By Suzanne Evans, MD, MPH, FASTRO, Vice-chair of ASTRO Clinical Affairs and Quality Council Steering Committee
Cyberattacks are increasingly affecting health care systems throughout the world and, in recent years, several high-profile cyberattacks have taken place against radiation oncology facilities. These attacks targeted patient data and medical records, putting the privacy and safety of patients with cancer at risk. An attack can lead to data breaches, resulting in data loss or data manipulation and delays in patient care. This is impactful on the patient level, where there can be a loss of trust and anxiety from delay in care, as well as loss of privacy or financial harm from identity theft. Organizations devote many hours to getting patients back onto treatment, which can involve large scale replanning efforts and may incur financial losses or reputational damage. Radiation oncology is especially vulnerable because of its reliance on technology to plan and deliver treatments, as well as the computer and network requirements to transfer relevant patient information safely and efficiently.
- In 2015, a cyberattack occurred on a large U.S.-based cancer treatment provider. The attack compromised the personal and medical data of millions of patients, including their names, Social Security numbers and medical histories.
- In 2019, a cyberattack in Canada affected a radiation oncology department, infecting the oncology information system (OIS). This resulted in several days of no treatment followed by several more days of treatment without the verification of an OIS.
- In October 2020, a U.S.-based academic center experienced clinical outages as result of a cyberattack that included a loss of access to the internet, hospital servers and clinical systems. Treatments at this institution resumed in less than two weeks.
- In April 2021, a major radiation oncology vendor had a ransomware attack, affecting more than 40 facilities across the United States, which resulted in the disconnection of regional cloud-based software and disabled back-up systems. This prevented access to the treatment delivery system, patient contact information and relevant treatment delivery details. In some instances, treatments at these facilities were interrupted for several weeks.
- In May 2021, a cyberattack in Ireland severely disrupted oncology services and over 500 patients had their course of radiation therapy interrupted for up to two weeks.
- In 2021, a ransomware cyberattack in New Zealand resulted in the shutdown of radiation therapy services for almost three weeks.
- In February 2023 in the U.S., three clinically appropriate images of patients undergoing radiation therapy treatment and seven related documents were illegally obtained from a radiation oncology facility and posted on the dark web by cybercriminals in retaliation for not paying a ransom. This breach did not disrupt any radiation treatments but revealed sensitive patient information.
These examples demonstrate the serious risks posed by cyber criminals and highlight the importance of taking proactive measures to safeguard patient data and protect against cyber threats. They also highlight how cyberattacks can impact radiation oncology facilities irrespective of size, location or practice setting. As technology continues to play an increasingly important role in the health care industry generally and radiation therapy specifically, it is essential that radiation oncology facilities remain vigilant and take all necessary steps to prevent cyberattacks.
Steps for prevention
Preventing attacks against a radiation oncology facility involves taking proactive measures to safeguard the facility's network and patient data. Some steps are outlined below that can be taken to help prevent cyberattacks as part of disaster preparedness:
- Conduct a risk assessment: Identify and assess potential security risks and vulnerabilities within your network and infrastructure. This will help to prioritize security measures and assist with the development of an effective security plan.
- Train staff: Routinely train all staff on best practices for cyber security, including how to recognize phishing attacks and how to create strong passwords. Ensure that staff members understand the importance of protecting patient data and the potential consequences of a cyberattack. Maintain a low threshold for alerting anything you find suspicious, and do not follow links unless you are certain you trust the sender.
- Implement strong access controls: Limit access to sensitive data and systems to authorized personnel only. Use multifactor authentication to verify user identities and restrict access based on job function.
- Keep software and systems up to date: Ensure that all software, oncology information systems and devices are updated with the latest security patches and upgrades. Outdated software can be a significant security risk.
- Routinely back up data: Back up all patient data and system configurations regularly. This will help to ensure that data can be restored in the event of a cyberattack or system failure.
- Use firewalls and anti-virus software: Install firewalls and anti-virus software to protect against malware and other cyber threats. Regularly update these programs and run scans to ensure they are functioning properly.
- Develop an incident response plan: Develop a plan to respond to cyberattacks if one occurs. This should include procedures for detecting, containing and recovering from an attack, including having communication plans to keep patients and other relevant parties informed.
- Follow APEx recommendations regarding the review of interim dose information during on-treatment visits and document the exact accumulated dose in the notes. It is useful to have this information in the electronic health record, which is a separate system from OIS, in the setting of a cyberattack. If the previous steps have been followed, there should be a backup of all data; however, it can be invaluable to verify delivered dose to date in such settings.
By implementing these measures, radiation oncology facilities can significantly reduce the risk of a cyberattack and protect patient data and systems from potential harm. Additionally, there are useful resources often created by those in the field with firsthand experience of these disruptions that should be evaluated when developing response plans.
Free course for ASTRO Members
The ASTRO Academy is offering a course, Cybersecurity and Radiation Oncology, free for members, where you can learn about recent attacks on the radiation oncology community and how to minimize risks at your own practice. This session was previously recorded from the 2022 Annual Meeting. This is free for ASTRO members and 1.25 CME credits are available.
Additional resources published in ASTRO journals:
- Joyce C, Roman FL, Miller B, et al. Emerging Cybersecurity Threats in Radiation Oncology. Advances in Radiation Oncology. Published September 18, 2021.
- Nelson CJ, Soisson ET, Li PC, et al. Impact of and Response to Cyberattacks in Radiation Oncology. Advances in Radiation Oncology. Published June 17, 2022.
- Flavin A, O'Toole E, Murphy L, et al. A National Cyberattack Affecting Radiation Therapy: The Irish Experience. Advances in Radiation Oncology. Published August 6, 2022.
- Oliver M, Pearce A, Stillwaugh L, et al. The Impact of a Cyberattack at a Radiation Oncology Department: Immediate Response and Future Preparedness. Advances in Radiation Oncology. Published June 16, 2022.
- Harrison AS, Sullivan P, Kubli A, et al. How to Respond to a Ransomware Attack? One Radiation Oncology Department’s Response to a Cyberattack on their Record and Verify System. Practical Radiation Oncology. Published October 10, 2021.
Suzanne Evans, MD, MPH, FASTRO, is a Professor of Therapeutic Radiology at Yale University and vice-chair of the ASTRO Clinical Affairs and Quality Council Steering Committee.
Posted: April 26, 2023
| 0 comments
By Katie Lichter, MD, MPH, Co-chair, Climate Change and Health Equity Task Force
As an intern physician in September 2020, I walked home after a night shift in the intensive care unit with my N95 mask still tightly secured. That morning, we had been advised not to remove our masks despite being outdoors. The air was thick with a reddish-brown haze, an ominous blanket covering San Francisco. It was 8:30 a.m., yet the morning light struggled to penetrate the thick smoke from the Northern California wildfires that drifted downwards over the Bay. Overnight, an elderly man with advanced non-small cell lung cancer had been admitted with disease progression. Due to the wildfires, he had missed several crucial weeks of chemoradiation weeks as he was lost to follow-up, in addition to losing his home and supportive community.
In that moment, I realized that climate change would significantly impact my ability to provide care to patients in the decades ahead. Vulnerable patients and communities were already subject to increasing climate-fueled disasters. Just as COVID-19 had tested the limits of the health care system, I understood that climate change will undoubtedly present new and unexpected challenges for health care professionals and communities alike to navigate.
Over the past few years, radiation oncologists have increasingly faced the fragility of our nation's health care infrastructure due to the pandemic and extreme weather events such as hurricanes, wildfires and flooding. Anna Paulsson, MD, summed it up well when she recently stated, "Practices deal with wildfires and other climate change-fueled disasters events every year, but it is challenging to know how to respond, prepare for clinics and patients, and react to these events." These events can cause radiation oncology facilities to shut down, upending the lives of patients, physicians and care teams crucial to treatment. In 2017, in response to Hurricane Maria, ASTRO collaborated with other health care organizations to direct patients to radiation oncology clinics that could accept displaced patients. However, unmet and growing concerns remain about the impact of climate change on patient care and the need for increased environmentally sustainable practices within radiation oncology.
These concerns are shared by other physician specialty organizations, including the American Medical Association, the American Society for Clinical Oncology and the American College of Radiology. To address these concerns, ASTRO joined the Medical Society Consortium on Climate and Health to advocate for climate change solutions that protect and promote public health. The Consortium also provides educational resources to inform health care professionals about the effects of climate change on patient health and guidance on sustainability best practices.
ASTRO task force to study impact of climate change
In January, the ASTRO Board of Directors approved the establishment of a Climate Change and Health Equity Task Force to explore the impact of climate change on radiation oncology. This task force is charged with developing a policy statement describing ASTRO's commitment to addressing climate change, its impact on radiation oncology and vice versa. The statement will include several key focus areas that will inform future activities. The group has reviewed literature on the impact of climate change on radiation oncology, cancer care and public health, as well as the activities of allied organizations, many of which are still evolving. Emerging from these discussions are areas of interest that include patient and provider education, disaster preparedness, building resiliency, sustainability and decarbonization, and identifying and addressing environmental justice and health equity.
In the coming months, the task force will explore these areas further to determine their impact on radiation oncology. Through these efforts, ASTRO hopes to mitigate the effects of climate change on patient care and promote environmental sustainability practices within our field, and even lead the way in doing so. By prioritizing environmental health and sustainability from a health equity lens, radiation oncologists can ensure equitable delivery of cancer care to all patients and communities, despite a changing climate.
Posted: April 18, 2023
| 4 comments
By Reshma Jagsi, MD, PhD, FASTRO, Krisha Howell, MD, and Kirsta Suggs, ASTRO DEI
Women’s participation in the medical profession increased steadily after the enactment in 1972 of Title IX, which proscribed discrimination by educational institutions, including medical schools’ decisions for admissions, hiring and promotions. Before either physician author of this post entered medical school themselves, women constituted over 40% of the medical student body. However, even today, women comprise under a third of all radiation oncologists. They remain in an even smaller minority in positions of influence and authority in the field, ranging from professional society board members and honorees to institutional deans and department chairs.
At the national level, organizations such as the Association of American Medical Colleges have long been engaged in generating and disseminating evidence regarding the status of women in medicine. The National Academies explicitly included medicine in its Committee for Women in Science and Medicine in 2007, soon after publishing a landmark report on gender bias. This allowed subsequent efforts, including reports on the sexual harassment of women, promising practices to promote equity, and the impact of COVID-19 on the scientific workforce to specifically include recommendations relevant to women in medicine. These efforts generated observations that those who challenge the status quo, such as those entering a field from which they had historically been excluded, are often targets of hostility and harassment. Gender bias can be so pervasive that a name change at the top of a CV is enough to have a meaningful impact on whether a candidate receives a job interview or is hired. Moreover, gendered expectations of society lead to differences in family care responsibilities that can challenge women’s full participation in the professions, something that has been both highlighted and amplified by the COVID-19 pandemic. These types of challenges ultimately act to the detriment of all, given the demonstrated value that diverse perspectives bring to any endeavor, especially one as important as the improvement of human health.
Although efforts at the level of the profession as a whole have had great impact, needs still exist for work at the level of individual specialties. In radiation oncology, women’s participation among physicians reached approximately 30% over three decades ago and then essentially flattened. This pattern, which differs from what is observed in medical oncology and many other fields, requires focused attention. For as long as we can remember, the American Association for Women Radiologists (AAWR) has generated tremendous interest in its annual luncheon bringing women together at the ASTRO Annual Meeting. The AAWR celebrated its 40th anniversary during the pandemic and its impact in facilitating both the understanding and mitigation of challenges disproportionately encountered by women in both diagnostic radiology and radiation oncology cannot be overstated.
In more recent years, led primarily by newer members of the profession, a stronger desire for groups specifically focused on women in radiation oncology has emerged. This led to the founding of the Society for Women in Radiation Oncology and the Radiation Oncology Women Physicians Facebook group. At the same time, broader efforts within ASTRO to develop a robust committee focused on equity, diversity and inclusion led to the Committee on Health Equity, Diversity and Inclusion (CHEDI) and ultimately the more recent establishment of the Council for Health Equity, Diversity and Inclusion (HEDI Council). An ad hoc ASTRO task force that was first formed in 2020 and focused on gender equity was recently retired. In its place, a new Women in Radiation Oncology Affinity Group was formally created in the summer of 2022 as a component of the HEDI Council.
As the chair, co-chair and ASTRO staff liaison of this Affinity Group, we write this post to share its structure and goals with the broader community of radiation oncologists. We are excited that this task force is particularly well situated to advance equity with an intersectional lens, as one of six standing units within the HEDI Council. The membership currently includes a diverse group of 24 members, including physicians and physicists, ASTRO Gold Medalists and trainees. We have created three working groups that will focus on 1) gender bias and harassment, 2) family caregiving, and 3) mentorship, sponsorship and leadership development. These groups will focus on developing education, research, policy and other initiatives in their areas of focus.
In this way, we seek to collaborate with, and build on, the tremendous foundation of existing groups, including those mentioned above, to create a unified forum within the primary professional society of our field to pursue research and initiatives that will promote equity for women in radiation oncology. We invite all interested members of the field to bring their ideas to our working groups and engage with us to pursue our mission. Please feel free to email us and join the Gender Equity community on the ROhub to start a conversation.
Posted: April 12, 2023
| 0 comments
By Lisa Braverman, PhD, ASTRO Journals, and Jennifer Jang, ASTRO Communications
With so many demands on your time, it’s easy to overlook the many benefits included in your ASTRO membership. Member benefits are always expanding, so we thought we would take a moment to list many of the free and discounted resources available to ASTRO members. Consider this your 2023 ASTRO membership “cheat sheet” — bookmark and revisit it every few months to ensure you are taking full advantage of the commitment you made to the field and to your colleagues when you joined ASTRO.
- Discounted Annual Meeting, specialty meeting and multidisciplinary meeting registration. Mark your calendar, registration and housing for the Annual Meeting open on May 18. Did you know that the Annual Meeting headquarters hotel is reserved primarily for members?
- Free/deeply discounted journal subscriptions, depending on your membership type. The vast majority of ASTRO members receive print and online access to the Red Journal and Practical Radiation Oncology free of charge. While Advances in Radiation Oncology is Open Access, members automatically receive eTOC alerts for each new issue.
- Exclusive networking. ASTRO membership is a gateway to making valuable connections. ASTRO’s free and popular members-only forum, the ROhub, offers an easy way to instantly connect with your colleagues for field-specific discussions. The Member Directory is a useful resource if you are looking for a colleague from your geographic region or the same school you attended to network with or for patient referral.
- Professional growth. Mentor Match has matched hundreds of mentors and mentees for career development and to share experiences. Peer-to-Peer provides a network of colleagues who are available to review patient cases, which is especially helpful to physicians in rural areas. The Leadership Pathway Program is a career development program aimed at increasing diversity among ASTRO leadership.
- Fast-track pathway to leadership. Committee participation is a great way to become involved with ASTRO. Each spring, a Call for Volunteers is announced in the ASTROgram. Committee participation is often a stepping stone to leadership positions within the Society.
- Streamlined opportunities to advocate for the field. U.S.-based members can participate in the Society’s advocacy initiatives to protect and promote radiation oncology and the interests of cancer patients. In addition to the opportunity to participate on Government Relations and Health Policy committees, each year, ASTRO holds a two-day fly-in where members learn about our legislative priorities and engage with their senators and representatives. Advocacy Day is free to attend and travel grants are available to Members-in-Training.
- The latest RO news delivered to your inbox. Keep apprised of important Society news and developments in the field by reading the weekly ASTROgram, which is mailed to members every Wednesday. ASTROnews is our quarterly magazine with timely themes and feature stories written by members. And, of course, ASTRO.org provides timely information about ASTRO’s many products and services.
- Advance notice of new job postings and discounted job listings. The ASTRO Career Center provides employers and job seekers with an easy to use and highly targeted resource for employment connections. Employers receive member rates for job postings and member job seekers have access to posting three days before other job seekers.
- New this year! Free access to Annual Meeting Science Highlights. Each month ASTRO members have free access to one of the Science Highlights presented at the ASTRO Annual Meeting. Science Highlights are housed in the ASTRO Academy and announced in the ASTROgram. So far this year Central Nervous System, Lung Cancer/Thoracic Malignancies and Innovations in Patient Safety and Quality of Care have been released.
- Complimentary Journal CME. Need CME? Also complimentary and housed in the ASTRO Academy, the latest Red Journal, PRO and Advances journal activities are available for members. Discover educational topics on every disease site, patient safety, palliative care and multiple modalities. These journal activities offer participants access to the latest peer-reviewed science and help practitioners continue to provide the best care for their patients while earning CME
We are so excited to share these important benefits with you, and we are always looking to serve ASTRO members better. Please reach out with feedback or questions at any time to ASTRO Membership and be sure to complete your annual membership survey!
Posted: April 5, 2023
| 1 comments