Coal operations and cancer in the US: A systematic review

Soon after declaring its first national energy emergency in January 2025, the US government committed to increasing coal production and use. Coal operations (e.g., mining, processing, burning, waste management) not only contribute to climate change but also have environmental and public health consequences that may influence cancer risk and outcomes. The aim of this systematic review is to synthesize published evidence on cancer risk and outcomes associated with exposure to coal operations in the US.

Systematic review.

We searched PubMed, Embase, Scopus, and CINAHL for quantitative studies published in English between January 1980 and April 2025 evaluating any type of exposure to coal operations and cancer outcomes in the US. Grey literature, non-epidemiological studies, and studies that used cancer cases as controls were excluded. Risk of bias was assessed using ROBINS-E.

The search identified 3065 unique articles, 45 of which were included. All 18 studies that evaluated residential exposures and cancer mortality found statistically significant associations. Similarly, all occupational studies published after 2003 found statistically significant associations with increased cancer mortality. Competing risks, healthy worker bias, and ecological fallacy were the most common limitations of studies included in the review. Findings from 19 studies evaluating either residential or occupational exposure to coal operations and cancer incidence were mixed, and no significant association was found with residential exposure in the single study of cancer-related hospitalizations. Surveillance and research infrastructure supported by the US federal government was used in 82% of studies evaluating the association between coal operations and cancer.

Occupational and residential exposure to coal operations are associated with worse cancer mortality, underscoring the importance of public health surveillance and research efforts to inform local decision-making on initiating and/or expanding coal operations in the US.