By Curtiland Deville Jr., MD, Deputy Editor, International Journal of Radiation Oncology • Biology • Physics

The following includes excerpts from Dr. Deville’s editorials in the two special HEDI issues of the Red Journal. Read the full editorials and explore each special issue at www.redjournal.org.

It’s been said that we often overestimate what can be accomplished in a year and underestimate what can be accomplished in a decade. It’s been over a decade since Christina Chapman, MD, MS, and I published the first physician workforce diversity analysis in our specialty.¹ At the time, I found only a single publication discussing concepts of diversity, underrepresentation and exclusion in our field — an editorial by Reshma Jagsi, MD, PhD, FASTRO, and Nancy Tarbell, MD, FASTRO, discussing the lack of gender representation and the need to address the proverbial “glass ceiling.”²

Over a decade later, hundreds of manuscripts exploring health equity, diversity and inclusion (HEDI) across a range of topics in radiation oncology, biology and physics have since been published, and we arrive today at the Red Journal’s HEDI special editions with dozens more contributions carrying the potential to inform and shape the field. But progress does not occur simply with the passing of time. Tireless, restless, persistent and courageous efforts by early, mid-, and advanced-level trainees, physicians, physicists, scientists, administrators and leaders have facilitated the awakening and commitment to diversity, equity and inclusion in our field, ultimately to the benefit of our future patients, colleagues and staff. Below, I give a brief overview of several studies included in each issue, but I strongly encourage all readers of this blog to study both special issues carefully.

The first HEDI special issue includes a number of analyses and interventions to address health equity in radiation oncology, medical physics and radiation biology. In their manuscript, Radiotherapy Deserts: The Impact of Race, Poverty and the Rural-Urban Continuum on Density of Providers and Use of Radiation Therapy in the United States, Alcorn et al. characterize so-called radiation deserts — areas with the greatest mismatch of oncologic need and radiation resources — and provide an online tool to drive targeted investigation of underlying barriers to care in areas of highest need, with the goal of reducing health inequities in this context.

Kronfli et al. report on a psychosocial needs assessment implemented for patients with cancer undergoing curative radiation therapy in an inner-city, academic center to address radiation disparities. In their companion editorial, Suneja et al. laud the efforts of this group’s targeted intervention to address social determinants of health such as socioeconomic and transportation barriers, delve further into fundamental concepts in health equity, and provide cautionary guidance for investigators to ensure that their analyses and author teams do not themselves perpetuate inequities, exclusion and bias and moreover risk engaging in health equity tourism.³

Regarding progress toward inclusive clinical trial enrollment, Roy et al. provide a framework in their critical review Increasing Diversity of Patients in Radiation Oncology Clinical Trials, while Chen et al. discuss why the Inclusion of Sexual Orientation and Gender Identity in Clinical Trials is Necessary for Health Equity, and Patel et al. discuss the role of industry partners in Carrots or Sticks: An Industry Perspective on the Significance of Regulatory Guidance in Promoting Participant Diversity in Clinical Trials.

The second volume of the HEDI special issue highlights needs and innovations across a variety of domains: the physician, physics and basic scientist workforce, education, technology access and global health. With respect to workforce diversity and inclusion, analyses of demographic representation trends reveal that women and historically underrepresented racial and ethnic groups in medicine (URiM) remain excluded, likely along with a host of other marginalized groups for whom data is largely unavailable.

The review by Jimenez et al. entitled Using Holistic Residency Applicant Review and Selection in Radiation Oncology to Enhance Diversity and Inclusion, an ASTRO SCAROP-ADROP-ARRO Collaboration, opens with a detailed review of current representation trends and the lack of significant changes in representation for women and URiM trainees in radiation oncology over the past decade, despite gains in the overall U.S. graduate medical education trainee pool. Broadening the scope of diversity with additional dimensions is increasingly needed to assure equity, inclusion and belonging. Such historically marginalized dimensions include deaf and disabled status, veteran status, sexual orientation and gender identification (SOGI), first generation and low income (FGLI), religion, geography (e.g., urban versus rural) and disadvantaged background. Limited data exist regarding representation of many of these groups within medicine and radiation oncology specifically, but several data collection initiatives are underway and included in this edition.

Marginalized demographic groups remain disproportionately underrepresented and ultimately excluded in radiation oncology relative to the available pool. This indicates that simply increasing the pipeline is not enough without thoughtful recruitment, applicant review and selection, and retention and advancement strategies as reviewed in the HEDI focus issues.

Our charge is that the next decade and beyond bring scaled, sustained, strategic departmental, organizational and societal policies and interventions that address the long-standing disparate representation in the radiation oncology physician, medical physics and radiation biology scientist workforce. These efforts are requisite if we wish to dismantle structural bias and systemic inequities in the specialty and ensure that our workforce is reflective of the ever-diversifying domestic and global patient populations and communities we serve.

References

1. Chapman CH, Hwang WT, Deville C. Diversity based on race, ethnicity, and sex, of the US radiation oncology physician workforce. Int J Radiat Oncol Biol Phys. 2013 Mar 15;85(4):912-8.
2. Jagsi R, Tarbell NJ. Women in radiation oncology: time to break through the glass ceiling. J Am Coll Radiol. 2006 Dec;3(12):901-3.
3. Lett E, Adekunle D, McMurray P, et al. Health Equity Tourism: Ravaging the Justice Landscape. J Med Syst. 2022 Feb 12;46(3):17.

By Sue Yom, MD, PhD, MAS, FASTRO, Editor-in-Chief, International Journal of Radiation Oncology · Biology ·Physics

The gift giving season has just passed, but there’s nothing to say that we can’t continue to give throughout the year. As many of you know, I’ve just become the editor-in-chief (EIC) of the International Journal of Radiation Oncology · Biology · Physics (IJROBP or the Red Journal). It’s a great privilege to be named to this position. One of my first acts as EIC is to announce that the ASTRO journals staff and editors have joined together in an effort to enhance the experience of our associate editors and reviewers. This new initiative, called the Reviewer Recognition Program (RRP), officially began January 1, 2022.

We’re aware that these days, everyone has growing pressures on their time and during COVID, many of us are running on empty. Speaking from my experience, it’s amazing to me that despite this sense of barely making it through, everyone at the Red Journal remains so energized and dedicated. Our editors and reviewers continue to find the best content and provide the best review process possible for our authors. As a result, our journal is thriving.

I hope others share my experience that the Red Journal is (already) rewarding. On those gloomy days when it’s all been too much, it is uplifting to me to see that our community of radiation oncology perseveres. I am in awe of my brilliant, articulate peers who continue to work on science, for this idealistic dream of bettering conditions for patients and our field. I love that the Red Journal is a stimulus for our community to learn, to communicate, to disagree. I am sure the other ASTRO editors-in-chief feel exactly the same. These journals are each a truly unique nexus, and the community they create is so much more than just publishing articles.

The Reviewer Recognition Program will be multifaceted, but the first component rolls out now. Reviewers and Associate Editors are eligible to receive a voucher for a free or reduced Article Processing Charge (APC) after reviewing 12 papers within three years. Here’s how it works. We will provide a Review Recognition Form that can be filled out listing the article numbers and dates of filing corresponding to 12 reviews that have been completed for any of the three ASTRO journals. Associate editors, who at times write extensive reviews of submissions themselves, are eligible to claim an especially detailed set of editorial comments for credit. The claimed reviews must have a reasonable level of quality and timeliness. Reviews of article revisions can be claimed if they demonstrate a reasonable level of additional new effort. The reviewer will submit the Review Voucher Form to the ASTRO editorial office. After verification and approval of the form, it will be redeemable for one voucher code. This voucher can be used as credit towards one-half of the APC for an IJROBP or Practical Radiation Oncology Open Access paper, or for one full APC at Advances in Radiation Oncology.

What’s an APC, you say? An APC is the cost charged to an author for the expenses of publishing an Open Access article. Therefore, at Advances, one APC credit would cover the whole cost of publishing, whereas at IJROBP or PRO it will cover half of the cost of publishing your article as Open Access (should you choose that option for your accepted paper). The voucher can be redeemed by its holder after a paper is accepted, as long as the holder is a named author on the accepted paper. Additionally, we will develop a database called the Preferred Reviewer Program, to which reviewers can subscribe so that they can signal their willingness to review often. To maintain Preferred Reviewer status, participants must accept >75% of invitations and complete their reviews within 14 days. In return, editors will preferentially invite Preferred Reviewers with the goal of completing the RRP requirements within three years.

We hope you’ll agree that the RRP satisfies a number of purposes at once. Most importantly and foremost, it gives our reviewers and associate editors a tangible recognition of their efforts. Greater recognition of our reviewers has been a long-cherished dream and we are thrilled to take this step in the right direction. It also moves us toward greater promotion of Open Access, which is a vehicle for wider public dissemination of radiation oncology research and higher citations of our early-career authors. It makes our journals more attractive as Open Access publishing venues for the best radiation-related research. It promotes the careers of our most dedicated and frequent reviewers. In addition, it provides our editors with a pathway to identify and recognize top reviewers and develop those persons for the future.

We will be rolling out other forms of recognition for editors and reviewers in the future. If you have ideas on this subject, please let me know. On behalf of myself and the other ASTRO journals editors, we look forward to the success of this endeavor and thank all of you for your ongoing support of the ASTRO journals.

Learn more: Reviewer Recognition Program

By Anthony Zietman, MD, FASTRO

As I end my 10-year tenure as editor-in-chief of the Red Journal, I can draw breath and reflect on what this journal has become, and what, as a team, we have achieved for both its authors and its readers.

Starting with the authors, they had complained to me about the slow process of peer-review, the uncertain standards for acceptance, and the impression, rightly or wrongly, that there was a level of bias or favoritism toward work from certain institutions. To address these concerns, we gave the editorial board a structure and put the emphasis on youth and energy for its members. This created a system for manuscripts that flowed swiftly and without hindrance. We ensured that review was double-anonymized, meaning that neither reviewers nor authors knew one another’s identity or location. And we discussed within our editorial teams the criteria that had to be met to accept a paper and posted these on our website. Soon we had the time from submission to first decision down from many months to just three weeks, and our acceptance rate down from close to one half to only one in five papers.

The bar was raised, and every effort was made to keep it horizontal across disease sites. Today, the Red Journal’s Impact Factor is over 7, superb for a small specialty journal, and the feedback from authors is gratitude for the swift decisions (even if they are negative!) and a sense that the Red Journal has become a real destination for the best science in radiation oncology.

From the perspective of the reader, we wanted to ride the movement to web-based publishing and to take advantage of all that the web has to offer. This included immediate in press publication on acceptance, very important for topical papers. It also included several new features and categories such as Gray Zone, Cover Art and atlases that formed either teaching tools or fabulous collections for browsing. The interactive nature of the journal is only going to increase in the years ahead. We also chose to make the journal much more current in its discussions to truly reflect anything that a practicing radiation oncologist may be talking about that affects their personal or clinical decisions. Hence, we ran articles and discussion pieces on health policy and economics, the job market, equity and the future of the specialty. These, we believe, made the journal a far less dry read, and much more relevant.

And finally, I wanted us to live up to our title. Previously the words Physics and Biology had been printed on the cover in smaller font than the word Oncology implying lesser importance. That was an easy fix! But the word International is featured first and that needed to be honored if we were to be more than a North American journal. Attention to the composition of the editorial board, double-anonymized review and Around the Globe feature articles all helped to raise our global profile and now more than 50% of submissions come from nations other than the U.S. and Canada.

I was only the third editor-in-chief of the Red Journal in its more than 40-year history. If my tenure is remembered for anything I would like it to be that we brought the journal into the 21st century and into the lives of radiation oncologists by making it accessible, immediate and a “good read.” Social media has become the medical journal’s biggest competitor, but by adding value through thoughtful review and discussion, journals remain important and respected. A journal’s discussion is usually cooler and more reflective than those found in social media and, consequentially, more durable.

What I never realized before I took the post was how all-consuming it was. My desire to increase our speed of throughput, coupled with the endless decisions, editorials, features, invitations and production deadlines, meant that for 10 years I have not truly had a free day. There was always something that needed to be done for the journal! It seeped into every crack in my life, before breakfast, between patients, through the evenings and weekends. And, because we are a global journal, midnight in the U.S. is midday in Australia and they are submitting! The Chinese do not recognize Veterans Day, nor the British Patriots Day, and still the manuscripts come.

In the first few weeks since I have stepped back, I have reclaimed parts of my life that have been lying fallow for so many years. It was the greatest privilege of my career to serve the Red Journal, and it will be a great pleasure now to return to my “day job” and more. My garden and my dance floor need much more attention than I have been giving them these recent years!

By Robert C. Miller, MD, MBA, FASTRO, and Faustin Laurentiu Roman, MsC

In the weeks leading up to the U.S. national elections in November 2020, while much of our nation’s attention was focused on political issues, there was a series of cyberattacks on U.S. health care institutions. The U.S Department of Health and Human Services (HHS) Office of the Assistant Secretary for Preparedness and Response, along with the Federal Bureau of Investigation (FBI) and the Cybersecurity and Infrastructure Safety Agency (CISA), issued an advisory on October 28, 2020, noting that “CISA, FBI and HHS have credible information of  an increased and imminent cybercrime threat to U.S. hospitals and health care providers.”¹

In a recent letter to the editor in ASTRO’s Advances in Radiation Oncology, Nelson and colleagues detail the challenges they faced when the University of Vermont Health Network was attacked on October 28 in a ransomware incident.² The resulting IT outage lasted more than 40 days and was estimated to have cost more than $63 million to resolve.³ Delivery of radiation therapy was delayed for as many as 13 days for some patients due to the loss of the radiation oncology department’s information management system.

This incident was unique in the severity of the impact of the attack but hardly a unique occurrence. It does illustrate the trend away from broad-based attacks and toward persistent attempts to compromise high-value targets that have a high financial yield. The following challenges in cybersecurity and cybercrime will rise in importance throughout 2021⁴:

• Social engineering attacks, such as email phishing and business email compromise.
• Increased attempts to exploit internet-facing vulnerabilities of organizations. 
• Exploitation of system administration tools.
• Ineffective monitoring of critical IT systems.
• Human-operated ransomware risks.

The very technical and complex nature of radiation oncology⁵, combined with the escalation of cyber-attacks and changes of tactics from malicious actors, may influence the risk profile of service providers,⁶ especially when the delay in receiving treatments may prove to be fatal.⁷

Radiation oncology, reliant on connected technology, is particularly vulnerable.⁸ The inherent top threats to health care⁹, (e.g., communication errors, lost and stolen devices, insider threats), or more sophisticated cyber espionage threats,¹⁰ add up to a wide range of threat actors and risks that demands better collaboration, (e.g. threat intelligence sharing),¹¹ meaningful action beyond compliance “tick-box” exercises, and appropriate funding to respond adequately and become resilient to the rising cybersecurity risks.

ASTRO’s Advances welcomes the submissions of scientific manuscripts, commentary and firsthand accounts of how providers and institutions are meeting these challenges. Our deadline for manuscript submission is October 31, 2021. To submit, send papers through the journal’s submission system and select “Cybersecurity” as the article type. Please reach out to the editorial office with any questions at advances@astro.org.

References

1. Cybersecurity and Infrastructure Security Agency. “Alert (AA20-302A) Ransomware Activity Targeting the Healthcare and Public Health Sector.”  Accessed online February 1, 2021: https://us-cert.cisa.gov/ncas/alerts/aa20-302a.
2. Nelson, C. J., Lester-Coll, N. H., Li, P. C., Gagne, H., Anker, C. J., Deeley, M. A., & Wallace, H. J. (2020). Development of Rapid Response Plan for Radiation Oncology in Response to Cyberattack. Advances in radiation oncology, 6(1), 100613. https://doi.org/10.1016/j.adro.2020.11.001
3. Becker’s Healthcare, “The 5 most significant cyberattacks in healthcare for 2020.”  Accessed online February 1, 2021: https://www.beckershospitalreview.com/cybersecurity/the-5-most-significant-cyberattacks-in-healthcare-for-2020.html
4. Thibodeaux, B.  Five cyber threats to watch in 2021.  Security.  January 2021.  Accessed online February 1, 2021: https://www.securitymagazine.com/articles/94343-five-cyber-threats-to-watch-in-2021
5. The impact of cybersecurity in radiation oncology: Logistics and challenges (appliedradiationoncology.com)
6. CISA Launches Campaign to Reduce the Risk of Ransomware | CISA
7. Ralston, W.  Wired magazine, Accessed online February 4, 2021 at:  The untold story of a cyberattack, a hospital and a dying woman | WIRED UK
8. Impact of Ripple20 Vulnerabilities on Healthcare IoT, Connected Devices (healthitsecurity.com)
9. Healthcare Data Breaches & Security | Verizon Enterprise Solutions
10. Beyond Compliance: Cyber Threats and Healthcare (fireeye.com)
11. H-ISAC Information Sharing Best Practices - (h-isac.org)