation to increased temperatures (Turek-Hankins et al., 2021 ). Our participants did not report cost as a limitation on the use of air conditioning and instead reported a willingness to forgo household and recreational expenses other than medical and cooling costs. Hernandez et al. (2018) conceptualized resilience reserves from their study of Hurricane Sandy, where resources for resilience that should be preserved for use in a specific event, such as in response to a climate-related disaster, become depleted due to frequent use in response to a greater prevalence of chronic stressors. In our study, we found that chronically elevated medical and financial costs serve to deplete resilience reserves necessary to cope with acute shocks and stresses. There is a growing number of Americans, currently exceeding eighteen million, with a history of cancer in the US (Miller et al., 2022 ; Tonorezos et al., 2024 ). Concurrently, modeling studies indicate that dangerously high heat index values that typically occur no more than once each year in the Southeast US will become increasingly frequent, with between ten to twenty occurrences annually, by the middle of this century (Dahl et al., 2019 , Wodzicki et al., 2024; Fanning et al., 2025 ). In regions that experience tropical climates such as South Florida, such heat stress can persist throughout the daytime and nighttime hours, reducing the opportunity for necessary human thermoregulation (Muse at al., 2024). Thus, the interaction between health status among people with cancer and heat exposure warrants proactive investigation that might inform adaptation and mitigation policy with co-benefits for health and climate resilience. Future biological studies might seek to elucidate the physiological consequences of cancer treatment under heat stress, while behavioral studies might seek to understand health-protective behaviors patterned by heat avoidance rather than heat-related morbidity and mortality. This study is a crucial first step toward elucidating heat impacts and coping strategies among people with cancer (Fig. 1 ). Limitations The limitations of this study include the self-reporting of health status and heat impacts, because these data are subject to bias, a type of mismatch between participants’ reality and the reality may be presented to researchers (Bergen & Labonté, 2020). To account for participant bias, interviewers were provided with probes to clarify participant responses. Second, South Florida is a region that suffers chronically elevated heat and humidity (Cruz et al., 2025 ), making it challenging to inquire about heat as an acute hazard. Some of our interview questions asked about heat as a general phenomenon, while others inquired about heat extremes, but participants did not delineate between the two, instead referring to the heat as an inevitability in this region. Thus, our findings may have limited applicability in locations that experience heat as an acute hazard, including periodic heat waves. Finally, future studies would benefit from enhanced sociodemographic diversity. For example, due to our facility-based recruiting methods, each participant in our study population had health insurance coverage, which reduces financial burdens related to medical treatment that we sought to further understand. Our sample is also over representative of Black and African American people, given the demographics of South Florida. However, our study participants represent the populations of color and low-income communities that suffer a disproportionate burden of both cancer mortality and exposure to extreme temperatures due to the legacies of discriminatory housing and environmental policies (Ashad-Bishop et al., 2023 ; Berberian et al., 2022 ; Nogueira & Yabroff, 2024 ). Conclusions In this pilot study, people with cancer described physical and mental heat impacts due to heat exposure in a chronically hot and humid region as well as adaptation strategies to manage that are health-harming in relation to their cancer diagnosis. While the potential heat sensitivity of people with cancer has been acknowledged, there is a dearth of information about the extent of impacts on quality of life, access to healthcare, and social interactions. Improving our understanding of the multifaceted nature of heat impacts among people with cancer, and among medically vulnerable people at-large, may inform climate-resilient health policy and recommendations that address population health disparities. Declarations Acknowledgements We would like to acknowledge Neydeen Doval for her contributions to research administration. CRediT Author Statement Kilan C. Ashad-Bishop: Conceptualization, Methodology, Investigation, Data Curation, Formal analysis, Writing - Original Draft, Writing - Review & Editing, Project administration Felicia O. Casanova : Data Curation, Formal analysis, Writing - Review & Editing Mayra Cruz Conceptualization, Methodology, Writing - Review & Editing Nkosi Muse Writing - Original Draft, Writing - Review & Editing Elayna Bassuk Investigation, Data Curation, Formal analysis Maurice J. Chery Investigation, Data Curation, Writing - Review & Editing Jovanka Ravix Investigation, Data Curation, Writing - Review & Editing Zinzi D. Bailey Conceptualization, Methodology, Writing - Review & Editing Daniela M. Zuniga Carlier Project administration Katharine J. Mach Conceptualization, Methodology, Writing - Review & Editing, Supervision Lynee L. Turek-Hankins Conceptualization, Writing - Review & Editing Amy Clement Conceptualization, Methodology, Writing - Review & Editing, Supervision, Funding acquisition Sophia HL George Conceptualization, Methodology, Resources, Writing - Review & Editing, Supervision References Ashad-Bishop, K. C., Cruz, M., Bailey, Z. D., & Kobetz, E. K. (2023). Intersectional disparities in climate vulnerability and cancer risk. Cancer , 129 (14), 2122–2127. https://doi.org/10.1002/cncr.34817 Berberian, A. G., Gonzalez, D. J. X., & Cushing, L. J. (2022). Racial Disparities in Climate Change-Related Health Effects in the United States. 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Clement","email":"","orcid":"","institution":"University of Miami Rosenstiel School of Marine, Atmospheric, and Earth Science","correspondingAuthor":false,"prefix":"","firstName":"Amy","middleName":"C.","lastName":"Clement","suffix":""},{"id":508163171,"identity":"03afdf74-04ec-4829-83e2-9f053ed25d4e","order_by":12,"name":"Sophia HL George","email":"","orcid":"","institution":"University of Miami Miller School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Sophia","middleName":"HL","lastName":"George","suffix":""}],"badges":[],"createdAt":"2025-08-28 19:14:07","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-7482903/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7482903/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":90484839,"identity":"98a2e27f-bf4d-466a-bb20-40b6a156374f","added_by":"auto","created_at":"2025-09-03 08:42:41","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":50856,"visible":true,"origin":"","legend":"\u003cp\u003eConceptual map for the study of heat adaptation among medically vulnerable populations. Rectangles indicate contextual factors that inform direct (ovals) and indirect impacts (hexagons). Potential points of intervention by healthcare professionals are indicated in rhombi.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7482903/v1/f9a6a5de505a5217375adb79.png"},{"id":90487454,"identity":"eee5cc02-36ac-4b35-b9b0-d25b07b1bee9","added_by":"auto","created_at":"2025-09-03 09:06:41","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1219607,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7482903/v1/4a65727c-0355-4309-a243-bb345d5aef92.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e“When It Comes to Heat, I Retreat”: Heat Impacts and Adaptation Practices Among People with Cancer\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eIn much of the continental United States, the prevalence of heat hazard extremes have been increasing over at least the past 60 years (Habeeb et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2015\u003c/span\u003e; Vose et al., \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Across the country\u0026rsquo;s diverse physical geography and climate (Beck et al. 2023), such heat hazards are experienced differently\u0026mdash;from more persistent, chronic heat in the lower subtropics (Cruz et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2025\u003c/span\u003e, Wodzicki et al., 2024), to an increased frequency and duration of extreme temperatures at midlatitudes (Heeter et al., 2023, Lyon and Barston, 2017). In addition, extensive urbanization has further intensified hazards via the urban heat island effect, amplifying heat risks in cities that house most of the U.S. population (Muse et al., \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2024\u003c/span\u003e, Li et al., 2025, Tadros et al. 2021).\u003c/p\u003e\u003cp\u003eHeat hazards have well-documented health consequences, including associations with increased incidence of respiratory, heart, and infectious diseases, poor mental health, hospital admissions, injuries, and deaths (Bobb et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Bunker et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Ebi et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Ellis, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e1972\u003c/span\u003e; Nori-Sarma et al., \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). These impacts are amplified among people with heat-sensitive chronic health conditions (Ebi et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2021\u003c/span\u003e), especially older adults who suffer impaired thermoregulation in response to extreme temperatures (Bunker et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Kohon et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Millyard et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2020\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn the United States in 2025, there will be an estimated 2\u0026nbsp;million new diagnoses of cancer, a common chronic illness that requires costly, coordinated, and multidisciplinary care (Siegel et al., \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). Further, over 18\u0026nbsp;million people with a history of cancer in the United States (Siegel et al., \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Tonorezos et al., \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e2024\u003c/span\u003e) are at disproportionate risk of heat negatively impacting their health due to the prevalence of comorbidities that are independently associated with risk of heat-related illness (Fowler et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Hassan et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Sarfati et al., \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Stoltzfus et al., \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Further, common oncology treatments can induce dehydration and fatigue, warranting precaution regarding sun, heat, and humidity exposure from both healthcare providers and patients (Blakely et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Glassock et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e1977\u003c/span\u003e; Sarhill et al., \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2001\u003c/span\u003e; Vassal et al., \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e1987\u003c/span\u003e). Despite these risks to the burgeoning number of people bearing the burden of cancer in the United States, there are few studies considering how people with cancer are being impacted by, coping with, and adapting to the increased frequency and severity of elevated heat and humidity.\u003c/p\u003e\u003cp\u003eResidents of South Florida, a region where high temperature and humidity co-occur throughout a significant part of the year (Clement et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Cloutier-Bisbee et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; McAllister et al., \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2022\u003c/span\u003e), are impacted in unique and complex ways to seasonally high levels of elevated heat and humidity (Cruz et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2025\u003c/span\u003e; Turek-Hankins et al., \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). The objective of this qualitative investigation was to assess the impacts of chronic heat on health, quality of life, and healthcare access among 20 people with a history of cancer in South Florida.\u003c/p\u003e"},{"header":"Methods \u0026 Materials","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy Participants\u003c/h2\u003e\u003cp\u003eParticipants included 20 people with a history of cancer, defined as having ever been diagnosed with cancer, living in South Florida, a region of the US that suffers persistent and varied heat exposure (Clement et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Participants were recruited from 1) two ongoing clinical studies in which participants provided their consent to be contacted for future research studies and 2) University of Miami\u0026rsquo;s clinical research recruitment website, UMiamiHealthResearch.com. Both clinical studies had distinct aims from the current qualitative study.\u003c/p\u003e\u003cp\u003eFirst, we conducted a telephone screen to recruit participants from ongoing clinical studies who met the following inclusion criteria: 1) being 18 years of age or older, 2) residing in South Florida (Miami-Dade, Broward, Monroe, or Palm Beach County), and 3) having a history of a cancer diagnosis or treatment. Participants were excluded if they were unable to provide consent or unable to speak in either English or Haitian Kreyol. Enrollees who were interested and eligible were consented, interviewed either virtually or on-site, and compensated \u003cspan\u003e$\u003c/span\u003e100. The study was conducted in Miami, FL. All study procedures were reviewed and approved by the Institutional Review Board at University of Miami.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eData Collection\u003c/h3\u003e\n\u003cp\u003eInterviews were completed either virtually or on-site between May 2024 and January 2025 and audio-recorded using Zoom. Prior to any study activities, participants provided verbal consent to participate (following IRB-approved study procedures). Our consent protocol involved a study team member reading participants consent information, which informed them of the study objectives and procedures, risks and benefits of participating, the voluntary nature of their participation in the study, their right to withdraw from the study, data confidentiality and storage, and contact information for the study PI and overseeing IRB. After indicating verbal consent to participate, the study team member proceeded to ask a brief series of demographic questions prior to their interview. The demographic survey included questions about housing, income, education, employment status, age, sex and gender identity, and race/ethnicity.\u003c/p\u003e\u003cp\u003eAfter the demographics survey, participants completed semi-structured interviews with one of four trained study staff in English (n\u0026thinsp;=\u0026thinsp;16) or Haitian Kreyol (n\u0026thinsp;=\u0026thinsp;4). A semi-structured interview guide (~\u0026thinsp;45\u0026ndash;60 minutes) developed by KCB, MC, and KJM guided the interviews. The Haitian Kreyol translation of the interview guide was forward and back translated by two separate individuals bilingual in English and Haitian Kreyol and approved by the IRB. The interview guide, which was iteratively adapted as we analyzed initial insights using grounded theory techniques (Charmaz, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2006\u003c/span\u003e), explored the domains of heat impacts and access to care, social impacts and adaptation practices, and bill consciousness. During the interviews, participants were asked to describe (1) their medical history and any electricity-dependence considerations for current treatments, (2) their experiences of extreme heat, including physical and mental health impacts pre- and post-diagnosis, access to healthcare resulting from heat impacts, and conversations with health professionals about heat interactions with cancer treatments, (3) the ways they cope with and adapt to extreme heat, including social networks and support programs, and (4) any financial tradeoffs necessary to manage medical bills and energy needs for cooling. The complete sociodemographic survey and interview script are provided in the eMethods Supplement. Upon completion of the interviews, data were securely stored using a university-approved Cloud platform that only the study team could access, as approved in our IRB protocol.\u003c/p\u003e\n\u003ch3\u003eQualitative Analysis\u003c/h3\u003e\n\u003cp\u003eRapid qualitative analysis, an established approach for expedited, rigorous implementation research, was employed to analyze the data collected for the current study (Nevedal et al., \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) from May 2024 to March 2025. Our rapid qualitative analysis involved the following steps, in accordance with the methodology established by Hamilton and Finley (Hamilton \u0026amp; Finley, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2019\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eFirst, KCB and EB developed an \u0026ldquo;interview summary\u0026rdquo; template in Microsoft Word based on the interview guide, accompanied by written instructions for completion of interview summaries. KCB trained all team members on how to use the interview summary template to systematically document key insights and quotations from each interview.\u003c/p\u003e\u003cp\u003eThen, KCB, EB, FC, MC, and JR followed a standardized process for completing and auditing interview summaries for each interview. Each interview was summarized directly from audio recordings by two independent team members using the interview summary template, then each interview summary was reviewed by the lead author. Key insights and quotations from interviews completed in Haitian Kreyol were translated and documented in English by bilingual team members.\u003c/p\u003e\u003cp\u003eNext, KCB and FC transferred key insights and quotations to a matrix summary in Microsoft Excel, allowing team members to view participant responses within each domain. Once the first ten interviews were completed and summarized, the data were transferred to the matrix summary document, where KCB, EB, and FC began analyzing data to identify emergent themes. Each analyst independently reviewed the data comprising the matrix summary to identify and define emergent themes and illustrative key quotations. Inconsistencies in themes identified across analysts were discussed among the study team until consensus was reached. The remaining ten interviews were summarized upon completion and integrated into the matrix summary. We continued to interview participants until saturation, or the point where no additional themes emerged, was reached. A final thematic summary document was developed based on the analysis of the matrix summary. All participants are referred to by pseudonyms in the reported results. All authors reviewed and agreed on the accuracy of the findings as reported in this manuscript.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003eSociodemographic Profile of Study Participants\u003c/h2\u003e\u003cp\u003eOverall, participants lived across Miami-Dade and Broward Counties (80% Miami-Dade, 20% Broward), across 18 unique zip codes. Participants were predominantly 45\u0026ndash;64 years old (55%) or 65 years of age or older (35%), with the largest racial/ethnic groups being Black (Non-Hispanic) (60.87%), Black (Hispanic) (17.39%), White (Hispanic) (8.7%) and White (Non-Hispanic) (8.7%). In terms of housing tenure, participants reported being renters (40%) or property owners (35%) or having other less formal arrangements, such as living with relatives or subleasing (25%). Most reported having 2\u0026ndash;4 people in the household (60%). Most had retired from the workforce (40%) or were on medical leave (25%), and separately, 35% of participants reported an annual household income of less than \u003cspan\u003e$\u003c/span\u003e30,000. All of our participants had health insurance (100%), whether employer-sponsored (25%) or subsidized healthcare programs for low-income individuals and families (45%). The sociodemographic profile of our study population is described in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eParticipant Characteristics\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCharacteristic\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo. (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eParticipants (n\u0026thinsp;=\u0026thinsp;20)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHousing Tenure\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eI own my home\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7 (35)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eI rent a room in a home\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 (25)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eI rent my home\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8 (40)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eHousing Type\u003c/b\u003e\u003csup\u003e\u003cb\u003ea\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eApartment, condo, or multiplex\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10 (50)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHouseless or in transition housing\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRoom in a single-family home or house\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (10)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSingle family home or house\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7 (35)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eNumber of Residents in Home\u003c/b\u003e\u003csup\u003e\u003cb\u003ea\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 (25)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2\u0026ndash;4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e12 (60)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5 or more\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 (15)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eHousehold Annual Income\u003c/b\u003e\u003csup\u003e\u003cb\u003ea\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLess than \u003cspan\u003e$\u003c/span\u003e30,000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7 (35)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cspan\u003e$\u003c/span\u003e30,000 to \u003cspan\u003e$\u003c/span\u003e60,000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 (20)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cspan\u003e$\u003c/span\u003e60,000 to \u003cspan\u003e$\u003c/span\u003e90,000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 (25)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMore than \u003cspan\u003e$\u003c/span\u003e90,000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 (20)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eHealth Insurance Coverage\u003c/b\u003e\u003csup\u003e\u003cb\u003ea\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAny other type of health insurance or health coverage plan\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 (20)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFor people 65 and older, or people with certain disabilities\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 (25)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInsurance purchased directly from an insurance company\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (10)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInsurance through a current or former employer or union\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 (25)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMedical Assistance, or any kind of government-assistance plan for those with low incomes or a disability\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 (15)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVA (enrolled for VA Health care)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eEmployment Status\u003c/b\u003e\u003csup\u003e\u003cb\u003ea\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFull-time\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 (25)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMedical leave\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 (25)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePart-time\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (10)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRetired\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8 (40)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003csup\u003e\u003cb\u003ea\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e25\u0026ndash;44\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (10)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e45\u0026ndash;64\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e11 (55)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e65 and older\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7 (35)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003csup\u003e\u003cb\u003ea\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCisgender woman or female\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8 (40)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCisgender man or male\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e11 (55)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTrans/non-binary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eRace \u0026amp; Ethnicity\u003c/b\u003e\u003csup\u003e\u003cb\u003eb\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWhite (Non-Hispanic)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (8.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWhite (Hispanic)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (8.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBlack (Non-Hispanic)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e14 (60.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBlack (Hispanic)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 (17.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAmerican Indian or Alaska Native (Non-Hispanic)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (4.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003csup\u003ea\u003c/sup\u003e Self-identified by participants from closed-ended questions.\u003c/p\u003e\u003cp\u003e\u003csup\u003eb\u003c/sup\u003e Self-identified by participants from closed-ended questions. Racial identity was not limited to one selection, resulting in a total number greater than the number of participants. No participants identified as Asian, Native Hawaiian, or Pacific Islander.\u003c/p\u003e\u003cp\u003eFour themes emerged from our rapid qualitative analysis reflecting how heat exposure is affecting people with cancer: (1) heat interacts with health status to adversely affect quality of life among people with cancer, (2) increased cooling needs result in significant lifestyle adjustments, (3) patient-provider communications are underutilized opportunities to discuss heat risks and heat-responsive health-promoting behaviors, and (4) social support facilitates heat adaptation. The primary themes are presented along with the related subthemes and their descriptions in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eStudy Themes, Subthemes, and Descriptions\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrimary Theme\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSubtheme\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eDescription\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHeat Interacts with Health Status to Adversely Affect Quality of Life Among People with Cancer\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eThis theme encompasses participant descriptions of the way that heat interacts with their cancer diagnoses and comorbidities to impact quality of life and heat adaptation needs.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eIncreased Cooling Needs Result in Significant Lifestyle Adjustments\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHeat Avoidance as a Coping Mechanism\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eThis theme describes short-term strategies to meet increased cooling needs among participants and experiences with the expenses associated with those adjustments.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMedical and Cooling Expenses Are Equally Prioritized as Lifestyle Adjustments\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003ePatient-Provider Communications Are Underutilized Opportunities to Discuss Heat Risks and Heat-Responsive Health-Promoting Behaviors\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eInfrequent Conversations with Healthcare Providers About Heat\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eThis theme relates to participant interactions with medical providers, including aspects of patient-provider conversations and how heat exposure influences adherence to physician recommendations.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLimited Adherence to Doctor-Recommended Health Protective Behaviors\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eSocial Support Facilitates Heat Adaptation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLack of Financial Support for Expenses Associated with Cooling\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eThis theme relates to participant experiences with heat adaptation, including financial and social support for cooling.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSocial Support as a Means of Adaptation\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eHeat Interacts with Health Status to Adversely Affect Quality of Life Among People with Cancer\u003c/h2\u003e\u003cp\u003eAll of our study participants reported being impacted by heat either before or after their cancer diagnosis. Whereas 14 (70%) participants reported that heat impacted their physical or mental health prior to their cancer diagnosis, the remaining 6 (30%) reported impacts that began after their cancer diagnosis. Among our study participants, there was substantial variability in comorbidity burden and consequent pre-diagnosis vulnerability to heat exposure; This variability contributed to differences in the way that participants attributed post-diagnosis heat impacts to interactions between their cancer diagnosis or treatment and heat. Among our study population, only 3 (15%) of participants self-reported cancer as the sole chronic disease they were managing. Participants reported comorbidities including physical health issues such as type 2 diabetes, HIV, high blood pressure, thyroid disease, rheumatoid arthritis, osteoarthritis, kidney disease, hypertension, and autoimmunity, as well as mental health issues such as bipolar disorder and generalized anxiety.\u003c/p\u003e\u003cp\u003eThese conditions had ranging impacts on participants\u0026rsquo; experiences with heat sensitivity, from both the conditions themselves and the corresponding treatments. A prostate cancer survivor, here forth referred to as Miles, reported that before his cancer diagnosis, prolonged heat exposure led to exhaustion. Post-diagnosis, he can only stay in the heat for 30\u0026ndash;45 minutes, with prolonged heat exposure leading to loss of mental acuity. Another person undergoing treatment for prostate cancer, here forth referred to as Leon, who was similarly impacted, shared that the heat \u0026ldquo;sucks the life out of him.\u0026rdquo; Anita, who was admitted to the hospital for a heat-induced seizure reported:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI can\u0026rsquo;t have heat exposure with my medications. Some of them bring out hives, rashes, so I can\u0026rsquo;t, that\u0026rsquo;s the first thing they told me [after the incident]. So, if you like to be outside in the sun, you can\u0026rsquo;t. So, I haven\u0026rsquo;t.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eConversely, a less heat-impacted breast cancer survivor, here forth referred to as Ayra, described experiencing mild heat intolerance both pre- and post-diagnosis but shared that she did not see a connection between heat intolerance and cancer:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI did not correlate heat and humidity with our cancers. I correlate our food and our water because it\u0026rsquo;s easily consumed.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThis highlights that although heat impacts were widespread among our study population, they were not always mentioned as being a result of or exacerbated by chronic health conditions or treatments. Still, from the commonality of heat impacts emerged a shared sentiment that avoiding the heat and staying cool was not only a priority, but a necessity.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eIncreased Cooling Needs Result in Significant Lifestyle Adjustments\u003c/h3\u003e\n\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\u003ch2\u003eHeat Avoidance as a Coping Mechanism\u003c/h2\u003e\u003cp\u003eMany of our participants reported staying cool as a necessity, and a shared sentiment was that a comfortable temperature had to be maintained no matter the cost. The cost was not exclusively financial, participants also described staying cool to the detriment of time spent outdoors and social participation. This resignation to adapting to heat impacts, despite the cost, was described by Billie, a breast cancer survivor:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;The heat isn't going anywhere, we must resign ourselves to it.\"\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eParticipants shared that to avoid heat exposure, they initiated lifestyle adaptations including only leaving the house early in the morning or late at night when temperatures aren\u0026rsquo;t as extreme, scheduling and traveling to medical appointments in the morning before the heat peaks, and near constant use of air-conditioning, ice packs, cool and protective clothing, and fans. Michael, who is managing prostate cancer, kidney disease, and hypertension, shared:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\"I know the side effects of heat stroke can be very serious and with my co-morbidities I don't want to fool with it, so I stay out of the heat as much as possible.\"\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e A common theme among participants\u0026rsquo; accounts of heat adaptation practices was withdrawal from social participation. Leon recounted a general lack of social interactions that require time spent outside:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\"If there is going to be a line for an event, I avoid it. If there comes time for voting, I registered for an absentee ballot to avoid possibly being an hour outside\u0026hellip;When it comes to heat, I retreat!\u0026rdquo;\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eand James, a prostate cancer survivor, stated:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\"I might go outside 30 minutes to an hour at most. I'm basically inside all day. Staying cool is what it's all about for me.\"\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eMedical and Cooling Expenses Are Equally Prioritized as Lifestyle Adjustments\u003c/h2\u003e\u003cp\u003eDue to the consensus regarding the importance of cooling, we sought to understand whether tradeoffs were being made between elevated medical and cooling expenses. No tradeoffs for electricity or medical bills were reported, but elevated medical bills led participants to cut down on recreational expenses. A shared sentiment that emerged was a resignation to a new reality of having to forgo other daily costs for essential expenses such as food and housing. Marian, who is managing breast cancer, high cholesterol, and hypertension, shared:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\"Sometimes I want to do something or buy something to eat, but I have no money left because I have to cover the expenses related to my illness.\"\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eMost participants did not articulate in what ways they were at financial capacity, but expressed having to borrow from their 401K or retirement, borrow money from family members, and pursue additional revenue streams such as additional jobs or pawning personal items. Ayra expressed the taxing financial implications of chronic disease:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI call cancer a Gucci disease, a designer disease, it\u0026rsquo;s costly.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eDespite social withdrawal, our study population reported consistent interactions with healthcare providers due to the sensitive nature of the health conditions they are managing.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003ePatient-Provider Communications Are Underutilized Opportunities to Discuss Heat Risks and Heat-Responsive Health-Promoting Behaviors\u003c/h2\u003e\u003cp\u003eCancer is a complex disease that requires coordinated, multidisciplinary, and often multisite care. Two subthemes emerged related to patient-provider interactions as opportunities to communicate around heat risks and opportunities to mitigate heat-related health impacts.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eInfrequent Conversations with Healthcare Providers About Heat\u003c/h2\u003e\u003cp\u003eOur study found that despite frequent and consistent interactions with a range of healthcare providers, there were limited reports of provider-initiated conversations about heat. Of the nine participants who reported having a heat-related conversation with a healthcare provider, only six of those conversations were provider-initiated. The conversations that were reported mostly centered interactions with medications and medical devices. Patient-initiated conversations, which were usually in response to an adverse health event, were reported as poorly received. Anita, who is managing recurrent lymphoma, recounted an experience where she attempted to initiate a conversation about heat sensitivity,\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\"I have told them [about heat sensitivity]. One nurse told me it\u0026rsquo;s menopause.\u0026rdquo;\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eAnita was later admitted to the emergency room due to a heat-induced seizure. Grace, a breast cancer survivor, also mentioned initiating a conversation about heat sensitivity where she did not feel heard. Eventually, her doctor offered therapeutic intervention for hot flashes. In contrast, male participants in this study reported provider-initiated conversations about heat that were accompanied by lifestyle recommendations including avoidance of heat exposure, the importance of hydration, apparel recommendations to support cooling, and vitamin supplementation due to inadequate sun exposure. Interestingly, participants that reported patient-provider conversations also reported seeking care for symptoms of heat-related illness, which indicates the importance of these interactions in mitigating potential negative health outcomes including physical and mental illness, morbidity, and mortality.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eLimited Adherence to Doctor-Recommended Health-Protective Behaviors\u003c/h2\u003e\u003cp\u003eParticipants often cited difficulties adhering to doctor-recommended health-protective behaviors such as physical activity. Those who were committed to adherence reported walking and working out indoors, but the majority of participants reported a lack of adherence because of heat avoidance or lack of convenience. Ray, who has conversed with his cardiologist about heat risks and does all of his physical activity indoors when it is hotter outside, shared,\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThe only person that I\u0026rsquo;ve had the discussion with is my cardiologist because he looks after my hypertension...That\u0026rsquo;s tied to me going up stairs and keeping myself in the kind of condition that I can get some exercise in.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eJames, on the other hand, spends most of his time indoors and limits his physical activity,\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\"Yea, I can [go walking], but I don\u0026rsquo;t want to go out there in that heat. If I do do it, I can\u0026rsquo;t walk around but one time. I usually do like 3 or 4 [laps]...but it\u0026rsquo;s too hot for all that.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eand Anita, who has medication-induced heat sensitivity, shared a similar sentiment,\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThey [the doctors] sent me to walk everyday but to tell you the truth of where I live there\u0026rsquo;s no parks close by and the heat, it doesn\u0026rsquo;t let me, so I don\u0026rsquo;t get no exercise.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eMoreover, Grace described how extreme heat compounded the fatigue she already faced as a cancer survivor and influenced her to forego a doctor\u0026rsquo;s appointments to avoid heat exposure:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eyeah, actually, I have. I'm thinking about, because sometimes I have skipped doctor's appointments, and sometimes it's because I quite literally don't want to get in the shower. And I'm so disgusting like, too tired to get in the shower. So I reschedule.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eFrom these data, a clear opportunity emerged to provide heat-responsive recommendations for health-protective behaviors that may further positive cancer outcomes.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eSocial Support Facilitates Heat Adaptation\u003c/h2\u003e\u003cp\u003eThe heat adaptation theme described the ways that people supported their increased cooling and medical needs. Three specific subthemes were evident in the participants\u0026rsquo; accounts regarding support for lifestyle changes, including financial adjustments, which were necessary to accommodate increased cooling and medical needs.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eLack of Financial Support for Expenses Associated with Cooling\u003c/h2\u003e\u003cp\u003eVery few people reported the receipt of financial support for cooling despite some knowledge of support programs, most financial support was received for medical bills. All of our study participants were covered by medical insurance, which lessens the burden of medical expenses. However, a common sentiment discussed was the burden of reconciling medical bills and other healthcare expenses with insurance and healthcare systems, which made it difficult to plan for medical expenses. The unpredictable nature of medical expenses was a sharp contrast to the expected, elevated expenses associated with cooling. Yet even among the participants who reported some knowledge of financial support programs, very few (2; 10%) applied or received any consistent support. This internalized responsibility for expenses seemed to underlie patient-initiated lifestyle changes unless social support networks were present.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003eSocial Support as a Means of Adaptation\u003c/h2\u003e\u003cp\u003eIn the absence of financial support for elevated medical and cooling expenses, a common patient-initiated lifestyle change was withdrawal from social participation to avoid heat. However, strong social networks were able to attenuate the consequences of social isolation. Louis, a prostate cancer survivor who is also managing diabetes, did not report lifestyle changes because of his love of the outdoors, describing:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;We [he and his wife] both figure out, you know, if we need to take ice, or whatever, or I try to make sure I have, you know, things that can help me. Portable fans, you know, ice packs, you know, little things that I know that I may need. If I\u0026rsquo;m gonna be in the sun long I try to make sure I have a cooler or a bag full of stuff.\u0026rdquo;\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eRay shared a diverging sentiment since he spends most of his time indoors in the AC, stating:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;She [my wife] would tell you that she\u0026rsquo;s literally freezing. You know it\u0026rsquo;s uncomfortable for her, but it\u0026rsquo;s very comfortable for me.\u0026rdquo;\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe willingness of family and friends to sacrifice personal comfort for the comfort of the participants was commonly reported. Further, social support ranged from familial support for cooling, transportation, medical expenses, and emergencies to health-system mediated support for physical and mental well-being. However, only one participant reported social support that was specifically offered to mitigate potential heat impacts on healthcare access. Anita, who had a history of skipping medical appointments due to heat-related fatigue, explained,\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eSo I don\u0026rsquo;t miss appointments, they come pick me up in an Uber.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThese patient experiences suggest many opportunities for programs and policies to mitigate heat impacts, including physical health, mental health, and financial burdens, on population health among people with cancer. As heat intensifies, opportunities may present to encourage healthcare access for regularly scheduled visits, as well as unexpected visits for heat-related illnesses, among this extremely sensitive population.\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis is, to our knowledge, the first qualitative assessment of how heat negatively impacts quality of life among people with cancer and patterns health-protective behaviors to mitigate heat exposure in a chronically hot and humid region. We found that our study population reported prevalent experiences of deleterious heat impacts patterned by both cancer and comorbidities that are independently associated with sensitivity to heat exposure. The common sentiment was that cooling became a necessity, and our participants adapted to increased cooling needs through staying indoors and constant use of air conditioning. Despite reports of elevated electricity costs due to increased cooling needs, there was little reported awareness of or receipt of assistance from energy assistance programs. Due to their health status, participants reported consistent and frequent interactions with healthcare providers. These patient-provider interactions emerged as underutilized opportunities to discuss heat risks and maladaptive coping strategies, including withdrawal from social and physical activities that require time spent outdoors.\u003c/p\u003e\u003cp\u003ePrevious literature on heat impacts among people with chronic disease has largely focused on chronic diseases with biological determinants of vulnerability such as cardiovascular disease, diabetes, mental health conditions, kidney diseases, and respiratory disorders (Ebi et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Kenny et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2010\u003c/span\u003e; Vaidyanathan, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Though it has been posited that people with cancer are particularly sensitive to heat impacts due to the physical, psychological, and socioeconomic consequences of cancer diagnosis, treatment, and survivorship care (Hassan et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2023\u003c/span\u003e), very little is known about the ways that heat hazards impact quality of life among this population and how people with cancer cope and adapt.\u003c/p\u003e\u003cp\u003eSo, although previous studies have not specifically studied heat impacts and strategies for coping and adaptation among people with cancer, our data represents an expansion of an emerging body of literature on climate, aging, and health. Cancer is most prevalent among people over the age of 50 years (Siegel et al., \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2025\u003c/span\u003e), the same population that is also at the greatest risk of heat-related mortality due to physiological challenges, including decreased capacity for thermoregulation which may be exacerbated by treatment-induced heat intolerance (Jung et al., \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Millyard et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). A recent study found that two-thirds of people diagnosed with cancer had at least one comorbidity at the time of their diagnosis (Fowler et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Similarly, our study population reported a range of comorbidities including chronic conditions that are independently associated with sensitivity to heat exposure (Gao et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Layton et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Liu et al., \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Qu et al., \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). These varied, intersecting health conditions interacted with chronically elevated heat and humidity in South Florida to increase financial stress, disrupt social networks, and decrease quality of life. In these ways, these impacts ring similar to the mechanistic framework established by Zuelsdorff \u0026amp; Limaye (2024). However, our findings diverge from this framework in a few crucial dimensions.\u003c/p\u003e\u003cp\u003eCommon coping strategies reported among our study participants were staying indoors at home and constant use of air conditioning and, consequently, withdrawing from social and physical activities to avoid heat exposure. Social isolation has adverse impacts on the health of people with cancer, including cancer mortality (Wang et al., 2024), and conversely, social support and interaction positively impact quality of life among people with cancer by enhancing resilience and optimism (Ruiz-Rodr\u0026iacute;guez et al., \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Our finding that social support facilitates heat adaptation aligns with previous studies that establish the importance of social support in preventing treatment and follow-up related quality of life declines among people with cancer. Previous studies have largely delineated social support into three types: emotional, instrumental, and informational support (Ruiz-Rodr\u0026iacute;guez et al., \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). While this study did not explicitly ask about these delineated types of social support, emotional and instrumental support from family and friends, which have been positively associated with quality of life among people with cancer, were the predominant types of social support reported in this study. While each type of support has a unique function (Ruiz-Rodr\u0026iacute;guez et al., \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2022\u003c/span\u003e), our findings revealed a crucial gap in informational support from healthcare providers.\u003c/p\u003e\u003cp\u003ePatient-initiated health-protective behaviors, including social isolation and lack of adherence to doctor-recommended physical activity that require time spent outdoors, were reported to be effective in mitigating heat exposure. Notably, while these maladaptive behaviors serve to minimize stress related to heat exposure in the short term, they can ultimately serve to worsen overall health and well-being (Thiamwong et al., \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Heat-responsive, health-protective lifestyle recommendations from healthcare providers may increase quality of life among people with cancer through informational support. Other clinical interventions for heat risk communication could include the identification of social, physiological, and environmental factors that increase the possibility of negative health risks, with referrals to responsive resources (Sorensen \u0026amp; Fried, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). It is crucial to note that despite the promise of patient-provider communication as a co-beneficial heat and health intervention, there are well-documented institutional, environmental, and personal challenges associated with the delivery of such tailored, patient-centered care (Kwame \u0026amp; Petrucka, 2021). Additionally, behavioral interventions are often more effective when incentivized by financial support and structural changes that can reduce area-level heat build-up and reduce the need for artificial cooling (Johar et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2025\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eImportantly, social withdrawal and lack of patient-initiated conversations with healthcare providers were attributed to the financial burden of elevated medical and electricity costs without the receipt of financial support. Despite expressed need, there was little reported awareness of or receipt of assistance from the few energy assistance programs available in South Florida such as the federally funded low-income home energy assistance program (LIHEAP) or the locally funded Florida Power \u0026amp; Light Care to Share Program. All of our study participants were insured, which serves to decrease the financial burden of medical care in a multi-payer health system. Our study participants reported simultaneous experiences of financial toxicity associated with cancer diagnosis and treatment (Carrera et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Khan et al., 2023) alongside increased energy demands, highlighting an important intersection of energy insecurity, climate, and health previously described by Jessel et al. (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Greater adoption and use of air conditioning is a commonly reported and highly effective response to increasing climate change. However, previous literature has reported barriers to the adoption of this strategy including cost and reliance on electricity, as well as a lack of acclimation to increased temperatures (Turek-Hankins et al., \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Our participants did not report cost as a limitation on the use of air conditioning and instead reported a willingness to forgo household and recreational expenses other than medical and cooling costs. Hernandez et al. (2018) conceptualized resilience reserves from their study of Hurricane Sandy, where resources for resilience that should be preserved for use in a specific event, such as in response to a climate-related disaster, become depleted due to frequent use in response to a greater prevalence of chronic stressors. In our study, we found that chronically elevated medical and financial costs serve to deplete resilience reserves necessary to cope with acute shocks and stresses.\u003c/p\u003e\u003cp\u003eThere is a growing number of Americans, currently exceeding eighteen million, with a history of cancer in the US (Miller et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Tonorezos et al., \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Concurrently, modeling studies indicate that dangerously high heat index values that typically occur no more than once each year in the Southeast US will become increasingly frequent, with between ten to twenty occurrences annually, by the middle of this century (Dahl et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2019\u003c/span\u003e, Wodzicki et al., 2024; Fanning et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). In regions that experience tropical climates such as South Florida, such heat stress can persist throughout the daytime and nighttime hours, reducing the opportunity for necessary human thermoregulation (Muse at al., 2024). Thus, the interaction between health status among people with cancer and heat exposure warrants proactive investigation that might inform adaptation and mitigation policy with co-benefits for health and climate resilience. Future biological studies might seek to elucidate the physiological consequences of cancer treatment under heat stress, while behavioral studies might seek to understand health-protective behaviors patterned by heat avoidance rather than heat-related morbidity and mortality. This study is a crucial first step toward elucidating heat impacts and coping strategies among people with cancer (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003eLimitations\u003c/h2\u003e\u003cp\u003eThe limitations of this study include the self-reporting of health status and heat impacts, because these data are subject to bias, a type of mismatch between participants\u0026rsquo; reality and the reality may be presented to researchers (Bergen \u0026amp; Labont\u0026eacute;, 2020). To account for participant bias, interviewers were provided with probes to clarify participant responses. Second, South Florida is a region that suffers chronically elevated heat and humidity (Cruz et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2025\u003c/span\u003e), making it challenging to inquire about heat as an acute hazard. Some of our interview questions asked about heat as a general phenomenon, while others inquired about heat extremes, but participants did not delineate between the two, instead referring to the heat as an inevitability in this region. Thus, our findings may have limited applicability in locations that experience heat as an acute hazard, including periodic heat waves. Finally, future studies would benefit from enhanced sociodemographic diversity. For example, due to our facility-based recruiting methods, each participant in our study population had health insurance coverage, which reduces financial burdens related to medical treatment that we sought to further understand. Our sample is also over representative of Black and African American people, given the demographics of South Florida. However, our study participants represent the populations of color and low-income communities that suffer a disproportionate burden of both cancer mortality and exposure to extreme temperatures due to the legacies of discriminatory housing and environmental policies (Ashad-Bishop et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Berberian et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Nogueira \u0026amp; Yabroff, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2024\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn this pilot study, people with cancer described physical and mental heat impacts due to heat exposure in a chronically hot and humid region as well as adaptation strategies to manage that are health-harming in relation to their cancer diagnosis. While the potential heat sensitivity of people with cancer has been acknowledged, there is a dearth of information about the extent of impacts on quality of life, access to healthcare, and social interactions. Improving our understanding of the multifaceted nature of heat impacts among people with cancer, and among medically vulnerable people at-large, may inform climate-resilient health policy and recommendations that address population health disparities.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to acknowledge Neydeen Doval for her contributions to research administration.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCRediT Author Statement\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eKilan C. Ashad-Bishop:\u003c/strong\u003e Conceptualization, Methodology, Investigation, Data Curation, Formal analysis, Writing - Original Draft, Writing - Review \u0026amp; Editing, Project administration \u003cstrong\u003eFelicia O. Casanova\u003c/strong\u003e: Data Curation, Formal analysis, Writing - Review \u0026amp; Editing \u003cstrong\u003eMayra Cruz\u003c/strong\u003eConceptualization, Methodology, Writing - Review \u0026amp; Editing \u003cstrong\u003eNkosi Muse\u003c/strong\u003eWriting - Original Draft, Writing - Review \u0026amp; Editing \u003cstrong\u003eElayna Bassuk\u0026nbsp;\u003c/strong\u003eInvestigation, Data Curation, Formal analysis \u003cstrong\u003eMaurice J. Chery\u003c/strong\u003e Investigation, Data Curation, Writing - Review \u0026amp; Editing \u003cstrong\u003eJovanka Ravix\u0026nbsp;\u003c/strong\u003eInvestigation, Data Curation, Writing - Review \u0026amp; Editing\u003cstrong\u003eZinzi D. Bailey\u003c/strong\u003eConceptualization, Methodology, Writing - Review \u0026amp; Editing \u003cstrong\u003eDaniela M. Zuniga Carlier\u003c/strong\u003eProject administration \u003cstrong\u003eKatharine J. Mach\u0026nbsp;\u003c/strong\u003eConceptualization, Methodology, Writing - Review \u0026amp; Editing, Supervision\u003cstrong\u003eLynee L. Turek-Hankins\u0026nbsp;\u003c/strong\u003eConceptualization, Writing - Review \u0026amp; Editing\u003cstrong\u003e\u0026nbsp;Amy Clement\u0026nbsp;\u003c/strong\u003eConceptualization, Methodology, Writing - Review \u0026amp; Editing, Supervision, Funding acquisition \u003cstrong\u003eSophia HL George\u003c/strong\u003eConceptualization, Methodology, Resources, Writing - Review \u0026amp; Editing, Supervision\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAshad-Bishop, K. C., Cruz, M., Bailey, Z. D., \u0026amp; Kobetz, E. K. (2023). Intersectional disparities in climate vulnerability and cancer risk. \u003cem\u003eCancer\u003c/em\u003e, \u003cem\u003e129\u003c/em\u003e(14), 2122\u0026ndash;2127. https://doi.org/10.1002/cncr.34817\u003c/li\u003e\n\u003cli\u003eBerberian, A. G., Gonzalez, D. J. X., \u0026amp; Cushing, L. J. (2022). Racial Disparities in Climate Change-Related Health Effects in the United States. \u003cem\u003eCurrent Environmental Health Reports\u003c/em\u003e, \u003cem\u003e9\u003c/em\u003e(3), 451\u0026ndash;464. https://doi.org/10.1007/s40572-022-00360-w\u003c/li\u003e\n\u003cli\u003eBlakely, K. M., Drucker, A. M., \u0026amp; Rosen, C. F. (2019). Drug-Induced Photosensitivity\u0026mdash;An Update: Culprit Drugs, Prevention and Management. \u003cem\u003eDrug Safety\u003c/em\u003e, \u003cem\u003e42\u003c/em\u003e(7), 827\u0026ndash;847. https://doi.org/10.1007/s40264-019-00806-5\u003c/li\u003e\n\u003cli\u003eBobb, J. F., Obermeyer, Z., Wang, Y., \u0026amp; Dominici, F. (2014). Cause-Specific Risk of Hospital Admission Related to Extreme Heat in Older Adults. \u003cem\u003eJAMA\u003c/em\u003e, \u003cem\u003e312\u003c/em\u003e(24), 2659\u0026ndash;2667. https://doi.org/10.1001/jama.2014.15715\u003c/li\u003e\n\u003cli\u003eBunker, A., Wildenhain, J., Vandenbergh, A., Henschke, N., Rockl\u0026ouml;v, J., Hajat, S., \u0026amp; Sauerborn, R. (2016). Effects of Air Temperature on Climate-Sensitive Mortality and Morbidity Outcomes in the Elderly; a Systematic Review and Meta-analysis of Epidemiological Evidence. \u003cem\u003eEBioMedicine\u003c/em\u003e, \u003cem\u003e6\u003c/em\u003e, 258\u0026ndash;268. https://doi.org/10.1016/j.ebiom.2016.02.034\u003c/li\u003e\n\u003cli\u003eCarrera, P. M., Kantarjian, H. M., \u0026amp; Blinder, V. S. (2018). 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Temperature changes in the United States. \u003cem\u003eClimate Science Special Report: Fourth National Climate Assessment\u003c/em\u003e, \u003cem\u003e1\u003c/em\u003e(GSFC-E-DAA-TN49028). https://ntrs.nasa.gov/citations/20180001314\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"University of Miami","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Cancer Survivors, Extreme Heat, Quality of Life, Heat Adaptation, Social Support","lastPublishedDoi":"10.21203/rs.3.rs-7482903/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7482903/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eAcross the US, increasingly prevalent heat extremes pose diverse threats to population health and well-being. Due to sensitivities from age-related declines in thermoregulation, elevated prevalence of comorbidities, drug-induced dehydration and fatigue, as well as decreased disposable income, people with cancer are recognized as particularly susceptible to heat impacts. Yet, little empirical research has focused on this population. Our objective was to understand heat impacts, coping mechanisms, and adaptation practices among people with cancer. This qualitative study used semi-structured interviews of adults with a history of cancer in South Florida. Between May 2024 and January 2025, a total of 20 participants across 18 unique zip codes were interviewed, and data were analyzed using rapid qualitative methodology. Four key themes reflected ongoing challenges related to how people with cancer experience and adapt to heat in the region: (1) heat interacts with health status to adversely affect quality of life among people with cancer, (2) increased cooling needs result in significant lifestyle adjustments, (3) patient-provider communications are underutilized opportunities to discuss heat risks and heat-responsive health-promoting behaviors, and (4) social support facilitates heat adaptation. Our findings indicate that heat exposure leads to prominent health impacts among people with cancer, as well as a prioritization of access to cooling despite financial and social consequences. This need to stay cool often decreased quality of life due to social withdrawal, but quality of life impacts were mitigated by social support. Our findings indicate that heat exposure may differentially affect people with preexisting conditions such as cancer, leading to social withdrawal and maladaptive behaviors, which indicates a need for heat adaptation policy tools to be tailored to the unique needs of medically vulnerable populations. Future research should seek to further our understanding of behavioral changes among people with chronic disease in response to heat exposure, specifically across regions with chronic heat and humidity.\u003c/p\u003e","manuscriptTitle":"“When It Comes to Heat, I Retreat”: Heat Impacts and Adaptation Practices Among People with Cancer","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-03 08:42:36","doi":"10.21203/rs.3.rs-7482903/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5d19a91a-cd9b-4bbf-b6f6-6e08586e2076","owner":[],"postedDate":"September 3rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-04-21T14:31:25+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-03 08:42:36","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7482903","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7482903","identity":"rs-7482903","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}